A nursing assessment is a process where a nurse gathers, sorts and analyzes a patient’s health information using evidence informed tools to learn more about a patient’s overall health, symptoms and concerns. This includes considering the patient’s biological, social, psychological, cultural and spiritual values and beliefs.^[1]

Assessments are critical to client safety. Timely and comprehensive assessments is a fundamental skill nurses should demonstrate in any area of nursing practice. Nurses are accountable to document and follow up as needed on any information that may inform the client’s plan of care and ongoing decision-making about the client’s health status, which may include identifying urgent, emergent and/or life-threatening conditions.

During a nursing assessment the nurse collects both subjective and objective information using evidence informed tools to assess the patient as a whole. A nursing assessment may include, but is not limited to the following:

• environmental assessment
• cultural assessment
• physical assessment
• psychological assessment
• safety assessment
• psychosocial assessment

Nurses are expected to use their clinical judgment to determine whether they are competent to complete an assessment and provide safe client care. This may include consistently reassessing clients as needed. Nurses are accountable to collaborate and communicate their findings with the broader health care team and if required, escalate their concerns to an appropriate health care provider.

Nurses are accountable to reassess patients frequently to make sure the care plan still meets the patients needs and address any changes to the patients’ health condition. Consistently reassessing patients is a key component to maintaining patient safety and improving patient health outcomes. Not doing so, may pose significant risks to their health.

Though performing assessments are part of a nurse's foundational competencies, it is critical that nurses maintain this knowledge and skill. Nurses can maintain or increase competence in assessments through specialized education or developing new skills throughout the course of their nursing practice. All nurses are accountable to reflect on their practice every day to determine their learning needs and actively update their knowledge and skills to maintain their competence. Nurses are expected to participate in Quality Assurance and continue their ongoing learning and development.

Nurses do not require an order to perform assessments. Nurses have the authority to perform an assessment (including vital signs) using their nursing knowledge, skill and judgment. Employer policies may provide additional direction related to nursing assessments, such as processes, tools and best practices.

A theory, framework or evidence-based tool should be used when describing the patients’ situation. Nurses should also consult the patient and other members of the health care team to create a patient-centered care plan.

Nursing documentation provides a clear picture of:

• the client’s needs or goals,
• the nurses actions based on the needs assessment
• the outcomes and evaluations of those actions

Assessment findings should be documented along with any changes to the client’s care plan.

To support a collaborative approach to care, nurses should ensure their documentation is a complete record of the nursing care and reflects all aspects of the nursing process, including assessment, planning, intervention (independent and collaborative) and evaluation.

Employers are encouraged to have clear policies that align with the standards of practice, that meet the needs of the practice setting including requirements for nursing assessments.