This document provides guidance on writing informal reports, including their typical parts and format. It discusses the three main parts of any report: introduction, discussion sections, and conclusion. The introduction includes a statement of the problem or situation, the task assigned, and the report's purpose and scope. Discussion sections may include headings, lists, and visuals to break up the text. The conclusion should remind readers of any needed actions and provide contact information. The document also provides an example client report assignment, asking students to document a subjective assessment, objective findings, and actual or potential risk factors for the client.

1. Writing Informal Reports
Format
Memo header
To: (name and title of target audience)
From: (name and title of writer: remember to sign or initial if it
isn’t an electronic submission)
Date:
RE:
CC: (distribution list when necessary)
Introduction [No heading necessary]
Discussion sections [Use headings provided in the outline
attachment of the syllabus]
Conclusion [Reflection is the content]
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Parts of an informal report
Reports are written for many different reasons and use two
basic formats. One is the long or formal
report and the short or informal report. But EVERY report, like
every letter, essay, or article has 3
main parts: Introduction, Discussion sections, Conclusion.
These reports follow the same format as the
memo but are longer and more comprehensive. Because they are
longer than one or two pages, reports
also include such formatting elements as headings, bulleted or

2. numbered lists, and graphs and charts
or tables.
Introduction
The introductory section includes 3 parts:
1. a statement of the problem or situation,
2. the task assigned to the writer and the scope of the project.
3. purpose of the report and forecasts for the reader the topics
of the report.
(PLEASE REFER TO OUTLINE SECTION I.
INTRODUCTION)
Finally, when appropriate, the introduction ends with the
conclusion or recommendation reached by
the writer.
Discussion Sections
Another aspect of report writing that is somewhat different from
other business communications is the
reading patterns of various audiences. Remember that most
memos and reports have a target
audience, but a number of secondary audiences who must be
accommodated. Some of the readers will
skim the report. In other words, the report, particularly the
discussion sections, may not be read in a
linear way—from the first word progressing to the last.
Therefore, the writer must be certain the
report is comprehensible when read in that manner. Each section
must work together as part of the
whole report, but a reader should be able to read one section
and understand the context.
Anytime you use a list, or graphic or visual representation, you

3. should introduce that list or visual and
explain its purpose to the audience.
(PLEASE REFER TO OUTLINE SECTIONS II-VI)
Conclusion
Finally, the conclusion of a report, depending on its purpose,
should remind the reader of any action
needed, ask for a response, or indicate a willingness to answer
questions. This section may also provide
contact information for future communications. The Internship
Experience Report conclusion should
contain a final reflection of your internship experience.
(PLEASE REFER TO OUTLINE SECTION VII. REFLECTION)
Caution: Please note that the format of business and
professional reports includes short paragraphs of
text. So, do not use a heading as a paragraph marker. In other
words, a heading may be followed by
several paragraphs.
Clients Presentation:
Subjective Data (4 points):

4. Objective Data (4 points):
Describe 2 Actual/Potential Risk Factors (2 points):
Title:
Documentation of problem-based assessment of the
musculoskeletal system.
Purpose of Assignment:
Learning the required components of documenting a problem
based subjective and objective assessment of musculoskeletal
system. Identify abnormal findings.
Course Competency:
Demonstrate physical examination skills of the skin, hair, nails,
and musculoskeletal system.
Instructions:
You will perform a history of a musculoskeletal problem that
your instructor has provided you or one that you have
experienced and perform an assessment of the musculoskeletal

5. system. You will document your subjective and objective
findings, identify actual or potential risks, and submit this in a
Word document to the drop box provided. Your subjective
portion of the documentation should briefly describe your
“client”. In terms of your objective findings, remember to only
record what you have assessed. Do not make a diagnosis or state
the cause of a finding. You are not coming to any conclusions
within your documentation. Your client information is noted
below.
Client Name: Mackenzie Carlson
DOB: 10-10-1986
This client is a 37-year-old white female complaining of a
painful, swollen ankle. States that she stepped ‘funny’ off a step
two days ago and thinks she heard a ripping sound. She takes no
medications and has no allergies. The client reports pain as 5/10
with sharp twinges when trying to walk, a notable limp is noted
when the client walks favoring the affected extremity. She
states resting and ice decreases pain to 2/10 aching. Pain is
primarily in the outer aspect of ankle and foot. Has no prior
injury to this area. No significant past medical history. When
you examine the ankle the outer aspect of the malleolus is
swollen and reddened with 2+ edema noted to the area, pedal
pulses are palpable and strong.
You will submit this documentation as a Word document to the
drop box provided.
Content: Use of three sections:
· Subjective
· Objective
· Actual or potential risk factors for the client based on the
assessment findings

6. Format:
· Standard American English (correct grammar, punctuation,
etc.)
http://extmedia.kaplan.edu/nursing/preBSN/Global/APA_Progre
ssionLadder_prelicensureBSN.pdf
Resources:
Chapter 5: SOAP Notes: The subjective and objective portion
only
Sullivan, D. D. (2012).
Guide to clinical documentation. [E-Book]. Retrieved
from
http://ezproxy.rasmussen.edu/login?url=http://search.ebscohost.
com/login.aspx?direct=true&db=nlebk&AN=495456&site=eds-
live&ebv=EB&ppid=pp_91
Smith, L. S. (2001, September). Documentation do’s and don’ts.
Nursing, 31(9), 30. Retrieved from
http://ezproxy.rasmussen.edu/login?url=http://search.ebscohost.
com/login.aspx?direct=true&db=rzh&AN=107055742&site=eds-
live
Documentation Grading Rubric- 10 possible points
Levels of Achievement
Criteria
Emerging
Competence
Proficiency
Mastery
Subjective
(4 Pts)
Missing components such as biographic data, medications, or
allergies. Symptoms analysis is incomplete. May contain
objective data.

7. Basic biographic data provided. Medications and allergies
included. Symptoms analysis incomplete. Lacking detail. No
objective data.
Basic biographic data provided. Included list of medications and
allergies. Symptoms analysis: PQRSTU completed. Lacking
detail. No objective data. Information is solely what “client”
provided.
Basic biographic data provided. Included list of medications and
allergies. Symptoms analysis: PQRSTU completed. Detailed. No
objective data. Information is solely what “client” provided.
Points: 0.5
Points: 1
Points: 2
Points: 4
Objective
(4 Pts)
Missing components of assessment for particular system. May
contain subjective data. May have signs of bias or explanation
of findings. May have included words such as “normal”,
“appropriate”,
“okay”, and “good”.
Includes all components of assessment for particular system.
Lacks detail. Uses words such as “normal”, “appropriate”, or
“good”. Contains all objective information. May have signs of
bias or explanation of findings.
Includes all components of assessment for particular system.
Avoided use of words such as “normal”, “appropriate”, or
“good”. No bias or explanation for findings evident Contains
all objective information
Includes all components of assessment for particular system.
Detailed information provided. Avoided use of words such as
“normal”, “appropriate”, or “good”. No bias or explanation for
findings evident. All objective information

8. Points: 1
Points: 2
Points: 3
Points: 4
Actual or Potential Risk Factors
(2 pts)
Lists one to two actual or potential risk factors for the client
based on the assessment findings with no description or reason
for selection of them.
Failure to provide any potential or actual risk
factors will result in zero points for this criteria.
Brief description of one or two actual or potential risk factors
for the client based on assessment findings.
Limited description of two actual or potential risk factors for
the client based on the assessment findings.
Comprehensive, detailed description of two actual or potential
risk factors for the client based on the assessment findings.
Points: 0.5
Points: 1
Points: 1.5
Points: 2