A long term care admission or baseline nursing care plan must be as comprehensive as possible. A head to toe assessment is the only way to make sure the gathering of information is complete.

This begins with the first interaction between the nurse and the resident. It is about seeing, hearing, and touching – Looking at the resident, talking to the resident, and using palpation when needed.

The results of a head to toe nursing assessment are best conveyed in the narrative form. “Resident admitted from Mercy Hospital via wheelchair accompanied by daughter. Resident is an elderly well nourished female. A/O x 3. Skin pink and warm to touch. Denies any complaint….”

This detailed physical assessment and the questions and answers from the other admission assessments form the foundation of the MDS, Comprehensive Admission Assessment, and the baseline nursing care plan. It is the starting reference point to compare future assessments to and gauge the resident’s progression or decline.

Digital menus and drop down boxes cannot replace actual physical contact and meaningful communication.