Admission Nursing Note Example
An admission nursing note documents a patient's arrival and the baseline nursing assessment and orientation completed at admission.
Educational use & privacy
Educational documentation practice only. Use fictional or instructor-provided information. Do not enter real patient information or protected health information (PHI). Documentation requirements vary by organization, setting, role, policy, and applicable law.
Nursing Notes Privacy & SafetyContent status: Draft — not yet professionally reviewed.
Why it is structured this way
The admission note sets the baseline that later findings are compared against, so accuracy and specificity matter. Many facilities collect much of this in structured admission screens; the note captures what the screens do not.
When this may be used
- At admission to a unit or facility.
- Documentation requirements, frequency and screens vary by organization, setting and EHR. Follow your program's and facility's policy.
Components
Arrival
How and when the patient arrived.
What belongs here
- Time, method of arrival, who accompanied
What does not belong
- Guesses about arrival time
Reason for admission
Why the patient is here.
What belongs here
- As stated by patient or in the record, labeled with source
What does not belong
- Your own diagnosis
Baseline assessment
Starting point.
What belongs here
- Findings actually obtained
What does not belong
- Unassessed systems
Orientation and safety
Patient orientation to the environment.
What belongs here
- Call light, bed controls, safety measures in place
What does not belong
- Safety measures not implemented
Short fictional example
- Narrative
- 1410: Arrived to room 12 by stretcher from the emergency department, accompanied by transport staff. Patient states "I've been short of breath for two days." Respirations 22; SpO2 94% on 2 L/min nasal cannula. Oriented to room and call light.
More detailed fictional example
- Arrival
- 1410: Arrived by wheelchair from the emergency department with spouse.
- Reason for admission
- Patient states "I passed out in the kitchen this morning." Admitted for observation per admission order.
- Baseline assessment
- Alert and oriented ×4. Blood pressure 112/70 lying and 104/66 sitting. Heart rate 84, regular. Skin warm and dry. Patient rates pain 0/10.
- Allergies / history reviewed
- Allergies reviewed with patient and spouse; matches the allergy list in the record.
- Orientation and safety
- Oriented to room, call light and bed controls. Bed in low position. Patient instructed to call before getting up; patient restated "call before I stand."
Annotated example
Notes on the detailed example above:
Patient states "I passed out in the kitchen this morning."
— The history is attributed to the patient.112/70 lying and 104/66 sitting
— Specific measurements are recorded with position.patient restated "call before I stand."
— Understanding is documented through what the patient actually said.
Common mistakes
- Writing the reason for admission as a diagnosis you made.
- Charting orientation to the room before it happened.
- Leaving out who provided the history.
Good vs poor documentation
Weaker (fictional)
Admitted, oriented, all normal.
Stronger (fictional)
Oriented to room and call light; bed in low position; patient restated "call before I stand."
Why: Specific actions and response.
Blank educational template
Admission note: Baseline documentation on arrival. Prompts only; nothing is prefilled.
- Arrival
- [Time, how the patient arrived, accompanied by]
- Reason for admission
- [As reported / documented]
- Baseline assessment
- [Findings actually obtained]
- Allergies / history reviewed
- [What was reviewed and with whom]
- Orientation and safety
- [Orientation to room, safety measures in place]
- Belongings / other
- [Per facility policy]
Practice this format
- Practice Note Builder — write a practice note from a fictional scenario.
- Documentation practice questions
Related documentation guides
Sources
- ANA's Principles for Nursing Documentation (2010) — American Nurses Association.
- Nursing Fundamentals 2e — 2.5 Documentation — Open RN (Chippewa Valley Technical College).
- Fundamentals of Nursing — 14.5 Guidelines for Effective Documentation — OpenStax.
All examples on this page are original and fictional. Sources are used to check principles; they do not endorse Dosage Calcs. See Privacy & Safety.