Hospice Nursing Assessment

Nurses capture vital signs, level of consciousness, pain, rest quality and background history in a single visit. Emergency contacts, allergies and current medication are recorded alongside them. The completed assessment guides the care plan and is signed by whoever carried it out.

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Assessment Date

Assessment Time

Patient Name

Nombre

Apellido

Patient Age

Patient Date of Birth

Patient Gender

Female Male Other Prefer not to say

Patient Phone Number

Patient Email

Patient Address

Dirección

Ciudad

Estado / Provincia

Código postal

Emergency Contact Person

Nombre

Apellido

Emergency contact phone

Relationship to the contact person

Is the patient experiencing pain?

Yes No Intermittently

Can the patient communicate?

Yes, without difficulty In a limited way No

Non-verbal signs the patient is showing:

Is the patient getting enough sleep?

Yes No Sometimes

What is the quality of sleep like?

Restful Interrupted Insomnia Excessive sleepiness Needs medication to sleep

Allergies

Family history of illness

Name of the nurse who carried out the assessment

Nombre

Apellido

Position / job title

Phone Number

Signature of the nurse

Sign here

Date Signed

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