The objective of the Documentation of Normal Findings Assignment is to demonstrate understanding of a comprehensive ROS and physical examination of the focus system.
Grading Category: SOAP Notes
The objective of the Documentation of Normal Findings Assignment is to demonstrate understanding of a comprehensive ROS and physical examination of the focus system. It is essential to understand and recognize what is normal in order to identify abnormal findings. Use the template as a guide.
Normal findings change over time. Assume each patient has presented to the clinic for a comprehensive wellness exam. Subjective and objective findings are NORMAL. Demonstrate that you know specific questions to ask to obtain a detailed subjective history for the focus system for a selected (pediatric, adult, OR geriatric) patient, and objective findings for a focused physical examination, including specialty maneuvers for a pediatric, adult, AND geriatric patient. Complete the following for each focus system:
Identify the focus system.
Subjective Findings – Identify the population (pediatric, adult, OR geriatric patient)
Enter data for a comprehensive ROS (Subjective History) for the focus system for the identified patient population. All reported information should be NORMAL.
Objective Findings – Determine the age of EACH patient within each category (pediatric, adult, and geriatric). For example, consider that the skin assessment of a newborn versus a teenager is very different.
Enter data for a comprehensive physical examination of the focus system for EACH patient. All data should represent NORMAL findings.
Note that objectives findings are needed for a pediatric, adult, and geriatric patient. See the Rubric.
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