The Admission Chart: Assign Precautions, Close the Safety Goals
A flat electronic record frame with a tab row notching into the panel edge and four unnumbered open squares in the notes gutter marking findings the reader must name.
ADMISSION · ORDERS · NURSES' NOTES · VITAL SIGNS · LABORATORY · MEDICATION RECORD
ADMISSION Age 74. Transferred from a skilled nursing facility at 14:10. Six weeks of productive cough, unintentional weight loss of 18 pounds over two months, drenching night sweats. History of type 2 diabetes. Assigned to bed B of a two-bed room. Bed A holds a postoperative patient on day 2 after hip arthroplasty.
VITAL SIGNS
| Time | Temperature | Heart rate | Respirations | Blood pressure | Oxygen saturation |
|---|---|---|---|---|---|
| 14:15 | 100.8 °F | 98 | 24 | 128/74 | 94 percent on room air |
| 18:00 | 101.4 °F | 104 | 26 | 122/70 | 93 percent on room air |
ORDERS
- Chest imaging, two views, today.
- Sputum collection, three specimens, on separate days.
- Regular diet.
- Vital signs every 4 hours.
- No isolation order is written.
MEDICATION RECORD
- Metformin 500 milligrams by mouth twice daily with meals.
- Acetaminophen 650 milligrams by mouth every 6 hours as needed for temperature above 101 °F.
NURSES' NOTES
- 14:40 Patient identity verified using the room number and the admitting diagnosis before the first medication was given.
- 16:05 Bedside monitor alarm sounding; alarm silenced. No assessment documented.
- 17:20 Basin of clear solution left on the bedside table for wound cleansing. Container unlabeled.
- 19:45 Soft wrist restraints applied bilaterally for pulling at the intravenous line. Order on the chart reads "soft wrist restraints as needed for safety."
TASK PANEL A · Precautions State the category, the room, the door state, the respiratory protection, and what happens to the roommate.
TASK PANEL B · Safety goals Mark each of the four notes against the current year's Joint Commission National Patient Safety Goals for the hospital program. The applicable short titles are: identify patients correctly; improve staff communication; use medications safely; use alarms safely; prevent infection; identify patient safety risks; prevent mistakes in surgery.
NPSG EDITION 2026 — current-year, verify at reprint
Margin noteThe missing order is the answer.
TakeawayAn exhibit hides the finding in what is absent as often as in what is written.