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    Admission, Discharge and Transfer

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    RNdrei dela Cruz
    The document discusses the admission, discharge, and transfer processes in a healthcare setting. It covers: 1) The admission process which involves physician authorization, collecting billing information, completing admission with nursing, and obtaining initial medical orders. 2) Nursing responsibilities for admission which include preparing the patient's room, identifying themselves, orienting the patient, and gathering health information. 3) The types of admissions including inpatient, usually longer than 24 hours, and outpatient, usually less than 24 hours. 4) The discharge process which involves coordinating medications, environment, treatments, health teaching, and outpatient referrals, as well as the nurses' role in discharge.

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    © All Rights Reserved
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    Admission, Discharge and Transfer

    Uploaded by

    RNdrei dela Cruz
    2K views24 pages
    The document discusses the admission, discharge, and transfer processes in a healthcare setting. It covers: 1) The admission process which involves physician authorization, collecting billing information, completing admission with nursing, and obtaining initial medical orders. 2) Nursing responsibilities for admission which include preparing the patient's room, identifying themselves, orienting the patient, and gathering health information. 3) The types of admissions including inpatient, usually longer than 24 hours, and outpatient, usually less than 24 hours. 4) The discharge process which involves coordinating medications, environment, treatments, health teaching, and outpatient referrals, as well as the nurses' role in discharge.

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    Admission, Discharge and Transfer

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    The document discusses the admission, discharge, and transfer processes in a healthcare setting. It covers: 1) The admission process which involves physician authorization, collecting billing information, completing admission with nursing, and obtaining initial medical orders. 2) Nursing responsibilities for admission which include preparing the patient's room, identifying themselves, orienting the patient, and gathering health information. 3) The types of admissions including inpatient, usually longer than 24 hours, and outpatient, usually less than 24 hours. 4) The discharge process which involves coordinating medications, environment, treatments, health teaching, and outpatient referrals, as well as the nurses' role in discharge.

    Copyright:

    © All Rights Reserved
    Download as PPT, PDF, TXT or read online from Scribd
    Download as ppt, pdf, or txt
    2K views24 pages

    Admission, Discharge and Transfer

    Uploaded by

    RNdrei dela Cruz
    The document discusses the admission, discharge, and transfer processes in a healthcare setting. It covers: 1) The admission process which involves physician authorization, collecting billing information, completing admission with nursing, and obtaining initial medical orders. 2) Nursing responsibilities for admission which include preparing the patient's room, identifying themselves, orienting the patient, and gathering health information. 3) The types of admissions including inpatient, usually longer than 24 hours, and outpatient, usually less than 24 hours. 4) The discharge process which involves coordinating medications, environment, treatments, health teaching, and outpatient referrals, as well as the nurses' role in discharge.

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    The key takeaways are the steps involved in the admission, discharge and transfer process of patients including the responsibilities of different departments and types of admissions.

    The steps involved in the admission process are authorization from a physician, collection of billing information, completion of admission by nursing, documenting medical history and physical exam, and obtaining initial medical orders.

    The responsibilities of the admitting department include gathering information for billing, initiating the medical record, preparing ID bracelets, obtaining consent forms, and providing a verbal report to the floor nurse.

    ADMISSIONS/DISCHARGE/TRANSFER

    ADMISSION
    (ENTERING A HEALTH CARE AGENCY FOR NURSING
    CARE AND MEDICAL/SURGICAL TREATMENT)
    INVOLVES:
    A. AUTHORIZATION FROM A PHYSICIAN
    B. COLLECTION OF BILLING INFO FROM THE
    ADMITTING DEPARTMENT
    C. COMPLETION OF THE ADMISSION PROCESS BY
    NURSING
    D. DOCUMENTING PTS MED HX & PHYSICAL EXAM
    E. 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 PATIENT
    LOCATION OF NURSES
    STATION
    CLOTHES STORAGE
    CALL LIGHT
    BED CONTROLS
    LIGHT SWITCHES
    TELEPHONE POLICY
    TV CONTROLS
    MEALTIMES

    SAFETY MEASURES SUCH


    AS BEDRAILS
    VISITING HOURS
    WHAT TESTS ARE
    SCHEDULED
    DIET
    ROOM BOUNDARIES
    SCHEDULED SURGERY
    TIME
    TIMES FOR DR VISITS

    GATHER INFORMATION
    THE NURSE WILL GATHER INFO ABOUT:
    MEDICAL ORDERS
    TXS
    LABS
    TESTS
    DIET
    ACTIVITY
    PHYSICAL ASSESSMENT WITHIN 24HRS.

    TYPES OF ADMISSION

    INPATIENT

    OUTPATIENT

    INPATIENT STAY
    LONGER THAN 24HRS
    PLANNED:
    NO IMMEDIATE THREAT
    PLANNED ELECTIVE SURGERY, TESTS
    PT IS PREPARED
    EMERGENCY:
    UNPLANNED
    STABILIZE IN EMERGENCY ROOM (CHEST PAIN, TRAUMA)
    DIRECT ADMISSION:
    UNPLANNED
    BYPASS EMERGENCY (VOMITING, DIARRHEA)

    OUTPATIENT STAY
    LESS THAN 24 HRS
    OBSERVATIONAL:
    HEAD INJURY
    PREMATURE LABOR
    UNSTABLE VITAL SIGNS

    VALUABLES
    WHEN DOCUMENTING VALUABLES, MAKE
    SURE TO USE WORDS LIKE:
    WHITE/YELLOW METAL NOT GOLD
    CLEAR STONE NOT DIAMONDS, RUBIES, ETC.
    HAVE A WITNESS
    HAVE NURSE & PT SIGN VALUABLES LIST
    DONT FORGET DENTURES, GLASSES, ETC.
    WHEN TRANSFERRING PT, SIGN-OFF WITH
    NURSE
    KNOW YOUR FACILITYS VALUABLES POLICY

    PATIENT COMFORT
    PROVIDE 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 TXS, 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
    APPEARANCE
    Exhibits Separation
    Anxiety.
    Sad.
    Worried.
    Restless.
    Reduced Appetite.
    Insomnia.

    HOW TO HELP
    Acknowledge 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 PRIVACY
    Pull 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.)

    DISCHARGE
    TERMINATION OF CARE FROM
    A HEALTH CARE AGENCY
    METHOD (ACRONYM)
    M-MEDS
    E-ENVIRONMENT
    T-TREATMENT
    H-HEALTH TEACHING
    O-OUTPATIENT REFERRAL
    D-DIET
    AMA (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 INVENTORY


    ARRANGE TRANSPORTATION
    INFORM PT OF CHECKOUT TIME TO AVOID
    BEING BILLED FOR AN EXTRA DAY
    ESCORT UNTIL PT SAFELY INSIDE VEHICLE
    WRITE DISCHARGE SUMMARY
    TERMINAL CLEANING. BED STRIPPED AND
    DISINFECTANT USED. BEDSIDE CABINET
    RESTOCKED/CLEANED.

    TRANSFER
    DISCHARGING A PATIENT
    FROM ONE UNIT OR
    AGENCY AND ADMITTING
    THEM TO ANOTHER UNIT
    INFORMS PATIENT/FAMILY
    COMPLETE TRANSFER
    SUMMARY
    SPEAKS WITH NURSE ON
    TRANSFER UNIT
    TRANSPORTS
    PATIENT/BELONGINGS/SU
    PPLIES & CHART
    CHECKS ORDERS/MAKES
    NEW ADDRESSOGRAPH
    CARD W/NEW ROOM #

    WHO/WHAT IS INVOLVED IN A PLANNED DISCHARGE?


    PHYSICIANS ORDER

    UNIT SECRETARY
    CALLS 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 NURSES ASSOCIATION
    SETS THE STANDARD FOR PT CARE &
    DOCUMENTATION FOR RNS
    LPNS ARE GOVERNED BY JCAH
    DO 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.

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