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BURAIDAH C ENTRAL H OSPITAL

Department : NURSING SERVICE

B. C. H.

DPP

Policy Index : New Replace Number : XXXXX PP-BCH-NR/GNR-028-DPP-E Title : NURSING ASSESSMENT FOR ADMISSION OF Number of Pages: ADULT PATIENT 3 Applies to : Effective Date : Review Due : All Nursing Staff 01-01-1432 H 01-12-1433 H

1. PURPOSE :
1.1 To systematically collect relevant data about the patient, as the initial step of the Nursing Care Process. 1.2 To accurately document assessment findings on an approved form in the medical record. 1.3 To establish a comprehensive information base for decision making about each patient care.

2. DEFINITION :
2.1 Patient Assessment is an on-going process that begins before patient is admitted and con tinuous throughout the hospitalization.

3. POLICY: 3.1 The assessment process will determine the need for care and / or treatment, the type of care to be provided and the needs through the continuum of care. 3.2 Initial patients assessment needing nursing care in all department, will be performed by a registered nurse. Further assessment and re -assessment will be based on a collabora tive effort. 3.3 The assessment process will be collaborative to facilitate, identify and prioritize the patients needs and determine care. 3.4 Admission assessment form became a permanent part of each patient medical records.

4. PROCEDURES :
Prepared by: Magdalena Venzuela Nurse Supervisor

4.1 An initial assessment will be completed by the assigned nurse within the shift on which Approval
Approved by : Ahmad Abdulla Al-Omar Hospital Director Page Number: 1/3 Stamp

Form Index: BCH-QM-009-E

they are admitted ( not later than 8 hours after admission.) : 4.1.1 The Nursing Assessment includes : 4.1.1.1 History / Health Assessment. 4.1.1.2 Medical History.

4.1.1.3 Nutrition / Dietary Screen. 4.1.1.4 Infectious Disease Screen. 4.1.1.5 Dental Screen. 4.1.1.6 Allergies. 4.1.1.7 Functional Screen. 4.1.1.8 Hygiene / Sleep Pattern. 4.1.1.9 Alcohol / Drug. 4.1.1.10 Patient / Family Education. 4.1.1.11 Fall Risk. 4.1.1.12 Review of System. 4.2 Select an appropriate place to perform assessment. 4.3 Inform the patient of their mutual roles and responsibilities in the assessment and encourage the patients participation. 4.4 Utilize interview, behavioural observation, physical and mental status, assessment skills to achieve a thorough and accurate assessmnet of patient care needs. 4.5 Assess each patient at the time of admission and continuously throughout the patients hos pitalization. 4.6 If possible, seek out and utilize information pertinent to the assessment not only from the pa tient, but also from family members, significant others and other health care members. 4.7 Document the assessment findings on the nursing assessment form. This information is used to establish the initial plan of care which is formulated within 24 hours of the patient admission. 4.8 If at the time of admission, sufficient assessment data is unable to be collected due to the severity of the patient symptoms. The patient will be re - assessed within 24 hours of admission. 4.9 Completion of the admission assessment will be coordinated by all registered nurses assigned to the unit, where the admission occurs. Nurse Supervisors are available to assist with the assessment when necessary.

5.

FORMS AND EQUIPMENTS :

5.1 Patients Chart. 5.2 Adult Nursing Assessment Form. 5.3 B/P Apparatus. 5.4 Stethoscope. 5.5 Thermometer. 5.6 Weighing Scale.

6. REFERENCES:
Policy6.1 msh.mt.gov Number: Title: / nrsg.services. Page Number: 2/3 Approval Stamp PP-BCH-NR/GNR-028-DPP-E NURSING ASSESSMENT FOR ADMISSION OF ADULT PATIENT.

Form Index: BCH-QM-009-E

7. APPENDIX: 7.1 N/A.

8. APPROVAL :

Name Prepared by: Magdalena Venzuela 1. Abdulla Obeid Al-Harby Reviewed by: 2. Ehab El Husseiny 3. Manae Al-Belaihy Approved by: Ahmad Abdulla Al-Omar

Position Nurse Supervisor Nursing Director QM Director Medical Director Hospital Director

Signature

Date
22-11-1431 H 24-11-1431 H 29-11-1431 H 29-11-1431 H 01-12-1431 H

Policy Number: PP-BCH-NR/GNR-028-DPP-E

Title: NURSING ASSESSMENT FOR ADMISSION OF ADULT PATIENT

Page Number : 3/3

Approval Stamp

Form Index: BCH-QM-009-E