Neurological System Documentation
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
- 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 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.