NSG 121 Unit 6 documentation practice set example

Six Observations Turned Into Documentation: Location From a Landmark, Size in Millimeters, Character in the Text's Terms, and No Causes Named

Student Name

Department of Nursing, Herzing University

NSG 121: Health Assessment

Instructor Name

February 19, 2026

Six Observations Turned Into Documentation: Location From a Landmark, Size in Millimeters, Character in the Text's Terms, and No Causes Named

How Each Entry Works

Each entry opens with the observation in one plain line, as it might be said aloud at the bedside, and then converts it into documentation: location measured from a landmark, size in millimeters or centimeters using a ruler, and character in the descriptive vocabulary of the course text and the international dermatology glossary (Jarvis, 2020; Nast et al., 2016). Pertinent negatives are included where they matter. No entry names a cause. All observations come from composite adults seen in the skills lab and clinic.

Measurement was done with a flexible paper ruler laid flat on the skin, reading the longest dimension first and the dimension at right angles to it second. Where a lesion was too small to measure reliably, the smallest unit that could be read, 1 mm, was used as the limit and stated. Colors are described by name rather than by comparison with objects, and a glass slide pressed on the skin was used to test whether redness blanches.

Entry 1

Observation: "There's a brown bump on his upper back."

Documentation: Single raised lesion on the posterior trunk, 6 cm below the vertebra prominens and 4 cm to the left of the spinous processes. Papule, 7 mm by 5 mm, oval. Uniform medium brown. Border regular and sharp. Surface rough and slightly waxy, appearing stuck onto the skin. No bleeding, crusting, or ulceration. Not tender. Patient reports it has been present "for years" without change.

Entry 2

Observation: "A little red dot on her stomach."

Documentation: Single lesion on the anterior abdomen, 5 cm above and 3 cm to the right of the umbilicus. Dome-shaped papule, 3 mm in diameter. Bright cherry red, uniform. Border smooth and regular. Blanches partly with pressure from a glass slide. No scale, no surrounding redness, not tender.

Entry 3

Observation: "He scraped his arm on a shelf."

Documentation: Area of superficial skin loss on the dorsal right forearm, beginning 8 cm distal to the olecranon and running toward the wrist, 4.0 cm long by 1.5 cm wide at the widest point. Wound bed pink and moist, with scattered pinpoint dark red dots. Edges irregular. Thin yellow-brown crust along the upper third. Skin around the area slightly pink for 3 mm beyond the edge; no swelling; not warm compared with the other forearm. No drainage on the dressing removed. Patient reports it occurred two days ago.

Entry 4

Observation: "She has a scar from her gallbladder surgery."

Documentation: Four healed linear marks on the abdomen: one 1.5 cm long at the lower edge of the umbilicus; one 1.0 cm long in the midline 10 cm above the umbilicus; two 0.8 cm long below the right costal margin, 4 and 9 cm lateral to the midline. All flat, pale, and level with the surrounding skin, without redness, raised tissue, or tenderness.

Entry 5

Observation: "I can feel a lump in his neck."

Documentation: Single palpable node on the left side of the neck, anterior to the sternocleidomastoid muscle, 3 cm below the angle of the mandible. 12 mm by 8 mm, oval. Soft to rubbery, smooth. Moves freely under the fingers, not fixed to skin or deeper tissue. Mildly tender. Skin over it normal in color and temperature. No other nodes palpable in the neck, above the clavicles, or under the arms.

Entry 6

Observation: "A dark mole on her leg."

Documentation: Single flat lesion on the posterior left calf, 12 cm below the popliteal crease and 2 cm medial to the midline. Macule, 8 mm by 6 mm, irregular in outline. Two shades, dark brown and black, with the darker area on the lower edge. Border notched on the medial side and less distinct on the lower edge. Surface smooth, not raised. No bleeding or crusting. Patient does not know how long it has been there.

Two Similar-Looking Observations, Documented Differently

Entries 1 and 6 might both be called "a brown mole" in conversation, and a student could be tempted to document them the same way. The documentation separates them. Entry 1 is raised, one uniform color, sharply and regularly bordered, with a rough, stuck-on surface, and has been stable for years. Entry 6 is flat, contains two colors, has a notched and partly indistinct border, is larger in one direction, and has no known history. Nothing in either entry names what the lesion is, but a reader of the record can see that the second has features the first does not, and that it should be looked at by a clinician. Writing "brown mole, left calf" would have removed every one of those details.

The descriptive terms used here, papule, macule, border, and surface, come from the course text (Jarvis, 2020) and the international glossary for describing skin lesions (Nast et al., 2016). Lymph node terms follow Bickley et al. (2021).

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.

Jarvis, C. (2020). Physical examination & health assessment (8th ed.). Elsevier.

Nast, A., Griffiths, C. E. M., Hay, R., Sterry, W., & Bolognia, J. L. (2016). The 2016 International League of Dermatological Societies' revised glossary for the description of cutaneous lesions. British Journal of Dermatology, 174(6), 1351-1358. https://doi.org/10.1111/bjd.14419