Ms. Ogidan
Weekly Lab Assignment Template
Directions and Grading Criteria 1. Use the this form to take notes while completing your physical examination as described in the “Weekly Lab Assignment Guidelines.pdf” found in Doc Sharing as well as the Faculty Assignment page in your course shell. 2. Record only objective data. Score is based on THOROUGHNESS and being CONCISE. 3. Avoid vague terms such as “good turgor” or “normal nodes”. For example, use “capillary refill less than 3 sec.” instead of “good capillary refill”. Use “Tympanic membranes intact, landmarks noted” instead of “normal TM”. 4. Complete each section of the document based on the current week’s lab practice. Each week you will turn in this same document with the additional sections completed. So you will basically pass this document back and forth adding to it each time. We will continue to use it in NR 304 culminating in a total Physical sample documentation 5. Each week it will be graded with the expectation that comments will be utilized for improvement the following week. ~ | Your Description | General Survey & Vital Signs Document the physical appearance, mental status, behavior, and mobility.Document blood pressure, pulse, respiratory rate, oxygen saturation, and temperature. | • Physical Appearance – Patient is a healthy 33 year old African American Male with dark brown eyes. Ht: 5’10Wt: 196 poundsColor: Even Skin Tone, Pt. lips are pink in color so dehydration is not present.pain level 0/10 on pain scale. No over the counter medications have been taken.Orientation: A&O x3 (time, place, and person), client denies any depression or anxiety; answers all questions appropriately when asked. Dress and Grooming: Patient was well groomed, and had appropriate footwear. Hair is short and neatly groomed. (Pt. stated no dryness and breakage).Mobility: Patient had normal mobility denied any pain or joint weakness in x4 extremities; posture is normal with no deviations or
Directions and Grading Criteria 1. Use the this form to take notes while completing your physical examination as described in the “Weekly Lab Assignment Guidelines.pdf” found in Doc Sharing as well as the Faculty Assignment page in your course shell. 2. Record only objective data. Score is based on THOROUGHNESS and being CONCISE. 3. Avoid vague terms such as “good turgor” or “normal nodes”. For example, use “capillary refill less than 3 sec.” instead of “good capillary refill”. Use “Tympanic membranes intact, landmarks noted” instead of “normal TM”. 4. Complete each section of the document based on the current week’s lab practice. Each week you will turn in this same document with the additional sections completed. So you will basically pass this document back and forth adding to it each time. We will continue to use it in NR 304 culminating in a total Physical sample documentation 5. Each week it will be graded with the expectation that comments will be utilized for improvement the following week. ~ | Your Description | General Survey & Vital Signs Document the physical appearance, mental status, behavior, and mobility.Document blood pressure, pulse, respiratory rate, oxygen saturation, and temperature. | • Physical Appearance – Patient is a healthy 33 year old African American Male with dark brown eyes. Ht: 5’10Wt: 196 poundsColor: Even Skin Tone, Pt. lips are pink in color so dehydration is not present.pain level 0/10 on pain scale. No over the counter medications have been taken.Orientation: A&O x3 (time, place, and person), client denies any depression or anxiety; answers all questions appropriately when asked. Dress and Grooming: Patient was well groomed, and had appropriate footwear. Hair is short and neatly groomed. (Pt. stated no dryness and breakage).Mobility: Patient had normal mobility denied any pain or joint weakness in x4 extremities; posture is normal with no deviations or