• A colourful abstract logo featuring four interlocking heart-like shapes in red, grey, dark blue and light blue, arranged symmetrically around a central point, with a matching coloured circle at the outer end of each shape

  • Nursing Assessment

  • Date of Birth:*
     - -
  • Allergies*

  • 1. GENERAL / OBSERVATIONS

  • Appearance / hygiene:*
  • Consciousness / LOC:*
  • Behaviour / mood:*
  • Pain (0-10) / location:*

  • 2. NEUROLOGICAL

  • Orientation: person / place / time:*
  • Speech:*

  • 3. HEAD / FACE / EYES / EARS / NOSE / MOUTH

  • Eyes / vision:*
  • Ears / hearing:*
  • Nose / sinuses:*
  • Mouth / teeth / dentures / own teeth*

  • 4. GENITOURINARY / ELIMINATION

  • Continence:*

  • 5. MUSCULOSKELETAL / MOBILITY

  • Mobility / gait:*
  • Mobility aids*
  • Assistive devices:*
  • Falls risk / assistance required:*

  • 6. SKIN / PRESSURE INJURY RISK

  • Skin colour / temperature:*
  • Integrity / wounds:*
  • Pressure areas:*
  • Dressings / treatment:*
  • A colourful abstract logo featuring four interlocking heart-like shapes in red, grey, dark blue and light blue, arranged symmetrically around a central point, with a matching coloured circle at the outer end of each shape

  • Nursing Assessment

  • 7. LINES /DRAINS / DEVICES

  • Devices:*

  • 8. MEDICATION / ALLERGY CHECK

  • Medication concerns / recent changes:*
  • Allergies / reactions:*
  • PRN requirements / effectiveness:*

  • 9. MENTAL / PSYCHOSOCIAL

  • Mood / affect:*
  • Anxiety / distress:*
  • Communication needs:*
  • Support person / social concerns:*

  • 10. SAFETY / RISK

  • Falls risk:*
  • Pressure injury risk:*
  • Infection precautions:*
  • Other safety concerns:*

  • 11. OVERALL ASSESSMENT / NURSING NOTES

  • Main findings / concerns:*
  • Changes from baseline:*
  • Actions taken / interventions:*
  • Escalation / who notified:*
  • Plan / ongoing monitoring:*
  • Date/Time:*
     - -
  • Time*
  •  
  • Should be Empty: