What Goes Into a Nursing Assessment Form?

May 15, 2024
Table of Contents
Table of Contents

A nursing assessment form is an indispensable tool in the healthcare industry. It helps record a patient’s needs so that each can receive comprehensive care.

In this article, we’ll explore the nursing assessment form, starting by understanding its critical components and then concluding with steps to create one in Google Forms. If you’re ready for a thorough dissection of the nursing assessment form, let’s begin!

What is nursing assessment?

Nursing assessment is the process by which a licensed registered nurse gathers information about a patient's health status. This includes details about physical, psychological, social, emotional, and even cultural aspects. 

Nursing assessment is conducted through various methods, including interviews, physical examinations, observations, and medical record reviews. Nurses also assess vital signs, evaluate symptoms, inquire about medical history, and explore the patient's lifestyle, environment, and support systems.

A nursing assessment form helps systematically collect, record, and order this information. It guides them through thorough examinations and can even provide valuable clues for unlocking diagnoses and insights into symptoms. 

Types of nursing assessment forms

The structure of a nursing assessment form can vary depending on the type of assessment. Broadly speaking, there are four types of nursing assessments:

  1. Comprehensive assessment: This is a thorough examination of all aspects of a patient's health, including physical, psychological, social, cultural, and spiritual. 
  2. Initial assessment: Carried out when a patient is admitted to a healthcare facility. It establishes a baseline of the patient's health status.
  3. Focused assessment: This type of assessment usually follows an initial or comprehensive assessment and specifically targets identified health issues.
  4. Ongoing assessment: This involves regularly monitoring the patient's health throughout their stay in the healthcare facility to record progress.

Nursing assessment is a dynamic and comprehensive process that adapts to the patient’s needs. It also forms the basis for promoting health, preventing illness, and facilitating optimal patient outcomes. Nursing assessment forms that are accessible and time-efficient provide a standardized format for documenting assessments and promote compliance with legal and regulatory requirements.

How to create a printable nursing assessment form template with Google Forms

Step 1: Create a new Google Form

Go to your Google Forms.

Start a new form by clicking the ‘Blank form’ button. 

Title the form appropriately and enter a description. 

Step 2: Enter fields for patient personal information

Gathering personal information for accurate recordkeeping is the first essential step. Google Forms starts with a default multiple-choice question.

Enter a question in the question field to gather the patient’s full name. Click the button next to the question field to edit the question format. Opt for a ‘Short answer' type question.

Click the ‘Add question’ button in the floating menu to add more questions to gather personal details like:

  • Patient ID
  • Age
  • Gender identity
  • Address
  • Insurance details
  • Reason for Assessment

For most personal details, you should opt for the multiple-choice format to make the form quick and easy to fill out. 

Step 3: Add short answers for initial vital signs

The next thing to add is questions for essential physical information and vital signs like:

  • Height
  • Weight
  • Blood Pressure
  • Temperature 
  • Pulse rate

Add a new question for each, as shown in the previous step, and opt for the short answer question format. 

Step 4: Add any number of sections for different assessments

With basic information and vital signs done, you can start adding questions for the specific assessments. However, the type and nature of assessments carried out varies, with different assessments. Here are a few categories to consider:

  1. Physical assessment: Evaluates vital signs, skin integrity, cardiovascular, respiratory, gastrointestinal, musculoskeletal, and neurological systems.
  2. Psychosocial assessment: Assesses mental health, emotional well-being, social support, coping mechanisms, and psychosocial stressors.
  3. Functional assessment: Determines the patient's ability to perform daily activities, mobility, independence, and need for assistance.
  4. Nutritional assessment: This review includes dietary intake, nutritional status, weight changes, preferences, allergies, and special dietary needs.
  5. Pain assessment: Evaluates pain level, location, intensity, quality, duration, aggravating and alleviating factors, and impact on daily activities.
  6. Medication assessment: Reviews current medications, effectiveness, side effects, adherence, and medication-related issues.
  7. Risk assessment: This is to identify potential risks such as falls, pressure ulcers, infections, injury, and adverse events.

Depending on the type of assessment that the form is intended for, add different sections for each category.

To do this, click the ‘Add section’ button next to the question, after which you want to introduce a new section. 

Title the section and add relevant, helpful instruction in the description. Then, you can start adding questions as described in Step 2. 

Step 5: Add written section for comments or health plan

Now, it's time to add a section for comments or a detailed health plan. 

This is a written section, so add your question and opt for the ‘Paragraph’ format. Here, you can put down all the action steps you record based on what was entered above. This concludes the assessment part in the form. 

Step 6: Include an e-signature request

The nurse who conducts the assessment is generally required to sign off on the form, so let's learn how to add an e-signature request to your form. You’ll need a simple add-on to Google Forms called Form Publisher for this. Now, you can convert a simple Google Form to one that accepts e-signatures. Learn how you can add e-signature requests to this form. 

Step 7: Create a printable nursing assessment with Form Publisher

The last step is to ensure that your form is printable. While Google Forms allows printing of responses, it’s a long-winded process. By adding Form Publisher to your Google Forms, you’ve already simplified the process for yourself. 

Now, when a nurse fills in the nursing assessment form, the form response will instantly be converted to a response document that you can print out easily when needed. 

What’s more, you will no longer have to search for the filled-out form in the form responses in Google Forms. Your filled-out form will be automatically filed and saved in your preferred location on your Google Drive. Learn how you can easily print Google Form responses

Create nursing assessment form PDFs with Form Publisher

Creating nursing assessment forms in PDF format has multiple benefits. They’re easy to distribute, they’re accessible, and they standardize documentation. With Form Publisher, generating these PDFs becomes easy and efficient.

While Google Forms is streamlining your data collection process, let Form Publisher get to work on making it more efficient by compiling entered information into professional-looking PDF documents.

When healthcare providers focus more on patient care and less on administrative tasks, everyone wins! Try Form Publisher for your nursing assessment forms today!

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