Clinical template
Head-to-Toe Assessment Template
A head-to-toe assessment is a systematic physical exam from airway and neuro status down to skin and mobility. Use the blank below, then three fictional Canadian nursing assessments: COPD exacerbation on admission, post-op day 1 after laparoscopic cholecystectomy, and a post-fall review on a medical unit.
Blank head-to-toe template
Copy this into the admission assessment, a shift assessment, or a Scribeberry custom template. Abnormal first, then the pertinent normals. You do not need a novel on every system if that system is untouched and the flowsheet is complete.
Head-to-toe assessment
Date / time: Nurse / designation: | Patient: [initials, age] | Unit: Reason for assessment: admission / shift / post-fall / post-op / deterioration Allergies / isolation / code status: General: apparent distress, position, mobility into the room, devices (O2, IV, catheter, drains) Vitals: BP HR RR Temp SpO2 (on what) Pain (scale, location) Weight if relevant Neuro: GCS or A&O (person, place, time, situation), pupils, limbs power/sensation, speech, glucose if altered HEENT: airway, oxygen device, hearing aids/glasses, mucous membranes, JVP if relevant Respiratory: effort, trachea, auscultation (where the findings are), cough, sputum, incentive spirometer CVS: heart sounds, edema, capillary refill, pulses, calf tenderness, SCD/TEDs, rhythm vs monitor Abdomen: contour, scars, bowel sounds, tenderness, last BM / flatus, diet, NG/ostomy/drains (output) GU: voiding, catheter (size, urine appearance, hourly if ordered), LMP if relevant Skin / wounds: colour, turgor, pressure points (heels, sacrum), incisions, IV sites (phlebitis scale) MSK / mobility: ROM, weight-bearing, gait, aids, bed/chair transfer, fall-risk score Psychosocial: mood, safety, family present, language, delirium screen (CAM) if indicated Lines / tubes / epidurals (site, dressing, date): Focused add-on (neuro q1h, vascular checks, post-fall head-to-toe): Escalation / who notified:
Fictional patients
Every example on this page uses made-up names and findings. They are teaching material. They are not a substitute for CNO, BCCNM, CRNA, or other college standards, or for your unit's assessment policy. Review every generated assessment before you sign.
What a head-to-toe is for
Admission and once-per-shift assessments catch the problem the patient has not named yet: a cool pulseless foot after a catheter, a sacral blister, a new oxygen requirement. Focused exams follow. A post-fall head-to-toe is a different document from a routine nights check. Label which one you did.
| When | How complete | Usual add-on |
|---|---|---|
| Admission | Full systems, baseline skin, lines, fall score, CAM if older or confused | Weight, allergies, code status confirmation |
| Shift (stable) | Vitals, the systems that are active problems, skin, lines, mobility | Do not recopy a normal cranial-nerve exam from days ago |
| Post-op | Airway, pain, incision/drains, urine, neurovascular if a limb was involved | Epidural/PCA check, first void, first ambulation |
| Post-fall | Full, including head, neck, hips, neuro, skin, glucose | Who was notified, post-fall protocol, new vitals series |
| Deterioration | ABC first, then a rapid systems pass | MEWS/NEWS if your hospital uses one, MRP called |
Canadian nursing colleges expect an assessment that is timely and factual. Copy-forward of yesterday's 'chest clear' when the patient is now on 4 L is a documentation failure and a clinical one. If you used a generated draft, you still own every system you signed.
How to chart so the next nurse trusts it
Lead with general appearance and vitals. Then work down. Put the abnormal system in enough detail that a physician can act without repeating the entire exam. 'Crackles to both bases, worse right, using accessory muscles, speaking in 4-word sentences, SpO2 88% on 2 L (was 94% RA yesterday)' is an assessment. 'Respiratory system abnormal' is not.
Name devices: 20G IV left forearm, date, no redness; Foley 16 Fr, clear yellow, 40 mL last hour; JP drain 30 mL serosanguineous. Skin includes the sacrum and heels on anyone who cannot turn independently. Delirium screening belongs in neuro/psychosocial for older adults, not only after they have already climbed the rails.
Example 1 — COPD exacerbation
Admission, medical unit
68-year-old man, known COPD, St. John's. 07:50 admission from ED. Fictional.
07:50 admission assessment R. Doyle RN Isolation: droplet Code: full General: Sitting forward on stretcher, pursed-lip, speaking 4–5 word sentences, anxious but cooperative. O2 4 L NP from ED (target 88–92% per ED note). Vitals: BP 148/86, HR 104, RR 28, T 37.8, SpO2 90% on 4 L, pain 0. Weight 79.4 kg. Neuro: Alert, oriented x3, GCS 15, pupils 3 mm equal. No focal weakness. Speech dyspneic but coherent. Glucose 6.1. HEENT: Airway patent. Using accessory muscles. Mucous membranes dry. No JVP elevation I can see (neck short). Hearing aids in. Respiratory: Barrel chest. Trachea midline. Reduced air entry throughout, expiratory wheeze all fields, coarse crackles right base. Productive cough, yellow sputum x 1 cup this morning. No stridor. CVS: S1 S2, no edema, cap refill 2 s, pulses present. Calves soft. Telemetry sinus tach. Abdomen: Soft, non-tender, BS present, last BM yesterday. GU: Voids, amber urine, no catheter. Skin: No pressure injury. IV 18G R AC, date today, no phlebitis. Nicotine-stained fingers. MSK: Walks with rest stops; ED used wheelchair. MORSE high (O2, gait, IV). Psychosocial: Lives with wife, smokes 10 cig/day, "I knew this cold would get me." CAM negative. Lines: IV as above. No Foley. Escalation: RT in room for neb; MRP aware from ED. Target sats 88–92% written. ABG in ED: pH 7.36, PCO2 52, PO2 62 on 4 L (on chart).
Example 2 — post-op laparoscopic cholecystectomy
Surgical day unit / inpatient POD 1
41-year-old woman, POD 1 lap chole, London ON. 08:15 shift assessment. Fictional.
08:15 POD 1 S. Patel RN Allergies: NKDA Code: full General: In bed, HOB 30°, looks comfortable at rest, grimaces on sit. SCDs on. IV saline lock. Vitals: BP 118/72, HR 78, RR 16, T 36.9, SpO2 97% RA, pain 4/10 at rest, 7/10 on sit (right upper ports). Weight not repeated. Neuro: A&O x4, GCS 15. No residual anaesthesia fog. Pupils equal. HEENT: Airway patent, no O2. Mucous membranes moist. Sips of water tolerated. Respiratory: Easy, equal air entry, no crackles, IS 1500 mL this morning x 8. Encouraged q1h. CVS: Heart sounds dual, no edema, calves soft, SCDs on, cap refill <2 s. Abdomen: Four port sites: epigastric dressing dry, umbilical small serous spot 0.5 cm, R mid-clavicular and R flank dry. Abdomen soft, tender RUQ expected, no rebound, no rigidity. BS present. Flatus overnight. No drain. Voided 300 mL at 06:40 (first void POD 0 evening already done). GU: No catheter. Urine clear. Skin: No pressure injury. IV 20G L hand, date yesterday, site clean. MSK: Dangled last evening, walking in hall this a.m. with 1 assist, upright, slow. Fall risk moderate (post-op, opioid). Psychosocial: Partner present. Anxious about "bile leak I read about." Teaching started. Focused: Shoulder-tip gas pain 5/10, worse sitting — explained, heat pack. Last hydromorphone 0.4 mg PO 05:30. Escalation: none. Diet: clear fluids, advance if no vomiting. PT not required. Discharge teaching this afternoon if MRP agrees.
Example 3 — post-fall medical unit
Post-fall head-to-toe
81-year-old woman, pneumonia, found on floor beside bed, Quebec City. 03:20. Fictional.
03:20 unassisted fall, unwitnessed (bed alarm sounding). L. Gagnon RN. Post-fall protocol. General: Found on left side on the floor, attempting to pull herself up, gown around hips. Alert, crying, "I needed the toilet." No obvious deformity. Assisted back to bed with 2-person lift after rapid check. Vitals immediately: BP 162/90, HR 96, RR 20, T 36.7, SpO2 94% on 1 L (baseline), pain 8/10 left hip. Glucose 5.8. Neuro: GCS 15, oriented to name and hospital, not to time (was oriented last evening — possible worsening delirium). Pupils 3 mm equal, reactive. Moving all four limbs to command. No facial droop, speech unchanged. No amnesia for the event. Neck: denies pain, ROM intact, no midline tenderness — no collar applied. HEENT: No scalp hematoma, no Battle sign, no raccoon eyes, no oral trauma. Hearing aid on floor, replaced. Glasses on nightstand. Respiratory: Baseline coarse bases, no new distress, O2 still 1 L. CVS: Irregularly irregular (known AF), no new edema, no chest pain. Abdomen: Soft, no new tenderness, no incontinence of stool. Brief urinary incontinence on the floor. GU: No catheter. Incontinent of urine with the fall. Skin: 4 x 3 cm bruise forming L hip/greater trochanter, skin intact. Small skin tear 1 cm L forearm from the ID bracelet. Sacrum clear. Heels clear. MSK: L hip pain on log-roll, holds the limb in slight external rotation. Knee and ankle ROM ok. R side uninjured. Distal L foot warm, DP pulse present, sensation intact. Psychosocial: Frightened, CAM+ (inattention, fluctuating). Daughter not called yet (03:20). Escalation: Charge RN and MRP Dr. Côté notified 03:28. Bed rest. Hip/pelvis x-ray ordered. Neuro vitals q1h x 4. Bed alarm on, lowest bed, toilet round scheduled. Incident report completed. Family to be called after 07:00 unless x-ray is a fracture — then call now (daughter's stated preference on file).
Mistakes that show up in assessments
- Copy-forwarding 'chest clear' after oxygen has been up-titrated.
- A post-fall note with no head, no hip, and no who-was-notified.
- IV and wound sites never mentioned on a surgical patient.
- No fall-risk or CAM on an 80-year-old admitted at night.
- Pain score without location, or location without a score.
- Signing a generated full exam you did not perform (cranial nerves, pulses, rectal).
- Leaving isolation and code status blank on admission.
College complaints after falls and missed deterioration often show a tidy flowsheet and an empty narrative. CMPA hospital work follows the same record: if you assessed it, write it; if you did not, do not generate it. Timed vitals after a fall and a named physician are what the next reader looks for.
Head-to-toe vs focused exam
Do the full exam on admission, after a fall, after a transfer, and when the patient looks different. During a quiet shift, examine the active problems in depth and screen the rest. The template is a memory aid, not a requirement to auscultate 12 areas of bowel on a patient whose only issue is a PCA.
Draft the assessment from the bedside
Scribeberry takes dictation at the bedside or after the round and fills your head-to-toe headings. Edit the abnormals and the devices, then Smart Push. Pro is $99/month after the free trial.
Frequently asked questions
What is included in a head-to-toe assessment?
General appearance, vitals, neuro, HEENT/airway, respiratory, cardiovascular, abdomen, GU, skin and wounds, mobility/MSK, psychosocial, and every line or drain. Abnormal findings get the detail. Isolation, allergies, and code status belong on the admission pass.
How often should nurses do a head-to-toe?
On admission, typically once a shift on acute units, and again after a fall, a transfer, a new post-op, or a deterioration. Follow your unit policy. Stable patients still need a look at skin, lines, and the active problem, even if you do not rewrite every system.
What is different about a post-fall assessment?
It is a full exam plus mechanism, head and neck, hips, neuro series, glucose, skin, incontinence, who you notified, and the incident report. Do not call a two-line 'patient assisted back to bed, no injury' a post-fall assessment.
Can Scribeberry fill a head-to-toe template?
Yes. Dictate systems in order, generate, and delete any heading you did not actually examine before you sign. Custom templates can match your hospital's admission form.
Templates
