Assignment:
Documentation of a Cardiovascular System Examination
You will perform a history of a cardiac problem that your instructor has provided you or one that you have experienced, and you will perform a cardiac assessment. You will document your subjective and objective findings, identify actual or potential risks, and submit this in a Word document to the drop box provided.
Cardiac System Assignment
Submit your completed assignment by following the directions linked below. Please check the Course Calendar for specific due dates.
Save your assignment as a Microsoft Word document. (Mac users, please remember to append the ".docx" extension to the filename.) The name of the file should be your first initial and last name, followed by an underscore and the name of the assignment, and an underscore and the date. An example is shown below:
Title:
Documentation of problem based assessment of the cardiac system.
Purpose of Assignment:
Learning the required components of documenting a problem based subjective and objective assessment of cardiac system. Identify abnormal findings.
Course Competency:
Select appropriate physical examination skills for the cardiovascular and peripheral vascular systems.
Instructions:
Content:Use of three sections:
o Subjective
o Objective
o 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: 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.