Admissions, Transfers, and Discharge in Nursing

admissions transfers and discharge the responsibilities of nurses extend beyond the mere physical placement of a patient in a health care facility it involves a comprehensive admission assessment a critical step that provides essential Baseline data for the development of a tailored nursing care plan the admission assessment serves as a snapshot of the patient current health status offering valuable insights into their medical history current conditions and potential risks this information becomes the foundation upon which a personalized care plan is built ensuring that that each patient receives the precise care they need furthermore this initial assessment is not a one-time event comparisons with future assessments become pivotal in monitoring the client&#39;s ongoing status and their response to treatment this Dynamic approach enables nurses to adapt care plans as needed ensuring that interventions align with the patients evolving Health needs however we must acknowledge that the admission process is not always smooth sailing for patients many individuals experience heightened anxiety fear of the unknown and a profound sense of loss of Independence and self-identity when entering a hospital or health care facility for children the separation from parents during hospitalization can trigger separation anxiety adding an extra layer of complexity to the emotional landscape as nurses recognizing and addressing these concerns is Paramount by providing respectful culturally sensitive care we can significantly enhance our patients experiences and contribute to positive outcomes in the realm of transfers nurses once again play a pivotal role in ensuring a seamless transition of care whether it&#39;s a move between departments or facilities effective communication and collaboration are key patient information information must be transferred accurately and the receiving team should be well informed about the patient&#39;s history needs and ongoing care plan finally the discharge process is not merely the conclusion of a patient stay but a crucial step in their Journey towards recovery or management of their health nurses must ensure that patients and their families receive comprehensive education about post-d discharge care including medications follow-up appointments and any necessary lifestyle modifications nursing considerations for discharge planning discharge planning is an interprofessional process that starts at admission nurses play a vital role in discharge Planning by collaborating with clients families and other members of the healthcare team to ensure that clients have the resources and support they need to transition smoothly from the hospital to the community here are some specific nursing considerations for discharge planning assess the client&#39;s ability to participate in the admission assessment clients who are in distress or who have mental status changes may need to have a family member or other caregiver provide information on their behalf begin establishing the therapeutic relationship with the client and family during the admission process this will help to build trust and Rapport which is essential for effective communication and collaboration promote professional communication between providers nurses should communicate regularly with the client&#39;s physician and other members of the healthcare team to keep them updated on the client&#39;s progress and to discuss discharge plans use the nursing process as a guide to plan teaching and interventions for the client during discharge nurses should assess the client&#39;s learning needs and develop a teaching plan that covers topics such as medication management wound care and self-care nurses should also provide the client with resources and support to help them manage their condition at home use standard handoff communication tools such as introduction situation background assessment recommendation isbar to facilitate transfers and discharges isbar is a structured communication tool that helps to ensure that all relevant information is communicated accurately and efficiently here are some specific examples of nursing interventions that can be used to promote effective discharge planning educate the client and family about the discharge planning process explain what to expect and how they can participate assess the client&#39;s needs and resources this includes identifying any social determinants of Health that may impact the client&#39;s ability to manage their condition at home develop a discharge plan with the client and family this plan should include specific goals for the client as well as a timeline for achieving those goals make referrals to Community Resources such as Home Health Care outpatient clinics and support groups coordinate with the client&#39;s physician and other members of The healthc Care team to ensure that the discharge plan is implemented smoothly by following these nursing considerations nurses can help to ensure that clients have a successful transition from the hospital to the community admission process prior to the arrival of the client bring the necessary equipment into the room this should include appropriate documentation forms equipment to measure vital signs a pulse oximeter Hospital attire for the client procedure one introduce yourself and identify your role two explain the roles of other care delivery staff three if in a semi-private room introduce the client to their roommate four provide Hospital attire and assist as necessary five position the client comfortably six apply the identification bracelet and Allergy band if needed seven provide facility specific brochures and informational material 8 provide information about Advanced directives nine document the client&#39;s Advanced directives status in the medical record place a copy in the medical record if it is available here is an example of how to introduce yourself and identify your role hello my name is Julie and I&#39;m a registered nurse I&#39;ll be your nurse nurse for today I&#39;m here to help you get settled in and to answer any questions you have here is an example of how to explain the roles of other care delivery staff in addition to me there are other members of The healthc Care team who will be involved in your care these include doctors physical therapists occupational therapists and pharmacists your doctor is responsible for overseeing your care and making decisions about your treatment the physical therapist will help you with any Mobility or movement issues the occupational therapist will help you with any activities of daily living such as bathing and dressing the pharmacist will dispense your medications and answer any questions you have about them assessment and data collection for admission when a client is admitted to a health care facility it is important to assess and collect Baseline data this information will help the healthcare team to understand the client&#39;s current health status and to develop a plan of care Baseline data Baseline data includes Vital Signs temperature pulse respirations blood pressure height and weight allergy status biographical information name date of birth gender address contact information clients reason for seeking Health Care present illness and symptoms health history current illness current medications prescription and over-the-counter prior illnesses chronic diseases surgeries previous hospitalizations other relevant data family history hypertension cancer heart disease diabetes melodus psychosocial assessment Alcohol Tobacco drug and caffeine use history of mental illness history of abuse or homeless lessness home situation or significant others nutrition current diet any chewing or swallowing problems recent weight gain or loss use of nutritional or herbal supplements Dentures spiritual health or quality of life concerns religion Advanced directives living will review of systems safety assessments safety assessments are also important to conduct during admission these assessments can help to identify potential risks for Falls and injuries safety assessments include history of Falls sensory deficits Vision hearing use of assistive devices Walker cane crutches wheelchair discharge information it is also important to collect discharge information during admission this information will help the healthcare team to ensure that the client has a smooth transition from the health care facility to their home environment discharge information includes family members in the home transportation for discharge relevant phone numbers medical equipment needs at home Home Health Care needs at home the healthc care team will use the data collected during admission to develop a plan of care for the client the plan of care will include goals for the client as well as interventions to help the client achieve those goals tips for collecting data here are some tips for collecting data during admission be organized and efficient use a standard assessment form to ensure that all relevant information is collected be clear and concise in your questions give the client time to answer your questions be respectful of the client&#39;s privacy and confidentiality document all findings accurately and completely by following these tips you can help to ensure that the healthcare team has the information they need to provide the best possible care for the client inventorying personal items when a client is admitted to a health care facility it is important to inventory their personal items this is done to protect the client&#39;s belongings and to ensure that they are returned to the client upon discharge items that should be inventoried include clothing jewelry money credit cards assistive devices eyeglasses contacts hearing aids cane Dentures medications cell phones and other technology devices religious articles valuables such as money jewelry and credit cards should be discouraged from being kept at the bedside if the client insists on keeping valis at the bedside they should be documented as having done so the nurse should also document communicating with the client about the risks of keeping valuables at the bedside and about the facility&#39;s safekeeping policies if the client chooses to have their valuables stored in the facility safe the nurse should document this and provide the client with a receipt for their valuables the nurse should also document the time and date the valuables were deposited in the safe and the time and date they were retrieved from the safe here is an example of how to document communication with the client related to items left within the room and valuables locked in the facilities safe the client was informed of the risks of keeping valuables at the bedside including the possibility of loss or theft the client was also informed of the facility&#39;s safekeeping policies and was given the option of having their valuables stored in the safe the client declined to have their valuables stored in the safe and signed a document acknowledging this decision the client was provided with a receipt for their valuables that were deposited in the facility safe on date at time the client will be know to feed when their valuables are ready to be retrieved from the safe Orient the client and family to the room and the facility this is an example on how to orient the patient now let&#39;s go over some key points to help you familiarize yourself with the room and the facility call light operation if you need assistance from our staff please use the call light system it&#39;s a simple button located within easy reach pressing it will alert our nursing team and they will respond promptly to address your needs electric bed operation your bed is equipped with electric controls to ensure your comfort if you have any specific preferences or need assistance with adjusting the bed please let our nursing staff know and they&#39;ll be happy to assist you telephone services television controls in your room you&#39;ll find a telephone and a television feel free to use them at your convenience if you have any questions about their operation or if you encounter any issues our staff is here to help overhead lighting operation the overhead lighting in your room can be controlled using the switches located near the entrance adjust the lighting to your preference to create a comfortable environment smoking policy facility name is committed to providing a healthy and smoke-free environment smoking is strictly prohibited within the facility if you need assistance or information about smoking cessation programs please ask our staff restroom locations restrooms are conveniently located mention specific locations such as in each patient room or nearby if you require any assistance locating them feel free to ask our staff for guidance waiting areas we have designated waiting areas for your family and friends these areas are designed to provide a comfortable space for them while ensuring your private Y and well-being meal times our meal service is an important aspect of your care regular meal times are mentioned specific times and our dietary staff will be happy to accommodate any dietary restrictions or preferences you may have usual time for provids visits your health care providers will typically make rounds at mentioned specific times if you have any questions or specific topics you&#39;d like to discuss with them please inform our nursing staff dining vending Services we offer dining services and there are vending options available for snacks please refer to the information provided in your room for more details on dining options and their operating hours visiting policies we understand the importance of having loved ones by your side our visiting policies are designed to balance the need for support with the necessary rest and recovery of our patients please check with our staff regarding specific visiting hours and any special considerations we want you to feel at home during your stay at facility name our staff is here to assist you every step of the way if you have any questions or need further clarification on any of the points discussed please don&#39;t hesitate to ask indications for transfer and discharge in healthcare why might a patient need to be transferred or discharged there are there are several reasons and they are often tied to the evolving needs of the patient and the level of care required let&#39;s explore these indications in detail the first indication for transfer or discharge is a change in the level of care needed for instance if a patient&#39;s health status improves to the point where they no longer require intensive care it may be appropriate to consider transferring them to a lower level of care this is a positive outcome that reflects the effectiveness of the medical interventions provided sometimes a change in the patient&#39;s condition necessitates a move to a different setting this could be the case when a patient is transferred from a medical unit to a surgical Suite different settings offer varying levels of specialization and resources ensuring that the patient receives the most appropriate care for their current needs another crucial reason for transfer or discharge is when the facility is unable to provide the specific type of care that a patient now requires for example after the acute phase of a stroke a patient may need Specialized Care that the current facility cannot offer in such cases a transfer to a facility equipped to handle the patients evolving needs becomes necessary finally patients who no longer need inpatient care and are deemed ready for a return home represent another common indic for discharge this often occurs when the patient has reached a point in their recovery where they can continue their treatment and Rehabilitation in a home setting with appropriate support and follow-up care discharge planning discharge planning is a systematic process that begins upon admission and aims to prepare the patient for a safe return to their home environment it involves a a series of Assessments considerations and actions to guarantee the well-being of the patient post discharge the first step in discharge planning is to assess whether the patient will be able to return to their previous residence this includes evaluating the safety and suitability of the home environment for the patient&#39;s recovery additionally determine if the patient needs assistance at home and assess the need for any adaptations or specific equipment to address the broader social aspects a crucial step is making a referral to the social worker the social worker plays a key role in arranging community services that can support the patient in their postd discharge period this may include Home Health Services meal delivery or other community-based programs effective communication with community service providers is Paramount Health status and specific needs of the patent should be clearly conveyed to ensure a coordinated and supportive Network upon discharge this collaboration ensures continuity of care beyond the healthare facility while discharge planning progresses it is important to remember that a patient if legally competent has the right to leave the facility at any time in such cases the nurse is responsible for notifying the patient&#39;s provider obtaining necessary signatures and providing discharge teaching in every step of the discharge planning process it is crucial to involve the patient and their family as much as possible this collaborative approach not only enhances the patients understanding of their care plan but also promotes a sense of empowerment and responsibility discharge education the nurse discusses the discharge instructions with the client and provides a printed copy instructions should use Clear concise language that the client will understand the nurse should verify understanding of the instructions by the client standards for discharge education one identifying safety concerns at home two reviewing symptoms of potential complications and when to contact emergency care or the provider three providing the phone number of the provider four providing names and phone numbers of Community Resources that give Care at the client&#39;s residence five step-by-step instructions for performing continuing treatments such as dressing changes six dietary restrictions and guidelines including those that pertain to medication administration seven amount and frequency of therapies to perform to support continued Independence at home eight directions how to take medications potential interactions and why adherence is important equipment items to transfer or discharge with the client when transferring or discharging a client from a health care facility it is important to ensure that the client has all of the necessary equipment items these items may include personal belongings at the bedside and from dresser drawers and closet flowers books clothing Personal Care items valuables from the safe if leaving the facility medications especially that belong to the client or that cannot be returned to the pharmacy for credit assistive devices medical records or a transfer form personal belongings should be packed in a suitcase or bag that the client can easily carry or transport items to pack include clothing Personal Care items and any other items that the client may need during their transfer or discharge if the client has any valuables such as money jewelry or credit C cards these items should be retrieved from the safe and given to the client all medications should be transferred with the client this includes prescription medications over-the-counter medications and herbal supplements medications that belong to the client or that cannot be returned to the pharmacy for credit should be transferred in their original containers responsibilities of the nurse transferring or discharging a client one on the day and time of transfer confirm that the receiving facility or unit is expecting the client and that the room or bed is available this is important to ensure that the client has a smooth transition to their new care setting the nurse can confirm this information by calling the receiving facility or unit and speaking with a staff member two communicate the time the client will transfer to the receiving facility or unit this information is important for both the client and the receiving facility or unit the client needs to know when they will be transferring so that they can be prepared the receiving facility or unit needs to know when to expect the client so that they can staff appropriately three complete documentation medical records transfer form accurate and complete documentation is essential for the continuity of care the nurse should complete all necessary documentation including the client&#39;s medical records and a transfer form the transfer form should include information such as the client&#39;s name date of birth medical history current medications and any special needs four give a verbal transfer report in person or via telephone a verbal transfer report is a communication between the nurse transferring the client and the nurse receiving the client the verbal transfer report should include information such as the client&#39;s medical history current medications allergies any special needs and the client&#39;s current condition five confirm the mode of transportation the client will use to complete the transfer or discharge car wheelchair or ambulance the nurse needs to confirm the mode of transportation the client will be using to ensure that the transfer is safe and efficient if the client is going to be transported by car the nurse needs to make sure that the client is dressed appropriately and that they have a safe way to get to the car if the client is going to be transported by wheelchair the nurse needs to make sure that the wheelchair is in good condition and that the client is able to use it safely if the client is going to be transported by ambulance the nurse needs to contact the ambulance company and schedule a pickup time six make sure the client is dressed appropriately if going outside the facility the nurse needs to make sure that the client is dressed appropriately if they are going to be going outside the facility the client should be dressed in comfortable and weather appropriate clothing the client should also wear shoes that are comfortable and supportive seven account for all the clients valuables the nurse needs to to account for all the clients valuables before they are transferred or discharged this includes money jewelry credit cards and other personal belongings the nurse can account for the client&#39;s valuables by asking the client to verify that they have all of their belongings and by checking the client&#39;s room and belongings by following these responsibilities nurses can help to ensure that the transfer or discharge process is safe and efficient for the client respon responsibilities of the nurse when receiving a transferred client one have any specialized equipment ready if the transferred client will be using specialized equipment such as a ventilator or a dialysis machine the nurse should have this equipment ready before the client arrives this will help to ensure that the client&#39;s transfer is smooth and that they receive the care they need immediately two if a appropriate inform the client&#39;s roommate of the impending admission or transfer if the transferred client is going to be sharing a room with another client the nurse should inform the other client of the impending admission or transfer this will help to prepare the other client for the new roommate and to avoid any surprises three inform other Healthcare team members of the client&#39;s arrival and needs the nurse should inform other Healthcare team members such as the doctor and the respiratory therapist of the client&#39;s arrival and needs this will help to ensure that the client receives the care they need from all members of The healthc Care Team Four meet with the client and family on arrival to complete the admission process and Orient the client and family to the new facility or unit the nurse should meet with the transferred client and their family on arrival to complete the admission process and to orient them to the new facility or unit this includes reviewing the client&#39;s medical history current medications and allergies the nurse should also answer any questions that the client or their family may have five assess how the client tolerates the transfer the nurse should assess how the client tolerates the transfer this includes assessing the client&#39;s Vital Signs respiratory status and level of Consciousness the nurse should also assess the client for any signs of distress or discomfort six review transfer documentation the nurse should review the transfer documentation to ensure that all necessary information is included this information should include the client&#39;s medical history current medications allergies and any special needs seven Implement appropriate nursing interventions in a timely manner the nurse should Implement appropriate nursing interventions in a timely manner this may include administering medications providing wound care or monitoring the client&#39;s Vital Signs by following these steps nurses can help to ensure that transferred clients receive the care they need in a safe and efficient manner transfer documentation transfer documentation is a critical part of the patient care process it is important to ensure that all relevant information is transferred to the receiving facility or unit so that the patient can receive safe and effective care the following information should be included in transfer documentation one medical diagnosis and care providers this information includes the patient&#39;s primary diagnosis any secondary diagnoses and the names of their care providers two demographic information this information incl includes the patient&#39;s name date of birth gender address and phone number three overview of health status plan of care and recent progress this information should include a summary of the patient&#39;s current health status their plan of care and their recent progress four alterations that can precipitate an immediate concern this information should include any changes in the patient condition that could lead to an immediate iate concern such as a change in Vital Signs respiratory status or level of Consciousness five notification of Assessments or care essential within the next few hours this information should include any assessments or care that are essential for the patient safety and well-being within the next few hours such as medication administration or wound care six most recent Vital Signs and medications including PRN this information should include the patient most recent Vital Signs and a list of all the medications they are currently taking including PRN as needed medications seven allergies this information should include a list of all of the patients known allergies eight diet and activity orders this information should include the patient&#39;s current diet and activity orders nine specific equipment or adaptive devices oxygen suction wheelchair this information should include a list of any specific equipment or adaptive devices that the patient needs 10 Advanced directives and emergency code status this information should include the patients Advanced directives if any and their emergency code status 11 family involvement in care and Health Care proxy if applicable this information should include the names and contact information of the patients family members who are involved in their care as well as the name and contact information of their health care proxy if applicable it is important to note that this is just a general list of the information that should be included in transfer documentation the specific information that is needed may vary depending on the patient&#39;s individual circumstances here are some tips for completing transfer documentation be clear and concise use complete sentences and proper grammar avoid using abbreviations or acronyms that the receiving facility or unit may not understand document all relevant information even if it seems insignificant sign and date the transfer documentation by following these tips you can help to ensure that your transfer documentation is complete and accurate this will help to ensure that the patient receives safe and effective Care at the receiving facility or unit discharge documentation discharge documentation is an important part of the patient care process it provides a summary of the patient&#39;s hospitalization and provides instructions for their care after discharge the following information should be included in discharge documentation one type of discharge provider prescription or against medical advice AMA this information indicates whether the patient was discharged with the provider&#39;s approval or if they left the hospital against medical advice two date and time of discharge who went with the client and transportation wheelchair to car gurnie to ambulance this information includes the date and time the patient was discharged the name of the person who went with them and the mode of transportation they used to leave the hospital three where the client went home long-term care facility this information indicates where the patient went after they were discharged from the hospital four summary of the client&#39;s condition at discharge steady gate and ulating independently in no apparent distress this information provides a summary of the patients condition at the time of discharge including their Mobility level of Consciousness and overall condition five description of any unresolved difficulties and procedures for followup this information describes any unresolved difficulties that the patient is still experiencing at the time of discharge as well as the procedures for followup care six disposition of valuables medications brought from home and prescriptions this information indicates how the patient valuables medications brought from home and prescriptions were handled at the time of discharge it is important to note that this is just a general list of the information that should be included in discharge doc documentation the specific information that is needed may vary depending on the pant&#39;s individual circumstances discharge instructions discharge instructions are an important part of the patient care process they provide patients with the information they need to manage their care after they leave the hospital it is important to document that the patient understands their discharge instructions before they are discharged there are a few different ways to document a patient&#39;s understanding of their discharge instructions one way is to Simply ask the patient to repeat back the instructions to you another way is to have the patient fill out a questionnaire about the instructions you can also use a teachback method where you have the patient demonstrate how they will perform a task such as administering medication or changing addressing here are some specific things to document one written instructions in the client&#39;s language provide the patient with written instructions in their language this will help them to remember the instructions after they leave the hospital diet at home explain the patient diet at home including any restrictions or special instructions two step-by-step instructions for procedures at home provide the patient with stepbystep instructions for any procedure they will need to perform at home such as administering medication or changing a dressing be sure to demonstrate the procedures to the patient and have them practice three precautions to take when performing procedures or administering medications explain any precautions the patient needs to take when performing procedures or administering medications for example the patient may need to wear gloves or wash their hands before and after performing a procedure four signs and symptoms of complications to report explain the signs and symptoms of complications that the patient should report to their doctor for example the patient may need to report any fever redness or swelling at the site of an incision five names and numbers of providers and Community Services to contact provide the patient with the names and numbers of their providers and community services that they can Conta cont if they have any questions or concerns six plans for follow-up care and therapies explain the patients plans for follow-up care and therapies for example the patient may need to see their doctor in one week for a wound check or start physical therapy to help them regain their strength by documenting the patient understanding of their discharge instructions you can help to ensure that they receive safe and effective care after they leave the hospital here is an example of how to document the patients understanding of their discharge instructions documentation of understanding of discharge instructions patient name John Smith date 20235 I have reviewed the discharge instructions with Mr Smith he was able to repeat back the instructions accurately and demonstrate how he will perform the following procedures at home administering pain medication changing his dressing I have also explained the signs and symptoms of complications to report as well as the names and numbers of his providers and Community Services Mr Smith has expressed that he understands and agrees to follow all of his discharge instructions signature nurse Jane Doe date 2023 so 805 thank you for listening to my audio notes on nursing I hope you found them informative and helpful if you did please consider subscribing to my channel for more audio notes on a variety of nursing topics

admissions transfers and discharge the responsibilities of nurses extend beyond the mere physical placement of a patient in a health care facility it involves a comprehensive admission assessment a critical step that provides essential Baseline data for the development of a tailored nursing care plan the admission assessment serves as a snapshot of the patient current health status offering valuable insights into their medical history current conditions and potential risks this information becomes the foundation upon which a personalized care plan is built ensuring that that each patient receives the precise care they need furthermore this initial assessment is not a one-time event comparisons with future assessments become pivotal in monitoring the client&amp;#39;s ongoing status and their response to treatment this Dynamic approach enables nurses to adapt care plans as needed ensuring that interventions align with the patients evolving Health needs however we must acknowledge that the admission process is not always smooth sailing for patients many individuals experience heightened anxiety fear of the unknown and a profound sense of loss of Independence and self-identity when entering a hospital or health care facility for children the separation from parents during hospitalization can trigger separation anxiety adding an extra layer of complexity to the emotional landscape as nurses recognizing and addressing these concerns is Paramount by providing respectful culturally sensitive care we can significantly enhance our patients experiences and contribute to positive outcomes in the realm of transfers nurses once again play a pivotal role in ensuring a seamless transition of care whether it&amp;#39;s a move between departments or facilities effective communication and collaboration are key patient information information must be transferred accurately and the receiving team should be well informed about the patient&amp;#39;s history needs and ongoing care plan finally the discharge process is not merely the conclusion of a patient stay but a crucial step in their Journey towards recovery or management of their health nurses must ensure that patients and their families receive comprehensive education about post-d discharge care including medications follow-up appointments and any necessary lifestyle modifications nursing considerations for discharge planning discharge planning is an interprofessional process that starts at admission nurses play a vital role in discharge Planning by collaborating with clients families and other members of the healthcare team to ensure that clients have the resources and support they need to transition smoothly from the hospital to the community here are some specific nursing considerations for discharge planning assess the client&amp;#39;s ability to participate in the admission assessment clients who are in distress or who have mental status changes may need to have a family member or other caregiver provide information on their behalf begin establishing the therapeutic relationship with the client and family during the admission process this will help to build trust and Rapport which is essential for effective communication and collaboration promote professional communication between providers nurses should communicate regularly with the client&amp;#39;s physician and other members of the healthcare team to keep them updated on the client&amp;#39;s progress and to discuss discharge plans use the nursing process as a guide to plan teaching and interventions for the client during discharge nurses should assess the client&amp;#39;s learning needs and develop a teaching plan that covers topics such as medication management wound care and self-care nurses should also provide the client with resources and support to help them manage their condition at home use standard handoff communication tools such as introduction situation background assessment recommendation isbar to facilitate transfers and discharges isbar is a structured communication tool that helps to ensure that all relevant information is communicated accurately and efficiently here are some specific examples of nursing interventions that can be used to promote effective discharge planning educate the client and family about the discharge planning process explain what to expect and how they can participate assess the client&amp;#39;s needs and resources this includes identifying any social determinants of Health that may impact the client&amp;#39;s ability to manage their condition at home develop a discharge plan with the client and family this plan should include specific goals for the client as well as a timeline for achieving those goals make referrals to Community Resources such as Home Health Care outpatient clinics and support groups coordinate with the client&amp;#39;s physician and other members of The healthc Care team to ensure that the discharge plan is implemented smoothly by following these nursing considerations nurses can help to ensure that clients have a successful transition from the hospital to the community admission process prior to the arrival of the client bring the necessary equipment into the room this should include appropriate documentation forms equipment to measure vital signs a pulse oximeter Hospital attire for the client procedure one introduce yourself and identify your role two explain the roles of other care delivery staff three if in a semi-private room introduce the client to their roommate four provide Hospital attire and assist as necessary five position the client comfortably six apply the identification bracelet and Allergy band if needed seven provide facility specific brochures and informational material 8 provide information about Advanced directives nine document the client&amp;#39;s Advanced directives status in the medical record place a copy in the medical record if it is available here is an example of how to introduce yourself and identify your role hello my name is Julie and I&amp;#39;m a registered nurse I&amp;#39;ll be your nurse nurse for today I&amp;#39;m here to help you get settled in and to answer any questions you have here is an example of how to explain the roles of other care delivery staff in addition to me there are other members of The healthc Care team who will be involved in your care these include doctors physical therapists occupational therapists and pharmacists your doctor is responsible for overseeing your care and making decisions about your treatment the physical therapist will help you with any Mobility or movement issues the occupational therapist will help you with any activities of daily living such as bathing and dressing the pharmacist will dispense your medications and answer any questions you have about them assessment and data collection for admission when a client is admitted to a health care facility it is important to assess and collect Baseline data this information will help the healthcare team to understand the client&amp;#39;s current health status and to develop a plan of care Baseline data Baseline data includes Vital Signs temperature pulse respirations blood pressure height and weight allergy status biographical information name date of birth gender address contact information clients reason for seeking Health Care present illness and symptoms health history current illness current medications prescription and over-the-counter prior illnesses chronic diseases surgeries previous hospitalizations other relevant data family history hypertension cancer heart disease diabetes melodus psychosocial assessment Alcohol Tobacco drug and caffeine use history of mental illness history of abuse or homeless lessness home situation or significant others nutrition current diet any chewing or swallowing problems recent weight gain or loss use of nutritional or herbal supplements Dentures spiritual health or quality of life concerns religion Advanced directives living will review of systems safety assessments safety assessments are also important to conduct during admission these assessments can help to identify potential risks for Falls and injuries safety assessments include history of Falls sensory deficits Vision hearing use of assistive devices Walker cane crutches wheelchair discharge information it is also important to collect discharge information during admission this information will help the healthcare team to ensure that the client has a smooth transition from the health care facility to their home environment discharge information includes family members in the home transportation for discharge relevant phone numbers medical equipment needs at home Home Health Care needs at home the healthc care team will use the data collected during admission to develop a plan of care for the client the plan of care will include goals for the client as well as interventions to help the client achieve those goals tips for collecting data here are some tips for collecting data during admission be organized and efficient use a standard assessment form to ensure that all relevant information is collected be clear and concise in your questions give the client time to answer your questions be respectful of the client&amp;#39;s privacy and confidentiality document all findings accurately and completely by following these tips you can help to ensure that the healthcare team has the information they need to provide the best possible care for the client inventorying personal items when a client is admitted to a health care facility it is important to inventory their personal items this is done to protect the client&amp;#39;s belongings and to ensure that they are returned to the client upon discharge items that should be inventoried include clothing jewelry money credit cards assistive devices eyeglasses contacts hearing aids cane Dentures medications cell phones and other technology devices religious articles valuables such as money jewelry and credit cards should be discouraged from being kept at the bedside if the client insists on keeping valis at the bedside they should be documented as having done so the nurse should also document communicating with the client about the risks of keeping valuables at the bedside and about the facility&amp;#39;s safekeeping policies if the client chooses to have their valuables stored in the facility safe the nurse should document this and provide the client with a receipt for their valuables the nurse should also document the time and date the valuables were deposited in the safe and the time and date they were retrieved from the safe here is an example of how to document communication with the client related to items left within the room and valuables locked in the facilities safe the client was informed of the risks of keeping valuables at the bedside including the possibility of loss or theft the client was also informed of the facility&amp;#39;s safekeeping policies and was given the option of having their valuables stored in the safe the client declined to have their valuables stored in the safe and signed a document acknowledging this decision the client was provided with a receipt for their valuables that were deposited in the facility safe on date at time the client will be know to feed when their valuables are ready to be retrieved from the safe Orient the client and family to the room and the facility this is an example on how to orient the patient now let&amp;#39;s go over some key points to help you familiarize yourself with the room and the facility call light operation if you need assistance from our staff please use the call light system it&amp;#39;s a simple button located within easy reach pressing it will alert our nursing team and they will respond promptly to address your needs electric bed operation your bed is equipped with electric controls to ensure your comfort if you have any specific preferences or need assistance with adjusting the bed please let our nursing staff know and they&amp;#39;ll be happy to assist you telephone services television controls in your room you&amp;#39;ll find a telephone and a television feel free to use them at your convenience if you have any questions about their operation or if you encounter any issues our staff is here to help overhead lighting operation the overhead lighting in your room can be controlled using the switches located near the entrance adjust the lighting to your preference to create a comfortable environment smoking policy facility name is committed to providing a healthy and smoke-free environment smoking is strictly prohibited within the facility if you need assistance or information about smoking cessation programs please ask our staff restroom locations restrooms are conveniently located mention specific locations such as in each patient room or nearby if you require any assistance locating them feel free to ask our staff for guidance waiting areas we have designated waiting areas for your family and friends these areas are designed to provide a comfortable space for them while ensuring your private Y and well-being meal times our meal service is an important aspect of your care regular meal times are mentioned specific times and our dietary staff will be happy to accommodate any dietary restrictions or preferences you may have usual time for provids visits your health care providers will typically make rounds at mentioned specific times if you have any questions or specific topics you&amp;#39;d like to discuss with them please inform our nursing staff dining vending Services we offer dining services and there are vending options available for snacks please refer to the information provided in your room for more details on dining options and their operating hours visiting policies we understand the importance of having loved ones by your side our visiting policies are designed to balance the need for support with the necessary rest and recovery of our patients please check with our staff regarding specific visiting hours and any special considerations we want you to feel at home during your stay at facility name our staff is here to assist you every step of the way if you have any questions or need further clarification on any of the points discussed please don&amp;#39;t hesitate to ask indications for transfer and discharge in healthcare why might a patient need to be transferred or discharged there are there are several reasons and they are often tied to the evolving needs of the patient and the level of care required let&amp;#39;s explore these indications in detail the first indication for transfer or discharge is a change in the level of care needed for instance if a patient&amp;#39;s health status improves to the point where they no longer require intensive care it may be appropriate to consider transferring them to a lower level of care this is a positive outcome that reflects the effectiveness of the medical interventions provided sometimes a change in the patient&amp;#39;s condition necessitates a move to a different setting this could be the case when a patient is transferred from a medical unit to a surgical Suite different settings offer varying levels of specialization and resources ensuring that the patient receives the most appropriate care for their current needs another crucial reason for transfer or discharge is when the facility is unable to provide the specific type of care that a patient now requires for example after the acute phase of a stroke a patient may need Specialized Care that the current facility cannot offer in such cases a transfer to a facility equipped to handle the patients evolving needs becomes necessary finally patients who no longer need inpatient care and are deemed ready for a return home represent another common indic for discharge this often occurs when the patient has reached a point in their recovery where they can continue their treatment and Rehabilitation in a home setting with appropriate support and follow-up care discharge planning discharge planning is a systematic process that begins upon admission and aims to prepare the patient for a safe return to their home environment it involves a a series of Assessments considerations and actions to guarantee the well-being of the patient post discharge the first step in discharge planning is to assess whether the patient will be able to return to their previous residence this includes evaluating the safety and suitability of the home environment for the patient&amp;#39;s recovery additionally determine if the patient needs assistance at home and assess the need for any adaptations or specific equipment to address the broader social aspects a crucial step is making a referral to the social worker the social worker plays a key role in arranging community services that can support the patient in their postd discharge period this may include Home Health Services meal delivery or other community-based programs effective communication with community service providers is Paramount Health status and specific needs of the patent should be clearly conveyed to ensure a coordinated and supportive Network upon discharge this collaboration ensures continuity of care beyond the healthare facility while discharge planning progresses it is important to remember that a patient if legally competent has the right to leave the facility at any time in such cases the nurse is responsible for notifying the patient&amp;#39;s provider obtaining necessary signatures and providing discharge teaching in every step of the discharge planning process it is crucial to involve the patient and their family as much as possible this collaborative approach not only enhances the patients understanding of their care plan but also promotes a sense of empowerment and responsibility discharge education the nurse discusses the discharge instructions with the client and provides a printed copy instructions should use Clear concise language that the client will understand the nurse should verify understanding of the instructions by the client standards for discharge education one identifying safety concerns at home two reviewing symptoms of potential complications and when to contact emergency care or the provider three providing the phone number of the provider four providing names and phone numbers of Community Resources that give Care at the client&amp;#39;s residence five step-by-step instructions for performing continuing treatments such as dressing changes six dietary restrictions and guidelines including those that pertain to medication administration seven amount and frequency of therapies to perform to support continued Independence at home eight directions how to take medications potential interactions and why adherence is important equipment items to transfer or discharge with the client when transferring or discharging a client from a health care facility it is important to ensure that the client has all of the necessary equipment items these items may include personal belongings at the bedside and from dresser drawers and closet flowers books clothing Personal Care items valuables from the safe if leaving the facility medications especially that belong to the client or that cannot be returned to the pharmacy for credit assistive devices medical records or a transfer form personal belongings should be packed in a suitcase or bag that the client can easily carry or transport items to pack include clothing Personal Care items and any other items that the client may need during their transfer or discharge if the client has any valuables such as money jewelry or credit C cards these items should be retrieved from the safe and given to the client all medications should be transferred with the client this includes prescription medications over-the-counter medications and herbal supplements medications that belong to the client or that cannot be returned to the pharmacy for credit should be transferred in their original containers responsibilities of the nurse transferring or discharging a client one on the day and time of transfer confirm that the receiving facility or unit is expecting the client and that the room or bed is available this is important to ensure that the client has a smooth transition to their new care setting the nurse can confirm this information by calling the receiving facility or unit and speaking with a staff member two communicate the time the client will transfer to the receiving facility or unit this information is important for both the client and the receiving facility or unit the client needs to know when they will be transferring so that they can be prepared the receiving facility or unit needs to know when to expect the client so that they can staff appropriately three complete documentation medical records transfer form accurate and complete documentation is essential for the continuity of care the nurse should complete all necessary documentation including the client&amp;#39;s medical records and a transfer form the transfer form should include information such as the client&amp;#39;s name date of birth medical history current medications and any special needs four give a verbal transfer report in person or via telephone a verbal transfer report is a communication between the nurse transferring the client and the nurse receiving the client the verbal transfer report should include information such as the client&amp;#39;s medical history current medications allergies any special needs and the client&amp;#39;s current condition five confirm the mode of transportation the client will use to complete the transfer or discharge car wheelchair or ambulance the nurse needs to confirm the mode of transportation the client will be using to ensure that the transfer is safe and efficient if the client is going to be transported by car the nurse needs to make sure that the client is dressed appropriately and that they have a safe way to get to the car if the client is going to be transported by wheelchair the nurse needs to make sure that the wheelchair is in good condition and that the client is able to use it safely if the client is going to be transported by ambulance the nurse needs to contact the ambulance company and schedule a pickup time six make sure the client is dressed appropriately if going outside the facility the nurse needs to make sure that the client is dressed appropriately if they are going to be going outside the facility the client should be dressed in comfortable and weather appropriate clothing the client should also wear shoes that are comfortable and supportive seven account for all the clients valuables the nurse needs to to account for all the clients valuables before they are transferred or discharged this includes money jewelry credit cards and other personal belongings the nurse can account for the client&amp;#39;s valuables by asking the client to verify that they have all of their belongings and by checking the client&amp;#39;s room and belongings by following these responsibilities nurses can help to ensure that the transfer or discharge process is safe and efficient for the client respon responsibilities of the nurse when receiving a transferred client one have any specialized equipment ready if the transferred client will be using specialized equipment such as a ventilator or a dialysis machine the nurse should have this equipment ready before the client arrives this will help to ensure that the client&amp;#39;s transfer is smooth and that they receive the care they need immediately two if a appropriate inform the client&amp;#39;s roommate of the impending admission or transfer if the transferred client is going to be sharing a room with another client the nurse should inform the other client of the impending admission or transfer this will help to prepare the other client for the new roommate and to avoid any surprises three inform other Healthcare team members of the client&amp;#39;s arrival and needs the nurse should inform other Healthcare team members such as the doctor and the respiratory therapist of the client&amp;#39;s arrival and needs this will help to ensure that the client receives the care they need from all members of The healthc Care Team Four meet with the client and family on arrival to complete the admission process and Orient the client and family to the new facility or unit the nurse should meet with the transferred client and their family on arrival to complete the admission process and to orient them to the new facility or unit this includes reviewing the client&amp;#39;s medical history current medications and allergies the nurse should also answer any questions that the client or their family may have five assess how the client tolerates the transfer the nurse should assess how the client tolerates the transfer this includes assessing the client&amp;#39;s Vital Signs respiratory status and level of Consciousness the nurse should also assess the client for any signs of distress or discomfort six review transfer documentation the nurse should review the transfer documentation to ensure that all necessary information is included this information should include the client&amp;#39;s medical history current medications allergies and any special needs seven Implement appropriate nursing interventions in a timely manner the nurse should Implement appropriate nursing interventions in a timely manner this may include administering medications providing wound care or monitoring the client&amp;#39;s Vital Signs by following these steps nurses can help to ensure that transferred clients receive the care they need in a safe and efficient manner transfer documentation transfer documentation is a critical part of the patient care process it is important to ensure that all relevant information is transferred to the receiving facility or unit so that the patient can receive safe and effective care the following information should be included in transfer documentation one medical diagnosis and care providers this information includes the patient&amp;#39;s primary diagnosis any secondary diagnoses and the names of their care providers two demographic information this information incl includes the patient&amp;#39;s name date of birth gender address and phone number three overview of health status plan of care and recent progress this information should include a summary of the patient&amp;#39;s current health status their plan of care and their recent progress four alterations that can precipitate an immediate concern this information should include any changes in the patient condition that could lead to an immediate iate concern such as a change in Vital Signs respiratory status or level of Consciousness five notification of Assessments or care essential within the next few hours this information should include any assessments or care that are essential for the patient safety and well-being within the next few hours such as medication administration or wound care six most recent Vital Signs and medications including PRN this information should include the patient most recent Vital Signs and a list of all the medications they are currently taking including PRN as needed medications seven allergies this information should include a list of all of the patients known allergies eight diet and activity orders this information should include the patient&amp;#39;s current diet and activity orders nine specific equipment or adaptive devices oxygen suction wheelchair this information should include a list of any specific equipment or adaptive devices that the patient needs 10 Advanced directives and emergency code status this information should include the patients Advanced directives if any and their emergency code status 11 family involvement in care and Health Care proxy if applicable this information should include the names and contact information of the patients family members who are involved in their care as well as the name and contact information of their health care proxy if applicable it is important to note that this is just a general list of the information that should be included in transfer documentation the specific information that is needed may vary depending on the patient&amp;#39;s individual circumstances here are some tips for completing transfer documentation be clear and concise use complete sentences and proper grammar avoid using abbreviations or acronyms that the receiving facility or unit may not understand document all relevant information even if it seems insignificant sign and date the transfer documentation by following these tips you can help to ensure that your transfer documentation is complete and accurate this will help to ensure that the patient receives safe and effective Care at the receiving facility or unit discharge documentation discharge documentation is an important part of the patient care process it provides a summary of the patient&amp;#39;s hospitalization and provides instructions for their care after discharge the following information should be included in discharge documentation one type of discharge provider prescription or against medical advice AMA this information indicates whether the patient was discharged with the provider&amp;#39;s approval or if they left the hospital against medical advice two date and time of discharge who went with the client and transportation wheelchair to car gurnie to ambulance this information includes the date and time the patient was discharged the name of the person who went with them and the mode of transportation they used to leave the hospital three where the client went home long-term care facility this information indicates where the patient went after they were discharged from the hospital four summary of the client&amp;#39;s condition at discharge steady gate and ulating independently in no apparent distress this information provides a summary of the patients condition at the time of discharge including their Mobility level of Consciousness and overall condition five description of any unresolved difficulties and procedures for followup this information describes any unresolved difficulties that the patient is still experiencing at the time of discharge as well as the procedures for followup care six disposition of valuables medications brought from home and prescriptions this information indicates how the patient valuables medications brought from home and prescriptions were handled at the time of discharge it is important to note that this is just a general list of the information that should be included in discharge doc documentation the specific information that is needed may vary depending on the pant&amp;#39;s individual circumstances discharge instructions discharge instructions are an important part of the patient care process they provide patients with the information they need to manage their care after they leave the hospital it is important to document that the patient understands their discharge instructions before they are discharged there are a few different ways to document a patient&amp;#39;s understanding of their discharge instructions one way is to Simply ask the patient to repeat back the instructions to you another way is to have the patient fill out a questionnaire about the instructions you can also use a teachback method where you have the patient demonstrate how they will perform a task such as administering medication or changing addressing here are some specific things to document one written instructions in the client&amp;#39;s language provide the patient with written instructions in their language this will help them to remember the instructions after they leave the hospital diet at home explain the patient diet at home including any restrictions or special instructions two step-by-step instructions for procedures at home provide the patient with stepbystep instructions for any procedure they will need to perform at home such as administering medication or changing a dressing be sure to demonstrate the procedures to the patient and have them practice three precautions to take when performing procedures or administering medications explain any precautions the patient needs to take when performing procedures or administering medications for example the patient may need to wear gloves or wash their hands before and after performing a procedure four signs and symptoms of complications to report explain the signs and symptoms of complications that the patient should report to their doctor for example the patient may need to report any fever redness or swelling at the site of an incision five names and numbers of providers and Community Services to contact provide the patient with the names and numbers of their providers and community services that they can Conta cont if they have any questions or concerns six plans for follow-up care and therapies explain the patients plans for follow-up care and therapies for example the patient may need to see their doctor in one week for a wound check or start physical therapy to help them regain their strength by documenting the patient understanding of their discharge instructions you can help to ensure that they receive safe and effective care after they leave the hospital here is an example of how to document the patients understanding of their discharge instructions documentation of understanding of discharge instructions patient name John Smith date 20235 I have reviewed the discharge instructions with Mr Smith he was able to repeat back the instructions accurately and demonstrate how he will perform the following procedures at home administering pain medication changing his dressing I have also explained the signs and symptoms of complications to report as well as the names and numbers of his providers and Community Services Mr Smith has expressed that he understands and agrees to follow all of his discharge instructions signature nurse Jane Doe date 2023 so 805 thank you for listening to my audio notes on nursing I hope you found them informative and helpful if you did please consider subscribing to my channel for more audio notes on a variety of nursing topics

Transcript for:Admissions, Transfers, and Discharge in Nursing

Transcript for:
Admissions, Transfers, and Discharge in Nursing