Table 1. Essential clinical dataset elements.

	Section label	Data element	Evidence -Based Practice	Regulatory	Evidence from nursing Practice
1	General information	Preferred spoken language		X
	These data elements only apply if Spoken Language is other than English
1a	Interpretive services	Interpretation modality		X
1b	Interpretive services	Interpreter services declined reason		X
1c	Interpretive services	Interpreter staff/in-house		X
1d	Interpretive services	Interpreter name		X
1e	Interpretive services	Interpreter ID number		X
1f	Interpretive services	Interpreter agency name		X
2	General information	Preferred written language		X
3	General information	Preferred mode of communication		X
4	General information	Sensory deficits		X
5	General information	Sensory devices needed		X
6	General information	Sensory items at bedside		X
7	General information	Preferred name		X
8	General information	Admission information given by		X
9	General information	Pregnancy status (only for female patients)		X
10	Advance directives	Advance directive		X
11	Advance directives	Patient wishes to receive further information on advance directives		X
12	Infectious disease risk screening	Recent travel history (Patient)		X
13	Infectious disease risk screening	Recent travel location (Patient)		X
14	Infectious disease risk screening	Family member travel history		X
15	Infectious disease risk screening	Family member recent travel location		X
16	Infectious disease risk screening	Infectious disease symptoms—20 Y/N answers		X
17	Infectious disease risk screening	Tuberculosis risk factors—8 Y/N answers		X
18	Infectious disease risk screening	Tuberculosis description		X
19	Infectious disease risk screening	Date of treatment for TB		X
20	Infectious disease risk screening	Verify droplet, contact isolation for Ebola		X
21	Infectious disease risk screening	Verify airborne, contact isolation for MERS		X
22	Infectious disease risk screening	Condition compromising immune system—22 selections		X
23	Nutritional screening	Home diet		X
24	Nutritional screening	Nutritional risk factors	X
25	Columbia Suicide Severity Rating Scale 9	Have you wished you were dead or wished you could go to sleep and not wake up?	X
26	Columbia Suicide Severity Rating Scale 9	Since last asked, have you actually had any thoughts of killing yourself?	X
27	Columbia Suicide Severity Rating Scale 9	Since last asked, have you been thinking about how you might kill yourself?	X
28	Columbia Suicide Severity Rating Scale 9	Since last asked, have you had these thoughts and had some intention of acting on them?	X
29	Columbia Suicide Severity Rating Scale 9	Since last asked, have you started to work out or worked out the details of how to kill yourself? Do you intend to carry out this plan?	X
30	Columbia Suicide Severity Rating Scale 9	Since last asked, have you ever done anything, started to do anything, or prepared to do anything to end your life?	X
31	Educational needs/learning style	Barriers to learning		X
32	Educational needs/learning style	Patient learning style preference		X
33	Visitors	Will anyone be staying with you while in the hospital?		X
34	Visitors	Relationship to patient		X
35	Visitors	Visitor Name		X
36	Visitors	Visitor restrictions (Y/N)		X
37	Visitors	free-text comment
38	Anticipated discharge needs	Discharge to		X
Additional elements that are part of the longitudinal patient record and validated/captured by the RN as part of the Admission Intake process
	Social history	Tobacco, alcohol, substance use, abuse and neglect, nutrition and diet		X
	Allergies		X
	Home medications	Home medications and compliance		X
	Immunizations	Influenza		X

Abbreviations: MERS, Middle East respiratory syndrome; TB, tuberculosis.