Free Professional Nursing Assessment Checklist Template
Professional Nursing Assessment Checklist
Prepared by: [YOUR NAME], [YOUR COMPANY NAME]
I. Patient Identification
# |
Task |
Check |
---|---|---|
1 |
Verify the patient’s full name. |
|
2 |
Confirm date of birth. |
|
3 |
Cross-check medical record number (MRN). |
|
4 |
Ensure wristband information is accurate. |
|
5 |
Document the patient’s contact details. |
|
II. Vital Signs and Medical History
# |
Task |
Check |
---|---|---|
1 |
Measure and record body temperature. |
|
2 |
Take pulse rate, respiratory rate, and blood pressure. |
|
3 |
Monitor oxygen saturation levels (SpO2). |
|
4 |
Review chronic conditions and current medications. |
|
5 |
Note any allergies and surgical history. |
|
III. Physical Examination
# |
Task |
Check |
---|---|---|
1 |
Inspect the skin for wounds, rashes, or discoloration. |
|
2 |
Assess mobility and range of motion. |
|
3 |
Check the respiratory system (e.g., lung sounds). |
|
4 |
Evaluate the cardiovascular system (e.g., heart sounds, circulation). |
|
5 |
Palpate the abdomen for tenderness or abnormalities. |
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IV. Pain and Mental Health Assessment
# |
Task |
Check |
---|---|---|
1 |
Determine pain level using a scale (0–10). |
|
2 |
Identify pain location, duration, and nature. |
|
3 |
Observe emotional state (e.g., calm, agitated). |
|
4 |
Assess cognitive function and behavioral patterns. |
|
5 |
Screen for signs of anxiety or depression. |
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V. Nutritional and Hydration Status
# |
Task |
Check |
---|---|---|
1 |
Review dietary intake and feeding habits. |
|
2 |
Check hydration levels (fluid intake/output). |
|
3 |
Assess for signs of malnutrition or obesity. |
|
4 |
Identify any dietary restrictions. |
|
5 |
Recommend nutritional interventions if needed. |
|
VI. Nursing Diagnoses and Care Plan
# |
Task |
Check |
---|---|---|
1 |
Summarize findings from the assessment. |
|
2 |
Identify key nursing diagnoses. |
|
3 |
Develop a care plan based on the findings. |
|
4 |
Communicate care plans with the healthcare team. |
|
5 |
Educate the patient and family about the care plan. |
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VII. Documentation and Finalization
# |
Task |
Check |
---|---|---|
1 |
Review the completed checklist for accuracy. |
|
2 |
Sign and date the completed assessment. |
|
3 |
File the checklist in the patient’s medical record. |
|
4 |
Update the electronic health record (EHR) if applicable. |
|
5 |
Confirm checklist completion with a supervisor if required. |
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