ADMI SSI ONS/DI SCHARGE/TRANSFER

ADMI SSI ON
(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
RESPONSI BI LI TI ES OF THE ADMI TTI NG 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

NURSI NG RESPONSI BI LI TES

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.
I DENTI FY SELF
MAKES PT FEEL SECURE

MAKES PT FEEL WELCOME

ALLEVIATES ANXIETY/FEAR
ORI ENT PATI ENT
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 I NFORMATI ON
THE NURSE WILL GATHER INFO ABOUT:
MEDICAL ORDERS
TXS
LABS
TESTS
DIET
ACTIVITY
PHYSICAL ASSESSMENT WITHIN 24HRS.
TYPES OF ADMI SSI ON


INPATIENT


OUTPATIENT
I NPATI ENT 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)

OUTPATI ENT 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
PATI ENT 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 MEDI CAL HI STORY
IDENTIFYING DATA
CHIEF COMPLAINT
PERSONAL HX
PAST HEALTH HX
HX OF PRESENT ILLNESS
FAMILY HX
REVIEW OF BODY SYSTEMS
CONCLUSION
WHAT TO WATCH FOR I N NEWLY ADMI TTED PATI ENTS
ANXIETY

LONELINESS

DECREASED PRIVACY

LOSS OF IDENTITY
ANXI ETY
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.
LONELI NESS
Make frequent contact with your
patient.

Orient your client.

Allow liberal visitation.
DECREASED PRI VACY
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 I DENTI TY
Call patient by name
they prefer.
Allow patient to
wear own gown.
Display pictures.
Give them some
choices. (bathing,
eating, etc.)




DI SCHARGE
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 RESPONSI BI LI TY FOR DI SCHARGI NG A PATI ENT
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/SUP
PLIES & CHART
CHECKS ORDERS/MAKES
NEW ADDRESSOGRAPH
CARD W/NEW ROOM #

WHO/WHAT I S I NVOLVED I N A PLANNED DI SCHARGE?
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
SETTI NG 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.