Clinical Assessment Tools
Standardised nursing and geriatric screening instruments. All tools support learning and workflow practice; scores must always be integrated with comprehensive clinical judgment.
Health History Frameworks
OLDCARTS
OLDCARTS — History of Present Illness
8-dimension HPI documentation framework: Onset, Location, Duration, Character, Aggravating factors, Relieving factors, Timing, Severity. Generates a formatted HPI summary for documentation practice.
PQRSTU
PQRSTU — History of Present Illness
6-dimension HPI framework: Provocation/Palliation, Quality, Region/Radiation, Severity, Timing, Understanding. The 'U' dimension captures patient health beliefs affecting education and adherence.
ROS
Review of Systems — Systematic Symptom Inventory
14-system head-to-toe symptom review. Mark each system Negative, Positive, or Not Asked. Positive systems expand for detail. Generates a formatted ROS documentation summary for comprehensive health history practice.
Adolescent Assessment
HEEADSSS
HEEADSSS — Adolescent Psychosocial Assessment
8-domain structured adolescent psychosocial interview: Home, Education, Eating, Activities/Affect/Ambitions, Drugs, Sexuality, Suicide/Depression, Safety. Conduct privately. Safety-critical domains flagged. Generates a formatted summary.
PACES
PACES — Adolescent Psychosocial Assessment
5-domain rapid adolescent psychosocial screen: Parents/Peers, Accidents/Alcohol/Drugs, Cigarettes, Emotional Issues, School/Sexuality. Shorter format for rapid screening or as a complement to HEEADSSS.
Procedure Builder
Mood & Mental Health
PHQ-2
Patient Health Questionnaire-2
2-item ultra-brief depression screen. Score ≥ 3 triggers the full PHQ-9.
GDS-15
Geriatric Depression Scale-15
15-item yes/no depression screen for older adults. Score ≥ 5 suggests depressive symptoms.
PHQ-9
Patient Health Questionnaire-9
9-item, 0–27 point severity screen for depression. Includes safety flag when item 9 is positive.
Cognition & Delirium
Mini-Cog
Mini-Cog
3-word recall + clock drawing (0–5). Score ≤ 2 is screen positive for cognitive impairment.
CAM
Confusion Assessment Method
Four-feature delirium algorithm. Positive when Features 1 + 2 and either 3 or 4 are present.
MoCA
Montreal Cognitive Assessment
30-point rapid cognitive screen across 7 domains. Score ≥ 26 = normal; < 26 = possible impairment. Add 1 pt for ≤ 12 years education.
MMSE
Mini-Mental State Examination
30-point cognitive screen across 6 domains. Score 24–30 = no impairment; 18–23 = mild; 10–17 = moderate; 0–9 = severe. Proprietary — educational use only.
GDS (Reisberg)
Global Deterioration Scale
7-stage dementia severity framework. Guides care planning and goals-of-care conversations.
Neurological Assessment
GCS
Glasgow Coma Scale
Eye, verbal, and motor responses scored 3–15. GCS ≤ 8 signals severe impairment requiring airway assessment.
AVPU
AVPU Scale
Rapid 4-level consciousness screen: Alert, Voice, Pain, Unresponsive. Used for rapid deterioration detection.
RASS
Richmond Agitation-Sedation Scale
10-level scale (−5 to +4) for ICU sedation and agitation monitoring. Compare against prescribed target.
Vital Signs & Deterioration
Vascular & Orthopedic Assessment
Geriatric Screening
SPICES
SPICES Geriatric Screening Tool
Six-domain nursing-sensitive geriatric screen: Sleep, Problems with eating, Incontinence, Confusion, Evidence of falls, Skin breakdown. Any positive domain triggers targeted comprehensive assessment.
5Ms
Geriatric 5Ms Framework
AGS/CGS framework organising geriatric care around Mind, Mobility, Medications, Multi-complexity, and Matters Most. Includes clinical prompts, linked tools, and a goal-concordant care planning summary.
Beers Criteria®
AGS Beers Criteria® — Medication Safety
2023 AGS Beers Criteria® reference. For each potentially inappropriate medication (PIM) in adults ≥ 65: why it is on the list, specific nursing monitoring points, and safer alternatives. Searchable by drug name, class, or condition.
ISAR
Identification of Seniors At Risk
6-item yes/no screen for frail older adults presenting to emergency or acute care. Score ≥ 2 = positive screen (high risk for adverse outcomes). Identifies patients needing comprehensive geriatric assessment.
Geriatric Assessment Frameworks
Stroke Assessment
Functional Status – ADL
Katz Index
Katz Index of Independence in ADL
6-item basic ADL independence scale (0–6). Score 6 = fully independent.
Barthel Index
Barthel Index
Weighted 10-item ADL scale (0–100). Guides rehabilitation planning and level-of-care decisions.
FIM
Functional Independence Measure
18-item motor + cognitive scale (18–126). Educational use only; clinical use requires UDSMR license.
Functional Status – IADL
Mobility & Fall Risk
TUG
Timed Up and Go Test
Clinician enters time in seconds. ≥ 12 s associated with fall risk in community-dwelling older adults.
MFS
Morse Fall Scale
6-item inpatient fall risk screen (0–125). Score ≥ 45 = high risk; drives prevention protocol selection.
JHFRAT
Johns Hopkins Fall Risk Assessment Tool
7-domain inpatient fall risk screen. Score 0–5 = low; 6–13 = moderate; ≥ 14 = high risk.
Hendrich II
Hendrich II Fall Risk Model
8-item inpatient fall risk screen including Get Up and Go test (0–16). Score ≥ 5 = high risk.
Pain Assessment
NRS
Numerical Rating Scale — Pain
0–10 patient-reported pain intensity. Simple and widely used for adults and children ≥ 9 years.
FPS-R
Faces Pain Scale – Revised
6-face self-report scale (0–10). Validated for children 4–16 and adults who struggle with numeric scales.
PAINAD
Pain Assessment in Advanced Dementia
5-item observational pain tool (0–10) for non-verbal patients with advanced dementia.
PACSLAC
Pain Assessment Checklist for Seniors with Limited Ability to Communicate
60-item observational checklist (0–60) for non-verbal seniors with dementia. Score ≥ 15 = severe pain.
Skin & Wound Risk
Braden Scale
Braden Scale for Pressure Injury Risk
6-subscale tool (6–23). Lower scores = higher risk. Drives pressure injury prevention protocol.
REEDA Scale
REEDA Scale — Surgical Incision Healing
Five-domain wound healing scale (0–15): Redness, Edema, Ecchymosis, Discharge, Approximation. Score 0 = optimal healing; ≥ 10 = significant complications.
Surgical Incision
Surgical Incision Assessment
Comprehensive wound documentation tool covering wound edges, tissue type, exudate, periwound skin, odor, pain (NRS), and SIADIE infection checklist. Generates a flagged summary.
Ostomy Assessment
Nutritional Assessment
MNA-SF
Mini Nutritional Assessment – Short Form
6-item nutritional screen for older adults (0–14). Score ≥ 12 = normal; 8–11 = at risk; 0–7 = malnourished.
MUST
Malnutrition Universal Screening Tool
3-step nutritional risk screen for all adult settings. Score 0 = low; 1 = medium; ≥ 2 = high risk.
NRS-2002
Nutritional Risk Screening 2002
Two-step ESPEN-endorsed hospital nutritional screen. Total score ≥ 3 = at nutritional risk.
DETERMINE
DETERMINE Nutritional Health Checklist
9-item community nutritional risk screen for older adults. Score 0–2 = good; 3–5 = moderate; 6+ = high risk.
Swallowing Assessment
FOIS
Functional Oral Intake Scale
7-level ordinal scale rating functional oral intake. Level 1 = NPO; Level 7 = no dietary restrictions.
3-oz Water
3-Ounce Water Swallow Test
Bedside dysphagia screen: patient swallows 90 mL water continuously. Any coughing, wet voice, or choking = positive.
MMASA
Modified Mann Assessment of Swallowing Ability
14-item bedside dysphagia screen for neurological patients (0–140). Score ≤ 100 = dysphagia likely.
EAT-10
Eating Assessment Tool-10
10-item patient-reported dysphagia severity questionnaire (0–40). Score ≥ 3 indicates swallowing problem warranting speech-language pathology evaluation.
GI & Bowel Assessment
Eating Disorder Screening
Hearing & Balance
Rinne Test
Rinne Test
Tuning-fork test comparing air and bone conduction to distinguish conductive from sensorineural loss.
Weber Test
Weber Test
Tuning-fork lateralisation test detecting unilateral hearing loss type.
Whisper Test
Whisper Test
Bedside hearing screen at 2 feet. Sensitivity ~80%. Fail warrants formal audiometry referral.
Romberg Test
Romberg Test
Balance test evaluating proprioception. Positive sign suggests sensory ataxia or vestibular dysfunction.
Alcohol Screening
AUDIT-C
Alcohol Use Disorders Identification Test — Concise
3-item screen for hazardous alcohol use (0–12). Positive at ≥ 3 (women) or ≥ 4 (men). Integrates with nutritional and medication safety assessments.
CAGE
CAGE Questionnaire
4-item yes/no alcohol use screen. Score ≥ 2 is clinically significant and warrants comprehensive assessment. Used as a rapid initial screen before AUDIT.
Substance Use Screening
DAST-10
Drug Abuse Screening Test-10
10-item yes/no drug use screen (past 12 months). Score 0 = none; 1–2 = low; 3–5 = moderate; 6–10 = high risk. Item 3 is reverse-scored.
CRAFFT
CRAFFT Adolescent Substance Use Screen
6-item yes/no substance use screen for adolescents (ages 12–21). Score 0–1 = no concern; 2 = positive screen; 3–6 = high concern. Car, Relax, Alone, Forget, Friends, Trouble.
TACE
TACE Alcohol Screen — Pregnancy
4-item alcohol use screen for pregnant patients. Score ≥ 2 = positive screen. T item (tolerance) weighted at 2 points. Specifically validated for prenatal settings.
Pediatric & Adolescent Assessment
HEEADSSS
HEEADSSS — Adolescent Psychosocial Assessment
Eight-domain structured interview framework for adolescent psychosocial assessment (ages 12–21): Home, Education, Eating, Activities/Affect, Drugs, Sexuality, Suicide/Depression, Safety. Conduct with adolescent alone.
Tanner Stages
Tanner Stages — Sexual Maturity Rating
Reference tables for pubertal development staging: female breast (5 stages), female pubic hair (6 stages), male genital (5 stages), male pubic hair (6 stages). Clinical descriptions and typical age ranges.
Spiritual & Cultural Assessment
FICA
FICA — Spiritual Assessment Tool
Four-domain spiritual history interview: Faith/belief/meaning, Importance and influence, Community, Address in care. Developed by Dr. Christina Puchalski. Not scored — a structured conversation guide for whole-person care.
LEARN
LEARN — Culturally Responsive Communication Model
Five-step cross-cultural communication framework: Listen, Explain, Acknowledge, Recommend, Negotiate. Berlin & Fowkes (1983). Bridges clinical and patient explanatory models of illness.
Family Violence & Safety
Sleep Assessment
Medication Side Effects — Movement Disorders
AIMS
Abnormal Involuntary Movement Scale
12-item clinician-rated scale detecting tardive dyskinesia and other antipsychotic-induced involuntary movements. Administer at baseline and every 3–6 months.
BARS
Barnes Akathisia Rating Scale
4-item scale for drug-induced akathisia (0–5 global score). Score ≥ 2 = clinically significant akathisia. Prevents misidentification as worsening psychosis.
SAS
Simpson-Angus Rating Scale
10-item scale for antipsychotic-induced parkinsonism (mean score 0–4). Mean > 0.3 = clinically significant EPS. Differentiates drug-induced parkinsonism from depression.
Urinary Assessment
IPSS
International Prostate Symptom Score
7-item self-administered LUTS severity questionnaire (0–35). Score 0–7 = mild; 8–19 = moderate; 20–35 = severe. Includes quality-of-life item.
ICIQ-SF
International Consultation on Incontinence Questionnaire — Short Form
4-item urinary incontinence screen (0–21). Score 1–5 = slight; 6–12 = moderate; 13–21 = severe–very severe. Item 4 identifies incontinence type.
Oxford Grading
Oxford Grading Scale — Pelvic Floor Muscle Strength
6-point ordinal scale (0–5) for pelvic floor muscle strength assessed by internal examination. Grade 0 = no contraction; Grade 5 = strong sustained contraction against resistance.