SOAP note for the case study of Neurological Examination

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Title:

Documentation of problem based assessment of the neurological system.

Purpose of Assignment:

Learning the required components of documenting a problem based subjective and objective assessment of neurological system. Identify abnormal findings.

Course Competency:

Apply assessment techniques for the neurological and respiratory systems.

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 Assessment and nursing intervention.

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

Documentation Grading Rubric- 10 possible points

Levels of Achievement

Criteria

Emerging

Competence

Proficiency

Mastery

Subjective

(4 Pts)

Missing components such as biographic data, medications, or allergies. Symptoms analysis is incomplete. May contain objective data.

Basic biographic data provided. Medications and allergies included. Symptoms analysis incomplete. Lacking detail. No objective data.

Basic biographic data provided. Included list of medications and allergies. Symptoms analysis: PQRSTU completed. Lacking detail. No objective data. Information is solely what “client” provided.

Basic biographic data provided. Included list of medications and allergies. Symptoms analysis: PQRSTU completed. Detailed. No objective data. Information is solely what “client” provided.

Points: 0.5

Points:1

Points: 2

Points:4

Objective

(4 Pts)

Missing components of assessment for particular system. May contain subjective data. May have signs of bias or explanation of findings. May have included words such as “normal”, “appropriate”,
“okay”, and “good”.

Includes all components of assessment for particular system. Lacks detail. Uses words such as “normal”, “appropriate”, or “good”.Contains all objective information. May have signs of bias or explanation of findings.

Includes all components of assessment for particular system. Avoided use of words such as “normal”, “appropriate”, or “good”.No bias or explanation for findings evident Contains all objective information

Includes all components of assessment for particular system. Detailed information provided.Avoided use of words such as “normal”, “appropriate”, or “good”.No bias or explanation for findings evident. All objective information

Points: 1

Points: 2

Points: 3

Points: 4

Strength and Weakness

(2 Pts)

Lists one strength and one weakness with no description or reason for selection of them. Failure to provide both one strength and weakness will result in zero points for this criteria.

Provides brief description of one strength and one weakness with no reason for identification of the strength and weakness.

Provides description of one strength and one weakness noted on assessment. Gives reason for identification of the strength and weakness.

Detailed description of one strength and one weakness noted during assessment. Detailed reason provided for identifying the strength and weakness.

Points: 0.5

Points: 1

Points: 1.5

Points: 2

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