*This guide for writing nursing clinical
write-ups was written by Bethany Babovec, a
former Writing Center Consultant, in fulfillment of an assignment
for Topics in Composition, the Writing Center staff development
Further instructions on assignment: The expected method for gathering data for the paper includes providing appropriate patient care through holism (addressing the entire patient), balancing subjective and objective data, and organizing the paper according to the Nursing department model and based on NANDA standards. The purpose of this assignment is to gain a greater knowledge of patient care and practice documentation. Past student have acknowledged that the skills learned while writing these papers are recycled again and again in later courses. Any questions that are not answered in the syllabus or on this webpage may be asked during lecture or during an appointment with the clinical instructor. Changes throughout the semester will be announced during lecture or written on individual papers.
Other additional materials: Is it expected that each student will use their copy of The Health and Physical Assessment book and their NANDA Nursing Diagnosis book in addition to the HAT (Health Assessment Tool) provided in the syllabus. Mosby's Medical Dictionary and many other medical textbooks are available in the library. These additional books should be used to clarify and eliminate errors in documentation.
Guidelines for grading: This is a Pass/Fail course. Grading is based on the student's knowledge shown through correct usage of the HAT. Organization of the paper is also important. It is expected that each week the write-up will become more specific and a better example of nursing documentation. Grading will affect this gradual improvement. Clarity will be explained during lecture and in individual side-notes from the instructor. An evaluation of clinical ability, teaching, and writing will be done at mid-term and at the end of the year.
Common issues: Styles: The data gained from interviews should be in a list format. Stressor development paragraphs should be in a narrative style. The NANDA (high priority and assessment) diagnosis should be exacting and specific following the Nurses Association guidelines. Students are expected to use proper medical terms (learned in lecture and reading), grammar, and spelling.
The most common concerns with student's writing involve:
The intended audience for the writing: The papers
should be appropriate for reading by all other health care
providers and nursing instructors.
Useful suggestions from other sources:
This web site created and maintained by the Coe Writing Center. Copyright 2001.
E-mail Dr. Bob Marrs with any questions, comments or suggestions.