Ppg-gdch-nur-47 Notification of Physcician Following Nursing Assessment

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GULFDIAGNOSTICCENTER

HOSPITAL

NURSING POLICY Policy No:MED-NUR-P0047/12

TITLE: NOTIFICATION TO PHYSICIAN,

FOLLOWING NURSING ASSESSMENT

Issue Date : November 2012

Revision No.: Original 01

Department : Nursing Revision Date :

Section : Nursing Care Next Revision : November 2014

Distribution : Hospital Wide Page 1 of 4

NOTIFICATION TO PHYSICIAN, FOLLOWINGNURSING ASSESSMENT

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

DOCUMENT AMENDMENT RECORD SHEET

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Appendix: Yes [ ] No [ ]


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Date Description of Change Page EffectedRevisionNumber

1. PURPOSE

1.1 To provide a standardized process to refer patients to the appropriate multidiscipline.1.2 To ensure uniformity in the process of physician notification.

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1.3 To ensure that the patients receive appropriate care from the required services in thehospital.

2. DEFINITION:

2.1 Notification to physician: Process whereby a nurse communicates with the concernedtreating physician about any significant finding, abnormalities and information

identified following initial nursing assessment that has potential detrimentaleffect on patients health, therapeutic plan and compliance to treatment.

3. POLICY

3.1 All patients shall have an initial assessment upon admission in accordance with thehospital policy.

3.2 Nurse shall identify special needs of patients (if any) and notify the treating physicianbased on set criteria.

3.3 The scope of notification of patients includes observations related (but not limited) tofunctional, nutritional, social, economic and psychological areas.

3.4 The criteria for notifying the physician about the need for potential referral of patients to

various health care specialties shall be as follows (but not limited to):3.4.1 Functional:

3.4.1.1 Immobility3.4.1.2 Presence of prosthesis3.4.1.3 Use of walking aids3.4.1.4 Deformity3.4.1.5 Assistance required for ADL

3.4.2 Nutritional:3.4.2.1 Malnourished3.4.2.2 Obesity3.4.2.3 Anorexia

3.4.2.4 Need for special diet3.4.2.5 Diseases with nutritional risk such as (but not limited to):

3.4.2.5.1 Extensive surgeries3.4.2.5.2 Hypertension3.4.2.5.3 Edema3.4.2.5.4 Diabetes3.4.2.5.5 Anemia3.4.2.5.6 Malabsorption (ulcerative colitis, crohns disease etc.)

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3.4.2.5.7 End-stage renal diseases3.4.2.5.8 Gastritis3.4.2.5.9 Cancer3.4.2.5.10 Non healing wounds3.4.2.5.11 Cardiovascular disease

3.4.3 Social:3.4.3.1 Lack of family/support group

3.4.4 Psychological:3.4.4.1 Sad/withdrawn3.4.4.2 Anxious3.4.4.3 Tearful3.4.4.4 Expresses guilt3.4.4.5 Negative feeling about self

3.4.5 Economical:3.4.5.1 Unemployed3.4.5.2 Low income and unable to meet expenses of treatment3.4.5.3 Dependants

4. SCOPE 4.1 Notifying physician following a nursing assessment in Gulf Diagnostic Center Hospital.

5. RESPONSIBILITY

5.1 Nurses5.2 Treating physician

6. REFERENCES

6.1 JCIA Standard for Hospital-2008 Assessment of Patients

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Ppg-gdch-nur-47 Notification of Physcician Following Nursing Assessment