If you’ve ever gone to see a doctor or, more specifically, if you’ve ever been hospitalized, chances are you have had to answer some fairly specific questions regarding your overall health and habits. These questions are usually asked and recorded by the nurse in charge of your case and transferred to what is known as a nursing assessment form. In this article we will briefly define the purpose behind the nursing assessment form and show you what type of questions and information are usually included.
What Is a Nursing Assessment Form and Why Is It Necessary?
If you become hospitalized for any reason, chances are you will see the doctor in charge of your case only when absolutely necessary. The reason for this is that doctors typically have large caseloads and are required to see multiple patients each and every day. As a result, most of the interaction you will have as a patient is with the nurse in charge of your case, and one of his or her primary duties is to record some very specific information regarding your overall health and well-being. This data is usually placed on a nursing assessment form and will be used by the doctor to make case by case decisions regarding your need for care, and it will also alert him of any sensitive health information that will enable him to treat you in the best possible manner.
What Type of Information Is Included on a Nursing Assessment Form?
A nursing assessment is a comprehensive document used to collect a variety of information on patients. Some of the items that would typically be included on one of these forms include:
• Allergies. Whether the patient is hospitalized or being treated as an outpatient, all allergies will need to be recorded so as to avoid exposure to these allergens. This includes allergies to certain foods, substances and medications.
• Immunizations. Doctors need to know about all immunizations in order to treat patients effectively.
• Medical History. The medical history is easily the most time consuming portion of the nursing assessment. It is here that patients will be asked whether or not they have, or have had certain conditions, including surgical procedures.
• Medications. All medications currently being taken by the patient need to be included on the assessment form.
• Family History with Regard to Certain Health Conditions.
• Special Needs and Limitations. Special needs and limitations, such as mobility issues, feeding and toileting need to be dutifully recorded to ensure patient comfort and safety.
• Sleep Patterns. Normal—and abnormal—sleep patterns should also be included on the form.
• Religious Preference of the Patient.
• Dietary Restrictions. Patients will often be placed on special diets while undergoing treatment.
• Daily Habits. The daily habits of the patient, including hobbies and interests, are essential pieces of information for the attending physician.
• Recommendations. Nurses, because they spend more time with patients, are required to make recommendations as to the best way to treat them.
The nursing assessment form is absolutely critical in the healthcare field. It allows doctors to get a quick snapshot with regard to the patient while still freeing him or her up to see multiple patients at once. Moreover, it enables the entire team to offer the best possible treatment in the most efficient manner.