Nursing 3300 Health Assessment
Governors State University
Tips for Weekly Write Ups
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
Format for weekly Write Ups
Perform a focused assessment on a volunteer
OK to use a pt as long as they give
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
2nd- Objective Data – Your findings- Use
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 fashioned.
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
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
Stay away from descriptive words that can be
interpreted as judgmental such as “nice,
pretty, God fearing”.
Be sure to fully describe any abnormal
Measure anything that can be measured such
as “scars, edema or birthmarks”.
Be complete and comprehensive in your write
Don’t include interventions in the focused
Don’t use assessments taken from patient
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 yourself.
Put pt. comments in quotations.
Don’t narrate the assessment