Nursing assessment forms are called such because they are used solely by nurses, as opposed to medical assessment forms which are mainly used by doctors. Nursing assessment forms also focus on the nursing needs of the individual and utilizes nursing diagnoses, rather than medical diagnoses of problems. Typically, nursing assessment is done in hospitals and in clinics.

Components of a Nursing Assessment Form

A nursing assessment form will require information concerning the health status of the patient, present complaints, circumstances leading to the present illness, the current management of the illness, past medical history, social history, and the perception of the illness by the individual. In some instances a criminal background check is also included as well as information on previous 911 calls made by the patient. All these information are part of the nursing history assessment. Other components of the nursing assessment includes the psychological and social examination and for the last part, the physical examination.

The psychological examination deals with questions dealing with the patient’s emotional health as well as questions related to the patient’s social, emotional and spiritual health.

Lastly, the physical assessment is done by taking specific measurements and vital signs, which includes the temperature, blood pressure, pulse or heart rate and respiratory rate.

Electronic or Online Nursing Assessment Forms

Nursing assessment forms used to be done by hand but with most patient data are now encoded directly into the computer so that it can be readily accessed by members of the health care team. Updates or revisions to existing patients records can be done right away when the nursing assessment form and other patient forms are electronic. Electronic storage of nursing assessment information also makes it less prone to damage or loss.

Head to toe assessment forms are also available online for those who want to see how a nursing assessment is done. Forms also vary according to the individual being assessed. For example, a nursing assessment for a child or an infant differs from a nursing assessment for an elderly person.

Why Nursing Assessment is Done

Nursing assessment is done to gather information about the current health status of the individual. The data gathered is used by the nurse to formulate a nursing diagnosis and in turn create a management plan for the patient. The nursing assessment is perhaps the most important step in nursing care, making the nursing assessment form an integral part of the nursing process.

In the nursing assessment forms, there are lots of health topics that can be asked. The following are the possible topics that can be included:

Immunizations

• The series of immunization completed is very important in assessing the health history of the patient in order to know if this is related to the patient’s present health status. Incomplete immunizations can also have a chance to be completed.

Allergies

• Allergies to certain foods and medications are crucial to know in order to avoid allergic reactions or even worse, an anaphylactic reaction.

History of certain diseases in the family

• This is to know if the patient is susceptible to certain familial and chronic diseases.

Vices

• This is asked to know if there are contributing factors that may have caused the health problem.

Past medical history

• It determines the possible past health conditions that can affect present health status as well as the chance of reoccurrence of the past health problem.

Cultural and spiritual beliefs

• This is important in giving respect to every individual’s culture and belief while giving nursing care.

Signs and symptoms felt from time to time

• This is useful in planning the course of care that needed to be extended in order to relieve signs and symptoms.

Perception of oneself in accordance to present health status

• Through this a nurse can evaluate if the patient is experiencing emotional problem. It’s a part of a nurse’s duty to provide emotional support to the patients.

Physical assessment that should be done by the nurse is also included in the nursing assessment forms. It is composed of inspection, palpation, percussion and auscultation. In this case, physical assessment can be in checklist type. In inspection, the nurse looks for any marked alteration in the skin such as a rash, bruise and wounds. Palpation, on the other hand, feels if there is any mass and tenderness present. Percussion involves tapping the underlying structures to determine the size. And lastly, auscultation enables the nurse to hear if there are any abnormal sounds present. After this, all of the findings are recorded in the form. The nurse can also add other additional observations on the form as long as it is consistent and informative.