Policy Number
Chapter
Effective Date
Approval Date
Supersedes
Policy: Nursing Admission History
CL 30-05.04
Clinical
Pending
Pending
April 2007
Applicable to
VUH
Children’s Hospital
VMG
VMG Off-Site
Locations
VPH
VUSN
VUSM
Other:
Team Members Performing
All faculty
& staff
Faculty & staff
providing direct
patient care or contact
MD
House Staff
APRN/PA
RN
LPN
Other: EMT-P
Lead Author & Content Experts
Lead Author: Karen Hughart, MSN, RN-BC – Director, System Support Services
Vickie Thompson, RN, MSN
Tiffany Richmond, BSN, RN
Laura Hollis, BSN, RN
SPECIFIC EDUCATION REQUIRED:
YES
NO
Table of Contents
I.
I.
Purpose: ........................................................................................1
II.
Policy:...........................................................................................2
III.
Specific Information:....................................................................3
IV.
References: ...................................................................................5
V.
Endorsement: ................................................................................5
VI.
Approval: ......................................................................................6
Purpose:
To collect pertinent current, past, health and social data from patients, patients’
families and/or significant others. Data collected is for the purpose of initiating
the plan of care, managing patient care and begin discharge planning during the
current hospitalization.
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Inquiries: Accreditation & Standards (615) 322-1117
Nursing Admission History
Policy Number CL 30-05.04
II.
Policy:
The nursing admission history data is collected within 24 hours of admission. A
completed admission assessment may be collected in a shorter timeframe as
appropriate to the patient population based on anticipated length of stay. The
admission history data set is divided into three sections (see A, B and C below).
In cases where it is not in the best interest of the patient to collect and document
the entire data set at the time of admission, the following guidelines are followed:
A.
Section 1 Data: Required to initiate safe patient care.
Complete this section during the initial admission period
B.
Section 2 Data: Required for initiation of individualized Plan of Care.
Collect and document data within the first 8 hours of the admission.
Note: Plan of Care is started within 8 hours of admission.
C.
Section 3 Data: Required for initiation of individualized Discharge Plan.
Collect and document data within the first 24 hours of admission. Note:
Discharge Plan is started within 24 hours of admission.
Data in each section may be deferred only under the following
circumstances:
a.
b.
In cases where data cannot be obtained from patient,
family, or significant others, or from available medical
records; or
When delay of care to obtain and document the data would
jeopardize patient safety.
Note: In cases where there is a delay beyond the defined time limit in each
section above, this data is collected and documented as soon as available.
(See References for link to document containing all elements of the forms)
D.
Short Stay Patients (including Same Day Surgery or Procedure,
Observation, and other patients who typically have < 1 day Length of Stay
(LOS)): a plan of care and discharge plan is developed by the midpoint in
the anticipated LOS. Patients receiving sedation or anesthesia in
conjunction with surgical or non-surgical procedures have the appropriate
admission history completed prior to sedation or analgesia. Some elements
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Nursing Admission History
Policy Number CL 30-05.04
of the Admission History are appropriately abbreviated for Short Stay
patients.
E.
When planned as Short Stay and patients subsequently require admission
as an Inpatient, additional inpatient admission data elements are
documented. The Plan of Care and Discharge Plans are revised as
appropriate to reflect changes in patient’s status.
F.
Admission History Data is documented in the following systems:
1.
2.
3.
4.
G.
III.
StarPanel Admission History StarForm(s) is used in most areas for
Inpatients and Short-Stay patients.
Vanderbilt Perioperative Information System (VPIMS) is used for
or Same Day Surgery Patients or Inpatients admitted day of
surgery to perioperative areas. StarPanel is used to document
Admit History when VPIMS is unavailable.
WITT Cath Lab Nursing Documentation System is used for
Inpatients or Same Days Procedure Patients admitted day of the
procedure to Cath Lab Holding Room area. StarPanel is used to
documents Admit History when WITT is unavailable.
Age-appropriate Downtime Admission History form in E-Docs is
used when StarPanel is down.
NICU and Newborn Nurseries utilize unit-specific tools and processes to
document admission history on patients in those areas.
Specific Information:
A.
The Nursing Admission History consists of data entered in the areaspecific Admission History system (i.e., StarPanel, VPIMS, and WITT). A
full assessment per unit standards is documented in the nursing
documentation application or paper form for that area. Provider
documentation in the admission history and physical and any assessments
documented by other disciplines complete the multidisciplinary team
Admission History. StarPanel is the definitive source for admission history
data documented electronically in Horizon Expert Documentation (HED),
VPIMS, or WITT. Downtime Admission History Forms are scanned into
the Electronic Medical Record (EMR) and can also be viewed in
StarPanel. The following applies:
1.
2.
Admission history elements documented in one application do not
need to be duplicated in another system.
If the Admission History is completed in VPIMS, WITT, or
StarPanel, it will be available for viewing in StarPanel by all users.
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Nursing Admission History
Policy Number CL 30-05.04
3.
4.
If the admission history is incomplete in VPIMS, WITT, or
StarPanel, the initial data can be viewed in StarPanel. The missing
data elements are documented in the departmental system.
Until all applications are completely integrated, it may be
necessary to view the admission history data documented across
two or more applications in order to review the patient’s admission
history.
B.
When the Admission History StarForm is opened, some data from other
VUMC clinical information systems or from previous Admission Histories
will auto-import. Auto-imported data is carefully reviewed for accuracy
and revised as needed.
C.
Complete each section within defined timeframes. If patient unable to
provide history, utilize family members, friends, medical record and other
available sources for information. If there are no sources available for data
element completion in the appropriate timeframes, check “Unable to
complete Section X at this time”.
D.
Each user will save as draft until all sections completed or until further
information cannot be obtained. The final document is saved under the
name of the last person who documents on the form. The electronic
database includes information on the date, time, and user that each data
element is entered. In cases where data is changed, this electronic record
retains initial entry data and data for any subsequent entries. Various drafts
can be viewed by using “Show Version” feature.
E.
If additional information becomes available after the final revision, open
the document (from All Docs or OPC view in StarPanel) and amend the
document. Note: The data cannot be altered once form is saved as
“complete”.
If the document cannot be edited, updates are completed using “type a
note” feature or by handwriting on the paper Progress Notes form and scan
into StarPanel at discharge. At discharge, all admission history data is
available in StarPanel EMR.
F.
All members of the health care team utilize the admission history
information for developing the plan of care and for discharge planning.
G.
Only a registered nurse (RN) may complete the admission history in
StarPanel. Other personnel may contribute data, but an RN reviews and
finalizes.
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Nursing Admission History
Policy Number CL 30-05.04
H.
IV.
If an admission history is started during a pre-admission workup, the RN
reviews it for accuracy upon admission and notes any changes since the
pre-admission assessment. The admission history database is available in
Star Panel; an addendum must be made in the admission history if it was
finalized by the admission RN. Revisions are made in an addendum to the
admission and history if the original was finalized.
References:
VUMC Policy Manual. Accessed October 10, 2011, via
https://mcapps.mc.vanderbilt.edu/E-Manual/Hpolicy.nsf
Clinical Policy Manual:
CL 30-02.01 Clinical Practice Guidelines: Adult
CL 30-05.06 Discharge Plan
CL 30-19.15 Pediatric Clinical Practice Guidelines
Operations Policy Manual:
OP 10-50.04 Patient and Family Education
OP 60-10.09 Pastoral Care
The Joint Commission’s Comprehensive Accreditation Manual for Hospitals
(CAMH). Retrieved online October 10, 2011, via Eskind Digital Library (search
word “CAMH”, then select “Accreditation Requirements”)
http://www.mc.vanderbilt.edu/diglib/
Provision of Care Standards
PC.01.02.01: The hospital assesses and reassesses its patients.
Elements 1, 2 &3
PC.01.02.03: The hospital assesses and reassesses the patient and his or
her condition according to defined timeframes.
Elements 1&2
PC.01.02.09: The hospital assesses the patient who may be a victim of
possible abuse and neglect. Elements 1, 2 &3
PC.02.03.01: The hospital provides patient education and training based
on each patient's needs and abilities. Element 1
Rights and Responsibilities of the Individual Standard
RI.01.05.01: The hospital addresses patient decisions about care,
treatment, and services.
V.
Endorsement:
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Nursing Admission History
Policy Number CL 30-05.04
VI.
Documentation Steering Committee
September 2011
Children’s Clinical Policy and Practice Committee
Date
Clinical Practice Committee
Date
Medical Center Medical Board
Date
Margaret Head MSN, RN
Chief Operating Officer & Chief Nursing Officer
Vanderbilt Medical Group
Date
Susan Hernandez MBA, RN
Associate Hospital Director, Nursing
Monroe Carell Jr. Children’s Hospital at Vanderbilt
Date
Pam Jones MSN, RN
Chief Nursing Officer
Vanderbilt University Hospital
Date
Approval:
Marilyn Dubree RN, MSN, NE-BC
Executive Chief Nursing Officer
Date
C. Wright Pinson MBA, MD
Date
Deputy Vice Chancellor for Health Affairs
Chief Executive Officer of Hospitals and Clinics for VUMC
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