CareBridge · RN Assessment Guide
Know the assessment.
Arrive prepared.
Get familiar with each part of the patient assessment before your home visit. Explore the questions, understand the response choices, and see when more detail is needed.
19 sections · 108 questions · Visit preparation reference
Before your visit
Take a closer look at the questions.
Select a topic to explore its questions in a compact preview. For the full detail, continue to the reference below, where answer choices, required fields and conditional prompts are explained together.
Read the full question referenceCareBridge RN
Your assessment flow
Assessment workflow preview · After arrival
RN review throughout. Office document review follows submission.
Confirm the visit details against the referral and record who is present. Note the patient’s household and communication circumstances without assuming that supplied information is current.
- 01
Is the caregiver attending this visit?
Yes / NoRequired - 02
Is another person related to the patient present in the home?
Yes / NoRequired - 03
State this person’s relationship to the patient.
Free textRequiredShown when #2 = Yes
Record measured values with the relevant units, site and technique. Describe observed patterns accurately and follow patient-specific instructions for findings that need escalation.
- 01
Temperature in degrees Fahrenheit (°F)
NumericRequiredMethod: Oral / Axillary / Rectal / Remote/Forehead
- 02
Blood pressure: systolic / diastolic
NumericRequiredMethod: In the Right Arm / In the Left Arm
- 03
Pulse in beats per minute (bpm)
NumericRequiredMethod: Regular / Irregular
- 04
Respirations per minute
NumericRequiredMethod: Regular / Shallow / Labored
- 05
Add your clinical narrative for the teaching-provided record.
Free text
Reconcile reported medicines, supplements and over-the-counter products with the records available. Verify names, doses and routes; record discrepancies for the appropriate clinical contact.
- 01
Does the patient use any medicines, vitamins or over-the-counter products?
Yes / NoRequired - 02
Current medication list
Medication listRequiredShown when #1 = Yes
Record each medication’s name, form, route and dose using the approved documentation process. Verify entries before finalizing the record.
- 03
Add your clinical narrative for the teaching-provided record.
Free text
Narrative and teaching review follows this section.
Document relevant health history and recent hospital care. Identify the source of the information and distinguish confirmed diagnoses from the patient’s account or an unresolved concern.
- 01
Describe the patient’s medical background and known conditions. For any hospitalization within the last six months, include the reason and the patient’s condition following discharge.
Free textRequired
Suggested diagnosis review follows this section.
Ask about pain and document its location, intensity and effect on the patient. Record interventions and the actual response, including pain that remains unchanged or increases.
- 01
During the past three days, has the patient reported pain or displayed pain behaviors such as grimacing, guarding, moaning or crying?
Present / Not PresentRequired- Present
- Not Present
- 02
What was the greatest pain intensity during the past three days?
Scale 0–10Required - 03
Select the qualities of the pain.
Multi-selectRequired- Burning
- Aching
- Throbbing
- Sharp
- Crushing
- Radiating
- Other
- 04
Describe the usual duration of each pain episode over the past three days, such as seconds, minutes, hours or continuous pain.
Free textRequired - 05
Identify the location of the pain.
Free textRequired - 06
What eases the pain—for example medication, ice or elevation?
Free textRequired - 07
Does the patient feel the current measures control the pain adequately?
Yes / NoRequired - 08
Record the pain score after the intervention.
Scale 0–10RequiredRecord the actual response, including unchanged or increased pain. Document further action and follow the agreed clinical escalation procedure.
- 09
Select all nonverbal pain behaviors observed in the past three days.
Multi-selectRequired- None Reported/Observed
- Facial Grimaces
- Restlessness
- Guarding
- Rigidity
- Moaning
- Crying
- 10
Add your clinical narrative for the teaching-provided record.
Free text
Suggested diagnosis review follows this section.
Document the neurological findings relevant to the visit and describe changes reported by the patient or caregiver. Record observations separately from established diagnoses.
- 01
How alert is the patient today?
Single selectRequired- Alert
- Lethargic
- Comatose
- 02
Is the patient oriented to person, place and time?
Single selectRequired- Oriented
- Disoriented
- 03
Select any mood or behavioral findings.
Multi-selectRequired- None
- Depressed
- Forgetful/Memory loss
- Agitated
- Anxiety
- Fearful
- Suicidal thoughts
- Hallucinations
- Delusions
- Poor insight/Judgment
- History of previous psych illness
- Other
- 04
Select any neurological symptoms.
Multi-selectRequired- None
- Tremors
- Seizures
- Paralysis
- Ataxia
- Headache
- Dizziness
- Other
- 05
Add your clinical narrative for the teaching-provided record.
Free text
Suggested diagnosis review follows this section.
Narrative and teaching review follows this section.
Review concerns involving vision, hearing, the mouth, nose or throat. Note aids used by the patient and any limitations on communication or assessment.
- 01
Select any symptoms involving the head or face.
Multi-selectRequired- None
- Drainage
- Alopecia
- Epistaxis
- Congestion
- Facial Twitching
- Sinus Abnormality
- Other
- 02
Select any eye or vision conditions.
Multi-selectRequired- None
- Visual Impairment (not correctable with glasses)
- Visual Impairment (Correctable with glasses)
- Glaucoma
- Cataracts
- Legally Blind
- Discharge
- Other
- 03
Identify hearing difficulties, ear conditions or hearing-device use.
Multi-selectRequired- None
- Hearing Loss (partial)
- Deaf (complete loss)
- Tinnitus (ringing)
- Discharge
- Other
- 04
Select any symptoms affecting the mouth, throat or speech.
Multi-selectRequired- None
- Bleeding Gums
- Speech Impairment
- Hoarseness
- Dysphagia
- Dentures
- Sore Throat
- Gingivitis
- Missing Teeth
- Ageusia
- Anosmia
- Other
- 05
Add your clinical narrative for the teaching-provided record.
Free text
Suggested diagnosis review follows this section.
Narrative and teaching review follows this section.
Record relevant heart and breathing findings, symptoms and supports in use. Document actions and communication when findings require clinical attention.
- 01
Select any cardiac or circulatory symptoms.
Multi-selectRequired- None
- Chest Pain
- Palpitations
- Syncope (fainting)
- Edema (swelling)
- Cyanosis (bluish skin/lips)
- Murmur
- Fatigues Easily
- Activity Intolerance
- Clubbing (widening of fingertips, curved nails)
- Other
- 02
Location of edema
Single selectRequiredShown when Edema is selected in #1
- Ankle
- Pedal
- Calf
- 03
Grade of edema
Single selectRequiredShown when Edema is selected in #1
- Trace
- 1+
- 2+
- 3+
- 04
Which cardiovascular devices does the patient use? Select all that apply.
Multi-selectRequired- None
- Pacemaker
- 05
Select any respiratory or lung symptoms.
Multi-selectRequired- None
- Cough
- Shortness of Breath at Rest (SOB)
- Orthopnea (difficulty breathing lying flat)
- Paroxysmal Nocturnal Dyspnea (PND)
- Sputum production
- Other
- 06
Which respiratory support devices are used?
Multi-selectRequired- None
- Oxygen
- BiPAP
- CPAP
- Ventilator
- Tracheostomy
- Other
- 07
Select the oxygen delivery method.
Single selectRequiredShown when Oxygen is selected in #6
- Nasal cannula
- Simple face mask
- Non-rebreather mask
- Venturi mask
- High-flow nasal cannula
- Tracheostomy collar
- Other
- 08
Oxygen flow in liters per minute (LPM)
NumericRequiredShown when Oxygen is selected in #6
- 09
Select how frequently oxygen is used.
Single selectRequiredShown when Oxygen is selected in #6
- PRN (as needed)
- Intermittent
- Other
- 10
For PRN oxygen, select the as-needed frequency.
Single selectRequiredShown when PRN is selected in #9
- Every 2 hours PRN
- Every 4 hours PRN
- Every 6 hours PRN
- With activity PRN
- For shortness of breath PRN
- Other
- 11
Select the intermittent oxygen schedule.
Single selectRequiredShown when Intermittent is selected in #9
- Every 2 hours
- Every 4 hours
- Every 6 hours
- During sleep only
- During activity only
- Other
- 12
Select the lung sounds heard on assessment.
Single selectRequired- Clear
- Rales
- Wheezing
- Rhonchi
- Diminished
- Absent
- Other
- 13
Add your clinical narrative for the teaching-provided record.
Free text
Suggested diagnosis review follows this section.
Narrative and teaching review follows this section.
Describe movement, strength and assistance needs relevant to daily activities. Identify information that was reported rather than directly observed.
- 01
Select any muscle, bone or joint symptoms.
Multi-selectRequired- None
- Numbness
- Weakness
- Gait Abnormality
- Amputation
- Coordination Problems
- Stiffness
- Deformities
- Limited ROM
- Other
- 02
Add your clinical narrative for the teaching-provided record.
Free text
Suggested diagnosis review follows this section.
Narrative and teaching review follows this section.
Document relevant gastrointestinal, urinary and reproductive history and findings. Ask questions according to clinical relevance and the patient’s anatomy and history.
- 01
Select any gastrointestinal or digestive symptoms.
Multi-selectRequired- None
- Hernia
- Nausea/Vomiting
- Ulcers
- Incontinence
- Rectal Bleeding
- Hemorrhoids
- Diarrhea
- Indigestion
- Tenderness
- Pain
- Constipation
- Other
- 02
Does the patient have an ostomy?
Yes / NoRequired - 03
Describe the ostomy type and location.
Free textRequiredShown when #2 = Yes
- 04
Select any bladder or urinary symptoms.
Multi-selectRequired- None
- Burning (dysuria)
- Frequency
- Urgency
- Hesitancy
- Nocturia
- Retention
- Incontinence
- Polyuria (excess urination)
- Oliguria (low urine output)
- Anuria (no urine output)
- Hematuria (blood in urine)
- Other
- 05
Patient gender
Locked / Pre-filled - 06
Select all applicable female reproductive or breast conditions and history.
Multi-selectRequiredShown when Gender = Female
- None
- Hysterectomy
- Mastectomy
- Breast Abnormalities
- Other
- 07
Select all applicable male reproductive conditions, symptoms and history.
Multi-selectRequiredShown when Gender = Male
- None
- Prostate Disorder
- Prostatectomy
- Scrotal Edema
- Other
- 08
Add your clinical narrative for the teaching-provided record.
Free text
Suggested diagnosis review follows this section.
Narrative and teaching review follows this section.
Describe skin and wound findings before assigning a classification. Pressure-injury staging applies only where appropriate; record uncertainty and seek clinical guidance when needed.
- 01
Select all current skin symptoms or problems.
Multi-selectRequired- None
- Dry
- Rash
- Pallor
- Fistula
- Wound
- Incisions
- Pressure areas
- Poor Turgor
- Scars
- Bruises
- Pruritus
- Lesions
- Other
- 02
Location of the wound
Free textRequiredShown when Wound is selected in #1
- 03
Dimensions of the wound
Free textRequiredShown when Wound is selected in #1
- 04
Describe the wound’s appearance.
Free textRequiredShown when Wound is selected in #1
- 05
Pressure-injury classification, when applicable
Single selectRequiredShown when Wound is selected in #1
- Stage 1
- Stage 2
- Stage 3
- Stage 4
- Unstageable
- Deep tissue pressure injury
- Not a pressure injury
- Unable to determine
Do not apply pressure-injury stages to other wound types. Record observed findings and seek clinical guidance when classification is uncertain.
- 06
Select all applicable blood-related conditions.
Multi-selectRequired- None
- Anemia
- Excessive Bleeding or Bruising
- Intolerance to Heat & Cold
- Clotting Disorder
- Other
- 07
Select all endocrine or gland-related conditions.
Multi-selectRequired- None
- Diabetes
- Hypothyroidism
- Hyperthyroidism
- Other
- 08
Select the diabetes education provided.
Multi-selectRequiredShown when Diabetes is selected in #7
- Importance of adhering to blood glucose monitoring as prescribed
- Sharps safety including proper disposal of needles
- Signs and symptoms of hypo/hyperglycemia
- Importance of following prescribed medication regimen
- Follow the patient-specific orders and agency escalation procedure for abnormal blood glucose findings
- 09
Blood glucose reading
NumericRequiredShown when Diabetes is selected in #7
- 10
Skin color observed during examination
Single selectRequired- WNL
- Pale
- Cyanotic
- Jaundice
- 11
Add your clinical narrative for the teaching-provided record.
Free text
Suggested diagnosis review follows this section.
Narrative and teaching review follows this section.
Record known allergies and reported reactions, along with nutrition and swallowing concerns. Identify the source of allergy information and any discrepancies requiring follow-up.
- 01
How would you describe the patient’s appetite during the past three days?
Single selectRequired- Good
- Fair
- Poor
- Excessive
- 02
Present weight in pounds (lbs)
NumericRequired - 03
How does the current weight compare with the usual weight over recent months?
Single selectRequired- Stable
- Loss
- Gain
- 04
Has a fluid restriction been prescribed?
Yes / NoRequired - 05
Prescribed fluid allowance
Free textRequiredShown when #4 = Yes
- 06
How has the patient managed eating and drinking during the past three days?
Single selectRequired- Independent
- Needs Assistance
- Dependent
- Tube Feeding
- NPO
- Other
- 07
Select all prescribed medical diets.
Multi-selectRequired- Cardiac (complete heart diet)
- Renal (complete kidney diet)
- 1800 Cal ADA (complete diabetic diet)
- None of the above
- Other
- 08
Select additional nutrient restrictions not already covered by the medical diet.
Multi-selectRequired- Low Sodium
- Low Fat
- Low Cholesterol
- Low Sugar
- No Concentrated Sweets
- High Fiber
- None of the above
- Other
- 09
Select any food texture changes needed for chewing or swallowing difficulties.
Multi-selectRequired- Soft — Easy-to-chew foods
- Pureed — Blended/smooth texture foods
- No texture modifications
- Other
- 10
List medication allergies, such as penicillin, sulfa, cephalosporins, aspirin, NSAIDs or opioids.
Free textRequired - 11
List food allergies, such as shellfish, milk, peanuts, tree nuts or fish.
Free textRequired - 12
List substance or environmental allergies, such as latex, pollen, dust mites, mold, pet dander or insect stings.
Free textRequired - 13
Add your clinical narrative for the teaching-provided record.
Free text
Narrative and teaching review follows this section.
Record the home conditions and support arrangements relevant to safety. Describe observed hazards and the action or communication that follows.
- 01
Describe the patient’s living arrangement.
Single selectRequired- Lives Alone
- With Spouse
- Lives with family
- Other
- 02
Select any environmental or safety hazards in the home.
Multi-selectRequired- None
- House/Apartment structure inadequate
- Inadequate heating/cooling
- Inadequate plumbing/water
- Inadequate electricity
- Non-functioning smoke detectors
- No carbon monoxide detector
- Telephone not accessible
- Stairs without handrails
- No bathroom grab bars
- Inadequate lighting
- Obstructed pathways
- Throw rugs unsecured
- Electrical cords unsafely placed
- No emergency exit plan
- Medications not safely stored
- Other
- 03
Add your clinical narrative for the teaching-provided record.
Free text
Narrative and teaching review follows this section.
List equipment and supplies relevant to the care plan, including how they are used and any problems reported or observed. Record needs requiring agency follow-up.
- 01
Select all mobility equipment currently used.
Multi-selectRequired- None
- Cane
- Quad Cane
- Walker
- Wheelchair
- Other
- 02
Select all bathroom safety equipment available or used at home.
Multi-selectRequired- None
- Grab Bars
- Hand Rails
- Shower Rails
- Bedside Commode
- Shower Chair
- Other
- 03
Select all bedroom or positioning equipment available or used.
Multi-selectRequired- None
- Hospital bed
- Hoyer Lift
- Bed rails / assist handle
- Adjustable bed
- Trapeze bar
- Sleeps in recliner / lift chair
- 04
Select all medical supplies regularly used at home.
Multi-selectRequired- None
- Glucometer/Strips
- Wound Care Supplies
- Incontinence supplies (diapers/pull-ups, pads, bed pads, wipes, etc.)
- Other
- 05
Add your clinical narrative for the teaching-provided record.
Free text
Narrative and teaching review follows this section.
Verify available emergency contacts and relevant advance-directive information. Document what was reviewed and where information remains unavailable.
- 01
Emergency contact: name, address and telephone
Free textRequiredContact person outside of the home - includes name, address, and phone number
- 02
Patient’s physician
Physician selectorRequiredSearch/add physician
- 03
Was the emergency plan discussed?
Yes / NoRequired - 04
Emergency preparedness checklist
Multi-selectRequired- Medication list current and accessible
- 7-day supply of medications available
- Medical equipment backup/alternative plan
- Emergency phone numbers posted
- Evacuation plan established
- Medical alert device if needed
- 05
Advance directive status
Single selectRequired- None
- Healthcare Proxy
- DNR
- Other
- 06
Document the teaching provided.
Free text
Record available vaccination information and its source. Distinguish documented dates from recalled history and note any information that could not be confirmed.
- 01
Influenza vaccination
Yes / NoRequiredIf yes, enter date of immunization
- 02
Pneumonia vaccination
Yes / NoRequiredIf yes, enter date of immunization
- 03
COVID-19 vaccination
Yes / NoRequiredIf yes, enter date of immunization
- 04
Tetanus vaccination
Yes / NoRequiredIf yes, enter date of immunization
- 05
Hepatitis B vaccination
Yes / NoRequiredIf yes, enter date of immunization
- 06
Additional immunizations
Yes / NoRequiredIf yes, enter name and date of immunization
- 07
Has the patient declined immunizations?
Yes / NoRequired - 08
Was immunization education provided?
Yes / NoRequired - 09
Add your clinical narrative for the teaching-provided record.
Free text
Narrative and teaching review follows this section.
Verify diagnosis entries and applicable codes against the supporting clinical record. Machine suggestions, if used in an approved workflow, require RN verification and approval; medicines alone do not establish a diagnosis.
- 01
Review the diagnosis codes.
Diagnosis codesRequiredVerify codes against supported diagnoses. A medication or machine suggestion alone does not establish a medical diagnosis.
- 02
I approve these diagnosis codes for submission after reviewing them.
CheckboxMust be checked to proceed
Document reported falls and their circumstances, then follow the agency’s approved risk-assessment process. A history question alone is not a complete scored fall-risk assessment.
- 01
Has the patient fallen during the past three months?
Yes / NoRequired - 02
Add your clinical narrative for the teaching-provided record.
Free textThis text will be included in the teaching provided section
Narrative and teaching review follows this section.
Review the record for omissions and inconsistencies before signing. Follow the applicable process for patient acknowledgment, declined signatures and clinical approval before delivery.
- 01
Patient’s signature
SignatureRequired - 02
Registered nurse’s signature
SignatureRequired
Before your first visit
Questions from our nurses
Practical guidance on assignments, documentation and working with CareBridge.
Can I apply if I am new to home assessments?
Tell us about your nursing background and home care experience when you apply. Our team will discuss the role, preparation and credential requirements with you. This guide helps you become familiar with assessment documentation; it does not replace onboarding or confirmation that you are cleared for an assignment.
Do I need to commit to a set number of visits?
Share your availability with our team during onboarding. Any minimum commitment or scheduling expectations will be discussed before you accept assignments.
How much time should I allow for an assessment?
Visit length depends on the assessment type, the patient’s needs and the required documentation. Confirm the expected time and any additional requirements with the coordination team before the visit.
What payment schedule applies to my visits?
Your payment schedule and submission requirements are set out in your agreement with CareBridge. Confirm these details during onboarding, and contact our team with questions about a completed visit or payment.
Which documents will I complete for a visit?
The required documents depend on the assignment and the agency’s instructions. They may include a patient assessment, a plan of care and a supervisory report. Confirm the required package before the visit and use this guide to review the assessment questions.
What is my role during an assessment visit?
Your assignment focuses on assessing the patient and documenting your findings within the agreed scope. Review the agency’s instructions and clarify any requested treatment or ongoing care responsibilities with the coordination team before accepting the assignment.
What should I do if a patient declines the assessment?
Respect the patient’s decision, notify the coordination team and follow the agency’s procedure for documenting a declined visit. Confirm next steps with the team, including any rescheduling and the payment terms that apply to the assignment.
What happens if the patient is not at home?
Contact the coordination team and follow the agreed contact and missed-visit procedure. Record the attempted visit and contact attempts accurately. The team can advise on next steps; any travel or missed-visit payment depends on your agreement.
What if the appointment has not been confirmed?
Check with the coordination team before travelling. A proposed appointment is not the same as a confirmed visit. Ask the team to clarify whether to proceed, wait for confirmation or reschedule.
How should I record information that is unavailable?
Document what could not be obtained and the reason, following the form instructions and agency procedure. Do not guess or use “not applicable” when the information is simply unknown. Ask your clinical contact for guidance if you are unsure how to complete a required field.
Is travel reimbursed when a visit cannot be completed?
Travel and missed-visit compensation depend on your agreement with CareBridge. Confirm the applicable terms before travelling and report any unsuccessful visit promptly to the coordination team.
How many visits can I accept each week?
Discuss your preferred schedule and coverage area with our team. The number of available assignments depends on agency demand, location, your credentials and your availability. Confirm each assignment before making travel plans.
Need help with your situation? Contact our team.