Nursing Ongoing Patient Assessment Checklist Form
Comprehensive checklist for routine ongoing patient assessment and care tracking. Please complete each section based on your current observations.
Patient Initials
*
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
Level of Consciousness
*
Alert
Drowsy
Unresponsive
Pain Level (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
Mobility Status
*
Independent
Assisted
Bedridden
Skin Integrity
*
Intact
Redness/At risk
Open area/Breakdown
Mood and Orientation
*
Calm and Oriented
Anxious/Disoriented
Agitated
Intake/Output (Select all that apply)
*
Oral intake adequate
IV fluids running
Urine output adequate
Low output/Concern
Fall Risk Assessment
*
Low
Moderate
High
Nursing Interventions/Notes
Submit Assessment
Should be Empty: