Nursing Skin Color Assessment Checklist
Document nursing observations of skin color and related findings for a patient assessment.
Patient & Assessment Details
Patient Name
*
First Name
Middle Name
Last Name
Date of Birth
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Age
Medical Record Number
Unit / Ward
*
Room / Bed
Date and Time of Assessment
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Assessor Name and Role
*
First Name
Middle Name
Last Name
Skin Color Assessment
Face
*
Please Select
Normal
Pale
Cyanotic
Flushed
Jaundiced
Mottled
Dusky
Other
Lips
*
Please Select
Normal
Pale
Cyanotic
Flushed
Jaundiced
Mottled
Dusky
Other
Nail Beds
*
Please Select
Normal
Pale
Cyanotic
Flushed
Jaundiced
Mottled
Dusky
Other
Hands
*
Please Select
Normal
Pale
Cyanotic
Flushed
Jaundiced
Mottled
Dusky
Other
Arms
*
Please Select
Normal
Pale
Cyanotic
Flushed
Jaundiced
Mottled
Dusky
Other
Legs
*
Please Select
Normal
Pale
Cyanotic
Flushed
Jaundiced
Mottled
Dusky
Other
Trunk
*
Please Select
Normal
Pale
Cyanotic
Flushed
Jaundiced
Mottled
Dusky
Other
Mucous Membranes
*
Please Select
Normal
Pale
Cyanotic
Flushed
Jaundiced
Mottled
Dusky
Other
Pattern, Onset, and Baseline Match
*
Localized
Generalized
Both
Onset Unknown
Associated Clinical Findings & Follow-up
Urgency / Escalation Level
*
Routine
Monitor Closely
Urgent
Immediate Escalation
Other
Associated Clinical Findings
Skin warm
Skin cool
Skin hot
Delayed capillary refill
Edema
Rash
Bruising
Pain
Itching
Shortness of breath
Using oxygen
Other
Skin Temperature
Capillary Refill Time
Additional Observations
Follow-up / Action Taken
*
Please Select
Notify provider
Recheck later
Document only
Apply nursing intervention
Other
Notes / Details of Action
Submit Assessment
Should be Empty: