University:
West Coast University
Course:
NURS 103 | Fundamentals of Nursing
Academic year:

2021
Views:

453

Pages:

1
Author:

kaleidoscope71ex

ADMISSION NOTES The format of an admission note may vary in different institutions, but the note generally contains the following information: 1. Name of the patient 2. Age 3. Sex 4. Reason for admission (presenting complaint or diagnosis) 5. Informant (historian) 6. Referring physician or health professional (if referred) 7. History of present illness 8. Past medical history (including, as indicated, prenatal and newborn history) 9. Immunizations 10. Allergies 11. Current medications 12. Hospitalizations 13. Surgeries 14. Developmental history 15. Review of systems 16. Physical measurements (height, weight, head circumference) 17. Vital signs (usually temperature, pulse, respiratory rate, blood pressure) 18. Physical examination 19. Assessment 20. Plan The organization of the admission note may vary. Because pediatrics encompasses a broad age range, certain elements may be included or excluded, depending on the situation. For example, the elements of the history for a 3-year-old with seizures and developmental delay may not be the same as those for a 16-year-old with an ankle fracture.