NNNSG0108 03/19/10
Date: Time: / Disposition of Valuables / Personal Belongings
Reason for Admission: / Patient / Family(Name) / Home / Security
Language: English  Other: / Dentures  upper  lower
Communication Barriers:  Y  N ______
Religious/cultural practices that will impact care/education?
 N  Y ______Occupational concerns that could impact care:______/ Glasses / Contacts (Circle)
Hearing Aids  LT  RT
Other:
Advance Directives:  None  Copy on Chart / RESTRAINT NOTIFICATION STATUS: (Family / Caregiver)
 Yes  No
 Copy requested or Summary Complete
Does patient want to execute advance directives?  Y N
Physician other than Admitting MD / PSYCHIATRIC ADMISSION STATUS:
 Voluntary  Involuntary
SURGERIES / HISTORY REVIEW OF SYSTEMS
NEURO/MUSCULOSKELETAL/EENT  Denies Problem / CARDIOVASCULAR
 Chest Pain
 Palpitations
 MI Date ______
 MVP
 HTN
 Bleeding Disorder
 Sickle Cell
 Pacemaker
 AICD /  Denies problem
 Blood Transfusions
 Edema
 Thrombus
 Anemia
 Hepatitis
 Stents
 Surgeries:
______
______
______
______/ ELIMINATION
RENAL
 Denies Problem
 Dysuria
 UTI
 Kidney Stones
 Incontinence *
 Catheter
 Ileo Conduit
 Prostrate Problems / GI
 Denies problem
 Constipation
 Diarrhea
 Incontinence *
 Ulcer Disease
 Hiatal Hernia
 Hemorrhoids
 Laxatives
 Dizziness
 Seizures
 Blackouts
 Numbness
 Paralysis* *
 Stroke*/* * /  Disc/Bone/Joint Problems
 Prosthesis* * ______
 Amputation**:______
 Walks with / Assisted by: * *
 Cane  Crutch  Brace
 Falls (Past 3 months) * *
 Cognitive Impaired*
 Headache  Vision Impairment  Hearing Impariment
Surgeries: ______
______
*Speech Referral * *PT Referral / Surgeries:______
______
* Fall Risk Strategy Tool
NUTRITION  Denies Problems / ENDOCRINE  Denies Problems
Last Menstrual Period ______
Pregnant  Y  N
BCP  Y  N
Tubal ligation  Y  N
Hysterectomy  Y  N
Thyroid  Y  N
Diabetes  Y  N
Other ______
______
______/ RESPIRATORY  Denies Problems
 Emphysema  TB or Exposure
 Asthma  Dyspnea
Last attack _____  SOB
Tobacco use within  Recent cough
the last 12 months*
Type ______
Frequency ______
______
______
Date Stopped ______
Surgeries ______
* Smoking Cessation referral
 Eating Disorder*
 Recent Unintentional Weight Change*
Amt. ______
 Chewing/Swallowing Problems*
 ETOH Amt/ Type ______
 Special Diet: (Tube Feeds/TPN)* _____
Malnutrition*
Lactating Mother* / Pregnant
* Nutrition Referral Place consult
in HBO: HBO order #______
EDUCATION LEARNING ASSESSMENT / PLAN (Refer to Patient / Family Documentation for Teaching)
Did the patient receive pre-hospital teaching?  Yes  No Subject: ______ Understanding
Does the patient have difficulty with reading?  Yes  No If Yes, Describe ______
Is the patient / family ready to learn? Yes  No If No, Describe ______
Can the patient follow and understand directions?Yes  No If No, Describe ______
The following needs are anticipated:  None Identified  Diet  Activity  Medication  Skin Care  Wound Care  Disease Process  Pre-operative
 Home Care  Advance Directives  Community Resources ______
Patient preference to learn:  Reading  Demonstration  Listening  Other ______
Admitting Nurse: Signature/ Initial: ______RN Signature/Initial ______LPN

Nursing Admission Summary Psychiatric Services

Page 1 of 6 / *«PatientNumber»*
Acct# «PatientNumber» MR# «MedicalRecordNumber» «Location»«Room»«Bed»
«PatientName» «AdmitDate»
«AdmittingDoctorName»«BirthDate»«Age»«Gender»
PHYSICAL ASSESSMENT * Fall Risk Strategy Tool / TO BE COMPLETED BY ADMITTING NURSE / POSTOP NURSE
REFERRALS
 No referral  Lactation #1978
 ET – 940-5400 or 2582  Speech Referral #1655
 Nutrition - #1752  Oriented to Room / Nurse Call System
 Quit for Life Smoking Cessation  Extreme Fall Risk: (Dir./CC Notified)
 Physical Therapy - #1655
(if admitted for mastectomy / lumpectomy or breast radiation – PT referral)
ADULT IMMUNIZATION STATUS
Pneumonia Vaccine: ______Influenza Vaccine:______
(date) (date)
DISCHARGE PLANNING NEEDS / PSYCHOSOCIAL ASSESSMENT
* Discharge planning social service referral
PATIENT LIVES:
 at home with assistance
 at home with no assistance
 at home with Home Health visiting: Name of Agency *
 on Group Home or Assisted Living; Name of facility *
 in skilled nursing home; Name of facility *
 other ______
PATIENT’S FUNCTIONAL/DEVELOPMENTAL STATUS:
 Independent with Activity of Daily Living (ADL)
 Requires help with ADL’s and family / friend willing to assist
 Requires help with ADL’s and no help at home *
 Patient is a primary caregiver for disabled person *
 Patient has developmental disability (specify)______
______
SOCIAL EMOTIONAL CONCERNS:  None
 Patient / Family needs further Education
 Patient is suspected of having a drug / alcohol problem
 Patient is experiencing traumatic medical condition and/or emotional stress *
 Suspicion of child/spouse/elder abuse or neglect (physical/mental) *
 Other ______
 Patient unable to plan his/her discharge*
Person assisting with discharge planning and/or patient care in the home is:
Name ______Relationship ______
HOME ENVIRONMENT CONCERNS:  None
 Obstacles present in the home* (i.e., stairs, throw rugs, other) ______
Lack of  heating,*  sir conditioning, * indoor plumbing, *  shower or tub,*
 electricity, * refrigeration,*  telephone,  other ______
______
Referral to Case Management  Yes  No Nurse ______
Case Management Notes: ______Date ______Time
______
______
______
______
______
______
Completed by: Signature / Initial
NEURO / Level of Consciousness *
Mobility *
See completed Falls Risk Strategy Tool
Cognitive Impairment
CARDIOVASCULAR / Rate – Apical/Radial
Telemetry/Rhythm-Reg/Irreg
Color (Mucous Membrane) Normal
Temperature (Skin) Normal
Pedal Pulses  Present
Edema  None
Pacemaker 
RESPIRATION / Breath Sounds Normal
Cough  None
Sputum Character
SKIN / Bony Prominences  Intact
Pressure Ulcer / Wounds  None  Yes Consult ET
Describe:
Incontinent:  Yes  No
Malnourished *Braden Score:______
If Wound/Pressure Ulcer Present,
Rash – Location  None
Bruises – Location  None
ELIMINATION / Bowel Sounds Normal
Abdominal Character Normal
Date Last BM Bowel Prep
BM Character
Urine Character Normal
Urine Color Normal
Foley  Condom  Suprapubic 
IV ACCESS /  IVCVC
Type: ______Location: ______
Appearance: ______Inserted at: ______(facility)
COMFORT / Difficulty Sleeping  None
Sleep Aids  None
Normal Hours of Sleep
Chronic Pain / Discomfort Location ______Pain Level ______
Relief Measures
Acute Pain / Discomfort Location ______Pain Level ______
Relief Measures
NNNSG0108 03/19/10

Nursing Admission Summary Psychiatric Services

Page 2 of 6 / *«PatientNumber»*
Acct# «PatientNumber» MR# «MedicalRecordNumber» «Location»«Room»«Bed»
«PatientName» «AdmitDate»
«AdmittingDoctorName»«BirthDate»«Age»«Gender»
LOC: Alert  Responsive  Decreased Consciousness
Orientation: Person  Place Situation  Time
Mood:  Appropriate  Anxious  Depressed  Manic
 Paranoid
Affect:  Bright  Angry  Flat  Labile  Sad
Thought Process:  Goal directed  Disorganized
 Flight of ideas
Comments______
Thought Content:  Appropriate to situation
 Paranoid
Hallucinations:
 Auditory  Visual  Tactile  Olfactory
 Gustatory
Delusions:
 Persecutory  Grandiose
Comments______
______
Speech: Normal rate/volume
 Loud  Slurred  Mute  Pressured  Hesitant
Comments____________
Appearance: Clean  Well groomed  Neat
 Appropriate for climate  Disheveled  Poor hygiene
 Other (specify) ______
Comments______
______
ADLs:  Self  Encourage  Minimal assist  Refused
 Total care
Comments______
Interaction:  Appropriate  Attends groups  Hostile  Initiates  Intrusive  Selective  Withdrawn
Behavior: ______/

 N/A Trauma Screen

Has patient ever experienced any psychological trauma (event) that was so frightening, horrible or upsetting that it is impacting current coping by one or more of the following?

 having thoughts about it when they do not want to
 trying hard not to think about it (e.g. went out of their way to
avoid situations reminding them of it)
 having nightmares about it
 being excessively on guard, watchful or easily startled

feeling numb or detached from others, activities, or surroundings

Potential for Harm to Self

 None evident or expressed by patient
 Past suicide attempt by anyone in patient’s family
 Family history of suicide
 Intentional cutting burning, bruising, or damaging self
 Bangs head, throws self into objects, hits self, pulls hair, picks
at skin
 Suicidal thoughts in the past month
 Suicidal plan in the past month
 Prior suicidal attempts
Dates:______
 Other:______

Potential for Elopement or AWOL

 None evident or expressed by patient
 History of polysubstance abuse
 Patient does not want to be in hospital, expresses desire to
leave, involuntary admission
 History of runaway behavior, antisocial behavior, incarceration
 Awaiting long term placement or conservatorship
 Oppositional / defiant behaviors
 Patient constantly stands at unit exit door
 History of AWOL or attempts
 Other: ______
______

Substance /Alcohol Abuse Screen

Any in past 12 months?  No  Yes If yes, see page 4 for detailed list.
If yes has there been a negative affect on one or more of the following?
 Important relationships (family, friends, schoolmates, co-worker)
______
______
 Work or school ______
 Daily functioning (e.g., personal hygiene, caring for self or others in your charge, attending to medical & emotional health, driving, shopping, or paying bills) ______
______
NNNSG0108 03/19/10

Nursing Admission Summary Psychiatric Services

Page 3 of 6 / *«PatientNumber»*
Acct# «PatientNumber» MR# «MedicalRecordNumber» «Location»«Room»«Bed»
«PatientName» «AdmitDate»
«AdmittingDoctorName»«BirthDate»«Age»«Gender»
SYMPTOMS / BEHAVIORS DESCRIPTION
(Reference each symptom checked by #, indicate amount, frequency, last usage and history)
Alcohol and Non-prescription Drug Use over past 12 months / # / Amt. / Freq. / Last Use / History
44. / Alcohol
45. / Tobacco
46. / Caffeine
47. / Tranquilizers
48. / Marijuana
49. / Barbiturates
50. / Stimulants
51. / LSD or other hallucinogens
52. / PCP
53. / Sedative
54. / Pain Medications
55. / Heroin
56. / Cocaine / crack
57. / Methadone
58. / Inhalants, glue, Freon, butanes, gasoline
59. / Over the counter medications
(Reference each symptom checked by #, indicate history of, current and comments)
# / History
60. / Anorexia
61. / Nausea and vomiting
62. / Diarrhea
63. / Irritability
64. / Weakness
65. / Cramps
66. / Tingling, Numbness
67. / Tremor
68. / Tachycardia
69. / Increased blood pressure
70. / Diaphoresis
71. / Fever, Chills
72. / Hallucinations
73. / Delirium, altered consciousness
74. / Effect on family, work, school
75. / Legal involvement
76. / Family drug / alcohol use
77. / Extreme agitation
78. / Legal charges
79. / Blackouts
80. / DT’s
81. / Aggressive / assaultive
RN ______LPN ______
Initial Initial
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Page 4 of 6 / *«PatientNumber»*
Acct# «PatientNumber» MR# «MedicalRecordNumber» «Location»«Room»«Bed»
«PatientName» «AdmitDate»
«AdmittingDoctorName»«BirthDate»«Age»«Gender»

Suicide Risk Assessment

Assessment Parameters / No Risk / Low Risk / Moderate Risk / High Risk
I. Current Ideation, Plan, and Intent

A. Suicidal Thoughts

/  None Present (0) /  Infrequent or passive thoughts without plan or intent (1) /  Frequent or passive with vague plan with no intent (3) /  Continuous and/or contain specific plan and/or stated intent (5)*

B. Suicide Plan

/  None Present (0) /  Unrealistic or low lethality with no intent; unavailable means (1) /  Vague but realistic plan; available means (3) /  Specific realistic plan with available means (5)*

C. Suicidal Intent

/  None Present (0) /  Passive desire to die without self-injurious actions or intent (1) /  Expresses vague intent without consideration of plan (3) /  Active intent to develop and/or carry out plan (5)*
D. Contract for Safety /  Able & willing (0) /  Ambivalent (3) /  Unable/Refused (5)*
II. History of Suicidal Behavior

A. History of Suicide Attempts

/  No previous history (0) /  1-2 low lethality attempts or non-suicidal self-injurious acts in past year (2) /  One or more serious attempts more than 12 months ago, or > 2 low lethality attempts or non-suicidal self-injurious acts in past year (3) /  History of suicide of family/close friend (4)
 One or more serious attempts within past 12 months (5)
B. Lethality of Past Self-Injurious Behavior (if more than one, score most severe) /  None Present (0) /  Superficial or non-suicidal self-injurious act without injury requiring treatment (1) /  Non-suicidal self-injury or serious attempt with non life-threatening injury requiring treatment (3) /  Serious attempt with actual or potential life-threatening injury (5)
III. Psychological Factors

A. Depression

/  None Present (0) /  Mild; feels “slightly down” (1) /  Moderate; moody, sad (2) /  Overwhelmed; hopeless; Sudden change in demeanor (4)

B. Anxiety

/  Little or none (0) /  Low; denies episodes of intense anxiety (1) /  Moderate; infrequent episodes of intense anxiety (3) /  High; Frequent episodes of intense anxiety; PTSD, or panic symptoms (4)

C. Psychosis

/  None (0) /  Some mild delusions but reality testing intact (1) /  Paranoid delusions or ideas of reference, with poor reality testing (3) /  Command hallucinations for self harm; severe unremitting delusions (5)*

D. Alcohol/Drug Use

/  None (0) /  Infrequent or past use only, no excessive use (1) /  Frequent use, not excessive; or occasional excessive use (3) /  Frequent, excessive, or indiscriminate use, or recent increase (4)

E. Anger/Impulsivity

/  None (0) /  Low; rare outbursts, few impulsive acts (1) /  Moderate; occasional outbursts, occasional impulsive acts (2) /  High; frequent or severe outbursts; frequent or aggressive impulsive acts (4)

IV. Medical Factors

/  None (0) /  Acute but short term, no disruption in ADL (1) /  Chronic or acute, with mild disruption of ADL (2) /  Chronic and/or severely debilitating (3)

V. Resources or Support

/  Adequate family/social resources (0) /  Limited family/social resources (1) /  Marginal family/social resources (2) /  Absent or hostile family/social resources (3)

VI. Situational Stressors*

/  Non-contributory (0) /  1-2 stressors (2) /  3 stressors (3) /  4 or more stressors (5)
* Examples include recent death of loved one, recent divorce, loss of employment, loss of home, severe interpersonal conflict, recent decline in health status, estrangement from family of origin or from children, legal involvement with possible incarceration.
No Risk: 0-7 Low Risk: 8-18 Moderate Risk -19-34 High Risk: 35+ or any indicator with (*)

Patient Score and assigned risk ______

Observation Level: /  15 Minute Checks /  Direct Observation
Clinical Staff Signature: / Date: Time:
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Page 5 of 6 / *«PatientNumber»*
Acct# «PatientNumber» MR# «MedicalRecordNumber» «Location»«Room»«Bed»
«PatientName» «AdmitDate»
«AdmittingDoctorName»«BirthDate»«Age»«Gender»
Psychiatric Services Violence Risk Assessment
Evaluate patient on each of the following factors. Make only one rating on each factor by checking the box that applies. Add the total number of points across all risk factors. Rating for each factor should be based on a combination of patient self-report, clinical observation, and collateral information.
RISK FACTOR
(within the past 6 months) / Absent
(0 pts) / Low
(1 pt) / Moderate
(2 pts) / High
(3 pts)
1. Age and Gender / Not Applicable
 / Male 25+
 / Male, age 19-24

2. History of Violence / None/ Not Applicable
 / History of generalized threats of harm to others; mild property damage.
 / Remote history of one act of violence to another person with no medical attention required
 / History of one act of violence to another person that required medical attention or resulted in death
History of serious criminal activity
Intentional infliction of harm on someone in the past month

3. Negative Attitudes / None/ Not Applicable
 / Feels pessimistic sometimes; views self as misunderstood.
 / Insensitive to the feelings of others; pessimistic most of the time.
 / Completely lacking in empathy toward others; cold or callous; has no hope for the future.

4. Anger / None/ Not Applicable
 / Mild anxiety or agitation
 / Marked irritability or anger; shouts angrily, curses, uses foul language
 / Intense feelings of rage or hostility;
Slams doors, throws objects

5. Psychosis / None/ Not Applicable
 / Over-valued ideas of paranoid nature, but not delusional
 / Schizophrenia, schizophreniform, schizoaffective disorder; paranoid or grandiose delusion; command hallucinations patient can resist.
 / Command hallucinations with violent content that patient is unable to resist; threat-control over-ride symptoms (e.g. delusion of thought insertion, control, or influence

6. Cognitive Functioning / None/ Not Applicable
 / Some rigidity or inflexibility in thinking
 / Close-minded, somewhat inflexible in thinking or decision –making
 / Personality change due to head injury; loss of executive functioning, mental retardation; neurocognitive disorder with aggressive behavior.

7. Violent Ideation / None/ Not Applicable
 / Sporadic thoughts of an aggressive nature, with no clear detail
 / Thoughts of harming someone else in the past month
 / Has persistent and vivid fantasies or ideas about hurting or injuring some other person.
Homicidal thoughts in the past month

8. Substance Abuse / None/ Not Applicable
 / Occasional substance abuse; social use of drugs or alcohol resulting in some difficulties (e.g., DWI)
 / Impulsive use of alcohol or drugs; uses substance recklessly in way that has led to legal or other behavioral problems
 / Drug and/or alcohol abuse AND major Axis 1 disorder; substance abuse or dependence resulting in aggression or violence.

9. Recent violent Behavior / None/ Not Applicable
 / Moderate behavioral gesturing or vague threats of violence
 / Recent threats verbalized to others; recent act of violence resulting in serious property damage
 / Recent act of aggression or violence resulting in injury to others

10. Legal Status / Voluntary or informal
 / Involuntary; court-ordered commitment

COLUMN SUBTOTALS

Observation Level: /  15 Minute Checks /  Hourly /  1:1 /  Discharge

TOTAL SCORE: ______

______Low Risk (1-7)  (Check when completed): Physician notified of individual with high risk factors

______Moderate Risk (8-17) Signature: ______

______High Risk (18-30)Date/Time: _________
NNNSG0108 03/19/10

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Acct# «PatientNumber» MR# «MedicalRecordNumber» «Location»«Room»«Bed»
«PatientName» «AdmitDate»
«AdmittingDoctorName»«BirthDate»«Age»«Gender»