nursing admission notes example

2 min read 28-02-2025

Meta Description: Learn how to write comprehensive nursing admission notes with our example and guide. Covering essential elements, legal considerations, and best practices for clear, concise documentation. Improve your charting skills and avoid common pitfalls! (158 characters)

Understanding the Importance of Admission Notes

Nursing admission notes are the cornerstone of a patient's medical record. They provide a snapshot of the patient's condition upon arrival, guiding subsequent care and treatment. Accurate and complete admission notes are crucial for continuity of care, legal protection, and effective communication among the healthcare team. Failing to document properly can have serious consequences.

Essential Components of a Nursing Admission Note Example

A well-written admission note includes several key components. Let's examine these elements through a practical example:

Example Patient: Mrs. Jane Doe, 65-year-old female admitted for chest pain.

1. Identifying Information:

Patient Name: Mrs. Jane Doe
Medical Record Number: 1234567
Date and Time of Admission: October 26, 2024, 14:30
Admitting Physician: Dr. John Smith

2. Reason for Admission (Chief Complaint):

"Chest pain radiating to the left arm, onset 2 hours prior to admission."

3. History of Present Illness (HPI):

"Mrs. Doe reports experiencing sudden onset of severe chest pain while at home. Pain described as crushing and tight. Associated symptoms include shortness of breath and diaphoresis. Denies nausea or vomiting."

4. Past Medical History (PMH):

Hypertension, hyperlipidemia, family history of coronary artery disease.

5. Current Medications:

Aspirin 81mg daily, Lisinopril 20mg daily, Atorvastatin 40mg daily.

6. Allergies:

NKDA (No Known Drug Allergies)

7. Physical Assessment:

General Appearance: Alert and oriented, appearing anxious. Skin warm and dry.
Vital Signs: BP 160/90 mmHg, HR 100 bpm, RR 22 breaths/min, Temp 98.6°F (37°C), O2 saturation 94% on room air.
Cardiovascular: Regular rhythm, tachycardic. Presence of S1 and S2 heart sounds. No murmurs, rubs, or gallops appreciated.
Respiratory: Breath sounds clear to auscultation bilaterally.
Neurological: Alert and oriented to person, place, and time. Cranial nerves II-XII intact.

8. Psychosocial Assessment:

Appears anxious and fearful about her condition. Family present for support.

9. Plan of Care:

12-lead ECG obtained, cardiac enzymes drawn.
Continuous cardiac monitoring initiated.
Oxygen therapy via nasal cannula at 2L/min.
IV access established with normal saline infusing at 100ml/hr.
Pain medication administered as prescribed by Dr. Smith.

10. Signature and Credentials:

Jane Nurse, RN

Legal Considerations and Best Practices

Accuracy: Ensure all information is accurate and factual.
Objectivity: Focus on observable findings rather than subjective interpretations.
Completeness: Document all relevant information, leaving no crucial details out.
Timeliness: Complete notes promptly after assessment.
Legibility: Write clearly and concisely using approved abbreviations. Avoid ambiguous language.
Confidentiality: Adhere strictly to HIPAA regulations.

How to Improve Your Nursing Admission Note Writing

Use a structured format: Following a consistent format ensures all necessary information is included.
Utilize templates: Many healthcare facilities provide templates to assist with note writing.
Practice regularly: Consistent practice will improve your speed and accuracy.
Seek feedback: Ask a senior nurse or preceptor to review your notes for improvement.
Stay updated: Familiarize yourself with changes to documentation policies and guidelines.

Conclusion

Comprehensive and accurate nursing admission notes are paramount for providing high-quality patient care. By following the guidelines and example provided in this article, nurses can significantly improve their documentation skills, contributing to better patient outcomes and protecting themselves legally. Remember, clear, concise documentation is a critical component of excellent nursing practice.