Nursing Facility Admission Note

Date and time of service: [Date and time of initial physician evaluation]

Facility and unit (room/bed): [Facility name], [Unit/Wing], [Room/Bed]

Note type: Nursing Facility Admission Note

Author (credentials): [Name, degree(s), role]

Payer/coverage context: [Medicare Part A SNF / Medicare Advantage / Medicaid / LTC-custodial / Commercial / Pending confirmation]

Sources and Reliability

Historian(s): [Sources used: resident, family, caregiver, hospital discharge summary, prior facility records, pharmacy records, EMS]

Reliability: [Reliable / Partially reliable / Limited] (If limited, specify reason: aphasia, delirium, dementia, hearing impairment, language barrier.)

Information gaps: [Critical unknowns and plan to obtain] (Include interim safety measures if applicable. Omit if no significant gaps.)

Reason for SNF Admission

[Plain-language reason for admission, anticipated skilled needs, and key precautions] (1–3 sentences beginning with why the resident was admitted. Include skilled needs such as therapy, IV antibiotics, wound care, complex monitoring, and key precautions such as aspiration, falls, isolation, weight-bearing restrictions.)

Hospital Course Summary

• Hospitalization: [Dates, facility, principal diagnosis, major procedures]
• Key events: [Complications such as delirium, AKI, falls, new oxygen requirement, dysphagia, infections]
• Active restrictions/devices: [Weight-bearing status, bracing, wound VAC, lines/drains/catheters, diet texture]
• Pending items: [Outstanding studies/results with follow-up plan]
• Scheduled follow-up: [Appointments with service, date, location, transportation needs]

Baseline Function and Cognition

• Pre-hospital living situation: [Home alone / with family / ALF / LTC; layout; stairs; support availability]
• Mobility baseline: [Assistive devices, level of independence, prior falls]
• ADLs/IADLs baseline: [Independence level for bathing, dressing, toileting, transfers, feeding, medications, finances]
• Baseline diet/swallowing: [Diet texture, liquid consistency, aspiration history]
• Baseline cognition/behavior: [Known diagnoses, orientation, behavioral symptoms]
• Current vs baseline: [Comparison and concern for delirium vs baseline dementia] (State if baseline unknown and plan to obtain collateral.)

Problem List

• [Problem 1 – most acute/unstable]
• [Problem 2]
• [Additional active problems in descending order of severity]
• [High-risk monitoring needs: anticoagulation, insulin, dialysis, heart failure, wounds, aspiration risk]
• [Functional impairments relevant to therapy]

Allergies and Medications

Allergies: [Allergen – reaction type – allergy vs intolerance – severity] (If unverified, state explicitly with interim safety measures and verification plan.)

Medication reconciliation:

• Sources compared: [Pre-hospital list / Discharge list / Pharmacy records / Prior facility MAR]
• Reconciled facility medication list:
  • [Medication, dose, route, frequency – Indication – Hold parameters if applicable]
• Significant changes: [Medications started / stopped / held / dose changed with rationale]
• High-risk medications: [Anticoagulants, opioids, insulin, sedatives, antipsychotics, antibiotics with monitoring parameters and notification thresholds]
• Reconciliation status: [Complete / Incomplete] (If incomplete, list missing elements, verification plan, and interim safety steps.)

Relevant History

• Past medical history: [Conditions impacting current care, rehab, medications, or risk]
• Past surgical history: [Relevant procedures]
• Social history: [Living situation, supports, caregiver availability, substance use if relevant to withdrawal risk]

Goals of Care

• Code status: [Full code / DNR / DNI / DNR-DNI / Other] (Document confirmation source: POLST/MOST, advance directive, surrogate statement. Do not infer.)
• Advance directives: [Present / Absent / Unknown – location if available]
• Surrogate decision-maker/HCPOA: [Name, relationship, contact information, basis of authority]
• Resident-stated goals: [Resident's own words when obtainable]
• Escalation preferences: [Treat in place vs transfer thresholds; preferred hospital]
• Clarification needed: [Action plan for unknown elements with responsible party and timeline] (Omit if all elements confirmed.)

Review of Systems

(Include only if the resident can provide a meaningful ROS that affects the differential or plan.)

[Targeted symptom review tied to active problems] (If ROS limited, document reason: aphasia, delirium, dementia, hearing impairment.)

Physical Exam

• General: [Appearance, distress, body habitus]
• Mental status: [Alertness, orientation, attention]
• Respiratory: [Effort, breath sounds, oxygen device/flow]
• Cardiovascular: [Rate/rhythm, edema, perfusion]
• Abdominal: [Soft/NT/ND, bowel sounds, tenderness]
• Neurologic: [Gross strength, sensation, focal deficits]
• Musculoskeletal/mobility: [ROM, weight-bearing ability, assistive devices, brace/cast fit]
• Skin: [Integrity, pressure injuries with location/stage, wounds with location/size/drainage]
• Lines/tubes/drains: [Type and site assessment] (Include if present.)
• Surgical site: [Incision status, dressing, drainage] (Include if applicable.)
• Swallow/voice: [Cough, wet voice, dysarthria] (Include if aspiration concern.)

(If any component deferred, document reason and when it will be completed.)

Objective Data

• Vital signs: [Latest vitals with trends if available]
• Weight: [Current weight; comparison to baseline if available]
• Oxygen requirement: [Device, flow rate, target SpO2]
• Key labs: [CBC, BMP, INR, A1c, cultures as applicable with dates]
• Pertinent imaging: [Actionable findings only]
• Therapy evaluations: [PT/OT/ST initial assessments and recommendations] (Include if available.)
• Isolation/antimicrobials: [Isolation type; antibiotic with dose/route, start date, planned stop date, indication]
• Data gaps: [Missing key data and plan to obtain] (Omit if none.)

Assessment and Plan

(Organize by problem. For each, include current status, interventions, monitoring parameters with targets, nursing instructions with hold parameters and notification thresholds, and reassessment interval.)

[Primary reason for SNF admission]: [Diagnosis]

• Status: [Current stability and concerns]
• Restrictions/precautions: [Weight-bearing, bracing, isolation, aspiration, fall risk]
• Pain management: [Multimodal plan; PRN limits; bowel regimen if opioids]
• Complication surveillance: [Specific risks and monitoring thresholds]
• Follow-up: [Specialty, timing, pre-appointment labs/imaging]
• Reassess: [Timeframe]

[Problem 2]: [Diagnosis]

• Plan: [Medications with doses; monitoring parameters with targets and notification thresholds; nursing instructions; reassessment interval]

Rehabilitation Plan

• Disciplines ordered: [PT / OT / ST with indications]
• Measurable goals: [Ambulation distance, transfer level, ADL targets, diet advancement goals]
• Barriers and mitigation: [Pain, cognition, endurance; strategies to address]
• Expected trajectory: [Anticipated progress and therapy frequency]
• Success/failure criteria: [Objective milestones and contingency plan]

Discharge Planning

• Estimated length of stay: [Range] (State determining factors.)
• Discharge destination: [Home with/without services / ALF / LTC] (List prerequisites: caregiver training, equipment, safety evaluation.)
• DME needs: [Equipment and responsible party for procurement]
• Follow-up appointments: [Specialty, date, location, transportation plan]
• Contingency: [Plan if goals not met]

Orders

• Medications: [Drug, dose, route, frequency; hold parameters; notification criteria]
• Therapy: [PT/OT/ST with frequency and focus areas]
• Nursing: [Vital frequency, daily weights, I/Os, wound care schedule, glucose monitoring with insulin parameters, oxygen titration targets, fall precautions, neuro checks, bowel regimen]
• Diet: [Texture, liquid consistency, supplements, aspiration precautions]
• Labs/Diagnostics: [Tests with timing]
• Consults: [Specialties and indication]
• Communication tasks: [Family update, records requests, care conference, benefit verification with responsible party and timeframe]

Skilled-Need Attestation

(Include for Medicare Part A SNF stay or when payer requires skilled justification.)

• Skilled services required: [Nursing services, therapy services, complex medication management] (Specify why services require skilled staff and SNF level of care.)
• Therapeutic goals: [Specific measurable goals with time-bound reassessment]
• Estimated length of stay: [Timeframe]
• Post-discharge plan: [Destination and anticipated services]