Admission Procedures, Abbreviations, and Data Collection

Admission Procedures: First Impressions and First Safety Checks

When a resident is admitted to a New Hampshire long-term care facility or hospital unit, the LNA often completes the practical welcome tasks while the nurse completes the clinical assessment. Your goals are safety, dignity, and accurate baseline data.

Core admission steps for the LNA:

1. Introduce yourself and explain your role in plain language.
2. Orient to the environment: bed controls, lights, thermostat if resident-operated, bathroom location, and how to call for help.
3. Demonstrate the call light and leave it within reach of the dominant or usable hand; verify the resident can activate it.
4. Complete a personal inventory of clothing, glasses, hearing aids, dentures, jewelry, and electronics. List items carefully; many facilities require a second staff signature as witness. Lock valuables per policy or send them home with family.
5. Label belongings and store them in the assigned closet or drawer.
6. Obtain baseline measurements as delegated: height, weight, vital signs, and sometimes intake preferences.
7. Report anything unusual immediately—open wounds, severe pain, confusion that seems acute, or belongings that do not match the inventory list.

Never leave a newly admitted resident without a working call light. Excel Testing and facility policy both treat call-light access as a non-negotiable safety expectation after care and at admission.

Fluid Measurement: The Excel 1 oz = 30 cc Rule

Intake and output (I&O) questions appear on knowledge tests and in skills documentation. Excel Testing sample-style math uses the conversion:

1 fluid ounce (oz) = 30 cubic centimeters (cc)
(Note: 1 cc equals 1 mL; facilities may chart either unit.)

Worked examples:

• A resident drinks 8 oz of water → 8 × 30 = 240 cc
• Juice 4 oz + milk 6 oz → (4 + 6) × 30 = 300 cc
• Half of a 240 cc carton left unfinished: if the full carton is 8 oz (240 cc) and half is consumed, record 120 cc intake—not "half a carton" in narrative alone when I&O is ordered.

Measure liquids at eye level in a graduated container when possible. Include fluids that melt at room temperature (ice cream, gelatin) if facility policy counts them as intake. Record IV fluids only if you are trained and permitted to document them; otherwise the nurse records IV intake.

High-Yield Abbreviations for the NH LNA Knowledge Exam

Abbreviations compress orders and care plans. Misreading them is a common exam trap and a real-world hazard.

If an abbreviation on the chart is unclear, ask the nurse before acting. Do not invent expansions. Facilities may ban dangerous abbreviations; when in doubt, write terms out fully in your notes if policy allows.

Observation Versus Interpretation

LNAs are the eyes and ears of the nursing team, but you must separate observation (objective fact) from interpretation (conclusion or diagnosis).

Observation (report this):

• "Resident ate 25% of lunch."
• "Left lower leg is warm, red, and swollen compared with the right."
• "Resident stated, 'My chest feels tight.'"
• "Blood pressure 88/54; resident dizzy when dangling."

Interpretation (avoid this in documentation):

• "Resident is having a heart attack."
• "Resident is noncompliant and lazy."
• "Infection is spreading in the left leg."

Report the facts to the nurse and let the licensed nurse assess and interpret. On exam questions, the correct answer usually chooses the objective statement or the action of notifying the nurse—not diagnosing.

What to Report Immediately

Some findings cannot wait until end-of-shift charting. Report immediately to the charge nurse when you notice:

• Chest pain, sudden shortness of breath, or blue/gray lips or nail beds
• Sudden change in level of consciousness, new confusion, or slurred speech
• Fall, or a near-fall with injury
• Vomiting blood, black tarry stools, or uncontrolled bleeding
• Vital signs outside the parameters the nurse gave you
• New difficulty swallowing, choking, or suspected aspiration
• Signs of abuse, neglect, or resident-to-resident harm
• NPO resident found eating or drinking
• Missing dentures, glasses, or hearing aids that affect safety

Immediate reporting protects the resident and documents that you fulfilled your duty. Delayed reporting is a frequent scenario on Excel-style knowledge items.

Documentation Accuracy and Excel Skills Tolerances

On the clinical skills exam, documentation is scored. When you measure blood pressure, urinary output, weight, or radial pulse, you must record a value within the allowed tolerance of the evaluator's reading. Habitual guessing, rounding wildly, or copying a previous shift's numbers fails the skill and, in practice, misleads the nurse.

Documentation habits that keep you safe:

• Chart promptly after the task—do not rely on memory hours later.
• Use facility-approved forms or electronic fields only.
• Record the correct units (cc vs oz; lb vs kg) and convert when required.
• Never chart care you did not give (fraudulent documentation is grounds for Board action under RSA 326-B).
• Correct errors per policy (single line, initials, date)—do not erase or cover with white-out if paper charting is used.
• Include the resident's response when relevant ("tolerated transfer without dizziness").

Admission orientation, accurate I&O math using 1 oz = 30 cc, fluent use of BID/TID/QID/PRN/NPO/AC/PC/HS/I&O, objective reporting, and documentation within tolerances form a single competency theme: collect data carefully, communicate it clearly, and never invent what you did not observe.