Help

[leeniebeanie_2767]

I am a student practical nurse and I am having trouble writing a proper assessment/nurses note. Can you please tell me the right way to write this? I know that it has to look like a paragraph with no spaces, but I believe I am adding too much information. I would appreciate any tips. Thank you. -Aileen

[PurrRN]

Why don't you give us an example of what you have been writing, and lets go from there? Tips would be more forthcoming if the nurses could see what you have or have not been putting in your assessments. Good Luck

[Melody1968]

Why don't you give us an example of what you have been writing, and lets go from there? Tips would be more forthcoming if the nurses could see what you have or have not been putting in your assessments. Good Luck

Great idea!!! :)

[Daytonite, BSN, RN]

leeniebeanie_2767. . .

here is a site where you can view samples of how history & physical exam assessment data should be written up. now, mind you this is from a medical school. however, when i took my physical assessment course for my bsn, we had to do our write-ups exactly as the doctors did them. we had to use the same kind of language. hope you find the site helpful.

http://medicine.ucsd.edu/clinicalmed/introduction.htm - a very nice site to help with doing physical assessments of patients from the university of california, san diego. explains how to examine the various parts of the body and has lots of photographs showing abnormal conditions and how to assess for them. there are two examples of how to write up your h&p findings on the site as well. click on the link that says "write-up" in the top section of the links.