OCTC Nursing
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Patient Assessment Flowsheet
Comprehensive nursing assessment documentation for Sister Dorris Jones (Age: 60, DOB: 2/12/1965). Use this flowsheet to systematically document assessment findings across all body systems.
General Information & Vital Signs
Allergies
Medication: _________________
Food: _____________________
Environmental: ______________
Current Medications
Name: _____________________
Dose: _____________________
Frequency: _________________
Last Dose Taken
Time: _____________________
Date: _____________________
Administered by: ____________

Neurological Assessment
Level of Consciousness
Alert □ Drowsy □ Lethargic □ Obtunded □ Stuporous □ Comatose □
Orientation
Person □ Place □ Time □ Situation □
Motor Function
Gait: Normal □ Abnormal □ Describe: __________
Pupillary Response
Right: Size___ Reactive___ Left: Size___ Reactive___
Additional Observations: Speech: __________ Coordination: __________ Acute Concerns: __________
Cardiovascular System

Heart Sounds
S1: Normal □ Abnormal □
S2: Normal □ Abnormal □
Murmurs: Yes □ No □

Peripheral Pulses
Radial: R___ L___
Pedal: R___ L___
Strength (0-4): ___

Capillary Refill
Upper: < 3sec □ > 3sec □
Lower: < 3sec □ > 3sec □

Edema
Location: _________
Pitting: +1 □ +2 □ +3 □ +4 □
Respiratory System
Respiratory Rate
Rate: ___ /min
Pattern: Regular □ Irregular □
Breath Sounds
Clear □ Wheezes □ Crackles □ Rhonchi □ Diminished □
Respiratory Effort
Normal □ Labored □ Use of accessory muscles □
O₂ Therapy
Type: __________ Rate: __________ L/min
Additional observations (cough, sputum): __________
Gastrointestinal & Genitourinary System

2

Abdomen
Visual: Flat □ Distended □ Scars □ Wounds □
2
Bowel Sounds
Present □ Absent □ Hypoactive □ Hyperactive □
Elimination
Last BM: Date____ Time____ Consistency____
Urination
Last void: Date____ Time____ Amount____ Color____
GI/GU Additional Assessment
Appetite: Normal □ Decreased □ Increased □
Nausea/Vomiting: Present □ Absent □ Last episode: ____
Urinary symptoms: Dysuria □ Frequency □ Urgency □ Retention □ Incontinence □
Current GI/GU Interventions
Tubes/Catheters: Foley □ NG □ Other: ____
Diet: Regular □ NPO □ Special diet: ____
Bowel regimen: ____
Musculoskeletal/Integumentary System
Upper Extremity Strength
Right arm: 0/5 □ 1/5 □ 2/5 □ 3/5 □ 4/5 □ 5/5 □
Left arm: 0/5 □ 1/5 □ 2/5 □ 3/5 □ 4/5 □ 5/5 □
Lower Extremity Strength
Right leg: 0/5 □ 1/5 □ 2/5 □ 3/5 □ 4/5 □ 5/5 □
Left leg: 0/5 □ 1/5 □ 2/5 □ 3/5 □ 4/5 □ 5/5 □
3
Range of Motion
Full □ Limited □ Location of limitation: ________
Skin Assessment
Color: ________ Temperature: ________ Moisture: ________
Integrity: Intact □ Non-intact □ Location: ________
Summary, Plan, & Student Notes
Key Findings
List priority concerns identified during assessment:
1. _______________________________
2. _______________________________
3. _______________________________
Nursing Interventions
Document planned actions based on assessment:
1. _______________________________
2. _______________________________
3. _______________________________
Student Signature: _____________ Date: _______ Instructor Review: _____________
Student Nursing Notes
Use this space to document your comprehensive nursing notes, observations, and reflections. Complete all sections below and print when finished.
Subjective Data (Patient Reports)
Objective Data (Clinical Observations)
Assessment (Clinical Interpretation)
Plan (Interventions & Follow-up)
Student Initials: _________ Date/Time: ____________