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ADMISSIONS/DISCHARGE/TRANSFER

ADMISSION
(ENTERING A HEALTH CARE AGENCY FOR NURSING CARE AND
MEDICAL/SURGICAL TREATMENT)

INVOLVES:
A.
B.
C.
D.
E.

AUTHORIZATION FROM A PHYSICIAN


COLLECTION OF BILLING INFO FROM THE ADMITTING DEPARTMENT
COMPLETION OF THE ADMISSION PROCESS BY NURSING
DOCUMENTING PTS MED HX & PHYSICAL EXAM
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


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 STRETCHER


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
MEAL TIMES
SAFETY MEASURES SUCH AS BEDRAILS
VISITING HOURS
WHAT TESTS ARE SCHEDULED
DIET
ROOM BOUNDARIES
SCHEDULED SURGERY TIME
TIMES FOR DOCTORS VISITS

GATHER INFORMATION
THE NURSE WILL GATHER INFO ABOUT:
MEDICAL ORDERS
TREATMENT
LABORATORY TEST
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
PATIENT 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

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
ACCOMPANY THE PT.UNTIL 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/SUPPLIES & CHART
CHECKS ORDERS/MAKES NEW ADDRESSOGRAPH CARD W/NEW ROOM #

REFERENCES:

Berman, Audrey. ( 2008 ). Fundamentals of nursing. 8th ed. Upper Saddle


River, NJ : Pearson Prentice Hall.
DeLaune, Sue C. ( 2006 ). Fundamentals of nursing: standards & practice.
N 3rd ed. Australia:Thomson Delmar Learning.
Nettina, Sandra N. (2001) The Lippincott Manual of Nursing Practice. 7th Ed
Walnut St. Philadelphia: Lippincot Williams & Wilins
White, Lois. ( 2005 ). Foundations of basic nursing. 2nd ed. Australia: Thomson
Delmar Learning.