Nursing Admission Notes: Guide, Template, & Examples

Nurses are often the first medical professionals that patients see upon arrival at a healthcare facility. They have an important job to do: they conduct the initial assessment and fill out the nursing admission note. This gives a vital snapshot of the patient’s health.

Nursing admission notes include details about a patient’s:

Health status
Medical history
Immediate needs

Nurses should write accurate and detailed admission notes. These help ensure patient safety, continuity of care, and enable clinicians to create an effective treatment plan.

Nursing admission notes must be accurate, as they convey key information to the medical team, such as allergies and past medical history. Inaccurate admission notes can lead to errors, treatment delays, or miscommunication.

Good patient care begins with clear and informative admission notes.

This article will explain the purpose of a nursing admission note, outline best practices for writing one, present standard note formats, and provide examples to support your note writing.

Let’s begin by clarifying what a nursing admission note is.

What is a nursing admission note?

A nursing admission note is the first entry in a patient’s chart. It provides the medical team with a holistic overview of the patient’s current condition. This includes:

Symptoms
Risks
Psychosocial factors

This first nursing note includes the full admission assessment, which is used to help create a care plan with nursing interventions and for ongoing monitoring.

In comparison, the physician’s admission note focuses on the medical reasons for admission, diagnosis, and treatment plan.

The nursing and physician admission notes, together, provide a more comprehensive health picture.

Key components of an effective nursing admission note

There are several key components of admission notes that are included.

Patient identification

Include the patient’s full name, date of birth, medical record number, and the source of admission.

Admission details

Record the date, time, and referral source of admission (e.g., if transferred from an intensive care unit).

Health status

Describe the patient’s current health status and presenting symptoms, using their own words when appropriate. The nursing note should also include objective findings, such as vital signs.

Read more about the difference between subjective and objective data in nursing practice here.

Patient’s history

Include the patient’s medical and surgical history, as well as relevant family health history.

Current medications and allergies

If the patient is taking medication, the note needs to include:

Dose and frequency of medication
Time of the last dose

Note if the patient has any allergies, such as to medication or food.

Baseline vital signs

Measure and record the patient’s baseline vital signs, including:

Blood pressure
Heart rate
Respiratory rate
Temperature
Oxygen saturation

Also, document their weight, height, and pain scale.

Nursing assessment results

Complete and record the results of relevant assessments:

Physical assessment (head-to-toe)
Neurological exam
Cardiorespiratory assessment
Abdominal assessment
Skin assessment
Functional mobility

Social supports and advance directives

Ask about and record the patient’s living situation, caregiver/family contact, and any advance directives.

Advance directives are legal documents that outline a patient’s medical wishes in the event that they are unable to communicate their own wishes. These documents typically include:

Living will: A living will specifies the types of medical treatment a patient does or does not want, such as life-sustaining measures, in case they are terminally ill or permanently unconscious.
Durable power of attorney for healthcare: A durable power of attorney for healthcare designates another person (a healthcare proxy or agent) to make medical decisions on the patient’s behalf if they are unable to do so.
Do not resuscitate (DNR) orders: A do-not-resuscitate (DNR) order indicates that a patient does not want resuscitative measures such as CPR in the event of cardiac arrest.

Advance directives help ensure that a patient's healthcare preferences are respected and that decisions align with their values and wishes, even when they cannot voice them.

Initial nursing care plan

The initial care plan outlines priority problems, nursing diagnoses, nursing interventions, and a monitoring plan.

How to write an admission note: A step-by-step guide

Now let’s look at how to write an effective nursing initial assessment note, following four clear steps:

Step 1: Gather information

Begin by reviewing the patient’s health records, for instance, handoff reports, triage notes, and transfer documentation.

Next, verify the patient’s identity and ask follow-up questions about their health condition to confirm details if they are able to communicate.

Review the patient’s previous charts or medication records, if applicable.

Step 2: Conduct an admission assessment

Each facility has specific guidelines for conducting an admission assessment. These guidelines often include the following:

Head-to-toe physical examination
Psychological status assessment
Activities of daily living evaluation
Pain and psychosocial needs screening

Step 3: Document objectively

When writing nursing admission notes, use clear, objective language. Avoid making assumptions about the patient’s condition and use only approved abbreviations.

You can use phrases such as "patient states…"

Step 4: Double-check before signing

Before you complete and sign, double-check these important details in the admission notes:

Patient’s personal information
Medication and allergy information
Any abnormal findings

Lastly, make sure that you have completed all required fields.

Nursing admission note template

You can use this template to write effective nursing admission notes.

Patient information

The patient information should include:

Name
Age and gender
Date and time of admission
Reason for admission
Allergies

Vital signs

Temperature
Heart rate
Respiratory rate
Blood pressure
Oxygen saturation

Medical history

Past medical conditions
Surgical history
Medications

Nursing assessment

General appearance
Level of consciousness
Pain assessment
Respiratory status
Cardiovascular status
Skin integrity
Mobility and fall risk
Nutrition and hydration
Psychosocial considerations

Safety risks identified

For example, in this section, you may include safety risks, such as patients at high risk of falls or those with high blood pressure.

Initial nursing interventions

In this section, describe your initial interventions, such as giving nonslip socks to reduce fall risk.

Plan of care priorities

Here, you can outline care plan priorities, like supporting mobility and ensuring safety.

Nurse signature and credentials

After reviewing the document, sign it and add your credentials.

Admission note documentation guidelines and best practices

Nursing admission notes must comply with legal and professional standards. Here are some admission note best practices for you to follow.

Ensure you follow institutional and national admission note guidelines. This includes:

Using only approved abbreviations
Completing all required fields
Documenting within the specified time

You must write the nursing note promptly. If you delay writing it, there is a greater risk of making a mistake or recording key details inaccurately. This could have ramifications later on for the patient’s care.

Your admission notes must comply with legal and ethical standards. Here are some tips for improving admission note accuracy:

Document facts, not your opinions.
Avoid emotional or judgmental language.
Double-check your data.
Take fast action if you find abnormalities.

If you want to improve your note writing, peer reviews, or documentation audits can be helpful. These can help you improve your skills and give you constructive feedback.

Nursing admission note formats

Facilities use different templates for nursing assessment documentation; however, these are the common types.

Narrative format

The narrative format is a more flexible style and allows longer, more detailed explanations. The drawback is that this can lead to more inaccuracy or inconsistency.

Checklist format

The checklist format is more structured, efficient, and minimizes errors. However, it doesn’t allow for longer, more complex details.

Problem orientated

These two formats can be helpful for problem-focused admission situations:

SOAP: Subjective, objective, assessment, plan
DAR: Data, action, response

Sample nursing admission notes: What works & what to avoid

Below are examples of effective and incomplete notes to guide your writing.

Effective nursing admission note

Patient: Joe Balwin

Date/time: 10 Dec 2025 - 9:20 p.m.

Admitting diagnosis: Pneumonia

Allergies: None

Code status: Full code

Assessment: Fatigued and has a fever of 104°F

Vital signs: T 104°F, HR 96, RR 22, BP 146/84, SpO₂ 93% on 2 L NC

Respiratory: Presenting with shortness of breath and a cough

Neuro/mobility: Requires help to walk, unsteady gait

Skin: Intact but fragile

Pain: 3/10 muscle fatigue

Elimination: Last bowel movement yesterday

Nutrition: Poor appetite, eating once a day

Psychosocial: Lives alone, but his supportive daughter lives close by

Fall risk: Morse fall score 60 (high)

Interventions: O₂ therapy per order; encouraged C/DB; safety education provided; MD notified of admission

Nurse signature: T Jorgen, RN

Incomplete/weak admission note

A 75-year-old man was admitted with pneumonia. He seems weak and tired. Trouble walking. Breathing heavy and not looking good. Has fallen recently. Took some precautions. Daughter was worried. Told doctor to speak to her.

Improving your admission note accuracy & efficiency

Good nursing admission notes don’t have to take you tons of time. Here are some strategies to help you write good notes faster.

Use templates and shortcuts

You can refer to the template in this article to help you write nursing admission notes. Your healthcare facility may also have an established template to use.

You can use electronic health record (EHR) macros to speed up the process. EHR macros are text shortcuts or command sequences that allow for efficient data entry.

Once you have finished writing your note, it may be helpful to have a checklist you can check against to make sure you have finished all the sections correctly and haven’t missed anything.

Prepare during handoff

Before meeting the patient, you can review their previous medical history to ensure you are up to speed. In the assessment, identify their priority concerns as soon as possible.

Audit your own notes

By being self-aware and reviewing your note-taking, you will improve. Review your admission note to ensure you have not missed any key data regarding ADLs, pain, or potential risks.

It may also be helpful to be aware of patterns in your note-taking and request a peer review or audit if you need to improve.

Use technology to support accuracy

EHR can alert you when a required field is incomplete. You can also use EHR to check the patient’s medication using a medication reconciliation tool. In fact, most healthcare facilities only use electronic medical records; therefore, much of your nursing admission assessment and notes will be documented digitally.

Share knowledge within the unit

Within your team, you can exchange effective nursing admission note examples. You can also ensure that you attend any documentation workshops or training sessions that are offered.

Nursing admission notes: FAQs

Here is a recap of frequently asked questions when it comes to nursing admission notes.

What is included in a nursing admission note?

The following details need to be included:

Patient identification
Admission details
Health status
Patient’s history
Current medications and allergies
Baseline vital signs
Initial nursing care plan

How does the nursing admission note improve patient safety?

An accurate note can prevent medical errors, highlight safety risks early, and ensure continuity of care throughout the team.

The nursing admission note is the first entry in a patient’s chart, and it is foundational for ensuring patient safety.

What template or charting format is best for admissions?

The format of the nursing admission note will depend on the facility’s established practice. Ideally, a hybrid format that combines a checklist and narrative will provide structure while allowing you to add detailed information.

How can I improve my admission documentation in nursing?

A registered nurse’s role in writing admission notes is vital, so ensure you do it effectively.

You can improve your nursing admission notes by double-checking key details before you sign. Ensure your language is clear and objective, and avoid vague or emotional language. When the opportunity arises, participate in documentation audits and workshops.

Nursing admission notes: Foundation of good healthcare

An effective nursing admission note can establish the foundation for good patient care. They can ensure patient safety, prevent medical errors, and ensure all team members have the correct information to treat the patient.

You can improve the quality of your admission notes by: