Hospital Admission Procedures PDF

# **ACCUEIL DU MALADE** ## I. LES FORMALITES ADMINISTRATIVES ### Les formalités administratives d'admission The hospital team is made up of many professionals who take care of the patients. They need to be sure of the patient's identity. * The patient must be properly identified: * Upon arr...

# **ACCUEIL DU MALADE** ## I. LES FORMALITES ADMINISTRATIVES ### Les formalités administratives d'admission The hospital team is made up of many professionals who take care of the patients. They need to be sure of the patient's identity. * The patient must be properly identified: * Upon arrival with the administrative staff * When staff ask for confirmation of identity The elements concerning the patient's identity must match the official identity documents: * Name (maiden and family name) and First Name * Date and place of birth * Sex * Current address ### Documents required: In addition to the admission prescription, the patient must present the following documents to the admissions office: * A photo ID * Proof of social insurance * A health insurance card The relevant department (admissions office or entrance) will give the patient a document called an "admission slip" or "admission bulletin". The patient or their accompanying person can complete the administrative admission procedures. ### Admission of the Patient: The patient's admission to the hospital may be done via the following methods: 1. Standard Admission: By appointment 2. Emergency 3. Evacuation 4. By requisition In the first two scenarios: The consulting physician provides the patient (or the accompanying parent) with a request for hospitalization, with which they present themselves to the admissions office (located at the entrance of the hospital). After presenting this request and following an interview with the patient, an admission bulletin containing the patient's administrative data will be established. The patient must bring the following documents: * The patient's ID card or social security card. * A card for the destitute or a beneficiary (social cases) * Authorization from the guardian for minors. A copy of the admission bulletin and a shuttle sheet will be given to the patient for their stay in one of the hospital wards. The shuttle sheet must contain all the medical, paramedical and diagnostic acts performed during the stay. ### For admission by evacuation: The accompanying staff must bring a referral from the originating facility, as well as full identification of the patient, an admission slip and a shuttle sheet. These will be issued by the admissions office. ### For admission on requisition: Certain patients are admitted on requisition by the public prosecutor or the Wilaya security services (in proven cases of psychiatry). On the patient's admission to the relevant department, an admission bulletin and a shuttle sheet are issued at the request of the staff of that department. ### Notes: * Nurses may be authorized by the head doctor to assist hospitalized patients (e.g. young children or seriously ill people). * A social worker can be made available to any patient who requests it. For this, contact the nursing staff (especially the supervising medical officer), who can direct you. ## **ACCUEIL DU MALADE ET DE SES PROCHES** * Listen to the patient or their loved ones and provide answers based on your skills. * Reassure and comfort the patient or their family based on their level of anxiety, to establish a trusting relationship ## **LES DIFFERENTS TYPES D'HOSPITALISATION** * **Full hospitalization** (full-time hospitalization). * **Partial hospitalization** (or session). * **Day Hospital (DAH)** or ambulatory surgery. * **Home hospitalization**. ## II. DEFINITION DE L'ACCUEIL The welcome is the first link in the chain of care: it sets the tone, the first impression and can make the rest of the relationship between the patient and the hospital easier or more difficult. The welcome process begins as soon as the patient has their first contact with the hospital, which may be during a consultation, in the emergency department, etc. This welcome, which is particularly important, involves a human touch on the part of the healthcare staff. This presence of the professional is necessary for patients who are in a place without bearings, in situations that make them vulnerable, and who are caused by the suffering due to illness and separation from their family. Welcome therefore responds to a need for information, guidance, but also to a need to be reassured. Over and above skills, welcome requires a certain demeanor: a smile, listening, professionalism, assurance. The concerned person, faced with the nurse, should feel heard and understood. ### 1.1 Human aspects of welcome: * Reassure the patient and their loved ones. * Smile * Don't make them wait too long. * Take the time to explain. * Avoid talking about trivial matters with colleagues in front of the patient. ### 1.2 Welcome procedure The welcome procedure involves several steps which can be described as follows: The person welcoming the patient should: * Introduce themselves * Identify their role * Introduce other staff involved in caring for the patient. The patient's care begins at this point, so it is important to: * Explain the reason for hospitalization and its duration, if known. * Check that the inventory of valuables has been carried out and that items of value have been deposited with the hospital administration or given to the attending persons. * Check that the patient has handed over their medical prescriptions (prescriptions), test result (biological or radiological). * Check that the patient has not kept any medication. * Assess whether the patient understands the information that has been given to them. * Ask the patient if they have any questions or concerns and answer them in simple terms. ## III. Les différents modes de sortie : * Simple discharge without specific care; * Simple discharge with specific care; * Discharge with a referral to a network or a home care nurse. * Transfer to another department within the same healthcare facility * Transfer to another healthcare facility. * Discharge against medical advice; * Escape; * Death ### Discharge documents: * Medical history sheet; * Standard hospitalization summary; * Hospitalization report; * Surgical report (surgery); * Treatment prescription; * Medical certificate of sick leave. ## LE DOSSIER DU PATIENT ### I. DEFINITION This is a collection of medical, nursing, social and administrative information that enables a holistic and coordinated approach to patient care in terms of care and health, by the various professionals involved in their care. ### II. BUTS DU « DOSSIER DU PATIENT » * A reminder for the health professional who needs it to be able to find all the historical information concerning the patient's health and care. * Basis for coordination of actions: Communication between healthcare professionals about information necessary for taking care of, such as communication between the general practitioner and the specialist, the doctor and the nurse, the doctor or nurses and social workers, or even management for administrative purposes, budgeting and funding. * Traceability of the various actions that concern the patient (medical-legal aspects) * Gathering of standardized information (coding, classifications, nomenclatures), for the purposes of research or evaluation. * Link to alert systems (alert regarding own practice, epidemiological alert) by linking the patient's record to systems based on knowledge. * His practice, epidemiological alert) by linking the patient's record to systems based on knowledge. * Evaluation of professional practices * The creation of case studies used for teaching and evaluation. **NB:** * There is no standard model. * The structure of a record varies depending on the specialty. * It should be designed to ensure straightforward extraction of data. ## III COMPOSITION DU « DOSSIER DU PATIENT » ### 1. Administrative file: * Patient identification sheet, including all administrative information: ADMISSION SHEET. ### 2. Medical file: * Observation sheet * Letter from the doctor who is the origin of the consultation or admission; * Reasons for hospitalization; * Research into previous medical history and risk factors; * Initial clinical assessment findings; * Type of care planned and prescriptions given on admission; * Clinical record including paraclinical tests, including imaging, the anesthesia record, surgical report or delivery report; * Blood transfusion record... ### 3. Paramedical file: The patient's care file is prepared by all staff members who are part of the team looking after the patient. It includes the following documents: * Patient identification sheet: allows better placement of the patient in their family and social context. * Patient information sheet, covering the medical, interpersonal and physical aspects: enables a complete nursing assessment. * Care process sheet, which describes the nursing actions stemming from the nurse's specific role. It also enables assessment of treatment effectiveness. * Medical prescription sheet: this sheet forms an integral part of the medical record. The nursing observation sheets record all of the patient-related information gathered during their hospitalization: * Administrative details: address, marital status, person of contact,... * Presentation of the person: collection of information, main reasons for admission... * Prescription sheets: written, dated, signed, therapeutic and additional tests... * Liaison sheets: department, operating theatre, consultation... * Monitoring and temperature sheets * Care diagrams, specific procedures performed, main procedures (nursing actions performed in accordance with their role and as prescribed, state of health...) * Main exit steps/liaison sheet, summary of hospitalization ### 4. Other files: * Psychology * Social worker ## IV ASPECT ETHIQUE ET JURIDIQUE DU « DOSSIER PARAMEDICAL » ### 1. ETHICAL ASPECT: * It is a tool that enables monitoring of patients under the responsibility of the nurse: it commits the professional involvement of qualified staff with responsibilities. * It is a multidisciplinary reference allowing for effective and personalized care of the patient. * It is a proven factor of professional recognition. * Ethics require that the relevant documentation respects professional confidentiality and contains only objective, precise and usable facts, without judgment being passed. Good management of nursing care records is a first step towards proving organized and respectful care. ### 1. LEGAL ASPECT: * Nursing care records are the key document for experts and judges. * Executive Decree No. 11-121 of 15 Rabie Ethani 1432 corresponding to March 20 2011 concerning the special status of civil servants belonging to the public health paramedical corps. **Art. 41.** Public health nurses are responsible, in particular, for: * Participating in the maintenance, restoration and promotion of physical and mental health of individuals; * Performing nursing care within their specific duties, on medical prescription or in the presence of a doctor, or in the event of an emergency on the basis of written emergency protocols; * Monitoring, evaluating and supervising the patient's health; * Drawing up a care plan, planning the appropriate activities, keeping and updating the patient's care records; * Welcoming and providing pedagogical follow-up to students and trainees.