Title: Documentation of Problem-Based Assessment of the Head, Ears, and Eyes.
Purpose of Assignment: To learn the required components of documenting a problem-based subjective and objective assessment of the head, ears, and eyes and to identify abnormal findings.
Course Competency: Demonstrate physical examination skills of the head, ears, and eyes, nose, mouth, neck, and regional lymphatics.
Instructions:
Content: Use three sections:
- Subjective
- Objective
- Actual or potential risk factors for the client based on the assessment findings with a description or reason for the selection of them.
Format:
- Standard American English (correct grammar, punctuation, etc.)
Resources:
Chapter 3: SOAP Notes (subjective and objective only) Sullivan, D. (2018). Guide to clinical documentation. Link to the eBook
Smith, L. S. (2001, September). Documentation do’s and don’ts. Nursing, 31(9), 30. Link to the article
Documentation Grading Rubric – 10 possible points Levels of Achievement:
- Emerging (1 point): Missing components such as biographic data, medications, or allergies. Symptoms analysis is incomplete. May contain objective data.
- Competence (2 points): Basic biographic data provided. Medications and allergies included. Symptoms analysis incomplete. Lacking detail. No objective data.
- Proficiency (3 points): Basic biographic data provided. Included a list of medications and allergies. Symptoms analysis: PQRSTU completed. Lacking detail. No objective data. Information is solely what the “client” provided.
- Mastery (4 points): Basic biographic data provided. Included a list of medications and allergies. Symptoms analysis: PQRSTU completed. Detailed. No objective data. Information is solely what the “client” provided.
Objective (4 Pts):
- Emerging (1 point): Missing components of assessment for a 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.”
- Competence (2 points): Includes all components of assessment for a 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.
- Proficiency (3 points): Includes all components of assessment for a particular system. Avoided the use of words such as “normal,” “appropriate,” or “good.” No bias or explanation for findings evident. Contains all objective information.
- Mastery (4 points): Includes all components of assessment for a particular system. Detailed information provided. Avoided the use of words such as “normal,” “appropriate,” or “good.” No bias or explanation for findings evident. All objective information.
Actual or Potential Risk Factors (2 pts):
- Emerging (0.5 point): Lists one to two actual or potential risk factors for the client based on the assessment findings with no description or reason for the selection of them. Failure to provide any potential or actual risk factors will result in zero points for this criterion.
- Competence (1 point): Brief description of one or two actual or potential risk factors for the client based on assessment findings with a description or reason for the selection of them.
- Proficiency (1.5 points): Limited description of two actual or potential risk factors for the client based on the assessment findings with a description or reason for the selection of them.
- Mastery (2 points): Comprehensive, detailed description of two actual or potential risk factors for the client based on the assessment findings with a description or reason for the selection of them.
Solution
Documentation of the Problem-based Assessment of the Head, Ears, and Eyes
Name
Institution
Date
Documentation of Problem-based Assessment of the Head, Ears and Eyes
Subjective
Mr. Smith a 26 years old Caucasian male presents to the office with pain and pus draining from the ear. He also mentions being experiencing a fever. He is a part-time swimming trainer and swimming is his major hobby. He is a third born in a family of five. He denies any use of drugs or alcohol. He enjoys support from both family and friends. He has been on Tylenol for the last 24 hours to ease pain and lower the fever.
Location: Ear
Onset: 4 days ago
Character: Radiating
Associated signs and symptoms: Fever, itching, redness of the skin around the ear
Timing: All the time
Exacerbating/relieving factors: Pain killer
Severity: 9/10 scale
Current Medications: Over the counter Tylenol
Allergies: No known drug or food allergies.
Objective
Vital signs: BP 140/80, P 70, Weight 130, Height 4’3″
Ears: Drainage from the ear, redness of the outer ear, itchiness, pain, swollen ear canal, conductive hearing loss
Head: swollen neck glands
Eyes: No blurred vision, no redness,
Potential Risk factors
Excess moisture in the ear canal
An individual might have excess moisture in the ear canal emanating from heavy perspiration, water getting trapped in the ear after swimming, or prolonged humid weather. A moist environment is conducive for the growth of bacteria and in rare cases the growth of fungus.
The use of cotton swabs or fingers
The cleaning of the ear with cotton swabs or fingers may interfere with the amount of wax in the ear canal. A lack of ear wax has been shown to contribute to the development of swimmer’s disease. Ear wax acts as a barrier against bacteria growth and moisture.
Ear devices
Ear devices like hearing aids, earbuds and hearing aids can cause tiny breaks in the skin providing a favorable environment for bacteria growth.