Template

Adult Nursing Assessment

by Sashah Rajkumar, from the Community

This adult nursing assessment template helps nurses complete a full head-to-toe evaluation and document patient status consistently. Sections cover general condition, neurological checks including Glasgow Coma Scale, cranial nerves, NIH Stroke Scale, respiratory assessment with breath sounds, cardiovascular and peripheral vascular checks, integumentary inspection with Braden risk factors, musculoskeletal range of motion and strength, abdominal assessment with bowel sounds, genitourinary and reproductive findings, and psychosocial status. It supports subjective and objective data collection, identification of risks such as delirium or pressure injury, and formation of a nursing care plan. Auditors are guided to validate documentation promptly after patient assessment.

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Confirm accountability and compliance with a digital log

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This community page makes available free workplace checklists and templates created by other users within the SafetyCulture community. SafetyCulture has re-published this content and where possible, has credited the original author. SafetyCulture has not verified the accuracy, reliability or suitability of any community content. You agree that your use of any of this content is in accordance with SafetyCulture’s Terms and Conditions.

Template
Adult Nursing Assessment Checklist
This adult nursing assessment template supports comprehensive patient evaluations across key systems. It guides auditors and nurses through general observations and detailed neurological checks, including cranial nerves and Glasgow Coma Scale, plus NIH Stroke Scale and Modified Rankin scoring. It covers respiratory assessment with breath sounds, thorax and lung inspection, and cardiovascular assessment with inspection, palpation, percussion and auscultation. Peripheral vascular checks include edema and capillary refill. Additional sections address head and neck, integumentary skin assessments with Braden Scale concepts, musculoskeletal mobility and strength, abdominal examination, genitourinary and reproductive findings, and psychosocial status. Fields are provided for identifiers, shift details and signatures to ensure accurate documentation and validation within required timeframes.
by Sashah Rajkumar, from the Community
Downloads: 30+
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Template
NNI Adult Nursing Assessment Checklist
This adult nursing assessment template helps nurses and auditors validate complete patient evaluations. It covers neurological checks including cranial nerves, level of consciousness and Glasgow Coma Scale, seizure assessment and NIH stroke scale. Respiratory assessments include pattern, rate, breath sounds and use of a stethoscope. Cardiovascular and peripheral vascular sections guide inspection, palpation, auscultation and capillary refill. The integumentary section supports skin assessment with Braden scoring for pressure injury risk. Musculoskeletal, abdominal, genitourinary and reproductive systems are included, along with psychosocial observations. Instructions note the audit should occur within one hour of the nurse’s documentation, with the auditor accompanying the nurse to the patient. Signature fields are provided to complete the record.
by Inna Acad, from the Community
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Template
Adult and Pediatric Physical Assessment Checklist
This checklist supports comprehensive adult and pediatric physical assessments at the bedside. It guides nurses through ISBAR handover, neurological status, head, eyes, ears, nose, and throat, lymph nodes, respiratory pattern and breath sounds, cardiovascular exam including S1 and S2, rhythm, murmurs, and jugular venous distension, and peripheral vascular checks such as edema and capillary refill. It covers integumentary health and Braden scoring, musculoskeletal posture and range of motion, abdominal inspection and bowel sounds, and genitourinary and reproductive considerations for male and female patients. It also includes urine characteristics and psychosocial observations to ensure consistent documentation and patient care.
by Sashah Rajkumar, from the Community
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Template
NNI QT Nursing Documentation Audit Tool
This nursing documentation audit tool supports quality and compliance checks across inpatient care. It helps confirm adult nursing assessments are completed on time, including vital signs, Glasgow Coma Scale and risk screening within required time frames. Review intake and output records, escalation of abnormal laboratory and imaging results to the primary team, and assessment of lines drains and airways with bundle documentation. Validate purposeful rounding, daily care safety and device care. Check pressure injury risk with the Braden Scale, complete SSKIN assessments, and record skin impairments in the Avatar system. Confirm fall risk screening with the Morse Scale, functional and psychosocial screening on admission, and timely nursing notes using the Epic handover template. Ensure care plans and patient goals are documented, education is provided, preferences are recorded, and shift documentation is complete.
by Inn Ymedaca, from the Community
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Adult Nursing Assessment

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Adult Nursing Assessment Checklist

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Adult Nursing Assessment Checklist

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