Holistic Health Assessment Assignment

Holistic Health Assessment Assignment
Holistic Health Assessment Assignment
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Rubric grading of assessment forms
One point is subtracted for each occurrence of the following, up to 10 points or more total for
the form. (Meaning students can’t get an A on the assessment if they use one of the
following 10 or more times.) See rubric for application in each form.
1. NA or Not applicable.
For this class, N/A or not applicable is appropriate only concerning the reproductive
system, if the item refers to a finding or process which does not apply to the sex of
the patient. For instance, date of last menstrual period (LMP): If the patient is male,
putting N/A for that item is allowed.
2. Good. For instance, referring to skin turgor as “good” is not sufficiently specific for
this class. Students need to describe the good finding: Elastic, for instance.
3. Normal. In this assessment class, students need to be more specific. Describing
bowel sounds as “normal in all 4 quadrants” is fine in a clinical setting, but for
purposes of this class, more specificity is required. The term “active” describes what
normal is, and is what is needed here.
4. Within normal limits. Describe what was found, even if that is normal. This makes
you use the terminology—say it. There are examples in the textbook for most
findings.
Here are a couple of things to keep in mind, and they are in table form, below:
When interviewing the assessment partner for the subjective finding, if the partner denies
having a problem, using the word “denies” is not sufficient documentation for that entry.
State what is denied.
Give a full description of findings for each entry, not leaving any blanks.
When describing a finding, state whether it is unilateral (on the left or the right) or bilateral.
Use units of measure: mmHg, millimeters. Your book no longer requires the use of
denominators for reporting strength (___out of 6) or reflexes (__out of 4) so you won’t get
points off for not using them, but they are still a good idea, and we encourage their use in
your assessments and in your employment. Do you remember “off the top of your head”
what a reflex is scored out of: 4, 5, or 6? It is 4, actually, but we can’t all remember for
every assessment! Assume the person reading the form doesn’t know the normal unit, and
you must supply it.
N3315 Holistic Health Assessment
Section of the Paper
Expectation (See Grading Rubric)
Error
Format Not
followed
Spelling Incorrect
Font An easily readable font such as Times New Roman, Ariel, or Calibri
Template
Not followed
Subjective Data See textbook for examples
Subjective and objective
Separate subjective and objective data Mixed up data
Follow template
Submission per stated guidelines
See Syllabus and instructions late
Describe assessment, avoid using vague terms such as normal, NA, good, etc.
Uses terms not allowed
If patient does not have finding, must state “denies __________”.
States only “denies”
Ecomap Detail
Accuracy
Legend
Legibility
Client not on legend
No names – use initials or relationships
Lymph nodes Missing name and / or Bilateral-each
Tonsils Bilateral, 0 to 4+
N3315 Holistic Health Assessment
TMJ Bilateral
Sinuses Percussion and/ or Transillumination Bilateral
Thyroid No masses and/ or Bilateral/bruits
MSK Name, ROM and / or Bilateral each
Temporal Artery
Bilateral
Carotid Artery Bilateral
Tympanic Membrane
Bilateral
Canal/cerumen Bilateral
Pinna, Tragus, Lobe
Bilateral
Neurological Technique (CN 1-Separate scents for each nostril)
CN name, number and correct test each error
Reflexes 1+ to 4+
Nails Cap Refill and /or angle with # of digits X10 digits
Resp Rate Breaths per minute Not listed as breaths/min
Heart Rate Beats per minute Not in cardiac
APETM Aortic
Pulmonic Erb’s point Tricuspid Mitral Abnormal heart sound name, grade, etc.
Not complete in Cardiac
Pulses Bilateral using amplitude scale in book: 0 – 4+