Notes on Admission and Discharge (Chapter 1):


May need to use family members for information in emergency situations
May go through admissions office or the nurse may admit
This is when we begin to plan for discharge

Admissions process includes:
Explanation and signing of paperwork – HIPAA, patient rights, advance directives
Discussion of payment source
Obtaining background personal information
Applying an id band
Blackout for anonymity
Assessment/testing/allergy or blood bracelets
Plan of care

Federal regulations and JCAHO (Joint Commission on Accreditation of Healthcare Organizations) define patients’ rights
Patient Self-Determination Act – right to accept or reject tx
HIPAA – Health Insurance Portability and Accountability Act

In a nutshell patients have the right:
To respect and dignity
To know their rights
To informed consent
To refuse care
To partner in care
To be free from abuse, neglect
To pain management
To advocacy
To privacy
To complaint resolution
To family inclusion in care
To address end of life decisions


Advance directives:
Provide directions for care if the patient loses decision-making ability
Provides for individuals, which may make decisions for them
May include a Living Will, Power of Attorney
A copy should be in the chart or the presence of its existence documented then a copy needs to be brought to the hospital
Attending is notified
Witnesses should not be medical personnel or family

Informed Consent:

*The nurse may delegate responsibilities such as room preparation, specimen collection but never the assessment!

*Assessment triangle: Assess for appearance, work of breathing and circulation first
If the patient is in pain, distress, or medically compromised these needs are addressed first (focused assessment) then the complete assessment can be finished.

During the complete assessment determine:
If the patient is at risk for falls
If the patient has allergies
If the patient is on any medications

Orient patient to the room and document

Orientation includes:
Call bell
Bed controls
Nurse shifts
Doctor’s orders

If the patient needs to be transferred additional consents and paperwork are necessary. A copy of the chart is sent with the patient as well as an SBAR report called to the receiving unit.
Appropriate transfer vehicle needed.
Chart patient’s stability, vital signs, LOC, IV, equipment who care was transferred to and that report was given to the transfer personnel and called to the receiving unit.

The Lewis Blackman Story


Discharge is an important part of patient care. Discharge planning begins at admission Teaching and assessment for discharge continues during the hospital stay.

Case Managers fill the vital role between in hospital nursing care and home care.

At discharge:
How, when, and who discharged? Ambulatory, wheelchair, @, by
Review of doctor’s discharge orders with patient
Nursing education/instructions
Medications, dosage, times, side effects
Normal expectations/possible complications
Follow up appointment
Names/phone numbers of physician or health care facility the patient can contact
Client signs and receives copy of document

Cultural considerations:
Religious days of observation, Orthodox Jews, Sabbath
Dietary considerations, Kosher meals
Family leadership, Hispanic, Asian
Spiritual considerations
Cultural healers, Hmongs

Communication (Chapter 2):

Interaction between 2 or more people
Verbal and nonverbal
3 Phases – orientation, working, termination

Be aware of your own feelings, nonverbal mannerisms
Focus on physical surroundings, private, quiet,

If interpreters are utilized look at the patient and speak to them not the interpreter
Speak slowly, distinctly
Be aware of cultural considerations, heads of family
Use gestures and pictures
Keep it simple
Avoid medical jargon
Use appropriate dictionary

Therapeutic Communication:
Active listening
Clarifying – I’m not sure that I understand, could you tell me again.
Comforting – I can imagine how you must feel…
Focusing – I think it might be helpful if we talk about ….
Informing, sharing perceptions, I sounds as if…
Interviewing, broad openings, What are you thinking about…you’re mighty quiet today.
Paraphrasing, reflecting, restating, summarizing
Silence is ok!
Humor – releases tension

Barriers to therapeutic communication include:
False reassurance, giving advice
Approval or disapproval, judgment
Changing topics
Dominating the conversation
Failure to listen
Uncomfortable with topic, refusing discussion

Therapeutic communication or not...

Anxious Client:
Mild anxiety – patients’ have increased alertness but can problem solve
Moderate anxiety – patients’ may have increased muscle tension and focus solely on relevant information.
Severe anxiety – patients’ may complain of headache, nausea,. They have poor focus and recall.
Panic – Terror, unable to cope with any problem

The Angry client:
Anger can be part of the grieving process, so expression of anger can be healthy
However, threatening behavior can be dangerous

Remain calm
Collect thoughts, do not take personally
Keep distance
Maintain an open exit; do not interfere with client leaving
Move slowly, talk quietly
Call for help
Least restrictive measures

Symptoms include:
Sadness, apathy, hopelessness, helplessness, worthlessness, guilt, anger, fatigue, sleep difficulties, thoughts of death, agitation, crying, passivity

***If a client is depressed ask them about suicidal thoughts and a plan

Nursing strategies for communication and support
Tears are a natural way to cope and release tension support patient in grief, allow tears
Low self esteem can create feelings of isolation, incompetence; define clear goals, give positive feedback
Anticipatory guidance to prepare patient each step of the way
Reminiscing and life review, helpful in resocializing, helps to see life as a unique story, increases satisfaction
Distraction redirects attention of confused or frightened patients
Problem solving and decision making, identify problem, identify options, examine pros and cons, develop plan, evaluate

Recording and Reporting (Chapter 3)

Not documented, not done…
Documentation now tied to reimbursements with DRGs (diagnosis-related groups)

Do not erase, use white out
Do not write personal, critical comments, just the facts
Correct errors, line through, initial
Do not leave blank spaces
Chart only for your self
Black ink
If question order, write clarification
Do not use general, vague terms, good day, seems, appears, Quote
Use precise amounts, size descriptions
Date, time, signature and title
Protect password
Only waste when seen
Only record assessment you completed

Medication administration
Test prep
Change in status
Admission, transfer, discharge, death

Different facilities may have different methods of record keeping
Admission history
Flow sheets
Acuity level
Standardized care plans
Problem-oriented medical records (POMR) all disciplines chart under problems
Source records – each discipline charts under their section
Charting by exception – only chart out of range behavior, results, complications
Standardized language NANDA
Case management and critical pathways
Computerized documentation – checklists with opportunity to add narrative
Home health documentation tied to reimbursements
Long term care weekly or monthly

Formats for progress reports:
SOAP (subjective, objective, assessment, analysis, plan)
PIE (problem, intervention, evaluation)
DAR (data, action, response)

Incident reports:
Use for any questionable event, not for punitive purposes
Use objective words, descriptions
What was observed?
Patient or visitor condition
Care measures
Notification of others

Tell the person you are reporting to who your are, who you are calling about, why you are calling and what is going on...
What has lead up to this...
Current data, why are we calling him...description of status, not diagnosis
Suggestion for care related to labs, medications, care

Potter, P. A., & Perry, A. G. (2009). Fundamentals of Nursing (7th ed.). St. Louis, Missouri: Mosby Elsevier.

Schuster, P. M. (2012). Concept Mapping: A critical thinking approach to care planning (3rd ed.). Philadelphia, PA: F. A. Davis Company.

Schuster, P. (2000). Communication:The key to the therapeutic relationship. Philadelphia, PA: F. A. Davis Company

What is Hipaa?



Informed consent

Lewis Blackman

Poor Communication