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advanced nursing procedure in health science

The document outlines the procedures for patient admission, transfer, and discharge in healthcare facilities, emphasizing the role of nurses in managing continuous nursing care. It details the types of admissions (planned and emergency), legal aspects regarding patient consent, as well as documentation requirements at different stages of patient care. Additionally, it discusses factors influencing patient experience during the admission process and the eventual discharge criteria based on the patient's health status.

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PATIENT ADMISSION, TRANSFER AND DISCHARGE Advanced Nursing LUCTURE 2 By: Abdi Rizak Warsame (SKN) 11/03/2024 1
PATIENTADMISSION, TRANSFER AND DISCHARGE Theoretical notes Patients are admitted to an inpatient healthcare facility if their health condition requires continuous healthcare for more than 24 hours. The term “hospitalization” means admitting the patient to an inpatient healthcare facility. Inpatient healthcare can be administered in various facilities such as hospitals or nursing care homes. Forms of healthcare: • Outpatient care; General, specialized; • Institutional care; • Pharmaceutical service.
Patient admission to healthcare facility Patient admission, hospital stays and discharges follow an established procedure, i.e. planned nursing activities. For patients requiring long-term care and repeated hospitalization, the activities must be coordinated so that the nursing care is continuous. The specific medical treatment prescribed by the doctor, and the nursing regime followed by the nurse, are administered by the nurse in order to meet patient needs. The nurse monitors patient responses throughout the stay.
Cont.. Types of patient admission according to priority: Planned admission – the patient has been previously booked for hospitalization, examination or surgery and it is expected that the patient will remain in hospital for the required period. The hospitalization period starts after initial examinations in the outpatient facility. Emergency admission – the patient is admitted without referral from a doctor in the case of a life-threatening condition. Patients can be admitted using: • Healthcare clinics • Patient admission centres • Accident and Emergency departments
Cont.. Legal aspects of patient admission • Providing information about the patient to family members and to the next of kin is governed by applicable legislation; • In the case of acutely ill patients who cannot express consent with hospitalization (e.g. unconscious, following strokes, etc.) a detention procedure or the “procedure concerning patient admission and detention by a healthcare facility” is put into place. The healthcare provider reports the patient admission without their consent to the court; • Under emergency hospitalization, the court will appoint a guardian to represent the patient during detention.
Cont.. Patient documentation Prior to patient admission to hospital, the forms that will be filed as part of the general medical records must be completed. Medical records are usually filed in a washable folder. Medical documentation consists of the following: Pre-hospitalization documentation (not always included). • For example, this consists of: The transfer medical and nursing report; application for admission to the after-care facility etc. Initial documentation • Contains for example: Initial medical examination report, including the care plan; nursing anamnesis etc.
Cont.. Daily records (medical records, daily report; daily recording of nursing care; records of evaluation techniques (e.g. educational sheet, record of ulcer care and skin defects, nutritional score, record of pain assessment). Special care records – nutritionist report, physiotherapy and occupational therapy progress records, social health record, psychotherapy record, speech therapy record etc. Informed consent forms (including those from other facilities), court report (clothes and valuables, proof of deposit, including advice) Discharge summary report (including the care plan). Complement, Consilium (laboratory test results, imaging, EEG, MMSE, consilium, including one time psychological record and other examinations). Ancillary documentation (e.g. extended hospitalization, police reports, copy of the document for patient placement in a social care facility, shelter home, voucher for the provision of home healthcare, copy of the previous discharge or transfer report, statements from other documentation etc.).
Cont.. Forms completed at the place of admission: • Case history • Daily report Forms completed on the ward: • Informed consent • Nursing anamnesis • Nursing plan • Request for additional diet allowances • House rules, code of ethics for patient rights • Cloakroom ticket, record of valuables deposited • Operational documents, e.g.: Cloakroom ticket, record of valuables deposited
Cont.. Patient admission to ward After the patient arrives to the ward, the on duty nurse greets the patient, introduces herself, and takes over the documentation, papers and any identification labels. In accordance with standards the nurse completes the patient documentation, informs the patient of the rules of stay, provides basic information on orientation in the ward, and performs all patient admission tasks. The nurse will accompany the patient to the room, show them their bed and other room facilities that the patient may need during hospitalization, and introduce the patient to other patients. Clothing and other personal items are usually stored in the patients room (in wardrobes, bedside tables), or in the institutional locker room. If the patient has any valuables, the items must be accurately described and stored according to the internal regulation of the healthcare facility.
Cont.. Accident and Emergency department admission Unlike planned admission, a patient suffering acute illness or injury is brought to the hospital’s accident and emergency department admission The care of a patient whose life is at risk (pre-hospital and hospital care) and subsequent admission to institutional care is more demanding in terms of speed, decisiveness and the foresight of the nurse. Transport of the patient is through: • Emergency service • Individually
Cont.. Complications at patient admission and prevention The patient may encounter many disturbing moments during admission to hospital. For example, unpleasant long waiting times, lack of fresh air, smells, lack of privacy, lack of information, intolerant behaviour of the staff etc. Preventive measures Well marked corridors, orientation signs, suitable spatial arrangement of the rooms, surgeries, and waiting rooms can all contribute to better adaptation of the patient to hospitalization. Other contributing factors may be clean and pleasant surroundings, sufficient information (leaflets), comfortable furniture, professional staff, and good work organization.
Patient transfer The patient is usually hospitalized in the same department from which they are discharged. The health condition changes in some patients so much that they are transferred and treated by another department or another treatment unit of the same or different department or in the same or another healthcare facility.
Cont.. The patient can be transferred to: • Another treatment unit, • Another ward or a clinic within the same hospital, • Another facility / hospital. The transfer of the patient to another treatment unit is based on the decision of the doctor, who will inform the patient, usually during their ward round, of the reason for the transfer. It is also important to inform the relatives of the patient, should the patient give their consent. In order to transfer the patient, the nurse will prepare the medical records together with the transfer report and the doctor will record the patient discharge summary report in the daily report.
Patient discharge If the patient’s condition improves so that treatment can be continued through an outpatient facility or at home, then the patient is discharged. The patient may also be discharged at their own request, known as DAMA, i.e. a declaration that they are leaving on their own request. The release is decided by the attending doctor after consultation with the senior consultant. After that the patient deals with the necessary matters, such as transportation from the hospital and notifies their relatives. If the patient is not collected by relatives, the nurse will book an ambulance if the patient's health condition requires it.