Admission, Transfer, and Discharge

What are the 2 steps of the “Welcome” part of the admitting procedure

1. Greet patient and family

2. Make patient feel comfortable

What are the 3 steps of the Verification part of the admitting procedure?

1. Identify patient: Confirm identification

2. Check insurance

3. Confirm reason for admission

Why do we determine the Level of Care during admission?

To ensure the patient is placed in the appropriate unit to receive the right monitoring, treatment, and nursing resources for safety and recovery.

What are the 3 steps of the Identification part of the admitting procedure?

1. Affix at admitting department/point of entry

2. JCAHO safety requirement

3. Use at least 2 identifiers:

Why do we explain the patients Rights and Responsibilities? (3)

To:

Inform them of their role in their care

Protect their legal and ethical rights’

Ensure they understand what to expect and what is expected of them during their hospital stay

Why do we Advance Directives during admission?

To ensure the patient’s healthcare wishes are:

Known

Documented

Respected

in case they become unable to make decisions for themselves.

What are the 4 steps of the General Consents part of the admitting procedure?

1. Consent to be treated in the hospital

2. Consent to be treated by hospital personnel

3. Agreement for unit/bed assignment

4. Teaching hospitals: Consent for treatment by students

Why do we Escort the Patient to Their Room during admission?

To ensure patient is comfortably taken to assigned room

What are the 2 steps of the History and Privacy part of the admitting procedure?

1. Obtain complete patient history

2. Ensure privacy (HIPAA compliance)

Why do we do Admission Assessment?

To get a baseline of the patients health

Why do we Review Medications during admission?

Review current medications and verify accuracy

Why do we get informed consent?

To ensure the patient:

1. Understands and agrees to the proposed treatments or procedures

2. Including the risks, benefits, and alternatives, protecting their autonomy and legal rights.

Why do we do Health Teachings during admission?

To educate the patient

What are the 3 steps of the Initial Measurements and Assessment part of the admitting procedure?

1. Vital signs

2. Body assessment

3. Height, weight, allergies

Why do we give the Physician Notification during admission? (3)

1. Inform the doctor that the patient has arrived

2. Share initial findings

3. Ensure timely review and initiation of the patient’s plan of care.

What are the 3 steps of the Plan of Care during admission?

1. Review physician’s plan of care

2. Formulate nursing diagnoses

3. Reminder: “If it’s not documented, it’s not done!”

What do we do once the patient is in the room? (4)

1. Patient safety and comfort

2. Ensure bed locked and in lowest position

3. Use siderails

4. Call light, telephone, TV remote in easy reach

For transfers, where does the report go? (4)

1. Other Unit

2. Hospital

3. ALF

4. Skilled Nursing Facility Hospice

What are the reasons for a transfers?

1. Increased/decreased acuity

2. Stipulations of 3rd party payer

3. Patient or family preference

What are the nurse’s responsibilites during a transfer? (7)

1. Obtain physician’s order and pt’s consent

2. Assess pt’s condition; EMTALA (emergency medical treatment and active labor act)

3. Complete medication reconciliation & transfer forms

4. Determine level of transport

5. Telephone report to receiving nurse

6. Escort patient

7. Document

What are the reasons for discharge? (2)

1. Condition improves (Home)

2. Patient/family request (To die at home)

What are the discharge preparations which begin at admission? (3)

1. 3 phases of discharge process

2. Ensure prescription for discharge

3. May need to involve case management/social work dep

What are the 3 phases of the discharge process?

1. Acute

2. Transitional

3. Continuing care