Nursing Admission Assessment (Inpatient)

Arrival Summary and Safety Check

Date/Time of Documentation: [Date and time] | Arrival Time to Unit: [Date and time]

Author: [Full name, credentials] | Unit/Room/Bed: [Unit/Room/Bed] | Attending/Service: [Name/Service or Unknown]

Information Source: [patient / family / transfer paperwork / chart review / other]. Reliability limitations: [None / sedated / confused / language barrier / aphasic / hearing or vision impairment / other] (Note interpreter use if applicable.)

[Arrival origin], [mode of transport], [presenting problem as understood by nursing], [initial general survey including level of distress, work of breathing, mental status, and immediate priorities]. (2–4 sentences.)

• Patient identification verified per policy: [Yes / No / Unable]
• Allergies: [Verified / Unknown] (If verified, list allergy types and reactions per policy.)
• Code status: [Full code / DNR / DNI / DNR-DNI / POLST on file / Unknown] (If unknown, document escalation action taken.)
• Isolation precautions: [None required / Contact / Droplet / Airborne / Enhanced / Unknown] (Specify type if initiated.)
• Immediate high-risk concerns: (Document each as present, absent, or unknown.)
  • Airway support needed: [Present / Absent / Unknown]
  • Active bleeding: [Present / Absent / Unknown]
  • Uncontrolled pain: [Present / Absent / Unknown]
  • Acute agitation or safety risk: [Present / Absent / Unknown]
  • High or escalating oxygen requirement: [Present / Absent / Unknown]
  • Critical infusions running: [Present / Absent / Unknown] (If present, list infusion names and current rates.)

Patient Profile and Baseline Status

(Include when relevant to immediate nursing care. If baseline is documented elsewhere and accessible, note only current functional status and exceptions relevant to this admission.)

• Language and interpreter needs: [Primary language]. Interpreter: [Used / Required / Declined / Not needed]
• Sensory deficits and devices: [None / Hearing / Vision / Speech / Other with assistive devices]
• Baseline cognition and decision-making capacity: [Description]. Surrogate decision maker: [Name, relationship, contact or Unknown or N/A]
• Baseline mobility and assist level: [Independent / Supervision / Assist x1 / Assist x2 / Bedbound / Wheelchair user / Other]
• Fall history: [Yes / No / Unknown] (Details if yes.)
• Home gait aids and equipment: [None / Cane / Walker / Wheelchair / Prosthesis / Orthosis / CPAP / Home oxygen / Other]
• Primary support person and contact: [Name, relationship, phone]. Info sharing consent: [Yes / No / Unknown]

Systems Assessment

(If detailed head-to-toe is documented in flowsheets, state this and document only abnormal findings, clinically important normals, and safety implications. For any system not assessed, document "Not assessed" with reason and reassessment plan if clinically important.)

Vitals: Temp [value and unit], HR [value], RR [value], BP [value and position], SpO2 [value] on [Room air / Nasal cannula / Simple mask / Nonrebreather / HFNC / NIV / Ventilator] at [settings], Pain [scale and score], Weight [value and unit] via [bed scale / standing scale / stated].

Neurologic: [Orientation level], [speech], [pupils if indicated], [gross motor and sensation], [behavior and safety concerns]. (For altered mental status, include last known normal if available and escalation actions.)

Respiratory: [Work of breathing], [breath sounds], [cough and sputum], [oxygen support device and settings]. (For advanced airways, document type and nursing-relevant parameters.)

Cardiovascular: [Rhythm source and rate], [perfusion indicators], [edema if present], [peripheral pulses if clinically indicated].

GI and Nutrition: [Abdomen assessment], [nausea or vomiting], [diet status], [swallow risk cues], [enteral access and tolerance if applicable].

GU: [Voiding status], [continence], [catheter details if present: type, patency, drainage characteristics, securement, indication if known].

Skin and Wounds: [Overall integrity], [moisture issues], [bruising or rashes]. (For pressure injuries or wounds present on admission, document location, size, drainage, staging when appropriate, and device-related skin risks.) Dual-nurse skin check: [Completed / Pending].

Musculoskeletal and Mobility: [Observed gait and transfer ability], [assist level required], [ROM limitations], [weight-bearing restrictions], [equipment in use].

Pain: [Pain denied / Pain present: location, intensity, quality, aggravating and relieving factors, patient goal]. (If unable to self-report, document behavioral pain tool used and score.)

Psychosocial: [Affect], [coping], [anxiety], [sleep concerns if pertinent]. Safety screening per organizational requirements: [Results for self-harm, violence, elopement risk as applicable].

Risk Screens and Interventions

(For each applicable screen, document tool used, score or category, key risk drivers, interventions initiated, and reassessment trigger.)

• Fall Risk: [Tool name], [score or category]. Risk drivers: [List]. Individualized interventions: [Interventions matched to specific risk factors]. Reassessment trigger: [Trigger].
• Pressure Injury Risk: [Tool name], [score or category]. Prevention plan: [Turning schedule, offloading, moisture management, device padding, nutrition consult as indicated].
• VTE Prophylaxis Status: Mechanical: [In place / Contraindicated / Refused / Not ordered]. Pharmacologic: [Ordered / Missing / Contraindicated]. (If missing or refused, document escalation action.)
• Delirium Screen: [Tool name], [result]. (Include per unit protocol, especially ICU or older adults.) Actions if positive: [Interventions and notifications].
• Aspiration and Swallow Screen: [Completed / Deferred / Not indicated]. Result: [Pass / Fail / At risk]. Next steps: [NPO / SLP consult / Diet advancement / Reassess].
• Sepsis Screening: [Triggered / Not triggered]. (If triggered, document actions taken.)
• Other unit-specific screens: [Tool, result, interventions, and reassessment plan as applicable].

Lines, Drains, and Devices

(Document each device with type, location and laterality, insertion date if known, patency and status, dressing and securement, and safety observations. For tubes and drains include connection integrity, suction settings, and output characteristics. For vascular access include signs of infiltration or phlebitis, current infusions, and compatibility concerns. For airway devices include settings and humidification or suction setup. If any information is unknown, document "Unknown" and plan to obtain. If no devices present, state "None present.")

• [Device type, location and laterality, insertion date, patency and status, dressing and securement, pertinent settings, current infusions or output characteristics, safety checks]
• [Additional devices as applicable]

Medications

• Medication reconciliation status: [Complete / In progress / Unable] (Source: [Patient / Family / Pharmacy / Transfer paperwork / Outpatient list / Other]. Reason if unable.)
• High-alert medications present on arrival: [Insulin infusion / Heparin / PCA / Vasoactive drips / Sedation / None]. Pump settings verified per policy: [Yes / No / N/A].
• Urgent discrepancies: [None / Description]. (If present, document escalation and response.)

Priority Nursing Problems and Plan of Care

(List 1–3 priority nursing problems, highest acuity first.)

1. Problem: [Problem statement]

   Supporting evidence: [Key findings and risk drivers]

   Goal: [Measurable goal with timeframe]

   Interventions initiated: [Specific actions; avoid generic terms like "monitor"]

   Coordination and escalation: [Notifications, consults, interprofessional coordination]

   Reassessment plan: [Timing and parameters]. Escalation triggers: [Thresholds and whom to notify].

2. Problem: [Problem statement]

   Supporting evidence: [Key findings and risk drivers]

   Goal: [Measurable goal with timeframe]

   Interventions initiated: [Specific actions]

   Coordination and escalation: [Details]

   Reassessment plan: [Details]. Escalation triggers: [Details].

3. Problem: [Problem statement]

   Supporting evidence: [Key findings and risk drivers]

   Goal: [Measurable goal with timeframe]

   Interventions initiated: [Specific actions]

   Coordination and escalation: [Details]

   Reassessment plan: [Details]. Escalation triggers: [Details].

Notifications and Pending Items

• Provider notifications: [Reason for notification], [whom notified], [time], [response and orders].
• Consults initiated: [Service], [reason], [status].
• Unresolved safety items at note close: [Items], [follow-up plan], [responsible party], [timeline].

Authentication

[Electronic signature], [Credentials], [Date and time signed]

(If co-signature required: [Co-signer name, credentials, date and time]. If late entry: Mark as late entry and document actual event time versus documentation time.)