This document discusses various aspects of nursing documentation including definitions, purposes, principles, types, methods, forms of recording data, consequences of inadequate documentation, definitions of reporting, types of reports, importance of records and reports, definitions of electronic documentation, guidelines for electronic documentation, advantages and disadvantages of electronic documentation, and the role of the nurse manager in documentation. It provides a comprehensive overview of documentation in nursing.
The document discusses hospital admission and discharge procedures. It defines admission as allowing a client to stay in the hospital for observation, investigations and treatment. Discharge is when a patient leaves the hospital. There are different types of admissions like emergency and elective, and different types of discharges like planned, transfer, absconding, and death.
The roles and responsibilities of nurses during admission include preparing the room, assessing the patient, documenting information, and making the patient comfortable. During discharge, nurses ensure instructions are understood, belongings are returned, documentation is complete, and transportation is arranged. Proper admission and discharge procedures are important for patient safety, continuity of care, and fulfilling legal and nursing principles.
This lesson will help the nursing students to learn and know the nursing records and reports and responsibility of the nurse in maintaining nursing records and reports in various health settings.
The document discusses various methods of nursing documentation and recording. It describes the purposes of accurate nursing documentation as communication, legal documentation, nursing audits, education, financial billing, nursing research, and improving the quality of care. The principles of quality documentation include being factual, accurate, complete, current, organized and timely. Common documentation methods discussed are narrative notes, problem-oriented medical records (POMR), source records, charting by exception, and case management plans.
The document discusses the discharge of patients from the hospital. It defines discharge as relieving a patient from the hospital setting after completing their initial treatment. There are two types of discharge: planned discharge after treatment is finished, and discharge against medical advice (DAMA). The steps for planned discharge include a doctor's order, completing paperwork, informing departments, and ensuring bills are paid. For DAMA, the patient must sign a consent form acknowledging they are leaving against advice. Nurses are responsible for preparing patients for discharge, assisting with the discharge process, and documenting discharge.
Nurses are responsible for maintaining adequate supplies and equipment for patients by placing indents with medical stores. An indent is an official order for supplies. Nurses classify equipment based on consumption rates and store accordingly. Inventory lists are maintained to track supplies and ensure availability. Methods for inventory control include visual inspection, ABC analysis which categorizes items based on costs, VED analysis which categorizes based on criticality, and a two bin system with main and backup supplies.
Record and Report in Nursing, Principles of Record and Report, Types of Record and Report, Filling of Record, Value and Uses of Record and Report, Guideline for Documentation,
Care of linens, rubber goods,glasswaresbaladinesh .K
This document provides guidance on the care of various items used in hospitals, including linens, rubber goods, and glassware. It outlines the proper cleaning, disinfection, and storage procedures for items like mackintoshes, hot water bags, gloves, test tubes, and thermometers. Maintaining cleanliness and proper care is important to prevent infection spread, remove stains, and prolong the life of these items. Key steps include washing with soap and water, drying completely, and disinfecting or sterilizing depending on the item.
This document discusses various aspects of nursing documentation including definitions, purposes, principles, types, methods, forms of recording data, consequences of inadequate documentation, definitions of reporting, types of reports, importance of records and reports, definitions of electronic documentation, guidelines for electronic documentation, advantages and disadvantages of electronic documentation, and the role of the nurse manager in documentation. It provides a comprehensive overview of documentation in nursing.
The document discusses hospital admission and discharge procedures. It defines admission as allowing a client to stay in the hospital for observation, investigations and treatment. Discharge is when a patient leaves the hospital. There are different types of admissions like emergency and elective, and different types of discharges like planned, transfer, absconding, and death.
The roles and responsibilities of nurses during admission include preparing the room, assessing the patient, documenting information, and making the patient comfortable. During discharge, nurses ensure instructions are understood, belongings are returned, documentation is complete, and transportation is arranged. Proper admission and discharge procedures are important for patient safety, continuity of care, and fulfilling legal and nursing principles.
This lesson will help the nursing students to learn and know the nursing records and reports and responsibility of the nurse in maintaining nursing records and reports in various health settings.
The document discusses various methods of nursing documentation and recording. It describes the purposes of accurate nursing documentation as communication, legal documentation, nursing audits, education, financial billing, nursing research, and improving the quality of care. The principles of quality documentation include being factual, accurate, complete, current, organized and timely. Common documentation methods discussed are narrative notes, problem-oriented medical records (POMR), source records, charting by exception, and case management plans.
The document discusses the discharge of patients from the hospital. It defines discharge as relieving a patient from the hospital setting after completing their initial treatment. There are two types of discharge: planned discharge after treatment is finished, and discharge against medical advice (DAMA). The steps for planned discharge include a doctor's order, completing paperwork, informing departments, and ensuring bills are paid. For DAMA, the patient must sign a consent form acknowledging they are leaving against advice. Nurses are responsible for preparing patients for discharge, assisting with the discharge process, and documenting discharge.
Nurses are responsible for maintaining adequate supplies and equipment for patients by placing indents with medical stores. An indent is an official order for supplies. Nurses classify equipment based on consumption rates and store accordingly. Inventory lists are maintained to track supplies and ensure availability. Methods for inventory control include visual inspection, ABC analysis which categorizes items based on costs, VED analysis which categorizes based on criticality, and a two bin system with main and backup supplies.
Record and Report in Nursing, Principles of Record and Report, Types of Record and Report, Filling of Record, Value and Uses of Record and Report, Guideline for Documentation,
Care of linens, rubber goods,glasswaresbaladinesh .K
This document provides guidance on the care of various items used in hospitals, including linens, rubber goods, and glassware. It outlines the proper cleaning, disinfection, and storage procedures for items like mackintoshes, hot water bags, gloves, test tubes, and thermometers. Maintaining cleanliness and proper care is important to prevent infection spread, remove stains, and prolong the life of these items. Key steps include washing with soap and water, drying completely, and disinfecting or sterilizing depending on the item.
This document discusses the transfer of a patient from one unit or hospital to another. It defines a patient transfer as discharging a patient from one unit or agency and admitting them to another without going home in between. The two main types of transfers discussed are between units in the same hospital and between different hospitals. The key steps outlined for an intra-hospital transfer are obtaining a physician order, informing the patient and receiving unit, completing documentation, arranging transportation, and ensuring the receiving unit admits the patient. The nurse's role in the process involves communication, documentation, collecting patient belongings, and assisting in the physical transfer of the patient between units.
This document discusses ethics, values, and advocacy in nursing. It defines key concepts like values, beliefs, attitudes, and moral principles. It explains how personal and professional values develop and the process of values clarification. The document also discusses ethical decision making, nursing codes of ethics, and the nurse's role as an advocate. Advocacy in nursing means protecting and supporting a patient's rights and well-being.
This document discusses hospital admission and discharge procedures. It covers the admission process including preparing the unit, admission types (emergency vs routine), admission procedures, and the nurse's role. Discharge topics include types (planned, LAMA, transfers), planning, procedures, considerations, and post-discharge unit care. Admission involves allowing a patient to stay for treatment/care. The nurse's responsibilities are to receive patients courteously, assess their condition, orient them to hospital policies and equipment, and coordinate initial care orders with physicians.
Hospital house keeping & care of rubber goodsSiva Nanda Reddy
1) Housekeeping in a hospital aims to provide a clean, comfortable, and safe environment for patients through cleaning, sanitation, and infection control practices.
2) Key components of hospital housekeeping include adequate water supply, clean toilets, proper waste disposal, pest control, and appealing interior design.
3) Proper housekeeping principles include using damp cloths for dusting, cleaning with soap and water, and storing cleaning supplies separately from other items. Heat, chemicals, and abrasives should be used carefully to avoid harming materials.
This document defines and provides guidelines for patient admission, transfer, and discharge in a hospital setting. It outlines the purposes, principles, equipment, and procedures involved in each process to ensure continuity of care and optimal patient outcomes. Key steps include collecting patient information, assessing needs, communicating with providers and family, documenting care provided, and educating patients for continued recovery after leaving the hospital. The overall aim is to safely and smoothly transition patients between levels of care while maintaining quality standards.
The nursing student will learn about key aspects of caring for patients who are dying or have died, including defining dying and death, signs of approaching death, diagnostic evaluation, management, cultural and religious beliefs, legal matters, and nursing diagnoses and family education. Key signs of impending death include irregular breathing patterns like Cheyne-Stokes respirations and alterations in vital signs. Proper care, respect and dignity must be provided to the deceased according to their wishes and beliefs. Documentation of death includes certifying and recording the cause and time of death along with notifications.
This document discusses the process for discharging a patient from the hospital. It involves coordination between the medical staff, patient, and family to plan for the patient's care after leaving the hospital. The nurse is responsible for ensuring the patient is ready for discharge and that they receive instructions for medications, diet, follow-up care, and any other needs. Discharge planning involves teaching the patient and family to care for the patient at home as well as documenting the discharge instructions and type of discharge.
Nursing assessment involves collecting data to understand a patient's health status. It includes gathering subjective information from the patient and objective data through examination. The nurse organizes, validates, and documents the assessment data to identify health problems, strengths, and needs to develop an appropriate plan of care. Common assessment techniques are inspection, palpation, percussion, and auscultation to examine each body system.
The document discusses health assessment, which involves a nurse collecting and analyzing client data through interaction to establish a health baseline and identify any health issues or risks. The purposes are to understand a client's normal health and any current problems, determine necessary treatment, and get a holistic view of their health. Key terms like diagnosis, prognosis, and subjective/objective symptoms are defined. Health history collection involves biographic data, chief complaints, medical history, family history, and psycho-social factors.
This document discusses the nursing diagnosis process. It begins by introducing nursing diagnosis as the second phase of the nursing process and a pivotal step. It then discusses NANDA's role in developing standardized nursing diagnoses and taxonomy. The document outlines the 13 domains of nursing diagnosis and characteristics such as being clear, evidence-based, and amenable to nursing intervention. It describes different types of diagnoses and provides examples. Finally, it discusses formulating diagnostic statements, including one, two and three part statements, and qualities of accurate diagnostic statements.
This document discusses admission and discharge procedures in a hospital setting. It defines admission as allowing a patient to stay in the hospital for treatment purposes. The admission process involves receiving the patient, collecting their history, orienting them and the family, and coordinating care. Discharge planning is an interdisciplinary process that ensures continuity of care after discharge and involves evaluating the patient's needs and arranging any follow up care. Nurses play an important role in both admission and discharge by properly caring for patients, educating them and families, and ensuring proper documentation and coordination of care.
This document discusses inventory control and material management in healthcare systems. It states that inventory control is an important aspect of material management that aims to ensure the right supplies are available at the right place and time. It describes several techniques used for inventory control, including ABC analysis, VED analysis, and FSN analysis to categorize items by importance and usage. The document outlines steps for planning, procuring, storing, and tracking inventory. Effective inventory control is important to minimize costs and ensure adequate supplies and equipment are available for healthcare workers to provide services.
The document defines records and reports, providing principles for maintaining accurate records. It describes different types of records like clinical records, staff records, and administrative records. Records are used for communication, diagnosis, education, research and legal documentation. Reports summarize services and are used for communication, planning, and interpreting services. Different types of reports like 24-hour reports and census reports are described. The responsibilities of nurses in accurate record keeping and reporting are also outlined.
The document discusses the evaluation phase of the nursing process. It defines evaluation as comparing a patient's responses to predetermined goals and outcomes. The nurse evaluates whether expected outcomes were met, not just if interventions were done. Key aspects of evaluation include collecting and interpreting data, comparing outcomes to goals, documenting findings, and revising the care plan if needed. The evaluation determines if care was effective and ensures continuous good patient outcomes.
This document provides information on caring for dying patients. It discusses assessing patient needs, communicating with patients and families, and meeting physiological, psychological and spiritual needs. It outlines the stages of dying according to Dr. Kubler-Ross and stages of grief. It describes signs that a patient is approaching death and signs of clinical death. It discusses caring for the patient's body after death, including cleaning and preparing the body for the family. The overall message is the importance of providing dignified, compassionate care and supporting patients and families during the dying process.
Reports are used in healthcare to communicate important information about patients. There are several types of reports nurses commonly use, including hand-off reports, telephone reports, and incident reports. Hand-off reports are given during shift changes or patient transfers to ensure continuity of care. They include key details about a patient's condition, treatments, and care needs. Telephone reports are used to update other providers about significant changes in a patient's status. Incident reports document any unexpected events involving patients to support quality improvement efforts.
This document discusses community health nursing. It begins by providing definitions of community health nursing from the American Nursing Association. It emphasizes health promotion, education, coordination of care, and taking a holistic approach. The aims of community health nursing are described as promoting health and efficiency, preventing and controlling diseases and disabilities, and providing comprehensive services to communities. A number of principles of community health nursing are also outlined, including recognizing community needs, defining objectives, involving community groups, and ensuring availability and continuity of services. Quality assurance models and approaches are discussed, including licensure, accreditation, and nursing audits. Several community nursing theories are also mentioned, such as the PRECEDE model, health belief model, and health promotion model.
Critical thinking in nursing involves recognizing issues, analyzing clinical data, evaluating information, and making conclusions. It is a continuous process of open-minded inquiry to determine which assumptions are true and relevant for each unique patient situation. Critical thinking skills for nurses include interpretation, analysis, inference, evaluation, explanation, and self-regulation. There are three levels of critical thinking - basic, complex, and commitment. Critical thinking competencies for nurses encompass general skills like scientific method and problem solving, as well as specific skills like diagnostic reasoning, clinical inference, and clinical decision making. Attitudes that are important for critical thinking include confidence, independent thinking, fairness, responsibility, risk taking, discipline, perseverance, creativity, curiosity, integrity, and
nursing records and reports, definition, purposes, principles, values and uses, types, records in hospital, types of reports, how to write better report, nursing responsibilities
1) Admission to the hospital can cause anxiety for patients due to the unfamiliar environment. Nurses play an important role in welcoming patients and making them feel comfortable.
2) Accurate documentation in patient records is essential for communication between healthcare providers, planning care, and fulfilling legal requirements. Records must be written clearly, concisely, and in a timely manner.
3) The discharge process involves preparing patients physically and psychologically to transition back home or to another facility, with education on self-care, follow-up, and warning signs requiring medical attention.
This document discusses the transfer of a patient from one unit or hospital to another. It defines a patient transfer as discharging a patient from one unit or agency and admitting them to another without going home in between. The two main types of transfers discussed are between units in the same hospital and between different hospitals. The key steps outlined for an intra-hospital transfer are obtaining a physician order, informing the patient and receiving unit, completing documentation, arranging transportation, and ensuring the receiving unit admits the patient. The nurse's role in the process involves communication, documentation, collecting patient belongings, and assisting in the physical transfer of the patient between units.
This document discusses ethics, values, and advocacy in nursing. It defines key concepts like values, beliefs, attitudes, and moral principles. It explains how personal and professional values develop and the process of values clarification. The document also discusses ethical decision making, nursing codes of ethics, and the nurse's role as an advocate. Advocacy in nursing means protecting and supporting a patient's rights and well-being.
This document discusses hospital admission and discharge procedures. It covers the admission process including preparing the unit, admission types (emergency vs routine), admission procedures, and the nurse's role. Discharge topics include types (planned, LAMA, transfers), planning, procedures, considerations, and post-discharge unit care. Admission involves allowing a patient to stay for treatment/care. The nurse's responsibilities are to receive patients courteously, assess their condition, orient them to hospital policies and equipment, and coordinate initial care orders with physicians.
Hospital house keeping & care of rubber goodsSiva Nanda Reddy
1) Housekeeping in a hospital aims to provide a clean, comfortable, and safe environment for patients through cleaning, sanitation, and infection control practices.
2) Key components of hospital housekeeping include adequate water supply, clean toilets, proper waste disposal, pest control, and appealing interior design.
3) Proper housekeeping principles include using damp cloths for dusting, cleaning with soap and water, and storing cleaning supplies separately from other items. Heat, chemicals, and abrasives should be used carefully to avoid harming materials.
This document defines and provides guidelines for patient admission, transfer, and discharge in a hospital setting. It outlines the purposes, principles, equipment, and procedures involved in each process to ensure continuity of care and optimal patient outcomes. Key steps include collecting patient information, assessing needs, communicating with providers and family, documenting care provided, and educating patients for continued recovery after leaving the hospital. The overall aim is to safely and smoothly transition patients between levels of care while maintaining quality standards.
The nursing student will learn about key aspects of caring for patients who are dying or have died, including defining dying and death, signs of approaching death, diagnostic evaluation, management, cultural and religious beliefs, legal matters, and nursing diagnoses and family education. Key signs of impending death include irregular breathing patterns like Cheyne-Stokes respirations and alterations in vital signs. Proper care, respect and dignity must be provided to the deceased according to their wishes and beliefs. Documentation of death includes certifying and recording the cause and time of death along with notifications.
This document discusses the process for discharging a patient from the hospital. It involves coordination between the medical staff, patient, and family to plan for the patient's care after leaving the hospital. The nurse is responsible for ensuring the patient is ready for discharge and that they receive instructions for medications, diet, follow-up care, and any other needs. Discharge planning involves teaching the patient and family to care for the patient at home as well as documenting the discharge instructions and type of discharge.
Nursing assessment involves collecting data to understand a patient's health status. It includes gathering subjective information from the patient and objective data through examination. The nurse organizes, validates, and documents the assessment data to identify health problems, strengths, and needs to develop an appropriate plan of care. Common assessment techniques are inspection, palpation, percussion, and auscultation to examine each body system.
The document discusses health assessment, which involves a nurse collecting and analyzing client data through interaction to establish a health baseline and identify any health issues or risks. The purposes are to understand a client's normal health and any current problems, determine necessary treatment, and get a holistic view of their health. Key terms like diagnosis, prognosis, and subjective/objective symptoms are defined. Health history collection involves biographic data, chief complaints, medical history, family history, and psycho-social factors.
This document discusses the nursing diagnosis process. It begins by introducing nursing diagnosis as the second phase of the nursing process and a pivotal step. It then discusses NANDA's role in developing standardized nursing diagnoses and taxonomy. The document outlines the 13 domains of nursing diagnosis and characteristics such as being clear, evidence-based, and amenable to nursing intervention. It describes different types of diagnoses and provides examples. Finally, it discusses formulating diagnostic statements, including one, two and three part statements, and qualities of accurate diagnostic statements.
This document discusses admission and discharge procedures in a hospital setting. It defines admission as allowing a patient to stay in the hospital for treatment purposes. The admission process involves receiving the patient, collecting their history, orienting them and the family, and coordinating care. Discharge planning is an interdisciplinary process that ensures continuity of care after discharge and involves evaluating the patient's needs and arranging any follow up care. Nurses play an important role in both admission and discharge by properly caring for patients, educating them and families, and ensuring proper documentation and coordination of care.
This document discusses inventory control and material management in healthcare systems. It states that inventory control is an important aspect of material management that aims to ensure the right supplies are available at the right place and time. It describes several techniques used for inventory control, including ABC analysis, VED analysis, and FSN analysis to categorize items by importance and usage. The document outlines steps for planning, procuring, storing, and tracking inventory. Effective inventory control is important to minimize costs and ensure adequate supplies and equipment are available for healthcare workers to provide services.
The document defines records and reports, providing principles for maintaining accurate records. It describes different types of records like clinical records, staff records, and administrative records. Records are used for communication, diagnosis, education, research and legal documentation. Reports summarize services and are used for communication, planning, and interpreting services. Different types of reports like 24-hour reports and census reports are described. The responsibilities of nurses in accurate record keeping and reporting are also outlined.
The document discusses the evaluation phase of the nursing process. It defines evaluation as comparing a patient's responses to predetermined goals and outcomes. The nurse evaluates whether expected outcomes were met, not just if interventions were done. Key aspects of evaluation include collecting and interpreting data, comparing outcomes to goals, documenting findings, and revising the care plan if needed. The evaluation determines if care was effective and ensures continuous good patient outcomes.
This document provides information on caring for dying patients. It discusses assessing patient needs, communicating with patients and families, and meeting physiological, psychological and spiritual needs. It outlines the stages of dying according to Dr. Kubler-Ross and stages of grief. It describes signs that a patient is approaching death and signs of clinical death. It discusses caring for the patient's body after death, including cleaning and preparing the body for the family. The overall message is the importance of providing dignified, compassionate care and supporting patients and families during the dying process.
Reports are used in healthcare to communicate important information about patients. There are several types of reports nurses commonly use, including hand-off reports, telephone reports, and incident reports. Hand-off reports are given during shift changes or patient transfers to ensure continuity of care. They include key details about a patient's condition, treatments, and care needs. Telephone reports are used to update other providers about significant changes in a patient's status. Incident reports document any unexpected events involving patients to support quality improvement efforts.
This document discusses community health nursing. It begins by providing definitions of community health nursing from the American Nursing Association. It emphasizes health promotion, education, coordination of care, and taking a holistic approach. The aims of community health nursing are described as promoting health and efficiency, preventing and controlling diseases and disabilities, and providing comprehensive services to communities. A number of principles of community health nursing are also outlined, including recognizing community needs, defining objectives, involving community groups, and ensuring availability and continuity of services. Quality assurance models and approaches are discussed, including licensure, accreditation, and nursing audits. Several community nursing theories are also mentioned, such as the PRECEDE model, health belief model, and health promotion model.
Critical thinking in nursing involves recognizing issues, analyzing clinical data, evaluating information, and making conclusions. It is a continuous process of open-minded inquiry to determine which assumptions are true and relevant for each unique patient situation. Critical thinking skills for nurses include interpretation, analysis, inference, evaluation, explanation, and self-regulation. There are three levels of critical thinking - basic, complex, and commitment. Critical thinking competencies for nurses encompass general skills like scientific method and problem solving, as well as specific skills like diagnostic reasoning, clinical inference, and clinical decision making. Attitudes that are important for critical thinking include confidence, independent thinking, fairness, responsibility, risk taking, discipline, perseverance, creativity, curiosity, integrity, and
nursing records and reports, definition, purposes, principles, values and uses, types, records in hospital, types of reports, how to write better report, nursing responsibilities
1) Admission to the hospital can cause anxiety for patients due to the unfamiliar environment. Nurses play an important role in welcoming patients and making them feel comfortable.
2) Accurate documentation in patient records is essential for communication between healthcare providers, planning care, and fulfilling legal requirements. Records must be written clearly, concisely, and in a timely manner.
3) The discharge process involves preparing patients physically and psychologically to transition back home or to another facility, with education on self-care, follow-up, and warning signs requiring medical attention.
This document discusses admission and discharge procedures in a hospital. It defines admission as allowing a patient to stay in the hospital for observation, investigation, treatment, and care. There are two main types of admission: emergency and routine. Discharge planning is a coordinated process that involves evaluating the patient's needs, discussing the discharge plan with the patient and family, and making arrangements for follow up care or transfer. Key responsibilities of nurses in admission and discharge include orienting and assessing patients, ensuring proper documentation, and communicating between departments to coordinate care.
This document outlines the duties of healthcare practitioners towards patients, including: providing good treatment by listening to patients and showing respect; achieving the patient's interests and guarding their rights by limiting unnecessary procedures and informing them of treatment options; obtaining valid consent by ensuring the patient understands risks and can consent voluntarily; reassuring patients by addressing psychological needs and breaking bad news sensitively; maintaining patient confidentiality with exceptions to protect others or report crimes; and obtaining proper consent before photographing or recording patients.
Information about the discharge of patients , educational propose, all nursing students and nurses to help them. The more useful in clinical practice nurses , and as well as tutor he help them in teaching.
The more knowledge about the client related .
The more essay to discharge the patient
The document discusses the processes of admission, transfer, and discharge of patients in a hospital. It defines key terms and outlines the procedures and responsibilities of nurses during admission, transfer, including preparing documentation, communicating with patients and staff, and ensuring patient safety and comfort. The document also examines common patient reactions to being hospitalized such as anger, anxiety, withdrawal and provides strategies for nurses to address these responses.
This document discusses the admission and discharge of mentally ill patients. It defines admission as allowing a patient to stay in the hospital for care and discharge as releasing a patient. Admission can be voluntary if requested by the patient or guardian, or involuntary if requested by others against the patient's will. Discharge includes releasing patients admitted voluntarily based on doctor approval, releasing involuntary patients to caregivers with bonds, and releasing prisoners based on fitness for trial. The roles of nurses include intake assessments, discharge planning, and ensuring legal and ethical standards are followed.
The document discusses admission, transfer, and discharge of patients from the hospital. It defines admission as allowing a patient to stay in the hospital for observation, investigation, treatment, and care. The main purposes of admission are to provide immediate care, safety, and comfort to the patient. There are different types of admission based on planning (emergency vs routine), time period (short-term vs long-term), and purpose (diagnostic vs therapeutic). The roles and responsibilities of nurses during admission include preparing the unit, collecting patient information, and orienting the patient. The document also outlines the procedures and types of patient transfer and discharge.
Admission+Discharge+Rights OF b.SC NURSING PSYCHIATRIC NURSING.pptelizakoirala3
This document discusses the legal aspects of psychiatric care, including admission and discharge procedures for mentally ill patients, the rights of mentally ill persons, and relevant mental health acts and policies. It provides details on voluntary versus involuntary admission, the admission process, types of discharge including conditional discharge, and the rights of mentally ill persons to privacy, confidentiality, consent in treatment, and least restrictive care.
The document discusses the admission and discharge process for patients in the hospital. When admitting a patient, nurses complete preliminary procedures like collecting patient information, vital signs, and specimens. They explain hospital routines and make the patient comfortable. For discharge, nurses prepare patients by addressing questions and needs, reviewing treatment plans, and arranging transportation. They provide medications, instructions, and arrange follow-up care. Effective discharge planning teaches patients about their conditions and home care to support recovery after leaving the hospital.
This document outlines the patient discharge policy and process at SVIMS hospital. It describes the responsibilities of doctors and staff and the steps to be followed for safe and well-organized discharge. These include making the discharge decision, preparing a discharge summary, counseling the patient, generating final bills, and maintaining accurate records. The policy aims to fully involve patients and ensure they receive appropriate aftercare information.
This document discusses hospital admission and discharge procedures. It defines admission as allowing a client to stay in the hospital for treatment and defines discharge as when a patient leaves the hospital. It describes the types of admission as emergency or routine. It outlines the roles and responsibilities of nurses in both admission and discharge procedures, including preparing the unit, obtaining patient information, and ensuring all paperwork and belongings are in order. It also discusses medico-legal cases and procedures for handling patient discharge against medical advice.
The document discusses the admission procedure for patients in a hospital. It defines admission as allowing a patient to stay in the hospital for observation, investigation, and treatment. The admission process involves preparing the patient's room, checking identification, collecting health information and vital signs, administering any ordered treatments, orienting the patient to hospital policies and facilities, and documenting the admission in the patient's records for legal and care purposes. The nurse plays an important role in facilitating the admission process and making patients feel comfortable in the unfamiliar hospital environment.
Patient's rights are policies that protect patients and their families and ensure ethical care. They include the right to respect and non-discrimination, quality care, information and communication, participation in treatment decisions, the ability to refuse treatment, make complaints, request transfers or discharge, and know financial obligations. Understanding patient's rights is important for healthcare providers to respect patients and provide excellent care.
The document discusses the admission and discharge process for patients in the hospital. It defines admission as allowing a patient to stay in the hospital for care and outlines the purposes of admission such as providing immediate care, assessing the patient, and establishing a nurse-patient relationship. The types of admission include emergency and routine admission. The document also discusses preparing the patient's room and unit for admission, the roles of the nurse during admission and discharge planning, and the steps to discharge a patient including completing records and ensuring instructions are understood.
This document provides guidelines for various quality and safety practices at a hospital. It discusses proper patient identification procedures, guidelines for verbal and telephone orders, procedures for high alert medications, surgical checklists including site marking and time outs, hand hygiene practices, fall risk assessment and prevention measures, occurrence variance reporting for documenting incidents, and the focus-PDCA methodology for quality improvement. Key areas of focus include correctly identifying patients, improving communication, ensuring surgery and medication safety, reducing healthcare associated infections and patient harm from falls.
This document discusses medical negligence and its defense. It defines professional negligence as failure to exercise reasonable care and skill by a medical practitioner that causes harm to a patient. Negligence can be through acts of omission or commission. There are two types of professional negligence - civil and criminal. Civil negligence involves disputes over compensation in court, while criminal negligence involves gross misconduct resulting in injury or death. The document outlines the elements required to prove civil negligence and penalties for criminal negligence. It also discusses defenses against negligence claims like contributory negligence. The Supreme Court of India has issued guidelines for courts to avoid unnecessary harassment of doctors in medical negligence cases.
Saudi German Hospitals Group is one of the largest private healthcare companies in the region, operating since 1988. Saudi German Hospital-Jeddah is one of the major hospitals in the Kingdom. The document provides information for patients about their rights and responsibilities, hospital policies including visiting hours, meals, and discharge procedures. It aims to welcome and inform patients during their stay at Saudi German Hospital in Jeddah.
Similar to Dama,absconded & out on pass med staff responsibility (20)
This document provides guidelines for moderate sedation/analgesia (conscious sedation). It defines levels of sedation from minimal to general anesthesia. Moderate sedation involves patients responding purposefully to verbal commands with spontaneous breathing. The guidelines discuss patient evaluation, monitoring, personnel, equipment, drugs and discharge criteria for providing moderate sedation. Proper patient screening, credentialed practitioners and personnel, appropriate facilities and emergency equipment are emphasized to minimize risks while allowing benefits of sedation for certain medical procedures.
The document discusses the benefits of exercise for mental health. Regular physical activity can help reduce anxiety and depression and improve mood and cognitive function. Exercise causes chemical changes in the brain that may help protect against mental illness and improve symptoms.
Blood units are transported from the central blood bank to the blood bank at BB Meegat General Hospital. Upon receipt, staff must monitor and record the temperature of transport containers to ensure blood products are within specified temperature ranges. Staff also inspect each blood unit, checking for hemolysis, leakage, damage, and verifying ABO and Rh typing. Units are then organized by blood type and labeled as ready for cross-match or reserved. Daily preservation tasks include temperature monitoring, checking expiration dates, and inventory levels. Blood is then delivered to hospital departments as needed upon receiving transfusion request forms and completing cross-match details.
Post covid-19 syndrome, also known as long covid, refers to symptoms that can persist for weeks or months after recovery from the initial acute illness. While people are not infectious during this time, there is no agreed upon definition. A wide range of long-term symptoms have been reported, including fatigue, chest pain, muscle pain, loss of smell, and depression. Certain groups, such as older individuals, those who are obese, and people with diabetes or lung/kidney disease, appear to be at higher risk of developing long-term effects from covid-19.
Sepsis and septic shock guidelines 2021. part 1MEEQAT HOSPITAL
1. Sepsis is a critical imbalance between oxygen supply and demand that can affect any system. Serum lactate levels rise in response to tissue hypoxia and higher levels correlate with poorer outcomes.
2. Guidelines recommend screening high-risk patients for sepsis and using standard treatment protocols. Blood lactate should be measured in suspected cases and treatment begun immediately.
3. Fluid resuscitation of at least 30mL/kg should begin within 3 hours, guided by dynamic measures over static parameters alone. Antimicrobial therapy should also begin immediately or within 1-3 hours depending on risk level and presence of shock.
sepsis SSC 2021 Updates Ventilation and additional therapyMEEQAT HOSPITAL
This document discusses ventilation strategies and additional therapies for sepsis patients with respiratory failure. It covers conservative oxygen targets, types of respiratory failure, benefits of non-invasive ventilation (NIV) and positive airway pressure (PAP), and risks of NIV. The Berlin definition for acute respiratory distress syndrome (ARDS) severity is also presented. Recommendations are provided for mechanical ventilation settings and various treatments for sepsis patients.
This document discusses sepsis scoring systems. It describes the historical definitions and consensus guidelines for sepsis from 1991 to 2016. It also discusses the Surviving Sepsis Campaign from 2004 to 2008. The document compares different scoring systems for sepsis like SIRS, SOFA, qSOFA, and MEWS and explains which are best for identifying sepsis in ICU versus non-ICU patients. It outlines the pathogens commonly associated with sepsis and trends in incidence and mortality.
This document defines medication error and outlines procedures for reporting medication errors. It also lists common types of medication errors including prescribing errors, omission errors, wrong time errors, and improper dose errors. Causes of errors include look-alike and sound-alike drug names, illegible handwriting, and unapproved abbreviations. Nursing responsibilities in preventing errors and standard precautions are discussed.
CRRT is a continuous renal replacement therapy that provides a gentler form of dialysis for critically ill patients. It works through slow, continuous removal of waste and fluid over multiple days rather than the typical 4 hour sessions of hemodialysis. This puts less stress on the heart. CRRT can be delivered through various modes including continuous venovenous hemofiltration, hemodialysis, or hemodiafiltration that utilize diffusion, convection, or both to clean the blood. Anticoagulation is required to prevent clotting of the dialysis circuit and can include regional citrate or low-dose heparin.
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MR. MOHAMMAD TALAL AL JOHANY
RESPIRATORY THERAPIST
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POST TEST
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Hassan Mohamed Ali
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𝐃𝐢𝐬𝐜𝐮𝐬𝐬 𝐭𝐡𝐞 𝐄𝐏𝐏 𝐂𝐮𝐫𝐫𝐢𝐜𝐮𝐥𝐮𝐦 𝐢𝐧 𝐭𝐡𝐞 𝐏𝐡𝐢𝐥𝐢𝐩𝐩𝐢𝐧𝐞𝐬:
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𝐄𝐱𝐩𝐥𝐚𝐢𝐧 𝐭𝐡𝐞 𝐍𝐚𝐭𝐮𝐫𝐞 𝐚𝐧𝐝 𝐒𝐜𝐨𝐩𝐞 𝐨𝐟 𝐚𝐧 𝐄𝐧𝐭𝐫𝐞𝐩𝐫𝐞𝐧𝐞𝐮𝐫:
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2. 1. Out on pass is an inpatient who is temporarily absent from a
ward, by arrangement, for not more than 48 hours because:
1. (S)he has been allowed to go home temporarily.
2. (S)he has been transferred to another hospital and is expected to
return.
3. (S)he has been transferred from a long stay specialty to another
specialty in the same hospital and is expected to return
2. DAMA- Discharge Against Medical Advised
1. Is a “self-discharge” or “discharge at own risk” occurs when a
patient chooses to leave the hospital before the treating
physician recommends discharge.
THEY HAVEN’T BEEN SEEN YET, BUT THE FACILITY HAS TOUCHED THEM., THEY SIGNED IN AND THEN THEY
DECIDED TO LEAVE, ALL OF THESE CAN BE CONSIDERED DAMA.
2. If an out on pass patient failed to come on specified time
decided by his physician or his/her designee.
3. Absconded- Patient who left the hospital without:
1. Proper discharge procedures.
2. Asking the physician or nurse’s permission out on pass.
3. POLICy:
-Is to provide proper steps, prompt and sufficient
response to the situation, guide in place that formalize
how staff respond to a patient refusal, including careful
documentation processes and follow-up when patient;
1. By arrangement, leave the hospital at specified time that is not more than 48
hours. OUT ON PASS
2. If an out on pass patient failed to come on specified time decided by his
physician or his/her designee. (DAMA)
3. When a patient chooses to leave the hospital before the treating physician
recommends discharge. DAMA
4. Patient who left the hospital without proper discharge procedures.
(ABSCONDED)
-It provides guide for the staff in documenting accurate
assessment of
RISK, criteria and legal responsibility on the patient file.
-Avoid confrontations and respect a patient’s right to
refuse- Offer alternatives to the care being refused.
4. Out on pass
1. Patient must pass through the admission procedure and completed preoperative workup before allowed to
leave the hospital.
2. A therapeutic pass may only be issued under a provider order, after
assessment that must specify :
2.1. The length of time the patient is authorized to be absent from
the unit based upon assessment of his/ her medical condition and
intervention he/she might need to come back before leaving the
hospital.
2.2. The reason for the absence
2.3. Any special instructions related to the pass.
3. Upon the patients return, department nurse staff would then chart
the time returned, who they were with when returning, & general
condition .
4. The patient must be informed that failure to return to the unit
within their expected return time may result in the patient being
discharged as DAMA and losing their bed.
5. 1. A patient that has been seen and haven’t been seen yet, but
the facility has touched them, they signed in and then they
decided to leave, all of these can be considered DAMA.
DAMA
2. If the general condition of the patient is critical
and there is life threatening clinical condition,
the patient relation personnel and social worker
will be informed to support the treating
physician and explain to the patient and his / her
family who wish to leave the hospital and
document these reasons in the patient file.
3. The hospital must reconcile any outstanding
diagnostics results: Any tests were ordered, the
hospital is still responsible for checking the results
to be sure nothing serious was identified and if there
is significant results came out after patient
discharge, the patient must be contacted and
informed
6. 3. Steps to take when patient verbalized DAMA plan:
1. The nurse must notify the attending physician or resident on-duty
regarding patients desire to go for DAMA
2. If the patient(and or family) cooperates and his / her clinical condition
is not critical and requesting to leave against medical advice, the reasons
behind his / her leave has to be discussed if can be solved and continue
his / her management by the treating physician together with social
worker.
3. If the same patient still insisting to leave the department for personal
reasons, he / she will sign the General Consent (DAMA) Form, the
treating physician, nurse must countersign his /her signature and
signature from administration on duty or patients affair for clearance.
4. The discharge summary should includes all patient medical and
surgical data, the plan of treatment, bring home medications ordered by
the treating physician and any other recommendations and how to
communicate the hospital in case of top emergency.
7. Absconded- Patient who left the hospital without:
2.1.1. Proper discharge procedures
2.1.2. Asking the physician or nurse’s permission
out on pass.
Risk factors of absconded patient:
1. There is a link between absconding and to serious self-harm, lesser extent
to violent behavior.
2. Absconding can also result in serious self-neglect which can lead to
death.
3. Absconding may lead to catastrophic loss of confidence by relatives who
expect the hospital to be a 'place of safety'.
4. When things do go wrong, there is a possibility that legal action may
be taken
8. Absconded patient can be categorized into:
1. HIGHRISK-patient is an individual who present a risk to themselves and/or others.
1.1. Rapid deterioration (life saving) in physical condition.
1.2. Those patients who are an immediate risk and have a significant likelihood to
suffer harm to them as an individual or as a threat to others.
1.3. An extremely young or an extremely old person.
1.4. Patient who is assessed as likely to attempt significant self-harm or suicide.
1.5. A patient who does not have the mental capacity to make a decision
1.6. At risk of spread of infection to community( eg. MERS)
2. Medium risk- is an individual who not considered to present any danger to
themselves and/or others.
2.1. A little risk of deterioration in their physical condition due to being outside the
hospital.
2.2. A patient that is assessed as likely to come to harm without medical assistance.
3. Low risk patient is not considered to present any danger to either themselves or
other.
These are patients who are willingly absent, but are able to function adequately
without assistance and are unlikely to come to harm under normal circumstances. It
would also cover cases where despite consideration of known risk factors, there are
still no grounds for believing the missing person is likely to come to harm.
9. RESPONSIBILITIES:
1. THE STAFFNURSE:
1.1. ENSURE THAT PATIENT IS ABSCONDED AND DETERMINES THE EXACT
TIME OF DISCOVERING THAT THE PATIENT ABSCONDED OR THE TIME OF
RETURN.
1.1. TO INFORM THE RESPONSIBLE PHYSICIAN THAT THE PATIENT WAS
ABSCONDED/MISSED.
1.2. TO INFORM DIRECT LINE MANAGER.
3.1.4. DOCUMENTS INCIDENT REPORT (OVR FORM).
3.1.5. DOCUMENT WHAT IS HAPPENED IN THE PATIENT’S FILE
2. DIRECTLINEMANAGER:
2.1. TO INFORM THE SECURITY AND START SEARCHING FOR THE PATIENT.
2.2. TO INFORM THE DIRECTOR ON-DUTY/ADMINISTRATOR.
2.3. TO INFORM SOCIAL WORKER AND OR PATIENT’S RELATIONS.
2.4. TO INFORM THE POLICE, IF INDICATED.
2.5. TO FILL THE ABSCONDED FORM .
3.PHYSICIAN IN CHARGE
3.1. TO DETERMINE HIGH-RISK PATIENT, NEEDED TO BE ALLOCATED AND
RECALL.
10. 3.2. To ensure full record in the patient’s medical record.
3.3. To complete the absconded form.
4. Socialworker/Directorondutyin pm/nightshiftandweekends.:
4.1. To collect all personal information.
4.2. To contact the relatives and inform them about the
situation.
4.3. To discuss with the patient the reasons of leaving and
the ability to back again.
5. Headof security(Policeofficer):
5.1. Responsible for patient safety and medical legal
implication.
6. AdmissionOfficer/Reception(SelfResources
Administration):
7.1. Provides patients information and admission status.
11. POLICY:
1. The policy applies to all inpatients across MGH.
2. Patient is categorized as absconded if he / she is not on bed for one
(1) hour after thorough search by Nursing Staff and Security Officer
2.1. Bed is blocked for six (6) hours. Patient will be discharged
after 6 hours.
2.2. Discharge should be accomplished by the Physician as soon as
possible.-
3. Determine the high-risk patient need to be allocated and recall
again to ED.
Procedures:
1. Determine absconded- If the patient identified out of bed/missing
after one (1) hour.
2. Stepsto be taken:
2.1. If the patient high risk: The charge nurse will assign some staff
nurse and security, to search the patient immediately without waiting
for return of the patient by himself, in the corridors, bathrooms,
visiting his neighbor patients, and external to the ED or hospital unit.
12. 2.2. If the patient moderate or low risk:
2.2.1. The nurse who discovered the absconding patient will report the
incident to his/her direct line manager.
2.2.2. The charge nurse can wait for one hour to alert the security and
start searching of the patient.
2.2.3. At the same time gather all available information concerning the
situation
3. Reviewthe situationof the patient:
4.1.History of previous event of going absconded either from hospital
or at home, it will be necessary to check patient record or information
if relatives are available.:
4. Recallback thepatient to ED/Unit:
4.1. The social worker and patient relationship will collect all the
personal information of the patient and RECALL patient back to
the hospital.
4.2. If the patient informed, a maximum of six hours will be allowed for
him or his relative to return from the time he/she leaves the hospital
13. 5. Police involvementin all casesof absconded:
5.1. Criteria before contacting the police service:
1. High risk, Critical patient level I & II.
2. Confused, dementia, aged, or drug addict.
3. Female, child and in-competent patient.
4. Disabled or handicapped.
5. Leaving the hospital with central or peripheral lines.
6. History of self-harming.
5. 2. Contacting the police as the correct course of action must be decided by
both charge nurse and concern doctor due to some legal issues.
6. Hospitalright: The hospital will not be responsible
6.1. For any sequel or complication in this condition
6.2. Any illegal act done in this period.
7.Patientswho return:
7.1. The patient must be seen and re-assess by the doctor.
1. Re-assessment will be done and previous management plan will be
changed base in the light of new clinical evaluation.
14. 2. Patients who absconded but who either return voluntarily or brought back by
the police back to emergency department and or unit should be considered as:
2.1. High risk for further episodes of absconding and their clinical assessment
must be priorities.
2.2. Patient may have changed condition due to:
2.2.1. Ingestion 2.2.2. Alcohol intake
2.2.3. Drugs 2.2.4. Abuse (self-harm) etc.
8. Prevention of absconding:
1. If the patient is adamant to leave even after all effort given by medical staff to stay,
then discharge patient with option to choose against medical advise ( ref to policy of
DAMA) but if the patient still to refuse the said option, then patient is considered as
ABSCONDED.
9. Documentation:
1. Complete ABSCONDED form. Make sure all concerned staff in the designated
area and space has been filled up with their side and signed.
2. Only after obtaining discharge order from the physician after 6 hours discharge
is confirmed, then nurse must release now the patient record from the unit
system as ABSCONDED.
3. Write an incident report (OVR).
15.
16.
17. 2. Authentication of Medical Record Entries:
1. Correctly identify patients should be made prior to
documenting
2. Initials can only be used on medical record forms
approved by the organization,such as flow sheets,
medication records or treatment records.
3. All entries shall be signed or initialed/authenticated by
the provider. Signatures must include first name or
initial, last name, and employment/status (e.g., SOD) or
licensure status (e.g., M.D.). Initials alone are not
acceptable
4. For authenticating paper medical record documentation,
handwritten signatures may be accompanied either by
the author legibly writing his/her name in block print or
by the use of a name stamp accompanied by a signature.
18. 5. Users shall not share their account(s), passwords, (PIN),
Security tokens (e.g., Smartcard), or similar information
or devices used. Individual identified by the electronic
signature or method of electronic authentication is the
only individual who may use it, as it denotes authorship
of medical record documents in electronic medical
records.
3. Timing and Dating of Entries:
1. All entries must be timed and dated.
2. Record times based upon 24-hour military time.
3. It is recommended that entries be recorded as closely
as possible to the time of the encounter.
4. It is recommended that all paper-based entries in the
papers must be in black or blue ink . Entries should not
be made in pencil.
19. “If it wasn’t written down, it didn’t happen.”
4. Chronological Entries:
1. It is strongly recommended that all materials in the
medical record be organized in a chronological and
systematic manner.
2. An entry should never attempt to preserve the
chronological order of the interaction/intervention date
and time by entering an artificial or inaccurate
documentation date and time.
3. When clinical documentation is entered out of
chronological order, it is a 'late entry' and shall identify:
5. Legibility and Clarity:
1. Regulations require that medical records be legible.
2. Do not use text message language in documentation
3. Do not use unapproved abbreviations.
4. Document in blue or black ink; no felt-tip pen.
20. .
Electronic documentation with these
systems can help decrease documentation
deficiencies and errors, as well, since an
EHR system’s prompts remind a nurse to
21. 5. Every entry must be dated, timed, and signed (can be
initial).
6. For non- computer documentation of FLOWSHEETS:
a. Place an “√” in the boxes that apply or circle the
appropriate responses.
b. If a subject on the flowsheet requires a written
response, and the response is not applicable, write
“NA” in the corresponding space.
7. Documentation of a NARRATIVE NOTES:
1. Each page (front and back if two-sided) must be
dated and notes must have the first initial, full last
name, and credentials of individual documenting on
the sheet.
22. 6. Error Correction Process:
1. At no time is it permissible to obliterate or remove a
previous entry in the medical record (paper or
electronic).
Note: When using late entries, document as soon as possible. There is no limit
to writing a late entry, however, keep in mind that the more time passes,
the less reliable the entry becomes.
a. When an error is made in a paper-based medical
record entry, the following error correction
procedures must be followed:
i. Draw a line through the entry. Make sure the
inaccurate information is still legible.
ii. Do not write error on the line.
iii. Sign and date the entry.
vi. Do Not obliterate or otherwise alter the original
entry by blacking out with marker, using whiteout
or writing over an entry.
23. b. When an error is made in an electronic medical
record entry, the following error correction must be
followed:
i. An “Addendum” note should be dictated or typed
referencing the incorrect documentation or dictation no.
ii. When correcting or making a change to an entry in the
computerized medical record/ (EHR), the original should be
viewable, the current date and time should be entered, the
person making the change should be identified, and the
reason should be noted.
7. System Downtime (Electrical Shutdown):
1. Refer to department downtime protocol.
8. Use of Cloned Documentation in the Electronic
Medical Record
1. Previously entered data, when used in a new note, should
always meticulously updated and edited.
24. 9. History and Physical
1. A History and Physical Examination (H&P) is required for all
hospital admissions (adequate for the duration of the hospital
stay).
10. Do not falsify any document.
1. Creation of purposely inaccurate entries or
documentation
2. Back-dating entries
3. Pre-dating entries
25. IPSG – 6 (REDUCE THE RISK OF PATIENT HARM RESULTING FROM
FALLS)