By North Essay Help Editorial Team ·
Head-to-Toe Assessment Documentation Example (Normal and Abnormal Findings)
A head-to-toe assessment checks every body system in order, and the documentation is what proves you did it. Instructors look for three things: findings are specific (numbers, sizes, descriptions), normal findings are stated rather than skipped, and abnormal findings are described clearly enough that the next nurse could spot a change. Below is a complete example by system, normal and abnormal versions side by side, and a checklist.
Order of assessment
Most programs teach this order: general survey and vital signs, then neurological, head and neck, cardiovascular, respiratory, gastrointestinal, genitourinary, musculoskeletal, integumentary (skin), and psychosocial. Follow your program's form if it uses a different order.
Complete example by system
The patient is fictional: a 64-year-old woman, day 2 after abdominal surgery, assessed at 0800.
| System | Normal finding (as documented) | Abnormal finding (as documented) |
|---|---|---|
| General survey | Alert, sitting up in bed, appears comfortable, dressed in gown, speech clear. | Lying still, guarding abdomen, grimaces when moving. |
| Vital signs | T 36.8°C oral, HR 78 regular, BP 124/76 left arm sitting, RR 16 unlaboured, SpO2 97% room air, pain 2/10. | T 38.4°C oral, HR 112 regular, BP 102/64, RR 24, SpO2 93% room air, pain 7/10 abdomen. |
| Neurological | Alert and oriented to person, place and time. PERRLA, 3 mm. Moves all limbs on command. Speech clear. | Oriented to person only; unsure of place and date. Pupils equal, 3 mm, reactive. |
| Head and neck | Head symmetrical. Mucous membranes moist and pink. Trachea midline. No jugular venous distension. | Mucous membranes dry. Lips cracked. |
| Cardiovascular | S1 S2 heard, regular rhythm, no murmurs. Radial and pedal pulses 2+ bilaterally. Capillary refill under 3 seconds. No oedema. | Irregular rhythm. Pedal pulses 1+ bilaterally. 2+ pitting oedema both ankles. |
| Respiratory | Breathing unlaboured. Chest expansion equal. Breath sounds clear in all lobes. No cough. | Crackles at right lower lobe. Productive cough, yellow sputum. Using accessory muscles. |
| Gastrointestinal | Abdomen soft, non-distended. Bowel sounds present in all four quadrants. Incision clean, dry, edges approximated. Tolerating clear fluids. Last BM yesterday. | Abdomen distended, firm, tender on light palpation. Bowel sounds hypoactive. Incision red 2 cm around lower edge with yellow drainage. Nausea after fluids. |
| Genitourinary | Voiding independently, urine clear yellow. Output 600 mL since 2400. | Urinary catheter draining dark amber urine, 120 mL since 2400. |
| Musculoskeletal | Full range of motion all limbs. Walks with steady gait, uses walker. Strength 5/5 bilaterally. | Weakness right leg, 3/5. Unable to walk without two-person assist. |
| Skin | Warm, dry, intact. Colour appropriate for ethnicity. Turgor brisk. Braden score 20. | Stage 2 pressure injury on sacrum, 2 cm x 1.5 cm, pink wound bed, no drainage. Braden score 13. |
| Psychosocial | Calm, engaged in conversation. Husband visiting. States she slept well. | Tearful. States, "I'm worried I won't be able to look after myself at home." |
| Lines and devices | Peripheral IV right forearm, 20G, inserted day of surgery, site clean, no redness, infusing as prescribed. | IV site left hand red and swollen 3 cm, patient reports pain at site. IV stopped; site documented. |
Phrases to avoid and what to write instead
| Avoid | Why | Write instead |
|---|---|---|
| WNL (within normal limits) | Doesn't say what you assessed or what normal means | State the finding: "Breath sounds clear in all lobes." |
| Patient fine / stable | No data | Record the vital signs and focused findings |
| Good pulses | Not measurable | "Radial pulses 2+ bilaterally" |
| Wound looks OK | Not descriptive | Size, colour, drainage, edges, surrounding skin |
| Confused | Too vague | "Oriented to person only; unsure of place and date" |
| Ate well | Not measurable | "Ate 75% of breakfast" |
| Abbreviations not on your unit's approved list | May be misread | Write it in full |
Head-to-toe checklist
Use this before you finish the assessment.
- Vital signs with units, site and position (BP arm and position, temperature route)
- Pain score, location and character
- Level of consciousness and orientation
- Pupils (size, equality, reaction)
- Heart sounds, pulses (rate, rhythm, strength), capillary refill, oedema
- Breath sounds in all lobes, work of breathing, oxygen
- Bowel sounds, abdomen, last bowel movement, diet tolerance
- Urine output and appearance, catheter if present
- Mobility, gait, strength, fall risk score
- Skin integrity, pressure areas, wounds, pressure injury risk score
- IV sites and devices: location, gauge, date, appearance
- Psychosocial status and what the patient says, in their words
- Changes since the last assessment, and who you reported them to
Writing it up for an assignment
If your course asks for a written head-to-toe assessment:
- Use the same system order as your clinical form.
- Keep subjective (what the patient says) and objective (what you find) separate.
- Write in the past tense and third person: "Breath sounds were clear."
- Include normal findings. Leaving a system blank reads as not assessed.
- De-identify: no names, initials, room numbers or exact dates.
Frequently asked questions
How long does a head-to-toe assessment take?
With practice, about 10 to 20 minutes for a stable adult. On a busy unit, nurses often do a focused assessment instead, based on the patient's main problem.
What's the difference between a head-to-toe and a focused assessment?
A head-to-toe assessment checks every system. A focused assessment looks in detail at one system or problem, for example a respiratory assessment for a patient with pneumonia.
Should I document normal findings?
Yes. Documenting normal findings shows you assessed the system and gives a baseline for spotting change.
Can I write WNL?
Avoid it unless your organization's approved abbreviation list includes it and defines what it covers. Most instructors want the actual findings.
How do I describe skin colour inclusively?
Describe the finding against the patient's usual skin tone, and use sites where changes are easier to see, such as mucous membranes, conjunctiva and nail beds. Write "colour appropriate for patient" rather than "pink".
How do I document a pressure injury?
Stage, location, size (length x width in cm, depth if measurable), wound bed appearance, drainage, edges and surrounding skin, plus your risk score (for example, Braden).
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Sources: College of Nurses of Ontario, Documentation practice standard (revised, effective February 1, 2026): document promptly, use only approved abbreviations, record objective and subjective information. Toronto Metropolitan University, Documentation in Nursing (open textbook). The patient is fictional and for learning only.
