Sync template from atomicqms-style deployment

Forms/Assessment-Tools/FRM-INP-001-Nursing-Admission-Assessment.md

@@ -0,0 +1,332 @@
+# Nursing Admission Assessment
+
+| Form ID | FRM-INP-001 | Revision | 1.0 |
+|---------|-------------|----------|-----|
+
+---
+
+## Patient Information
+
+| Field | Entry |
+|-------|-------|
+| Patient Name | |
+| MRN | |
+| Date of Birth | |
+| Admission Date | |
+| Admission Time | |
+| Admitting Physician | |
+| Unit/Room | |
+| Admitting Diagnosis | |
+| Source of Admission | ☐ Home ☐ ED ☐ Transfer ☐ Other: _______ |
+| Mode of Arrival | ☐ Ambulatory ☐ Wheelchair ☐ Stretcher |
+
+---
+
+## Vital Signs
+
+| Parameter | Value | Time |
+|-----------|-------|------|
+| Temperature | °F / °C | |
+| Heart Rate | bpm | |
+| Respiratory Rate | breaths/min | |
+| Blood Pressure | / mmHg | |
+| SpO2 | % on ☐ RA ☐ O2 ___L/min | |
+| Pain Level | /10 | |
+| Height | | |
+| Weight | | |
+
+---
+
+## Allergies
+
+☐ No Known Allergies (NKA)
+☐ No Known Drug Allergies (NKDA)
+
+| Allergen | Type | Reaction |
+|----------|------|----------|
+| | ☐ Drug ☐ Food ☐ Environmental ☐ Other | |
+| | ☐ Drug ☐ Food ☐ Environmental ☐ Other | |
+| | ☐ Drug ☐ Food ☐ Environmental ☐ Other | |
+
+**Allergy band applied?** ☐ Yes ☐ N/A
+
+---
+
+## Current Medications
+
+| Medication | Dose | Frequency | Last Taken | Continue? |
+|------------|------|-----------|------------|-----------|
+| | | | | ☐ Yes ☐ No |
+| | | | | ☐ Yes ☐ No |
+| | | | | ☐ Yes ☐ No |
+| | | | | ☐ Yes ☐ No |
+| | | | | ☐ Yes ☐ No |
+| | | | | ☐ Yes ☐ No |
+| | | | | ☐ Yes ☐ No |
+| | | | | ☐ Yes ☐ No |
+
+**Medication source:** ☐ Patient/Family ☐ Pharmacy Records ☐ PCP Records ☐ Other: _______
+
+**Medications brought to hospital?** ☐ Yes (inventory attached) ☐ No
+
+---
+
+## Medical History
+
+### Past Medical History
+☐ None significant
+
+| Condition | Notes |
+|-----------|-------|
+| ☐ Hypertension | |
+| ☐ Diabetes | Type: ☐ 1 ☐ 2 |
+| ☐ Heart Disease | |
+| ☐ COPD/Asthma | |
+| ☐ Stroke/TIA | |
+| ☐ Cancer | Type: |
+| ☐ Kidney Disease | |
+| ☐ Liver Disease | |
+| ☐ Seizures | |
+| ☐ Psychiatric | |
+| ☐ Other: | |
+
+### Past Surgical History
+☐ None
+
+| Surgery/Procedure | Year |
+|-------------------|------|
+| | |
+| | |
+| | |
+
+---
+
+## Review of Systems
+
+### General
+- ☐ Fatigue/Weakness
+- ☐ Fever/Chills
+- ☐ Weight Change
+- ☐ Night Sweats
+
+### Cardiovascular
+- ☐ Chest Pain
+- ☐ Palpitations
+- ☐ Edema
+- ☐ Shortness of Breath with Activity
+
+### Respiratory
+- ☐ Cough
+- ☐ Shortness of Breath at Rest
+- ☐ Oxygen Use at Home
+- ☐ CPAP/BiPAP Use
+
+### Gastrointestinal
+- ☐ Nausea/Vomiting
+- ☐ Abdominal Pain
+- ☐ Diarrhea
+- ☐ Constipation
+- ☐ Blood in Stool
+
+### Genitourinary
+- ☐ Incontinence
+- ☐ Dysuria
+- ☐ Urgency/Frequency
+- ☐ Foley Catheter
+
+### Neurological
+- ☐ Numbness/Tingling
+- ☐ Weakness
+- ☐ Confusion
+- ☐ Dizziness/Vertigo
+
+### Skin
+- ☐ Rash
+- ☐ Open Wounds
+- ☐ Bruising
+
+---
+
+## Pain Assessment
+
+| Field | Entry |
+|-------|-------|
+| Pain Present? | ☐ Yes ☐ No |
+| Location | |
+| Character | ☐ Sharp ☐ Dull ☐ Aching ☐ Burning ☐ Stabbing |
+| Intensity (0-10) | |
+| Duration | ☐ Constant ☐ Intermittent |
+| Aggravating Factors | |
+| Relieving Factors | |
+| Current Pain Management | |
+
+---
+
+## Fall Risk Assessment
+
+**Morse Fall Scale** (or institutional tool)
+
+| Risk Factor | Score |
+|-------------|-------|
+| History of falling | ☐ No (0) ☐ Yes (25) |
+| Secondary diagnosis | ☐ No (0) ☐ Yes (15) |
+| Ambulatory aid | ☐ None/Bed rest/Nurse assist (0) ☐ Crutches/Cane/Walker (15) ☐ Furniture (30) |
+| IV/Heparin Lock | ☐ No (0) ☐ Yes (20) |
+| Gait | ☐ Normal/Bed rest/Immobile (0) ☐ Weak (10) ☐ Impaired (20) |
+| Mental Status | ☐ Oriented to own ability (0) ☐ Overestimates/forgets limitations (15) |
+| **Total Score** | |
+
+**Risk Level:**
+- ☐ Low Risk (0-24)
+- ☐ Moderate Risk (25-44)
+- ☐ High Risk (≥45)
+
+**Fall precautions initiated?** ☐ Yes ☐ N/A
+
+---
+
+## Pressure Ulcer Risk Assessment
+
+**Braden Scale**
+
+| Category | Score (1-4) |
+|----------|-------------|
+| Sensory Perception | |
+| Moisture | |
+| Activity | |
+| Mobility | |
+| Nutrition | |
+| Friction/Shear | |
+| **Total Score** | |
+
+**Risk Level:**
+- ☐ Mild Risk (15-18)
+- ☐ Moderate Risk (13-14)
+- ☐ High Risk (10-12)
+- ☐ Very High Risk (≤9)
+
+**Skin interventions initiated?** ☐ Yes ☐ N/A
+
+---
+
+## Skin Assessment
+
+☐ Skin intact, no abnormalities noted
+
+**Abnormalities (document location and description):**
+
+| Location | Description | Size | Stage/Type |
+|----------|-------------|------|------------|
+| | | | |
+| | | | |
+
+---
+
+## Nutritional Screen
+
+| Field | Entry |
+|-------|-------|
+| Diet at Home | |
+| Recent Weight Loss? | ☐ Yes (____lbs in ____weeks) ☐ No |
+| Difficulty Swallowing? | ☐ Yes ☐ No |
+| Dentures? | ☐ Yes ☐ No |
+| Food Allergies/Intolerances | |
+| Special Diet Needs | |
+
+**Dietitian Referral Needed?** ☐ Yes ☐ No
+
+---
+
+## Functional Assessment
+
+### Mobility
+- ☐ Independent
+- ☐ Assistive Device: _______
+- ☐ Requires Assistance
+- ☐ Bed Bound
+
+### Activities of Daily Living
+
+| Activity | Independent | Needs Assistance | Dependent |
+|----------|-------------|------------------|-----------|
+| Bathing | ☐ | ☐ | ☐ |
+| Dressing | ☐ | ☐ | ☐ |
+| Toileting | ☐ | ☐ | ☐ |
+| Feeding | ☐ | ☐ | ☐ |
+| Transfers | ☐ | ☐ | ☐ |
+
+---
+
+## Psychosocial Assessment
+
+| Field | Entry |
+|-------|-------|
+| Living Situation | ☐ Alone ☐ With Family/Spouse ☐ Assisted Living ☐ SNF ☐ Other: _______ |
+| Primary Caregiver | |
+| Emergency Contact | |
+| Contact Phone | |
+| Relationship | |
+| Barriers to Care | ☐ None ☐ Language ☐ Transportation ☐ Financial ☐ Other: _______ |
+| Interpreter Needed? | ☐ Yes (Language: _______) ☐ No |
+
+---
+
+## Advance Directives
+
+| Field | Entry |
+|-------|-------|
+| Advance Directive on File? | ☐ Yes ☐ No ☐ Unknown |
+| Healthcare Proxy/POA? | ☐ Yes (Name: _______) ☐ No |
+| Copy Obtained? | ☐ Yes ☐ No ☐ N/A |
+| Code Status | ☐ Full Code ☐ DNR ☐ DNR/DNI ☐ Comfort Care Only |
+| Physician Order for Code Status? | ☐ Yes ☐ Pending |
+
+---
+
+## Discharge Planning Screen
+
+| Field | Entry |
+|-------|-------|
+| Anticipated Discharge Disposition | ☐ Home ☐ Home with Services ☐ Rehab ☐ SNF ☐ Unknown |
+| DME Needs Anticipated? | ☐ Yes ☐ No ☐ Unknown |
+| Home Health Needs? | ☐ Yes ☐ No ☐ Unknown |
+| Case Management Referral? | ☐ Yes ☐ No |
+| Social Work Referral? | ☐ Yes ☐ No |
+
+---
+
+## Safety Measures Initiated
+
+- [ ] Fall precautions per risk level
+- [ ] Skin precautions per risk level
+- [ ] Call light within reach
+- [ ] Bed in low position
+- [ ] Side rails per policy
+- [ ] Patient education on safety
+
+---
+
+## Orientation Provided
+
+- [ ] Room orientation (call light, bathroom, bed controls)
+- [ ] Visiting hours
+- [ ] Unit phone number
+- [ ] Patient rights information
+- [ ] Advance directive information
+- [ ] Valuables policy
+
+---
+
+## Assessment Completion
+
+| Field | Entry |
+|-------|-------|
+| Assessment Completed By | |
+| Credentials | |
+| Date | |
+| Time | |
+| Signature | |
+
+---
+
+*Form FRM-INP-001 Rev 1.0 - Nursing Admission Assessment*