Admission-Transfer & Discharge

NCM 103 Fundamentals of Nursing

Prepared by: NCM 103 Instructors

 Learning Objectives

1. Learn the importance of Admission,

Transfer and Discharge
2. Understand the different roles of Nurses
in Admission, Transfer and Discharge
3. Identify the Nursing responsibility in
Admission, Transfer and Discharge
 ADMISSION, TRANSFER AND DISCHARGE
A.) ADMISSION
• is the official entry of person in a
health care facility
• patient is the primary source of
information
• family may provide a useful
information that will help the nurse
to carry out assessment
 ADMISSION, TRANSFER AND DISCHARGE
RESPONSIBILITIES OF A NURSE DURING ADMISSION
1.Reviewing the physicians order
• Identify the reason for admission and
plans of medical care
• These tasks may require immediate
communication to other departments
• Some task may also be delegated to a
unit secretary or clerk
 ADMISSION, TRANSFER AND DISCHARGE
2. Meeting the person’s
immediate needs
• Brief general assessment is
needed to ascertain immediate
needs
• Immediate needs can be either
physical or psychosocial
3. Providing introduction and orientation
• Introduce the patient and family members to the
people in the environment
• Greetings should convey interest and concern for the
patient
• Explain what will occur during the admitting process
• An explanation of all items for the patient use is
needed during the orientation
• Explain in detail anything you expect the patient has
to do, from what exactly what to wear under hospital
gown
4. Performing a baseline assessment
• Varies from one facility to another based on common
needs and problems of the patient
• Admission assessment includes temperature, pulse
rate and respiratory rate
• Height and weight might be included
• Laboratory values as part of the baseline assessment
depending on diagnosis
• In some facilities patient are taken to the laboratory
are on the way to the unit
• Nursing history is obtained ( allergies, current
medications and perception of the chief complain)
interview is used to gather subjective information.
5. Caring for personal property
• There should be a routine for
checking and noting all personal
items a patient brings or wear to
the facility
• Items kept should be marked with
patient name particularly in a long
term facility
6. Documentation
• Documenting all parts of the
admission process is essential
to legal records
• Baseline assessment serves as
reference throughout the period
of care
• The nurse is responsible for
other records like Kardex,
medication record etc
 ADMISSION, TRANSFER AND DISCHARGE
B.) TRANSFER
• Within the unit or to other
facility
• Reason for transfer:
a) Patient deteriorates
b) Environment interfere with
the patient’s resting time.
RESPONSIBILITIES OF A NURSE DURING TRANSFER
1. Obtaining order to transfer
• The physician write the order
• In an emergency case, the transfer
is immediately done and the
physician write the order later
2. Notifying appropriate persons
• It includes nursing
supervisor, admitting
department personnel, the
patient’s family and the unit
or facility that will receive
the patient
3. Interacting with the patient
• Inform the patient about the
transfer plans
• If signs of anxiety is noted
about the transfer, spend
time with the patient
4. Caring for personal property
• Make sure that all
personal property is
checked and accompanies
the patient being
transferred
5. Completing and duplicating records,
assessment data and care plan
• Gather all assessment forms and care plan,
bedside equipment and plastic identification card
• Review assessment, care plan for completeness
and accuracy
• Make an appropriate entry in the record
concerning the transfer
• Update the data and care plan just before the
patient leaves
• Give the said documents to the authorized persons
6. Arranging transportation
• When patient transferred to other
facility the discharge planner often
makes arrangement for an ambulance
• When critical care is needed nurse
make arrangement particularly when
the patient needs special equipment
• If patient is to be transferred to another
unit of the facility decide whether pt is
transferred by wheel chair or stretcher
7. Giving report
• Same facility: call the new unit
and go with the patient
• Another facility: duplicate the
records and make telephone call
to the receiving staff, give them
comprehensive report regarding
patient
 ADMISSION, TRANSFER AND DISCHARGE

C. DISCHARGE
• Is the official departure of
the patient from the health
care setting.
RESPONSIBILITIES OF A NURSE DURING DISCHARGE
1. Obtaining order for discharge
• An order is needed
• If ordered verbally, prepare home
meds and assess patient prior to
discharged but wait for the
written discharge order before
finally discharging the patient
2. Planning for continuity of care
• Plan are made for continuity of care
for patient needed a long -term care
or those patient who went home
earlier than they used to be
• Identify the patient need that can be
address by the community
• Make referral to agencies that provide
variety home services
• Encourage patient to call the unit after
discharge if they have concerns
3. Providing patient teaching
• Talk with the patient regarding the
planned of his departure
• Inform the patient about the meds,
treatment activity, diet and
continued health supervision
• Teaching will be done earlier but not
earlier than the day of discharge
4. Preparation for the final assessment
• Do the final assessment ( Physical
status, Psychosocial and ability to
continue or participate in care)
• Report if patient is not ready for
discharge
5. Caring for personal property
• All personal belongings should
be given to the patient
including those that were
purchased
• Use the checklist that was use
during the admission
6. Performing business function
• Before the patient leaves
the facility, the patient or
family should consult
business office for the
financial matters
7. Documentation
Document the following:
a. Plan for the continuity of care
b. Patient teaching
c. Final assessment
d. Disposition of personal belongings
e. Completion of the business function
Thank you!