Nursing Acuity Assessment Form
Complete this form to assess patient care acuity and determine appropriate staffing or observation levels.
Patient Mobility
*
Independent
Requires minimal assistance
Requires moderate assistance
Bedbound/total assistance
Cognitive Status
*
Alert and oriented
Occasionally confused
Frequently confused
Unresponsive
Pain Level (0 = No Pain, 10 = Severe Pain)
*
No Pain
0
1
2
3
4
5
6
7
8
9
Severe Pain
10
0 is No Pain, 10 is Severe Pain
Risk of Falls
*
Low
Moderate
High
Frequency of Required Interventions
*
Hourly or less
Every 2-4 hours
Every shift
Observation Needs
*
Standard observation
Frequent observation
1:1 observation required
Complexity of Care
*
Routine care
Multiple interventions
Complex/multidisciplinary care
Assistance with Activities of Daily Living (ADLs)
*
Rows
None
Partial
Full
Feeding
1
2
3
Bathing
4
5
6
Dressing
7
8
9
Toileting
10
11
12
Infection or Isolation Risk
*
None
Standard precautions
Contact/airborne precautions
Overall Acuity Rating
*
Low
1
2
3
4
High
5
1 is Low, 5 is High
Submit Assessment
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