1.7 Checklist for General Survey
Open Resources for Nursing (Open RN)
Use this checklist to perform a “General Survey.” Checklists for hand washing, using hand sanitizer, and obtaining vital signs are included in Appendix A.
Steps
Disclaimer: Always review and follow agency policy regarding this specific skill.
- Knock, enter the room, greet the patient, and provide for privacy.
- Introduce yourself, your role, the purpose of your visit, and an estimate of the time it will take.
- Perform hand hygiene.
- Ask the patient their legal name and date of birth for the first identifier. Verify information provided in their chart or wristband, if present. Use one of the following for the second identifier:
- Scan wristband
- Compare name/DOB to MAR
- Ask staff to verify patient (in settings where wristbands are not worn)
- Compare picture on MAR to patient
- Address patient needs (pain, toileting, glasses/hearing aids) prior to starting assessment. Note if the patient has signs of distress such as difficulty breathing or chest pain. If signs are present, defer general survey and obtain emergency assistance per agency policy.
- Explain the procedure to the patient; ask if he/she has any questions. Obtain an interpreter as needed if English is not the patient’s primary language.
- Pause and explain to the instructor what you would purposefully observe and assess during a general survey assessment.
- Upon completion of the survey, thank the patient and ask if anything is needed.
- Ensure five safety measures before leaving the room:
- CALL LIGHT: Within reach
- BED: Low and locked (in lowest position and brakes on)
- SIDE RAILS: Secured
- TABLE: Within reach
- ROOM: Risk-free for falls (scan room and clear any obstacles)
- Perform hand hygiene and clean stethoscope.
- Follow agency policy for reporting findings outside of normal range.
- Document the assessment.