Admissions Flashcards
Who is usually the first person the patient encounters on the Nursing Unit?
unit clerk
urgent or direct admission
Occurs when a patient is brought directly to patient registration from a doctor’s office or clinic. They bypass the admitting and emergency department and go directly to the nursing unit. Direct admissions may be routine or emergency admissions.
routine, elective or scheduled admissions
Occurs when the patient and doctor elect when to schedule a non-emergency surgery or procedure and are planned in advance. When a physician sees a patient in their office and determines a procedure or surgery is necessary, the physician will contact the hospital and arrange a routine elective admission.
pre-admission clinic
PAC
Patients admitted to the hospital for surgery are pre-admitted by the PAC unit clerk. ) The PAC Unit Clerk will contact the patient as to when to come to the hospital. At that time a nurse will complete a history, obtain a signed consent and direct the patient to the appropriate department for a pre-admission work-up. The patient will then be given a date and time to arrive at the hospital for their surgery/procedure.
When are patients admitted for surgery or procedure?
The day of surgery/procedure or the day before
Where is the patient taken after surgery?
Recovery Room
What happens to the patient once their time in the Recovery Room is finished?
Admitted to the unit as an inpatient or discharged home if they are stable after day surgery
How is a Unit Clerk able to keep an eye on which patients are coming into or leaving their unit?
Checking the OR Room slate
emergency admission
These admissions are unplanned and are the result of an accident, sudden illness, or other medical crisis. Patients enter the hospital through the emergency department where they are assessed by a triage nurse. Some arrive by ambulance, others walking or by wheelchair. He/she will determine if the patient requires urgent care or those who are not urgent may have to wait longer to see a physician.
In the Emergency Dept., who determines if a patient should be admitted to the hospital?
ER physician
Who does the ER Unit Clerk contact if a patient is to be admitted?
Admitting Department
Who transfers the patients?
Porter
transfer from another facility
The patient will be admitted directly to the Unit from another hospital or Care Facility and is brought to the unit, often via ambulance.
Some hospitals require _____ to perform the duties of the admitting department.
Unit Clerk
When is the bed assignment made for emergency and direct admissions?
When the patient arrives at the hospital and is ready for a room
When is the bed assignment determined for an elective admission?
The evening before or at the beginning of the shift of the patient’s expected arrival
Where do you obtain current admitting information?
Admission-Separation Record
What is a Face Sheet?
The first form completed for the patient. It originates in the admitting department and then is sent to the unit to be placed into the patient’s chart.
What information is contained on a Face Sheet?
All of the patient’s pertinent information ex. patient’s full name, next of kin, address, doctor, diagnosis, personal healthcare number (PHN), allergies, etc.
What is a Consent for Treatment Form?
This allows the physician and other medical staff to treat, care and diagnose the patient while the patient is in the hospital. If the patient requires any surgery or invasive procedure, another consent form will be obtained. This must be signed by the patient.
What is the Discharge Summary Form?
A form that becomes part of the patient’s chart and when the patient is discharged from the hospital, the responsible physician will complete a brief summary of the patient’s care and history while in the hospital.
What is the Information Collection Authorization Form?
A form that allows the patient to decide whether they wish to have information disclosed about them during their hospital stay as laid out by the Freedom of Information and Protection of Privacy Act (FIPPA). It must be signed by the patient.
What is the Patient Release Form?
A form states the hospital is not responsible for personal effects brought into the hospital by the patient.
Who keeps an up-to-date census of all empty beds and co-ordinate the appropriate admissions for those beds?
Bed Control, Bed Utilization
This department can have other names
Who does the Unit Clerk in Bed Control communicate with regarding discharges?
Admitting Department
addressograph card
Plastic card still used in some hospitals
Where are extra identification labels stored?
At the front of the patient’s chart in a plastic sleeve
identification bracelet
A bracelet that is addressographed or labeled, then placed around the patient’s wrist for the duration of the patient’s stay
allergy bracelet
An additional bracelet to be worn by the patient if there are any allergies
hospital number
A number unique to that patient.
If a patient has been admitted to one particular hospital for the first time, what will they receive?
hospital number
If a patient is visiting the same hospital for a 2nd (or more) time, do they receive a new hospital number?
No, they use the same number as before.
There are 7 steps in the general process of admission. What are they?
- The patient is admitted at patient registration.
- A patient Admission-Separation form is completed.
- If the patient goes to Emergency they will be assessed, have a history taken, then be seen by a Physician.
- Prior to any procedures or bloodwork the patient will be given an identification armband.
- Sometimes bloodwork and other diagnostic tests are performed in ER such as an ECG, or CXR.
- If the patient is being admitted as an Inpatient to a Unit they will be assigned a bed in an appropriate Unit.
- The porter will transport them, their belongings and any paperwork generated in Admitting and ER.
Records from Admitting to the Nursing Unit
- Record of Admission/Separation
- Consent for Treatment (Release of Responsibility)
- Addressograph/Patient Identification Labels
- Armband/I.D. Bracelet (Allergy band prn)
armbands
Form of patient identification
Helps hospital staff identify that they are working with the correct patient. Must be confirmed before beginning any diagnostics or procedures
Where is the armband worn?
On the patient’s wrist
white armband
for inpatients, and is addressographed or labelled
red armband
For those patients with allergies. Worn on the opposite wrist from the white armband and the allergies are written in black permanent marker.
What are some things that Bed Control needs to take into account when making a decision?
- When a bed becomes available and then decide which patient to assign the bed to
- May require isolation, constant supervision, or specialty medical/surgical needs
List the 6 things that Bed Control needs to advise the Nursing Unit of for a new admission
- Patient Name
- Patient Age
- Admitting Diagnosis
- Attending Physician
- Room & Bed Number (may be discussed with Unit)
- If patient has any Isolation Precautions
What happens to the patient’s personal belongings upon admission?
They are placed somewhere that is known and accessible to the patient
What are some forms of storage available for the patient’s belongings?
A designated locker and bedside table in the patient’s room
Patients are discouraged from keeping large amounts of money or expensive jewelry with them. The Nurse will suggest they do one of two things. What are they?
- Be taken home by a family member
2. Placed in the hospital safe which is usually in the cashier’s office
Does the NUC have responsibility for a patient’s personal belongings?
Generally, no but they may be asked by the patient’s nurse to assist in taking any valuables to the hospital safe for safekeeping
Where are the patient’s personal belongings placed?
In a numbered valuables envelope
A form is included with the numbered valuables envelope. What needs to be done with this form?
All items in the envelope are listed on the form.
The form should be attached to the outside of the envelope with two carbon copies attached
Who signs the personal belongings envelope?
The patient or responsible party, as does the Nurse as a witness
What happens to all copies of the personal belongings form?
The original copy stays with the chart
Second copy goes to the patient
Third copy goes with the valuables
What happens to a patient’s valuables upon discharge?
The valuables will only be surrendered to the person whose name appears on the face of the envelope or someone authorized to act on their behalf
Does the hospital charge to store valuables?
No
What happens after hours with a patient’s valuables?
- They can sometimes be locked in the narcotics cupboard.
- Placed in a valuables envelope and the staff member (including the NUC) Patients are discouraged from keeping large amounts of money or expensive jewelry with them.
What happens if the patient does not claim their belongings?
Attempts are made by the hospital to contact the patient and arrange for these items to be picked up.
If unsuccessful or not followed up on by the patient, the items are sent to the Lost and Found Department
admission orders
Initial written directives by the doctor for the care and treatment of the patient.
What are the 9 common components of an admissions order?
Initial written directives by the doctor for the care and treatment of the patient.
hold tray
early tray
late tray
For patients going to or returning from OR, tests, or treatments
fluid restrictions
Patients retaining fluid in tissues (edema)
push or force fluids
Patients who are dehydrated and require additional juices, tea, etc.
natural laxatives
Bran, Fruitlax, etc. - ordered by the doctor.
calorie count
A 24 hour calorie count record. RN records each item the patient has eaten on the calorie count sheet
Patients on special diets receive a _______ between meals which is delivered to the patient by the _______.
Snack
RN
What do diabetic patients receive before bedtime?
A snack
Food and Nutrition Services delivers a quota of ______ to the unit.
Bottled water
What are some examples of food supplies ordered by the NUC?
- Juice
- Bread
- Becel / butter
- Jell-o
- Ice cream
- Milk
- Sugar
- Cheese
- Crackers
- Gingerale
- Popsicles
- Peanut butter
- Jam
What are the 3 methods of feeding?
- Ingestion (po)
- Enteral feeding – NG tube
- gastrostomy tube
* * liquid and semi-solid - Parenteral nutrition – TPN
* * carbohydrates, proteins, fats, electrolytes, vitamins & minerals
What are the 4 roles of Nutrition Services (Dietary)?
- To meet the therapeutic needs and dietary preferences of the patient.
- Preparing and serving food for patients.
- To aid in development and monitoring of special therapeutic diets.
- Providing dietary information to patients
There are 17 common dietary orders. Can you name some?
- Regular / DAT / General
- GI soft
- Mechanical soft
- Pureed / Minced
- No thin liquids / thick fluids only
- Diabetic diet
- Renal diet
- Neutropenic
- Lactose controlled
- Nothing by mouth (NPO)
- Clear fluids
- Full fluids
- Cardiac diet
- Controlled sodium
- Controlled calorie
- Tube feed
- Dysphagia / Thickened
regular / DAT / general
For patients who have no dietary restrictions
GI soft
For patients with nausea and distention, usually post surgical patient
mechanical soft
For patients who have trouble chewing or swallowing
pureed / minced
For patients with problems chewing and swallowing, ex. no dentures
no thin liquids / thick fluids only
To prevent choking
diabetic diet
For patients who cannot produce enough insulin
renal diet
For patients with renal disease
neutropenic
To reduce the number of bacteria entering the stomach for patients on chemotherapy or those with immune deficiency diseases
lactose controlled
For patients who experience stomach disturbances after drinking/eating products containing milk
nothing by mouth (NPO)
For patients pre & post surgery, scheduled for procedures, tests or as indicated
clear fluids
For patients whose digestive system should not or cannot digest whole foods.
Ex. Pre and post surgery
