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. Dont use Appears or Seems in your write ups. They make you look uncertain of your findings and are old fashioned. Dont use normal or WNL. Fully describe your findings even if they are normal. 5. Tips Dont use descriptive words that can mean different things to different examiners like good, average or moderate. Give precise information. Dont 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. Dont include interventions in the focused write up. Dont use assessments taken from patient charts. You dont 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. Dont use I to refer to yourself. Put pt. comments in quotations. Dont narrate the assessment