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Registered Nurse
5-10 minutes

Comprehensive Hospital Assessment Notes (Narrative Style)

The s10.ai Hospital Head to Toe Assessment Notes (Narrative Format) template is an essential resource for nurses, designed to meticulously document a patient's physical examination across all major body systems. This comprehensive tool is invaluable in hospital settings, where a detailed evaluation is crucial for accurate diagnosis and effective treatment planning. The narrative format of the template ensures that all clinical findings are seamlessly integrated into a cohesive report, enhancing communication among healthcare providers. Ideal for both initial assessments and ongoing evaluations, this template empowers nurses to deliver thorough and precise patient care in a hospital environment.

1,083 uses
4/5.0
J
Jordan Patel
Template Structure

Organized sections for comprehensive clinical documentation

The patient arrives with [insert summary of presenting complaint or reason for assessment] (provide a concise overview of the patient's current condition, including the onset, duration, and nature of symptoms. Include relevant medical history, reason for hospital admission or clinical review, and any significant contextual factors if mentioned).
Current medications include [insert medication list with dosages and frequency] (only include if explicitly stated. List all prescribed, over-the-counter, and supplemental medications relevant to the clinical context. Use a narrative sentence structure, integrated into the flow of the paragraph). Recent investigations show [insert summary of investigation findings] (only include if relevant investigations are mentioned. Describe key lab results, imaging findings, or diagnostic studies that inform the current clinical picture. Summarise in complete sentences within a paragraph).
The patient's hair, skin, and nails appear [insert description of condition] (include only if assessed. Describe texture, colour, turgor, presence of rashes, lesions, dryness, ulcers, or pressure injuries. Include inspection findings such as capillary refill or nail bed appearance as a flowing sentence within the paragraph). On examination of the head and neck, [insert head and neck findings] (include only if mentioned. Describe head shape, facial symmetry, lymph node palpation, thyroid findings, neck range of motion, or any visible abnormalities using full sentence structure).
Eye assessment reveals [insert findings from the eye examination] (include only if examined. Include descriptions of sclera, conjunctiva, pupils, and vision. Note the use of corrective lenses or any abnormal eye movements if assessed). The ears were also [insert ear assessment findings] (include only if examined. Include description of external ear, canal, hearing ability, and any signs of infection or discharge noted during examination). The nose and sinuses were found to be [insert nasal and sinus findings] (include only if assessed. Describe the nasal mucosa, patency, discharge, swelling, or sinus tenderness using descriptive narrative format). Meanwhile, oral cavity and throat examination showed [insert mouth and throat findings] (include only if examined. Comment on lips, tongue, teeth, gums, palate, uvula, and tonsils. Include any signs of inflammation, infection, dryness, or discomfort as part of the paragraph).
Cardiovascular assessment revealed [insert cardiovascular findings] and respiratory examination showed [insert respiratory findings] (only include if both systems were examined. For cardiovascular: describe heart sounds, rhythm, peripheral pulses, oedema, or murmurs. For respiratory: note breath sounds, respiratory effort, symmetry, or signs of respiratory distress. Integrate both findings into one continuous paragraph unless otherwise noted). Breast and lymph node examination findings include [insert relevant findings] (include only if performed. Note any palpable nodes, tenderness, asymmetry, skin changes, or discharge if mentioned). The abdomen was [insert abdominal findings] (only include if assessed. Describe contour, bowel sounds, tenderness, rigidity, distension, presence of masses, or surgical scars. Summarise all four examination techniques—inspection, auscultation, palpation, percussion—within a single paragraph).
Genitourinary findings include [insert findings] (include only if relevant and examined. Describe urinary function, catheter status, discharge, pain, or infection signs. Include reproductive examination only if clinically appropriate and explicitly mentioned). On the other hand, rectal examination showed [insert findings] (only include if performed. Describe tone, masses, haemorrhoids, fissures, or presence of blood. Ensure respectful and objective language throughout).
Extremity and musculoskeletal evaluation revealed [insert findings] (include only if examined. Note joint swelling, range of motion, strength, symmetry, gait, and use of mobility aids. Describe findings in an integrated narrative paragraph). Neurological examination also demonstrated [insert findings] (only include if performed. Include level of consciousness, orientation, cranial nerves, reflexes, motor and sensory function, and coordination. Present the findings in paragraph form with full clinical sentences).
Clinically, the overall assessment suggests [insert summary of assessment] (only include if explicitly stated. This should summarise the patient’s current condition based on the examination and available findings, including stability, deterioration, or areas of concern). The working diagnosis is [insert diagnosis] (only include if explicitly mentioned. Use recognised diagnostic terms and ensure clarity. Include whether the diagnosis is provisional or confirmed if relevant). So the plan includes [insert plan] (only include if explicitly provided. Describe ongoing monitoring, investigations, treatments, referrals, follow-up requirements, and any educational points discussed with the patient or caregivers. Use full sentences in a structured paragraph).
(Never come up with your own patient details, diagnosis, treatment, clinical observations, or conclusions – 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 in your output – just leave the relevant placeholder or omit the paragraph completely. (Use one paragraph per section and maintain a formal, clinical tone throughout.)
Sample Clinical Note

Example of completed documentation using this template

The patient reports a sudden onset of intense abdominal pain that started two days ago. The pain is described as sharp and persistent, located in the lower right quadrant. The patient has a history of appendicitis and was admitted for further assessment. Current medications include paracetamol 500 mg every 6 hours for pain relief. Recent tests show an elevated white blood cell count and an ultrasound indicating potential appendiceal inflammation.
The patient's hair, skin, and nails appear normal with no signs of rashes or lesions. Examination of the head and neck reveals no lymphadenopathy, and the neck has a full range of motion. Eye assessment shows clear sclera and conjunctiva, with pupils equal and reactive to light. The ears are normal with no signs of infection or discharge. The nose and sinuses are clear with no tenderness. The oral cavity and throat examination shows healthy gums and no signs of infection.
Cardiovascular assessment reveals regular heart sounds with no murmurs, and respiratory examination shows clear breath sounds bilaterally with no respiratory distress. Breast and lymph node examination findings include no palpable nodes or tenderness. The abdomen is tender in the lower right quadrant with guarding, and bowel sounds are present. No masses or surgical scars are noted.
Genitourinary findings include normal urinary function with no signs of infection. Rectal examination shows normal tone with no masses or hemorrhoids. Extremity and musculoskeletal evaluation reveal normal range of motion and strength, with no joint swelling or gait abnormalities. Neurological examination also demonstrates the patient is alert and oriented, with intact cranial nerves and normal reflexes.
Clinically, the overall assessment suggests acute appendicitis. The working diagnosis is appendicitis, and the plan includes surgical consultation for possible appendectomy, continued pain management, and monitoring of vital signs. The patient and family were educated on the signs of worsening condition and the importance of follow-up care.
Clinical Benefits

Key advantages of using this template in clinical practice

  • This comprehensive clinical template is designed to streamline patient assessments by providing a structured format for documenting presenting complaints, current medications, and recent investigation findings. It facilitates thorough examinations of the hair, skin, nails, head, neck, eyes, ears, nose, sinuses, oral cavity, and throat, ensuring no detail is overlooked. The template also includes sections for cardiovascular, respiratory, breast, lymph node, abdominal, genitourinary, rectal, extremity, musculoskeletal, and neurological evaluations. Clinicians can efficiently summarize the overall assessment, working diagnosis, and management plan, enhancing clinical decision-making and patient care. By adopting this template, healthcare professionals can ensure comprehensive documentation, improve patient outcomes, and optimize clinical workflows.
Frequently Asked Questions

Common questions about this template and its usage

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Comprehensive Hospital Assessment Notes (Narrative Style)