Admission Checklist  ·  Pro

Admit New Residents Safely and Reconcile Every Medication

Guide nurses through every step of a new resident admission, from code status and transfer documents to medication reconciliation and resident rights.

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Skilled Nursing Facility New Resident Admission & Medication Reconciliation Checklist
Resident Full Name
· · ·
Date of Birth
· · ·
Room & Bed Number
· · ·
Submit

The Skilled Nursing Facility New Resident Admission and Medication Reconciliation Checklist gives your nursing team a structured, step-by-step workflow for admitting new residents safely and consistently. It captures essential details such as the resident's full name, date of birth, room and bed number, admission date, where they were admitted from, primary payer source, and code status. Staff can check off required admission documents and upload transfer paperwork, including the discharge summary, orders, and medication list. Completed nursing admission assessments and referrals are recorded in the same organized place.

Designed for admission nurses, directors of nursing, MDS coordinators, and long-term care teams, the template includes a dedicated medication reconciliation section. Nurses document allergies and reactions (or NKA if none), confirm that at least two medication sources were reviewed, enter the reconciled medication list, flag any discrepancies found, and record that follow-up was completed. A final section verifies that resident rights, consents, and facility orientation were reviewed and signed off.

Care transitions are among the highest-risk moments for medication errors, and incomplete admission paperwork can create compliance and survey headaches. A standardized digital checklist helps your facility catch medication issues early, keep documentation consistent across shifts, and maintain a clear record of every admission. Customize the fields to match your policies, complete the form on any device, and start admitting residents with greater confidence today.

4 Pages
19 Questions
~6min To complete
Free No credit card needed
Field types Multiple Choice ×4 Dropdown ×3 Full Name ×2 Date ×2 choicematrix ×2 Short Text File Upload Long Text Table / Grid termsandconditions Signature

Questions in this template

Free template

The exact questions included — customize any of them to fit your needs.

Page 1 Resident & Admission Details 7 questions
Resident & Admission Details
1 Resident Full Name * Full Name
2 Date of Birth * Date
3 Room & Bed Number * Short Text
4 Admission Date * Date
5 Admitted From * Dropdown
6 Primary Payer Source * Dropdown
7 Code Status * Dropdown
Page 2 Admission Documents & Nursing Assessments 3 questions
Admission Documents & Nursing Assessments
1 Admission Documents Checklist * choicematrix
2 Upload Transfer Documents (discharge summary, orders, medication list) File Upload
3 Nursing Admission Assessments & Referrals * choicematrix
Page 3 Medication Reconciliation 5 questions
Medication Reconciliation
1 Allergies & Reactions (enter NKA if none) * Long Text
2 Medication Sources Reviewed (select at least two) * Multiple Choice
3 Reconciled Medication List * Table / Grid
4 Discrepancy Types Identified * Multiple Choice
5 Reconciliation Follow-Up Completed * Multiple Choice
Page 4 Resident Rights, Orientation & Sign-Off 4 questions
Resident Rights, Orientation & Sign-Off
1 Rights, Consents & Orientation Completed * Multiple Choice
2 Admitting Nurse Name * Full Name
3 I attest that the information in this admission checklist and medication reconciliation is accurate and complete to the best of my knowledge and that all medication discrepancies have been communicated to the prescriber. * termsandconditions
4 Admitting Nurse Signature * Signature

How to use this template

Click "Use This Template Free" to open it in the FormBuilder editor. From there you can add, remove, or reorder fields with drag-and-drop, switch themes for instant restyling, add your logo, configure email notifications, and set your success message. When ready, publish with a unique link and start collecting responses immediately.

  • Ready-to-use structure — pre-configured fields out of the box
  • Applied "Umber" theme — fonts, colors, and layout already set
  • Mobile-responsive — works on every device without extra configuration
  • Fully editable with drag-and-drop — change anything in seconds
  • Free to use on any plan, no credit card required

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Category Checklist
Subcategory Admission Checklist
Theme Umber
Badge Pro
Price Free
Coding required None

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