Entry Level AAC3

AAC3: Patients cared for by the organization undergo an established initial assessment.

AAC3a: The organization defines the content of the assessment for inpatients and emergency patients.

_______Hospital conducts a standardized initial assessment of In-patients and emergency patients. In case of emergency patients the receptionist informs to the doctor about the arrival of emergency patient and carries out the instructions given by the doctor.

SOP ON INITIAL ASSESSMENT

INTIAL ASSESSMENT AT EMERGENCY

Patients who come directly to the emergency department and need emergency care are received by the staff nurse; the RMO will attend to the patient immediately.

S.NO	Process	Responsibility	Supporting Documents
1	All patients who come to the emergency department shall be assessed	RMO/Treating Doctor/Staff Nurse	Medical record
2	The following parameters shall be assessed in detail : ·         Chief complaints ·         History of illness ·         Allergies or any associated disease ·         Temperature, pulse ,blood pressure and respiration ·         Physical examination.	RMO/Treating Doctor/Staff Nurse	Medical record
3	In case of mass casualties, triage shall be completed first, and then followed by assessment.	RMO/Treating Doctor/Staff Nurse	Medical record

INITIAL ASSESSMENT OF ADMITTED PATIENT:

Each patient upon admission shall be assessed by qualified individuals for appropriate care or treatment needs or need for further assessment, the scope intensity of the assessment shall be determined by:

·         The patient condition/diagnosis

·         The care setting

·         The patient’s response to any previous care and the patient’s consent treatment.

The patient shall be assessed and the records shall be documented. Then a documented plan of care is drawn up, based on the initial assessment.

S.No.	Process	Responsibility	Supporting Document
Initial assessment of Admitted Patient
1	Initial assessment is made and documented in medical record with name, time , date and signature	Treating doctor/doctor on duty	Medical records
2	The assessment shall include the following parameters : ·         Temperature, pulse, blood pressure and respiration. ·         Physical examination.	RMO/Treating Doctor/Staff Nurse	Medical records
3	The initial nursing assessment is done in the prescribed format	Staff nurse	Medical record
Assessment of Obstetric and High Risk Obstetric Patients
1	This includes pregnancies with diabetes, HTN, asthma, eclampsia, convulsion, multiple pregnancies, elderly primi (>30 years ) bad obstetric history (abortions)	Consultant	Medical record
2	The assessment shall include : ·         Weight, height ·         BP ·         Routine lab investigations ·         Hb, blood group, urine (routine and microbiological) ·         BT,CT ·         NST (Non Stress Test) ·         Foetal monitoring ·         months of pregnancy (regularly noted on each visit ) ·         Tetanus Injections ·         2-3 ultrasounds in whole period ( immediately after confirmation of pregnancy, 20 weeks anomaly and 32 week growth scan ) ·         PPTCT counseling ·         Multi disciplinary approach for patients with medical disorders in pregnancy		Medical record
3	All patients shall be given appropriate explanations about their conditions. Description of the following should be shared : ·         The diagnosis or provisional diagnosis as applicable ·         Plan of treatment as decided by the treating consultant	Treating doctor/staff nurse	Medical record
4	Special needs of the vulnerable patients who are receiving treatment will be assessed	Treating doctor/staff nurse	Medical record

The initial assessment for all the patients is entered in the case paper. Then a suitable action plan is worked out by the Consultants.