Assessing patients is part of a nurse’s professional practice to keep patients safe and improve their health outcomes.
The nursing scope of practice statement in the Nursing Act, 1991 includes the accountability of assessing patients.
Nursing scope of practice statement
- The practice of nursing is the promotion of health and the assessment of, the provision of care for and the treatment of health conditions by supportive, preventive, therapeutic, palliative and rehabilitative means in order to attain or maintain optimal function
What is a nursing assessment?
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. The nurse should consider the patient’s biological, social and psychological status, as well as their cultural and spiritual values and beliefs.[1]
Assessments are critical to client safety. Timely and comprehensive assessment is a fundamental skill nurses should demonstrate in any area of nursing practice. Nurses are accountable to document and follow up with the most appropriate provider, as needed, on any information that may inform the client’s plan of care and ongoing decision-making about the client’s health status. As part of these activities, nurses identify urgent, emergent and/or life-threatening conditions.
What is included in a nursing assessment?
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 the following, and can include other assessments:
- 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 care 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 conditions. Consistently reassessing patients is a key component in maintaining patient safety and improving patient health outcomes. Not doing so may pose significant risks to patient health.
Though performing assessments is 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.
Do I need an order to do a nursing assessment?
Nurses do not require an order to perform assessments. Nurses have the authority to perform an assessment (including obtaining 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.
What should a nurse consider when determining an assessment?
A theory, framework or evidence-based tool should be used when describing the patient’s situation. Nurses should also consult the patient and other members of the health care team to create a patient-centred care plan.
When should I document my assessment?
Nursing documentation provides a clear picture of:
- the client’s needs or goals
- the nurse's actions based on the needs assessment
- the outcomes and evaluations of those actions
Assessment findings should be documented along with any changes to the patient’s care plan.
To support a collaborative approach to care, nurses should ensure their documentation contains 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 and meet the needs of the practice setting, including requirements for nursing assessments.
Related Links
External Resources
- A-Z Guide of Clinical Assessment Tools for Nurses (U.K)
- Potter, P. A., Duggleby, W. D., & Astle, B. J. (2018). Canadian fundamentals of nursing (6th ed.). Elsevier Canada.
- Jarvis, C., Browne, A. J., MacDonald-Jenkins, J., & Luctkar-Flude, M. (2019). Physical examination & health assessment (3rd ed.). Elsevier Canada.