- Physical Assessment Section
- Do not leave anything blank, put not available (N/A), within normal limits (WNL), or “Unable to assess due to…..”
- Psychosocial Assessment Section
- For Erikson’s stages of development, use the client’s age to determine what stage they are in. If a previous stage has not been successfully passed, add a description of this stage as well. For example, “Although the client is currently in the generativity vs. stagnation stage, he has not completed the intimacy vs. isolation stage as evidenced by ….
- Write complete sentences in the section.
- Pathophysiological section
- Refer to resources in the course shell for APA help. Use a database for the article, do not use Google. Databases will give you a scholarly article, and Google will send you elsewhere.
- Do not forget to list references and use at least one in-text citation.
- You may use your textbook as a secondary reference; however, one outside source (scholarly article) is required. Webpages such as WebMD are not considered scholarly articles. A scholarly article is peer-reviewed and published in a journal.
- Nursing Process Section
- Use critical thinking skills to determine the priorities for the client. Safety is usually at the top of the list, but not always.
- Use quotes for the “subjective data” if possible.
- For SMART outcomes
- The timely component is often missed. Make sure there is a measurement of time included such as: “By time of discharge, Q shift, Q HS, Q AM, etc.…”
- Make interventions timely as well: “for 10 minutes Q shift, By discharge, etc.…”
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