MN552 · Unit 3

MN552 Unit 3 focused exam documentation example

Reviewed by Elspeth Marlowe, MSN, RN Advanced Health Assessment Purdue University Global Free custom sample in 24 to 48h

This page holds a complete MN552 Unit 3 focused exam documentation example in true form. A red right eye in a composite 47-year-old accountant, present since waking two days earlier, is recorded technique first, then finding, then laterality, with visual acuity at the top, redness described by pattern, the corneal stain method named, and a one-line summary that stops before diagnosis. Most sections set this unit as focused documentation of this kind.

What this page holds

The right eye, documented technique by technique: acuity with correction, pupils, movements, lids, conjunctival injection pattern, cornea under fluorescein, anterior chamber and red reflex, each eye recorded. Searches like "mn 552 unit 3 assignment example", "mn552 unit 3 sample" and "mn552 unit 3 example" land here.

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Focused Eye Examination: Right Eye Redness for Two Days in a 47-Year-Old Accountant

[Student Name]

Purdue University Global

MN552: Advanced Health Assessment

Unit 3 Assignment

[Instructor Name]

[Date]

Composite patient written as a model document. No real patient or clinician is described.

What this part is doingThe title gives the document type, the complaint, its duration and the patient, which is how a focused note is headed in practice. The composite line keeps the privacy question settled on the title page.
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Subjective

Composite 47-year-old accountant with redness of the right eye first noticed on waking on September 12, 2026, two days before this visit. She reports that the lashes of the right eye were stuck together with yellow crust on both mornings and that the eye feels gritty. She reports no pain, no change in vision, no light sensitivity and no halos. She wears glasses for distance and does not wear contact lenses. Her husband had a red eye the week before. She reports no trauma, no chemical exposure and no recent illness. She has not used any drops. Past ocular history: myopia corrected with glasses since age 12; no eye surgery, no prior episodes of red eye and no history of glaucoma. Current medications: none. Allergies: no known drug allergies; seasonal allergies are not a problem for her.

What this part is doingThe subjective section is kept to what the focused examination needs: onset with a date, discharge character, the negatives that separate a surface problem from a sight-threatening one, contact lens use and exposure. Nothing here is interpretive.
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Objective

Abbreviations: OD refers to the right eye, OS to the left eye and OU to both eyes. They are defined here once because this note may be read outside eye care.

Visual acuity (Snellen wall chart at 20 feet, with her distance glasses): OD 20/25, OS 20/20. Near vision not tested.

Pupils (penlight, dim room): OU equal at 3 mm, round and briskly reactive to direct and consensual light. Swinging flashlight test: no relative afferent pupillary defect.

Extraocular movements (six cardinal directions): OU full, with no pain on movement and no diplopia reported.

Lids and lashes (inspection with penlight): OD yellow crusting along the upper and lower lash lines, no lid swelling, no lid lesion. OS lids and lashes clear.

Conjunctiva (penlight with the lids gently everted): OD diffuse injection, densest in the upper and lower fornices and fading toward the limbus, with no ciliary flush around the cornea. OD scant mucopurulent discharge at the inner canthus. No follicles or papillae seen by penlight. OS conjunctiva white and quiet.

Cornea (fluorescein strip, cobalt blue penlight): OD no staining and no uptake. OS no staining and no uptake. OU corneal light reflex clear and symmetric.

Anterior chamber (penlight, oblique illumination): OU deep and clear, with no visible layering of cells or blood.

Red reflex (direct ophthalmoscope at arm's length): OU present and symmetric. Fundus not examined beyond the red reflex.

Preauricular lymph nodes (palpation): not palpable on either side.

What this part is doingEvery line names the technique first, then the finding, then the eye. A reader can see not only that the cornea was clear but how that was established, which is the first question an eye clinic would ask. The conjunctival pattern is written out because diffuse fornix-predominant redness and a ring of limbal flush carry different meanings. The fundus is recorded as not examined rather than as normal.
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Summary of Abnormal Findings

OD: yellow crusting of the lash lines, diffuse conjunctival injection greatest in the fornices without ciliary flush, and scant mucopurulent discharge, with visual acuity of 20/25 corrected. All other findings in OD and OS as recorded above.

What this part is doingThe summary lists the abnormal findings for the right eye and nothing more. The assignment asks for documentation, so diagnosis and plan are left for a separate section. That restraint is part of the grade in this unit.
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Documentation Notes

Visual acuity is placed first because it is the vital sign of the eye and because it must be measured before drops, stain or bright light alter what the patient can see (Bickley et al., 2021). The right eye reads one line below the left, and the note records that glasses were worn so a later examiner can compare like with like. Findings run from the outside of the eye inward, in the order of the examination. The pattern of redness, the presence or absence of ciliary flush, the stain result and the preauricular nodes are all recorded because each is used by clinicians to separate surface inflammation from conditions that threaten sight (Azari & Barney, 2013). Where a structure was not examined, the note says so, which keeps the record honest about what the penlight could and could not show (Ball et al., 2023).

What this part is doingThe closing notes explain the documentation choices without reaching a diagnosis. Tying each recorded detail to its clinical use shows why the note is organized this way, which is the connection this unit tends to look for.
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References

Azari, A. A., & Barney, N. P. (2013). Conjunctivitis: A systematic review of diagnosis and treatment. JAMA, 310(16), 1721-1729. https://doi.org/10.1001/jama.2013.280318

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2023). Seidel's guide to physical examination: An interprofessional approach (10th ed.). Elsevier.

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.

How this MN552 Unit 3 example is structured

Laterality is the organizing rule. Every line names OD, OS or both, and the note spells those abbreviations out once at first use because a reader outside eye care may not know them. Findings run from outside the eye inward, the order of the examination itself. Measured values sit in brackets: acuity lines, pupil size in millimeters, the chart distance. Each technique appears with its finding, which lets a reader see not only that the cornea was clear but how that was established. Pertinent negatives are written where they belong rather than gathered at the end. The note closes on a single sentence summarizing what was abnormal, crusting and conjunctival injection on the right, and deliberately stops there. Diagnosis and plan belong to a separate section this assignment typically leaves out.

Get an MN552 Unit 3 example written to your instructions

Sections differ on which system Unit 3 covers, so send whichever system your MN552 course assigned, the documentation format it requires and the rubric. A free first note, following those instructions, returns within 24-48h: that system recorded technique by technique, laterality on every line, values bracketed, and a summary listing abnormal findings without jumping to a diagnosis. The paper above is an original model document written by our desk, not a submitted student paper and not an official Purdue University Global document.

MN552 Unit 3 questions, answered

What if my section assigns a different system?

The same principles carry over. Whether the prompt names the eye, the heart or the abdomen, a strong focused note records each technique with its finding, states laterality or location on every line, and puts pertinent negatives where they belong. The sample follows the system your prompt names and the documentation format your instructor posted.

Should abbreviations like OD and OS be used?

Many programs accept them in eye documentation, but some discourage Latin abbreviations because they are easily confused. The sample defines each one at first use and uses it consistently afterward. If your program follows an error-prone abbreviation list or your instructor prefers right and left written out, the note is prepared that way instead.

Is a fundoscopic exam expected in a focused eye note?

It depends on the prompt and on what the examiner could actually see. An undilated view through a handheld ophthalmoscope often shows little beyond the red reflex and perhaps the disc. The sample records exactly what was visualized and states what was not, rather than writing fundus normal for structures that were never seen.