This page holds a finished NU 610 Unit 6 documentation critique with the note reproduced, a stated standard applied, defects sorted and one passage rewritten. Searches like "nu 610 unit 6 assignment example", "nu610 unit 6 sample" and "nu 610 unit 6 example" land here.
The NU 610 Unit 6 documentation critique, in full
Critique of a Peripheral Vascular Examination Note for Exertional Calf Pain
Student Name
Department of Nursing, Herzing University
NU 610: Advanced Health Assessment
Instructor Name
March 9, 2026
Critique of a Peripheral Vascular Examination Note for Exertional Calf Pain
The Note Under Examination
The excerpt below is a composite written for teaching. It is reproduced unedited so every claim in this critique can be checked against the same words.
"67 y/o M c/o L calf pain w/ walking x 3 mo. Exam: Ext WNL. Pulses nml. No edema. Skin intact. Cap refill ok. Sensation grossly intact. Hair loss LE. Neg Homans. Pt ambulatory. A: claudication vs MSK. P: ABI, f/u prn. Same as prior visit."
The standard applied is the descriptive documentation standard for the peripheral vascular examination in Bickley et al. (2021): each finding names the structure, the side, the method used to obtain it, and a description a second clinician could reproduce. For a patient with exertional leg pain, the expected content also follows the examination elements that Khan et al. (2006) found to carry real diagnostic value for lower extremity arterial disease, namely palpation of the foot pulses, auscultation for femoral bruits, comparison of skin temperature and color between the legs, and inspection of the feet.
Defects by Type
Labeled findings in place of descriptions. "Ext WNL," "Pulses nml," and "Cap refill ok" each report a verdict rather than an observation. The reader cannot tell which pulses were palpated, what grade was felt, or whether capillary refill took one second or three. For a patient whose complaint suggests arterial insufficiency, the pulses are the central finding, and "nml" makes it impossible to know whether the popliteal, dorsalis pedis, and posterior tibial pulses were examined at all.
Missing laterality. The complaint is on the left, yet no finding in the note has a side except the complaint itself. "Hair loss LE" could mean one leg or both, and the difference matters: symmetric hair thinning is common with age, while hair loss confined to the symptomatic leg supports reduced arterial flow on that side. "No edema" and "Skin intact" also lack sides, so a later clinician who finds a small ulcer on the left heel cannot know whether it was missed or new.
Maneuvers without method, and one maneuver that should not be there. "Sensation grossly intact" does not say whether light touch, monofilament, or vibration was tested, or where. "Neg Homans" records a test for deep vein thrombosis that has poor accuracy and does not address the complaint in the note, which is exertional pain that suggests an arterial cause; including it signals a template rather than an examination chosen for this patient. Nothing records whether femoral bruits were listened for, whether the feet were inspected between the toes, or whether skin temperature was compared side to side.
Ambiguous abbreviations and carried-forward text. "Nml" and "WNL" are shorthand of the kind that safety bodies treat as error-prone when it stands in for measured values (Institute for Safe Medication Practices, 2021), and "f/u prn" leaves the follow-up to the patient's judgment. The final sentence, "Same as prior visit," is the most serious defect. Weis and Levy (2014) describe how copied or referenced text makes it impossible to tell which findings were examined on the day of the note. If the prior visit was for a different complaint, the whole examination may never have been performed today.
What the Note Does Well
A fair critique also records what the original gets right, because the rewrite should keep it. The complaint is localized to the left calf, tied to walking, and given a duration of three months, which is the core of an exertional pain history. The assessment offers two named possibilities rather than a single label, which shows the writer was reasoning rather than filling in a diagnosis. The plan names a specific test, the ankle-brachial index, that directly addresses the leading possibility. Those three elements are the skeleton of a good entry; the defects above sit in the examination between them, which is exactly the part of the record this course asks students to master.
The note is also short, and brevity is not itself the problem. A peripheral vascular entry for this complaint can be written in six or seven lines and still meet the standard. The issue is that the brevity here was achieved by replacing observations with verdicts, which saves the writer a few seconds and costs every later reader the examination.
Rewritten Passage
Original: "Pulses nml. No edema. Cap refill ok. Hair loss LE."
Rewritten, at comparable length: "Pulses by palpation, patient supine: femoral 2+ R and L; popliteal 2+ R, 1+ L; DP 2+ R, absent L; PT 2+ R, 1+ L. No femoral bruit R or L. Cap refill great toe under 2 s R, 4 s L. Hair absent over dorsum of L foot and lower L shin; present R. No pitting edema either leg."
The rewrite is not longer in any meaningful sense and does not change the style of the original. It changes what a reader can do with it. A clinician reading the revision knows the left foot pulses are diminished or absent, knows the right is the comparison, and can repeat each finding in the same position to see whether anything has changed.
Who Reads This Note Next
Three readers depend on this entry. The vascular specialist who receives the ankle-brachial index referral needs the baseline pulse examination to judge whether the disease has progressed by the time of the appointment; with the original note, that specialist must repeat the full examination and cannot compare it with anything. The next primary care clinician needs the side-by-side findings to recognize a change such as a new cool foot or a new absent pulse, which would move the urgency from routine to same day. The patient, finally, is poorly served by "f/u prn," because a person with claudication should be told which changes, such as pain at rest or a wound that will not heal, mean he should return promptly.
The defect in this note that most changes what the next clinician would do is the undocumented pulse examination. If the left dorsalis pedis pulse is truly absent, the patient has objective evidence of arterial disease and needs risk factor management and a timely index measurement. If it is present, the working impression of claudication is weaker and the musculoskeletal explanation deserves more attention. As written, the note supports neither path.
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.
Institute for Safe Medication Practices. (2021). ISMP list of error-prone abbreviations, symbols, and dose designations. https://www.ismp.org/recommendations/error-prone-abbreviations-list
Khan, N. A., Rahim, S. A., Anand, S. S., Simel, D. L., & Panju, A. (2006). Does the clinical examination predict lower extremity peripheral arterial disease? JAMA, 295(5), 536-546. https://doi.org/10.1001/jama.295.5.536
Weis, J. M., & Levy, P. C. (2014). Copy, paste, and cloned notes in electronic health records. Chest, 145(3), 632-638. https://doi.org/10.1378/chest.13-0886
What a finished NU 610 Unit 6 documentation critique looks like
The finished example puts the note under examination on the page first, so the reader is judging the same text the writer judged. What follows is not a list of complaints but a sorted analysis: findings labeled instead of described, paired structures with no side, maneuvers whose results appear without the maneuver, entries that could not have been produced in the position recorded, abbreviations that carry more than one meaning, and text that has clearly been carried forward from an earlier encounter. Each defect is named with the line it sits on and the reason it matters to the next clinician. One passage is then rewritten in full, and the rewrite is close enough to the original that the difference is the documentation rather than the style.
How a NU 610 Unit 6 example is structured
The example moves from evidence to standard to consequence. It reproduces the note or the excerpt first, unedited, which is what allows every later claim to be checked. A short section then states the standard being applied and where it comes from, so the critique reads as measurement rather than as personal taste about charting. The body sorts defects by type instead of walking the note line by line, because a type-sorted critique shows a pattern while a line by line pass shows only a sequence. Each type carries its examples and a sentence on what a reader loses because of it. The rewritten passage follows, set beside the original. The closing section names the clinical consequence: who reads this note next, what they need from it, and what the current version forces them to repeat.
The note reproduced before judgment
The text under examination appears on the page unedited, so every defect the critique names can be checked against the same words.
A stated standard, not personal taste
The critique names the documentation expectation it is measuring against and cites it, which separates an analysis from an opinion about charting habits.
Defects sorted into types
Labeled findings, missing laterality and unnamed maneuvers are grouped as categories, because a pattern of failure says more than a list of instances.
One passage rewritten in full
A corrected version sits beside the original at the same length, proving the fix is achievable rather than merely recommended.
The next clinician named
The closing analysis says who reads this record afterward and exactly which work they are forced to repeat because of what is missing.
Where marks go in NU 610 Unit 6
Critiques lose marks by being polite or by being vague. A pass that finds the note generally thorough and suggests more detail has measured nothing, and the analysis criterion has nothing to reward. Judging style rather than verifiability is the second failure: sentence length and tone are not what the record is graded on, while an unrecorded side is. Critiques with no stated standard read as preference, so faculty cannot tell whether the writer knows the expectation or dislikes the note. Skipping the rewrite leaves the argument untested, because it is easy to demand specificity and harder to produce it. Critiques that never say who is harmed downstream stop at grammar. The strongest versions find a defect that changes what the next clinician would do.
Get a NU 610 Unit 6 example written to your instructions
Send the Unit 6 instructions and the rubric from your NU 610 classroom, along with the note your section supplied for critique. We write a custom example that applies a stated standard, sorts the defects and includes the rewritten passage, returned in 24 to 48 hours. The first custom sample is free. If the note came from practice, strip the identifiers before you send it.
NU 610 Unit 6 questions, answered
What standard should I judge the note against?
Start with whatever your instructions name, then support it with the documentation expectations already taught in this course and with published guidance on record keeping. The point is that the standard exists on the page before the critique begins. A critique measuring against an unstated internal sense of good charting cannot be scored for accuracy, however sound the observations underneath it are.
Can I critique a note from my own clinical site?
Only if your instructions permit it and only after every identifier is removed, including dates, unit names and anything that narrows the patient. Hours you log in practice, and any evaluation a preceptor puts a signature on, sit outside what anyone else can write for you. Where a section supplies its own sample note, use that instead, since faculty are scoring the critique rather than its source.
Is a rewrite required in a documentation critique?
Check the instructions, but include one even when it is optional. A rewritten passage is the fastest proof that the writer can produce the standard being demanded, and rubrics that reward application usually have somewhere to put it. Keep the rewrite the same length as the original so the improvement is clearly the documentation and not simply more words.