You will perform a history of a musculoskeletal problem that your instructor has provided you or one that you have experienced, and perform an assessment of the musculoskeletal system. You will document your subjective and objective findings.
Title:
Documentation of problem based assessment of the musculoskeletal system.
Purpose of Assignment:
Learning the required components of documenting a problem based subjective and objective assessment of musculoskeletal system. Identify abnormal findings.
Course Competency:
Demonstrate physical examination skills of the skin, hair, nails, and musculoskeletal system.
Instructions:
Content:
Format:
Resources:
Chapter 5: SOAP Notes: The subjective and objective portion only
Sullivan, D. D. (2012). Guide to clinical documentation. [E-Book]. Retrieved from
http://ezproxy.rasmussen.edu/login?url=http://search.ebscohost.com/login.aspx?direct=true&db=nlebk&AN=495456&site=eds-live&ebv=EB&ppid=pp_91
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