Admission Nursing Note
Discover what is included in an Admission Nursing Note and download a free PDF example to get started.
Fact Checked by Nate Lacson.
What is an Admission Nursing Note?
Nursing Admission Notes are an important part of the patient care process. They provide vital information about a patient's condition, medical history, medications, and treatment plan. They can help nurses assess a patient’s needs and inform decisions regarding their care.
A template is an easy way to keep notes organized and consistent. This template may include the patient's name, age, address, insurance information, contact information, medical history, medications, and allergies. It may also contain sections for any procedures or tests performed on the patient.
These documents are used for communication between nurses and other healthcare professionals, such as physicians, therapists, and social workers. They can help ensure everyone is on the same page regarding a patient's medical history, current treatment plan, and goals. In many cases, they provide the basis for developing individualized treatment plans.
Admission Nursing Note Template
Admission Nursing Note Example
How does it work?
This specific includes various sections to make it easier to record important patient information. Here's how to get started:
Step One: Download the template
Access the free Admission Nursing Note form using the link on this page. Alternatively, you can download it from the Carepatron app or our resources library.
Step Two: Fill in the template
Fill out the template with the necessary information. This may include patient demographic data, medical history, and any procedures or treatments performed.
Step Three: Save or print your worksheet
Save the document electronically or print it out for use in physical files. This ensures you're always up to date on your patient's medical history and treatment plans.
Step Four: Secure the Admission Nursing Note
Once everything is completed, store the document securely to ensure patient confidentiality. This can include an electronic filing system or physical files in locked cabinets.
If you want to see what a nursing notes template looks like, we have created one that serves as a good example to guide nurses in their documentation.
When would you use this Template?
You can use our free Admission Nursing Note template in various settings like hospitals, long-term care facilities, hospices, and home health care. You can also use this to:
Record important patient information
The Admission Nurse Note form can help you document patient information such as name, age, sex, medical history, allergies, and medications. This will help you provide better care for your patients.
Track medical treatments and procedures
This form documents any treatments or procedures needed for a patient. This includes prescription and non-prescription medicines, vaccinations, and any diagnostic tests that have been done.
Build a patient database
The Admission Nursing Note form is important for building a patient database. It provides the information you need to develop long-term care plans, track patient progress over time, and provide better patient outcomes.
Give a thorough patient overview to other healthcare providers
You can also use our template to provide other healthcare providers with an overview of the patient’s health and medical history. This will help them make better decisions and provide more efficient treatment.
Benefits of free Admission Nursing Note template
Our Admission Nursing Note template is designed to help you document important information quickly and accurately. Here are some of its other advantages:
It's easy to use and fully digital
The Admission Nursing Note template has various sections that can be filled out and saved digitally. This makes it easier for you to store patient information securely and access it when needed.
It's customizable
The form is customizable to meet the specific needs of your healthcare facility. It lets you capture the most relevant information and track the patient’s progress.
It's comprehensive
Our template covers various medical information, from medications to discharge plans. This makes it easier for you to provide comprehensive care for your patients.
It's versatile
You can use our free Admission Nursing Note worksheet for various purposes, such as patient assessment, discharge planning, follow-up care, and more. It's a versatile tool that can help streamline your workflow and improve patient care.
Commonly asked questions
Nurses and other healthcare professionals use Admission Nursing Notes for various purposes, such as patient assessment, discharge planning, follow-up care, and more.
Admission Nursing Notes are typically used during initial patient encounters and follow-up visits. They provide a comprehensive overview of the patient's care plan and can help ensure accuracy and continuity of care.
An Admission Nursing Note allows healthcare professionals to quickly and easily create detailed patient records. This helps improve patient care and organize patient data.
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