Dictate as you assess. Get every system written up.
Dictate your findings as you go or when you finish. Vero Scribe writes them in your head-to-toe template, system by system, for you to check, edit, and copy into the EHR.
Head-to-Toe Assessment Template
A head-to-toe assessment documents a systematic nursing assessment of every body system, with risk scores, lines and drains, and anything you escalated. Copy the free template, see two filled examples, and check what to record for each system.
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- Word and text downloads
- Two filled examples
Blank head-to-toe assessment template
FreeHEAD-TO-TOE ASSESSMENT Patient: [Name] Date of birth: [Date] Unit and room: [Location] Date and time: [Date, time] Reason for admission: [Diagnosis or procedure, and day of stay or post-op day] Allergies: [Drug, latex, and food allergies, with reactions] Code status: [Code status] Nurse: [Name, credentials] VITAL SIGNS AND PAIN Vital signs: [Temperature, HR, BP, RR, SpO2, and oxygen device and flow] Early warning score: [Score and tool, if your unit uses one] Pain: [Site, score and scale used, character, last dose, and reassessment] NEURO AND HEENT Level of consciousness: [Alert, responds to voice, responds to pain, or unresponsive] Orientation and cognition: [Person, place, and time; delirium screen result; usual baseline] Pupils: [Size, equality, and reaction to light] Speech and limbs: [Speech, and strength and sensation in all four limbs] HEENT: [Glasses or hearing aids, mucous membranes, dentures, swallowing] CARDIOVASCULAR Heart: [Apical rate and rhythm, heart sounds, telemetry rhythm if monitored] Circulation: [Peripheral pulses, capillary refill, skin color and temperature] Edema: [Site and grade] VTE prevention: [Compression devices, anticoagulant given, mobility] RESPIRATORY Breathing: [Rate, depth, effort, accessory muscle use] Breath sounds: [By lung field, with any added sounds] Cough and sputum: [Cough, sputum color and amount] Oxygen and devices: [Device and flow, incentive spirometer use] GI AND GU Abdomen: [Shape, bowel sounds, tenderness, distension] Intake: [Diet ordered, how much eaten and drunk, nausea or vomiting] Bowels: [Last bowel movement, flatus] Urine: [Voiding or catheter, color, output in mL, time of last void] MUSCULOSKELETAL AND SKIN Mobility: [Activity ordered, assistance and aids, weakness, range of motion] Skin: [Color, temperature, moisture, turgor] Wounds and incisions: [Site, appearance, drainage, dressing] Pressure injury risk: [Braden score, pressure points checked, repositioning] PSYCHOSOCIAL AND SAFETY Mood and coping: [Mood, anxiety, sleep, support present] Communication: [Language, interpreter, hearing or vision needs, teaching given] Fall risk: [Score and tool, precautions in place] Safety measures: [Bed low, call bell in reach, isolation, restraints if any] LINES AND DRAINS IV access: [Type, site, gauge, insertion date, site condition, infusions] Drains and tubes: [Type, site, output, and appearance] Urinary catheter: [Type, insertion date, ongoing need, or none] PLAN AND ESCALATION Changes since last assessment: [New or abnormal findings] Escalated to: [Name and role, time, what was reported, and the response or orders] Nursing plan: [Interventions, teaching, and next reassessment time] Signed: [Nurse name, credentials, date and time]
Use it for
- Admission assessments
- Start of shift
- Post-op care
- Change in condition
- Transfers between units
Two filled examples. Every part, filled in.
Each one follows the template. Use them to judge how much detail every part needs.
Head-to-toe assessment: post-op day 1
Surgical ward, start of day shift, 08:00
Vital signs and pain
66-year-old man, post-op day 1 after a laparoscopic right hemicolectomy. Allergic to penicillin (rash). Full code. T 37.6 °C (99.7 °F), HR 88, BP 128/76, RR 18, SpO2 95% on 2 L/min by nasal cannula. Early warning score 3 on the unit’s tool, unchanged from overnight. Incision pain 3/10 at rest and 6/10 on moving, numeric scale. Acetaminophen 1,000 mg and oxycodone 5 mg by mouth at 06:00; 2/10 at rest when rechecked at 07:00.
Neuro and HEENT
Alert; oriented to person, place, and time. Delirium screen negative. Pupils equal, 3 mm, reactive to light. Speech clear; moves all limbs with equal strength; sensation intact. Wears glasses. Lips dry, mucous membranes moist; swallowing sips without difficulty.
Cardiovascular
Apical HR 88, regular; S1 and S2, no added sounds. Radial and pedal pulses present and equal; capillary refill under 3 seconds; skin warm. No edema. Compression devices on both legs; enoxaparin 40 mg subcutaneous due at 09:00.
Respiratory
RR 18, even and unlabored. Clear in the upper lobes; diminished at both bases. Weak, dry cough. 2 L/min by nasal cannula. Incentive spirometer 750 mL, below his pre-op 1,500 mL; re-taught to use it 10 times an hour while awake.
GI and GU
Abdomen soft, mildly distended, tender around the port sites. Bowel sounds hypoactive; passing flatus since 05:00; no bowel movement since surgery. Clear fluids, 400 mL since midnight; no nausea. Urinary catheter removed at 06:00 per order; due to void by 12:00. Urine overnight 40 to 60 mL an hour, clear yellow.
Musculoskeletal and skin
Sat at the edge of the bed with 1 assist overnight; brief dizziness on standing, which passed. Moves all joints; no new weakness. Skin warm and dry. Five port sites and a small incision near the navel, closed with skin glue: edges together, no redness or drainage. Braden 18; heels and sacrum intact; repositions himself.
Psychosocial and safety
Calm; slept about 4 hours, woken by pain. Wife visiting at 10:00. Understands the plan to walk 3 times today. Morse Fall Scale 45: bed low, call bell in reach, non-slip socks, and 1 assist for all walking.
Lines and drains
Peripheral IV, 20 gauge, left forearm, inserted on the day of surgery: site clean, no redness or swelling, flushes easily; saline lock. No surgical drains. Urinary catheter removed, as above.
Plan and escalation
Change: SpO2 95% on 2 L/min with diminished bases. Reported to the surgical resident on rounds at 08:20: wean oxygen to the ordered target, encourage incentive spirometry and walking; no new orders. Nursing plan: orthostatic vital signs before the first walk; walk in the hallway 3 times today with 1 assist; bladder scan if no void by 12:00; full reassessment at 12:00, sooner if SpO2 drops or he becomes short of breath.
Head-to-toe assessment: older adult with pneumonia
Medical ward, start of day shift, 08:00, day 3 of admission
Vital signs and pain
81-year-old woman, day 3 of admission with right lower lobe pneumonia, on IV antibiotics. No known drug allergies. Full code. T 37.4 °C (99.3 °F), HR 86, BP 134/78, RR 20, SpO2 93% on 1 L/min by nasal cannula. Early warning score 2, down from 5 on admission. Right-sided chest pain on coughing, 3/10; acetaminophen 650 mg by mouth at 06:00; 1/10 at 07:00.
Neuro and HEENT
Alert; oriented to person and place, not to the date. Her daughter says she usually knows the date. Delirium screen negative today; positive on the first night. Pupils equal and reactive. Speech clear; generalized weakness, no one-sided weakness. Hearing aid in the right ear, in place and working; glasses on. Mouth dry; upper denture cleaned. Passed the nursing swallow screen on admission; no coughing with breakfast.
Cardiovascular
Apical HR 86, regular. Pedal pulses present on both sides; capillary refill under 3 seconds. Trace pitting edema at both ankles, which her daughter says is usual for her. Subcutaneous heparin for clot prevention, as ordered.
Respiratory
RR 20; mildly short of breath walking to the bathroom. Crackles in the right lower lobe; diminished at the right base; left lung clear. Productive cough, small amounts of yellow sputum. SpO2 93% on 1 L/min at rest, 89% after walking to the bathroom, back to 93% after 2 minutes of rest.
GI and GU
Abdomen soft, not tender; bowel sounds present. Ate about 25% of breakfast; poor appetite since admission. Drank about 900 mL in the last 24 hours. Last bowel movement 4 days ago, before admission. Voiding with help to the commode; urine dark yellow, about 150 mL each time, 3 times overnight.
Musculoskeletal and skin
Walks with a walker and 1 assist; uses a cane at home. Generalized weakness. Skin warm and dry; reduced turgor. New 2 cm area of non-blanchable redness over the sacrum, skin intact: stage 1 pressure injury. Heels intact. Braden 14. Weight 52 kg (115 lb).
Psychosocial and safety
Anxious about going home; lives alone, and her daughter visits daily. Uses her hearing aid; teach-back used for all teaching. Morse Fall Scale 60: bed alarm on, bed low, call bell and walker in reach, toileting offered every 2 hours.
Lines and drains
Peripheral IV, 22 gauge, right hand, inserted 2 days ago: site clean, no redness or swelling; saline lock between antibiotic doses. No urinary catheter or drains.
Plan and escalation
Changes: new stage 1 sacral pressure injury; low food and fluid intake; oxygen saturation drops on walking. Reported to the attending physician on rounds at 09:00: dietitian and wound care referrals ordered; oxygen to continue at 1 L/min, with SpO2 rechecked on walking; bowel regimen started. Nursing plan: reposition every 2 hours, pressure-redistributing mattress requested, heels offloaded, barrier cream; encourage fluids and record intake; walk with physical therapy; reassess at 12:00.
What goes in each part.
Vital signs and pain
The numbers that tell a reader how unwell the patient is right now, and whether pain is controlled.
- A full set of vital signs, with the oxygen device and flow
- The early warning score, if your unit uses one
- Pain site, score, and the scale used
- The last dose given, and the reassessment after it
Avoid: Recording a pain dose without the reassessment that followed it.
Neuro and HEENT
Level of consciousness and cognition first, compared with the patient’s usual baseline, then the head and senses.
- Level of consciousness and orientation
- Delirium screen result
- Baseline from family or the admission assessment
- Glasses, hearing aids, dentures, and swallowing
Avoid: Writing “confused” without a baseline. New confusion in an older adult can be the first sign of delirium.
Musculoskeletal and skin
How the patient moves, and the skin that immobility puts at risk.
- Activity level, aids, and assistance needed
- Wounds and incisions: site, appearance, drainage
- Braden score and pressure points checked
- Any pressure injury, staged and measured
Avoid: “Skin intact” without having checked the sacrum and heels.
Psychosocial and safety
How the patient is coping, and what keeps them safe on the unit.
- Mood, anxiety, sleep, and support
- Language and communication needs
- Fall risk score and the precautions in place
- Isolation or restraints, with the reason
Avoid: A fall risk score with no precautions listed.
Lines and drains
Every device: where it is, how long it has been in, and how it looks.
- IV type, gauge, site, insertion date, and site condition
- Infusions running, and their rates
- Drain type, output, and appearance
- Catheters, and whether each is still needed
Avoid: Leaving out the insertion date. Line and catheter days matter for infection risk and planned changes.
Plan and escalation
What changed, who you told, and what happens next.
- New or abnormal findings since the last assessment
- Who you escalated to, when, and what you reported
- The response, and any orders
- Nursing interventions and the next reassessment time
Avoid: “Physician aware.” Write who, when, what you said, and what was decided.
Common mistakes, and how to avoid them.
Copying the last shift’s assessment
A copied assessment hides changes such as new confusion or a new pressure injury. Chart what you found on this assessment.
Charting by exception with no defined normal
If your unit charts by exception, “within normal limits” only works when the normal is defined for each system. Write every abnormal finding in full.
Findings with no baseline
Ankle edema, confusion, or weakness mean different things if they are new. Compare with the admission assessment or ask the family, and record the baseline.
Risk scores with no actions
A Braden or fall risk score should be followed by what you put in place, such as repositioning, a mattress, or a bed alarm.
Oxygen saturation without the flow
SpO2 means little without the oxygen device and flow, or “room air.” Record them together every time, so a trend can be read.
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Frequently asked questions.
What order should a head-to-toe assessment follow?
Start with general appearance, vital signs, and pain, then work down: neurological, HEENT, cardiovascular, respiratory, abdomen and elimination, musculoskeletal, and skin. Finish with safety, lines, and drains. Follow your unit’s form; covering every system matters more than the order.
How often do nurses do a head-to-toe assessment?
On admission, at the start of each shift on most hospital units, and whenever the patient’s condition changes, with focused reassessments in between. Follow your unit’s policy.
What is the difference between a head-to-toe and a focused assessment?
A head-to-toe assessment covers every system. A focused assessment looks closely at one system or problem, such as breathing after a drop in oxygen saturation.
Can I chart a head-to-toe assessment by exception?
Only where your organization defines what normal means for each system. Write abnormal findings in full, and compare them with the baseline.
Is this head-to-toe assessment template free?
Yes. Copy it, or download it as a Word or text file. No account needed.
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