7.0 KiB
7.0 KiB
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