# 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

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## Orientation Provided

- [ ] Room orientation (call light, bathroom, bed controls)
- [ ] Visiting hours
- [ ] Unit phone number
- [ ] Patient rights information
- [ ] Advance directive information
- [ ] Valuables policy

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## Assessment Completion

| Field | Entry |
|-------|-------|
| Assessment Completed By | |
| Credentials | |
| Date | |
| Time | |
| Signature | |

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*Form FRM-INP-001 Rev 1.0 - Nursing Admission Assessment*