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Sample Assessment

Patient laying in bed awake, alert and oriented x 3, speech clear, pupils __mm PERRLA, sclera

white, vision intact (or wears glasses for nearsightedness), hearing intact (or hearing impairment

noted to L or R or both ears), smile symmetric, oral mucosa pink moist, teeth intact (or describe),

no JVD noted, trachea midline, respirations even/unlabored, breath sounds (clear to all lobes or

crackles noted to ___, course breath sounds noted to ___), S1S2 with regular rate and rhythm (or

regular rate and irregular rhythm), apical pulse ___(put whatever the rate is), skin temperature

warm, dry, intact (or document where it is not intact or where bruising or other skin irregularities

re noted), 2+ (or whatever they are) radial and pedal pulses bilaterally, cap refill < 3 seconds to

fingers and toes, abdomen soft, round, non-tender (if tender, note which quadrant and ask patient

to describe then document the type of pain felt and number on 1-10 pain scale) with

hypo/normo/hyperactive bowel sounds to 4 quadrants, (note if patient has PEG tube and which

quadrant it is located, what type of feeding is infusing and rate), indwelling urinary catheter

noted with ___ml of _____ colored urine noted in drainage bag, peripheral or PICC or midline

IV noted to (put where IVs are located), brisk (or sluggish or no blood return noted), each port

flushed with 10 ml NaCl, then put what type of IV fluid and rate are hanging if applicable) (Ex.

NaCl infusing at 100 ml/hr on pump), strong (or weak) hand grips noted to upper extremities

bilaterally (or document any weakness or paralysis), strong dorsal/plantar flexion noted to lower

extremities bilaterally (or document any weakness or paralysis), skin intact to posterior aspect of

body (or document where any skin breakdown is noted), side rails up x 2, bed locked and in

lowest position, call bell within reach, denies any pain or complaints at present, will continue to

observe.

Head to Toe Assessment Narrative Example