ADMISSIONS/DISCHARGE/TRANSFER

ADMISSION
(ENTERING A HEALTH CARE AGENCY FOR NURSING
CARE AND MEDICAL/SURGICAL TREATMENT)
INVOLVES:
A. AUTHORIZATION FROM A PHYSICIAN
B. COLLECTION OF BILLING INFO FROM THE
ADMITTING DEPARTMENT
C. COMPLETION OF THE ADMISSION PROCESS BY
NURSING
D. DOCUMENTING PTS MED HX & PHYSICAL EXAM
E. INITIAL MED ORDERS FOR TREATMENT

RESPONSIBILITIES OF THE ADMITTING DEPARTMENT

GATHER INFO FOR BILLING
INITIATE MEDICAL RECORD
PREPARE ID BRACELET. THIS IS
THE SINGLE MOST EFFECTIVE WAY
OF IDENTIFYING THE PATIENT
MAY BYPASS IN EMERGENCY
SITUATION
AN ADDRESSOGRAPH CARD IS
MADE
CONSENT FORMS ARE SIGNED, EG.
LIVING WILL, DIRECTIVES,
WAIVERS
INITIAL ORDERS OBTAINED
VERBAL REPORT GIVEN TO FLOOR
RN
PATIENT IS ESCORTED

NURSING RESPONSIBILITES
PREPARE ROOM
IDENTIFY SELF
ORIENT PATIENT
GATHER INFO

PREPARE ROOM
PROVIDE PERSONAL
CARE ITEMS
SUCTION
OXYGEN
IV POLE

BED IN HIGH
POSITION IF
ARRIVING BY
GUERNEY
BED IN LOW
POSITION IF
ARRIVING BY W/C
BLUE PADS IF NEC.

IDENTIFY SELF
MAKES PT FEEL SECURE
MAKES PT FEEL WELCOME
ALLEVIATES ANXIETY/FEAR

ORIENT PATIENT
LOCATION OF NURSES
STATION
CLOTHES STORAGE
CALL LIGHT
BED CONTROLS
LIGHT SWITCHES
TELEPHONE POLICY
TV CONTROLS
MEALTIMES

SAFETY MEASURES SUCH

AS BEDRAILS
VISITING HOURS
WHAT TESTS ARE
SCHEDULED
DIET
ROOM BOUNDARIES
SCHEDULED SURGERY
TIME
TIMES FOR DR VISITS

GATHER INFORMATION
THE NURSE WILL GATHER INFO ABOUT:
MEDICAL ORDERS
TXS
LABS
TESTS
DIET
ACTIVITY
PHYSICAL ASSESSMENT WITHIN 24HRS.

TYPES OF ADMISSION

INPATIENT

OUTPATIENT

INPATIENT STAY
LONGER THAN 24HRS
PLANNED:
NO IMMEDIATE THREAT
PLANNED ELECTIVE SURGERY, TESTS
PT IS PREPARED
EMERGENCY:
UNPLANNED
STABILIZE IN EMERGENCY ROOM (CHEST PAIN, TRAUMA)
DIRECT ADMISSION:
UNPLANNED
BYPASS EMERGENCY (VOMITING, DIARRHEA)

OUTPATIENT STAY
LESS THAN 24 HRS
OBSERVATIONAL:
HEAD INJURY
PREMATURE LABOR
UNSTABLE VITAL SIGNS

VALUABLES
WHEN DOCUMENTING VALUABLES, MAKE
SURE TO USE WORDS LIKE:
WHITE/YELLOW METAL NOT GOLD
CLEAR STONE NOT DIAMONDS, RUBIES, ETC.
HAVE A WITNESS
HAVE NURSE & PT SIGN VALUABLES LIST
DONT FORGET DENTURES, GLASSES, ETC.
WHEN TRANSFERRING PT, SIGN-OFF WITH
NURSE
KNOW YOUR FACILITYS VALUABLES POLICY

PATIENT COMFORT
PROVIDE PRIVACY. (SHUT DOOR & PULL
CURTAIN.)
ASSIST IF NEEDED TO REMOVE CLOTHING AND
PUT GOWN ON.
PROVIDE EXTRA BLANKETS IF REQUESTED.
COLLECT INFO FOR DATABASE.
PERFORM INITIAL ADMISSION ASSESSMENT IF
APPROPRIATE. (SOME FACILITIES REQUIRE AN
RN TO DO INITIAL ASSESSMENTS).
OBTAIN PHYSICIAN ORDERS FOR TXS, LABS,
TESTS, MEDS, ACTIVITY, ETC. WITHIN 24HRS.

COMPONENTS OF A MEDICAL HISTORY

IDENTIFYING DATA
CHIEF COMPLAINT
PERSONAL HX
PAST HEALTH HX
HX OF PRESENT ILLNESS
FAMILY HX
REVIEW OF BODY SYSTEMS
CONCLUSION

WHAT TO WATCH FOR IN NEWLY ADMITTED PATIENTS

ANXIETY
LONELINESS
DECREASED PRIVACY
LOSS OF IDENTITY

ANXIETY
APPEARANCE
Exhibits Separation
Anxiety.
Sad.
Worried.
Restless.
Reduced Appetite.
Insomnia.

HOW TO HELP
Acknowledge feelings.
Provide explanations and
instructions before
performing procedures.
Inquire about stress due
to children/pets/spouse
at home.
Reassure. Separation
Anxiety can cause the
elderly to be confused
and disoriented.

LONELINESS
Make frequent contact with your
patient.
Orient your client.
Allow liberal visitation.

DECREASED PRIVACY
Pull curtain and close
door.
Knock.
Identify room
boundaries, esp. if
sharing room.
Be careful of exposing
patient.
Patient feels
uncomfortable
because of unkempt
appearance, so
announce visitors.

LOSS OF IDENTITY
Call patient by
name they prefer.
Allow patient to
wear own gown.
Display pictures.
Give them some
choices. (bathing,
eating, etc.)

DISCHARGE
TERMINATION OF CARE FROM
A HEALTH CARE AGENCY
METHOD (ACRONYM)
M-MEDS
E-ENVIRONMENT
T-TREATMENT
H-HEALTH TEACHING
O-OUTPATIENT REFERRAL
D-DIET
AMA (Against Medical
Advice)
PT LEAVES PRIOR TO OBTAINING
A WRITTEN ORDER. NURSE
REQUESTS PT TO SIGN FORM. IF
REFUSES, NURSE MUST LET PT
LEAVE AND NOTE REFUSAL TO
SIGN AMA IN CHART.

NURSES RESPONSIBILITY FOR DISCHARGING A PATIENT

GATHER BELONGINGS/CHECK INVENTORY

ARRANGE TRANSPORTATION
INFORM PT OF CHECKOUT TIME TO AVOID
BEING BILLED FOR AN EXTRA DAY
ESCORT UNTIL PT SAFELY INSIDE VEHICLE
WRITE DISCHARGE SUMMARY
TERMINAL CLEANING. BED STRIPPED AND
DISINFECTANT USED. BEDSIDE CABINET
RESTOCKED/CLEANED.

TRANSFER
DISCHARGING A PATIENT
FROM ONE UNIT OR
AGENCY AND ADMITTING
THEM TO ANOTHER UNIT
INFORMS PATIENT/FAMILY
COMPLETE TRANSFER
SUMMARY
SPEAKS WITH NURSE ON
TRANSFER UNIT
TRANSPORTS
PATIENT/BELONGINGS/SU
PPLIES & CHART
CHECKS ORDERS/MAKES
NEW ADDRESSOGRAPH
CARD W/NEW ROOM #

WHO/WHAT IS INVOLVED IN A PLANNED DISCHARGE?

PHYSICIANS ORDER

UNIT SECRETARY
CALLS FOR TRANSPORT,
COPIES CHART/ORDERS

CARE PROVIDER

RN OR SOCIAL WORKER

SAFEKEEPING

EXTENDED CARE FACILITY

PATIENT

NURSE-EXPLAINS
DISCHARGE
INSTRUCTIONS TO
FAMILY/CARE GIVER

SETTING STANDARDS
*REMEMBER*
THE AMERICAN NURSES ASSOCIATION
SETS THE STANDARD FOR PT CARE &
DOCUMENTATION FOR RNS
LPNS ARE GOVERNED BY JCAH
DO NOT USE SEEMS OR APPEARS IN
DOCUMENTATION. IMPLIES DOUBT AND
LACK OF KNOWLEDGE.
STUDENTS DO NOT NEED TO READ P.126-129(EXTENDED CARE FACILITIES) BUT NEED TO
READ NURSING GUIDELINES ON TRANSFERRING A CLIENT, P. 126, GENERAL GERONTOLOGIC
CONSIDERATIONS & CRITICAL THINKING EXERCISES.