![]() Initial Plan of Care: Neurology consult, fall risk assessment, nutrition consult Example for suspected urinary tract infection and altered mental status: Geriatric Assessment: Confused, needs walker, underweight Medical History: Dementia, arthritis, hypertensionĬurrent Medications: Aricept, Metoprolol, Paracetamol Geriatric Admission Template:įocused on the elderly, considering chronic illnesses, geriatric syndromes, and medications. Initial Plan of Care: IV rehydration, oral rehydration as tolerated, monitoring of input and output 4. Physical Assessment: Decreased skin turgor, dry mucous membranes, alert Pediatric History: Full-term, up-to-date on vaccinations Reason for Admission: Dehydration secondary to gastroenteritis Initial Plan of Care: Pediatrician review, throat swab, hydration, fever management Example for dehydration secondary to gastroenteritis: Physical Assessment: Weight 20kg, Height 110cm, alert, lungs clear, throat red Pediatric History: Full-term, normal milestones Reason for Admission: Persistent fever and cough Tailored for pre-operative patients, including surgical history and specific pre-op assessments. Initial Plan of Care: Neurology consult, pain management, dark and quiet room 2. Physical Assessment: Photophobia, normal neurological exam Reason for Admission: Acute migraine with visual disturbancesĬurrent Medications: Sumatriptan, Ventolin Initial Plan of Care: Cardiology consult, chest X-ray, ECG, lab tests (CBC, lipid profile) Example for acute migraine with visual disturbances: Physical Assessment: Alert, oriented, chest auscultation clear, mild pedal edema ![]() Medical History: Hypertension, Type 2 DiabetesĬurrent Medications: Metformin, Lisinopril Reason for Admission: Chest pain and shortness of breath This not only improves documentation quality but also enhances overall efficiency in patient care management.Įxample for chest pain and shortness of breath: ![]() By reducing the repetitive typing of standard information, nurses can focus more on personalized patient care aspects, ensuring that each admission note is both comprehensive and tailored to the individual patient. Moreover, it ensures accuracy and consistency across patient records. This enables nurses to insert these sections into their notes with just a few keystrokes, saving valuable time. For instance, common phrases, assessment criteria, and care plans that are frequently used in nursing documentation can be pre-set in TextExpander. TextExpander is designed to assist nurses in quickly inserting standardized sections into their notes. In addition to templates, tools like TextExpander can further optimize the documentation process. These templates ensure that nurses cover all necessary information, reducing the likelihood of omissions. Utilizing templates for admission notes can greatly improve efficiency and consistency in documentation.
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