Documentation is graded on precision, and most students write it like a story
Health assessment write-ups are graded on whether a colleague could reconstruct the patient's state from your note. That rewards specific, structured, defensible language, and penalizes the narrative style most people default to.
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Subjective is what they told you. Objective is what you measured
Patient appears anxious is an interpretation sitting in the objective section. Patient reports feeling anxious is subjective. Respiratory rate 24, hands trembling, speaking in short sentences is objective. The distinction sounds academic until you realize documentation is a legal record, and it is where a large share of assessment points go.
The second recurring issue is vagueness. Normal, unremarkable and within normal limits are acceptable in some programs for some systems and unacceptable in others, and students often use them to cover systems they did not actually assess. Graders can usually tell.
The third is the assessment and plan sections of a SOAP note, which students frequently treat as a summary. The A is your clinical reasoning about what the S and O mean, and the P is what follows. Restating the findings there loses the points that section exists for.
- Subjective and objective kept properly separate
- Findings documented specifically enough to be reconstructed
- Assessment sections that reason rather than summarize
- Terminology used precisely, in the format your program wants
What we work on
Your own write-ups, with patient identifiers removed
- SOAP note structure, with the reasoning in the right section
- Head-to-toe documentation, system by system
- Describing abnormal findings in precise clinical language
- OLDCARTS, PQRST and other symptom analysis frameworks
- What counts as a defensible note if it were ever reviewed
Your patient, your assessment, your note
- We do not write your SOAP notes or assessment write-ups.
- We do not invent findings, vital signs or patient responses.
- We do not supply completed documentation to adapt.
- We do not complete anything you will submit or file clinically.
- We teach the format, review your draft, and explain where points went.
Never send us documentation containing identifiable patient information. Remove names, dates of birth, record numbers, dates of service and anything else identifying first. This matters more here than on any other nursing assignment. Read the full policy.
Frequently Asked Questions
Subjective is what the patient tells you, ideally in their words. Objective is what you observe or measure. The most common error is putting an interpretation in the objective section: patient appears uncomfortable is an inference, while patient grimacing, guarding right upper quadrant is an observation.
Subjective, what they reported. Objective, what you found. Assessment, your clinical reasoning about what that means. Plan, what happens next. The A is the section that carries the most points and gets written as a summary most often.
It depends on your program, and some explicitly prohibit it for systems in the focus area of the assessment. Where it is allowed it should only cover systems you genuinely assessed. Using it to cover systems you skipped is the version graders look for.
Detailed enough that another clinician could picture the patient. Your program's template sets the expected scope, and the usual failure is uneven depth, with three paragraphs on the system of interest and one line on everything else.
A framework for analyzing a symptom: onset, location, duration, character, aggravating factors, relieving factors, timing and severity. It gives structure to the subjective section and helps make sure you have not missed a dimension of the complaint. PQRST is an alternative covering similar ground.
Send the write-up, with identifiers removed
We will tell you where interpretation has crept into the objective section, where the documentation is too vague, and what the assessment section should be doing.
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