Progressive Care Nursing Assessment Form
Use this form to assess progressive care nursing needs and observations comprehensively. All responses help inform care priorities and support planning.
Date of Assessment
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Assessed By (Full Name)
*
First Name
Last Name
Patient Alertness Level
*
Fully alert
Drowsy but arousable
Confused
Unresponsive
Respiratory Status
*
Stable, no support needed
Requires supplemental oxygen
On non-invasive ventilation
Requires frequent monitoring
Pain Level (0 = No pain, 10 = Severe pain)
*
0
0
1
2
3
4
5
6
7
8
9
10
10
0 is 0, 10 is 10
Mobility Assessment
*
Independent
Requires minimal assistance
Requires moderate assistance
Bedbound
Nursing Intervention Needs (Select all that apply)
*
Frequent vital sign monitoring
Medication administration
Wound care
Mobility assistance
Nutritional support
Other
Key Indicators Assessment
*
Rows
Excellent
Good
Fair
Poor
Skin integrity
1
2
3
4
Fluid balance
5
6
7
8
Cognitive status
9
10
11
12
Emotional state
13
14
15
16
Overall Patient Risk Level
*
Low
Moderate
High
Additional Observations or Recommendations
Submit Assessment
Should be Empty: