Basics of nursing initial assessment needed to be done when a patient is received in the department. Done by the registered nurse, initial assessment is the basis on which further care is planned.
2. Purpose
• To identify parameters and define
responsibilities to plan and deliver the
appropriate level of care to meet the patient’s
needs
3. Points to note
• Initial assessment should commence within 15
minutes of receiving patient
• The nurse assigned to the patient is responsible for
completion
• Documentation should be in permanent ink
(black/blue ink)
• The nurse must write her name and sign with the
date and time
4.
5. Procedure
• Enter the patient’s name, MR no., age
• Enter time of admission, diagnosis, chief
complaints
• Document the source of information (patient,
family etc.)
• Enter previous hospitalization history
• Check vital signs, height and weight
• Assess and document location and severity of
pain
6. • Document history of allergy
• Check medicines brought to the hospital
• Document if they have valuables
7. Review of systems: Neuromuscular
• LOC and speech
• Pupils: reaction and appearance
• Extremity movement