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12 Cards in this Set

  • Front
  • Back
Process for admission
Obtain M.D. authorization

Obtain billing information

Complete nursing responsibilities such as orientation,and obtaining data base assessment

Fulfilling medical responsibilities such as the History and Physical (H&P)
Define Transfer
Discharging a client from one unit or agency

Admitting them to another unit or agency without the client going home in the interim.
What is different when doing a transfer within an agency
Does not require a dischareg if stayong within the agency
Why is a Written transfer summary important
It is the key to insuring continuity of care.
What is included in a Written transfer summary
A review of client's previous care, Discription of current conditon, Reason for transfer, Give a oral report to the nurse on the transfer unit, Coordinate care with transfer unit nurse, Document time and the mode of transportation.
What does a client transfer report include?
Client name, Age, Diagnosis,

Admitting physician, medical/surgical procedures, vital sign range, abmornam assessemnt data,

Pain assessment, diet and % of food eaten, special needs, labs and planned tests, medical orders, new drugs and responses, IVs taken and remaining, equipment needed and their settings, Physical review of systems, condition of incisions, color and amount of drainage, current wound treatment plan
What is the policy for keeping meds at bedside?
What areas of health care have grown most sense 1980
Post care
When does discharge planning begin
When the patient is admitted
What is the nurses role in discharge of a client
Obtain a written order, complete discharge instructions, notify business office, Help the client leave, write a discharge summary
What are the elements of thaking a nursing history
Presenting problem, Present illness, How ADL's are compromised, assistive devices needed, Impact on holistic person which include-physical, psychosicial, spritual, economic status.
What are the key elements of a Medical history
Physician gives this

Includes-chief complant, present illnesses, Personal history, Past health history, Family history, Review of body systems, Conclusions.