Charting a New Nursing Admission Patient’s History SHOW slide #14 Review objectives Develop Conceptual Knowledge: The Nursing Admission History section of a patient's chart is completed in StarPanel. There are 4 types: Adult, Peds, OB and Psych The form is completed when the patient is stable and admitted to a hospital unit for the first time in this occurrence. It is critical to complete this form on all admitted patients ASAP If a willing and able historian is present, patient or family, be diligent in completing the form in its entirety. If the patient is already in the system, the nurse will verify the information is correct and then complete the rest of the information. CASE STUDY INFORMATION: You are admitting a 54 year old patient with complaints of a deep and productive cough for 1 week with progressively worsening phlegm. He has run a fever for 2 days with a t-max of 102.0 F. He has managed at home with Tylenol and Robitussin. He is otherwise a healthy middle aged man without complaints of pain to speak of. He does have a contracture of his hand that is a result of a childhood injury. He comes with a double lumen PICC which was placed prior to his transfer to the floor. His admission order was entered and he was immediately transferred to one of your many empty beds. He has antibiotics running in the proximal port. He has oxygen via a nasal cannula running at 2L. He has brought his medication list with him.
Charting a New Patient’s Nursing Admission History SHOW slide #14 Review objectives Develop Conceptual Knowledge: The Nursing Admission History section of a patient's chart is completed in StarPanel. There are 4 types: Adult, Peds, OB and Psych The form is completed when the patient is stable and admitted to a hospital unit for the first time in this occurrence. It is critical to complete this form on all admitted patients ASAP If a willing and able historian is present, patient or family, be diligent in completing the form in its entirety. If the patient is already in the system, the nurse will verify the information is correct and then complete the rest of the information. CASE STUDY INFORMATION: You are admitting a 54 year old patient with complaints of a deep and productive cough for 1 week with progressively worsening phlegm. He has run a fever for 2 days with a t-max of 102.0 F. He has managed at home with Tylenol and Robitussin. He is otherwise a healthy middle aged man without complaints of pain to speak of. He does have a contracture of his hand that is a result of a childhood injury. He comes with a double lumen PICC which was placed prior to his transfer to the floor. His admission order was entered and he was immediately transferred to one of your many empty beds. He has antibiotics running in the proximal port. He has oxygen via a nasal cannula running at 2L. He has brought his medication list with him.
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