Ppg-Gdch-Nur-32 Registration of Outpatient and Admission of Patients Through Outpatients

GULF DIAGNOSTIC CENTER HOSPITAL
NURSING POLICY

Policy No: MED-NUR-P0032/12 Issue Date : July 2012 Revision No.: Original Revision Date : Next Revision : July 2014 Page 1 of 5
TITLE: Registration of Out Patients and Admission of Patients through Out Patient Clinics
Department Section Distribution : Nursing : Nursing Care : Hospital Wide
REGISTRATION OF OUT-PATIENTS AND ADMISSION OF PATIENTS THROUGH OUT-PATIENT CLINICS

APPROVAL SHEET Prepared by: Name Ms. Gela Mocanu Head of Nursing Department Reviewed by: Name Prof. Dr. Emad Al Rahmani Medical Director Signature Date Signature Date
Mr. Zuher Arawi IT, QA Manager Approved by: Name Mrs. Jamal Kaddoura Co-founder & Hospital Director Signature Date
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Appendix: Yes [ ]
No [ ]

NURSING POLICY

DOCUMENT AMENDMENT RECORD SHEET

Date Description of Change Page Effected Revision Number
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Appendix: Yes [ ]
No [ ]

NURSING POLICY

1. PURPOSE 1.1. To standardize the outpatient registration process. 1.2. To standardize the admission procedure through outpatient clinics. 1.3. To make the staff familiar with policies and procedures. 2. POLICY STATEMENT 2.1. GDHC shall adopt a standardized process for registering patients for out patient services. 2.2. GDHC shall adopt a standardized process to admit patients through outpatient clinics. 3. DEFINITIONS 3.1. Registration 3.2. Patient's Admission 3.3. Elective Admission 3.4. Admitting doctor Patients who attend the hospital on an outpatient basis, this could be for further treatment that doesnt require admission, or for follow up. Housing the patient in a hospital to provide definitive treatment or special interventional procedure(s), which cannot be accomplished on an outpatient basis A planned admission through admission office for non-urgent cases. The doctor from any specialty who decides to admit the patient in Hospital.
4. PROCEDURE AND RESPONSIBILITY Procedure Sequence Responsibilities 4.1. Out Patient Registration 4.1.1. At time of discharge from ED or inpatient unit the patient, if required will be given an outpatient Most Responsible appointment for follow up with the required specialty that Physician meets the needs of the patient, within GDCH facilities. 4.1.2. Patient seen in GDCH that requires further management will be transferred to the required specialty that meets the needs of the patient outside GDCH if the Treating Physician service is not provided or referred to another specialty for OPD services 4.2. Admission through OPD 4.2.1. DIRECT ADMIDSSION FROM CLINICS TO Admitting Doctor/ WARDS Clinic Nurse/ (Admission on same day) Charge Nurse IP After confirming that the patient requires admission, the admitting Doctor/Clinic Nurse informs RN in-charge regarding the new IP admission and availability of bed
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Appendix: Yes [ ]
No [ ]

NURSING POLICY

4.2.2. Patient / significant others are informed about charges for treatment as per the hospital payment policy. 4.2.3. Informs the clinical nurse of the availability of bed. 4.2.4. If bed is available, informs the concerned ward about the new admission, condition of the patient and provisional diagnosis. If bed is not available, treating doctor gives another appointment to the patient, or if the case is urgent, the patient will be transferred to another Health Care Facility. 4.2.5. Completes the admission notes in the patient's case record. Fills the medication chart/ online and requests necessary investigations. The Admitting Doctor will decide about the required screening & diagnostic tests after examining/before admitting the patient. Due to the fact that every patient has his own unique needs, the decision regarding what screening and diagnostic tests are to be performed, are left to the clinical judgment of the treating Physician. Consent (if required) is obtained at this time. 4.2.6. Decides about the mode of transportation of patient according to Patient's condition. ( i.e. by wheelchair/stretcher) 4.2.7. A nurse may accompany the patient depending upon his/her condition, and endorse the patient and his documentation to IP nurse. Endorsement should include Vital Signs, history, medical record, and plan of care. 4.2.8. Patients requesting blood investigations and other laboratory tests who are in stable condition are directed to laboratory. In emergency cases, the lab tech. will have to collect the specimen in the IP room. 4.2.9. Patients requiring surgery who are in stable condition are sent to anesthetic clinic for check up before seeking admission. In Emergency cases, the anesthesiologist will have to assess the patient in the IP room. 4.2.10. Ward Nurse accepts patient in the ward and ensures that provisional diagnosis is clear, investigations are requested and drugs are prescribed in the drug chart. The consent for surgery will be obtained and the patient should be informed about the procedure.
Accounts Department/ Clinical nurse RN in-charge-IP Treating Physician/ Clinic Nurse
Admitting Doctor/ Clinical Nurse
Admitting Doctor/ Clinical Nurse Clinic Nurse Treating doctor/ Laboratory personnel Treating Doctor/ Anesthesia Clinic Personnel
Ward Nurse
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Appendix: Yes [ ]
No [ ]

NURSING POLICY

4.3. As Scheduled Admissions (Admission at a later date) 4.3.1. After confirming the need for elective admission, the treating doctor completes the booking form for Operating Theater. Booking form will be endorsed by the Clinical Nurse to the OT in-charge with details about patients status and Insurance Approval Status. 4.3.2. Patient is given information about charges of treatment as per the hospital payment policy. 4.3.3. Patient is instructed to come to the in-patient reception on the scheduled day to complete the admission procedure. Patient should be informed regarding preoperative instructions such as fasting, being on time for the procedure, not to wear jewelries and contact lenses, not to drive after the procedure, and to make sure the consent for surgery is signed. 4.3.4. On the day of admission, inform the admitting team prior to admission of patient for availability of bed and final approval, thereafter informs the concerned ward about the admission. 4.3.5. If bed is not available, treating doctor will explain the delay of admission for the patient. 4.3.5.1. Inform patient and /or family (where applicable) about the anticipated delay for admission including the reason for admission to inpatient unit. 4.3.5.2. All inpatient care/treatment will be provided 4.3.5.3. The delay and the reason should be documented in patients notes 4.3.6. If bed is available 4.3.6.1. Patient is directed to the IP room. The IP nurse will have to conduct the per-operative assessment. 4.3.6.2. The patient will be visited again by the anesthesiologist for pre-operative assessment. 4.3.6.3. Consent for anesthesia and operation will be signed.
Treating Doctor
Accounts Department
Treating Doctor/ Clinical Nurses
Clinical Nurse
Treating Doctor
Clinical Nurse, Anesthesiologist, I.P Ward Nurse
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Appendix: Yes [ ]
No [ ]

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GULF DIAGNOSTIC CENTER HOSPITAL

REGISTRATION OF OUT-PATIENTS AND ADMISSION OF PATIENTS THROUGH OUT-PATIENT CLINICS

GULF DIAGNOSTIC CENTER HOSPITAL

DOCUMENT AMENDMENT RECORD SHEET

GULF DIAGNOSTIC CENTER HOSPITAL

GULF DIAGNOSTIC CENTER HOSPITAL

Accounts Department/ Clinical nurse RN in-charge-IP Treating Physician/ Clinic Nurse

Admitting Doctor/ Clinical Nurse

GULF DIAGNOSTIC CENTER HOSPITAL

Treating Doctor/ Clinical Nurses

Clinical Nurse, Anesthesiologist, I.P Ward Nurse

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