Admission Data Intake - Bhis Admission Screen

CWS NURSING INITIAL ASSESSMENT

State Form 54575 (1-11)

FAMILY & SOCIAL SERVICES ADMINISTRATION

RICHMOND STATE HOSPITAL

GENERAL
Client Name: (need full name at time of admission)
Admission Date(month, day, year): Avatar Chart Number:
Date of Assessment(month, day, year): Timeof Assessment:  AM  PM
Assessment Type: Initial  Initial Reassessment Annual  Annual Reassessment
Assessing Clinician:
Assessing Clinician 2:
Supervising Clinician:
Notification Comments:
Draft / Pending Approval / Final:  Draft Pending Approval  Final
Primary Language: (Aliased in from PM side)
Preferred Language:
Arabic
 French
Japanese
 Sign Language / Chinese
German
Other
 Spanish / English
Italian
Russian
Unknown
Interpreter Used:  No Yes
Language Comments:
Supplemental Face Sheet: (May be launched)
Informant Type:
Another provider
Family / Significant other
Legal Representative / Client
Gatekeeper
Records from previous admission / Current Assessments / Evaluations
Justice system
Other (specify)
Informant Comments: (Identify specific re: source of information / informants - assessed - reliability, validity. Informant comments re: reason for admission or events leading up to admission, symptoms described / reported, etc.).
HEALTH STATUS / VITAL SIGNS
Height: (Feet) / Height: (Inches) / Weight: (Pounds)
Waist Circumference: (In) / Body Mass Index: (BMI) / BMI Calculator
Temperature: (Degrees)
Temperature Method: Axillary Ear  Oral  Rectal Temporal
Pulse: (Beats / Minute) / Pulse Method:
Pulse Description: Normal  Weak Irregular Bounding
Respiration(Breaths / Minute)
Respiration Description: Normal  Shallow  Wheezing / 02 Saturation: (%)
Blood Pressure #1: / Blood Pressure Position #1:  Lying  Sitting  Standing
Blood Pressure #2: / Blood Pressure Position #2:  Lying  Sitting  Standing
Blood Pressure #3: / Blood Pressure Position #3:  Lying  Sitting  Standing
Vital Signs Comments:(Indicate where on body blood pressure was taken each time).
Appearance
Hair Color:
Bald
Brown/Brunette
Shaved / Black
Gray
Other (specify) / Blonde
Red/Auburn
Hair Comments:
Eye Color:
Blue
Green / Brown
Hazel / Gray
Other (specify)
Eye Comments:
General Appearance:
Adequate oral care
Appears older than stated age
Appears stated age
Appears younger than stated age
Clean / Clothing inappropriate to season
Disheveled
Excessive / Inappropriate make-up
Malodorous / Neat
Poor grooming
Poor oral care
Other (specify)

HEALTH STATUS / VITAL SIGNS (continued)
General Appearance Comments:
Allergies
Allergies:  No Yes No Known Allergies Unknown
Allergy Comments: (Indicate any known reactions from client responses and from previous hospitalization records on admission).
Medications
What Medications Are You Taking? (Indicate client response).
Did You Receive Any Medications Today?  No Yes Unknown
Medication Comments: (Clarify information obtained from client responses). (Include information obtained from previous hospitalization records on admission).
Are You Taking Any Over-the-Counter Meds?  No Yes Unknown
Overthe Counter Medication Comments: (Include herbal supplements, vitamins, etc.).
Habits
Do You Smoke?  No Yes Unknown
Smoking Comments: (Include duration, frequency and last time used per client response).
Alcoholor Drug Use?  No Yes Unknown
Alcohol / Drug Use Comments: (Include duration, frequency and last time used. Include special substances per client response).

HEALTH STATUS / VITAL SIGNS (continued)
Caffeine Use?  No Yes Unknown
Caffeine Use Comments: (Include duration and frequency per client response).
Has Gambling Ever Interfered With the Qualityof Your Life?  No Yes Unknown
Gambling Comments: (Include duration and frequency per client response. Include financial / personal losses as a result of gambling habit).
Pain Assessment
Do You Have Any Painor Discomfort? (Complete manual / paper pain assessment)  No Yes Unknown
Pain Comments: (Include pain location, duration, frequency and how it may interfere with quality of life).
Sleep Pattern
Current Sleep Pattern:
Difficulty falling asleep
Narcolepsy
Sleep apnea
None / Enuresis
Nightmares
Sleep walk
Other (specify) / Insomnia
Requires sleeping aid (specify)
Walking during night
Sleep Aid Note: (List any medications, devices, etc. that are required as an aid in sleeping).
Sleep Comments: (How long since slept)? (Include client’s responses and information obtained from previous hospitalization records).
Nutrition
Nutrition Issues:
Appetite Loss (50%<intake 3 days)
Difficulty chewing / Swallowing / Choking
High Cholesterol / Triglycerides
History of bulimia
HIV
Kidney disease
Non-insulin dependant diabetes
Tube feedings
Use of MAO inhibitor
Other (specify) / Decubitus
Food Allergies
History of anorexia
History of polydipsia
Insulin dependent diabetes
Morbid obesity
Pregnancy
Use of anticoagulant
Wasting appearance(<20% IBW) 10# loss / Gain
Nutrition Comments: (Indicate duration of issues noted with current / past effective / non-effective treatments if known).
Current Diet:
Nutrition Special Needs / Supplements: (Indicate frequency of supplements and any specific food / drink items preferred).

SYSTEMS
Circulatory
Circulatory:
Anemia
Dizziness
Hypertension
Other (specify) / Chest pain
Edema
Hypotension / Congestive heart failure
History of angina
Syncope / Cyanosis
History of stroke
No known difficulty
Circulatory Comments:(Include history of) (Include current / past treatment and how issues may have affected client’s quality of life).
Respiratory
Respiratory:
Congestion
Cough
History of asthma
Labored
Nasal epitaxis
Shortness of breath
No known difficulty / COPD
Hemoptysis
Hoarseness
Nasal drainage
Nasal redness / Irritation
Sputum (specify color in comments)
Other (specify)
Respiratory Comments:(Include color of sputum) (Include current / past treatment and how issues may have affected client’s quality of life).
TB Screening
TB Screened:(prior to admission)  No Yes Unknown

TB Screening Date Given(month, day, year): / 
TB Screening Date Read(month, day, year):
TB Screening Method:  Chest Xray / History of positive Mantoux  Mantoux  Unknown
TB Test Results:(MM) / (If positive or unknown refer to Infection Control).
TB Screen Results:  Negative Positive  Unknown
TB Symptoms:
Blood streaked sputum
Hoarseness
Loss of appetite
Persistent fatigue
Persistent wheezing
Shortness of breath
Unexplained weight loss
Other (specify) / Chest pain
Known exposure to TB in last year
Night sweats
Persistent low grade fever
Productive cough
Unexplained cough more than 2 weeks
No known symptoms
TB Comments:(Include duration frequency and severity of any signs / symptoms. Include current / past treatment and how issues may have affected client’s quality of life).

SYSTEMS (continued)
Genitourinary
Genitourinary:
Dysuria
Incontinence
Polyuria / Enuresis
Nocturia
Retention / Frequency
Oliguria
No known difficulty / Hematuria
Ostomy
Other (specify)
Genitourinary Comments: (Include duration frequency and severity of any signs / symptoms. Include current / past treatment and how issues may have affected client’s quality of life).
Dateof Last Menses Known?  No Yes Not applicable

Dateof Last Menses: / Are You Sexually Active?  No Yes Unknown
Typeof Contraceptives Used:
Abstinence
Intrauterine Device
Other (specify) / Condom
Oral
Unknown / Diaphragm
Patch / Injection
None / N/A
Contraceptive Note:
Have You Been Diagnoses Witha Sexually Transmitted Disease? (Lifetime)  No Yes Unknown
Chlamydia
Venereal Warts / Gonorrhea
Other (specify) / Herpes / HIV / AIDS / Syphilis
Sexual Activity Comments: (Specify frequency. Do you know of partners with STD? Did you seek treatment)?
Musculoskeletal
Musculoskeletal:(complete Falls Assessment)
Adaptive equipment
Unsteady gait / Arthritis
No known difficulty / Contractures
Other (specify) / Fractures
Adaptive Equipment:
Braces
Walker / Crutches
Wheelchair / Prosthesis
Other (specify)

SYSTEMS (continued)
Adaptive Equipment Note:
Musculoskeletal Comments: (Include duration frequency and severity of any signs / symptoms. Include current / past treatment and how issues may have affected client’s quality of life).
Gastrointestinal
Dateof Last Bowel Movement: / (If yes listen to client’s bowel sounds and single select from bowel sounds list).
Abdominal Distention:  No Yes
Bowel Sounds: Absent  Faint Hyperactive Present
Gastrointestinal:
Constipation
Flatus
Hemorrhoids
Ostomy
Vomiting / Diarrhea
GERD
Hiatal hernia
Rectal bleeding
No known difficulty / Encopresis
Heartburn
 Nausea
Ulcer
Other (specify)
Gastrointestinal Comments: (Include location of active or absent bowel sounds (per quadrant). Include frequency, duration and severity of issues. Include how issues may have affected client’s quality of life).
Endocrine
Endocrine:
Hyperthyroidism Hypothyroidism No known difficulty Other (specify)
Endocrine Comments: (Include duration and current /past treatment if known).
Does Client Have Diabetes?  No Yes Unknown
Diabetes Treatment:
Byetta
Insulin Pump /  Diet
Oral Medication / Insulin
Other (specify)
Diabetes Comments: (Include duration, severity and factors known to affect blood sugar. What is client’s usual blood sugar range).

SYSTEMS (continued)
Neurological:
Confused
Headaches
History of trans ischemic attack
Lethargic
Seizures
Weakness
Other (specify) / Disoriented
History of cardiovascular accident
Impaired balance
Paralysis
Tremors
No known difficulties
Neurological Comments: (Include duration frequency and severity of any signs / symptoms. Include current / past treatment and how issues may have affected client’s quality of life).
Special Senses
Vision Issues: (Optometrist referral)
Artificial lens / lens implant
Color blind
Prosthesis / Blind
Contacts
No known difficulties / Blurred
Glasses
Other (specify)
Last Vision Exam Date(month, day, year): (If known)
Vision Comments: (Include duration and how issues may have affected client’s quality of life. Include current / past treatment).
Hearing Issues:
Deaf
Other (specify) / Hard of hearing / Hearing aid / No known difficulty
Last Hearing Exam Date(month, day, year): (If known)
Hearing Comments: (Include duration and how issues may have affected client’s quality of life. Include current / past treatment).
Speech Communication Issues:
Easy to understand
Mute
Slurred
Other (specify) / Incoherent
Pressured
Soft / Loud
Rapid
Speech impediment / Mumbles
Slow
No known difficulties
SpeechComments: (Include duration, severity and current / past treatments. Include how issues may have affected client’s quality of life).

SYSTEMS (continued)
Ability to Understand Verbal Instructions?
 No Yes Unknown
Verbal Communications Comments: (Include specific known issues and client’s lack of response during the assessment if pertinent).
Dental Issues:
Bleeding
Edema
Pain
Other (specify) / Braces
 Edentulous
Partial plate / Dental caries
Loose teeth
Retainer / Dentures
Missing teeth
No known difficulties
Last Dental Exam Date(month, day, year): (If known)
Dental Comments: (Include duration, frequency and severity of dental issues).
Integumentary
Integumentary:(Complete Wound Assessment for all choices, including No Known Difficulty)
Clammy
Dry
Warm / Cold
Flushed
No known difficulty / Cyanotic
Jaundice
Other (specify) / Diaphoretic
Pale
Integumentary Comments: (Include duration, frequency and severity of issues. Include current / past treatments if known).
Skin Condition:
Birthmarks
Lesions
Tattoos / Bruises
 Piercings
No known difficulty / Burns
Rash
Other (specify) / Decubitus
Scars
Skin Condition Comments: (Include location and description)
Podiatry Concerns:
Athlete’s foot
Corns
No known difficulty / Blisters
Ingrown toenails
Other (specify) / Bunions
Spurs / Calluses
Warts
Podiatry Comments: (Include location and description) (Include duration and severity. Include current / past treatments if known).

PSYCHOSOCIAL
Activitiesof Daily Living:
Independent
Unknown / Requires assistance / Requires prompts / Requires total care
ADL Assistance Required:
Ambulating
Dressing
Medication / Bathing
Feeding
Toiletry / Caring for clothes / Room
Grooming
Other (specify)
ADL Comments:
Do You Wish to Seethe Hospital Chaplain?  No Yes
Spiritual / Cultural Issues That Might Affect Treatment?  No Yes
Spiritual / Cultural Comments:
Highest Levelof Education Completed: (If patient states otherwise, note difference in information in the comments field).
1 year college completed
2 years college completed
3 years college completed
4 + years college completed
4 yrs college completed / Associate’s
Bachelor’s
Doctorate
GED
*(Grade 1-12) Indicate highest level /  Master’s
 Never attended school
 Pre-School / Kindergarten
 Special Ed / Emotional handicap
 Trade or Business college
 Unknown
Do You Have Any Problems With Reading? No  Yes Unable to Assess
Reading Comments:
Do You Have Any Problems With Writing? No  Yes Unable to Assess
Writing Comments:

PRESENTING PROBLEMS / BEHAVIORS
Chief Complaint: (State complaint / issues in client’s own words).
Presenting Problems: (Include any identified reason/stressors that precipitated hospitalization).(Complete Suicide Assessment).
Aggression actual
Deterioration of self care
Homicide attempt
 Neglect
Self injurious behavior
Suicide attempt / Gesture / Aggression potential
Homicidal ideation
Legal issues
Physical abuse
Sexual inappropriate behavior
Suicide threat / Decompensation
Homicidal threat
Medication adjustment
Polydipsia / Fluid
Suicide ideation (complete Suicide Assess)
Other (specify)
Presenting Problems Comments: (Include duration and severity. Include current / past treatment if known. Include how issues may have affected client’s quality of life).
Current Behaviors: (Last 30 days.)
Aggressive
Evasive
Hypervigilant
 Interactive
Self injurious
Talkative / Difficult to interrupt
Other (specify) / Cooperative
Hostile
Intrusive
Manipulative
Sexual inappropriate
Threatening / Destructive
Hyperactive
Impulsive
Pacing
Suspicious
Uncooperative
Current Behavior Comments: (Describe behaviors in detail. Include specific examples if known).
Current Mood:
Agitated
Euphoric
Pleasant / Angry
Fearful
Sad / Anxious
Happy
 Withdrawn / Content
Irritable
Other (specify)
Current Mood Comments:(Can include additional assessment information, i.e. SAD, Beck Depression inventory).

PRESENTING PROBLEMS / BEHAVIORS (continued)
Current Affect:
Appropriate Blunted Flat Inappropriate Labile
Current Affect Comments: (Elaborate on current affect).
What Upsets Client / Behavioral Triggers:
Authority conflicts
Boredom
Delay of request
 Invasion of privacy
Other people talking about me
Provoked / Teased / Being ignored
Certain time of year
Delusions
Loss of property
Pain / Discomfort
Task demand / Being touched
Darkness
Hearing voices
Noise
Personal space / Crowding
Other (specify)
Behavioral Triggers Comments: (Include client responses. Include special examples if known).
Behaviors When Triggered:
Bite
Destroy property
Hit people
 Kicks people
Self-Injurious behavior
Throws things / Cry
Fight
Hit things
Kicks things
Spits
Yells / Curse
Get away
Isolates self
Pacing
Throws tantrums
Other (specify)
Triggered Behavior Comments: (Include specific examples if known).
What Have You Tried That Helps You Calm Downor Cope?
Drugs / Alcohol
Meditation / Deep breathing
Smoke
Other (specify) / Journaling
Pray
Talk about it / Listen to music
Self-Injurious
Walk / Exercise
Coping Comments: (Include effectiveness of coping skills).

TRAUMA / RISK
How Can Staff Assist You?
Allow venting
Leave Client alone / Give them space
Medication
 Provide journaling
Talk to client
Other (specify) / Don’t touch client
Listening
Offer choices
Refocus
Walks with client
Staff Assistance Comments: (Include what has been helpful for the client).
Use of interventions / safety measures
Have You Ever Experienced Seclusionand / or Restraint?  No Yes Unknown
Tell Me About That Experience(use client’s own words)
Seclusion / Restraint Comments:
Is There Anyone You Want Us to Notifyif Seclusion / Restraint Becomes Necessary?
 No Yes Unknown
Whoto Notifyif Seclusionor Restraint? (Complete Release of Information form).
Attempted to Run Away / Leave Facility Without Permission?  No Yes Unknown
Thoughtsof Leaving Facility Now?  No Yes Unknown
Elopement Risk Comments: (Include past history of any elopements).

TRAUMA / RISK (continued)
Trauma
Have You Ever Experienced Physical, Emotional, or Sexual Abuseor Neglect?
 No Yes Unknown
Abuse Comments: (Include current and past episodes).
Physically, Emotionally, Sexually Abused Another Person?  No Yes Denies Unknown
Abuse Perpetrator Comments:
Ever Triedto Hurt Yourselfinthepast? (If yes, complete self harm comments).
 No Yes Denies Unknown
Thoughtsof Doing Harmto Yourself Now? (If yes, complete self harm comments).
 No Yes Denies Unknown
Self-Harm Comments: (Include client statements) (Complete Suicide Assessment)
ALERTS / PLAN OF CARE
Physician Alert: No  Yes
Physician Alert Type:
Audiologist
Dental
Dietary
 Internal medicine
Ophthalmologist / Optometrist
Speech therapy / Burn care
Dermatology
Educational
Neurology
Physical therapy
Wound care / Cardiology
Diabetic
Infection control
Occupational therapy
Podiatry
Other(specify)
Physician Alert Comments: (Specify other and elaborate on physician alerts).

ALERTS / PLAN OF CARE (continued)
Clinical Summary: (Integration of all Nursing clinical assessment factors that will identify strengths, goals, needs, limitations, barriers, and treatment recommendations to enable recovery and discharge).
Nursing Recommended Areas of Focus / Initial Planof Care: (Priority issues to be addressed by Nursing re: patient needs to be considered in initial treatment plan. Can include Nursing diagnosis if applicable).
Signature of Nursing (including credentials and position title) / Date (month, day, year) / Time