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INITIAL(1).pptx WHICH HELPS TO ORGANAIZE THE PATIEENNT PRACTICE
- 1. PREPARED BY, BINCY PAUL ASSESSMENTOF OUT PATIENT
- 2. DEFINITION Assessment refers tothe systematic collection and review of patient data collected through observation, interview, me asurement and diagnostic test
- 4. Purpose To ensure thatall out patient have documented, comprehensive and up dated assessment appropriate to the age and medical condition
- 5. POLICY ALL PATIENTSMUST BE RECEIVE COMPREHENCIVELY OUT PATIENT CINI CALASSESSMENT UPON THEIR FIRST VISIT. EVERY PATIENT MUST BE REASSESSED PERIODICALLY IN EACH SUBSEQUE NT VISITS CINICALASSESSMENT MUST BE CONDUCTED WITHIN OR EQUAL TO 30 DA YS ,ALONG WITH PRIOR TO ADMISSION AND OPD PROCEDURE. ANY CHANGES IN PATITENT CONDITION SINCE THE ASSESSMENT OR NO C HAGE ARE DOCUMENTED IN THE PATIENT MEDICAL RECORD AT THE TIM E OF PRIOR TO ADMISSION AND OPD PROCEDURE. IF THE MEDICALASSESSMENT GREATER THAN 30 DAYS THE MEDICAL HIS TORY AND PHYSICAL EXAMINATION UPDATED AND REPEATED RESPECTIV EY. CLINICALASSESSMENT OF THE PATIENT SHALL INCLUDE THE PRESENT C OMPLAINT AND ADDITIONALASSESSMENT SHALL BE PERFORMED WHEN NEEDED
- 6. EACH SPECIALITYAND SUB SPECIALITY SH OULD DO THE MOST APPROPRIATE ASSESSM ENT ACC. TO THE PATIENT OWN CLINICA CONDITION AND PROCEDURE . THE ASSESSMENT OF OUT PATIENT IS THE S HARED RESPONSIBLILTY OF PHYSICIAN AN D NURSE AND THE FINDINGS OF ASSESSME NT MUST BE DOCUMENTED IN THE MEDICA L RECORED OR ELECTRONICALY.THE RELE VENT INFORMATION SHALL BE OBTAINED P ATIENT OR THEIR FAMILY MEMBERS
- 7. COMPONENTS OF PATIENTASSESSMENT ASSESSMENT PHYSICIAN GENERAL ASSESSMENT NURSING GENERAL ASSESSMENT
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- 9. NURSING GENERAL ASSESSMENT •Assessment of spoken language • General patient information • Vital signs documentation • Mode of assess, reason for visit • Accompanied by whom,pregnency status, diet and allergy status • Chief complaints • Immunization status • Braden scale • Fall risk assessment
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- 12. MINIMAL NURSING ASSESMENT PT IDENTIFIACTIONO SKINASSESSMENT NUTRITIONAL ASSESSMENT SOCIAL ASSESSMENT PSYCHOLOGICAL ASSESSMENT FUNCTIONAL SCREENING ECONOMICAL ASSESSMENT PAIN ASSESSMENT
- 13. PEDIATRIC OUT PATIENTASSESSMENT PEDIATRIC PHYSICIAN • HEIGH • BIRTH HISTORY HEAD CIRCUMFERRENCE • MILE STONES PEDIATRIC NURSING • GROWTH CHART • IMMUNAIZATION STATUS,NEW BORN SCREENING STATUS AND AGE DEVELOPMENT STATUS
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- 15. OBSTRETICS AND GYNECOLOGICAL ASSEESSMENT PHYSICIANASSESSMENT ANTE NATAL CARE OBSTRETICS HISTORY MEDICALAND SURGICAL HISTORY GENETIC OR TETROLOGY SCREENING GYNECOLOGY ASSESSMENT
- 16. • .PRE ANSTHESIAOR PRE SEDATION ASSESSMENT • ANSTHESIA OR SEDATION ASSESSMENT NURSING ASSESSMENT PERIOPERATIVE ASSESSMENT POST OPERATIVE ASSESSMENT
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- 18. • All thecomponents of patient assess ment shall be updated every 30 days. For follow up visit is done within a pe riod of 30 days. Validated competencies needed for to performing nursing assessment
- 19. OPD PHYSICIAN OPDNURSE ASSEESSMENT:Initial assessment must be conducted by the physician in their conce rned department. • All assessmment should be documented in the p atient record • Discus regarding the treatment,alternatives,risk s and complication with pt INITIAL ASSESSMENT: ALL OUT PATIENT ASSESSMENT SHOULD B E INCLUDED THE ABOVE MENTIONED POIN TS UPON THE FIRST VISIT REASSESSMENT • It should be done on each visit according t o the condition of the patient REASSESSMENT • All opd reassessment in nsg must be done in ev ery subsequent visit include the current complai nt,any changes in the patient condition and pain assessment • It shoud be done if any changes occure in pt co ndition. PROCEDURE