Nursing Notes on Patient Admission, Transfer, and Discharge

Admission

Entry of a patient into the health care facility, beginning in the admissions department.

HIPAA

Health Insurance Portability and Accountability Act which addresses patient privacy.

Admission

Entry of a patient into the health care facility, beginning in the admissions department.

HIPAA

Health Insurance Portability and Accountability Act which addresses patient privacy.

Common Patient Reactions

Common responses to hospitalization including fear of the unknown, loss of identity, and loneliness.

Nursing Interventions

Actions taken to support patients' reactions during hospitalization, including empathy and respect.

Cultural Considerations

Considerations involving the provision of care respecting the patient's cultural practices and involving family in decision-making.

Nursing Process

A systematic approach including assessment, planning, implementation, and evaluation in patient care.

Patient Self-Determination Act of 1991

Legislation that addresses a patient's right to refuse or accept medical treatment.

Discharge Planning

A systematic process for planning patient care after leaving the hospital, requiring multidisciplinary involvement.

Transfer

The process of moving a patient to another unit or facility due to improved or critical condition.

Patient Reactions to Hospitalization

Reactions such as disorientation and separation anxiety that nurses should anticipate.

Admitting Procedure

The steps taken by a nurse to admit a patient including checking ID and assessing immediate needs.

Nurse's Responsibilities

Tasks a nurse must complete prior to a patient's arrival including preparing the room and greeting the patient.

Discharging a Patient

The process involving written instructions and documentation of understanding for the patient for home care.

Discharge Against Medical Advice (AMA)

When a patient leaves a facility without a provider's discharge order.

Documentation

The careful documentation required during patient transfer and discharge processes.

Evaluation

The step of the nursing process to assess the effectiveness of care provided.

Health History

Initial patient assessment conducted by the nurse upon admission.

Multidisciplinary Action

Involvement of multiple health care professionals in the discharge planning process.

Orientation to the Unit

An explanation given to patients about hospital routines and their new surroundings.

Safety of Facility

Legal rights and responsibilities regarding patient discharge against medical advice.

Nurse's Role in Discharge

The nurse prepares and informs the patient about discharge details and instructions.