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. Nurses Safety Article

The Admission Process: Make Sure You Actually Say Something of Importance!

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?

0 Votes
pinkiepieRN

About pinkiepieRN

I started out as a psych nurse, thought there was greener grass and am now coming back to psych. I've never stopped using my psych skills and never regret having not worked med-surg.

1 Article   385 Posts

Share this post

Share on other sites
Specializes in GI,Telemetry, Trauma ICU, Endoscopy.
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.

Sounds like you hit the nail right on the head here. Either during their orientation no one ever sat down with them to exemplify a proper admission note, or they never took the time to learn. I can't speak for all programs, but the program that I attended was very heavily focused toward acute care where the MD typically writes the admitting H&P and orders. I know I probably would have not had a clue how to write a detailed admission note in your facility based on my experience in school. Maybe this is an excellent teaching point for these new grads. Whether they accept the teaching is another story :saint:

0 Votes
Specializes in Med/Surg, Academics.

This is an article? Whatever....

Anyway, from posts here from new grads, LTC orientation is often much shorter than acute care. You said yourself that you've never seen an orientation checklist in use. While it behooves the new grad to ask for guidance, especially something as paperwork heavy and important as an admission, I feel that your anger at the new grad is a bit misplaced. You spend an inordinate amount of time blaming the new grad for her "shortcomings" on the admission, but you did not state your guidance to her. I suspect there wasn't any.

I get report from a lot if new grads that work night shift. If I see paperwork missing or something else done incorrectly, I tell them and show them the correct way, rather than seething about it and correcting it without any support to them. Congratulations, you just set her up to do it incorrectly again.

0 Votes
Specializes in Emergency & Trauma/Adult ICU.

So if there is no template or other resource for them to refer to when writing admission notes ... how are they supposed to magically know what should be included?

0 Votes
Specializes in Gerontology, Med surg, Home Health.

We all were new once, remember? I wouldn't expect everything YOU listed to be in an admission note. Is it really important to know what race the patient is? All that information is available on the face sheet which is done before admission or right after. No need to double document. A head to toe assessment? We get 5-6 admissions some days and most arrive after 3PM. None of them are what you'd call stable so our admission note focuses in on the reason they have been admitted. New knee? We'd chart the condition of the wound and the level of pain. Pneumonia? Lung sounds, shortness of breath, use of accessory muscles. I don't need to know if they have positive bowel sounds in all 4 quads unless they were admitted with a small bowel obstruction or a new colostomy.

Your time would be better spent helping the new grads understand what they are supposed to chart

0 Votes
Specializes in adult psych, LTC/SNF, child psych.
This is an article? Whatever.... Anyway from posts here from new grads, LTC orientation is often much shorter than acute care. You said yourself that you've never seen an orientation checklist in use. While it behooves the new grad to ask for guidance, especially something as paperwork heavy and important as an admission, I feel that your anger at the new grad is a bit misplaced. You spend an inordinate amount of time blaming the new grad for her "shortcomings" on the admission, but you did not state your guidance to her. I suspect there wasn't any. I get report from a lot if new grads that work night shift. If I see paperwork missing or something else done incorrectly, I tell them and show them the correct way, rather than seething about it and correcting it without any support to them. Congratulations, you just set her up to do it incorrectly again.[/quote']

Perhaps my anger is misplaced and it's not so much the new grad as the fact that the new grad just off of orientation had a new grad on orientation "do" the admission, even though she wrote the admission note. When I go in tonight, I will correct but my problem is not so much the correction I had to do but the fact that I was given the impression that all I had to do was write the treatments, which clearly wasn't the case.

0 Votes
Specializes in adult psych, LTC/SNF, child psych.
We all were new once remember? I wouldn't expect everything YOU listed to be in an admission note. Is it really important to know what race the patient is? All that information is available on the face sheet which is done before admission or right after. No need to double document. A head to toe assessment? We get 5-6 admissions some days and most arrive after 3PM. None of them are what you'd call stable so our admission note focuses in on the reason they have been admitted. New knee? We'd chart the condition of the wound and the level of pain. Pneumonia? Lung sounds, shortness of breath, use of accessory muscles. I don't need to know if they have positive bowel sounds in all 4 quads unless they were admitted with a small bowel obstruction or a new colostomy. Your time would be better spent helping the new grads understand what they are supposed to chart[/quote']

The focused assessment was the part that bothered me the most. I know when admissions come in and this patient came in s/p CHF exacerbation and fluid overload, bilateral lower extremity edema, deconditioned and in for rehab.

Ugh now I just feel really sheepish for posting this. I do not want to or like feeling like new grads should be eaten for breakfast. Where was the 3-11 supervisor in addition to the precepting nurse? I learned by fire in this facility but it shouldn't have to be this way.

0 Votes
Specializes in psych, general, emerg, mash.

each hospital intake is different, or is it! List only the problems patient is having.

0 Votes

If you make some templates and step by step guidelines that new grads can print out and keep with them in situations like this, you could save yourself a lot of time in the future. AND, they can never say, "Well I didn't know."

Also, nursing school is kind of focused on head to toe assessments, the nursing notes I wrote for clinicals looked kind of like that. Until new grads get more familiar with how the system works, it can be tough to know what information is important enough to write down. I swear, I wrote "PERRLA, mucous membranes moist and intact" on every single one of my nursing notes for clinicals.

0 Votes
Specializes in nursing education.

Agreed with above comments- I think that if you stepped back and looked at it from the new grads' perspective, you could help them learn what they need to do and invest in the team. Let them know what is expected, and guide them to do it. Likely they didn't have LTC as a clinical and it is very different (well, every setting is different).

If you find a need in your setting- see what EBP says- and if you have power to make a positive change like a tool or a template, then do it.

0 Votes

We have a complete packet that addresses all those individual things not in the admission note. We also have a check list of what each shift are to handle on admission. What the first shift receiving has to complete, until three shifts have done their part in 24 hours. Our admission noted is very basic, the diagnosis are listed in the PCC (electronic record), if someone can in for something like a hip replacement, I will address that with the size of surgical site and amount of staples, I will mention if alert or confused, ambulatory status isn't mentioned until PT assesses. It sounds like more education in this arena needs to be clearer, every facility does things differently.

0 Votes

I think It is good to know where to start with writing admission note and when to stop depending on unit policy. Generally It should be focused.

0 Votes
+ Add a Comment