ADMISSION DATABASE

SECTION I

Nursing Unit Admission Data

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)?
Foreign Language ATT interpreter line contacted 1-800-874-9426; ID # 212173
NO
YES If yes,
Amplifier requested for HOH
Sign Language Interpreter
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

Radial:
Apical:

BLOOD PRESSURE

R:

RESP

Admission Diagnosis/Reason for Admission:

L:

HEIGHT: _______________ ft/in

WEIGHT: _________ lbs _________ kg

Standing

Chair

Bed

Not weighed

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

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?

Do you wish to have additional information?

Yes

Yes

No

Placed on chart

Stated weight: __________ lbs/kg

Family to Bring Copy within 48 hours

No ______________________________________________________

Notify Pastoral Care

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?

SECTION II

Patient History

Yes

No

Yes

No

Name: __________________________ Phone: ________________

Has the content changed?

Yes

No

N/A

Are you an organ donor?

None Known

Yes List Below:

Drug/Other:

Reaction:

Drug/Other:

Reaction:

Drug/Other:

Reaction:

Drug/Other:

Reaction:

Drug/Other:

Reaction:

Drug/Other:

Reaction:

None

The patient or caregiver

is unable to provide
information to complete
this section.

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

Dose

Frequency

The patient is taking an

investigational or foreign
medication.
Last
Taken

Form 6379 R: 1/02

PLEASE CONTINUE ADMISSION DATABASE ON BACK OF FORM

Page 1 of 6

No

(May be completed by RN/LPN)

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

MEDICATIONS:

Yes

Patient takes
glucophage

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

Patient takes
glucovance

Dose

Frequency

Last
Taken

SECTION II

Patient History

(CONTINUEDTo be completed by RN/LPN)

PAST MEDICAL HISTORY:

RESPIRATORY:COPD/Emphysema

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

No Respiratory
History Applies
See PEAT Form
See ED Form

Home oxygen: ____________ liters

CARDIOVASCULAR:

Hypertension: ___________________

No Cardiovascular
History Applies

Hypotension: ____________________

See PEAT Form

See ED Form

Supplier: ________________________________________________________
DVT: ___________________

Bleeding Problems: ___________________

Heart Disease: ___________________

Angina

Pacemaker: __________________________

Hx. Heart Cath: __________________

Hx. Angioplasty: _____________________

Stroke

CHF

MI

Implanted Defibrillator (AICD)

Residual Effect: ______________________________________________________________________________

MISCELLANEOUS:

Bone/Joint: _____________________

Cancer: _______________________

Depression: ______________________

No Miscellaneous
History Applies

Diabetes : _____________________

Glaucoma: ____________________

Gastrointestinal: ___________________

Hepatitis: _______________________

Kidney: _______________________

Muscular: ________________________

Seizures: _______________________

Syncope: ______________________

Thyroid: __________________________

Urinary: ________________________

Infectious Disease: ______________

Other: ___________________________

See PEAT Form

See ED Form

Provide Diabetic Education for the newly diagnosed patient or as ordered

PAST SURGICAL:

Nicotine Use:

No

Yes

Amount: _________________ How long: ______________

Last Use: _________________

Alcohol Use:

No

Yes

Amount: _________________ How long: ______________

Last Use: _________________

Substance / Drug Use:

No

Yes

Amount: _________________ How long: ______________

Last Use: _________________

No Prior History

List any anesthetic complication:

No Complications

LOCAL PHYSICIANS: FAMILY PHYSICIANS / CONSULTS

Information obtained from:

YEAR
(If possible)

See PEAT Form

Patient

Family

PURPOSE

Transfer/Old records

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

Other: _________________________________________________

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

(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 ____________________
ASSESSMENT
STANDARDS

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.

Initial

Initial

Slurred speech _____________

Recent
Pupils unequal
Aphasic ___________________
Recent
Confused
Impaired Cognitive Level ______
Recent
Lethargic
Decreased Independence
Comatose
with ADLs _________________
Recent
*Please Note: Recent = within the past 7 days to trigger a therapy referral.
Comments: _____________________________________________
_______________________________________________________

FALL RISK ASSESSMENT: (The patient is at risk for falls if 4 or more of the following are checked or based on nursing judgement.)
On 3 or more medications
Syncope
Dizziness
Seizure
Insomnia

Loss of Balance
Loss of Coordination
Loss of Sensation
Disoriented
Uncooperative

Interventions for Prevention

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

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

Unable to evaluate due to condition

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
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: ______________________________________________________________
_______________________________________________________________________

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
NG tube: ___________
Nausea, vomiting or diarrhea 5 days
Bowel Sounds:
Chewing, swallowing difficulties
Absent
which are new onset (Possible
speech referral)
Hypoactive
Mouth sores which are new onset
Hyperactive
and affect eating
Bowel Pattern:
No teeth present
Constipation 5 days
Non-elective surgery 80 yrs of age
Diarrhea 5 days
Pregnant or lactating mother admitted
Incontinent
to non-ob area
Rectal bleeding
Nutrition Services Referral
Tarry stools
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: Consult Nutrition Services Score 12 or less: 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

Crutches

Wheelchair

Prosthesis: _____________________

PERIPHERAL VASCULAR ASSESSMENT:

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

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

Initial

Initial

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.
Home

ECF

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

Initial

Cultural/Spiritual needs : ______________________

Comments: _____________________________________
_______________________________________________

Initial

Current Home Health : ________________________

New needs : ________________________________
Notify Case Management
Comments: _____________________________________

: ______________________________________________________________

Who will assist you upon discharge: _____________________________________________________________________

SIGNATURE / TITLE

INITIALS

SIGNATURE / TITLE

POS (Perioperative Services)

INITIALS

SIGNATURE / TITLE

R.N. SIGNATURE

INITIALS

DATE

TIME

R.N. SIGNATURE

INITIALS

DATE

TIME

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

INITIALS
R.N.

Page 4 of 6

Homeless

Phone #: _____________________

K
E
Y

PEAT (Pre-Admission Testing)

Sections completed

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

(Name of Facility)

I
N
I
T
I
A
L

Recent
Recent
Recent
Recent

Loss of interest in self

Excessive fear
Hallucinations
Suicide attempt/Ideation
Homicide attempt/Ideation
Notify attending physician for possible consult/order.
Comments: _____________________________________
_______________________________________________

2. Are you currently feeling depressed/anxious but this is not related to your
hospitalization/diagnosis?
Yes
No

PRIOR LIVING ARRANGEMENTS:

Limited ROM/Immobility: _____________

Deformity/Amputation: _______________
Muscular weakness/Paralysis: _________
Unsteady Gait: ______________________

Initial

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

Department Needed
For Consult / Referral

Method of Notification

Requested By &
Reason for Consult / Referral
(Initials)

Entered &
Contacted By:
(Initials)

Nutrition Services

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

Page 5 of 6

INITIAL

SIGNATURE / TITLE

INITIAL

SIGNATURE / TITLE

INITIAL

INTERDISCIPLINARY PATIENT EDUCATION RECORD

MOTIVATIONAL LEVEL:
Cooperative / Interested

BARRIERS TO LEARNING:
Uncooperative / Uninterested

Unable

LEARNING PREFERENCES: Do you prefer to learn by:

Seeing

Doing

Hearing

Language
Anxiety
Vision
Language Spoken _______________________
None

ACTION
(Date & Initials)

PATIENT EDUCATION

Hearing
Pain
Unable Due to Condition
FOLLOW-UP
(Date & Initials)

OUTCOME

*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

SIGNATURE / TITLE

INITIAL

SIGNATURE / TITLE

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

INITIAL

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

SIGNATURE / TITLE

AT = Audio Tape
RD = Return Demonstration
E = Explanation

INITIAL

V = Video
W = Written
S = Sacrament