Admission Nursing Note

Assessment & Plan Elements
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[date] Admission Note: Patient is a [text size="10"] year old [checkbox value="Male|Female"][text size="10"] admitted [checkbox value="Voluntary|Involuntary"] from [text size="10"]. Admitting Diagnosis: [text size="50"]. Reason for admission: [textarea cols="50" rows="10"]. Medication adherence has been [checkbox value="Good|Fair|Poor|Questionable|Not taking medications as prescribed|Taking more than prescribed"] [text size="50"]. [checkbox value="Allergies include |No known allergies"][text size="50"]. [checkbox value="Medical history includes |No known noteable medical history"][text size="50"]. On admission patient was [checkbox value="Calm and cooperative|Irritable|Oppositional|Oriented and ambulatory|Disorganized|Responding to internal stimuli|Required significant support following direction|Sedated|Unsteady on feet|Unable to participate in admission process"]. On admission patient denied [checkbox value="Suicidal ideation|Homicidal ideation|Auditory hallucinations|Visual hallucinations|Tactile hallucinations|Recent alcohol use|Recent recreational drug use|recent falls/fall risk"]. Reported positive for [checkbox value="Suicidal ideation with a plan|Suicidal ideation with no plan|Homicidal ideation with a plan|Homicidal ideation toward no one in particular/no plan.|Auditory hallucinations|Auditory hallucinations command to hurt self|Auditory hallucinations command to hurt others|Auditory hallucinations inaudible voices|Visual hallucinations|Tactile hallucinations|Recent alcohol use|Recent recreational drug use"].[text size="50"][checkbox value="Medications confirmed with patient's pharmacy|Unable to confirm patient's medications at this time|Fall precautions initiated|Elopement signs in place|Staff notified of contact precautions|Message left with infection control|CIWA initiated|COWS initiated|Peanut butter removed from unit|Patient placed on staggered checks|Patient placed in FNP book for "][text size="50"]. Plan to monitor patient for safety, encourage patient to participate in treatment programming, encourage patient to accept scheduled medications. [checkbox value="Plan to "][checkbox value="Maintain contact precautions|Maintain fall precautions|Maintain CIWA protocol|Maintain COWS protocol"]. [text size="50"] CCardurns, RN
Admission Note: Patient is a year old admitted from . Admitting Diagnosis: . Reason for admission: . Medication adherence has been . . . On admission patient was . On admission patient denied . Reported positive for . . Plan to monitor patient for safety, encourage patient to participate in treatment programming, encourage patient to accept scheduled medications. . CCardurns, RN
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