Ppg-gdch-nur-41 General Policy of Assessing in-patients

GULF DIAGNOSTIC

CENTER HOSPITAL

مستشفى مركزالخليجللتشخيص

NURSING POLICY Policy No: MED-NUR-P0041/12TITLE: GENERAL POLICY ON ASSESSMENT

OF IN-PATIENTSIssue Date : October 2012Revision No.: Original 01

Department : Nursing Revision Date : Section : Nursing Care Next Revision : October 2014Distribution : Hospital Wide Page 1 of 5

GENERAL POLICY ON ASSESSMENT OF IN-PATIENTS

APPROVAL SHEET

Prepared by:

Name Signature Date

Ms. Jennelyn PaderanActing Charge Nurse, In-patient Ward

Reviewed by:

Name Signature Date

Ms. Nemesio AbusoActing Head of Nursing

Mr. Zuher ArawiQuality Manager

Approved by:

Name Signature Date

Dr Emad Yassin Al RahmaniMedical Director

Mrs. Jamal KaddouraHospital Director and Co-Founder

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Appendix: Yes [ ] No [ ]

GULF DIAGNOSTIC

CENTER HOSPITAL





DOCUMENT AMENDMENT RECORD SHEET

Date Description of Change Page EffectedRevision Number

1. PURPOSE

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GULF DIAGNOSTIC

CENTER HOSPITAL





1.1 To provide quality health care service through comprehensive assessment of in-patients and observation of standards of practice of care.

1.2 To provide uniform assessment guidelines for in-patients.

1.3 To provide assessment guidelines to meet international standards.

2. POLICY

2.1 All patients admitted in Gulf Diagnostic Center Hospital have a comprehensive in-patient assessment prior to their treatment.

2.2 The individualized assessment is documented in the patient’s record within 24 hours after the patient’s admission a in-patient or earlier as indicated by the patient’s condition and available for use by all those caring for the patient.

3. SCOPE

3.1 Assessment of in-patients in Gulf Diagnostic Center Hospital.

4. RESPONSIBILITY

4.1 Physician4.2 Nurses4.3 Health Care Assistant

5. PROCEDURE

5.1 Upon admission, the In-patient Ward obtains the following data:5.1.1 Patient’s complete name5.1.2 Date of Birth5.1.3 Height and weight5.1.4 Next of kin to contact in case of emergency and contact number

5.2 Nurse in charge of patients do initial assessment by obtaining information through comprehensive History and Physical Examination:

5.2 1 History:5.2.1.1 Chief Complaint/Reason for Admission 5.2.1.2 History of Present Illness5.2.1.3 Review of Systems5.2.1.4 Past medical history including complete list of medications (e.g prescribed and non

prescribed medications; herbal medications, vitamins) taken.

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GULF DIAGNOSTIC

CENTER HOSPITAL





5.2.1.5 Personal history5.2.1.6 Family history5.2.1.7 Social history5.2.1.8 Allergies5.2.1.9 Diagnostic done as out-patient prior to hospitalization5.2.1.10 Previous admission

5.2.2 Physical Examination:5.2.2.1 Vital Signs5.2.1.2 Pain Assessment5.2.1.3 General appearance5.2.1.4 Pain assessment5.2.1.5 Findings of musculoskeletal system5.2.2.6 Findings of the head and neck5.2.1.7 Findings of the eyes, ears, nose and throat and mouth5.2.2.8 Findings of the endocrine system5.2.2.9 Findings of the reproductive system5.2.2.10 Findings of the chest and lungs5.2.2.11 Findings of the heart and blood vessels5.2.2.12 Findings of the gastroinetestinal system5.2.2.13 Findings of the genitourinary system5.2.2.14 Findings of the neurological system5.2.2.15 Psychiatric findings

5.3 The nurse in charge of the patient also includes on her initial assessment the nutritional screening, skin risk assessment, socio-economic, fall safety risk, functional screening, special needs, educational and discharge assessment.

5.4 Based in initial assessment, patient’s care needs are identified and staffing assignments/referrals are made based on these identified needs.

5.5 Care plan will be documented by the nurse in charge of the patient in accord with applicable nursing care plan.

5.6 Patient and family are informed of the initial and continuing assessment and care plan.5.7 Reassessment are documented in the progress notes. Reassessment is done to document patient’s

response to treatment and intervention and or if there is significant change in the patient’s medical condition.

5.8 Based on patient’s initial assessment, the need for early discharge planning is determined.

6. REFERENCES

6.1 JCIA Standard

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GULF DIAGNOSTIC

CENTER HOSPITAL





7. RELATED DOCUMENTS

7.1 Nursing Admission Assessment

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Documents

Ppg-gdch-nur-41 General Policy of Assessing in-patients