Documentation of problem based assessment of the neurological system.
Purpose of Assignment:
Learning the required components of documenting a problem based subjective and objective assessment of neurological system. Identify abnormal findings.
Apply assessment techniques for the neurological and respiratory systems.
Content: Use of three sections:
· Actual or potential risk factors for the client based on the assessment findings with description or reason for selection of them.
· Standard American English (correct grammar, punctuation, etc.)
Chapter 5: SOAP Notes: The subjective and objective portion only
Sullivan, D. D. (2012). Guide to clinical documentation. [E-Book]. Retrieved from