Admissions, Transfers, Discharge and Community Resources

Client Admission and Baseline Data Collection

Admission processes may begin before the client reaches a clinical unit, such as during preadmission or in the emergency department; unit admission procedures begin when the client arrives on the unit. Preparing the admission room prior to arrival with necessary equipment, such as functional oxygen delivery systems and suction setups, ensures that the healthcare team can safely receive the client. When the client enters the room, the practical nurse checks the identification band against two approved client identifiers, verifies documented allergies, and checks for an allergy band when indicated.

The division of responsibilities during admission is defined by nursing scope of practice. The registered nurse performs the initial comprehensive admission assessment and establishes the plan of care. The practical nurse assists the registered nurse by collecting baseline data. This role includes obtaining and documenting baseline vital signs, height, and weight. The practical nurse also reviews and lists the client's home medications to assist the healthcare team with medication reconciliation, an essential process that prevents adverse drug interactions and omission errors.

Safety and advocacy remain top priorities throughout the intake process. The practical nurse documents and secures the client's personal belongings and valuables upon arrival to protect client property from loss. Orienting the client to the physical surroundings, specifically showing how to operate the call light system, locate the bathroom, and navigate the room, significantly reduces client anxiety and decreases fall risk. During admission, the practical nurse may ask whether the client has an advance directive, document the information obtained according to facility policy, and report it to the registered nurse; the facility is responsible for meeting Patient Self-Determination Act requirements.

During baseline data collection, the practical nurse collects fall-risk data, gathers pressure-injury risk data, notes skin findings, and promptly reports these findings to the registered nurse for comprehensive assessment. The practical nurse promptly reports abnormal admission findings to the registered nurse; if the client is in acute distress, the practical nurse also initiates appropriate immediate safety measures and the emergency response according to training and facility policy.