This document provides tips for weekly write-ups for a Nursing 3300 Health Assessment course. It outlines that weekly assignments will include a complete health history in week 1 and focused write-ups in subsequent weeks, with each focusing on 1-2 body systems. The focused write-ups should include 2 paragraphs, one for subjective data from the patient and one for objective assessment findings. Examples are provided in the textbook. Tips are given on formatting, word choice, level of detail, and style to ensure write-ups are clear, precise, and follow best practices for documentation.

1. Nursing 3300 Health Assessment
Governors State University
Tips for Weekly Write Ups

2. Weekly assignments
 Week 1- a complete health history
 Week 2 to 7
 Focused write ups- 2 paragraphs
 Subjective and Objective (S and O from a SOAP note)
 Most weeks have more than one body system
 A separate write up is required for each body system
 Sample write ups appear in your textbook
 Subjective information = questions to assess
symptoms in text
 Objective information = complete assessment in
text

3. Format for weekly Write Ups
 Perform a focused assessment on a volunteer
 OK to use a pt as long as they give
permission
 Write up your assessment and submit by
midnight on Sunday at midnight of the week.
 Format = 2 paragraphs
 1st – subjective data – what the pt tells you.
Use your textbook – “questions to assess
symptoms”
 2nd- Objective Data – Your findings- Use
your textbook
 Samples are in your text book

4. Tips
 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 “class resources”.
 Don’t use “Appears or Seems” in your write
ups. They make you look uncertain of your
findings and are old fashioned.
 Don’t use “normal or WNL”. Fully describe
your findings even if they are normal.

5. Tips
 Don’t use descriptive words that can mean
different things to different examiners like
“good, average or moderate”. Give precise
information.
 Don’t use lay terms like “ear drum, belly
button or arm pit”
 Be careful of words that sound similar. Ie
“Ancillary and axillary or palpable and
palatable”.
 Stay away from descriptive words that can be
interpreted as judgmental such as “nice,
pretty, God fearing”.
 Be sure to fully describe any abnormal

6. Tips
 Measure anything that can be measured such
as “scars, edema or birthmarks”.
 Be complete and comprehensive in your write
up.
 Don’t include interventions in the focused
write up.
 Don’t use assessments taken from patient
charts.
 You don’t 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

7. Tips
 Stay in third person in write ups. Don’t use “I”
to refer to yourself.
 Put pt. comments in quotations.
 Don’t narrate the assessment