For Nursing Practice

1. Nursing Admission and
Discharge
Nursing Service Training

2. Purpose
• To guide the nursing staff in the proper admission of patients.

3. Policy
• All nursing staff should adhere to the policy of
admission.

4. PROCEDURES:
• 1. Check the Doctors order for admission
• 2. Note for the patient’s classification (pay, semi-pay philhealth,
PIDAF, or service)
• 3. The NOD should makes sure that all diagnostic procedures are done
(if available and no special preparation) before transfer to ward
• 4. Detach the admission slip and instruct the watcher to bring it to
the admitting section for the interview of patients data
• 5. NOD informs the ward nurse for such admission to include the
equipment needed for the patient (O2, Mech Vent etc.)
• 6. The NOD (from and to) should confirm if the bed/equipment are
ready for the admission

5. • 7. The NOD should accompany the UW transferring the patient to
ward and endorsed to the ward ICU nurse on duty all details regarding:
• a. Patient’s diagnosis
• b. Done lab work ups (for follow-up of results)
• c. Meds given at ER
• d. All procedures not yet done
Note: Informs Admitting Section of the Admission and
or movement of Patient (LOXAL 5021)
Endorse other needs and continuity of care to
next shift completely and accurately

6. WARD/ICU ADMISSION
• 1. The nurse on duty will receive endorsement from the
ED/WARD nurse.
• 2. Accompany the patient to his/her room or bed
• 3. Assess the patient from head to foot
• 4. Introduce herself to the patient and relatives
• 5. Check and note down for contraptions

7. • 6. Orient the patient and relatives regarding:
• a. The physical set up of the unit
• b. Visiting hours
• c. Proper waste disposal
• d. Other hospital rules and regulation

8. • 7. Review patients chart and:
• a. Re-emphasize the patients diet
• b. Review diagnostic procedures if done at ER
• c. Instruct the patient re: preparations needed for such procedure
• d. Arrange the chart according to sequence
• e. Complete all headings, write the full middle name in all sheets
• f. Make a kardex and bed tag (Full name, date admitted, resident in
charge)
• g. Enter admission to the 24 hour report
• h. Provide nursing care according to the needs

9. • OTHERS:
• 1. Render total patient care, include safety and comfort
• 2. Maintain one watcher per patient to avoid overcrowding
• 3. Observe silence at all times. No unnecessary noise.
• 4. Never make fun of patients and their condition.
• 5. Avoid arguments and unnecessary remarks/comments. Always
show respect to the opinion of

10. Patient Chart
• A. Formal:
• 1. Correct sequence
• 2. Laboratory results attached according to dates
• 3. All sheets have appropriate headings, dated
• 4. Intake and output records complete
• 5. TPR complete and recorded every 24 hrs

11. Doctors Order
• 1. Doctor’s orders in generic name
• 2. Orders are carried out, transcribed dated, timed and
• Signed within the hour
• 3. All verbal orders are countersigned by physicians within 30 minutes
• 4. Standing orders are signed by Resident/consultant
• 5. STAT orders are carried out, signed, timed, charted within half an
hour
• 6. Special procedures/referrals noted and accomplished within the
shift.

12. Nurses Notes
• 1. Nurse’s admission notes are:
• a. Complete

13. Patient Care Audit
• A. Hygiene and Physical Comfort
1. Bathed either by NA/Watcher & skin care given
2. Mouth is clean
3. Well groomed
4. Special attention given to pressure areas
5. Dressings clean and dry
6. Linens are straigthened & dry
7. Bedside tables are arranged and clean

14. ACTIVITIES & BODY MECHANICS
• 1. Patient activity (dangling, sits up on chair,
ambulatory) executed as indicated
• 2. Exercises given as indicated
• 3. Pt’s condition conducive to recovery or to proper
therapy
• 4. Turned to sides
• 5. Supports (footboard, sandbags, pillow) used
correctly
• 6. Splints, slings applied correctly

15. REST & SLEEP
• 1. Quietness maintained at night & during rest
periods
• 2. Lightings controlled at all times
• 3. Comfort measures (repositioning, listening to
music induce sleep and rest

16. Safety
• 1. Pt is assisted during his initial activity (post-
op)
• 2. Side rails up
• 3. Restraints applied properly
• 4. Floors safe from hazards

17. . OXYGEN & VENTILATOR
• 1. Pt encouraged to turn, cough and deep breath
at intervals
• 2. O2 therapy given(rate, humidity)
• 3. Suction equipment properly set-up
• 4. Tracheostomy patent and clean
• 5. Respirator used correctly
• 6. Pt & family understand reason for precautions

18. SENSORY
• 1. eyeglasses, hearing aids, dentures are
properly cared
• 2. Appropriate measures used for effective
communication

19. MEETING EMOTIONAL NEEDS
• 1. Treated with kindness
• 2. Oriented to hospital
• 3. Nurse listens to the pt, encourages questions &
generally make the pt feel at ease
• 4. Nurse stays with anxious fearful pts
• 5. Pt’s family feels at ease in the hospital setting
• 6. Staff notifies the pt’s family as indicated
• 7. Dying pt & family treated with compassion

20. CONSIDERING SPECIAL & SPIRITUAL NEEDS
• 1. Aware of the availability of religious counsel
and services
• 2. Priest or lay minister informed if requested
• 3. Protocol of the pt’s religion observed by the
staff

21. PATIENT & FAMILY TEACHING
•1. Pt teachings included
•2. Family involved in health teachings as
indicated

22. TRANSFER OF PATIENTS
• A. TRANSFER TO OTHER WARD
• 1. Check physicians order of transfer
• 2. Coordinate to admitting section
• 3. Notify the corresponding ward/unit where the
patient be transferred
• 4. Inform the nurse on duty regarding the needs
of the patient (what to prepare)
• 5. Accompany the patient and endorse properly

23. • B. TRANSFER OF SERVICE
• 1. Inform the Resident in Charge/Consultant regarding patient
who request transfer of service.
• 2. The physician should order transfer of service in the patients
chart
• 3. Inform the admitting section and instruct relatives to go to
the admitting section for a change of service in the data sheet

24. •If the patient is from pay to service:
• 1. Inform the resident in charge and the
consultant
• 2. Instruct the relative to coordinate to the
billing section for the settlement of the hospital
bill as pay

25. C. TRANSFER TO OTHER HOSPITAL
• 1. The resident physician coordinates to the resident of
hospital of choice
• 2. Check for transfer order
• 3. Issue billing notice to settle accounts
• 4. The physician accomplishes ambulance conduction
form and inter-agency referral
• 5. The patient is accompanied by RIC and utility on
duty

26. DISCHARGE PROCESS
1. Verify Doctor’s Order Who, when it was carried out.
2. Check discharge requirement such as CF4, medication, supplies if encoded by
the Resident on duty
3. Check the following
a. Medical Abstract
b. Surgical Memo
c. Tagubilin
d. Death Certificate if expired
e. Remind relative if Government ID is required (Next of kin should process if
possible)
f. PF Form to be accomplished by Resident on Duty

27. f.Attached blood with complete details
d. Instruct relatives to the following areas
1. Laboratory Blood Bank
2. Billing
3. Cashier
4. Medical Social Service/PCSO and Malasakit Center
e. Instruct relatives to Receive Discharge Notice from Billing
Department

28. • Once OK for discharge
Discuss the details/ instructions in TAGUBILIN following your health
teachings.
HAND OFF the Disharge Notice
1. Inform the Utility Worker on Duty
2. Inform the Admitting Section
3. Transport the patient