Ppg Gdch Nur 31 Assessment and Reassessment

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GULFDIAGNOSTICCENTER

HOSPITAL

NURSING POLICY Policy No:MED-NUR-P0031/12

TITLE: ADMISSION ASSESSMENT AND

REASSESSMENT OF PATIENTS

Issue Date : May 2012

Revision No.: Original

Department : Nursing Revision Date : May 2012

Section : Nursing Care Next Revision : May 2014

Distribution : Hospital Wide Page 1 of 10

ADMISSION ASSESSMENT AND REASSESSMENT OFPATIENTS

APPROVAL SHEET

Prepared by:Name Signature Date

Ms. Jennelyn PaderanActing Charge Nurse, In-patient Ward

Reviewed by:

Name Signature Date

Ms. Gela Mocanu

Acting Head of Nursing Department

Mr. Zuher ArawiQuality Manager

Approved by:

Name Signature Date

Dr Emad Yassin Al RahmaniMedical Director

Mr. Rami KaddouraExecutive President & C.O.O

________________________________________________________________________________________________________________________________________________________________________________________________________________________

Appendix: Yes [ ] No [ ]


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DOCUMENT AMENDMENT RECORD SHEET

Date Description of Change Page EffectedRevisionNumber

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TABLE OF CONTENTS:

SUBJECTS PAGE NO.

PURPOSE 4

POLICY 4

SCOPE 4

DEFINITIONS/ABBREVIATIONS 5

PROCEDURE 5

REFERNCES 10

RELATED FORMS 10

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1. PURPOSE

1.1. To ensure the timely Interdisciplinary Assessment and Reassessment of each patientsneeds for care by qualified competent professionals.

1.2. To ensure that every patient of the hospital, whether an in-patient, emergency servicepatient, or an outpatient is provided care that meets generally acceptable standards ofprofessional practice

2. POLICY2.1. Data for assessment includes, but not limited to:

2.1.1. History and physical examination2.1.2. Diagnostic testing2.1.3. Multidisciplinary screen (such as nutritional, psychological, psychosocial,

functional, socioeconomic and educational).2.2. Interdisciplinary assessment of needs and determination of goals is the framework utilized

to determine the plan of care that will be implemented with the patient.2.3. Initial assessments are performed upon entry into the Emergency Room, In-patient Unit

or Out-patient within a time frame determined by the patients conditions and currentpolicy.

2.4. Patients are reassessed at intervals as indicated by their condition, course of treatmentand their plan of care. These indications include but are not limited to:

2.4.1. When a significant change occurs in the patients condition and/or diagnosis.2.4.2 Upon intra-hospital and inter-hospital transfer.2.4.3 Prior to, during, and after operative and other invasive procedures.2.4.4 When patients needs are identified.2.4.5 Upon discharge.

3. SCOPE3.1. Assessment and reassessments are performed by all providers of care, including but may

not be limited to the physician, licensed nurse and anesthetist.

4. DEFINITIONS/ABBREVIATIONS4.1 ASSESSMENT

4.1.1 Assessment includes the collection and analysis of data about the patient in orderto determine the patient care and treatment needs.

4.1.2 Reassessment is conducted minimum once a day for non acute patients and morethan once or continuous for acute patient life threatening conditions includingFridays and public Holidays.

4.2 REASSESSMENT4.2.1 Reassessment is the re evaluation of the patient at regularly specified times

according to the patients course of treatment, response to treatment or when a________________________________________________________________________________________________________________________________________________________________________________________________________________________



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significant change occurs in the patients condition and/or diagnosis. Patients areassessed against the goals established for the patient initial assessment.

5. PROCEDUREEach member of the interdisciplinary team will assess and/or reassess the patient as per policy,

on the appropriate hospital specific form(s).

5.1. Assessment and Reassessment of Patients by PHYSICIAN

5.1.1. EMERGENCY Triage Assessment reassessment should be done onendorsement and when needed if there is change in patients condition and upondischarge.

5.1.1.1. Category 1 RESCUCITATION Assessment should be immediate;Reassessment should be continuous.

5.1.1.2. Category 2 EMERGENT Assessment should be 15 minutes; should beafter 15 minutes

5.1.1.3. Category 3 URGENT Assessment should be 30 minutes; Reassessmentshould be after 30 minutes

5.1.1.4. Category 4 LESS URGENT Assessment should be 60 minutes;Reassessment should be after 60 minutes

5.1.1.5. Category 5 NON URGENT Assessment should be 120 minutes;reassessment should be after 20 minutes

5.1.2. OUT-PATIENT CLINIC5.1.2.1. Assessment with each visit and on follow up visits using Patient Screening

Form5.1.2.2. Pre-admission assessment within 30 days prior to admission. Brief

assessment notes upon admission.

5.1.3. IN-PATIENT5.1.3.1. Initial Admission Assessment is to be done within 24 hours with attending

counter signature and stamp. Patients for which surgery is planned, have amedical assessment performed before the surgery. The initial medicalassessment is documented before anesthesia or surgical treatment. Re-assessment is on endorsement and when needed if there is a change on patientscondition and upon discharge. Admission Assessment Form can be used.

5.1.3.2. Physician assess an acute care patient at least daily, including weekends.Reassessment should be done when there has been a change in the patientscondition or if the patients diagnosis has changed or the care needs requirerevised planning and in a response to a significant change in the patientscondition. Also, reassessment is done to determine if the medications and other

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treatments have been successful and the patient can be transferred ordischarged. Form to be use is Doctors Progress/Treatment Notes.

5.1.3.3. Physician assess on pre-operative period, intra-operative period and post-operative period. Reassessment should be done prior to induction and every 5minutes while in O.R. Post operative in recovery room reassessment isaccording to ALDRETE Criteria for discharge from the Recovery Room.

5.2. Assessment and Reassessment of Patients by NURSES5.2.1. EMERGENCY - Triage Assessment reassessment should be done on

endorsement and when needed if there is change in patients condition and upondischarge.

5.2.1.1. Category 1 RESCUCITATION Assessment should be immediate;Reassessment should be continuous.

5.2.1.2. Category 2EMERGENT Assessment should be 15 minutes; Reassessmentshould be after 15 minutes

5.2.1.3. Category 3 URGENT Assessment should be 30 minutes; Reassessmentshould be after 30 minutes

5.2.1.4. Category 4 LESS URGENT Assessment should be 60 minutes;

Reassessment should be after 60 minutes5.2.1.5. Category 5 NON URGENT Assessment should be 120 minutes;

reassessment should be after 20 minutes

5.2.2. OUT-PATIENT CLINIC5.2.2.1. Assessment with each visit and on follow up visits using Patient Form

Assessment and Patient Assessment Form

5.2.3. IN-PATIENT5.2.3.1. Initial assessment is done within 24 hours of admission. Reassessment is

done upon patient admission. Form to be use is Admission Assessment Form.

5.2.3.2. Assessment using nurses notes should be done every shift. Reassessment isevery shift and can be more frequent according to significant findings in thepatients condition.

5.2.3.3. Assessment of pain using pain Assessment form is upon admission andreassessment is every shift (within first 4 hours from the start of the shift)hourly for 4 hours after surgery and on invasive procedure. Reassessment isalso done upon patients request for analgesia and 30 minutes to 1 hour aftergiving pain relief (medical/non-medical) until pain subsides. Reassess pain every2 hours while pain is active.

5.2.3.4. Assessment of fall risk using Fall Risk assessment form is upon admissionand the reassessment will be every shift (within first 4 hours) from the start ofthe shift. If risk score is more than 3 reassess every 4 hours. If risk score is less

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than 3 reassessment is done every shift. If condition changes, reassess (e.g.pain medication, post operative cases).

5.2.3.5. Assessment using Nursing Care Plan Form is upon admission and thereassessment will be every shift for all cases.

5.2.3.6. Nutritional assessment which is part of the nursing assessment should bedone upon admission. Patient in all wards who requires nutritional assessment isdone by the dietitian on a daily basis. Reassessment should be as needed. Forpatients with long stay in hospital, follow up is done.

5.2.4. RECOVERY ROOM

5.2.4.1. Assessment in the Recovery Room is immediately after the surgery and thereassessment is upon admission at the recovery Room, after 10 minutes, 20minutes, 45 minutes and at the time of discharge from PACU according toAldrete post anesthesia score.

5.3. The Minimum Content of assessment performed in In-patient setting is definedbelow.

5.3.1. PHYSICIAN - SCOPE OF ASSESSMENT

5.3.1.1. Chief Complain5.3.1.2. History of present illness5.3.1.3. Health history (current and past health history); Physical history5.3.1.4. Allergies5.3.1.5. Family/Social history; other risk factors and previous hospitalizations5.3.1.6. Review of systems5.3.1.7. General appearance of the patient5.3.1.8. Physician assessment and plan5.3.1.9. Exposure to infectious disease, immunization and prenatal and birth history

(in pediatric cases)5.3.1.10. Obs/gynae history, ante-natal. Anti-D, rectal and pelvic examination (in

obs/gynae cases)

5.3.2. PHYSCIAN - SCOPE OF REASSESSMENT5.3.2.1. Daily reassessment of all patients5.3.2.2. Reassessment can occur more than daily as appropriate individual patient

needs and acuity and it is documented in the patients record (refer to table5.1.1).

5.3.3. NURSES -SCOPE OF ASSESSMENT:Assessment includes:5.3.3.1. Vital signs5.3.3.2. Medication history5.3.3.3. Psychological assessment

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5.3.3.4. Sleep/rest assessment5.3.3.5. Education needs5.3.3.6. Discharge planning needs5.3.3.7. Pain assessment (e.g location, intensity, character, frequency, duration and

radiation) when applicable5.3.3.8. Nutritional Screen/assessment5.3.3.9. Growth and development5.3.3.10. Functional screen assessment5.3.3.11. Orientation to the unit5.3.3.12. Skin integrity5.3.3.13. Patient rights and responsibilities5.3.3.14. Fall/safety risk valuables/equipments5.3.3.15. Socio-economic5.3.3.16. Dependence level or infants less than 1 year

5.3.4. NURSES - SCOPE OF REASSESSMENT5.3.4.1. Vital signs every shift according to doctors order5.3.4.2. Pain assessment once per shift if there is no pain or if pain noted

5.3.4.3. Educational need assessment5.3.4.4. Nursing patient reassessment/ nurses note every shift5.3.4.5. Fall risk assessment once per shift if no fall risk identified or if risk identified.

5.4. The Minimum Content of Assessments performed in out-patient settings:For Out-patient Visits, Patient is assessed for

5.4.1. Vital signs (e.g. weight, height. BMI, immunization status whenapplicable)

5.4.2. Pain scale (e.g. location, intensity, character. Frequency, duration and radiation)5.4.3. Current medication5.4.4. Allergies

5.4.5. Head circumference for newborns and pediatric cases5.4.6. Ultrasound findings in antenatal care and gynecology cases5.4.7. Additional assessment such as (e.g. educational, functional, nutritional,

psychological).5.4.8. History of present illness5.4.9. Past medical history5.4.10. Past surgical history5.4.11. Family history5.4.12. Social history5.4.13. Review of system5.4.14. Triage category (E.R patients)5.4.15. Procedures and treatments performed5.4.16. Final diagnosis

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5.3.2 Reassessment of patients attending OPD will be done during follow up visits.

5.5. Nutritional Services:5.5.1. SCOPE OF ASSESSMENTNutritional Assessment includes:

5.5.1.1. Admitting height and weight5.5.1.2. BMI5.5.1.3. Diet history5.5.1.4. Medications5.5.1.5. Physical activity5.5.1.6. Food allergy5.5.1.7. Preferred diet5.5.1.8. Appetite5.5.1.9. Physical findings5.5.1.10. Risk factor assessment

5.5.2. SCOPE OF REASSESSMENT5.5.2.1. Follow up of patients response to dietary regime

5.6. Rehabilitation Medicine:5.6.1. SCOPE OF ASSESSMENT:

Initial Assessment includes:5.6.1.1. Medical history5.6.1.2. Physical examination5.6.1.3. Treatment plan

5.6.2. SCOPE OF REASSESSMENT5.5.2.1 Follow up of patients response to rehabilitative treatment.

5.7. Respiratory Care5.7.1. SCOPE OF ASSESSMENT

5.7.1.1. Mechanical ventilation patient care5.7.1.1.1. Assessment of patients respiratory status5.7.1.1.2. Assessment of ventilation parameters5.7.1.1.3. Assessment of response to treatment

5.7.2. SCOPE OF REASSESSMENT5.7.2.1. Reassessment of patients response to respiratory therapy

5.8. Outcome of Care5.8.1. The patient and his and her family are informed of the planned care and

treatment and participate in the decisions about the priority needs to be met.________________________________________________________________________________________________________________________________________________________________________________________________________________________



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5.8.2. The patient and his and her family are informed of the outcomes of theassessment process and any confirmed diagnosis by the attending physician.

6. REFERENCES:6.1. JCIA Assessment of Patient

7. RELATED FORMS AND DOCUMENTS7.1. OPD Patient Assessment Form7.2. Pre-oeparative Doctors Orders7.3. Admission Assessment Form (Adult, Pediatric and Obs/Gyne)7.4. Doctors Progress/Treatment notes7.5. Nurses Notes7.6. Nutrition assessment In-patient Record7.7. Fall risk Assessment/re-assessment Form7.8. Vital signs Sheet7.9. Interdisciplinary Patient Family Education Record7.10. Nursing care Plan7.11. Anesthetic Record

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Ppg Gdch Nur 31 Assessment and Reassessment

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