Admission assessment

.admission_assessment

Subjective: Patient
name
is a
age
,
gender
, who is experiencing
symptoms
. Patient reports
special concerns
and is concerned about
specific outcomes or after-care requirements
.

Objective:
- History:
Pertinent medical/surgical history

- Negatives:
Pertinent negatives

- Vitals:
Biometrics and vitals

- Medications:
Medications

- Allergies:
Allergies


Assessment:
- Symptoms:
Current symptoms

- Contraindications:
Contraindications

- Discharge concerns:
Discharge concerns

- Care gaps:
Gaps in care


Plan:
- Orders received:
Orders received

- Orders requested:
Orders requested

- Nursing care plan:
Care plan

- Discharge planning:
Discharge plan
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