Regional Write-up & Case Study “Gloria”
Purpose: To give students opportunity to use Critical thinking and Clinical Judgement and document their finding using the Reginal Write-up and the SOAP note format.
- Assess your lab partner and document findings (subjective and objective) using Regional Write-up list on pg.161 from Jarvis workbook.
- Read the Case Study “Gloria” and associated questions carefully.
- Answer 5 Case Study questions. This is to help you link theory to practice.
- Submit to Canvas for grading.
|Content||Points Possible||Earned Points|
|Regional Write up – Lungs and Thorax from page 161 in Jarvis workbook Data Complete (subjective and objective)Used correct terminology||10|
|Highlight relevant subjective information in yellow and objective information in green. All relevant information highlighted||4|
|Write out a symptom analysis for Gloria’s present illness. Choose one of the following mnemonics: PQRSTU, OLD CARTS or COLD SPA). Please label the mnemonic. Data CompleteAddressed all issuesLabeled mnemonic.||2|
|Are you missing any information? What further subjective questions would you want to ask Gloria? (Name at least 4 questions with rationales). Addressed main concernsIncluded correct number of questions and included rationales||4|
|Review the subjective and objective data and then cluster the patient data. What do you think is going on with Gloria and why? Includes all relevant subjective and objective informationUses clinical judgement||1|
|Write a SOAP note using Subjective and Objective information only to summarize the key health history and physical assessment findings. Data Complete / Included all relevant information (Subjective and Objective)Information clear, organized and documented in the correct system.||4|
|Total points possible||25|
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