So a few months back I started scouring these boards for a assessment worksheet or head-to-toe assessment guide that I could use to help me with my charting in clinical, something that could help me organize my thoughts and become better at charting all of my assessments. So after looking at quite a few different worksheets that people have submitted on this website and on the web in general I have decided to come up with my own. Finally after weeks of working on it in my spare time I think I am done with it and now I want to see what nursing students, nurses and nursing instructors think about it. I want to make it clear that it is not meant to replace charting your assessments but more serve as a guide to help nursing students organize their thoughts and make sure that they have their bases covered so to speak. Plus I think they are helpful to make sure you have all of your findings for when you submit your careplans and patient preps to your instructors (if your school has you do that). So please feel free to download it, take a look at it and certainly use it if you think it is helpful. Please let me know what you think about it and any suggestions to improve it. It may seem obvious but just in case it isn't, anything that has a blank space for you to fill in then write it in and circle any of the findings that apply to your patient.
I'm thinking of making one for Peds. to but I'm not sure yet. You think I should? I was thinking of doing one for OB patients but honestly I'm not even close to being an expert in that area and I don't think I could do it justice.
This is fantastic! I'm going to point the others in my class towards this post, and I'll definitely be downloading any others you come up with. Thank you VERY much.
I think this is a great assessment worksheet!! The only thing I can think of that you might want to add is a section on the last page for discharge planning.
I'm only saying this because we have to do an asignment on discharge planning for one patient this semester and I know it's a part of PT care.
I think this is a great assessment worksheet!! The only thing I can think of that you might want to add is a section on the last page for discharge planning.
I'm only saying this because we have to do an asignment on discharge planning for one patient this semester and I know it's a part of PT care.
Great idea! I can add it on the last page, probably just after the teaching portion.
Kudos on the work ethic! I do have a question: didn't your nursing school provide you with one of these forms or a 5 page list of questions that you're supposed to ask?
Kudos on the work ethic! I do have a question: didn't your nursing school provide you with one of these forms or a 5 page list of questions that you're supposed to ask?
That's an excellent question. After taking a semester of Physical Assessment we are expected to know how to do and document a full assessment on a hospitalized patient (keeping in mind we didn't spend a lot of time doing or practicing documentation in this course) and when we go to clinicals (say Med/Surg for instance) we are given these sheets that look like this....
Physical Assessment:
Cardiovascular -
GI -
GU -
Neuro
etc. etc.
They are just these big blank boxes for the areas of physical assessment and you are just expected to fill them in without any form of guidance. I understand that we should know how to assess a patient but I think that my assessment sheet helps students (especially sophomore and junior level students) to remind them on the most important points to have a fairly comprehensive assessment of your typical hospitalized Med/Surg patient.
sweet!! I need this for my clinical. We were told to find something similar so we can use it during our physical assessment in the hospital. Yeah!! no need to search, this is perfect!! thank you!!
I have been looking for this exact form forever. I didn't have the ambition to do it myself. Thanks for taking the time to help us all out! I've saved it, printed it and am going to try it out for clinicals next week! Thanks Again!
I'm learning assessments now and this will really help me out! I can't use it as my school gives us forms we have to use but it will certainly help me find appropriate words to use and probing questions to ask to get the answers I need as ours are purely fill in the blank. Many thanks!!
cjcsoon2bnp, MSN, RN, NP
7 Articles; 1,156 Posts
I'm thinking of making one for Peds. to but I'm not sure yet. You think I should? I was thinking of doing one for OB patients but honestly I'm not even close to being an expert in that area and I don't think I could do it justice.
!Chris