Reference no: EM132516113
Lab Assignment - Documentation of an Assessment of the Head, Ears, and Eyes
You will perform a history of a head, ear, or eye problem that your instructor has provided you or one that you have experienced and perform an assessment including head, ears, and eyes. You will document your findings, note any abnormal findings, and submit this in a Word document to the drop box provided.
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, and Abnormal Findings.
Short descriptive paragraph of findings for each section.
Format: Standard American English (correct grammar, punctuation, etc.).
Resources: Chapter 5: SOAP Notes: The subjective and objective portion only Sullivan, D. D. (2012). Guide to clinical documentation. [E-Book]. Smith, L. S. (2001, September). Documentation do's and don'ts. Nursing, 31(9), 30.