Abdominal Assessment Write-Up
There is NO SOAP note for your abdominal exam video. You will complete a write-up of the abdominal assessment. What this means is you will describe what a normal abdominal assessment includes in a 1-2 page document. I should be able to read your directions and complete the exam as if I did not know how to do it myself prior to reading your instructions. This should include all Inspection, Auscultation, Percussion, Palpation, and Specialty tests of your exam. If fact, you can use these items as headings. Your rubric is a great guide for this! Think of it as describing how to do the exam and what you are looking for during the exam. Your specialty tests should include how you perform the assessment, what it is ruling in/out, and what would be normal/abnormal findings. The specialty test section is the only area you will describe abnormal findings.