CHECKLIST ON HEALTH ASSESSMENT

Name of the Student: ……………………………. Evaluated by: …………………………..

Date : ………………. Time : ………………….. Place: …………………………

Sl no. Description Yes No Remarks

1. Preliminary assessment of patient
1.1 Assess the priority of the patient
1.2 Assess the general health condition
1.3 Establishment of good IPR
2. Perform hand hygiene.
3. Preparation of the environment
3.1 Close door or bed curtains and explain the procedure to the patient and patient's
family.
3.2 Position patient comfortably. Expose only areas one by one as per the procedure.
3.3 Put on light and put-off fan
4. Ensure that an appropriate waste receptacle is within easy reach of work area.
5. Set up sterile supplies:
5.1 Clear bedside table; wipe surface with paper towel and hand sanitizer, soap /water,
or other disinfectant available.
5.2 Check for availability and working conditions of all articles.
5.3 Gather all articles.
6. Don clean gloves (If necessary)
6.1 Assess the Emotional State of the patient (Anxious/Calm/Angry/Co-
operative/Restless/Withdrawn)
6.2 Assess the cardio-vascular status of the patient (Regular Pulse/Cyanosis/
Pallor/ Edema/ peripheral pulses/Heart sounds/Blood Pressure/Arrythmia).
6.3 Assess the Circulation (Warmth of Extremities, Colour perfusion, Sensation,
ability to move in all extremities).
6.4 Assess Respiratory Status (Chest movement/ Respiratory pattern/ Air entry/
Breath sounds/ Presence of dyspnea, cough/ Oxygen on flow).
6.5 Assess the Gastro-intestinal Assessment (Tenderness/ vomiting/ Nausea/
Constipation/ Diarrhea/ Bowel Sounds).
6.6 Carry out the Genito-urinary Assessment (Sufficient regular voiding/ clarity
and colour of urine).
6.7 Assess the Neurological status of the patients (Levels of consciousness/
Orientation to date, time, person/ Speech/ Tremors/ Seizures/ Muscle
Weakness/ Gait).
6.8 Assess the status of Musculoskeletal System (Full ROM/ Ability to move
extremities/ Ambulation status.)
6.9 Carry out assessment of skin (Use of Braden Scale, warmth, intact skin,
Diabetic foot care.
6.1 Check for the status of the Invasive Line (Site and condition of Central Line/
0 Peripheral Line/ Arterial Line)
 6.1 Assess the condition of the Incisional Wound (Site/ Healthy/Oozing/ Gaping/
1 Dressing) if present.
6.1 Assess pain of patients using Universal Pain Assessment Tool.
2
6.1 Carry out Fall Risk Assessment of patients.
3
6.1 Give comfortable position to the patient after the assessment.
4
7.
8. Perform hand hygiene.
9. Document procedure (Recording and reporting).

Total score: Obtained score:

Signature of the Student Signature of the Evaluator

Date: ……………… Date: ………………