Admission first nursing note

I'm used to what you are describing as being part of the assessment.My admit note is a PIEP note, which includes a narrative that fills in the blanks of what wasn't in the assessment form, and gives a basic picture of what's going on with the patient, Today.

My admission note format looks like this:

Pt brought to unit(location) at (time) escorted by (police officer/nursing supervisor/admitting doctor). Dressed in hospital gowns/pajama pants, gait (steady, unsteady, shuffling, etc). Appeared (disheveled with strong body odor...or...bright, heavy make-up, etc) Speech (soft and difficult to understand...or...loud and pressured, interrupts frequently, etc). Affect (flat, distant, tearful, irritable, demanding, threatening...or...friendly, pleasant, intrusive and difficult to direct, etc)

Pt was offered meal tray and (ate/didn't eat) Oriented to unit, staff and room (#). Given (medication if any was given upon admission, time, route and reason) Denies food/med allergies. Placed on special observation q 15 min for risk of (aggression/suicidal behavior, etc) Personal belongings checked and logged by (staff)

Pt was cooperative for assessment/interview. Pt was (forthcoming with information...or...guarded throughout the interview/reluctant to answer questions) Stated; "(I like to use quotes to show the overall mental status)" Made good eye contact throughout. or Appeared to be watching/responding to unseen others, poor eye contact. Denies auditory/visual hallucinations. Pt reports mood as; "I feel great!" or "sad", "ok" "depressed". Meaningfully contracts for safety.(Presence of any involuntary movements/EPS, etc) Pt has (fine rash or superficial scratches in varying stages of healing/signs of infection...if so, where) Conversation was relevant, thoughts logical and organized...or...delusional ideas present throughout interview, believes wife and children are being held in the White House and someone is trying to make him "look crazy"....special powers to "move between death and living", (etc...) VS: (enter them) weight: (X). Pt is calm and currently watching TV and interacting with peers appropriately at this time.

*Doesn't have to be too long because the nursing assessment picks up all the details. You just want to give a thumbnail impression of how they were when they came in and document what you did.

The first part is visible data, initial appearance. Then actions: what I did for them and last: what were their psychiatric symptoms/thought process/ mental status or physical issues related to psychiatric symptoms that were discovered during the assessment. So... data-action-response, if you are allowed to write in that format. If it's straight narrative, just think in that format.

Easy! Right?

Thanks Jayesse7!! I always do a complete head to toe, and thought I was thorough in the psych, but you pull it together very nicely. I rarely see admissions as our pts stay for a very long time before going out into the community (those that can). Your psych assessment will come in handy. It's everything I observe but often fail to really put well into words.

Excellent narrative. Thank you.