(This may have been said, just seeing how my admission compares)
1. Patient belongings (sometimes done by ER)
2. Latex Allergy disclaimer
3. Permission to treat and bill (if insurance is not varifiable)
4. Master Care Plan
5. Check off MAR (Unit Assistant transcribes, I approve)
7. Inital Assessment Sheet (Includes Braden, falls risk, referral form, advance directives, admission assessment, special needs, religious preferences, rtc...)
8. Patient/Family Learning checklist
9. Chronic Conditions refereral
10. Patient Rights (Nothing to sign, just summarize for new admits)
11. Daily Nursing Care Plan, which we only state "See Initial Assessment form" and complete a short summary along with other care rendered through out the shift.
12. Update Kardex
Nurse-Lou, I'd probably want to do my own assessment when the patient hits the floor, just to be on the safe side. You never know what could've been missed, IMHO. But I do wonder why the ER can't do the Permission to treat, Latex Allergy, patient belongings (ALL THE TIME) and Chronic Conditions referral. Then again, I guess they are busy too.....
Paperwork, Paperwork...Come what may....
Paperwork, Paperwork...Go AWAY!!!!!