Documentation - consistency throughout all patient care areas

Nurses General Nursing


We have a question that we need input from other patient care locations.

We have an inhouse Same Day Surgical area, that admits surgical patients, as well as patients coming into the hospital as Outpatient blood transfusions, antibiotic infusions, neupogen injections etc. This area is staffed Monday thru Friday. On this unit, an admission history is done on each patient, and an adult admission physical assessment is also done, however the systems are listed as not assessed except for a pain assessment.

On the floors however, these same patients are cared for, but a complete physical assessment is done on these patients who are straight inpatients, as well as those blood transfusions and antibiotics that have to come in to have treatment over the weekend.

We do computerized charting by the way. What are question is, is are you doing different admission documentation according to patient type or patient care area, or do you have a standardized admission record that is done for every admission no matter the type or kind of patient? Please let us know, we anxiously await your answers.

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