Nursing assessments are a core part of the critical skill set required for giving safe and quality client care. Through assessment, nurses gather and organize information about a client’s health status, strengths, concerns and risks. This process requires thoughtful use of knowledge, skills and clinical judgment to recognize relevant findings, identify changes and determine appropriate nursing actions. When done using a client-centered, trauma- and evidence-informed approach, nursing assessments support decision making, guide care planning and interventions, and contribute to improved client safety, care quality and positive health outcomes.
The Nursing Act, 1991 defines nursing as:
"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."
Professional Responsibilities
Using nursing knowledge, skills and judgment, nurses do assessments to:
- show an in-depth understanding of a client’s health status
- identify and confirm health concerns or risks
- monitor changes in health status over time
- identify deviations from baseline and raise concerns to the right health care team members
- inform care planning and treatment decisions
- ensure continuity and coordination of care
Before doing any assessment, nurses must consider their role, the practice setting and the risk level involved, and must ensure they have the competence needed to perform the assessment safely.
Orders and Authority to Perform Nursing Assessments
Working within their roles and responsibilities as outlined by their practice setting, nurses may carry out routine assessments and procedures without an order, including those involving certain controlled acts, as long as the nurse:
- takes responsibility and has the knowledge, skill and judgment to do the assessment safely, effectively and ethically
- determines that the client’s condition warrants the assessment
- considers risks and benefits, their own ability to manage any potential outcomes, available resources and safeguards and any other relevant factors
When Nursing Assessment Involves a Controlled Act
Regulation 275/94 under the Nursing Act, 1991, authorizes nurses to initiate specific controlled acts to assess a client. These include assessment procedures involving putting:
The assessment type and frequency are guided by the nurse’s professional judgement, employer policies and practices and the client’s acuity level. Workplaces may have their own policies or practices on nursing assessments involving controlled acts.
Also, as outlined in the Nursing Act, 1991, in some practice settings, RNs and RPNs may initiate, without an order, specific procedures involving controlled acts. This authority applies when the nurse has the knowledge, skill and judgment to do the procedure safely and when all regulatory expectations are met. Further details are outlined in Appendix D of CNO’s Scope of Practice standard.