The Admission Process: Make Sure You Actually Say Something of Importance!
If you don't put in the details, how is anyone else supposed to follow your work and pick things up on the next shift? This article is about how clear expectations need to be set. Your admission is the first procedure the resident or patient experiences in your facility. Make it worth your while as well as their time.
NursesSafetyArticle
I work in LTC so this may not be applicable across the board, but here goes.
We've picked up some new grads on 3-11 and I'm not exactly happy with them. The one that's off of orientation and working the floor had an admission that she said she let the other new grad (who is still on orientation) "do". She didn't even give me report on him, only for me to find out that she's the one who wrote the admission note. Seriously, all she told me was that the orientee "did" the admission, but what they did, I'm not all that sure. And then I read her admission note, it clearly showed she didn't know anything about the resident.
Let's see what she wrote (this is paraphrasing but it doesn't really matter)
Quote
PERRLA. Skin turgor brisk. Mucous membranes intact and moist. Abdominal sound present in all 4 quadrants. Breath sounds equal and even, CTA. Capillary refill time
I'm sure there's more that I'm missing, but you get the idea. I'm surprised she didn't state: "all 10 fingers and toes intact."
Let's see what she excluded
Age
Gender
Race
Code status
Vaccination status
Primary medical diagnosis
Transferring facility
Reason for admission to transferring facility
Reason for transfer to sub acute rehab
Ambulatory status
Appointments to be scheduled
Mental status and orientation
Assistive devices such as a walker or wheelchair
This was a seriously underwhelming experience and it was tedious for me to have to go through all of the admission paperwork! Unless something major stands out on my physical assessment, I don't chart stuff like PERRLA, lungs CTA, etc. Most of our rehab residents are medically stable with chronic medical conditions and anything acute (aside from ABT for an infection) was treated in the hospital. I tend to write relatively detailed notes but they're succinct and note details that are relevant. I hate that admission notes from social work often are more detailed about past medical history, current diagnoses, prognosis or disposition than nursing notes.
Hell, because I didn't get a detailed report, I almost forgot to even chart on the guy because the only interaction I had with him was when he was in the bathroom and had some concerns about his stool. I didn't even know to expect him to *BE* in the bathroom without assistance (although PT cleared him for independent ambulation this morning after their assessment)! Thank GODS he didn't have dialysis today or out of the building early because again that's something I wasn't told! They told me to write the treatments on the Kardex but what they failed to tell me was that the orders hadn't even been transcribed so I had to scramble and copy basic admission orders from another chart. The admission checklist was nowhere in sight, but I know why - they didn't use it! There wasn't even a "code status" paper or face sheet in the chart. Honestly, I don't know what they did other than write admission medication orders.
I generally like new grads, you know untainted young impressionable minds and all, but this left a really bad taste in my mouth. I know neither of them watched a seasoned nurse write an admission note like that (or at least I hope not), but I can't be sure. While I've been able to locate a nursing orientation checklist on the Intranet from corporate, never have I actually seen one in use.
Maybe TPTB think that the process of admitting someone is just something that comes with practice, but I think there needs to be change. I'm all for doing a complete head to toe assessment, but it's important to know what's abnormal outside of that, right?
