How to Write Nursing Admission Notes with Templates & Examples

A Nursing Admission Note is a crucial document in a patient’s medical record, typically completed by a nurse upon a patient’s admission to a healthcare facility. It provides a comprehensive overview of the patient’s initial health status, medical history, and other pertinent information. This note helps healthcare providers understand the patient’s baseline condition and plan appropriate care.

Writing effective admission notes begins with understanding their significance in the patient care continuum. This section of the note is a critical communication tool, conveying essential patient information to the healthcare team.

Essential Elements: Every nursing admission note should include vital components such as patient identification, medical and medication history, allergies, vital signs, and a detailed physical assessment. The inclusion of these elements ensures a comprehensive understanding of the patient’s health status.

Here are the key components generally included in a Nursing Admission Note:

1. Patient Info: Name, age, sex, date of birth, medical record number.
2. Admission Details: Date/time of admission, admitting diagnosis.
3. Medical History: Brief overview of past conditions, surgeries, and family history.
4. Current Medications: List of current medications and dosages.
5. Allergies: Known allergies.
6. Vital Signs: Initial readings (temperature, pulse, respiration rate, blood pressure).
7. Physical Assessment: Summary of initial physical exam findings.
8. Pain Assessment: Pain location and intensity.
9. Functional Status: Mobility, ADLs, and assistive devices.
10. Initial Nursing Plan: Immediate care interventions.

Best Practices: Clarity, accuracy, and brevity are key in admission note writing. Nurses should strive to use clear, straightforward language, and avoid medical jargon where possible. The information provided must be up-to-date and accurate, adhering to both legal and ethical documentation standards.

Utilizing Admission Note Templates in healthcare settings provides numerous advantages, enhancing both the efficiency and quality of patient care. Here are five key benefits of using Admission Note Templates:

1. Consistency: Ensures all essential patient information is consistently documented, reducing the risk of omissions.
2. Efficiency: Saves time by providing a structured format, allowing healthcare providers to quickly and accurately complete notes.
3. Accuracy: Reduces errors by guiding the nurse to include all relevant information, improving the overall quality of the notes.
4. Improved Communication: Enhances communication among healthcare team members by providing clear and comprehensive patient information.
5. Quality of Care: Helps deliver high-quality patient care by ensuring all critical aspects of the patient’s health and needs are documented and addressed promptly.

How TextExpander Can Help

TextExpander can significantly streamline the process of creating nursing admission notes by offering several key benefits:

• Efficiency: By using TextExpander, nurses can quickly insert frequently used phrases, checklists, and standard information into admission notes, saving valuable time.
• Consistency: TextExpander ensures that all notes contain consistent language and essential information, reducing the risk of omissions and errors.
• Customization: Nurses can create personalized snippets tailored to specific admission scenarios, allowing for flexibility while maintaining a structured approach.
• Accuracy: Automated insertion of standardized text reduces the likelihood of typographical errors and ensures that critical details are correctly documented.
• Training: TextExpander can serve as a training tool for new staff by providing them with ready-to-use templates and standardized language, helping them learn the correct way to document admission notes.

1. General Medical Admission Template:

Covers general patient information, including a comprehensive medical history and current symptomatology.

Example for chest pain and shortness of breath:

Patient Information:
– John Doe
– 01/01/1955
– 1234567

Reason for Admission: Chest pain and shortness of breath

Medical History: Hypertension, Type 2 Diabetes

Current Medications: Metformin, Lisinopril

Allergies: Penicillin

Vital Signs: BP 150/90, HR 88, Temp 98.6°F, RR 20

Physical Assessment: Alert, oriented, chest auscultation clear, mild pedal edema

Initial Plan of Care: Cardiology consult, chest X-ray, ECG, lab tests (CBC, lipid profile)

Example for acute migraine with visual disturbances:

Patient Information:
– Laura Martinez
– 07/07/1975
– 4567890

Reason for Admission: Acute migraine with visual disturbances

Medical History: Migraine, asthma

Current Medications: Sumatriptan, Ventolin

Allergies: NSAIDs

Vital Signs: BP 120/80, HR 76, Temp 98.6°F, RR 18

Physical Assessment: Photophobia, normal neurological exam

Initial Plan of Care: Neurology consult, pain management, dark and quiet room

2. Surgical Admission Template:

Tailored for pre-operative patients, including surgical history and specific pre-op assessments.

Example for Total Knee Replacement:

Patient Information:
– Jane Smith
– 02/02/1960
– 7654321

Surgical Procedure: Total Knee Replacement

Surgical History: Appendectomy (1995)

Last Meals: NPO since midnight

Pre-Op Medications: None

Consent: Signed and witnessed

Physical Examination: Right knee tender, limited range of motion

Pre-Op Orders: Pre-op blood work, IV fluids, mark operative site

Example for Laparoscopic Cholecystectomy:

Patient Information:
– Ahmed Khan
– 09/09/1985
– 6543210

Surgical Procedure: Laparoscopic Cholecystectomy

Surgical History: No previous surgeries

Last Meals: Last meal 8 hours prior, NPO since then

Pre-Op Medications: IV antibiotics

Consent: Signed and witnessed by family member

Physical Examination: Abdominal tenderness in the right upper quadrant

Pre-Op Orders: Nil per os (NPO), IV fluids, pre-op labs

3. Pediatric Admission Template:

Includes elements unique to pediatric care, such as developmental milestones and pediatric-specific assessments.

Example for persistent fever and cough:

Patient Information:
– Emily Johnson
– 05/05/2015
– 123890

Reason for Admission: Persistent fever and cough

Parent/Guardian: Sarah Johnson, mother

Pediatric History: Full-term, normal milestones

Vaccinations: Up to date

Current Medications: None

Allergies: No known allergies

Physical Assessment: Weight 20kg, Height 110cm, alert, lungs clear, throat red

Initial Plan of Care: Pediatrician review, throat swab, hydration, fever management

Example for dehydration secondary to gastroenteritis:

Patient Information:
– Olivia Chen
– 12/12/2018
– 6789012

Reason for Admission: Dehydration secondary to gastroenteritis

Parent/Guardian: Helen Chen, mother

Pediatric History: Full-term, up-to-date on vaccinations

Vaccinations: Up-to-date

Current Medications: None

Allergies: No known allergies

Physical Assessment: Decreased skin turgor, dry mucous membranes, alert

Initial Plan of Care: IV rehydration, oral rehydration as tolerated, monitoring of input and output

4. Geriatric Admission Template:

Focused on the elderly, considering chronic illnesses, geriatric syndromes, and medications.

Example for falls and confusion:

Patient Information:
– Robert Brown
– 01/01/1935
– 987654

Reason for Admission: Falls, confusion

Medical History: Dementia, arthritis, hypertension

Current Medications: Aricept, Metoprolol, Paracetamol

Allergies: Aspirin

Vital Signs: BP 135/85, HR 70, Temp 97.8°F, RR 16

Geriatric Assessment: Confused, needs walker, underweight

Initial Plan of Care: Neurology consult, fall risk assessment, nutrition consult

Example for suspected urinary tract infection and altered mental status:

Patient Information:
– Margaret O’Connor
– 04/04/1930
– 2345678

Reason for Admission: Suspected urinary tract infection, altered mental status

Medical History: Chronic kidney disease, hypertension

Current Medications: Amlodipine, Furosemide

Allergies: Sulfa drugs

Vital Signs: BP 150/90, HR 88, Temp 99.5°F, RR 20

Geriatric Assessment: Confused, reduced mobility, incontinent

Initial Plan of Care: Urinalysis and culture, antibiotics as indicated, hydration, geriatric assessment

5. Emergency Care Admission Template:

For rapid assessment and documentation of acute and critical conditions.

Example for severe abdominal pain:

Patient Information:
– Michael Davis
– 03/03/1980
– 321456

Presenting Complaint: Severe abdominal pain

History of Present Illness: Pain began 6 hours ago, localized to the right lower quadrant

Past Medical History: None significant

Medications: None

Allergies: No known allergies

Vital Signs: BP 160/100, HR 110, Temp 101°F, RR 22

Initial Assessment: Tenderness in right lower quadrant, guarding

Immediate Interventions: IV access established, pain relief administered, urgent surgical consult

Example for shortness of breath and wheezing:

Patient Information:
– Zoe Williams
– 06/06/1990
– 9870123

Presenting Complaint: Shortness of breath, wheezing

History of Present Illness: Asthma exacerbation, non-responsive to home nebulizer

Past Medical History: Asthma, eczema

Medications: Inhaled corticosteroids, salbutamol nebulizer

Allergies: No known allergies

Vital Signs: BP 135/85, HR 102, Temp 98.6°F, RR 28, Oxygen Saturation 92% on room air

Initial Assessment: Audible wheezing, use of accessory muscles to breathe

Immediate Interventions: High-flow oxygen, nebulized salbutamol, IV corticosteroids, admission to observation for respiratory monitoring

Effective nursing admission notes are pivotal for high-quality patient care. They provide a clear and comprehensive picture of the patient at admission, guiding the healthcare team in their care decisions. Templates and tools like TextExpander can enhance the efficiency and accuracy of these notes, ultimately contributing to better patient outcomes.