1. Tips for Weekly Write Ups
Nursing 3300 Health Assessment
Governors State University
2. Weekly assignments
ï Week 1- a complete health history
ï Week 2 to 7
ï Focused write ups- 2 paragraphs
ï Subjective and Objective (S and O from a SOAP note)
ï Most weeks have more than one body system
ï A separate write up is required for each body system
ï Sample write ups appear in your textbook
ï Subjective information = questions to assess symptoms in text
ï Objective information = complete assessment in text
3. Format for weekly Write Ups
ï Perform a focused assessment on a volunteer
ï OK to use a pt as long as they give permission
ï Write up your assessment and submit by midnight on
Sunday at midnight of the week.
ï Format = 2 paragraphs
ï 1st â subjective data â what the pt tells you. Use your
textbook â âquestions to assess symptomsâ
ï 2nd- Objective Data âYour findings- Use your
textbook
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Samples are in your text book
4. Tips
ï Be sure to follow the correct format. Only include the
subjective information you would gather from the review
of systems in the history and the objective data gathered
from the physical assessment. See the examples posted
under âclass resourcesâ.
ï Donât use âAppears or Seemsâ in your write ups. They
make you look uncertain of your findings and are old
fashioned.
ï Donât use ânormal or WNLâ. Fully describe your findings
even if they are normal.
5. Tips
ï Donât use descriptive words that can mean different
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things to different examiners like âgood, average or
moderateâ. Give precise information.
Donât use lay terms like âear drum, belly button or arm
pitâ
Be careful of words that sound similar. Ie âAncillary and
axillary or palpable and palatableâ.
Stay away from descriptive words that can be interpreted
as judgmental such as ânice, pretty, God fearingâ.
Be sure to fully describe any abnormal findings.
6. Tips
ï Measure anything that can be measured such as âscars,
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edema or birthmarksâ.
Be complete and comprehensive in your write up.
Donât include interventions in the focused write up.
Donât use assessments taken from patient charts.
You donât have to write in full sentences but make sure
your write up is easy to read by using formatting such as
separate paragraphs, underlining, bolding or bullet
points.
7. Tips
ï Stay in third person in write ups. Donât use âIâ to refer to
yourself.
ï Put pt. comments in quotations.
ï Donât narrate the assessment