These are my assessment questions, head to toe.
Any headaches, neck aches, neck pain, stiffness? (look for glasses or hearing aids).
CP, shortness of breath, cough, palpitations?
Look at their breathing, NOTE* sometimes they will say no cough but yet you
will hear them cough (mostly post surg or pts with lung issues)
When was the last time you had a BM? N/V/C/D? (last episode)
Pain or burning with urination? (asses color of urine, or ask aid if poss)
Falls in the last year? Assistive devices? ( assess extremities, check for edema)
Then ask the patient if you can listen to their innards (I like to be funny)? (listen to heart lungs, abd).
I am constantly assessing every time I look at my patient. Looking around the room. It only takes 5 minutes, maybe more depending on the patient to complete my assessment (charting is MUCH different, but we all know how that goes).
While you are doing their skin assessment (they are walking to the bathroom or turning in bed - look at their back side) look for IV, bruising, wounds, surgical site.
I could easily be asking them while I am doing my med pass. I am not always able to get all of my information at the same time so I rely on frequent contact with the patient. If I don't have part of my assessment complete I at least start charting (when I can) and fill in the blanks later.
I do have an awesome assessment sheet I use that helps me to remember so I don't have to ask the patient again or go back to reassess. We use COWS, so I am able to make notes as I go. If you would like to check it out let me know. I would be happy to email it to you. You can make changes to it as well, tweak it to your specific needs.