9/23/’21 – Additional Notes (Ma’am Hernandez) consultant :on board; under to them

is med resident)
 Roles in Admission (WARD)
 Admitting nurse
- ask the ward if there is vacant
- reservations for room: 6 hours only
- call the ward, then ask the ff:
*name, age, cc, & preparation
needed
 Pt arrived in the ward – via wheelchair /
stretcher
 General / Executive check-up: pt not
sick but needed a thorough check-up
either yearly/ordered
 Out on Past – like OPD; can go out the
hospital
 Greet pt with a smile, then with a little
overview (explain briefly to patient why
he/she is admitted); give instructions
about the room/cautions/warnings
 Transcribe all medical order then carry it
out. Go back again to pt bedside and
explain the med/procedures
 Before carrying out the orders: CHECK
all attachments and etc of the pt
 Give THOROUGH instruction
 The BEST person to give instructions:
ABLE TO UNDERSTAND (1st – patient
as long as able; 2nd - watcher) Patient:
Goal is to be INDEPENDENT from the
condition
 Encoded (“requested”)– not allowed to
be written in the Nurse’s notes
 Slip with watcher – no pondo or
discount so need to be paid by the
watcher first before carrying out
 ASSESS & ASSIST
 Spot O2 – check the O2 sat (call RT
dept)
- Be checked by pulse oximeter
- If low O2 level: stay the pulse
oximeter until Dr. tells so (remove) –
for monitoring
 D/C O2 & other procedures – always
assess and monitor, then document
 Status quo – no improvement; no
changes; no deterioration
- Discharge summary: data of pt, cc,
brief clinical history; physical exam
findings, labs
- Request family member to
photocopy the lab results from
medical records accompanied by
the orderly (allowed to bring the
chart and photocopy)
2. Discharge AMA:
- Pt sign the waiver
- Dr explain all the advantages and
risks of their decisions
- Give instructions r/t to their health
- If with tubes or gadgets: ALL will be
removed b4 transport (to the vehicle)
3. MGH or chronic
- Let family participate in the way of
care; give instructions & teach them
(chronic)
- Discharge & home medication
instructions – done by the Dr. ;
discuss with the family member &
reinforce by asking (MGH well)
- METHOD (2 copies)
- Before going out: check all pt things
- Discharge per wheelchair with
accounting clearance (write @end of
nurse’s notes)
- Exit clearance / discharge slip =
write time with sign
- Same time should be reflected &
orderly will facilitate the discharge
process- by schedule
- If will request for MED CERT -
inform the DR. ahead of time

 Patient Discharge
- To be transferred to other hospital
- MGH or refer for chronic care
- Death (Post Mortem)

1. If to be transferred to other hosp:

- Request family member to go to the
hospital to assess the hospital’s lay-
out (if magustuhan or nope)
- Doctor will be doing DISCHARGE
SUMMARY (written by intern; if
none-med resident will do so;