Assessment Forms Used for Documentation
Standardized assessment forms have been developed to ensure that content in documentation and
assessment data meets regulatory requirements and provides a thorough database
Types of assessment forms used for documentation varies according to health care institution
Three types of assessment forms are used to document data:
1. Initial assessment form
2. Frequent or ongoing assessment form
3. Focused or specialized assessment form
Initial Assessment Form
Called a nursing admission or admission database
Four types of frequently used initial assessment documentation forms: open-ended,
cued/checklist, integrated cued checklist, and nursing minimum data assessment (NMDS) forms.
o Open-ended forms calls for narrative description of problem and listing of topics,
provides lines for comments, individualizes information, provides total picture, including
specific complaints and symptoms in the client’s own words, increases risk of failing to
ask a pertinent question because questions are not standardized, and requires lot of
time to complete database
o Cued/Checklist forms standardizes data collection, lists (categorizes) information that
alerts the nurse to specific problems or symptoms assessed for each client, usually
includes a comment section after each category to allow for individualization, prevents
missed questions, promotes easy &rapid documentation, makes documentation
somewhat like data entry because it requires nurse to place check marks in boxes
instead of writing narrative, and poses chance that a significant piece of data may be
missed because the checklist does not include the area of concern
o Integrated Cued Checklist combines assessment data with identified nursing diagnoses,
helps cluster data, focuses on nursing diagnoses, assists in validating nursing diagnosis
labels, combines assessment with my problem listing in one form, and promotes use by
different levels of caregivers, resulting in enhanced communication among the
disciplines
o Nursing Minimum Data Set comprises the commonly used in long-term care facilities,
has a cued format that prompts nurse for specific criteria; usually computerized,
includes specialized information, such as cognitive patterns, communication (hearing
and vision) patterns, physical function and structural patterns, activity patterns,
restorative care and the like, meets the needs of multiple data users in the health care
system, and establishes comparability of nursing data across clinical populations,
settings, geographic areas, and time
Frequent or Ongoing Assessment form
Various institutions have created flowcharts that help staff to record and retrieve data for
frequent reassessments
Examples of two types of flowcharts are: frequent vital signs sheet (allows for vital signs to be
recorded in a graphic format that promotes easy visualization of abnormalities), and assessment
flowchart (allows rapid comparison of recorded assessment data from one time period to the
next)
Progress notes may be used to document unusual events, responses, significant observations, or
interactions whose data are inappropriate for flow records
Flow sheets streamline the documentation process and prevent needless repetition of data
Emphasis is placed on quality not quantity of documentation
Focused or Specialty Area Assessment form
Some institutions may use assessment forms that are focused on one major area of the body for
clients who have a particular problem e.g.: cardiovascular or neurologic assessment
documentation forms.
For example, a form may be used as a screening tool to assess specific concerns/risks such ass
falling or skin problems
These forms are usually abbreviated versions of admission data sheets, with specific assessment
data related to the purpose of the assessment
