My experience!

Nursing assessment forms are a vital part in the hospital environment. They are essential in ensuring that data and documentation about a patient is verified and contains accurate and complete information. These forms help doctors and nurses alike in recording and capturing a patient’s medical history and information.

Nursing assessment forms include the following:

• Data Base and History — This includes the basic information about the patient like the name, date of birth, sex, age, address, civil status, date and time of admission, initial vital signs, and the chief complaints and history of the current illness. Allergies and admitting diagnosis are also included in this part as well as the name of the attending physician.
• Nursing Assessment – Is the part that has the information on the medical assessment on the patient. This includes subjective and objective items. Objective items like general appearance (skin, eyes, mouth, tongue etc.), while subjective items are about the usual diet, food restrictions and intolerance.
• Laboratory and diagnostic examinations
• Nursing Care Plan – The plan on how to care for the patient like the medications and the dosage and frequency they should be taken.
• Drug Study – The list of medications that the patient is taking and how they affect him or her at a certain period of time.
• Health Teachings – What was advised to the patient with regard to his diet, exercise, and lifestyle to be able to keep his or her health.
• Pathophysiology (also physiopathology) — Which includes the functional changes related with or resulting from disease or injury.