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Tips for weekly write ups. Nurs 330- Spring 2011
1. Tips for Weekly Write Ups
Nursing 3300 Health Assessment
Governors State University
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