One thing I noticed, is that I do a head to toe but the systems interlock, so when trying to chart it (and it's chart by exception), I don't chart in the order that I performed it.
Example: edema and pedal pulses I usually consider part of my CV assessment, but swollen feet are the last thing I look at.
And, edema could be considered in the fluid category or possibly respiratory, considering what else is going on. Since mine are mostly cardiac first patients, I chart:
-how I found 'em, physically, what are they doing. (sitting in bed awake?)
-telemetry reading, blood pressure, edema, peripheral pulses,
-other cardiac stuff like murmurs, JVD, groin sites for post cardiac cath
-cough, lung sounds, O2 sats if not normal or changed a lot
-what's going in the IV and how is pt tolerating it
-any problems with elimination, if pt has a foley what is in it?
-any other system that may need attention: if they are constipated, what's the bowel sounds like, what does the abdomen feel like, etc.
Hope that helps.