How to Write Nursing Admission Notes with Templates & Examples

Updated: December 01, 2023

Nursing admission notes are a critical aspect of patient care, serving as the foundation for the treatment plan and ensuring continuity of care. These notes, documented at the point of patient admission, are essential for communicating a patient’s condition, history, and care needs to the entire healthcare team. Understanding how to effectively write these notes is crucial for nurses to ensure comprehensive and efficient patient care.

What is a Nursing Admission Note?

A Nursing Admission Note is a comprehensive record created by a nurse during a patient’s admission to a healthcare facility. It includes a detailed account of the patient’s current health status, medical history, and the planned approach for their care. This document is a key part of the patient’s medical record, aiding in diagnosis, treatment, and subsequent care.

Tips for Writing Admission Notes

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.
  • 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.

Benefits of Admission Note Templates

Utilizing templates for admission notes can greatly improve efficiency and consistency in documentation. These templates ensure that nurses cover all necessary information, reducing the likelihood of omissions.

In addition to templates, tools like TextExpander can further optimize the documentation process. TextExpander is designed to assist nurses in quickly inserting standardized sections into their notes. For instance, common phrases, assessment criteria, and care plans that are frequently used in nursing documentation can be pre-set in TextExpander. This enables nurses to insert these sections into their notes with just a few keystrokes, saving valuable time.

Moreover, it ensures accuracy and consistency across patient records. By reducing the repetitive typing of standard information, nurses can focus more on personalized patient care aspects, ensuring that each admission note is both comprehensive and tailored to the individual patient. This not only improves documentation quality but also enhances overall efficiency in patient care management.

Nursing Admission Note Templates and Examples

1. General Medical Admission Template:

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

General Medical Admission Template Copy Snippet Copied!

Patient Information:
– Name
– DOB (Date of Birth)
– MRN (Medical Record Number)

Reason for Admission: [Brief description]

Medical History: [List of conditions]

Current Medications: [List of medications]

Allergies: [List of allergies]

Vital Signs: [Blood pressure, heart rate, temperature, respiratory rate]

Physical Assessment: [Systematic examination findings]

Initial Plan of Care: [Proposed interventions and treatments]

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.

Surgical Admission Template Copy Snippet Copied!

Patient Information:
– Name
– DOB (Date of Birth)
– MRN (Medical Record Number)

Surgical Procedure: [Procedure name]

Surgical History: [Previous surgeries]

Last Meals: [Time and type of last meal]

Pre-Op Medications: [List of medications]

Consent: [Confirmation of informed consent]

Physical Examination: [Focused examination relevant to surgery]

Pre-Op Orders: [List any pre-operative orders]

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.

Pediatric Admission Template Copy Snippet Copied!

Patient Information:
– Name
– DOB (Date of Birth)
– MRN (Medical Record Number)

Reason for Admission: [Brief description]

Parent/Guardian: [Name and contact]

Pediatric History: [Birth history, developmental milestones]

Vaccinations: [Status of vaccinations]

Current Medications: [List of medications]

Allergies: [List of allergies]

Physical Assessment: [Growth parameters, pediatric-specific findings]

Initial Plan of Care: [Treatment and monitoring plans]

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.

Geriatric Admission Template Copy Snippet Copied!

Patient Information:
– Name
– DOB (Date of Birth)
– MRN (Medical Record Number)

Reason for Admission: [Brief description]

Medical History: [Chronic illnesses, geriatric syndromes]

Current Medications: [List of medications, focus on polypharmacy]

Allergies: [List of allergies]

Vital Signs: [Blood pressure, heart rate, temperature, respiratory rate]

Geriatric Assessment: [Cognitive status, mobility, nutritional status]

Initial Plan of Care: [Geriatric-focused interventions]

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.

Emergency Care Admission Template Copy Snippet Copied!

Patient Information:
– Name
– DOB (Date of Birth)
– MRN (Medical Record Number)

Presenting Complaint: [Brief description]

History of Present Illness: [Detailed account of current illness/injury]

Past Medical History: [Relevant past conditions]

Medications: [Current medications]

Allergies: [List of allergies]

Vital Signs: [Blood pressure, heart rate, temperature, respiratory rate]

Initial Assessment: [Rapid assessment findings]

Immediate Interventions: [Emergency treatments administered]

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.

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With TextExpander, you can store and quickly expand full email templates, email addresses, and more anywhere you type. That means you’ll never have to misspell, memorize, or type the same things over and over again.

Patient Information: <br>- Name <br>- DOB (Date of Birth) <br>- MRN (Medical Record Number) <br> <br>Reason for Admission: [Brief description] <br> <br>Medical History: [List of conditions] <br> <br>Current Medications: [List of medications] <br> <br>Allergies: [List of allergies] <br> <br>Vital Signs: [Blood pressure, heart rate, temperature, respiratory rate] <br> <br>Physical Assessment: [Systematic examination findings] <br> <br>Initial Plan of Care: [Proposed interventions and treatments]
Patient Information: <br>- Name <br>- DOB (Date of Birth) <br>- MRN (Medical Record Number) <br> <br>Surgical Procedure: [Procedure name] <br> <br>Surgical History: [Previous surgeries] <br> <br>Last Meals: [Time and type of last meal] <br> <br>Pre-Op Medications: [List of medications] <br> <br>Consent: [Confirmation of informed consent] <br> <br>Physical Examination: [Focused examination relevant to surgery] <br> <br>Pre-Op Orders: [List any pre-operative orders]
Patient Information: <br>- Name <br>- DOB (Date of Birth) <br>- MRN (Medical Record Number) <br> <br>Reason for Admission: [Brief description] <br> <br>Parent/Guardian: [Name and contact] <br> <br>Pediatric History: [Birth history, developmental milestones] <br> <br>Vaccinations: [Status of vaccinations] <br> <br>Current Medications: [List of medications] <br> <br>Allergies: [List of allergies] <br> <br>Physical Assessment: [Growth parameters, pediatric-specific findings] <br> <br>Initial Plan of Care: [Treatment and monitoring plans]
Patient Information: <br>- Name <br>- DOB (Date of Birth) <br>- MRN (Medical Record Number) <br> <br>Reason for Admission: [Brief description] <br> <br>Medical History: [Chronic illnesses, geriatric syndromes] <br> <br>Current Medications: [List of medications, focus on polypharmacy] <br> <br>Allergies: [List of allergies] <br> <br>Vital Signs: [Blood pressure, heart rate, temperature, respiratory rate] <br> <br>Geriatric Assessment: [Cognitive status, mobility, nutritional status] <br> <br>Initial Plan of Care: [Geriatric-focused interventions]
Patient Information: <br>- Name <br>- DOB (Date of Birth) <br>- MRN (Medical Record Number) <br> <br>Presenting Complaint: [Brief description] <br> <br>History of Present Illness: [Detailed account of current illness/injury] <br> <br>Past Medical History: [Relevant past conditions] <br> <br>Medications: [Current medications] <br> <br>Allergies: [List of allergies] <br> <br>Vital Signs: [Blood pressure, heart rate, temperature, respiratory rate] <br> <br>Initial Assessment: [Rapid assessment findings] <br> <br>Immediate Interventions: [Emergency treatments administered]

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