Head-To-Toe Assessment Checklist: A Step-By-Step Guide To Using eForms For Physical Examination

Medical workers cite poor organizational transfer of knowledge and inadequate information flow among the most common root causes of medical errors.

Head-to-toe assessment checklists make sure that nurses and other health professionals do not make mistakes and do not skip any steps during the physical examination of a patient.

Let’s look at how electronic forms help medical professionals conduct error-free health assessments and instill order into this very complex procedure.

What Is a Head-To-Toe Assessment Checklist?

A head-to-toe assessment checklist, or form, is a document that processes and reviews the patient’s physical state and functions.

Head-to-toe checklists are used by nurses, EMTs, doctors and physician assistants to perform and document a complete check of a patient’s physical state.

These documents are also used in instances of primary care visits and annual physical checks, and less often with patients that present a specific health problem they may be experiencing.

Why Use a Head-To-Toe Assessment eForm?

Head-to-toe assessment checklist documentation is a critical part of the physical examination process.

By recording relevant patient info, nurses provide the necessary data to doctors and other medical experts that they can translate into a comprehensive care plan.

Using head-to-toe checklists makes sure examiners remember and document all the vital parts of the examination.

Other benefits of using head-to-toe assessment electronic forms include:

• Timely diagnosis of warning signs: The physical examination and head-to-toe assessment checklist provide primary objective data through inspection, percussion, palpation and auscultation. The assessment checklist includes all the bodily systems and its findings inform healthcare professionals on the patient’s overall condition, including symptoms that could point to a bigger issue.

• Introducing order in a very complex procedure: Physical examination is a very complex process that includes a lot of steps. Even for seasoned examination professionals, it’s easy to lose sight of any step in the procedure. Head-to-toe examination checklists make sure they are all documented and easy to follow.

• Eliminating paperwork and related risks of losing data: Electronic form head-to-toe checklists reduce the need for physical storage of paperwork by keeping all checklists, reports and other patient files on a cloud or a local hard drive. This also eliminates the danger of checklists getting lost or damaged.

Nursing head-to-toe assessment checklists streamline the physical examination processes for patients of any age group.

Preparing To Use A Nursing Head-to-Toe Physical Assessment Checklist: Take These Steps To Prepare A Patient For Your Checklist

The objective of a head-to-toe assessment checklist is to gain insight into the patient’s current health status, health needs, and their goals for health outcomes.

Since the patient’s needs are what drives head-to-toe assessment forms, they set off several precautions and conditions that examiners must meet before they use the checklist.

Here are the steps that examiners need to take before making their nursing head-to-toe assessment checklist, which also informs all the vital parts of this document.

• Establish a relationship with the patient: Before the actual head-to-toe checklist steps in, the nurse or other examiner should verify the patient’s identity and establish a personal relationship of trust and respect with the patient. They should also assess how the patient is feeling, and make sure they are properly draped and comfortable.

• Check your equipment and include it in the checklist: A nurse or any other medical worker performing the physical check will need a set of equipment that includes:
  • Gloves
  • Thermometer
  • Blood pressure cuff
  • Watch
  • Stethoscope
  • Scale
  • Height wall ruler
  • Tape measure
  • Penlight
  • Otoscope
  • Ophthalmoscope
  • Reflex hammer
  • Tongue depressor
  • Sterile sharp object
  • Sterile soft object
  • A bottle of an alcohol swab or something else for a patient to smell

• Differentiate what to look for during the head-to-toe assessment: It is very important to set the standards of normal and abnormal examination findings. Changes in respiratory rate that indicate respiratory distress is an example of an abnormal finding, as is a drastic change in skin color that may imply certain ailments. The examiner needs to make note of any unusual asymmetry in the human body or face or different rates of strength in different sides of the body. These anomalies will inform the examiner of what to prioritize in the head-to-toe assessment checklist and what to pay particular attention at.

Some of the items that nurses and medical workers should include on their nursing head to toe physical assessment checklist, before the actual physical examination takes place, are:

• Perform hand hygiene
• Check room for contact precautions
• Introduce yourself to the patient
• Verify the patient’s identity by asking about their name and date of birth
• Check for the right equipment
• Explain the process to the patient
• Ensure the patient’s privacy and dignity
• Listen to the patient and their cues
• Be organized and systematic with your assessment
• Assess the air, lighting and other conditions within the room
• Check vital signs
• Complete necessary assessments

What To Consider Before Building A Nursing Head-To-Toe Assessment Checklist

The process of health examination comes with certain traits that may vary and impact the content of the checklist, as well as the way the examiner uses it.

These changing qualities are:

• Types of physical assessment: There are two main types of physical examinations that define the head-to-toe assessment checklist:
  • A complete health assessment: A thorough, detailed examination that includes a comprehensive exam and a look into full health history.
  • A problem-focused health assessment: This type of examination is based on certain care goals and is focused on specific body systems such as cardiac or respiratory.

• Length of physical assessment: Exam duration correlates to the patient’s overall health status. Some health practices have their patients complete their health history and pre-visit forms prior to comprehensive checkup. Depending on the patient’s general health status, the head-to-toe assessment checklist will contain more or fewer items.

• The sequence of physical assessment: The head-to-toe sequence usually begins with the least invasive – like the patient’s overall appearance or status – and moves towards the most invasive because this allows the patient to have more time to become comfortable with the examination. This sequence is also important because, this way, the examiner is less likely to forget something from the checklist during the exam.

Head-to-toe assessment forms help healthcare professionals prescribe the right treatment to patients.

58 Test Items That A Nurse Practitioner Head-To-Toe Assessment Checklist Should Contain

Head-to-toe assessment checklists need to comply with the health organization’s specifications, as different health systems may have a diverse set of tests that nurses and other examiners perform on patients.

Also, checklists will differ to some extent for different patients, including age groups, genders and medical history. In general, though, these documents collect objective patient data via physical examination of all the body systems.

The body systems and their corresponding tests that comprise a head-to-toe checklist are:

General Health Status

1. Patient orientation
2. Vital signs
3. Temperature
4. Heart rate
5. Blood pressure
6. Pulse oximetry
7. Respiratory rate
8. Pain

Head, Ears, Eyes, Nose & Throat

1. Inspect teeth and gums
2. Examine tongue
3. Examine tonsils
4. Examine at uvula
5. Register the wetness and color of lips
6. Assess palate and buccal mucosa
7. Palpate nose
8. Assess nose symmetry
9. Check inside nostrils
10. Verify patency of nares
11. Check patient’s sense of smell
12. Palpate patient’s sinuses
13. Do a whisper test to examine patient’s hearing
14. Perform Rinne test/Tuning Fork test/Weber’s test
15. Look inside ear
16. Ear discharge and tympanic membrane
17. Check sclera and conjunctive
18. Assess eye symmetry
19. Eyebrow and eyelash distribution
20. PERRLA (pupils are equal, round, reactive to light and accommodation)
21. Check vision with Snellen Chart
22. Check six cardinal positions of the gaze

Neck and Shoulders

1. Palpate lymph nodes
2. Observe and palpate trachea and neck
3. Check for Jugular Venous Distention
4. Check neck range of motion
5. Assess shoulder shrug with resistance

Lungs And Respiratory System

1. Assess respiratory expansion levels
2. Listen to lung sounds
3. Ask a patient about their coughing
4. Palpate thorax

Circulatory System And Abdomen

1. Listen to the heartbeat
2. Palpate the carotid and temporal pulses bilaterally
3. Examine abdomen
4. Listen to 4 quadrants of the abdomen for bowel sounds
5. Palpate 4 quadrants of the abdomen for pain/tenderness
6. Ask the patient about problems with bowel or bladder

Pulse

1. Check radial, femoral, posterior tibial and dorsalis pedis pulses in arms, legs and feet

Extremities

1. Assess a range of motion and strength in arms, legs and ankles
2. Assess sharp and dull sensation in arms and legs
3. Check capillary refill on toenails and fingernails

Skin

1. Check is patient is pale, dry, cold, hot, flushed or clammy
2. Check skin turgor
3. Check skin for lesions, abrasions, rashes, tenderness and lumps

Neurology

1. Check coordination
2. Check reflexes
3. Assess gait
4. Check Glasgow Coma Scale score

Optional Tests

1. Breast exam
2. Genitourinary exam

How To Create A Full Head-To-Toe Assessment Checklist With doForms

doForms makes head-to-toe assessment checklists very simple to make according to specific health organization’s type and need.

Thanks to several pre-made nursing head to toe physical assessment checklist templates and more than 30 drag-and-drop features, our DIY mobile forms provide the necessary flexibility and scalability for creating checklists from scratch.

The intuitive dashboard makes it very easy to compile a tailored list of tests, without requiring an internet connection. You can upload and sync the captured data to your cloud database from any smartphone or tablet device.

Takeaways On Head-To-Toe Assessment Checklist

Electronic head to toe assessment forms makes sure that nurses and other professional examiners don’t miss a single test item during the patient’s physical exam.

They also provide a full and timely insight into the health condition of a patient and can point to some early symptoms that may require early attention.

doForms head-to-toe nursing assessment checklists eliminate the excessive paperwork, offer numerous customization options, and seamless creation of checklists via drag-and-drop functions and pre-made templates.

Ready to build your own head to toe inspection checklist? Get in touch!