AKH / NABH /NSG/ 08

APOLLO KH Doc. No.

HOSPITAL Issue No. 03

Date 21-05-2019
NURSING MANUAL
Page Page 1 of 8

INITIAL ASSESSMENT AND REASSESSMENT

1. Purpose:

The purpose of this Procedure is to provide guidelines for the initial assessment and

reassessment of the patients attending Apollo KH hospital.

2. Scope:

This Procedure is applicable to all those who perform initial assessment in OPD,

In-patient and in Emergency areas.

3. Responsibility:

OPD - The OPD nurses are responsible for completing the initial assessment of out

patients

IP- The Consultants/Residents and the Staff Nurses in the Wards are responsible for

Completing the initial assessment of inpatients

Emergency patients – The Emergency Physician, Residents and the Staff nurses in

Emergency are responsible for completing the initial assessment of emergency patients.

4. Procedure:

4.1 General:

 All patients cared at Apollo KH Hospital undergo an established initial assessment.

 AKH / NABH /NSG/ 08
APOLLO KH Doc. No.

HOSPITAL Issue No. 03

Date 21-05-2019
NURSING MANUAL
Page Page 2 of 8

 The content of such assessments is clearly defined for out-patients, in-patients and

emergency patients for all the specialties.

 AKH has clearly defined the personnel who can perform such assessments.

 AKH defines the timeframe within which the initial assessment is completed.

 The initial assessment for in-patients is documented within 24 hours or earlier as per the

patient’s condition.

 Nutritional needs are also assessed as part of the initial assessment.

 This initial assessment results in a documented plan of care.

 The plan of care also includes preventive aspects of care.

 Results of initial assessment are monitored in subsequent re-assessments. This is also

documented and included in patient’s plan of care.

INITIAL ASSESSMENT OF PATIENTS

 All patients receiving Inpatient, Outpatient or Emergency Services at the hospital have an

initial assessment based upon their individual needs by qualified individuals. During the

initial presentation, all patients assessed by consultants (in case of out-patients) or during

clinical rounds (in case of in-patients).

 The initial assessment results in a documented plan of care.

 AKH / NABH /NSG/ 08
APOLLO KH Doc. No.

HOSPITAL Issue No. 03

Date 21-05-2019
NURSING MANUAL
Page Page 3 of 8

 The following are authorized to perform assessments related to their functional areas:

o Doctors including consultants

o Dieticians

o Nurses

o Physiotherapists

 Initial assessment also includes, as appropriate

o Medical and pain status

o Nursing Assessment

o Nutritional needs

o Plan of care

 The initial assessment for in-patients is completed and documented as soon as possible.

Assessment includes as appropriate:

 Diagnostic testing procedures which includes:

o Laboratory

o Invasive/non-invasive procedures for diagnostic imaging

 Condition specific

 The applicable scope of assessment for each discipline or various categories of patients will

be further defined in departmental procedures.

 The Admitting Physician is required to countersign in patient medical record within 24 hours
 AKH / NABH /NSG/ 08
APOLLO KH Doc. No.

HOSPITAL Issue No. 03

Date 21-05-2019
NURSING MANUAL
Page Page 4 of 8

 All Telephonic orders by a physician are required to be countersigned by him/her on the

patient medical record within 24 hours.

Scope and Responsibilities of Involved Disciplines:

MEDICAL STAFF

o The admitting consultant is the leader of the patient care team in the planning and provision

of care throughout the continuum.

o Each patient undergoes an initial assessment by a medical staff member, who assesses the

physical and medical status of the patient to identify appropriate care needs or the need for

further assessment.

o Assessments by the medical staff are documented in the following reports:

o The Assessment must document the following criteria at a minimum:

1. Patient Complaints and history

2. Vital signs

3. History of allergies

4. Medication History

5. Family history

6. Physical examination findings

7. Active Problem List

8. Reason For admission/Provisional diagnosis

 AKH / NABH /NSG/ 08
APOLLO KH Doc. No.

HOSPITAL Issue No. 03

Date 21-05-2019
NURSING MANUAL
Page Page 5 of 8

9. Treatment Plan

Specific Assessment Criteria will be as per care setting. Other assessments are performed

and documented by Nutritional Services, Nursing Services, Rehabilitation Services, other

applicable functions.

EMERGENCY DEPARTMENT

o All patients presenting for treatment in the emergency department receive a medical

screening by the Emergency Physician immediately.

o Patients seeking medical care are seen by the Emergency Physician

o The Emergency Physician assesses and evaluates each patient prior to making any

referrals or decisions regarding disposition.

An assessment is performed by the Physician for each patient. The assessment is recorded in the

Patient Case record.

Record includes, but is not limited to:

o Patient complaints

o Brief history of present illness

o Any similar illness in past or in family.

o Treatment prior to arrival to the Emergency

 AKH / NABH /NSG/ 08
APOLLO KH Doc. No.

HOSPITAL Issue No. 03

Date 21-05-2019
NURSING MANUAL
Page Page 6 of 8

o Vital signs and general physical examination and mental status examination

o Initial and continued treatment during Emergency visit.

Definitions:

o Emergent: Patients who have conditions that may result in loss of life or limb if not

treated immediately.

o Urgent: Patients that require urgent care, but will not generally cause loss of life or

permanent severe impairment if left untreated for several hours.

o Non-urgent: Patients in this category generally need evaluation and treatment, but time

is not a critical factor.

ICU

Within the first 15 minutes, a complete initial assessment is done. Department specific forms

supplement and provide additional assessment and documentation as it pertains to

operative/invasive procedures.

Dietetics

All patients admitted to our hospital will have a nutritional screen completed within 8 hours of

admission (during routine hours and within 12 hours during non-routine hours) by dieticians and

provide nutritional assessments, to establish nutritional plans.

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APOLLO KH Doc. No.

HOSPITAL Issue No. 03

Date 21-05-2019
NURSING MANUAL
Page Page 7 of 8

Rehabilitation

The physiotherapist's initial assessment strives to identify problem areas contributing to or

having the potential to contribute to functional losses. Accordingly a treatment plan is

developed.

A physiotherapy assessment is completed within 24 hours of referral

Time Frame:

a. The initial assessment of outpatients shall be completed within ½ hour on patient

reporting to the hospital. The initial assessment of an in-patient shall be

completed within ½ hour the patient gets admitted.

b. For emergency patients the initial assessment shall be completed within 5 min the

patient is brought to the emergency ward.

c. Initial Assessment of the patient shall be completed by a assigned nurse and to be

re assessment to be done as per requirement of patient.

Content of Nursing Assessment: Form:

The In - patient Nursing Assessment Form shall include

 Patient’s Name, age, Sex, PID No, Bed No and Doctor Name

 Vital parameters
 AKH / NABH /NSG/ 08
APOLLO KH Doc. No.

HOSPITAL Issue No. 03

Date 21-05-2019
NURSING MANUAL
Page Page 8 of 8

 Orientation to the Patient Environment

 Allergies/Adverse Reactions

 Fall Risk Assessment

 Ability to perform activities of Daily life

 Social History

 Current Medications

 Pain Assessment Scale

 Psychological Status

 Nutritional Status

 Nursing Needs

5. Records:

 EMR Assessment Form

 OP Nursing Assessment Form

 Nursing Admission Assessment

6. Annexures:

Nil

7. References:

Nil