Tips for Weekly Write Ups
Nursing 3300 Health Assessment
Governors State University
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
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
Samples are in your text book
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
Don’t use “normal or WNL”. Fully describe your findings
even if they are normal.
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
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 findings.
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
Stay in third person in write ups. Don’t use “I” to refer to
Put pt. comments in quotations.
Don’t narrate the assessment