This document provides a script for safely assessing a patient in the hospital or community setting. It includes introducing oneself, checking the patient's identification band, asking about allergies and pain levels, explaining the assessment process, taking vital signs including blood pressure, pulse oximetry, pulse, respiration, and temperature, assessing alertness using the Glasgow Coma Scale, documenting findings, communicating the patient's condition and NEWS score, addressing any concerns, and ensuring safety before leaving. The script emphasizes infection control through hand hygiene and maintaining patient privacy and comfort.

1. ASSESSMENT
CheckSAFETY
Close door,curtainor windowforprivacy
Hand Hygiene
Ensure hand washing 7 stepsasper whoguideline for 30 sec
Introduce selfand role
PreferredName (pt.name)
Wristband check
Pt say theirname and DOB, hospital numberor addressif communitybased
Look at wristbandandcheckagainstthe admissionpaperwork
Allergyandreaction
Latex allergy
Checkspainand comfort
Score pain 0-10 if withpain
Checkif theyknowwhythey’re admitted
Offerrepositioningof comfortability
State you are doingobservations(BP,PR,RR,Temp,O2)
Checksequipmentif cleanedandcalibrated
BP – anyfistula?Surgery?wound?preferredarm?
Pulse oximeter–capillaryrefill<2sec,nonail polish
Pulse – countfor 1 full minute
Respiration- countfor1 full minute afterpulserate
Temperature –check forhearingaid(tempshouldbe checkedafter30minof hearingaidremoval),
no woundnordischarges
CORRECT NEWSSCORE/GCS/PHQ9 SCORE
State NEWS score to patientandstate whenare yougoing to redoit.
Escalatingto doctoror nurse incharge as perNEWS SCORE
Checkingunderstanding
Buzzerand bedon the lowestpart
Verbal Documentation
Hand Hygiene

2. SCRIPT FOR ASSESSMENT:
Scene issafe for me to approach
Close curtainsor doorsfor privacy anddignity
Hand washingUSING7 STEPS ASPER WHO GUIDELINES for 30 sec (dryhandsbefore approachingpt)
Hi My name is _______, I am your nurse fortoday
May I knowyourname please?
Is italrightif check yourwristband?
Couldyouplease confirmyourfull name anddate of birthplease?(checkitagainstthe admission
paper)
Do youhave any allergies?
YES – What are youallergicwithandwhatis the reaction?
Thank youfor givingme thatinformation,Iwill make sure youwillnotgetanymedicationcontaining
Penicillin.
Do youhave any pain?Can youscore itfrom 0-10 0 as no pain10 as verypainful.
Do youknowwhy youare here (ptname).(If ptisunable to answer,orienthimtotime andplace)
I am here todayto do yourobservationsandthiswill consistof respirations,oxygenlevel,pulserate,
bloodpressure andtemperature,willthatbe alright?
I will justgrabthe OBS machine andwill come backto you. Here isthe call bell if youneedanything
else.
The OBS machine hasbeencleanedandcalibratedinthe last24 hoursand I am happyto use it.
(Handgel before goingbackto patient)
Hi (ptname),I’ll be gettingyourOBSnow.
I’ll be takingyourblood pressure,whicharmdo youprefer?
No surgeries?Nofistula?
NextI’ll pop/putthisprobe on youropposite finger. Thisistocheckyou oxygen saturations.
No nail polishandcapillaryrefillis<2sec
I’ll be checkingyourpulse for2 minutes
ExaminerIwill nottell the patientthatIwill be countingthe respirationsaswell sothatIcan get the
accurate result.
Lastly,I’ll checkyourtemperature,doyouhave anyhearingaids?(YES – ill use a differentearorif
bothears have hearingaid,remove the aidandwaitfor 30minutes – justverbalize this),I
can see no woundsnordischarge hasbeennoted.
*FOR GCS*
Can youplease raise bothof your arms andresistitwhenI’mpushingitdownward(NORMAL
POWER)
Can youplease liftyourRightlegandresistwhenI’mpushingitdownward(NORMALPOWER)
Can youplease liftyourleftlegandresist whenI’mpushingitdownward(NORMALPOWER)

3. (Pt.name) I am done takingthe observationsandI’ll be documentingitnow.Here isthe call bell if
youneedme.(COMPUTE NEWS SCORE)
Ms. Examiner,the NEWSSCORE is _____, I will /will notescalate itand I will retake itafter (asper
NEWS POLICY).
HANDHYGIENE whengoingbackto patient.
Hi,Pt name,I am nowdone documenting,everythingisalright(state if anyobsare elevated)andI
will redoyourOBSafter 12/4/6 hours/30min.
Before Ileave doyouhave any concerns?
(IFYES – addressit)
(IFNO – reassure)
Here is the call bell if youneedanything.
I’ll putthe bedrailsup for safetyandbedat itslowestposition.
FINALHANDHYGIENE