Admission Checklist
Name
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First Name
Last Name
Patient No:
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Date Of Admission
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Month
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Day
Year
Date
CHECKLIST ITEMS
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Rows
Yes Complete
No
Not Applicable
Notes:
Verification of ID
A list of medications that the person is currently taking
A list of allergies to medications and any other allergies
Name of Primary Healthcare Provider
A list of medical diagnosis
A list of past surgeries and outpatient procedures
Do we have a comprehensive knowledge of the family medical history.
If a paediatric patient is being admitted, have we completed the patient consent form with agreement from both parents?
Have baseline investigations been requested for the suspected diagnosis?
Has the patient been referred from another medical facility?
If yes to the above question, then have we been provided with sufficient information and documentation via referral letter, investigations performed, diagnosis etc
Does the patient have a next of kin?
Have we documented the next of kin's active contact number?
Is the next of kin a direct family relative?
Has the patient been brought to the facility as a result of their involvement in criminal activity?
If the above is the case, then has the incident been reported to the police?
Is the patient a victim of crime/a gunshot wound?
If the above is the case, then has the incident been reported to the police?
Is there a preliminary diagnosis of sepsis?
If the above is the case, then does the patient meet SIRS, Sepsis, Severe Sepsis, Septic Shock or Multiple Organ Dysfunction Syndrome Criteria? If so, then please indicate.
What is the Quick SOFA score?
What is the National Early Warning Score?
Patient relatives, next of kin or guardian has agreed to provide toiletries, food, blood (if necessary) etc.
Job Title:
Name
First Name
Last Name
Signature
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Date
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Month
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Day
Year
Date
Submit
Submit
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