Which nursing process would the nurse undertake when collecting the medical history?

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Assessing patients is part of a nurse’s professional practice to keep patient’s safe and improve a patient’s health outcomes.  

The Nursing Act, 1991 includes the accountability of assessing patients in the nursing scope of practice statement.

Nursing scope of practice statement

1. The practice of nursing is the promotion of health and the assessment of, the provision of care for and the treatment of health conditions by supportive, preventive, therapeutic, palliative and rehabilitative means in order to attain or maintain optimal function

What is a nursing assessment?

A nursing assessment is a process where a nurse gathers, sorts and analyzes a patient’s health information using evidence informed tools to learn more about a patient’s overall health, symptoms and concerns. This includes considering the patient’s biological, social, psychological, cultural and spiritual values and beliefs.[1] A nurse then documents and interprets this information to inform the patient’s care plan and ongoing decision-making about the patient’s health status, which may include identifying urgent, emergent and or life-threatening conditions.

Assessments are critical to patient safety because lack of nursing assessments can pose a patient safety risk.  Timely and appropriate holistic nursing assessment is a fundamental skill that all nurses should demonstrate in any area of nursing practice.

What is included in a nursing assessment?

During a nursing assessment the nurse collect both subjective and objective information using evidence informed tools to assess the patient as a whole. A nursing assessment may include, but is not limited to the following:

• environmental assessment
• cultural assessment
• physical assessment
• psychological assessment
• safety assessment
• psychosocial assessment

Nurses use critical thinking when analyzing the findings of their assessments to inform decisions about a patient’s plan of care. Recognizing normal and abnormal patient physiology helps nurses to prioritize interventions and care delivery. Nurses also consult and collaborate with the broader healthcare team to inform their decisions to support safe patient care.  

Nurses are accountable to reassess patients frequently to make sure the care plan still meets the patients needs and address any changes to the patients’ health condition.  Consistently reassessing patients is a key component to maintaining patient safety and improving patient health outcomes. Not doing so, may pose significant risks to their health.

Though performing assessments are part of a nurses’ foundational competencies, it is critical that nurses maintain this knowledge and skill. Nurses can maintain or increase competence in assessments through specialized education or developing new skills throughout the course of their nursing practice. All nurses are accountable to reflect on their practice every day to determine their learning needs and actively update their knowledge and skills to maintain their competence. Nurses are expected to participate in Quality Assurance and continue their ongoing learning and development.

Do I need an order to do a nursing assessment?

Nurses have the authority to perform a nursing assessment using their nursing knowledge, skill and judgment. Employer policies may provide additional direction related to nursing assessments, such as processes, tools and best practices. Nurses do not require a directive or order to perform assessments. 

What should a nurse consider when determining an assessment?

A theory, framework or evidence-based tool should be used when describing the patients’ situation. Nurses should also consult the patient and other members of the health care team to create a patient-centered care plan.

It is important to include the patient in their care decisions because the patient is the expert of their own lives. The care plan should identify the patient’s goals, wishes and preferences. Patient’s choices can be based on their individual values or stem from cultural and religious beliefs. Nurses are sensitive to and respect their patients’ decisions.

When should I document my assessment?

Nurses assess patients regularly while providing care. Nursing documentation provides a clear picture of:

• the patient’s needs or goals,
• the nurses actions based on the needs assessment
• the outcomes and evaluations of those actions

Every assessment is documented along with any changes to the patient’s care plan. Nurses also evaluate the outcomes of each approach, re-assess the patient’s situation and modify the plan if required. Failure to assess or re-assess a patient can result in serious consequences, such as patient decline in health and even death.

To support a collaborative approach to care, nurses should ensure their documentation is a complete record of nursing care provided and reflects all aspects of the nursing process, including assessment, planning, intervention (independent and collaborative) and evaluation. This ensures communication to all health care providers of the plan of care of patients.

To support documentation practices, employers should ensure they have policies that reflect the Documentation practice standard and guide nursing practice within specific settings. For example, having explicit assessment norms and documentation expectations.

CNO Standards and Guidelines

• Code of Conduct
• Professional Standards
• Therapeutic Nurse-Client Relationship
• NP Practice Standard
• Understanding your scope of practice
• Entry-to-practice Competencies for Ontario Registered Practical Nurses
• Entry-to-practice Competencies for Registered Nurses
• Entry-to-practice Competencies for Nurse Practitioners

External Resources

A-Z Guide of Clinical Assessment Tools for Nurses (U.K)

Potter, P. A., Duggleby, W. D., & Astle, B. J. (2018). Canadian fundamentals of nursing (6th ed.). Elsevier Canada.

Jarvis, C., Browne, A. J., MacDonald-Jenkins, J., & Luctkar-Flude, M. (2019). Physical examination & health assessment (3rd ed.). Elsevier Canada.

Which nursing process with the nurse undertake when collecting the medical history of a client?

Which step in the nursing process includes the careful taking of a history and a nursing examination?

What are the 5 stages of the nursing process?

Which step of the nursing process would include interpretation of data collected about the client?