Free Professional Nursing Assessment Checklist

1

Verify the patient’s full name.

2

Confirm date of birth.

3

Cross-check medical record number (MRN).

4

Ensure wristband information is accurate.

5

Document the patient’s contact details.

1

Measure and record body temperature.

2

Take pulse rate, respiratory rate, and blood pressure.

3

Monitor oxygen saturation levels (SpO2).

4

Review chronic conditions and current medications.

5

Note any allergies and surgical history.

1

Inspect the skin for wounds, rashes, or discoloration.

2

Assess mobility and range of motion.

3

Check the respiratory system (e.g., lung sounds).

4

Evaluate the cardiovascular system (e.g., heart sounds, circulation).

5

Palpate the abdomen for tenderness or abnormalities.

1

Determine pain level using a scale (0–10).

2

Identify pain location, duration, and nature.

3

Observe emotional state (e.g., calm, agitated).

4

Assess cognitive function and behavioral patterns.

5

Screen for signs of anxiety or depression.

1

Review dietary intake and feeding habits.

2

Check hydration levels (fluid intake/output).

3

Assess for signs of malnutrition or obesity.

4

Identify any dietary restrictions.

5

Recommend nutritional interventions if needed.

1

Summarize findings from the assessment.

2

Identify key nursing diagnoses.

3

Develop a care plan based on the findings.

4

Communicate care plans with the healthcare team.

5

Educate the patient and family about the care plan.

1

Review the completed checklist for accuracy.

2

Sign and date the completed assessment.

3

File the checklist in the patient’s medical record.

4

Update the electronic health record (EHR) if applicable.

5

Confirm checklist completion with a supervisor if required.