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.