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SFN Tool

New Admission Note Builder

SFNs New Admission Note Builder — Version 1

First working version for testing and education. Generated notes must be reviewed by the nurse before use.

Enter the resident's admission details below. When you click Generate Note, a complete, organized New Admission Nursing Note is produced — ready to review and copy into your charting system.

Active Resident
Resident A
Each resident is kept separate. Nothing carries over between residents.
Autosave on

Charting Mode

Training/test mode removes real resident, provider, and nurse names from the generated note. Switch to final charting mode only when documenting an actual resident.

Training/Test Mode uses fictional or de-identified information for nurse education, practice, and testing. Do not enter real resident identifiers.

Admission Details

Resident History / Source of Information

Resident Status

Height / Weight

Select how the weight was obtained. Follow facility policy/protocol for obtaining and documenting weights.

Mobility / Transfer Equipment

Vital Signs

Respiratory

Skin

Select skin finding and location. Add details only if assessed. Do not document wound stage, measurements, drainage, treatment, or provider notification unless verified.

Pain

Document pain only if assessed. If pain assessment is pending, do not generate pain findings. Do not add medication, intervention, provider notification, family notification, or resident response unless entered by the nurse.

Diet / Nutrition

Notification

Document provider and family/responsible party notification only if completed. Nothing is generated unless selected or typed.

Advance Directive

Code status and advance directive are not the same. Verify per facility policy/protocol and documentation/orders before charting.

Follow-up / Plan

Hazel Marie — SFNs Documentation Assistant

Hazel Marie writes in Cynthia's practical LTC/SNF floor-nurse voice.

Hazel Marie asks one question at a time, never invents clinical facts, and never diagnoses. Hazel Marie organizes the answers you entered above into a structured nursing note. Always review, edit, and verify before copying into the facility EHR.

Fill in the form above, then ask Hazel Marie to organize your answers — or ask a documentation question. Hazel Marie will guide you one step at a time.

3-Day Note Review

Paste the last 3 days of nursing notes to get a nurse-friendly review. The summary uses only the notes you paste, does not diagnose, and does not replace nursing judgment.

Draft

Form entries, the generated note, and the corrected version are auto-saved on this device.