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Yes/No/NA

Order to admit/discharge summary signed by physician

Physician notified of admission, admission orders verified

Diagnosis given for each prescribed medication

Orders transcribed to medication and treatment administration sheets

Nurses’ notes give time of admission, initial nursing assessment

Inventory of resident possessions filled out, signed by resident or family

Acute care plan implemented

Allergies noted on chart and medication administration sheet

Resident name band in place

Diet order sent to dietary department

Resident added to all census information

All departments notified of admission

Face sheet with vital information in chart

Advance Directives in place

TB test recorded with results

Admission vital signs, height, and weight documented

Labs ordered

Fall risk assessment completed

Skin breakdown assessment completed

Pain assessment completed