Admission paperwork

[deespoohbear]

I was wondering how much paperwork other medsurg nurses have when a new patient is admitted. We just found out that we are going to have two more papers to fill out when we do an admission. So for us we have the following: a four page admission assessment, a teaching sheet, a valuables check off list, Braden Skin Assessment paper, an advanced directive paper, and a fall risk assessment. I think that is it. Oh, plus we have the graphics page, and the check off page to fill out. Then if someone is diabetic or on anticoagulants, we have another flow sheet to fill out. So now instead of taking an hour to fill out all the paperwork, now it will be an hour and a half. The really dumb part is about this whole thing is a lot of this is at least double charted if not triple charting. We keep trying to tell the higher ups that this is way too much, but no one wants to listen to us. The real catch of this is that the people who are making up these new forms do not work the floor at all! I think these people should have to work the floor a couple times a month and take 6 or 7 patients then have to do an admission or two. Maybe the paperwork would be reduced if that happened. I doubt it though. We would probably be told that we need to be more organized! LOL!!

[suzannasue]

We also have an hour and a half of paper work on each and every admission...done with point of care computers at the bedside. My co-workers and I have complained about the lengthy, repetitive charting but so far,nothing has been done. I especially appreciate the fact that many of our admissions are discharged the next morning....

Informatics tells us that we are satisfying JCAOH requirements...I think we are just trying to be a BIG DOG hospital in a small kennel.

The information is also supposed to be more readily available for the MD's,however, only a couple have learned to read the printout properly.

Oh well...thus is progress.

[deespoohbear]

Don't you just love it when you do an admission on 3-11 and they are discharged before 9 am the next day!! This happens frequently to us also. We are small hospital that has to transfer patients to larger hospitals for more definitive care such as cardiac caths, orthopaedics, and other complex medical problems. We have one ER physician who is notorious for admitting a pt who is on dialysis to our medsurg floor. The pt is scheduled for dialysis the next day, so we end up having to transfer the pt the next morning since we don't have dialysis at our facility. What a waste of paperwork and time!! I am sure by the time you pay the nursing staff and all the other ancillary staff their wages for taking care of this pt, is much more than what the facility will get reimbursed by Medicare/Medicaid/private insurance. Just don't understand the logic behind all this!!

[RNforLongTime]

I have always wondered why an Admission Assessment form cannot be initiated by the ER staff. I'm sure that they'll say that they are just WAY too busy. Am I not any busier than they are being a med/surg nurse? I can't tell you how many people get irritated with me when I have to ask them the same questions that they were asked hours ago by the ED staff. Like their medications. I need to know what they take, the dosage, how often they take it and if they took it today. The ER nurse has already asked them this question. I just don't understand why then that the ER nurse can't enter this information onto the Admission form.

On my unit we have a 4 page Admission assessment form, a Braden scale pressure ulcer risk form, a Functional screening form (this is to assess for the need of PT or OT), a care plan that has to be entered into a different computer. THEN after we finish assessing the patient, we have to call the doctor for orders. At my hospital, patients almost NEVER come form the ER with orders.

So all in all this can take upwards of 4 or 5 hours. If a certain Md admits a patient, he gives 2 full pages of orders. If you can get him to return the pages and beeps. There have been times where we have gotten his patients FROM HIS OFFICE--he sent NO ORDERS . This patient arrived at about 4pm. The nurse caring for this patient tried numerous times to get in contact with this doc and he never called back. She didn't get orders on this patient unitl 10:30 pm AT NIGHT when he came in to make his evening rounds! Needless to say, she wrote this doctor up cause that is just plain ridiculous!

[deespoohbear]

No admission orders from the ER when the patient arrives to the floor? That just blows me away! Our ER pts ALWAYS have admission orders when they arrive to our unit, even if it is just the bare essentials. What a waste a time for nurses to have to call for something that should have been done in the first place!! We get direct admits from the doctors' offices. Two of the docs are notorious about sending a pt without any orders. All the calling in the world doesn't seem to make any difference. I used to get really upset about it, but anymore I make ONE phone call to the doc's office and ask nicely for orders. If I don't have my orders within 1/2 hour, I make out an incident report. Then when the patient asks me why I haven't started the IV, fed them, sent them for test, or anything else, I just sweetly explain that I am waiting on their physician to send orders. Makes the doc look like an a** instead of the nursing staff. My basic feeling is that if a doctor thinks a pt is sick enough to be admitted to the hospital then that pt is sick enough to have orders written in a timely manner. 'Nuff said. :)

[ktwlpn, LPN]

Our local hospital found the belongings sheet to be extraneous-after they decided that they would not be responsible for lost or broken personal effects and the inclusion of such a sheet implies responsibility. 1 less form to complete...

[deespoohbear]

How did your hospital reach that decision? Did they contact an attorney or something? I would love to present that idea to our administration but I would need evidence to back it up!!

[rebelwaclause, ASN, RN]

(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!!!!!

[caroladybelle, BSN, RN]

Pt enters ER at 1530. Blood drawn - Pt answers tons o'questions.

First consultant sees pt for abdominal pain at 1700. Second Md sees pt at 1800. Tests run at 1900. Third MD sees pt at 2100 -writes orders - some stat - admits pt - pt has been NPO so far but has diet ordered. Pt has answered questions for several nurses and three MDs. Nothing gets done after 2230 on pt.

MS unit gets notified at 0330 that they will be receiving pt. Report gets called at 0345. Pt received at 0530 - hungry, no paperwork done, not even a pain med ordered, no meal, no sleep, stats not given, bloodwork not called to MD (several panic values-contraindicating some current orders) and the pt/MD called this late/receiving nurse is ticked/tired/aggravated - and we wonder why.

?

[preciousnurse]

Where do the patients go after they leave the ER? DUH, we are busy too!!!!!!!!!!!!