Head-to-toe checklist
Tick what you assessed. Practice only — not a medical record.
Vital signs / Pain
- BP (mmHg)
- HR (bpm)
- RR
- Temp
- SpO₂ (%)
- O₂ delivery
- Pain present
- Pain score (0–10) + location
Neurological
- Level of consciousness
- Orientation
- Speech
- Pupils
- Grip strength
- Sensation
- Coordination / gait
HEENT
- Eyes
- Ears
- Nose
- Throat / mouth
Cardiovascular
- Heart sounds / rhythm
- Edema (R / L)
- Pulses (R / L · upper & lower)
- Chest pain / discomfort now
Respiratory
- Work of breathing / effort
- Breath sounds (per lung field)
- Cough
- Oxygen / airway device
Gastrointestinal
- Abdomen
- Bowel sounds
- Last bowel movement
- Appetite
- Nausea / vomiting
Genitourinary
- Voiding
- Urine appearance
- Urinary catheter
Musculoskeletal
- Moves all extremities
- Strength — upper right
- Strength — lower right
- Strength — upper left
- Strength — lower left
- Range of motion
- Assist / mobility level
Integumentary / Skin
- Skin color
- Turgor / moisture
- Skin integrity
- Wound / incision present
Psychosocial / Safety
- Mood / affect
- Fall-risk awareness (practice)
- Safety concerns
Also free in the app: Pain Assessment, Fall Mobility, Skin Risk, and Wound Assessment.
Practice charting free at bettercharting.com
Normal parameters vary depending on your hospital/employer policy.
Sample note — fictional adult, med-surg
Practice example only. This is not a real patient and not a medical record.
Vital signs: blood pressure 128/74, heart rate 84, respirations 18, oral temperature 98.4 °F, oxygen saturation 96% on room air. Pain is present at the lower abdominal midline incision, 5 out of 10, sharper with a cough.
Neurological: alert. Oriented to person, place, time, and situation. Speech clear. Pupils about 3 mm and brisk on both sides. Grip equal. Light touch intact in both arms and both legs. Walks steadily with one person beside them.
HEENT: eyes clear, no drainage. Ears clear, no hearing aid. Nose clear. Mouth moist, and sips of water go down without coughing.
Cardiovascular: regular S1 S2. No chest pain or pressure now. No edema at the ankles. Pulses +2 in both arms and both legs.
Respiratory: breathing unlabored, no tugging at the neck. Upper chest clear on both sides. Crackles at both bases. An occasional cough brings nothing up. Room air.
Gastrointestinal: abdomen soft, tender along the incision. Bowel sounds present in all four quadrants. Last bowel movement yesterday. Appetite fair. No nausea or vomiting.
Genitourinary: voids on their own without leaking. Urine clear yellow. No urinary catheter.
Musculoskeletal: moves both arms and both legs. Strength strong in all four limbs. Bends and straightens the elbows and knees fully. Walks to the chair with one-person assist.
Skin: color matches this person’s usual tone. Warm, dry, and elastic. Midline abdominal incision under a dry dressing. No other break in the skin.
Psychosocial and safety: mood matches the conversation. Asks for help before getting up. Call light within reach. Bed kept low. No other safety concern noted this pass.