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Admission Transfer & Discharge of the Patient - Coggle Diagram
Admission Transfer & Discharge of the Patient
Patient documentation
application for admission .
Case history
Daily report
Initial documentation
Initial medical examination report
including the care plan
Comple the forms filed
Medical records filed in a washable folder.
Daily records
medical records
daily report
daily recording of nursing care
Special care records
progress records
social health record
psychotherapy record
speech therapy record etc
Informed consent forms
Discharge summary report (including the care plan).
Complement, (laboratory test results, imaging, EEG,
nutritionist report
physiotherapy and occupational therapy
Records of evaluation
court report (clothes and valuables, proof of deposit, .
police reports
voucher for the provision of home
healthcare
copy of the previous discharge or transfer report
Forms completed at the place of admission:
Case history
Daily report
Forms completed on the ward:
Informed consent
Nursing plan
Request for additional diet allowances
Types of patient admission according to priority
Planned admission
Emergency admission
Admission& Discharge of the Patient
Patient admission to healthcare facility ,
medical treatment prescribed by the doctor
the nursing regime followed by the nurse
monitors Patient responses
nurse in order to meet patient needs.
hospital stays and discharges
Cases Admissions
Temporary
Permanent
Daily records
medical records
daily report
daily recording of nursing care
records of evaluation
Special care records – nutritionist report
physiotherapy and occupational therapy progress records
social health record
psychotherapy record
peech therapy record etc.
Informed consent forms
court report (clothes and valuables, proof of deposit, including advice)
Forms completed on the ward:
Informed consent
Nursing plan
Request for additional diet allowances
House rules
code of ethics for patient rights
record of valuables deposited
Helping Patients Adjust
Strange surroundings
Busy nursing staff
Sight of other patients
May not know what to expect
Prepare the patient’s room
Envelope for patient’s valuables
Soap / towels / lotion
Bedpan and/or urinal
IV pole if needed
Emesis basin
Recording the Data
Complete the admission checklist.
Fill in the date and time of admission.
Method of admission ( the way the patient came into the room) wheelchair , ambulatory ,stretcher.
Observations or unusual conditions noted.
Chief complaint of the patient, Be brief but complete and write legibly.
Documentation of discharge
Chart the date and time of discharge.
How patient left the facility.
Any special instructions given to the patient.
Make a notation that the patient’s personal belongings were sent with the patient.