Nursing Assessment: Head-to-Toe (Video)

The head-to-toe assessment in nursing is an important physical health assessment that nurses perform. In a nursing home, 42 CFR § 483.21 requires development of a baseline care plan within 48 hours of admission. A comprehensive care plan must be developed within 7 days.

42 CFR § 483.20 provides that a facility must make a comprehensive assessment of a resident’s needs, strengths, goals, life history and preferences, using the resident assessment instrument (RAI) specified by CMS. The assessment must include at least the following:

Identification and demographic information.
Customary routine.
Cognitive patterns.
Communication.
Vision.
Mood and behavior patterns.
Psychosocial well-being.
Physical functioning and structural problems.
Continence.
Disease diagnoses and health conditions.
Dental and nutritional status.
Skin condition.
Activity pursuit.
Medications.
Special treatments and procedures.
Discharge planning.
Documentation of summary information regarding the additional assessment performed on the care areas triggered by the completion of the Minimum Data Set (MDS).
Documentation of participation in assessment. The assessment process must include direct observation and communication with the resident, as well as communication with licensed and nonlicensed direct care staff members on all shifts.

The comprehensive assessment must take place Within 14 calendar days after admission, excluding readmissions in which there is no significant change in the resident’s physical or mental condition. (For purposes of this section, “readmission” means a return to the facility following a temporary absence for hospitalization or for therapeutic leave); within 14 calendar days after the facility determines, or should have determined, that there has been a significant change in the resident’s physical or mental condition. (For purposes of this section, a “significant change” means a major decline or improvement in the resident’s status that will not normally resolve itself without further intervention by staff or by implementing standard disease-related clinical interventions, that has an impact on more than one area of the resident’s health status, and requires interdisciplinary review or revision of the care plan, or both); and Not less often than once every 12 months. The assessment must also be updated not less frequently than once every three months. See Section 483.20(b)(2) and (c). The assessment must accurately reflect the resident’s status. See Section 483.20(g).