What must be documented in a resident's record upon admission?

The requirement to document both admission orders and a physical examination in a resident's record upon admission is essential for several reasons. Firstly, admission orders provide care instructions and protocols set by the physician, which are crucial for the immediate care and safety of the resident. These orders guide the nursing staff and ensure that the resident's unique health needs are met promptly.

In addition to the admission orders, the physical examination is vital as it establishes a baseline of the resident's health status upon entry into the facility. This examination may identify existing health conditions, necessary treatments, and special care needs that should be addressed immediately. Documenting this information ensures continuity of care and enables healthcare providers to monitor changes in the resident's condition over time, aiding in effective treatment planning and interventions.

Comprehensive documentation upon admission is not only a best practice in healthcare but also a requirement under many regulatory standards that govern health facilities. It supports improved clinical outcomes by ensuring all caregivers have access to crucial information about the resident's health status and care plan from the start of their residency.