Best advice on completing an admission on Med/Surg, any tips or tricks?

Make the admission into a conversation. No one likes a battery of questions, but if it seems like a comfortable conversation the patient is more likely to be more forthcoming and truthful with their situation. I introduce myself then ask what brought them to the hospital today. Take that story then broaden it…”shortly after waking you had chest pain? Has this ever happened to you before? Do you live alone? Oh you’re married? Was your wife home to help you? Were you able to ambulate? Do you normally use a cane?” These are all vital pieces of info for your admission. Turn your admission questions into open ended questions and you’ll yield better results. Have your admission complete in half the time

I agree into having just like a conversation with the patient instead of Q and A. Familiarize yourself with your facilities' assessment form or make a cheat sheet to guide you into making sure you have discussed important points. Ask open ended questions to obtain more information instead of answerable by just yes or no. Good luck.

I agree with Wendy! Most questions can be made to feel like small talk. Big questions not to forget! Any recent falls? List of medication and last time taken. SI/HI? Be direct but compassionate. Good luck!

My biggest piece of advice is do your admission the same way each time. Meaning always do things in the same order. This helps ensure you won’t forget anything, helps you if you ever have to do an admission during charting system downtime by making the questions and assessments second nature, and take every opportunity you can to participate in admissions (seeing how your coworkers do it on your floor is likely more helpful than anything). Best of luck!

Pull up Dr's notes for history, ask patient and family of any changes, quick review with them. Head-to-toe assessment will become second nature, you will start before they are even off the stretcher and on the bed, listen to lungs, and access skin as you position them in the bed. Ask for a medication list, any changes, last taken. Before you know it you will be banging the admission out with all the pertinent information efficiently. Just a few tips, you will get in your own groove. Always, have a family member's number for anything the patient cannot recall or answer. Good-luck.

I found the admission assessment to be the most valuable part of a patient's hospital stay. The responses from the patient and the physical assessment, with the documented findings helps to have an in-depth baseline so that changes (even subtle ones) can indicate early warnings for pt. condition for deterioration or improvement.
The thoroughness of the in-depth questions and physical evaluation of each of the body systems will also be the best and most accurate information to share with clinical team members through the course of the patient's admission for comparison. Taking an assessment course early in my career was very helpful to assist with
critical thinking and decision making skills to know when to escalate observations requiring interventions.