Rapid Assessment Sheet

Level of Consciousness:

AAOX4

The person knows person,

place, time and event.

AAOX3

The person knows person,

place and time, but not event.

AAOX2

The person knows person and

place, but not time and event.

AAOX1

The person knows person, but

not place, time and event.

AAOX0

The person is awake and alert,

but is disoriented.

HEENT:
Speech:
Clear
Slurred
Aphasic

Garbled

Facial
Symmetry:_________________________
Pupils:
Equally round bilaterally
Reactive to light
Pupil size: R__________

Orientation:

Glasgow Coma Scale

Lowest = 3 deep coma/death
Highest = 15 fully awake
Best Eye 4 opens spontaneously
Opening 3 to voice
2 to pain
1 none
Best
5 oriented
Verbal
4 confused
3 Inappropriate words
2 incomprehensible
sounds
1 makes no sounds
Best
6 obeys commands
Motor
5 localizes painful
stimuli
4 withdrawal to painful
stimulation
3 abnormal flex. to pain
stim. (cecorticate)
2 extension to pain
stim. (decerebrate)
1 makes no
movements

L_____________
Accommodation
Hearing Loss?:
Y/N________________________
Mouth:
Lips cracked?: Y/N_________________
Dry mouth?: Y/N___________________
Any Neck Pain?: Y/N______________________

Rapid Assessment Sheet

Respiratory:
Characteristics:
Regular Irregular SOB
Bradypnea Tachypnea
Apnea

Cardiovascular:
Heart Rate(Apical):

Cough: None Non-productive

Productive
Characteristics:_________________
_

Heart Sounds:

S1:

S2:

S3:

S4:

Strong Faint

Capillary Refill:_________________
Oxygen via___________@________%
Artificial Airway present?:
_____________
If yes, explain:
__________________
Chest tube present?:
__________________

Regular
Irregular
Tachycardic Bradycardic

Murmur
o Where?:_______
___________
Other: _________
_______________

Jugular Vein Distension?: Y/N ______

HOB 30______
HOB 60______
HOB 90______

Peripheral Pulses*:
Right
Clear

Left
Clear

Crackles

Crackles

Wheezes

Wheezes

Radial
Right

Radial
Left
A

Present

Faint
A
Equal to apical?____
Post. Tibial
Right
A

Present

Edema:

Faint
A
Equal to apical?____
Post.
Tibial
Left
A

Present

Faint
A
Dorsalis pedis
Right
Present

Present

Faint

Faint
A
Dorsalis pedis
Left
Present
Faint

A
A

Present Location________

GI:
Feeding Tube (type):
N/A
A
A
Suction:

NG GT

Absent
Pitting: Y/N Where?:__________
Grade:_____
GU:
Catheter: Y/N _________; If yes, Type:
F/C
I/O
SupraA
A
A
pubic

Rapid Assessment Sheet

N/A
Condom
A
A
A
A
Continuous
Intermittent
Drainage:_______________________ Voiding: Y/N__________
Ostomy: Y/N describe
Urine Characteristics:
_______________
Clear
A
A
A
A
Cloudy Yellow Amber
Bowel Sounds: Present Absent
Red-tinged
Sediment
LBM:_________________
A
A
Other
Characteristics:
A
A
A
_______________________________
Firm
Soft
Loose
A
A
Liquid
Color:
A
A
A
A
Brown Black
Red-tinged
Other Incontinent Continent
A
A
S/T
Incontinent
________
A

A
A
Pain on Urination:
Incontinent
Y/N_____________________
Continent
S/T
Incontinent
A
Other: ___________________________________
__________________________________________
Palpate:
Soft
Firm __________________________________________
A
A
A
Distended
Tender
A
Nausea/Vomiting:_____________________
Nutrition:______________________________
______________________________________
Musculoskeletal:
Pain: Describe _______________________
Gait: Describe _______________________
Muscle grading and strength:
Arms R____________
L____________
Hands R___________
L____________
Legs R_____________
L___________
Feet R_____________ L___________
ROM***:
Cervical spine:
o Flexion___________

Skin:
Color:
Pale Cyanotic Flushed Jaundice
Consistent with ethnicity
Characteristics: Warm Cool Dry
Moist
**Turgor: Immediate Rebound
Delayed Rebound
Wound (site, dressing):
_______________________________
_______________________________
Other:
____________________________________

Rapid Assessment Sheet

Extension_________
Lateral bending R_____
L______
o Rotation R________
L__________
Shoulders
o Flexion R__________
L__________
o Extension R________
L_________
o Abduction R________ L________
o Adduction R________ L________
o Internal Rotation R____
L______
o External Rotation R____
L______
Elbows
o Flexion R__________
L__________
o Extension R________
L_________
o Pronation R________
L_________
o Supination R________
L________
Wrists and hands
o Wrist extension R______
L______
o Finger extension R_____
L______
o Ulnar deviation R______
L______
o Radial deviation R_____
L______
o Fingers spread R______
L______
o Make fist R_________
L_________
o Touch thumb to each finger
______________________________
Hips
o Flexion R__________
L__________
o Extension R________
L_________
o Internal Rotation R____
L______
o
o

Rapid Assessment Sheet

External Rotation R____
L______
o Abduction R________ L________
o Adduction R________ L________
Knees (Watch gait)
o Flexion R__________
L__________
o Extension R________
L_________
o Walk ________________________
o Knee bend R________
L________
Ankles and feet
o Dorsiflexion R________
L________
o Plantar flexion R______
L_______
o Inversion R_________
L_________
o Eversion R_________
L__________
Spine
o Flexion___________
o Extension_________
o Lateral bending R_____
L______
o Rotation R________
L__________
o

Notes:
*If you cannot palpate dorsalis pedis, try the posterior tibialis.
**Skin turgor not needed, unless elderly.
***Typically only do ROM of extremities in rapid unless problem noted.