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B0C08ADB

Name: Admission
Last Review Date: 05/11/2017
Next Review Date: 05/11/2020
Expiry Date: 05/19/2067
Description: Admission, C01.001
Policy Number: C01.001
Origination Date: 09/29/1980
Purpose: To define responsibilities of the RN in the patient admission
process.
Policy:
A. Within 15 minutes of patient arrival to the inpatient area:

1. The assigned nurse will inform the Health Unit Coordinator

(HUC) of the patient's arrival.

2. Evaluate the patient for immediate physical and safety

needs. Obtain vital signs including measured (when possible)
height and weight (in kilograms).

B. Within one hour of admission to the patient care unit:

1. The RN will contact the physician and acknowledge orders.

2. If the patient is a transfer from another facility, the RN will

review the transfer papers. The HUC will file these in the medical
record after the RN and/or physician has reviewed them.

C. Within 8 hours of admission to the patient care area, the RN

will complete the Admission Navigator.

1. Nursing students under the direction of their clinical

instructor and Nurse Externs may complete the Admission
Navigator. This is to be validated by a RN.

2. In the event where the patient is unable to respond or is

uncooperative, and a secondary source is unavailable, the nurse
will indicate this information in a note. When the patient is
responsive/cooperative or the secondary source is available, the
RN will complete the Admission Navigator.

D. Before placement of the ID band, the RN will verify patient

 identification by asking the patient to spell their name and state
their birth date. If the patient is unable to do so, the RN will ask
the patient’s significant other to verify this information or verify
patient identification from a police report, ambulance record or
transfer papers.

E. The RN will verify allergies/reactions and place the appropriate

color armband clip on the patient.

F. Appropriate referrals are initiated by a communication order

to Social Services, Spiritual Services, Nutrition Services and Case
Management based on assessment information, Best Practice
Advisories and patient need.

G. Within 24 hours of admission:

1. Appropriate plans of care will be initiated. (See Care Plan
and Patient Education in the Inpatient Environment - Policy
CPM.0176)

2. The patient and significant other, when appropriate and

available, will be included in the plan of care.

H. The RN will give the patient an information folder which

includes reviewing all of the enclosures in the folder with the
patient and his/her family. The patient is educated and
encouraged to report any concerns related to care, treatment,
services and patient safety issues before being discharged.
Procedure: A. Signed/Held Orders

1. In the Unit or Lab Draw section, the RN will document the

patient's blood collection status as Unit Collect or Lab Collect to
determine the location lab labels will print.

2. In the Sign/Held Orders section, the RN can view orders that

are signed and held for that patient.

3. In the Release Orders section, the RN can release signed and

held orders when the patient is located in their unit system list.
This will make the orders active.

B. Overview

1. Patient Belongings - Document the belongings at the

bedside, the valuables received upon arrival and inform the
patient that the hospital is not responsible for lost or stolen
articles at the bedside. (See Policy CPM.0012 - Valuables and
Belonging)

2. Active LDA - Review/document/edit the properties for any

LDA's that are present/not present when the patient arrives to
the unit.

3. Allergies - Verify the allergies with the patient and enter

appropriate updates. When completed, select "Mark as
Reviewed." If the patient reports not having any allergies, "No
Known Allergies" is charted in the section and select the "Mark
as Reviewed" button.

4. PTA Medications - Pharmacist will verify these with the

patient and enter appropriate updates.

5. Immunization Report - Review the previously documented

immunization history, when available.

a. Verify the immunization history with the patient and enter

appropriate updates in the Imm/Injections activity (by selecting
the hyperlink in the Immunization Summary Report).

b. If the day of the immunization is unknown, default to the

first day of the month that most closely approximates the
immunization date.

c. Document in the comments section "estimated date per

patient report."

d. Select "Mark as Reviewed" when this information is

verified with the patient.

6. Vaccine Screen - Access the Wisconsin Immunization

Registry and/or the Immunization report within the electronic
health record to help complete the vaccine screen. Complete the
pneumococcal and influenza screening per Policy CPM.0102 -
Pneumococcal and Influenza Vaccination Standing Order
Protocol.

7. History - Verify the medical, surgical, substance and

sexuality history with the patient, as appropriate. Select "Mark as
Reviewed" when applicable information is verified.

8. OB/GYN Status - Document the information as applicable for

the patient.

9. Scanned Advance Directives - View only screen of the

patient's advance directives that have been scanned into the
chart.

C. Patient Profile

1. General Information/Advance Directives - Document where

the patient arrived from, significant relationships, primary roles /
responsibilities, who the patient provides primary care for,
tobacco cessation, if the patient has advance directives and that
we gave the patient information about advance directives.

2. Audit C Alcohol Screen - Complete the alcohol screening per

Policy C01.353 - Alcohol Screening for Patients.

3. Discharge Planning - Document the reason for admission,

expected length of hospitalization, anticipated discharge
disposition, whom they live with, living arrangements, home
accessibility and transportation availability.

4. Nutrition Screen - Document the diet prior to

admission/restrictions/preferences, current appetite and
complete the nutrition screen.

5. Functional Status Section - Document the prior and current

functional level of the patient.

6. Pain History - Document the Pain History of the patient.

7. Abuse Screen - Document if the patient is or has been

threatened or abused physically, emotionally or sexually by a
partner / spouse / family member.

8. Suicide/Homicide Risk - Document if the patient is having

suicidal ideations.

9. Values/Beliefs/Spiritual Care - Document any cultural,

religious, spiritual practices that are important for staff to know
and if the patient requests a chaplain visit.

10. Patient Profile Doc Flow Sheet - Any other information

applicable to the care of the patient will be updated and
documented throughout the patient hospital stay.

D. Assessment

1. Fall Risk - Document the falls risk assessment. (See Policy

CPM.0132 - Inpatient Fall Prevention and Management Program)
 2. Elopement Risk - Document the elopement risk assessment.
(See Policy CPM.0071 - Unauthorized Absence of a Patient)

3. Braden Scale - Document the Braden scale assessment. (See

Policy C01.011 - Physical Assessment and Nursing Process
Documentation)

4. Pain Assessment - Document an initial pain assessment. (See

Policy CPM.0067 - Pain Management)

5. Patient Care Summary - See Policy C01.011 - Physical

Assessment and Nursing Process Documentation.

6. Progress Note - Document an admission note; utilize the

Smart Text RN IP Admission Note.

7. Respiratory Safety Assessment - Document the STOPBang

assessment. (See Policy CPM.0203 - Respiratory Safety Program
for the Management of Confirmed and Potential Obstructive
Sleep Apnea in the Inpatient Environment.)

E. Interventions

1. Best Practice Advisories - Reviewed, accepted and ordered

as appropriate. (See Policy CPM.0172 - Orders - Patient Care)

2. Care Planning - (See Policy CPM.0176 - Care Plan and Patient

Education in the Inpatient Environment)

3. Patient Education - (See Policy CPM.0176 - Care Plan and

Patient Education in the Inpatient Environment)

F. Pediatric Admissions

1. The Pediatric Admission Navigator in Epic will be triggered

for all patients less than 18 years of age.
Related Policies: Alcohol Screening and Intervention for the Inpatient
Care Plan and Patient Education in the Inpatient Environment
Fall Prevention and Management Program in the Inpatient
Environment, Day Surgery and Emergency Department
Orders - Patient Care
Pain Management
Patient Assessment and Nursing Process Documentation
Pneumococcal and Influenza Vaccination Standing Order
Protocol
Respiratory Safety Program for the Management of Confirmed
 and Potential Obstructive Sleep Apnea in the Inpatient
Environment
Unauthorized Absence, Patients at Risk for Elopement
Patient Valuables and Belongings
Reference Details: Smith, S.F., Duell, D.J. & Martin, B.C. (2012). Clinical Nursing Skills
(8th ed.). New Jersey: Pearson Education
Issuing Authority: FMLH Professional Practice Council
Distribution: Froedtert Memorial Lutheran Hospital
Reference Type: Evidence Based Practice
Content Details URL: http://fhpolicy.s1.fchhome.com/d.aspx?d=W37n83V81dB9