Nursing Assessment Form

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Nursing Assessment Form

What is a nursing assessment form?

A nursing assessment form is a document used by nurses to assess patients. Nursing assessment forms will generally fall into one of two categories: forms for general patient assessments and forms for ongoing assessments related to specific health conditions.

Nurses often conduct comprehensive evaluations – covering general quality of health, pre-existing conditions, lifestyle choices and habits, and so on – on patients that join a healthcare practice for the first time. Alternatively, nurses may carry out regular assessments on patients undergoing long-term treatment for an illness such as cancer, chronic pain, heart disease, and so on. 

Nursing assessment forms can be used to determine the appropriate level of urgency if a patient has a particular complaint and ensure that they are assigned to the doctor best suited to treat the issue. This process is also commonly referred to as “triaging”. 

Are all nursing assessment forms all the same? 

While nursing assessment forms are tailored to the particular healthcare organization responsible for issuing them, they tend to be uniform in structure. They will usually include similar sections for vital signs (body temperature, respiratory rate, blood pressure, pulse rate, etc.), lifestyle habits (exercise, smoking, alcohol consumption, etc.), and any specific medical issues. 

What are nursing assessment forms used for?

Nursing assessment forms are used to gather information about new and existing patients and identify any current, ongoing, or potential care needs. They allow medical organizations to collect data in a standardized manner, thus enabling healthcare professionals to administer treatment and track patient health efficiently. 

If your organization regularly uses nursing assessment forms, you will likely be able to save significant amounts of resources and employee time by streamlining your workflow, specifically by using a base template and automating parts of the information-gathering and storage process. 

How does a nursing assessment form differ from a physical assessment?

It is common for nurses to perform a physical exam, which will usually involve monitoring “vital signs” like pulse rate and blood pressure, when filling out nursing assessment forms. 

Unlike physical assessments, however, nursing assessments are also used to record information about the following: 

  • Medical history
  • Habits and lifestyle choices
  • Long-term health conditions of close family members
  • Current treatment or medication plans
  • Current symptoms
  • Results of a health examination
  • Results of any lab tests (for example, blood and saliva) conducted before the assessment

Sometimes, a psychological evaluation may also be involved. Finally, if a patient has any additional cultural requirements, such as the need for a translator or a doctor of a particular sex, this information may also be included. 

What are the four types of nursing assessments?

It’s common for nursing assessments to fall into one of the following four categories:

  • Preliminary assessment – During an initial health assessment (or “triage”), which represents the first stage of the nursing process, a nurse or caregiver will gather general patient details and put together a health history. Registered nurses may conduct tests to measure turgor pressure, capillary refill time, musculoskeletal pain, cardiovascular, gastrointestinal, neurological,  psychosocial, and mental health, presence of edema, hypertension, or cyanosis, and so on. 
  • Tailored assessment – During a tailored or focused assessment, any specific problems which became apparent during the preliminary evaluation are investigated in more depth for the purpose of putting together a personal treatment or care plan. 
  • Follow-up assessment – A follow-up assessment is conducted after a patient has received treatment. It is designed to measure the rate of recovery and to identify any ongoing nursing care needs related to health status, which may be the case in individuals with impairments, catheters, and so on. 
  • Emergency assessment – Emergency assessments are used to identify immediate problems in high-risk patients requiring hospitalization. 

What are the different types of nursing assessment forms?

Nursing forms are used in a wide variety of situations. They are usually tailored to the unique needs of the organization responsible for drafting them. That said, nursing assessment forms will usually fall into one of the following three loose categories: 

  • New patient assessment – Whenever a new patient enrolls with a medical organization, they will often be required to undergo an evaluation conducted by a nurse. New patient assessments tend to be geared towards collecting a broad set of data-points, including medical history, measurements of vital signs, daily habits, lifestyle choices, chronic conditions, and so on. 
  • Ongoing care assessment – Patients who require continuing care will often have regular reviews to track their treatment plan’s efficacy and so that their care package can be adjusted based on any progress or deterioration. Often, this kind of nursing assessment will focus on a small handful of relevant measurements. 
  • Triage assessment – During triage, a nurse will identify and record symptoms so that a patient can be assigned an urgency level and directed to the best-qualified specialist. 

It’s also worth pointing out that a nursing assessment is not the same as a medical diagnosis, for which a doctor would usually be responsible. Instead, nursing assessment forms are used to evaluate the patient’s general health, identify any current or potential care needs, and flag any issues that need to be looked at by a doctor or qualified expert. 

What is included in a nursing assessment form? 

Nursing assessment forms are almost always tailored to meet the specific needs of the organizations that will be using them. However, there are usually several commonalities in terms of structure and general areas of information.

Here are the main areas that a nursing assessment form should include: 

  • Patient information – Nurse assessment forms usually begin with a section for basic patient information like name, address, contact details, and occupation. 
  • Patient evaluation – The patient evaluation area may include sections for measurements of vital signs, personal information such as height, weight, and any existing medical conditions or allergies, and information about current medical complaints and symptoms. 
  • Patient medical history – The patient’s medical history will usually include fields for past conditions and any common family illnesses. 
  • Nurse signature – Assessment forms will have a field for the nurse conducting the evaluation to provide their details and signature. 

Should you use a template to create nursing assessment forms?

Because most medical organizations use large amounts of nursing assessment forms, it is often possible for them to save significant amounts of time and money by working from a template. Rather than draft a document from scratch every time a new form is needed, organizations can work from a tested template, making adjustments as required. 

What’s more, once a template has been verified by every individual involved in the drafting process, it will be possible to make minor adjustments without the need for extensive checks, dramatically cutting down on completion time. 

Get started with the free, fully-customizable nursing evaluation form template provided by PandaDoc.