ADMISSIONS/DISCHARGE/TRANSFER
Feb 05, 2016
ADMISSIONS/DISCHARGE/TRANSFER
ADMISSION(ENTERING A HEALTH CARE AGENCY FOR NURSING CARE AND MEDICAL/SURGICAL
TREATMENT)INVOLVES:A. AUTHORIZATION FROM A PHYSICIANB. COLLECTION OF BILLING INFO FROM THE ADMITTING DEPARTMENTC. COMPLETION OF THE ADMISSION PROCESS BY NURSINGD. DOCUMENTING PT’S MED HX & PHYSICAL EXAME. INITIAL MED ORDERS FOR TREATMENT
RESPONSIBILITIES OF THE ADMITTING DEPARTMENT
GATHER INFO FOR BILLING
INITIATE MEDICAL RECORD
PREPARE ID BRACELET. THIS IS THE SINGLE MOST EFFECTIVE WAY OF IDENTIFYING THE PATIENT
MAY BYPASS IN EMERGENCY SITUATION
AN ADDRESSOGRAPH CARD IS MADE
CONSENT FORMS ARE SIGNED, EG. LIVING WILL, DIRECTIVES, WAIVERS
INITIAL ORDERS OBTAINED
VERBAL REPORT GIVEN TO FLOOR RN
PATIENT IS ESCORTED
NURSING RESPONSIBILITES
PREPARE ROOM
IDENTIFY SELF
ORIENT PATIENT
GATHER INFO
PREPARE ROOM
PROVIDE PERSONAL CARE ITEMS
SUCTION
OXYGEN
IV POLE
BED IN HIGH POSITION IF ARRIVING BY GUERNEY
BED IN LOW POSITION IF ARRIVING BY W/C
BLUE PADS IF NEC.
IDENTIFY SELF
MAKES PT FEEL SECURE
MAKES PT FEEL WELCOME
ALLEVIATES ANXIETY/FEAR
ORIENT PATIENTLOCATION OF NURSE’S STATIONCLOTHES STORAGECALL LIGHTBED CONTROLSLIGHT SWITCHESTELEPHONE POLICYTV CONTROLSMEALTIMES
SAFETY MEASURES SUCH AS BEDRAILSVISITING HOURSWHAT TESTS ARE SCHEDULEDDIETROOM BOUNDARIESSCHEDULED SURGERY TIMETIMES FOR DR VISITS
GATHER INFORMATION
THE NURSE WILL GATHER INFO ABOUT:MEDICAL ORDERSTX’SLABSTESTSDIETACTIVITYPHYSICAL ASSESSMENT WITHIN 24HRS.
TYPES OF ADMISSION
INPATIENT
OUTPATIENT
INPATIENT STAY
LONGER THAN 24HRS
PLANNED:NO IMMEDIATE THREATPLANNED ELECTIVE SURGERY, TESTSPT IS PREPAREDEMERGENCY:UNPLANNEDSTABILIZE IN EMERGENCY ROOM (CHEST PAIN, TRAUMA)DIRECT ADMISSION:UNPLANNEDBYPASS EMERGENCY (VOMITING, DIARRHEA)
OUTPATIENT STAY
LESS THAN 24 HRS
OBSERVATIONAL:HEAD INJURYPREMATURE LABORUNSTABLE VITAL SIGNS
VALUABLES
WHEN DOCUMENTING VALUABLES, MAKE SURE TO USE WORDS LIKE:
WHITE/YELLOW METAL NOT GOLDCLEAR STONE NOT DIAMONDS, RUBIES, ETC.HAVE A WITNESSHAVE NURSE & PT SIGN VALUABLES LISTDON’T FORGET DENTURES, GLASSES, ETC.WHEN TRANSFERRING PT, SIGN-OFF WITH NURSEKNOW YOUR FACILITY’S VALUABLES POLICY
PATIENT COMFORTPROVIDE PRIVACY. (SHUT DOOR & PULL CURTAIN.)ASSIST IF NEEDED TO REMOVE CLOTHING AND PUT GOWN ON.PROVIDE EXTRA BLANKETS IF REQUESTED.COLLECT INFO FOR DATABASE.PERFORM INITIAL ADMISSION ASSESSMENT IF APPROPRIATE. (SOME FACILITIES REQUIRE AN RN TO DO INITIAL ASSESSMENTS).OBTAIN PHYSICIAN ORDERS FOR TX’S, LABS, TESTS, MEDS, ACTIVITY, ETC. WITHIN 24HRS.
COMPONENTS OF A MEDICAL HISTORY
•IDENTIFYING DATA
•CHIEF COMPLAINT
•PERSONAL HX
•PAST HEALTH HX
•HX OF PRESENT ILLNESS
•FAMILY HX
•REVIEW OF BODY SYSTEMS
•CONCLUSION
WHAT TO WATCH FOR IN NEWLY ADMITTED PATIENTS
ANXIETY
LONELINESS
DECREASED PRIVACY
LOSS OF IDENTITY
ANXIETY
APPEARANCEExhibits Separation Anxiety.Sad.Worried.Restless.Reduced Appetite.Insomnia.
HOW TO HELPAcknowledge feelings.Provide explanations and instructions before performing procedures.Inquire about stress due to children/pets/spouse at home.Reassure. Separation Anxiety can cause the elderly to be confused and disoriented.
LONELINESS
Make frequent contact with your patient.
Orient your client.
Allow liberal visitation.
DECREASED PRIVACYPull curtain and close door.Knock.Identify room boundaries, esp. if sharing room.Be careful of exposing patient.Patient feels uncomfortable because of unkempt appearance, so announce visitors.
LOSS OF IDENTITY
Call patient by name they prefer.Allow patient to wear own gown.Display pictures.Give them some choices. (bathing, eating, etc.)
DISCHARGETERMINATION OF CARE FROM A HEALTH CARE
AGENCYMETHOD (ACRONYM)M-MEDSE-ENVIRONMENTT-TREATMENTH-HEALTH TEACHINGO-OUTPATIENT REFERRALD-DIETAMA (Against Medical Advice)PT LEAVES PRIOR TO OBTAINING A WRITTEN ORDER. NURSE REQUESTS PT TO SIGN FORM. IF REFUSES, NURSE MUST LET PT LEAVE AND NOTE REFUSAL TO SIGN AMA IN CHART.
NURSES RESPONSIBILITY FOR DISCHARGING A PATIENT
GATHER BELONGINGS/CHECK INVENTORYARRANGE TRANSPORTATIONINFORM PT OF CHECKOUT TIME TO AVOID BEING BILLED FOR AN EXTRA DAYESCORT UNTIL PT SAFELY INSIDE VEHICLEWRITE DISCHARGE SUMMARYTERMINAL CLEANING. BED STRIPPED AND DISINFECTANT USED. BEDSIDE CABINET RESTOCKED/CLEANED.
TRANSFERDISCHARGING A PATIENT FROM ONE UNIT OR AGENCY AND ADMITTING THEM TO ANOTHER UNITINFORMS PATIENT/FAMILYCOMPLETE TRANSFER SUMMARYSPEAKS WITH NURSE ON TRANSFER UNITTRANSPORTS PATIENT/BELONGINGS/SUPPLIES & CHARTCHECKS ORDERS/MAKES NEW ADDRESSOGRAPH CARD W/NEW ROOM #
WHO/WHAT IS INVOLVED IN A PLANNED DISCHARGE?
PHYSICIAN’S ORDER UNIT SECRETARYCALLS FOR TRANSPORT, COPIES CHART/ORDERS
CARE PROVIDER RN OR SOCIAL WORKER
SAFEKEEPING EXTENDED CARE FACILITY
PATIENT NURSE-EXPLAINS DISCHARGE INSTRUCTIONS TO FAMILY/CARE GIVER
SETTING STANDARDS
*REMEMBER*THE AMERICAN NURSE’S ASSOCIATION SETS THE STANDARD FOR PT CARE & DOCUMENTATION FOR RN’SLPN’S ARE GOVERNED BY JCAHDO NOT USE “SEEMS” OR “APPEARS” IN DOCUMENTATION. IMPLIES DOUBT AND LACK OF KNOWLEDGE.STUDENTS DO NOT NEED TO READ P.126-129(EXTENDED CARE FACILITIES) BUT NEED TO READ NURSING GUIDELINES ON TRANSFERRING A CLIENT, P. 126, GENERAL GERONTOLOGIC CONSIDERATIONS & CRITICAL THINKING EXERCISES.