Head-to-Toe Assessment Checklist Template

The Head-to-Toe Assessment Checklist template is a structured documentation tool designed to guide nurses through the complete physical assessment in a consistent, top-down order. With dedicated sections for vital signs, general survey, HEENT, neck, respiratory and cardiovascular, abdomen, extremities and neurological, skin, and lines and devices, it ensures no system is skipped between the bedside and the chart. Each item includes the expected finding for quick reference and space to record what you actually observed.

It's especially useful for admission and start-of-shift assessments, nursing students in clinical rotations, and preceptors onboarding new graduates. By standardizing the sequence, the template makes changes from baseline easier to spot and supports clear, objective documentation and handoffs. Optimized for use with Sully.ai's AI Scribe, it helps nurses complete a thorough assessment while staying focused on the patient instead of the screen.