Beruflich Dokumente
Kultur Dokumente
Absconded
1. Out on pass is an inpatient who is temporarily absent from a
ward, by arrangement, for not more than 48 hours because:
1. (S)he has been allowed to go home temporarily.
2. (S)he has been transferred to another hospital and is expected to
return.
3. (S)he has been transferred from a long stay specialty to another
specialty in the same hospital and is expected to return
2. DAMA- Discharge Against Medical Advised
1. Is a “self-discharge” or “discharge at own risk” occurs when a
patient chooses to leave the hospital before the treating
physician recommends discharge.
THEY HAVEN’T BEEN SEEN YET, BUT THE FACILITY HAS TOUCHED THEM., THEY SIGNED IN AND THEN THEY
DECIDED TO LEAVE, ALL OF THESE CAN BE CONSIDERED DAMA.
2. Steps to be taken:
2.1. If the patient high risk: The charge nurse will assign some staff
nurse and security, to search the patient immediately without waiting
for return of the patient by himself, in the corridors, bathrooms,
visiting his neighbor patients, and external to the ED or hospital unit.
2.2. If the patient moderate or low risk:
2.2.1. The nurse who discovered the absconding patient will report the
incident to his/her direct line manager.
2.2.2. The charge nurse can wait for one hour to alert the security and
start searching of the patient.
2.2.3. At the same time gather all available information concerning the
situation
3. Review the situation of the patient:
4.1.History of previous event of going absconded either from hospital
or at home, it will be necessary to check patient record or information
if relatives are available.:
4. Recall back the patient to ED/Unit:
4.1. The social worker and patient relationship will collect all the
personal information of the patient and RECALL patient back to
the hospital.
4.2. If the patient informed, a maximum of six hours will be allowed for
him or his relative to return from the time he/she leaves the hospital
5. Police involvement in all cases of absconded:
5.1. Criteria before contacting the police service:
1. High risk, Critical patient level I & II.
2. Confused, dementia, aged, or drug addict.
3. Female, child and in-competent patient.
4. Disabled or handicapped.
5. Leaving the hospital with central or peripheral lines.
6. History of self-harming.
5. 2. Contacting the police as the correct course of action must be decided by
both charge nurse and concern doctor due to some legal issues.
6. Hospital right: The hospital will not be responsible
6.1. For any sequel or complication in this condition
6.2. Any illegal act done in this period.
7.Patients who return:
7.1. The patient must be seen and re-assess by the doctor.
1. Re-assessment will be done and previous management plan will be
changed base in the light of new clinical evaluation.
2. Patients who absconded but who either return voluntarily or brought back by
the police back to emergency department and or unit should be considered as:
2.1. High risk for further episodes of absconding and their clinical assessment
must be priorities.
2.2. Patient may have changed condition due to:
2.2.1. Ingestion 2.2.2. Alcohol intake
2.2.3. Drugs 2.2.4. Abuse (self-harm) etc.
8. Prevention of absconding:
1. If the patient is adamant to leave even after all effort given by medical staff to stay,
then discharge patient with option to choose against medical advise ( ref to policy of
DAMA) but if the patient still to refuse the said option, then patient is considered as
ABSCONDED.
9. Documentation:
1. Complete ABSCONDED form. Make sure all concerned staff in the designated
area and space has been filled up with their side and signed.
2. Only after obtaining discharge order from the physician after 6 hours discharge
is confirmed, then nurse must release now the patient record from the unit
system as ABSCONDED.
3. Write an incident report (OVR).
2. Authentication of Medical Record Entries:
1. Correctly identify patients should be made prior to
documenting
2. Initials can only be used on medical record forms
approved by the organization,such as flow sheets,
medication records or treatment records.
3. All entries shall be signed or initialed/authenticated by
the provider. Signatures must include first name or
initial, last name, and employment/status (e.g., SOD) or
licensure status (e.g., M.D.). Initials alone are not
acceptable
4. For authenticating paper medical record documentation,
handwritten signatures may be accompanied either by
the author legibly writing his/her name in block print or
by the use of a name stamp accompanied by a signature.
5. Users shall not share their account(s), passwords, (PIN),
Security tokens (e.g., Smartcard), or similar information
or devices used. Individual identified by the electronic
signature or method of electronic authentication is the
only individual who may use it, as it denotes authorship
of medical record documents in electronic medical
records.
3. Timing and Dating of Entries:
1. All entries must be timed and dated.
2. Record times based upon 24-hour military time.
3. It is recommended that entries be recorded as closely
as possible to the time of the encounter.
4. It is recommended that all paper-based entries in the
papers must be in black or blue ink . Entries should not
be made in pencil.
4. Chronological Entries:
1. It is strongly recommended that all materials in the
medical record be organized in a chronological and
systematic manner.
2. An entry should never attempt to preserve the
chronological order of the interaction/intervention date
and time by entering an artificial or inaccurate
documentation date and time.
3. When clinical documentation is entered out of
chronological order, it is a 'late entry' and shall identify:
5. Legibility and Clarity:
1. Regulations require that medical records be legible.
2. Do not use“If text message
it wasn’t language
written down, in documentation
it didn’t happen.”
3. Do not use unapproved abbreviations.
4. Document in blue or black ink; no felt-tip pen.
.