DA Form 3888: Nursing History and Assessment PDF

DA Form 3888: Nursing History and Assessment PDF – U.S. Army form used in military healthcare facilities to document a patient’s initial nursing history and comprehensive physical/psychosocial assessment upon admission.

It supports the nursing process by establishing a baseline for individualized care planning, in accordance with AR 40-66 (Medical Record Administration and Healthcare Documentation).

Download the official DA Form 3888 here: https://armypubs.army.mil/pub/eforms/DR_a/pdf/A3888.pdf

What Is DA Form 3888?

DA Form 3888, titled Medical Record – Nursing History and Assessment, is an official Department of the Army form (February 2003 edition). Nurses use it primarily in inpatient settings at military treatment facilities (MTFs) to record a patient’s admission details, subjective history (in the patient’s own words when possible), and objective nursing assessment across multiple body systems.

It forms the foundation for nursing care plans (often continued on related forms like DA Form 3888-1 or 3888-2) and ensures continuity of care, legal documentation, and compliance with Army medical standards.

Purpose and Importance in Army Medical Records

This form captures essential data for planning patient care. It documents:

  • Patient-reported history and concerns.
  • Baseline vital signs and physical assessment.
  • Psychosocial factors.
  • Special needs or valuables inventory.

Accurate completion supports high-quality, patient-centered care in military environments, where patients may include active-duty service members, families, or retirees. It aligns with broader DoD health record policies and the nursing process (assessment, diagnosis, planning, implementation, evaluation).

Proper use aids in communication among healthcare teams, supports medicolegal requirements, and helps track changes in patient condition during hospitalization.

Key Sections of DA Form 3888

The form is structured for efficiency:

Admission and Identification Information

  • Date and Time of Admission (YYYYMMDD format).
  • Admission Diagnosis.
  • Patient Identification block.

Nursing History (Patient Interview)

Nurses document in the patient’s own words:

  • Knowledge of illness/injury/hospitalization.
  • Other health problems.
  • Previous hospitalizations.
  • Current medications (prescription, OTC, duration).
  • Allergies and reactions.
  • Special needs (diet, ADLs, prosthetics like dentures/glasses).
  • Other concerns and how the team can help.
  • Next of Kin (NOK)/local contact information.

Personal Articles and Valuables

Inventory of items with disposition (bedside, home, treasurer, other) and initials.

Physical and Systems Assessment

Detailed categories include:

  • Growth and Development.
  • Neurological (orientation, LOC, reflexes).
  • Eyes, Ears, Nose, Throat.
  • Cardiovascular (skin, pulses, edema, IVs, pain).
  • Pulmonary (respirations, breath sounds, oxygen, cough).
  • Gastrointestinal.
  • Genitourinary.
  • Integumentary (skin, lesions).
  • Musculoskeletal (ROM, strength).
  • Psycho-Social (adjustment, mood, behavior).

Additional space exists for vital signs (TPR, BP, WT, HT) and other data. The RN signs and dates the assessment.

How to Fill Out DA Form 3888: Step-by-Step Guide?

  1. Complete Header and Admission Data — Enter date/time, diagnosis, and patient identifiers accurately.
  2. Conduct Patient Interview — Use open-ended questions. Record responses clearly, preferably in the patient’s words.
  3. Document Allergies, Medications, and History — Be specific about reactions, durations, and details.
  4. Inventory Valuables — List items and disposition; have patient or witness initial where required.
  5. Perform and Record Assessment — Use standard techniques for each system. Note abnormalities clearly.
  6. Sign and Date — Include typed/printed name, signature, rank/title, and date/time.

Tips: Be concise, objective, and legible. Follow AR 40-66 guidelines for corrections and abbreviations. Use continuation sheets (e.g., DA Form 3888-1) as needed.

  • DA Form 3888-1: Continuation of assessment and care plan.
  • DA Form 3888-2: Nursing Care Plan (for identified problems and outcomes).
  • DA Form 3888-3: Nursing Discharge Summary.

These work together to provide complete inpatient nursing records.

Access and Official Resources

  • Official PDF: Download directly from Army Publishing Directorate: DA Form 3888 PDF.
  • Governing Regulation: AR 40-66, Medical Record Administration and Healthcare Documentation (current versions available on Army sites).
  • For training or specific MTF policies, consult your facility’s nursing standards or the Office of The Surgeon General (OTSG).

Note: This form is for authorized military healthcare use. Always follow current Army regulations and local protocols.

For U.S. Army medical personnel and affiliated healthcare providers, mastering DA Form 3888 ensures compliant, effective documentation that directly supports mission readiness and patient outcomes. If you need fillable versions or related training materials, check official Army Publishing Directorate resources.