Head-to-Toe Assessment Documentation
Head-to-toe assessment documentation records the findings of a systematic physical assessment, usually organized by body system.
Educational use & privacy
Educational documentation practice only. Use fictional or instructor-provided information. Do not enter real patient information or protected health information (PHI). Documentation requirements vary by organization, setting, role, policy, and applicable law.
Nursing Notes Privacy & SafetyContent status: Draft — not yet professionally reviewed.
Why it is structured this way
Organizing by system helps readers find information quickly and helps the writer notice what has not been assessed yet. The most important rule: only document assessments actually performed and findings actually observed or obtained. A system you did not assess should not appear as normal.
When this may be used
- On admission and at intervals defined by facility policy.
- After a change in condition.
- Documentation requirements, frequency and screens vary by organization, setting and EHR. Follow your program's and facility's policy.
Only document what you actually assessed
Do not chart normal findings for a system you did not assess, and do not copy findings forward from an earlier assessment. If a system was not assessed, follow your facility's policy for showing that.
Components
General appearance
First impression.
What belongs here
- Observed appearance, behavior, apparent distress
What does not belong
- Judgments like "lazy" or "difficult"
Neurological
Mental status and neuro findings.
What belongs here
- Level of consciousness, orientation, speech, pupils if assessed
What does not belong
- "Neuro intact" if not assessed
Respiratory
Breathing.
What belongs here
- Rate, effort, breath sounds by area, oxygen device and flow, SpO2 if obtained
What does not belong
- "Lungs clear" without auscultating
Cardiovascular
Circulation.
What belongs here
- Heart rate and rhythm, pulses, capillary refill, edema
What does not belong
- Findings from another nurse's assessment presented as yours
Gastrointestinal
Abdomen and nutrition.
What belongs here
- Abdomen appearance/palpation, bowel sounds, diet tolerance, last BM as reported
What does not belong
- Assumptions about intake
Genitourinary
Elimination, where applicable.
What belongs here
- Voiding, urine characteristics, catheter
What does not belong
- Unassessed findings
Musculoskeletal / mobility
Movement.
What belongs here
- Strength, range of motion, gait, assistance needed
What does not belong
- "Ambulates well" without detail
Skin
Integrity.
What belongs here
- Color, temperature, moisture, integrity, wounds
What does not belong
- Wound stage you are not trained to assign
Pain
Comfort.
What belongs here
- Rating, location and characteristics as reported
What does not belong
- Your estimate of their pain presented as their rating
Lines, tubes, drains
Devices, when present.
What belongs here
- Type, site, condition, patency as assessed
What does not belong
- Devices not checked
Safety
Precautions.
What belongs here
- Measures actually in place
What does not belong
- Measures you intended but did not implement
Psychosocial
Relevant observations.
What belongs here
- Mood as described by patient, observed behavior, support present
What does not belong
- Labels or diagnoses
Short fictional example
- Respiratory
- Respirations 18, even and unlabored. Breath sounds clear in all lobes. SpO2 97% on room air.
- Cardiovascular
- Apical pulse 78, regular. Radial pulses 2+ bilaterally. No edema in lower extremities.
More detailed fictional example
- General appearance
- Sitting up in bed, groomed, speaking in full sentences.
- Neurological
- Alert and oriented to person, place, time and situation. Speech clear. Pupils equal, round, reactive to light.
- Respiratory
- Respirations 18, even and unlabored. Breath sounds clear in all lobes. SpO2 97% on room air.
- Cardiovascular
- Apical pulse 78, regular. Radial and pedal pulses 2+ bilaterally. Capillary refill less than 3 seconds. No edema.
- Gastrointestinal
- Abdomen soft, nontender. Bowel sounds active in all four quadrants. Patient reports last bowel movement yesterday evening.
- Genitourinary
- Patient reports voiding without difficulty. Urine clear yellow.
- Musculoskeletal / mobility
- Moves all extremities. Hand grips equal. Walked to bathroom with standby assistance.
- Skin
- Warm, dry, intact. No redness over sacrum or heels.
- Pain
- Patient rates pain 0/10.
- Lines / tubes / drains
- Saline lock in left forearm; site without redness or swelling; flushes without resistance.
- Safety
- Bed in low position, call light within reach, nonskid socks on.
- Psychosocial
- Patient states "I'm worried about my dog at home." Spouse visiting.
Annotated example
Notes on the detailed example above:
Every finding below was assessed in this scenario.
— The example only includes systems assessed. In practice, leave out or mark per policy anything you did not assess.Breath sounds clear in all lobes
— Says where the nurse listened, not just "lungs clear."Patient reports last bowel movement yesterday evening.
— Reported information is labeled as reported."I'm worried about my dog at home."
— Psychosocial content quotes the patient rather than labeling them "anxious."
Common mistakes
- Charting a full normal assessment when only part was assessed.
- Copying findings forward from the previous shift.
- Using "WNL" or "WDL" without the organization's definitions.
- Mixing patient reports and observations without labeling them.
Good vs poor documentation
Weaker (fictional)
Head-to-toe WNL.
Stronger (fictional)
Respiratory: respirations 18, even and unlabored; breath sounds clear in all lobes; SpO2 97% on room air.
Why: Specific findings show what was actually assessed.
Blank educational template
Head-to-toe assessment: Document only the systems actually assessed. Prompts only; nothing is prefilled.
- General appearance
- [Observed appearance, behavior, distress level]
- Neurological
- [Level of consciousness, orientation, other findings assessed]
- Respiratory
- [Rate, effort, breath sounds, oxygen use, SpO2 if obtained]
- Cardiovascular
- [Heart rate/rhythm, pulses, capillary refill, edema if assessed]
- Gastrointestinal
- [Abdomen, bowel sounds, diet tolerance, last BM if obtained]
- Genitourinary
- [Voiding, output, catheter if applicable]
- Musculoskeletal / mobility
- [Strength, gait, assistance needed]
- Skin
- [Color, temperature, integrity, any wounds]
- Pain
- [Pain rating and characteristics if assessed]
- Lines / tubes / drains
- [Type, site, condition, if present]
- Safety
- [Safety measures actually in place]
- Psychosocial
- [Relevant observations or statements]
Practice this format
- Practice Note Builder — write a practice note from a fictional scenario.
- Documentation practice questions
Related documentation guides
- Charting by exception
- Admission note
- Objective vs subjective
- NCLEX Reduction of Risk Potential review — Assessment findings and changes in status.
Sources
- ANA's Principles for Nursing Documentation (2010) — American Nurses Association.
- Nursing Fundamentals 2e — 2.5 Documentation — Open RN (Chippewa Valley Technical College).
- Fundamentals of Nursing — 14.5 Guidelines for Effective Documentation — OpenStax.
All examples on this page are original and fictional. Sources are used to check principles; they do not endorse Dosage Calcs. See Privacy & Safety.