Nurse Template

Brief Head to Toe Assessment Notes

A professional Nurse template for healthcare professionals.

About this template

The Brief Head to Toe Assessment Notes template is an essential tool for nurses conducting quick patient evaluations. This template allows for detailed documentation of vital signs, HEENT, respiratory, cardiac, abdominal, musculoskeletal, and skin assessments. It ensures that 6 critical aspects of a patient's condition are recorded in a structured and thorough manner. Ideal for use in various healthcare settings, this template supports nurses in delivering high-quality care by providing a clear and concise record of patient assessments. This template is particularly useful for creating nursing progress notes and clinical documentation examples.

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Vital Signs: The patient presented with a temperature of 37.2°C, pulse rate of 78 beats per minute, respiratory rate of 16 breaths per minute, blood pressure of 120/80 mmHg, and oxygen saturation of 98% on room air. The patient was alert and oriented, with a pain score of 2 out of 10, indicating mild discomfort. HEENT (Head, Eyes, Ears, Nose, Throat): Examination revealed a symmetrical scalp with no lesions. Pupils were equal, round, and reactive to light and accommodation. Conjunctivae were clear, and vision was intact. Hearing was normal bilaterally. The nasal passages were clear without congestion or drainage. Oral mucosa was moist, and the pharynx was non-erythematous with no tonsillar enlargement. Respiratory: The patient exhibited a regular respiratory rate and rhythm with no use of accessory muscles. Breath sounds were clear on auscultation bilaterally, and there were no signs of respiratory distress such as dyspnoea, wheezing, or coughing. Chest symmetry and air entry were normal. Cardiac: The cardiovascular assessment showed a regular heart rate and rhythm with no murmurs, gallops, or rubs. Peripheral pulses were palpable and strong, with a capillary refill time of less than 2 seconds. There were no signs of circulatory compromise such as cyanosis, oedema, or pallor. Abdominal: The abdomen was soft and non-tender with normal bowel sounds present in all quadrants. There was no distension or palpable masses. No surgical scars or stomas were noted. Musculoskeletal: The patient demonstrated full range of motion in all joints with no tenderness or swelling. There were no gross deformities, and limb symmetry was maintained. Gait was steady, and balance was intact. Skin: Skin inspection revealed normal colour and temperature with no excessive moisture. Skin integrity was intact with no rashes, lesions, bruising, or pressure areas observed. There were no wounds present.

Vital Signs: [Enter the patient’s vital signs] (include only if measured or documented. Provide temperature, pulse, respiratory rate, blood pressure, and oxygen saturation. Include the patient's level of consciousness and pain score if assessed. This section should be written as a complete paragraph in full sentences and may comment on whether values are within normal limits, elevated, or concerning.) HEENT (Head, Eyes, Ears, Nose, Throat): [Enter findings related to the head, eyes, ears, nose, and throat] (include only if assessed. Describe any abnormalities in scalp, cranial symmetry, pupillary reaction, conjunctival appearance, vision, hearing, nasal congestion or drainage, oral mucosa, pharynx, or tonsils. Include only relevant elements observed during the examination, written in paragraph format with complete sentences.) Respiratory: [Enter findings from the respiratory examination] (include only if assessed. Document respiratory rate, rhythm, effort, use of accessory muscles, breath sounds on auscultation, and any signs of distress such as dyspnoea, wheezing, or coughing. Mention chest symmetry and air entry as applicable. Write as a paragraph using formal clinical language.) Cardiac: [Enter findings from the cardiovascular assessment] (include only if assessed. Note heart rate and rhythm, presence of murmurs, gallops or rubs, peripheral pulses, capillary refill, and any signs of circulatory compromise such as cyanosis, oedema, or pallor. Write as a single structured paragraph in full sentences.) Abdominal: [Enter findings from abdominal inspection, auscultation, and palpation] (include only if assessed. Comment on contour, presence or absence of bowel sounds, tenderness, distension, or palpable masses. Include findings related to surgical scars or stomas only if relevant. Write this section in narrative paragraph form.) Musculoskeletal: [Enter findings related to musculoskeletal structure, strength, and function] (include only if assessed. Describe range of motion, joint tenderness or swelling, gross deformities, limb symmetry, and mobility status. Include observations of gait or balance only if examined. Write using complete sentences within a paragraph.) Skin: [Enter findings from skin inspection] (include only if assessed. Describe colour, temperature, moisture, integrity, rashes, lesions, bruising, or pressure areas. If wounds are present, comment on their location, size, and any signs of infection. Write in full sentences using objective clinical terminology.) (Never come up with your own patient findings, vital signs, examination details, or clinical impressions – use only the transcript, contextual notes, or clinical note as a reference for the information included in your note. If any information related to a placeholder has not been explicitly mentioned in the transcript, contextual notes, or clinical note, you must not state that the information has not been mentioned – just leave the relevant placeholder or omit the paragraph completely.)

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