Having you been scouring the Internet, looking for nursing assessment forms you can use as a template of some kind? If you have, you probably already know that there is no shortage of these types of online forms, but which one should you choose? Which is the most appropriate for your situation? Unfortunately, there is no easy answer to this, and it all depends on the quality of the site you visit. The truth is that of all the categories of sites on the Internet today, there is perhaps no category that can boast more websites than the medical field. Whether you’re looking for information on traditional medicine, alternative medicine, holistic treatments or just good old home-spun remedies, you’re bound to find thousands of sites that offer up a solution to your problem. Sadly, though, many of these sites are not recognized as being truly authentic, so you have to be very careful about what you choose as fact. The same can be said when searching for nursing assessment forms; with so much information out there, choosing the one that is right for you can present a challenge.
Nursing Assessment Forms: What to Look For
Nursing assessment forms can range from very simple to very elaborate, depending on the purpose of the form. They are typically used by nurses in a hospital setting, especially by those nurses working in emergency medicine, but they can also be used during simple doctor visits or in clinics.
In short, the purpose of the nursing assessment form is to collect as much pertinent and relative information about the patient and the current problem that he or she is experiencing. This is so the nurse can “assess” the patient’s condition accurately, administer any immediate and crucial care needed and prioritize the patient’s condition in relation to the other patients on a doctor’s current caseload.
Each of these forms will have a space to record the patient’s name and identifying information such as height, weight and age. Some forms will also call for insurance information as well, but typically, that type of information, along with address, telephone number and other contact details related to the patient, is collected later on a separate billing form.
Whether the case is an emergency or merely a routine visit, the nurse working the case is required to take a patient’s vital signs. The results of these tests, tests which measure blood pressure, pulse, temperature and respiration, are almost always included on the nursing assessment form.
After contact information and vital signs have been established and documented, the nurse will usually ask a series of questions to help with the assessment. Some of these questions include:
• What Are Your Symptoms? With this question the nurse is attempting to ascertain not only what the symptoms are, but when the onset of the symptoms occurred and how they actually “feel” at the present moment. For example, is the pain sharp or dull, consistent or intermittent, localized or radiating?
• History and Family History. Understanding the patient’s history of illnesses, surgeries and disease, as well as his/her family’s medical history can help nurses make a more accurate assessment of the current problem.
• Allergies. Listing a patient’s allergies to certain food, medication or other substances will help ensure that the patient is treated properly.
• Lifestyle. A patient’s lifestyle could include things like addictions, sexual activity and work habits.
When searching for appropriate nursing assessment forms online, keep in mind that at minimum they should contain space to list and record the above-mentioned items. Each of these is absolutely necessary for a nurse to make a proper assessment and to recommend care options and expediency of care to the attending physician.