Head to Toe Assessment – Skills Checklist

Student Name: Date:

Evaluator Name:

Scoring Key: 0 = step omitted/does not meet competency

1 = partially wrong/approaching competency
2 = accurate performance/competent

SKILL PEER SELF INSTR.

Important: All patient assessments and findings

are to be verbalized along with their performance

Student displays professionalism 0 1 2 0 1 2 0 1 2

(appropriate neat/ clean school uniform, name tag
1
visible, hair pulled back and up, nails are trimmed
short with no polish/acrylics, no jewelry, etc.)

Introduce self, confirm client identity 0 1 2 0 1 2 0 1 2

2
using three patient identifiers, explain
procedure
Hand hygiene, provide privacy 0 1 2 0 1 2 0 1 2
3

Considers ergonomics and sets up for 0 1 2 0 1 2 0 1 2

4 assessment appropriately.

Assesses appearance and cognition of patient 0 1 2 0 1 2 0 1 2

5 (position, self-care, speech articulation)

Performs vital signs 0 1 2 0 1 2 0 1 2

(Temperature, B/P, Pulse, Respirations & O2
6
saturation)

Assess patient pain level: 0 1 2 0 1 2 0 1 2

Asks patient about pain
Uses the appropriate explanation of pain scale
7
used to ensure optimal evaluation of a patient’s
pain level

Performs neurological assessment: 0 1 2 0 1 2 0 1 2

(LOC, orientation, PERRLA, facial symmetry,
8
equal hand grips, moves all extremities equally)

Performs cardiovascular assessment: 0 1 2 0 1 2 0 1 2

(apical pulse, heart sounds, bilateral comparison
of radial pulse, pulse regular or irregular, capillary
9
refill, pedal pulses (compare bilaterally), calf
tenderness, peripheral edema)

1
 Head to Toe Assessment – Skills Checklist
Performs respiratory assessment: 0 1 2 0 1 2 0 1 2
(auscultates all lung fields anteriorly and
posteriorly using zig-zag technique, presence of
10
cough, respiratory rhythm and depth, oxygen
therapy, SOB)

Performs gastrointestinal assessment: 0 1 2 0 1 2 0 1 2

(auscultates bowel sounds RLQ-RUQ-LUQ-LLQ,
abdomen shape, palpate for tenderness- light and
11 deep, last BM – date, quantity, consistency, color,
continence, diet, oral cavity mucosa, teeth,
swallowing)

Performs genitourinary assessment: 0 1 2 0 1 2 0 1 2

(urine output – color, quantity, continence, burning, itching,
11
vaginal/penile discharge, distention)

Performs musculoskeletal assessment 0 1 2 0 1 2 0 1 2

(arm strength and leg strength with bilateral
12 comparison, gait, ROM and inspect joint areas
and palpation of bony articulations, swelling,
crepitus, pain)

Performs integument assessment: this 0 1 2 0 1 2 0 1 2

assessment may be done while conducting other
13 body system assessments
(color, temperature, moisture, lesions, edema,
itching, numbness)
0 1 2
Upon completion of assessments: 0 1 2 0 1 2
Communicates to the patient that they are finished with assessment
and when they may return

14 Asks if patient requires anything or assistance before leaving

Lowers bed and returns side table if relocated for assessment, call
bell use articulated to patient and placed within patient reach

Effective and clear communication techniques used throughout 0 1 2 0 1 2 0 1 2

15
assessments

Additional Comments:

TOTAL SCORE: