Admission Documentation- NTX

In partnership with our North Texas facilities, please review the admission documentation requirements below.  Please note that these may vary depending on the facility, so always seek confirmation from the Charge Nurse to ensure accuracy as per facility policies.

• • Assessment & admission
  • Medication reconciliation
  • Preferred Pharmacy- update every admission
  • Tele start- review order and put patient on Tele monitor
  • Vaccine- COVID, Flu & Pneumonia
  • 1^st Point of Contact- within 24 hours of admission
  • Fall Risk Assessment- Morse Scale Moderate & High- implement Fall Bundle
  • MRSA high risk screening- collect MRSA if applicable
  • Patient Weight required for all admissions
  • Lines/Drains/Airways- every shift- lines- dated & clean dry & intact; Foleys- know reason, date
  • CHG- must be documented every shift under Hygiene Care
  • Pain reassessment- PO- 1hour, IV-30minutes
  • Restraints- documented Q15 min 3x per hour, Q2hr-release, perform neurovascular & skin checks
  • Stroke Education- NIH-every shift, Neuro Q4hr, Dysphagia screening- prior to feeding, if patient failed- keep NPO and consult ST
  • Teach/Educate- patient specific- every shift and at discharge
    
    

Thank you for your continued commitment to our patients!