How to Write Nursing Admission Notes with Templates & Examples
Updated: December 01, 2023Nursing 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.
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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
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
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
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
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
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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