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Tips for weekly write ups. Nurs 330- Spring 2011


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Tips for weekly write ups. Nurs 330- Spring 2011

  1. 1. Tips for Weekly Write Ups Nursing 3300 Health Assessment Governors State University
  2. 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. 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. 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. 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. 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. 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