Chapter 20 Admission, Transfer, and Discharge

Admission to Healthcare Facilities

Overview of Admission Process

• Direct Admission: Patients may be admitted directly from a physician's office to a hospital prior to admission.
     - Variability exists in the direct admission process among different hospitals.
• The nurse plays a crucial role during this process, including receiving or providing information regarding patient transfers.
     - Documentation: It is essential to document the source of the information provided regarding transfers.
• The nurse's demeanor is important; they should maintain a positive approach when interacting with patients.
     - Non-verbal Communication: Eye contact should be made, and the nurse should avoid speaking in a rushed manner.

Patient Reactions to Admission

• Patients' emotional responses during admission can vary widely, but common feelings include:
     - Fear: Fear of the unknown in a new environment.
     - Anxiety: Particularly related to separation from family or familiar surroundings.
     - Loss of Control: Patients may feel they have lost control over their circumstances.
• Additional psychological reactions include:
     - Loss of Identity: Patients may feel a loss of personal identity due to the hospital environment which alters their attire and decisions.
         - Modesty and Attire: Patients might struggle with changing into hospital gowns and the implications it has on their privacy.
         - Decision Making: Patients may find they are not in charge of their healthcare decisions upon admission.

Cultural Considerations in Communication

Box 20-2 Culturally Savvy Communication

• Effective Communication: Navigating communication with patients from diverse backgrounds can be challenging, especially with cultural differences and potential language barriers.
     - Addressing Patients: Always greet patients formally using titles (Mr., Mrs., Miss, or Ms.) and their last name, unless they request otherwise.
     - Avoid Slang: Utilize clear and effective language.
     - Language Barriers: Provide interpreters for patients with language differences; rely on family members for translation only if specifically requested.
     - Cultural Context: Avoid using ethnic dialects unless fluent, as this can lead to misunderstandings or disrespect.
     - Eye Contact: Be mindful of cultural variances regarding eye contact, which can be interpreted differently across cultures (sometimes viewed as disrespectful).
     - Facial Communication: Patients should be positioned to see the nurse’s face for lip-reading if necessary, paying attention to nonverbal cues (facial expressions, body language).
     - Respect Differences: Exhibit respect for each patient's beliefs relating to healthcare, family, traditions, and religion, and clarify any misunderstood communications.

Admitting Procedure

• Patient's Chart Initiation: Begins at the time of admission.
     - Includes completing various admission forms specific to the hospital’s policies.
• Essential data collected includes:
     - Demographic Data: Personal identifying information of the patient.
     - Authority to Treat: Verification of consent for treatment.
     - Identification Bands: Safety measure for correct patient identification.

Legal Considerations for Minors

• A minor may legally authorize their treatment if they are an emancipated minor.
     - True Statement: It is acknowledged legally (Correct answer: A. True).
     - Variances exist by state regarding the age of majority; usually, it is 18 years.

Nursing Responsibilities during Admission

• The nurse must follow several key duties when admitting a patient:
     - Introduction: Properly introduce oneself to establish rapport.
     - Admission Kit: Provide the patient with necessary items or information.
     - Personal Belongings Inventory: Account for all personal items brought by the patient.
     - Data Collection: Conduct an initial assessment, which includes:
         - Gathering both objective and subjective data.
         - Documenting patient history and vital signs.
     - Analysis of Data: Evaluate collected data for any care considerations.
     - Discharge Planning: Initiates at admission and continues through the patient’s stay.

Discharge Process Overview

• Primary Goal: To ensure the patient’s hospital stay is as brief as possible without compromising health.
     - Discharge Planning: It is a continuous process starting from admission to facilitate a smoother discharge.
• The discharge process includes several steps:
     - Provider's Order: Always check for healthcare provider discharge orders including patients wanting to leave AMA (Against Medical Advice).
     - Medication Reconciliation: Ensuring no duplicate medications are prescribed and verifying that dosages are correct.
     - Providing Instructions: Offer discharge instructions, medications, and essential patient education.
     - Personal Items: Assist the patient in gathering their belongings and valuables.
     - Documenting Condition: Record the patient’s condition and vital signs prior to discharge.
     - Assisting Out: Help the patient to their transportation once ready.
     - Cleaning Notification: Notify housekeeping of room availability post-discharge.

Discharge Planning Details

• Education provided during discharge planning includes:
     - Patient Education: Discuss the patient's illness impact, dietary alterations, safe medication use, and techniques for home treatment.
     - Adaptation Strategies: Teach methods to adapt to daily living needs.
     - Support Groups & Resources: Recommend support groups and provide a comprehensive list of community resources.
     - Referrals: Offer referrals to appropriate agencies for ongoing care post-discharge.
     - Long-Term Care Assistance: Help families to locate long-term care or assisted living options as needed.

Physician’s Discharge Order

• The physician must provide a written discharge order which may include a paragraph on leaving against medical advice (AMA).
     - Utilize a specific Leaving AMA form when necessary.

Rationale for Leaving AMA Form (Clicker Question 2)

• In situations where a patient opts to leave against medical advice, it is crucial to:
     - Attempt persuasion by explaining the risks involved in leaving prematurely.
     - If persuasion fails, you must have the patient sign a Leaving AMA form to document their choice. (Correct answer: B)

Reconciliation of Medications

• Essential steps in medication reconciliation include:
     - Ensuring no duplicate medications existed on the list.
     - Confirming that dosages are correct and that any changes were intentional and documented.
     - Making sure all medications from the patient's home have been appropriately acknowledged (continued or discontinued).
     - Providing prescriptions for any new medications initiated during the hospital stay.
     - Offering patients a written list of their medications upon discharge.
  

Components of Discharge Form

• The discharge form should include critical information:
     - When to schedule follow-up with a physician.
     - A comprehensive medication list with usage instructions and potential side effects.
     - Dietary modifications or activity restrictions required post-discharge.
     - Warning signs and symptoms that need physician notification.
     - Information on ongoing care or treatments to be continued at home.

Transfer Procedures Within and Outside the Facility

Transfer Within the Facility

• Steps include:
     - Obtaining the physician’s order for the transfer.
     - Clarifying the reasons behind the transfer to the patient.
     - Medication reconciliation prior to transfer.
     - Assisting the patient in gathering personal belongings.
     - Completing a transfer summary form.
     - Conducting a phone report of the patient’s condition to the receiving unit.
     - Documenting both the time of transfer and transfer details.

Transfer to Another Facility

• Necessary actions encompass:
     - Securing a physician’s official transfer order.
     - Notifying the receiving office regarding the impending transfer.
     - Helping facilitate transportation arrangements for the patient.
     - Compiling a transfer summary and an accompanying discharge summary.
     - Notation of any valuable items the patient is taking with them.
     - Ensure consent for releasing medical information is obtained prior to transfer.