Documentation of problem based assessment of the head, ears, and eyes

Title:

Documentation of problem based assessment of the head, ears, and eyes.

Purpose of Assignment:

Learning the required components of documenting a problem based subjective and objective assessment of a head, ears, and eyes. Identify abnormal findings.

Course Competency:

Demonstrate physical examination skills of the head, ears, and eyes, nose, mouth, neck, and regional lymphatics.

Instructions:

Content:  Use of three sections:

  • Subjective
    • Objective
    • Actual or potential risk factors for the client based on the assessment findings with description or reason for selection of them.

Format:

  • Standard American English (correct grammar, punctuation, etc.)

Resources:

Chapter 3: SOAP Notes (subjective and objective only)

Sullivan, D. (2018). Guide to clinical documentation. https://ebookcentral.proquest.com/lib/ras/detail.action?docID=5553403

Smith, L. S. (2001, September). Documentation do’s and don’ts. Nursing, 31(9), 30. Retrieved from http://ezproxy.rasmussen.edu/login?url=http://search.ebscohost.com/login.aspx?direct=true&db=rzh&AN=107055742&site=eds-live

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