Hospital Patient Assessment Checklist
Complete this checklist during a patient assessment to record key observations and findings.
Patient Initials
*
Assessment Date and Time
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Vital Signs (Check all observed)
*
Temperature within normal range
Heart rate regular
Blood pressure stable
Respiratory rate normal
General Observations (Check all that apply)
Alert and oriented
Skin color normal
No signs of distress
Mobility unimpaired
Symptom Checklist (Check all present symptoms)
Fever
Cough
Shortness of breath
Pain
Nausea or vomiting
Other (specify below)
Pain Assessment (0 = No pain, 10 = Worst pain)
0
0
1
2
3
4
5
6
7
8
9
10
10
0 is 0, 10 is 10
Mental Status
Alert
Confused
Drowsy
Unresponsive
Mobility Assessment
Independent
Needs assistance
Bedridden
Input Table: Assessment Summary
Rows
Normal
Abnormal
Not Assessed
Cardiac
1
2
3
Respiratory
4
5
6
Neurological
7
8
9
Additional Notes
Submit Assessment
Should be Empty: