Here's what I stuck in my palm pilot for an admission note. Let me know if anyone has any suggestions or a good example of a regular daily note, or discharge note. Thanks.
Time of Admission, Awake, Alert, Oriented? Where from --> going to? Ambulating? How well?
Placed on CO. Vitals. See nursing assessment
form. Calm/Cooperative? Assess SI/HI. Contract for safety. Thought process? Flight of ideas?
Mood. Allergies? Signed for receipt of bill of rights. Oriented to unit. Reviewed schedule and encouraged to attend groups. Physical problems?