Compliance • Audits/Analysis • Reimbursement/Regulatory • Education/Efficiency
Admission and Re-admission Nursing Notes: Harmony Healthcare International (HHI) suggests that the following information be included in all admission notes:
- Time and date of admission.
- Mode of Transportation, assist level and number of assist with transfers and bed mobility.
- ADL care provided (Bed mobility, Eating, Transfer, Toilet).
- Location prior to admission.
- Age, primary diagnosis, other pertinent medical history.
- Prior level of functioning and if possible, discharge diagnoses.
- List daily skilled needs.
Example Admission Nursing Narrative
“Patient was admitted on 9/21/08 at 5:30 p.m. from Hospital, via ambulance requiring 2-person staff assist with transfer from the stretcher and for positioning on the bed. Primary diagnosis is s/p left TKR performed on 9/18/08. Medical history includes IDDM, HTN, and CAD. He lives with his wife and he ambulated with a cane, and he plans to return home. Patient self -administered his medication daily. Patient will require daily skilled nursing assessments for complications related to knee replacement and multiple medical complications. He currently requires assist of 2 for toileting using bedside commode. Surgical incision on left knee is clean, dry, staples in place. He eats independently with set up. Daily observation and assessment of vital signs, monitoring for pain and response to medication, daily assessment of wound, drainage and treatment, effects of immobility, pulmonary assessment, observation for signs and symptoms of infection, hypo or hyperglycemia, embolism and thrombophlebitis.
There are 4 categories of skilled nursing documentation:
- Inherent Complexity:
Direct skilled nursing services that due to their inherent complexity may only be performed by a licensed nurse.
- Skilled Observation and Assessment:
Indicated when there is a reasonable probability or possibility for complication or the potential for further acute episodes.
- Management and Evaluation of a Care Plan:
Based on the Physician’s orders, these services require the involvement of skilled nursing to meet the resident’s medical needs, promote recovery and ensure medical safety. This area may include the sum of unskilled services.
- Teaching and Training:
Activities which require skilled nursing or skilled rehabilitation personnel to teach a patient and/or family member how to manage the patient’s treatment regimen.