N495 Module 6 assignment: head-to-toe assessment documentation, a full sample

Reviewed by Maren Hollowell, MSN, RN Aspen University True APA form Annotated

A complete N495 Module 6 example: the written documentation that accompanies the head-to-toe assessment video, recorded system by system for a composite healthy 34-year-old volunteer, with vital signs taken to the AHA measurement standard, the abdominal sequence correct, graded pulses, strength and reflexes, and technique notes where a reviewer watching the video would look. The video itself is your own performance and is not sampled.

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Head-to-Toe Physical Assessment Documentation: A Healthy 34-Year-Old Adult Volunteer

Student Name

RN to BSN Program, Aspen University

N495: Health Assessment

Instructor Name

Month Day, Year

What this page is doingDocumentation titles should be plain and factual, and this one names the exam type and the subject. The assignment's video is the student's own performance; the written documentation that accompanies it is what this sample models. APA 7 student title page.
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Head-to-Toe Physical Assessment Documentation: A Healthy 34-Year-Old Adult Volunteer

Purpose and Setting

This document records a complete head-to-toe physical assessment performed on a healthy adult volunteer for a recorded skills demonstration. The volunteer, called Ms. A. here, is a composite 34-year-old woman with no chronic conditions who consented to the examination and the recording. The assessment was performed in a quiet, well-lit room with the volunteer seated and then supine, looking first, then feeling, then percussing, then listening for each system, except for the abdomen, where auscultation precedes percussion and palpation (Bickley et al., 2021). Findings are documented by system using standard terminology, and the rationale for key techniques is noted where a reviewer watching the video would look for it.

What this page is doingThe opening states the context, consent and sequence, including the one exception to the usual order (the abdomen), which graders often check. It also makes clear that the video itself is the student's own work, and this page models the documentation only.
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General Survey and Vital Signs

General survey: alert, oriented to person, place, time, and situation; well groomed; appropriate dress; posture erect; gait steady and even; speech clear with normal rate; no apparent distress.

Vital signs: temperature 36.8 degrees Celsius oral; heart rate 72 beats per minute, regular; respiratory rate 14 breaths per minute, unlabored; blood pressure 116/74 mmHg right arm and 114/72 mmHg left arm, seated after five minutes of rest with feet flat, back supported, arm at heart level, and an appropriately sized cuff; SpO2 99 percent breathing room air; height 165 cm; weight 61 kg; body mass index 22.4 kg/m2. Blood pressure technique followed current recommendations for accurate measurement, including rest, positioning, cuff size, and measurement in both arms at the first visit (Muntner et al., 2019). Denies any current pain.

What this page is doingVital signs are complete, with units, and the blood pressure entry documents the technique details that make the reading trustworthy, citing the scientific statement that defines them. Measuring both arms at an initial visit is a recommended step that many students omit.
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Skin, Hair, and Nails

Skin: color appropriate for ethnicity; warm, dry, and intact; turgor brisk with immediate recoil; no lesions, rashes, or bruising; no edema. Hair: evenly distributed, normal texture. Nails: pink nail beds, smooth, capillary refill less than 2 seconds in fingers and toes, no clubbing.

What this page is doingSkin findings use the standard descriptors (color, temperature, moisture, integrity, turgor, lesions) and note capillary refill in both fingers and toes. Concise, parallel phrasing is the correct register for assessment documentation.
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Head, Eyes, Ears, Nose, Mouth, and Throat

Head: normocephalic, atraumatic; scalp without lesions; face symmetrical at rest and with movement. Eyes: visual acuity 20/20 in both eyes by Snellen chart; conjunctivae pink; sclerae white; pupils 3 mm, round, equal, briskly reactive to direct and consensual light, and constricting on near focus; extraocular movements intact without nystagmus in six cardinal fields; red reflex present bilaterally.

Ears: external ears without lesions; tympanic membranes pearly gray with visible landmarks and cone of light bilaterally; whispered voice heard at 2 feet bilaterally. Nose: septum midline; mucosa pink and moist; no discharge; frontal and maxillary sinuses nontender. Mouth and throat: lips and oral mucosa pink and moist; teeth in good repair; tongue midline; uvula rises symmetrically; tonsils 1+ without exudate; gag reflex deferred.

What this page is doingThe HEENT section includes the screening tests a reviewer expects to see performed on video, such as Snellen acuity, the six cardinal fields, the whispered voice test and otoscopy with landmarks. Documenting a deferred step (gag reflex) rather than omitting it is accurate practice.
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Neck

Trachea midline. Thyroid not enlarged, no nodules palpated, moves with swallowing. No palpable cervical, supraclavicular, or axillary lymphadenopathy. Carotid pulses 2+ and equal bilaterally, palpated one side at a time; no bruits. Full range of motion without pain.

What this page is doingPalpating the carotids one side at a time is a safety technique worth documenting, because a reviewer watching the video will look for it. Lymph node chains are named specifically rather than summarized as normal.
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Respiratory

Inspection: chest symmetrical; anteroposterior to lateral diameter approximately 1 to 2; respirations regular and unlabored without accessory muscle use. Palpation: symmetrical chest expansion; tactile fremitus equal bilaterally. Percussion: resonant throughout all lung fields. Auscultation: vesicular breath sounds in peripheral fields, bronchovesicular over the main bronchi; no crackles, wheezes, or rubs. Auscultation performed on bare skin, comparing side to side, anterior and posterior, with the volunteer breathing through the mouth.

What this page is doingThe respiratory exam follows the full four-technique sequence and uses correct names for normal breath sounds by location. Noting technique (bare skin, side to side, mouth breathing) connects the documentation to what a reviewer sees in the video.
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Cardiovascular

Point of maximal impulse palpated at the fifth intercostal space, midclavicular line; no heaves or thrills. S1 and S2 clear with regular rate and rhythm; no murmurs, gallops, or rubs, heard at all five classic listening posts (aortic, pulmonic, Erb's point, tricuspid, mitral), first with the diaphragm and then with the bell. Pulses 2+ and symmetric at the radial, brachial, femoral, and popliteal sites, and at both pedal sites. No jugular venous distension with head of bed at 45 degrees. Extremities warm without edema or varicosities.

What this page is doingAll five auscultation areas are named, both diaphragm and bell are documented and pulses are graded on the standard scale at six sites. Precision like this is what separates documentation that proves an exam was done from documentation that merely asserts it.
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Abdomen

Inspection: flat, symmetrical; umbilicus midline; no scars, lesions, or visible pulsations. Auscultation: bowel sounds present and normoactive in all four quadrants; no bruits heard over the abdominal aorta or the renal and iliac arteries. Percussion: tympany predominates across the quadrants; liver span about 8 cm at the right midclavicular line. Palpation: soft, nontender to light and deep palpation; no masses; liver edge and spleen not palpable; no costovertebral angle tenderness.

What this page is doingThe abdomen is documented in the correct altered order, with auscultation before percussion and palpation to avoid changing bowel sounds. A measured liver span and the check for costovertebral angle tenderness show thoroughness.
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Musculoskeletal and Neurological

Musculoskeletal: full active range of motion in all joints without pain or crepitus; muscle strength 5 of 5 and symmetrical in upper and lower extremities; spine without curvature on forward bend. Neurological: cranial nerves II through XII grossly intact; light touch felt equally in all four limbs; coordination accurate on finger-to-nose testing and on heel-to-shin testing; rapid alternating movements intact; Romberg negative; deep tendon reflexes 2+ and symmetrical at biceps, triceps, brachioradialis, patellar, and Achilles; plantar reflexes flexor bilaterally.

What this page is doingMusculoskeletal and neurological findings use graded scales (strength out of 5, reflexes on the 0 to 4+ scale) and name each coordination test performed. Recording plantar responses as flexor, rather than writing "Babinski negative," reflects precise terminology.
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Technique Notes for the Recording

Several choices during the recording were made so that a reviewer can verify technique on screen. Hand hygiene was performed and narrated at the start and before contact with the face. The volunteer was draped so that only the area being examined was exposed, and each exposure was announced before it happened, which protects privacy and keeps the volunteer informed. The stethoscope was placed directly on skin for every auscultation, and each lung field was compared with the same field on the opposite side before moving down. The camera was positioned at the volunteer's right side, the side from which the examination was performed, so that hand placement for palpation of the thyroid, the point of maximal impulse and the liver edge would be visible.

The examination took 14 minutes, inside the 15-minute limit, because the sequence was rehearsed in advance and grouped by position: seated components first, then supine, then standing for gait and Romberg testing. Grouping by position is also more comfortable for older or frail patients, who should not be asked to change position more often than necessary.

What this page is doingTechnique notes connect the written record to what a reviewer sees on the video, and they show clinical reasoning about privacy, positioning and efficiency. Grouping the exam by position is a practical skill graders recognize.
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Psychosocial and Summary

Psychosocial: mood described as "good"; affect congruent; thought process logical; denies stress beyond usual work demands, tobacco use, or recreational drug use; drinks alcohol socially, one to two drinks per week; lives with spouse; feels safe at home.

Summary: healthy 34-year-old woman with a normal head-to-toe examination. No abnormal findings requiring follow-up. Health promotion topics identified for discussion include cervical cancer screening status, influenza vaccination, and sun protection. Components sometimes omitted in routine practice, such as the red reflex, whispered voice test, liver span, and coordination testing, were included to demonstrate a complete examination (Jarvis & Eckhardt, 2024).

What this page is doingThe summary states the overall finding, identifies health promotion topics appropriate to the volunteer's age and ties back to the module's discussion about rarely used exam components. Ending with a summary line is how complete assessment documentation closes.
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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., & Eckhardt, A. L. (2024). Physical examination and health assessment (9th ed.). Elsevier.

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. (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

How this N 495 Module 6 example is structured

N495 Module 6 typically asks you to record a head-to-toe physical assessment of an adult on video, usually 15 minutes or less, and submit it with a documentation guide. The recording is your own performance and is never produced for you. This example models the written documentation only: organized by system, in standard clinical terminology, with graded scales, the correct exam sequence, deferred steps recorded as deferred, and a short summary with health promotion topics.

N495 Module 6 questions, answered

What does N495 Module 6 usually ask for?

Commonly a video of you performing a head-to-toe physical assessment on an adult, 15 minutes or less, uploaded with a documentation guide of your findings. The module's discussion often asks which parts of the physical assessment are rarely used in practice and why they matter.

What order should the head-to-toe exam follow?

Inspection, palpation, percussion and auscultation for most systems, but auscultation before percussion and palpation for the abdomen, so that manipulation does not alter bowel sounds. The sample documents that sequence explicitly.

How detailed should the documentation be?

Detailed enough to show each technique was performed and what was found: named sites, graded scales for pulses, strength and reflexes, measured values with units, and any step deferred. Writing only 'within normal limits' for a system gives a grader nothing to check.

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