The Basics on Nursing Assessment Forms

Nursing assessment forms are forms used to gather data about the patient’s physical, mental, emotional and spiritual health but it is used strictly by nurse practitioners. This type of form is an important part in the first step of the nursing process, which is assessment.

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.