Nursing Admission Note: 5 Best Practices for Facilities

Upon a patient’s admission to a facility, nurses must act swiftly to conduct initial assessments and document key information that will be referenced by the healthcare team to tailor the patient’s treatment plan. As this is the first step in the overall care process, the nursing admission note can play an important role in shaping patient-centered care and health outcomes.

It’s crucial that facility leaders understand how to support their nurses in writing the best notes possible. To help you equip your staff with proper tools and knowledge, we’ll describe five essential practices to follow when providing training on admission documentation for nursing professionals.

What Is a Nursing Admission Note?

A nursing admission note is a written record containing essential information about a patient upon their admission to a unit. This information facilitates communication among the entire healthcare team, helping other nurses and providers deliver care that is tailored to the physical, spiritual, and cultural needs of each patient.

In addition to recording administrative information such as the initial time and date of transfer, nurses may document on anything that can help inform a patient’s plan of care, such as:

• Patient demographics.
• Chief complaints.
• Physical assessment.
• Relevant medical history.
• Learning/language requirements.
• Plan of care recommendations.

Since there is no standard way to write an admission note, documentation can vary depending on the type of facility that a nurse works in. We’ll walk through tips on how to tailor admission notes to your facility later on. But for now, let’s take a look at examples of what a narrative admission note can look like, both good and bad.

Nursing Admission Notes: Example Comparison

Bad Example

“A 67-year-old p/t was admitted with chest pain and shortness of breath, seems alert and oriented. Daughter is currently with the patient.”

In the above example, the admission note very minimally states the patient’s reason for being admitted. It’s difficult to figure out how to tailor a care plan using this information, which is probably also duplicative of what other members of the healthcare team are charting.

Now, let’s see how adding a bit more specific detail can really enhance this admission note and make it useful for people reading it.

Good Example

“67-year-old Asian female patient admitted to ED via ambulance from home with complaints of severe chest pain and shortness of breath. P/t reports a history of hypertension and allergy to shellfish. P/t’s daughter was present upon admission and translating for p/t whose primary language is Korean. Daughter requests interpreter. P/t is A&O x3 with diminished breath sounds in both lung fields. Pulmonary assessment and Q1 vital signs needed.”

Unlike the first example, this note provides all relevant nursing assessment findings, with very specific notes highlighting the patient’s cultural and physical needs. This provides a much better foundation to inform the care process for the patient.

Best Practices for Facilities

Now that we’ve walked through what a nursing admission note is and how it’s used, we can dive into best practices on training your nurses. Follow these strategies to support efficient and effective admission documentation among your staff (and be sure to check out our article about writing a nursing discharge note).

1. Define Essential Elements

Documentation burden is common in nursing, so it’s important for facilities to identify and define what’s essential to include in a nurse’s admission note. According to nursing informaticists, admission notes by nurses should be grounded in three key elements:

2. Create an Accessible and Standard Format

Admission notes can be written in narrative format (as in the examples above) or within specific charting fields built into your facility’s health record system. Either way, it’s important to have a standard, accessible mode of documentation for admissions since they can happen quickly and frequently. Make sure your nurses know exactly where and how to document admissions in the patient’s medical chart so that notes aren’t floating around in hard-to-reference places.

3. Ensure Notes Are Succinct and Relevant

It’s also helpful to provide guidelines on what information is most relevant to your patient population. This can also help make admission notes more succinct and useful.

For instance, when writing an admission note, nursing homes may benefit from more emphasis on a resident’s baseline independence in daily activities, such as walking or eating. Conversely, acute care staff may require more comprehensive notes on a patient’s presenting condition and physical assessment to inform an intensive care plan.

4. Enforce Timely Documentation

The purpose of an admission note is to capture the patient’s condition at the time of admission, so it’s important to enforce timely documentation. Studies have also shown that notes taken closer to admission lead to better patient outcomes. Ensure that your nurses are aware of the importance of documenting at the time of admission, or as close to the admission as possible.

5. Provide Proper Training and Resources

It’s crucial to provide thorough training and resources for your nurses who will be carrying out the practices outlined by your facility. Provide documentation training during orientation, in addition to easily accessible written guidelines about your facility’s admission note requirements. Additionally, if you update or redesign your EHR system, ensure that your nurses remain aware of where and how to create their admission notes.

Learn More Ways to Enhance Documentation and Overall Care

Writing a quality nursing admission note is just the first step to improving the patient experience. Don’t miss out on even more tips and strategies that can help you support your workforce in delivering the best care possible.