Dread hearing that an admission is coming? Tired of trying to fit it in your initial assessment with everything else you have to do? If you consider that this assessment is one of the more important aspects of providing high quality care, you know you need to make it a priority. It will mean all the difference to your patients’ care not only at the beginning of their stay with you, but the entire time you care for them. Here’s three key points to help make doing nursing admission assessments easier:
Look at what you know so far about the patient from the nurse to nurse report (Read my blog, “Checklist for Giving a Complete Verbal Report When Patients Move From One Facility to Another”), transfer orders, discharge summary and the family. Hone in on specific information such as the patient’s medical diagnosis, why the patient was in the previous facility, any current nursing issues. Gather your supplies and the forms you will need so you do not have to leave the patient’s side during the assessment. Delegate so you have the time to do a thorough and accurate initial assessment. Minimize interruptions if you can.
2. Plan when you will interview and examine the patient
If you know the patient is incapable of answering your questions, make sure you do the admission when his family or significant other is available in person or by phone. My father, who had suffered a stroke, was being transferred from an acute care hospital to a rehabilitation facility. My dad, mom and I waited five hours for the discharge to take place. By the time the ambulance finally arrived, drove across town and deposited dad in his new bed, we were all exhausted. Dad slept while mom and I waited for another two and a half hours for the admission process to begin. I wanted to spare Dad all the questions I knew his nurse would ask so I had compiled a list of his page long diagnoses, his nursing problems and what was currently being done or what night need to be done. In other words, a nursing care plan. When no one came, I asked the evening nurse when Dad would be admitted. She said she was waiting for my mother and me to leave. We gladly handed her the information I had written and dragged ourselves home too tired to eat much supper. If only the nurse had communicated her plan to us.
3. Document your findings
If you fill out an admission assessment form, you can write your nursing notes one of two different ways. One is to highlight only the problems that need to be addressed in your care plan. The other way is in addition to your abnormal findings, to include important facts about your patient the rest of the nursing staff need to know. How you do this depends in part on the systems your facility has in place. For a sample of how I like to write an admission note, give me your email address on the right of this article. I will send it to you.
With a good nursing admission assessment of what your patient’s mental and physical status was at the time of admission, it is much easier to know when there has been a critical change in your patient’s condition. So next time you are getting a new admission to your unit, plan, prepare and document. You will be less likely to make the mistake of contacting the patient’s physician or nurse practitioner to find out that what you thought was a new problem is long standing and does not need any treatment. How embarrassing! Not only does this make you look like you do not know what you are doing but it also hurts the trust you have developed with that physician or nurse practitioner.