Head-to-Toe Assessment Template

Order of the assessment

Standard order: general appearance → vitals → neurological → HEENT (head/eyes/ears/nose/throat) → cardiac → respiratory → abdominal/GI → genitourinary → musculoskeletal → integumentary (skin) → psychosocial. Some texts swap neuro and HEENT; some include vitals as a separate section. Use whatever order your facility's EHR follows so your documentation flows.

Neurological

Mental status: alert and oriented to person, place, time, situation (A&O x4). Cranial nerves: grossly intact (or document specific deficits). Motor: moves all extremities equal strength bilaterally (5/5). Sensory: grossly intact to light touch. Speech: clear and appropriate. Pupils: PERRLA (pupils equal, round, reactive to light, accommodation). Document any deviations precisely (e.g., 'left arm 4/5 strength, right arm 5/5').

Cardiac

Heart sounds: S1 and S2 audible, regular rate and rhythm, no murmurs, gallops, or rubs auscultated. Pulses: radial and pedal pulses 2+ bilaterally. Capillary refill: brisk (<3 seconds). Edema: none, or describe location, pitting grade (1+ to 4+), and bilateral vs unilateral. Telemetry: if monitored, note rhythm and rate. Red flags: new murmur, new edema, asymmetric pulses, prolonged capillary refill.

Respiratory

Effort: unlabored, no use of accessory muscles. Rate and depth: within normal range, even and unlabored. Lung sounds: clear to auscultation bilaterally in all fields (anterior, lateral, posterior). Cough: denies cough, or document non-productive vs productive (color of sputum). SpO2: document on room air or current oxygen delivery. Red flags: increased work of breathing, accessory muscle use, adventitious sounds (crackles, wheezes, stridor), decreasing SpO2.

Abdominal/GI

Inspection: abdomen flat (or soft, distended, etc.), no scars unless documented. Auscultation: bowel sounds active in all four quadrants (auscultate BEFORE palpating). Palpation: soft, non-tender, non-distended. Last BM: document date/time and consistency. Diet tolerance: tolerating diet without nausea/vomiting. Red flags: rigid or boardlike abdomen, hyperactive or absent bowel sounds, rebound tenderness, distention with vomiting.

Genitourinary

Output: urinating clear yellow urine without difficulty (or document Foley with rate, color, clarity). Frequency: document any urgency, frequency, dysuria, or hematuria. Catheter: if present, note insertion date, indication, securement, and patency. Red flags: oliguria (<30 mL/hr), anuria, hematuria, foul-smelling urine.

Musculoskeletal & Integumentary

MSK: moves all extremities, no joint deformity, no swelling. Skin: warm, dry, intact, color appropriate for ethnicity, no rashes or lesions unless documented. Pressure injury risk: document Braden score and any existing pressure injuries with stage, location, size, and treatment. Wounds: document location, size (length x width x depth in cm), drainage character, surrounding skin, and dressing. Red flags: new pressure injuries, dehiscence, signs of infection (erythema, warmth, purulent drainage).

How to actually do a head-to-toe in real clinical time

The textbook head-to-toe assessment takes 25–30 minutes if you do it linearly. Real bedside practice is closer to 6–10 minutes for an experienced nurse, and the secret is integrating systems rather than going system by system. While you check the IV pump and look at the lines, you are also looking at hand grip, capillary refill, pedal pulse on the side closest to the IV, and skin color. While you place the stethoscope for heart sounds, you are observing chest rise, accessory muscle use, JVD, and any visible scars. While you palpate the abdomen, you are watching facial expression for pain and listening for verbal responses (which screens cognition). The trick to fast assessment is overlap: every body region you touch yields three or four data points if you train yourself to look for them.

Documentation should match what you actually assessed. The biggest legal trap is "blanket charting" — the SmartPhrase that auto-populates "all systems within normal limits, patient denies pain, ambulating ad lib" without the nurse having actually verified those things. If a patient deteriorates and the chart shows the nurse documented a normal assessment that is incompatible with the deterioration, the chart becomes evidence against the nurse. Always edit the SmartPhrase to reflect what you actually found. Document specifics where they exist (left lung base diminished, 2+ pitting edema bilaterally to the knee), and document genuine negative findings explicitly ("no JVD, no peripheral edema").

Trending an assessment over a shift

The first head-to-toe of the shift is the baseline; everything after is a comparison to that baseline. Subsequent rounds — typically q4h on med-surg, q2h on telemetry, q1h on ICU — should be focused reassessments that explicitly compare the patient to the morning baseline. "Lung sounds unchanged from baseline, still diminished L base," "edema increased from 2+ to 3+ in past 4 hours," "patient now disoriented to time, was A&Ox4 at 0700." Trending is what catches subtle deterioration. A patient does not usually go from "fine" to "code blue" in 60 seconds; they go from "fine" to "slightly off" to "noticeably worse" over hours, and the nurse who documents trends rather than only acute findings is the one who catches that progression early.

The role of the head-to-toe in early-warning scoring

Most hospitals now use an early-warning score (NEWS2, MEWS, PEWS for pediatrics) integrated into the EHR. These scores combine vital signs, mental status, and oxygen requirement to flag patients at risk for deterioration. The score is only as good as the data — and the data is your assessment. A patient who is "alert" but is now slow to answer questions, who is sat-ing 96% but on 4L NC instead of room air, who has a heart rate of 112 instead of the 84 they were running yesterday, will have a quietly rising NEWS2 score. The nurse who documents A&Ox4 because the patient eventually answered, who logs the same SpO2 without noting the increased oxygen, who marks "afebrile, normotensive" without noting the new tachycardia, suppresses the score. Honest assessment documentation is the single most reliable input to safe-rapid-response systems. When in doubt, document what you saw, not what the SmartPhrase suggests.