Model Admission

(Date & Time) Patient was admitted to WARD from

Accident and Emergency Departmenuout
Patient Clinic, with Ward Review or Admission Order with a
history of
duration...3 days and location...abdomen}on a trolley/wheelchair/in an {complaint...pain:
ambulatory state
accompanied by an attendant/wife/sister/significant other with {0² therapy in progress 6 Lminy
Insitu therapy 5.2 DW in progress/|V access insitu to Rt.arm.} Past Medical History
(PMH):
Diabetes x l year, Hypertension x 2years, Asthmatic x 3years. Past Surgical History (PMH):
Hysterectomy x 4years, Amputation of 1 and 2nd left toes x 1year. Allergies: Shell food/
Penicillin/ Milk etc. Patient is presently on Metformin 500mg po bd x 3 days and Lasix 40mg po od
x 2 years etc. He/She is alert and oriented to time, place, person/patient is confused/unresponsive.
Information received from relatives/significant other. Vital signs on admission: T-36°C, P-72bpm.
R-20bpm, B/P-120/80 mmHg, RBS-1 82 mg/dl, Wt.-150 kg, Ht.-6 2", Urinalysis with results. Patient
was seen by MO. Plan as follows: 1- Admit to medical ward 10D. 2- Administer 50mg
Pethidine IM STAT with 50mg Gravol IM. 3- Blood Investigations. 4- CXR mane.Patient was
informed of Ward's Policy and oriented to Ward's environment, placed in bed and left lying in supine
position.Signature, BN22/RN.
1. Tag Patient: (Name, Date, Ward, Sex, Age)
2. Place Nurses' Notes and Doctors' notes in folders
3. Place X-rays in appropriate Rounds Trolley
4. Draw up Clinical Chart Lines and write patient's name and registration number on
each page in progress notes.
Taking Over Documentation
Patient was taken over awake in bed, lying in a semi fowler position, with bed rails elevated and wheels

locked,CNS: patient alert, conscious and oriented to time, person. placel pt. confused/pt.unresposive.
CVS: Radial pulse palpable with good volume and rhythm/ weak or absent pedal pulses. IV access insitu to
Lef hand with IV fluid on progress, 500 mls of N/S in bag. RESP: Breathing room air spontaneously/Pt.
on Oxygen therapy 6L/min via non-rebreathable mask. GIT: Tolerating orally. GUT: Voiding at
to touch/ skin
urge/Foley Catheter in place, 500 mls. amber urine drained in bag. INT: Skin afebrile
breakdown observed at...He/She denies pain and verbalized that he/she was ready to go home/ Patient
observed crying and verbalized that he/she is sick of being in the hospital.Sign. BN22/RN
on duty and a keener head
quick assessment of the unit is carried out from the moment the nurse arrives
A
to toe assessment is done when interacting to the patient. 1
 Take over nurse should be keenly observant at the point of taking oer for any further cues (grimdee.
delayed or slurredspeech, body language etc.) that demands further ivestigation.
OP DOCUMENTATION
ratlent ame to Main operating theatre department on a trolley accompanied by two attendants and a student
nurse. He/She was given over to theatre reception nurse in astable condition and alert to person. time and
place.
POST-OP

Patient returned from Main Operating Theatre (MOT), afier having umbilical hernia repair done by Dr.
Persad and Dr. James under general anesthetic. Patient was awakeand crying with complaints of pain at
surgical site/asleep/drowsy. IV access insitu at righ°Rt.Wrist. He/She was placed in bed and was visited by
both parents. The pain was reported to RN and both patient and parents were assured that after 2-4 hours
he/she would be given paracetamol for pain relief. Parents were allowed to stay with patient. The plan for
post op as follows: 1- Observe q. 15 mins. until fairly awake. (nurse would in form patient upon waking
up that they just came out of surgery...) 2- Analgesic paracetamol 125 mg po tds. 3-Allow free fluids.
4-OPD x L/52. Vital signs: T-36°C,P-80 bpm, R- 20 bpm, BP- 127/8ImmHg. Appointment was given to
parents/ spouse etc. Sign.BN22/RN
Another Post OP Documentation:
Patient was brought from Urology Theatre/MOT by attendant accompanied by an RN and Student Nurse at

2 pm after having Hip ReplacementbyDr. Blake. He/she was assisted onto Post-Op bed in a drowsy but
easily aroused state with Ringer's Lactate in progress 800mls to be infused; Wound drainage bag with
300mls blood stained fluid in bag: Urinary catheter insitu on free drainage 600mls. amber coloured urine in
bag. Dressing at surgical site dry and intact, no swelling observed. Post-Op Plan; Vital Signs; Complaints:
Patient left lying in semi-fowler's position, side rails up and locked in upright position, wheels
locked.Sign.BN22/RN

Sample Bed Bath Documentation

on righ°left
Patients taken over awake in bed, semi fowler's position. V access is secured and insitu
wrist/antccubital area. IV 99% Nomal Saline in progress with 200mls remaining in bag. Urinary catheter
tube insitu on the left
insitu on free drainage, 400mls blood stained/amber coloured urine in bag. Drainage
mat by
abdominal region on free drainage with blood stained fluid in bag. Personal and oral hygienic needs
two student nurses. Noabnormalities were observed in the oral cavity. Skin integrity
is intacvdecubitis
2
 ulcer size 2 cm
observed at sacral area
Passive/active (treatment administered). Pressure care done on other areas.
exercise was done. He/she
of slight pain, remained Icooperativethroughout the procedure, but complained
especially when turning/due to the surgery/...Clothing and linens were changed and the
environment was tidied. Patient was
left Iying in semi-fowler's position,. side rails were elevated, wheels
locked. Patient verbalized that he/she felt
comfortable.Sign., BN22/RN
Ambulance and Emergency Documentation
Patient was brought to A&E Department via EHS
Ambulance accompanied by wife/husband. He/sSne
presented with confusional states, cold sweating (whatever he/she came in with). The wife indicated her
husband's inability to pass urine for the past 3days. Medical
treatment was commenced by Dr. James and
included: 1- IV therapy 5% DSW. 2- Blood taken for investigation.
draining. 4- RBS: 183 mg/dI. 4- For X-ray, then admission to Wd.12.
3-Catheterized, 600 mis clear urine
Condition stable at time of
reporting.Sign.BN22/RN
Medication Documentation:
Patient prescribed P.O medication was administered and he/she/parent was
informed about the therapeutic
and side effects. Patient was advised to alert the nurse on duty
about any adverse effect of the drug, but was
assured that he/she will be checked on intermittently or in 30 minutes.

Re-admittance of Patients:
Date: Time Patient admitted to ward via admission order in an
ambulatory condition, accompanied by
relative. 1: Vital Signs, W., Ht, BP, RBS, Urinalysis, Medications, Blood donor slips. 2:
X-rays, ECG.
Reports placed on rounds trolley. Patient was placed in bed, tagged and left lying in the
semi-fowler's
position. He/she verbalized comfort, Signature, BN22/RN
Ward Report Documentation (End of Shift Renort)
Name: John Doe
Age: 36
Sex:M
Diagnosis: Anxiety, Depression, CRF, CCF, CHF
Vital Signs: T-36.8, P-69, R-20, BP- 127/83
CNS: Patient is conscious and alert. CVS: Peripheral pulse palpable and of good
volume. IV access insitu
to left wrist.

3
 RESP:Quiet, regular and unaided. GUT: Voiding at will/Abdomen distended with dialysate tluid. G11:
Tolerating orally. SKININTEG: Afebrile to touch/ Cool and clammy. Personal and oral hygiene needs
were met on bed: ate 100% breakfast. Prescribed medications administered. Patient was seen by Dr.
Hackett-Solomon and was scheduled for ultra sound today: continue other care. At time of reporing
patient in bed: general condition: serious, but stable. RBS@ 1l am: 144 mg/dISign.,BN22/R
MAKING THE UNOCCUPIED BED

PURPOSES:
To prepare to receive patient
To maintain aesthetics of environment
To promote patient's comfort and relaxation
REQUIREMENTS:
Trolley with:
TOP SHELE:
2 large sheets Idrawer sheet/Incontinent pad
Draw Mackintosh Pillow and pillow slip
Stool and chair Receiver with moist wipes
Disposable gloves (if linens are soiled)

BOTTOM SHELE:
Receptacle for soiled linen
Receiver for soiled wipes
Procedure Rationale
Maintain Principles of Bedmaking throughout.
1. Wash hands. To reduce microbes.
2. Collect requirements and place in order of Allows for easier bed making without
use. unnecessary delays organize task to deter the
spread of microrganisms.
3. Move locker and bed table away from bed. To provide easier access to bed and facilitates
free movement.
4. Place stool at head of bed, chairs at foot of Organization facilitates performance of task.
bed
S. Remove pillows, place on stool. To perform task.
6. Unfold top sheet, loosen all linen from Loosening linen helps prevent tugging and
head to foot to bed. tearing of linen.
7. Fold cach picce of usable linen separately Folding saves time and energy when usable
inthirds beginning from foot of bed and linen is replaced.
place in sequence over chair.
Procedure Rationale
8. Straighten mattress and place at the head of Allows more foot room for patient.
bed