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

[Cal-Neva]

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

[dudette10, MSN, RN]

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.

[Altra, BSN, RN]

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?

[CapeCodMermaid, RN]

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

[pinkiepieRN]

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.

[pinkiepieRN]

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.

[royhanosn]

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

[SubSippi]

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.

[SHGR, MSN, RN, CNS]

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.

[RN_2012, BSN, RN]

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.

[Aakanni]

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.