ADMISSION DATABASE

SECTION I Nursing Unit Admission Data

L Indicates the need to contact appropriate discipline/support service for further intervention. Refer to Page 5

(ALL WHITE AREAS to be completed. SHADED AREAS to be completed when appropriate to patient condition.)

DOES THE PATIENT REQUIRE INTERPRETIVE SERVICES (DEAF INTERPRETER OR FOREIGN LANGUAGE INTERPRETER)? L Foreign Language ATT interpreter line contacted 1-800-874-9426; ID # 212173 NO YES L If yes, L Amplifier requested for HOH L Sign Language Interpreter L Blind - contact CM ID BAND APPLIED OR IN PLACE NURSING UNIT ARRIVAL ROOM #: DATE: TIME: Ambulatory Cart Wheelchair Other: _______________________________________________________ METHOD OF ADMISSION: ED Physician Office Home PACU ECF Other: _____________________________________________ ADMITTED FROM / CONTACT PERSON: Hospital Transfer Contact Person _________________________ Relationship _____________ Phone #_________________ No Smoking Policy Call Light/Bedside & Bathroom Patient/family consents to use of siderails ORIENTATION TO ENVIRONMENT: Intercom/Bed Controls Phone/TV/Visiting hrs. Other Instructions: _________________________ None Valuables: Sent Home To Safe Family ______________________ BELONGINGS ACCOMPANYING PATIENT UPON ADMISSION: Name Glasses: Dentures/Complete: Upper Lower Hearing Aids: L R Assistive/Prosthetic devices: Contacts: Left Right Dentures/Partial: Upper Lower ___________________________________ Eye Prosthesis DISPOSITION OF PATIENTS OWN MEDS: Did not bring Family has Locked on Nursing Unit Other: __________________________
TEMP. PULSE BLOOD PRESSURE RESP Admission Diagnosis/Reason for Admission:

Radial: Apical:

R:

L: WEIGHT: _________ lbs _________ kg

(1 kg = 2.2 lbs., divide lbs. by 2.2 to obtain kg weight)

HEIGHT: _______________ ft/in

Standing

Chair

Bed

Not weighed

Each inpatient must be weighed upon admission and that data recorded in the medical record (unless contraindictated by the patients physical condition)

If not weighed, why: ____________________________________________________________________________ ADVANCE DIRECTIVES: Do you have a Living Will? Yes Yes No Placed on chart Do you wish to have additional information?

Stated weight: __________ lbs/kg Notify Pastoral Care L

Family to Bring Copy within 48 hours

No ______________________________________________________

If the Living Will is unavailable for review, please describe the content: ___________________________________________________________________ ________________________________________________________________________________________________________________________________ Do you have a Durable Medical Power of Attorney for Healthcare? Does the hospital have copies of the documents? Yes No Yes No Name: __________________________ Phone: ________________ Yes No N/A Are you an organ donor? Yes No Has the content changed?

SECTION II

Patient History

(May be completed by RN/LPN)

ALLERGIES: Is patient allergic to medication, food, tape, iodine or latex?

Drug/Other: Drug/Other: Drug/Other: Reaction: Reaction: Reaction:

None Known
Drug/Other: Drug/Other: Drug/Other:

Yes List Below:

Reaction: Reaction: Reaction:

MEDICATIONS:

None

The patient or caregiver is unable to provide information to complete this section.

Dose Frequency

The patient is taking an investigational or foreign medication.

Last Taken

Patient takes glucophage

Patient takes glucovance

Current Prescriptions / Medications / Over-theCounter Medications / Alternative Agents / Herbs

Current Prescriptions / Medications / Over-theCounter Medications / Alternative Agents / Herbs

Dose

Frequency

Last Taken

Form 6379 R: 1/02

PLEASE CONTINUE ADMISSION DATABASE ON BACK OF FORM

Page 1 of 6

SECTION II

Patient History

(CONTINUEDTo be completed by RN/LPN)

PAST MEDICAL HISTORY: RESPIRATORY:COPD/Emphysema No Respiratory History Applies See PEAT Form See ED Form Asthma Bronchitis Sleep Apnea Pneumonia TB

Have you had a persistent or productive cough for 3 weeks or more? If checked, continue: Presence of Blood in Sputum? Presence of Fever Recently? Presence of Night Sweat? Presence of Recent Unexplained Weight Loss? History of TB or Positive PPD? If 3 or more checked, make Infection Control referral L Home oxygen: ____________ liters Supplier: ________________________________________________________ DVT: ___________________ Bleeding Problems: ___________________

CARDIOVASCULAR: No Cardiovascular History Applies See PEAT Form See ED Form MISCELLANEOUS: No Miscellaneous History Applies See PEAT Form See ED Form

Hypertension: ___________________ Hypotension: ____________________ Heart Disease: ___________________ Hx. Heart Cath: __________________ Stroke

Angina

CHF

MI

Pacemaker: __________________________ Implanted Defibrillator (AICD)

Hx. Angioplasty: _____________________

Residual Effect: ______________________________________________________________________________ Cancer: _______________________ Glaucoma: ____________________ Kidney: _______________________ Syncope: ______________________ Infectious Disease: ______________ Depression: ______________________ Gastrointestinal: ___________________ Muscular: ________________________ Thyroid: __________________________ Other: ___________________________

Bone/Joint: _____________________ Diabetes L: _____________________ Hepatitis: _______________________ Seizures: _______________________ Urinary: ________________________

L Provide Diabetic Education for the newly diagnosed patient or as ordered Nicotine Use: Alcohol Use: Substance / Drug Use: PAST SURGICAL: No Prior History No No No Yes Yes Yes Amount: _________________ How long: ______________ Amount: _________________ How long: ______________ Amount: _________________ How long: ______________ Last Use: _________________ Last Use: _________________ Last Use: _________________
YEAR (If possible)

See PEAT Form

List any anesthetic complication:

No Complications

LOCAL PHYSICIANS: FAMILY PHYSICIANS / CONSULTS

PURPOSE

Information obtained from:

Patient

Family

Transfer/Old records

Other: _________________________________________________

Patient History obtained and documented on PEAT Form (see attached)

Patient History obtained and documented on ED Form (see attached)

If unable to complete any part of Admission Database, state reason: _________________________________________________________________________ ________________________________________________________________________________________________________________________________
Page 2 of 6

SECTION III Biophysical Assessment

ASSESSMENT STANDARDS

(TO BE COMPLETED BY RN)

= Standards NOT MET check appropriate box in right column or requires Narrative Note # Initials = Standard Met ALL WHITE AREAS to be assessed. SHADED AREAS to be assessed when appropriate to patient condition. PAIN: Are you having pain? QUALITY OF PAIN: Sharp Constant Scale Assess using Verbal/Visual Analogue Scale (VAS). Aching Dull Intermittent Pressure Scale: no pain 0 1 2 3 4 5 6 7 8 9 10 worst pain What makes your pain better? _______________ LOCATION: 1. Surgical 2. Head 3. RUE 4. LUE 5. RLE 6. LLE Location _______________________________________ 7. Chest 8. Abdomen 9. Back 10. Generalized 11. Other ____________________ NEUROLOGICAL ASSESSMENT: Alert, oriented to person, place, time, situation. Speech is clear. Pupils equal. SAFETY ASSESSMENT: Criteria: Patient consistently demonstrates the ability and willingness to follow safety instructions and activity orders. Seeks assistance for ADLs when indicated. Patient is not at risk for falls. Alert, oriented to person, place, time, situation. Speech is clear. Pupils equal. On 3 or more medications Syncope Dizziness Seizure Insomnia Loss of Balance Loss of Coordination Loss of Sensation Disoriented Uncooperative Slurred speech _____________ Recent L Pupils unequal Aphasic ___________________ Recent L Confused Impaired Cognitive Level ______ Recent L Lethargic Decreased Independence Comatose with ADLs _________________ Recent L *Please Note: Recent = within the past 7 days to trigger a therapy referral. Comments: _____________________________________________ _______________________________________________________

Initial

Initial

FALL RISK ASSESSMENT: (The patient is at risk for falls if 4 or more of the following are checked or based on nursing judgement.) Confused Blind Blurring of Vision Use of Assistive Device Weakness History of Falls Flacid 65 years of age or older Unable to move all extremeties Amputee Impaired Communication Impaired Mobility Catheter Urinary Frequency Diarrhea

Interventions for Prevention Address fall risk as a problem on the Plan of Care Educate patient / family on falls prevention Initiate Falls Prevention Protocol

Unable to evaluate due to condition Comments: ___________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Irregular rhythm Neck vein distention Skin cool Diaphoretic Abnormal heart tones Comments: _____________________________________________ _______________________________________________________ _______________________________________________________ _______________________________________________________ Labored / Dyspnea Retractions Crackles: ____________ Chest deformity ________________ Rhonchi: ____________ Tracheostomy Wheezing: ___________ BiPap, CPAP or Ventilator @ Home Cough, non-productive (notify Respiratory Services) Cough, productive: _____________________________________ Comments: _____________________________________________ Abdomen: Nutrition: Distended Rigid Unintentional weight loss of 7 or Pain / Tenderness more pounds in past 3 months L NG tube: ___________ Nausea, vomiting or diarrhea 5 days L Bowel Sounds: Chewing, swallowing difficulties Absent which are new onset L (Possible speech referral) Hypoactive Mouth sores which are new onset Hyperactive and affect eating L Bowel Pattern: No teeth present L Constipation 5 days Non-elective surgery 80 yrs of age L Diarrhea 5 days Pregnant or lactating mother admitted Incontinent to non-ob area L Rectal bleeding L Nutrition Services Referral Tarry stools Comments: _____________________________________________

CARDIAC ASSESSMENT: Patient non-monitored. Pulse regular. Rate 60-100 BPM. Skin warm & dry. Stable BP. States no discomfort in chest, arm, neck, jaw. MONITORED PATIENT skin warm & dry, stable BP, document rhythm and rate. Rhythm ________________ Rate ________________

Initial

SR = Sinus Rhythm, AF = Atrial Fibrillation, ST = Sinus Tachycardia, SB = Sinus Bradycardia, JR = Junctional Rhythm, P = Pacemaker, AFL = Atrial Flutter, HB = Heart Block, VT = Ventricular Tachycardia

RESPIRATORY ASSESSMENT: Respirations 12-24/min at rest, quiet and regular. Bilateral breath sounds Initial clear. Nail beds and mucous membranes pink. Sputum clear if present. Oxygen device: _______________ FiO2: _______________ O2 Sat _______________

GASTROINTESTINAL ASSESSMENT: Abdomen soft and non-tender; bowel sounds present x 4 quadrants; no Initial nausea/vomiting; continent; bowel pattern verified. Date of last BM: ___________________________ Ostomy: _____________________________________________________ ET Nurse L Feeding Tube / Peg ________________________ Supplement: _________________ Comments: ______________________________________________________________
FOOD / NUTRITION: No unintentional weight loss. No difficulty with swallowing, chewing. No Initial nausea or vomiting. No mouth sores that affect eating. Teeth are present. Diet: _______________________________________________________ Comments: ______________________________________________________________ _______________________________________________________________________

Urgency/Frequency Hemodialysis Genital discharge GENITOURINARY ASSESSMENT: Incontinent Genital rash/lesion Peritoneal Dialysis Voids without difficulty, pain or discomfort; continent; urinary catheter patent, Initial if present. Urine clear yellow to amber as observed or stated. Nocturia Vaginal bleeding Last treatment No genital discharge, rash or lesions stated or observed. Ileo-conduit Dysuria / Hematuria Date __________ Catheter Type: _____________ Size: _____________ Insertion Date: ______________ Comments: _____________________________________________ IV SITES: Peripheral IV site(s) without redness, swelling or tenderness. Central line Initial dressing intact; condition of site without redness, swelling or tenderness at time of site care. Date of site(s), infusion rate(s), infusion device(s) verified. IV site(s) checked per policy. Comments: ______________________________________________________ None
Page 3 of 6

Site: _____________________ Date/Time Inserted: _____________ Fluid: __________________________________________________ Site: _____________________ Date/Time Inserted: _____________ Fluid: __________________________________________________

SECTION III Biophysical Assessment

(CONTINUED TO BE COMPLETED BY RN)

Pressure ulcer/Wound Rash/Lesions SKIN/TISSUE ASSESSMENT: Ecchymosis Incision: _____________ Skin clean, dry, intact, no reddened areas. Patient is alert, cooperative and able to Initial Fragile skin Drain: _______________ reposition self independently. Moisture/Edema Comments: ____________________ Complete BRADEN SCALE: PRESSURE ULCER RISK BELOW BRADEN SCALE: PRESSURE ULCER RISK Sensory Perception: 1) Completely limited 2) Very limited 3) Slightly limited 4) No impairment _________ Moisture: 1) Constantly moist 2) Very moist 3) Occasionally moist 4) Rarely moist _________ Mobility: 1) Completely immobile 2) Very limited 3) Slightly limited 4) No limitations _________ Activity: 1) Bedfast 2) Chairfast 3) Walks occasionally 4) Walks frequently _________ Nutrition: 1) Very poor 2) Probably inadequate 3) Adequate 4) Excellent _________ TOTAL Friction & Sheer: 1) Problem 2) Potential problem 3) No apparent problem _________ SCORE Comments: Score 14 or less: L Consult Nutrition Services Score 12 or less: L Implement Skin Integrity Flowsheet MUSCULOSKELETAL ASSESSMENT: Independently able to move all extremities and perform functional activities as observed or stated. (Includes assistive devices) ASSISTIVE DEVICES: Cane Walker Initial Limited ROM/Immobility: _____________ Deformity/Amputation: _______________ Muscular weakness/Paralysis: _________ Unsteady Gait: ______________________ Recent Recent Recent Recent L L L L

Crutches

Wheelchair

Prosthesis: _____________________

*Please Note: Recent = within the past 7 days to trigger a therapy referral.

L Contact MD for possible Therapy consult/order Abbreviations: RUE LUE RLE LLE Comments: _____________________________________ Extremities cool: _______________________________ Edema: ______________________________________ Doppler pulses: ________________________________ Numbness/Tingling: ____________________________ Homans Sign positive: __________________________ Comments: _____________________________________ Poor hygiene/unkempt * Unexplained Bruises/injuries *
*Nurse may possibly notify Adult Protective Services-Phone (330) 451-8998

PERIPHERAL VASCULAR ASSESSMENT: Extremities warm. Capillary refill < 3 seconds. Peripheral pulses palpable and equal. No edema, numbness, tingling.

Initial

PSYCHO-SOCIAL: Behavior appropriate to situation. Expressed concerns and fears are being addressed. Has adequate support system. The assessment findings are compatible with information given. 1. Have you been treated for a psychiatric illness? Yes No 2. Are you currently feeling depressed/anxious but this is not related to your hospitalization/diagnosis? Yes No Unable to evaluate due to condition *When BOTH questions are answered yes, initiate Psychiatric Risk Assessment Form SPIRITUAL/CULTURAL: Patient indicates spiritual and cultural needs are being met. If requested, pastoral care is notified. Unable to evaluate due to condition DISCHARGE PLANNING: The Patient/Family is not expected to require home care assistance or additional care related to mobility, living arrangements, support systems, finance, equipment, medication administration, transportation, nutritional needs, or housekeeping/shopping at time of discharge. PRIOR LIVING ARRANGEMENTS: Home ECF

Initial

Loss of interest in self Excessive fear Hallucinations L Suicide attempt/Ideation L Homicide attempt/Ideation L L Notify attending physician for possible consult/order. Comments: _____________________________________ _______________________________________________ Cultural/Spiritual needs L : ______________________ Comments: _____________________________________ _______________________________________________ Current Home Health L : ________________________ New needs L : ________________________________ L Notify Case Management Comments: _____________________________________ Homeless L

Initial

Initial

L : ______________________________________________________________
(Name of Facility)

Who will assist you upon discharge: _____________________________________________________________________

I N I T I A L K E Y

Phone #: _____________________
INITIALS

SIGNATURE / TITLE

INITIALS

SIGNATURE / TITLE

INITIALS

SIGNATURE / TITLE

PEAT (Pre-Admission Testing) Sections completed POS (Perioperative Services)

R.N. SIGNATURE

INITIALS

DATE

TIME

R.N. SIGNATURE

INITIALS

DATE

TIME

PLAN OF CARE: To be completed by RN on nursing unit. I have reviewed the Admission Database. The Plan of Care and Education Record have been initiated.
R.N. SIGNATURE R.N. INITIALS DATE TIME

Page 4 of 6

Addressograph
INTERDISCIPLINARY CONSULT/REFERRAL REQUEST LIST
(Consult requires physician order referral from nursing or discipline)

Department Needed For Consult / Referral

Nutrition Services

Method of Notification

Requested By & Reason for Consult / Referral (Initials)

Entered & Contacted By: (Initials)

Enter consult / referral via computer Consult under category FNSN Referral under category REF Wound Care Center / Enter consult / referral via computer ET Nurse and Ostomy Need Consult under category PED Referral under category REF Rehabilitation Needs: Enter consult / referral via computer Occupational Therapy Consult under category OT Referral under category REF Physical Therapy Enter consult / referral via computer Consult under category PT Referral under category REF Speech Therapy Enter consult / referral via computer Consult under category ST Referral under category REF Case Management Enter consult / referral via computer (discharge planning, recent Consult under category SS hospitalization, etc.) Referral under category REF Diabetes Educator Enter consult / referral via computer Consult under category PED Referral under category REF Respiratory Therapy Enter consult / referral via computer Consult under category RT Referral under category REF Pastoral Care/Spiritual Enter referral via computer Services (referral only without consult) Referral under category REF Pain Management Enter physician order via computer Clinic Under category CONS Infection Control Enter referral via computer Referral under category REF General Psychological Enter consult / referral via computer Services Physician order under category CONS Referral under category REF Other:

Comments:

SIGNATURE / TITLE

INITIAL

SIGNATURE / TITLE

INITIAL

SIGNATURE / TITLE

INITIAL

Page 5 of 6

INTERDISCIPLINARY PATIENT EDUCATION RECORD

MOTIVATIONAL LEVEL:
Cooperative / Interested Seeing Doing Uncooperative / Uninterested Hearing Unable

BARRIERS TO LEARNING:
Language Anxiety Vision Language Spoken _______________________ None OUTCOME Hearing Pain Unable Due to Condition FOLLOW-UP (Date & Initials)

LEARNING PREFERENCES: Do you prefer to learn by:

PATIENT EDUCATION *REQUIRED PATIENT EDUCATION *Patient Rights & Responsibilities *Patient Involved In Plan Of Care *Education On Current Illness *Pain Management GENERAL PATIENT EDUCATION Cardiac Monitoring Wound Care/Dressing Change Suction/Drains Pre-op Teaching Post-op Teaching Blood Products IV PCA Falls Prevention Diabetes MOBILITY / REHABILITATION ADLs Assistive Devices Stairs CPM Weight Bearing Homegoing Exercises RESPIRATORY CARE Aerosol Therapy / IPPB CPT Incentive Spirometer MDI / Spacer Ventilator BIPAP / CPAP Oxygen Therapy PASTORAL CARE SPECIAL PROCEDURES NUTRITION / PHARMACY Coumadin Education SPECIAL DIETS

ACTION (Date & Initials)

SIGNATURE / TITLE

INITIAL

SIGNATURE / TITLE

INITIAL

SIGNATURE / TITLE

INITIAL

OUTCOME CODES: 1. Outcome met / Verbalizes Understanding / Performs Skills Independently 2. Further Intervention / Teaching / Planning Required 3. Unable to Comprehend 4. Contact Family or S.O. for Further Teaching / Planning Page 6 of 6

*ACTION CODES AS = Assessment D = Demonstration G = Group Class

AT = Audio Tape RD = Return Demonstration E = Explanation

V = Video W = Written S = Sacrament