Assesssment in Simulation
Template
Updated on 11 February 2021
College of Nursing
Health Assessment (NURS-204)
First Semester – AY 2024-2025
HEALTH ASSESSMENT CHECKLIST
General Survey
Student’s Name: …………………………………………………. .ID: ……………………………….
Student’s People Soft #: …………………… Group: ……….... Date: ……………………………
Procedure 2 1 0
1 Prepare the necessary equipment
2 Wash hands
3. Introduce yourself
4. Check the patient’s identity by full name and ID
5. Prepare the patient, suitable position, privacy and safety
General Survey: Inspection (Observing)
6. General appearance (dress, hygiene)
7. Gait
8. Ambulation
9. Color (skin, eye)
10. Skin (temperature, moisture, scars, lesions, wounds, redness or edema)
11. Speech (language, complete sentences, interrupted or incomprehensive)
12. Hygiene (Grooming, dressing, odor)
13. Body built (obese, overweight, ideal, underweight, emaciated)
14. Language (understandable, foreign language, need interpreter)
15. Mental status (alert, confused orientation, GCS)
16. Behavior (mood, affect)
17. Contraption (O2, IVF, foley’s catheter or NGT)
Patient Interview:
Patient Interview:
Demographic Data: Patients Name
Gender
Age
Nationality &Spoken language
Occupation
Marital Status
Educational Level
After Care
18. Explain to the patient that the assessment is complete.
19. Discard supplies, remove PPE, and perform hand hygiene.
20. Document assessment results on nurses’ notes.
21. Close room door and bedside curtain.
22. Notify health care provider of abnormal findings.
Total Score
Score out of 10:
2 = Correct/Complete 1=Correct/Incomplete 0=Wrong/Not Done
Student’s Signature:
Instructor’s Signature:
Assesssment in Simulation
Template
Updated on 11 February 2021
College of Nursing
Health Assessment (NURS-204)
First Semester – AY 2024-2025
HEALTH ASSESSMENT CHECKLIST
History Taking
Student’s Name: …………………………………………………. .ID: ……………………………….
Student’s People Soft #: …………………… Group: ……….... Date: ……………………………
Procedure 2 1 0
1 Prepare the necessary equipment.
2 Wash Hands
3. Introduce self, welcome the patient, explain your role and the procedure
(what you will do). Make sure that you have your ID on.
4. Prepare the patient, choose the suitable position.
Keep privacy and promote confidentiality
Assure safety,
History taking
5. What brings you to the clinic today?
What are the reasons that you are seeking health care today?
What is your major health problem or concerns at this time? and “How
do you feel about having to seek health care?”
What do you feel and is there any changes felt recently?
Do you have pain, burning, shortness of breath, chest
discomfort, change in bowel or bladder habits, change in
sleeping habits, cough, discharge from any orifice, depression,
sadness, or change in appetite?
Take note of non-verbal cues and gestures.
6. Present illness
Chief Complain (Reason for admission)
Onset (time start)
Location (site of complain)
Characteristic (feature of the complaint)
Severity (sharp, dull, acute, chronic) also using scale of pain
Aggravating factor (the factor increases or decrease the
complaint)
7. Medication History (Medication taken at home; indicate last dose &
reason)
Allergy (Food, Drugs…etc.)
Nutritional Status (good appetite, poor appetite)
Changes in bowel habits & bladder
8. Past Health History
Any childhood illness, immunization
Past Hospitalization
Past medical History (History of cancer, cardiac diseases,
thyroid gland abnormalities, hypertension, diabetes, and blood
diseases.)
Past Surgical History (any surgery done in the past)
Medication History
Allergies
Assesssment in Simulation
Template
Updated on 11 February 2021
Prescription of over-the-counter medication
9. Lifestyle
Smoking if present
Sleeping pattern (continuous, interrupted, how many
hours per day)
Physical Activity (active, lazy/sedentary, ranged)
10. Family History
Ask about the parents and close relatives
Any inherited disease in the family
11. Vital Signs.
Check the client’s temperature, blood pressure, respiration rate, pulse
rate and O2 saturation. Height and weight.
12. Start head to toe health assessment
13. Thank the patient and ask if the client has any concern.
14. Do aftercare of the equipment's used.
15. Discard gloves and do medical hand washing.
16. Document the procedure especially the abnormalities noted. Refer to a
specialist if necessary.
Total Score
Score out of 10:
2 = Correct/Complete 1=Correct/Incomplete 0=Wrong/Not Done
Student’s Signature:
Instructor’s Signature:
