| Course | NUR-5160 Advanced Health Assessment |
|---|---|
| Module | Module 1 |
| Paper type | Comprehensive history and physical write-up |
| Length | About 1,078 words, 6 pages |
| Format | APA 7 student paper |
| School | Thomas Edison State University |
| Program | Master of Science in Nursing |
| Updated | October 2026 |
Free sample paper for NUR 5160 Module 1
A Baseline Comprehensive Write-Up for a Well Adult Establishing Care, and the Documentation Conventions Behind Each Section
Student Name
Master of Science in Nursing (MSN), Thomas Edison State University
NUR-5160: Advanced Health Assessment
Mentor Name
Month Day, Year
A Baseline Comprehensive Write-Up for a Well Adult Establishing Care, and the Documentation Conventions Behind Each Section
Advanced health assessment begins by resetting habits. Registered nurses document constantly, but the comprehensive history and physical expected of an advanced practice nurse follows conventions that differ from bedside charting: subjective and objective data are kept apart, normal findings are recorded as specific observations rather than summary labels, and every abnormal finding leads somewhere in the assessment and plan. This paper presents a baseline comprehensive write-up for a composite well adult establishing primary care, followed by a section explaining the convention behind each part. The patient is a thirty-six-year-old ballet teacher; all identifying details are invented.
Subjective Data
Identifying data and source: thirty-six-year-old ballet teacher and studio owner, self-referred to establish care; patient is the source and appears reliable. Chief concern, in the patient's words: I need a regular doctor and I want my heart checked because my aunt died young. History of present concern: no current symptoms. The patient requests cardiovascular risk evaluation because a maternal aunt died suddenly at forty-one of what the family was told was an enlarged heart. The patient denies chest pain, palpitations, syncope or near-syncope, exertional dyspnea, orthopnea or edema, and teaches four hours of class daily without limitation.
Past history: no chronic illness; stress fracture of the left second metatarsal at twenty-two treated with a boot; no surgeries; no hospitalizations. Medications: ibuprofen 400 milligrams about twice a month for muscle soreness; a daily vitamin D supplement of 1,000 international units. Allergies: no known drug allergies. Immunizations: childhood series reported complete; last tetanus-diphtheria-pertussis booster unknown; influenza vaccine last season. Gynecologic and reproductive history: menarche at fifteen, regular cycles every thirty days, last menstrual period two weeks ago, no pregnancies, uses a levonorgestrel intrauterine device placed three years ago, last cervical screening four years ago reported normal. Family history: mother sixty-four with hypothyroidism; father sixty-seven with hypertension and hyperlipidemia; maternal aunt died at forty-one, cause reported as enlarged heart; one brother thirty-nine, well; no known family history of sudden unexplained death in others, inherited arrhythmia or early coronary disease.
Personal and social history: lives alone, owns a dance studio, teaches children and adults. Never smoker; alcohol two glasses of wine weekly; no other substances. Diet described as high protein with deliberate limits on carbohydrates during performance season. Sleep seven hours. Review of systems: negative in all systems except occasional ankle and foot soreness after long teaching days and intermittent lower back tightness, both relieved by stretching. Specifically denies amenorrhea, weight change, dizziness, heat or cold intolerance, bowel change and mood change.
Objective Data
Vital signs: height 165 centimeters, weight 55 kilograms, body mass index 20.2; blood pressure 108 over 68 millimeters of mercury on the right and 110 over 70 on the left, measured seated with a correctly sized cuff once the patient had rested five minutes; heart rate 56 and regular; respiratory rate 12; oral temperature 36.6 degrees Celsius; pulse oximetry 99 percent breathing room air. General: well-appearing, lean, muscular adult in no distress. Skin: warm, dry, intact; no suspicious nevi; calluses on the dorsal toes. Head, eyes, ears, nose and throat: normocephalic; pupils round, equal and briskly reactive; optic discs sharply outlined on ophthalmoscopy; tympanic membranes intact; oropharynx clear. Neck: supple, thyroid not enlarged, no lymphadenopathy, carotid upstrokes brisk without bruits.
Cardiovascular: apical impulse small and nondisplaced in the fifth interspace at the midclavicular line; regular rate and rhythm; normal S1 and physiologically split S2; no murmur at rest, with no change on standing or with the Valsalva maneuver; no rubs or gallops; pulses two plus and equal from the radial arteries down to both feet. Respiratory: clear to auscultation bilaterally, no adventitious sounds. Abdomen: flat, soft, nontender, no organomegaly. Musculoskeletal: every joint moves through its expected range, with generalized hypermobility at the elbows and knees without instability; mild tenderness at the left second metatarsal head. Neurological: oriented to person, place and time; cranial nerve testing normal throughout; full strength in all four limbs; symmetric two plus reflexes at the biceps, knees and ankles. Breast and pelvic examinations were deferred at the patient's request to a separate visit for cervical screening.
Assessment and Plan
Assessment: healthy thirty-six-year-old adult establishing care. One, family history of sudden death in a second-degree relative at forty-one with a reported enlarged heart, raising the possibility of an inherited cardiomyopathy; normal cardiovascular examination including no dynamic murmur; resting bradycardia consistent with athletic conditioning. Two, health maintenance: cervical screening due; tetanus-diphtheria-pertussis booster status unknown. Three, history of metatarsal stress fracture with current forefoot tenderness and a restrictive diet in performance season, which together warrant screening for low energy availability.
Plan: obtain a resting twelve-lead electrocardiogram today and discuss referral for transthoracic echocardiography, given that a normal examination does not exclude hypertrophic cardiomyopathy; ask the patient to obtain the aunt's records or autopsy findings if available. Schedule cervical screening and offer a tetanus-diphtheria-pertussis booster today. Explore dietary intake and menstrual history in more depth at the next visit using a validated screening tool for low energy availability in dancers, and offer referral to a sports dietitian. Return in four weeks to review results.
The Conventions Behind the Write-Up
Each section follows a convention with a purpose. Separating subjective from objective data dates to the problem-oriented record proposed by Weed (1968), who argued that a record should be built around the patient's problems and should expose the thinking behind each decision, so that a colleague can trace and question it. Recording the chief concern in the patient's words preserves the reason for the visit even when it differs from the clinician's priorities. Writing pertinent negatives tells the reader which dangerous possibilities were considered. Bickley et al. (2021) emphasize describing normal findings specifically, because a later clinician comparing a new finding with a vague baseline cannot tell whether anything has changed.
Measurement conventions matter as much as narrative ones. The blood pressure is recorded with arm, position, rest period and cuff size because each affects the reading, as the national measurement statement describes (Muntner et al., 2019). Finally, the assessment lists problems in order of importance and numbers them so that each plan item can be traced to its problem. A reader who sees an echocardiogram in the plan should be able to find the reason in the assessment and the evidence for it in the history. That traceability, more than completeness, is what distinguishes an advanced practice write-up from a nursing admission note.
References
Bickley, L. S., Szilagyi, P. G., Hoffman, R. M., & Soriano, R. P. (2021). Bates' guide to physical examination and history taking (13th ed.). Wolters Kluwer.
Muntner, P., Shimbo, D., Carey, R. M., Charleston, J. B., Gaillard, T., Misra, S., Myers, M. G., Ogedegbe, G., Schwartz, J. E., Townsend, R. R., Urbina, E. M., Viera, A. J., White, W. B., & Wright, J. T., Jr. (2019). Measurement of blood pressure in humans: A scientific statement from the American Heart Association. Hypertension, 73(5), e35-e66. https://doi.org/10.1161/HYP.0000000000000087
Weed, L. L. (1968). Medical records that guide and teach. New England Journal of Medicine, 278(11), 593-600. https://doi.org/10.1056/NEJM196803142781105
Reading the NUR 5160 Module 1 assignment instructions
The first module of NUR-5160 usually resets examination and documentation standards for graduate practice. Directions in many sections ask you to complete and document a comprehensive history and physical on a volunteer or standardized case, using the course's write-up format, and to explain or reflect on documentation conventions such as the separation of subjective and objective data, pertinent negatives and problem-oriented assessment. Some sections require a specific template or electronic platform. The TESU classroom carries the exact requirements; check whether a well-adult encounter is expected, whether certain examinations may be deferred, and whether your mentor wants references for the conventions you describe. Graduate mentors also expect measurement conditions for vital signs to be recorded.
How the NUR 5160 Module 1 example is put together
The sample is built in two parts. The first is the write-up itself, opening with who the patient is and who supplied the history, then the concern as the patient phrased it, a history of present concern with pertinent negatives tied to the family history, past history, medications, allergies, immunizations, reproductive history, family and social history and a focused review of systems, followed by vital signs and a full examination with specific normal findings and dynamic auscultation. A numbered assessment and plan close it. The second part explains the conventions behind each section, citing the problem-oriented record, the course text on describing normal findings and the national blood pressure measurement statement. The two parts can be read separately, but the explanation refers back to specific lines of the write-up.
Where the marks sit in the NUR 5160 Module 1 rubric
A baseline write-up is judged mainly on how complete the history and examination are, accurate use of documentation conventions, specificity of normal and abnormal findings, a logical assessment and plan, and professional writing. At the graduate level, mentors look for targeted precision: pertinent negatives related to the concern, a family history detailed enough to support risk assessment, and an examination visibly shaped by the history. Documentation using labels such as normal or WNL usually loses points. The assessment should number problems and the plan should trace to them. Where an explanatory section is required, it earns credit when conventions are justified with sources rather than asserted. Clear separation of the history from the examination is checked closely in the first module.
Common NUR 5160 Module 1 mistakes, and how to avoid them
Graduate write-ups often fall short in three places. Normal findings are summarized instead of described, so a later clinician cannot compare. The history of present illness for a well visit is left blank when the patient has a specific concern that deserves pertinent negatives. And the plan includes items with no matching problem in the assessment. Read your write-up from the plan backward and make sure every step has a reason above it. Keep subjective and objective data separate, and record measurement conditions for vital signs. Defer sensitive examinations appropriately and document the deferral. A write-up built from your own encounter notes can be prepared at the desk on request. Ask a classmate to read your plan and find its reason in the assessment.
Write yours, or have the desk draft it
This paper is an original model document written by our desk, not a submitted student paper and not an official Thomas Edison State University document. Read it for the moves, then write your own to the instructions in your classroom. If you want one built to your exact prompt and rubric, the first custom sample is free and arrives in 24 to 48 hours.
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NUR 5160 Module 1 questions, answered
Where can I find a free NUR 5160 Module 1 sample paper?
Yes: the whole write-up, title page to references, sits on this page, annotated sheet by sheet. The patient is an invented ballet teacher; your own volunteer's findings go into the same frame.
Is WNL acceptable in a NUR-5160 write-up?
Most graduate mentors do not accept it. Describe what you examined and what you found, such as sharp disc margins or a nondisplaced point of maximal impulse, so the baseline can be compared later.
What are pertinent negatives?
The things that are not there but would change the picture, for instance a teenager with a family history of sudden cardiac death who has never fainted or become short of breath on exertion. They show which serious possibilities you considered.
Can I defer parts of the examination?
Yes, when appropriate, such as sensitive examinations at the patient's request or when they are scheduled for another visit. Document the deferral and the reason, and include the plan to complete it.
Why separate subjective and objective data?
Separating what the patient reports from what the clinician observes makes reasoning transparent and lets another clinician weigh each kind of evidence. The convention comes from the problem-oriented record and remains standard in advanced practice documentation.