Free Nursing Templates/Nursing Assessment Form
Nursing Assessment Form
A structured assessment worksheet to help you organize patient history, findings, safety risks, priorities, and follow-up.
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Structured student worksheet for organizing assessment data, risks, priorities, and follow-up
1. Chief Complaint
What is the patient’s main concern?
Chief concern / reason for assessment
Patient-reported symptoms and onset
Patient concerns, goals, or questions
2. History of Present Illness
Onset, duration, severity, location, associated symptoms, relieving or aggravating factors.
Pain: location / quality / rating / aggravating–relieving factors
Relevant current diagnosis / procedure
Baseline function / mobility / communication
3. Past Medical History
HTNDiabetesHeart disease
COPD / asthmaCancerStroke
Kidney diseaseThyroid disorderOther
Other conditions / surgeries
Relevant family / social history
Substance / tobacco / alcohol history if relevant
4. Current Assessment
| System | Findings | Notes |
|---|---|---|
| General Appearance | ||
| Vital Signs | T ____ P ____ R ____ BP ____ / ____ SpO₂ ____ % | |
| Pain | Location ________ Scale (0–10) ____ | |
| HEENT | ||
| Cardiovascular | ||
| Respiratory | ||
| Gastrointestinal | ||
| Genitourinary | ||
| Musculoskeletal | ||
| Neurological | ||
| Skin / Integumentary | ||
| Psychosocial |
5. Medications
| Medication | Dose | Route | Frequency | Last given | Notes |
|---|---|---|---|---|---|
6. Risk Factors
Falls riskInfection riskSkin breakdown riskBleeding riskDevice / line riskOther
Immediate safety concerns requiring escalation
7. Plan / Follow-Up
Priority finding(s) and nursing action
Provider / RN notification or escalation
Patient education / support provided
Response to intervention · next assessment
Important: this assessment is a snapshot in time. Reassess and update as the patient’s condition changes.
Initials
A Simple Assessment Workflow
Collect first, organize second, then identify what needs nursing attention.
- 1ProfileWho is the patient?
- 2HistoryWhat matters from history?
- 3VitalsWhat do I measure?
- 4SystemsWhat do I observe?
- 5RisksWhat needs attention?
- 6PrioritizeWhat happens next?
What the Form Helps You Capture
Use this structured worksheet to capture the information that matters without turning an assessment into a scattered list of notes.
Patient Profile & Current Concern
Chief concern, symptoms, pain, current diagnosis, baseline function, and the patient’s own goals.
Relevant History & Medications
Medical and surgical history, medications, allergies, family and social history, and recent changes.
Vitals & General Observation
BP, HR, RR, temperature, SpO₂, appearance, level of consciousness, and measurements.
Focused / System Assessment
Neurologic, respiratory, cardiovascular, GI, GU, skin, mobility, and psychosocial findings.
Safety, Risks & Devices
Falls, skin, infection, lines and drains, and anything needing escalation.
Priorities, Actions & Follow-Up
Priority findings, nursing actions, escalation, education, response, and next assessment.
At the bedside
Collect first, decide second.
A structured sheet keeps the assessment from turning into scattered notes — and makes the priority obvious once the data is down.
From Data to Priority
A short example showing how assessment findings lead to nursing action.
Finding
Dizziness on standing and a significant postural blood-pressure change.
Risk / Priority
Fall risk related to symptomatic orthostatic change.
Action
Assist with position changes, use fall precautions, reassess, and escalate per protocol.
Follow-Up
Document the response and repeat the assessment as directed.
Always follow your instructor’s or clinical site’s required assessment format and documentation rules.