SCEI Southern Cross Education Institute Admission and Discharge Planning Admission template Student Name: Placement Type: Client Initials: Student ID: D.O.B: Sex: Have you ever had: Yes Not No Known Comments/Explanation Cardiac Heart Trouble Angina/ chest pains/ palpitations High Blood Pressure Rheumatic fever Pacemaker/ defibrillator Make: Model: Serial #: Do you experience shortness of breath or chest pain after exercise Respiratory Asthma/wheezing Asthma requiring hospital admission Bronchitis T.B Emphysema Pneumonia Vascular Bleeding Disorders Cerebrovascular Accident/Stroke Pulmonary Embolus Deep Vein Thrombosis Gastrointestinal Gastric Reflux/ Heartburn Hiatus Hernia Stomach or Duodenal Hernia Bowel problems (diarrhoea, constipation, Stoma/diverticulitis) Bladder problems (incontinence, urgency, UTI, incontinence, discomfort, catheter) Other Hepatitis Diabetes Type (Diet controlled/pills/insulin) Arthritis Muscle Disorders Epilepsy/Fits Fainting episodes CRICOS Provider Code 02934D Student Clinical Skills Logbook Page 117 of 136 RTO Number 121952 HLT54121 Diploma of Nursing Version 1.0 April 2022SCEI Southern Cross Education Institute Do you have problems with sleep apnea? Use of a CPAP machine: Any operations in the last 5 years? Any operations in the past (> 5 years) Hospital Admissions in the past 2 years? Multiresistant organism infection? (MRSA, Golden Staph, VRE) Open wounds, skin tears, fistulas? Infections or infectious diseases? Have you ever had: Yes No Unsure Comments/Explanation Dietary Any specific dietary requirements Unexplained weight loss/gain Nausea/vomiting Broken, chipped loose teeth Caps, crowns, dentures, plates Assistance feeding self Mobility Back problems (arthiritis, leg weakness, pain) Issues with mobility Mobility Aids Falls (in the last 12 months) Assistance to shower, dress, eat Assistance to get in/out of chair/bed Psych/ emotional/Preferences Depression/ anxiety Memory loss Diagnosed mental illness Sleeplessness, stress Religious, Belief or Spiritual Preference/s Gender preference Preferred Language Living arrangements Lives alone? Family? Housing (rental/own/storey) Do you have, or have had, Yes No Unsure Comments/Explanation Pain Sharp intermittent pain related to your admission Chronic Pain Pain that effects your sleep appetite, physical activity, concentration, relationships Other type of pain Pain therapy (other than medications) CRICOS Provider Code 02934D Student Clinical Skills Logbook Page 118 of 136 RTO Number 121952 HLT54121 Diploma of Nursing Version 1.0 April 2022SCEI Southern Cross Education Institute Comments Do you smoke? (If yes how many/day) Do you drink alcohol? (If yes how many/day) Do you take recreational drugs? Do you have a history of substance abuse Medications (generic name) Trade Name Dose Type (tablets, injections, suppositories etc) e.g. Paracetamol TD Capsules Panadol 100mg S Current Health status How would you describe your current health? CRICOS Provider Code 02934D Student Clinical Skills Logbook Page 119 of 136 RTO Number 121952 HLT54121 Diploma of Nursing Version 1.0 April 2022SCEI Southern Cross Education Institute Admission Checklist Time of Arrival: Use glasses or hearing aids: Observation: Skin integrity: Temp: RR Risk of Pressure Injury HR: BP if Yes, referral made to:_ Height: Weight: Concerns related psychosocial status: BMI Yes No Comments List of aids brought in Valuables locked securely away Medications checked and logged Patient history and documentation checked Relevant diagnostic results checked Patient history checked and confirmed with client/carer Next of Kin details confirmed: Facility & services explained Phones, TV, visiting hours, call bells explained Emergency evacuation explained Admission Nurse Designation Signature Name CRICOS Provider Code 02934D Student Clinical Skills Logbook Page 120 of 136 RTO Number 121952 HLT54121 Diploma of Nursing Version 1.0 April 2022