NUR 607 Module 1 Discussion Example

Reviewed by Delia Ravenscroft, MSN, RN

This NUR 607 Module 1 Discussion sample opens the course with the distinction every later write-up depends on: what the patient reports versus what the examiner observes and measures. It answers the first discussion of SNHU NUR 607, Advanced Health Assessment, the MSN family nurse practitioner course listed in the catalog as NUR-607. Drawing on the writer's own charting as a medical-surgical nurse, the post takes three real kinds of errors and rewrites each one. A symptom lands in the examination section, an impression such as swollen stands in for a measurement and an electronic template records a normal cardiac exam that tells the next reader nothing. The post explains why each version fails another clinician, grounds the argument in Weed's case for records that guide reasoning and in the American College of Physicians position on documentation, then asks classmates about their own templates.

CourseNUR 607 Advanced Health Assessment
ModuleModule 1
Paper typeDiscussion post on documentation of subjective and objective data
LengthAbout 410 words, 3 pages
FormatAPA 7 student paper
SchoolSouthern New Hampshire University
ProgramMSN
UpdatedSeptember 2026

Free sample paper for NUR 607 Module 1

1

Module One Discussion

Three Lines I Used to Write, Rewritten

Looking back at notes I wrote as a medical-surgical nurse, I found the same problem again and again: I mixed what patients told me with what I found, and I described instead of measuring. Here are three lines I have written, why each one fails the next reader and how I would write it now.

First: under the examination I once wrote, patient has chest tightness when walking. That is a symptom, and it belongs in the history of present illness or the review of systems, with its onset, duration, character and what relieves it. The examination section should hold only what I observed or measured, such as heart rate, rhythm, heart sounds and any murmur. Putting a symptom there makes it look as if I confirmed something I only heard.

Second: legs swollen. Swollen is an impression. A reader cannot tell whether I mean mild puffiness at the ankles or pitting to the knees, or whether it is one leg or both. Now I would write: 2+ pitting edema of both lower legs to the mid-shin, symmetric, no calf tenderness, calf circumference 36 cm on each side. The second version lets another clinician judge change at the next visit.

What this page is doingThe post opens with a candid admission, then works through concrete examples, rewriting each one so the principle is shown rather than stated.
2

Third: cardiac exam normal. Many templates default to this, and it tells the reader almost nothing about what was actually examined. A better line records the findings: regular rate and rhythm at 76 beats per minute, S1 and S2 crisp, nothing added over the aortic, pulmonic, tricuspid or mitral areas with the patient sitting and then turned to the left, and an apex beat roughly the size of a quarter, just medial to the nipple line on the left. If I did not listen in a position or perform a maneuver, the note should not imply that I did.

Weed (1968) argued that the medical record should show the clinician's reasoning, so that another reader can follow and check it. More recently, the American College of Physicians warned that documentation written mainly for billing and filled with template text has made notes longer but less useful to clinicians (Kuhn et al., 2015). Standard texts make the same point: subjective data come from the patient, objective data from the examiner, and each belongs in its own place (Bickley et al., 2021).

Question for classmates: does your current electronic record default any examination to normal, and how do you make sure your note shows what you actually examined?

What this page is doingThe second part finishes the third example, then supports the argument with a classic source, a current professional position and a standard text before ending with a practical discussion question.
3

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.

Kuhn, T., Basch, P., Barr, M., & Yackel, T. (2015). Clinical documentation in the 21st century: Executive summary of a policy position paper from the American College of Physicians. Annals of Internal Medicine, 162(4), 301-303. https://doi.org/10.7326/M14-2128

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

What the NUR 607 Module 1 instructions ask for

The opening NUR 607 discussion usually asks you to reflect on the purpose of health assessment and documentation, often by explaining the difference between subjective and objective data, comparing comprehensive and focused assessments or describing how advanced practice assessment differs from registered nurse assessment. Some prompts ask you to analyze a sample note. First posts commonly run 300 to 500 words, cite two or more scholarly sources in APA 7 and are followed by replies. Use concrete examples from charting you have done or seen, because rewriting a real line shows the distinction far better than defining it, and it gives classmates something specific to respond to in their replies later in the week.

How this NUR 607 Module 1 discussion example is built

The post is written by a composite medical-surgical nurse entering the family nurse practitioner track who looks back at old notes. It rewrites three errors: a symptom, chest tightness when walking, placed in the examination section; an impression, legs swollen, replaced with graded pitting edema, its extent and calf measurements; and a template line, cardiac exam normal, replaced with the actual rate, rhythm, heart sounds and point of maximal impulse. It then connects the lesson to Weed's argument that records should show reasoning, to the American College of Physicians position on template-heavy notes and to a standard assessment text, and it ends by asking classmates how their records handle default normals.

Where the NUR 607 Module 1 rubric puts the points

Discussion rubrics in NUR 607 generally score understanding of assessment concepts, application to practice, support from scholarly sources, APA 7 citation and meaningful replies. Posts earn more when they demonstrate the concept, for example by rewriting an actual line of documentation, than when they only define it. Precise language, including measurements and graded findings, shows the documentation standard the course expects from the start. Replies score well when they add a different example, a source or a practical strategy, such as how to override a template default. Graders also expect professional tone and posting by the deadlines, which are usually part of the rubric.

NUR 607 Module 1 help: the mistakes that cost points

First assessment posts often lose points by defining subjective and objective data without showing them, by using the word normal as though it were a finding or by citing only a textbook. Take a few lines from real charting, identify what is wrong with each, rewrite it with measurements and correct placement and connect the lesson to a scholarly source. Ask classmates something about their own documentation practice. If your prompt asks about comprehensive versus focused assessments or about the role of the nurse practitioner in assessment, send it with the rubric, and we can build a first post around examples from your own clinical background and the setting you work in now.

Get NUR 607 Module 1 written to your instructions

Send the discussion prompt and a few examples of documentation from your own practice. A first post that rewrites real lines with measured findings and correct placement, supported by scholarly sources, will be ready in 24 to 48 hours, and the first is free. The paper above is an original model document written by our desk, not a submitted student paper and not an official Southern New Hampshire University document.

Request this module free All NUR 607 modules

More NUR 607 papers and related MSN samples

NUR 607 Module 1 questions, answered

Where can I find a free NUR 607 Module 1 Discussion sample?

The full post is on this page: three documentation errors rewritten to separate subjective reports from objective findings, supported by three APA 7 sources.

What is the difference between subjective and objective data?

Subjective data are what the patient or family reports, such as symptoms and history. Objective data are what the examiner observes or measures, such as vital signs, examination findings and test results.

Why is writing normal on an exam a problem?

Normal does not say what was examined or found. Recording specific findings, such as heart rate, rhythm and heart sounds, lets another clinician judge the exam and compare it at the next visit.

How should edema be documented?

Record the grade of pitting, the extent, whether it is one side or both, and relevant measurements such as calf circumference, along with pertinent negatives like the absence of calf tenderness.

Where do symptoms belong in a history and physical?

In the history of present illness or the review of systems, described by onset, location, duration, character, aggravating and relieving factors and associated symptoms, not in the examination section.