Hospital Admission Procedure – A Simple Guide
for Nurses
Hospital Admission Procedure includes preparation of admitting patient, perform admission procedure, emergency admission, Routine admission, transfer in and discharge. Nurses need to follow strict protocol regarding admission and discharge in the hospital.
1. Preparation of Admitting Patient :
Entrance of a patient into the ward or unit for evaluation or treatment is called admission.
2. Perform Admission Procedure :
A. At the time of admission, the registered nurse perform complete assessment of the patient.
B. Enter patient name, date and time of admission, chief complains, medical diagnosis in the admission file or patient file.
C. Document – the source of information (family, patient, care giver or health care person or significant person).
D. Check the document if patient has previous hospitalization and past major illness.
E. Indicate if the patient was admitted from emergency room, home, clinic and accompanied by whom.
F. Take patient vital signs (pulse, temperature, respiratory rate, height and weight).
G. Document if patient and family has valuables brought to the hospital. If yes, hand it over to the relatives with their signatures.
H. At the time of arrival to the unit or ward patient and family will be given orientation regarding the unit, visiting rooms, patients right and responsibilities.
Emergency Admission :
The patient is admitted on emergency basis for critical care monitoring. E.g. poisoning, heart attack, accidents etc.
It is unplanned.
Stabilize in emergency room (chest pain or accidents).
Purpose :
1. Prepare the patient both physically and mentally for his stay in the hospital.
2. To help the patient to be comfortable and to provide him with a clear and safe environment for preventing infection.
3. To give a good impression of the hospital and its service so that the patient will fully co-operate with the treatment and nursing care.
Routine Admission :
Admission of a patient is planned and gets admitted in the hospital on routine basis for treatment, diagnostic test and recovery. E.g. fever, fracture, diabetes, hypertension, bronchitis etc.
Transfer In (within the hospital) :
Referral to another department within the hospital.
1. when the patient has to be shifted from medical to surgical department, the patient is discharged and readmitted. The procedure is the same as for “discharging the patient” and “admitting the patient”.
2. The procedure of discharge and readmission is not usually necessary for the patient who is to be shifted from one medical or surgical ward to another.
Discharge :
It is the preparation of the patient and discharge records to leave the hospital.
Purpose :
1. To ensure continuity of care to the patient after discharge.
2. To assist the patient in discharge process.
Types of Discharge :
1. cured and discharged.
2. Discharged against medical advice (DAMA).
3. Discharged on request.
4. Absconded.
5. Transferred to other hospital.
6. Death.
Nursing Procedure :
1. No patient should be discharged without doctors written orders.
2. Handover the case sheet and other record to the medical record department.
3. See that the patient personnel hygiene is maintained and change the dress into their own clothing.
4. Inform the hospital authorities about the discharge.
5. Hand over the discharge slip to the patient or relatives.
Leaving Against Medical Advice :
A client can decide to leave the hospital against medical advice. For this client must sign a form that releases the physician and the health care institution from any legal responsibility for his/her health status. The client is informed of any possible risks before signing the form.
Abscond :
To leave quickly and secretly and hide oneself. Often to avoid arrest or legal prosecution.
Referrals :
The act of sending of a patient to another physician for ongoing management of a specific problem, with the expectation that the patient will continue seeing the original physician for co-ordination of total care.