Assessment of Patient (AOP)

CHAPTER FOUR

Assessment of Patient (AOP):

• An individualized plan of care is developed and documented for each patient.
• Specialized assessment forms are used for special population/ vulnerable patient (e.g. neonatal, pediatric, OB-Gyne, ECU, ICU).
• Comprehensive assessment of the patient is completed prior to planned treatment/ surgery.
• All patients are assessed by a doctor and the form will be filled on admission and reassessed (specialist/consultant) within 24 hours of admission for ward admission and within 12 hours for critical care patients
• The nursing admission assessment is also done within 24 hours.
• Nutritional screening is done by doctors & nurses for all inpatients and dietician sees all cases as required.
• The patients on dialysis are assessed upon presentation for dialysis & PRN.
• Discharge planning is initiated at the time of admission.
• All patients are assessed for pain at the time of Signature with date and time for each entry in all forms placed inside the patient file (mandatory).

Medication Reconciliation /Current Medication List

It is a process to document all medications that the patient is receiving at the time of admission and to decide which medications need to be continued during hospital stay.

Assessment/ Re-assessment timeframes for other healthcare staff (e.g. PT, RT, Dietitian, Social Worker, and Patient Educator) will be as per condition of patient, per risk category, as per order/ referral.

Education needs assessment

Education needs are assessed on admission, during hospital stay if any additional procedure performed or change in condition and at discharge.

Early screening for discharge planning

Assessment for Expected Needs at Patient Discharge starts on admission using Discharge Screening Tool.

If patient condition changes/ reassessment for discharge need to be initiated.

Patient and Family education given by all specialties as required.

All patient teachings must be recorded in the Patient Teaching Record (PTR) form in electronic or manual form.

Vulnerable Patients:

1. Children below 14 years
2. Elderly above 65 years
3. Terminally ill/ dying patient
4. Patients with intense or chronic pain
5. Women in labor
6. Women experiencing medical terminations in pregnancy
7. Victims of abuse and neglect (children 8/ adult)
8. Patients with infectious or communicable diseases
9. Patients receiving radiation therapy
10. Patients whose immune systems are compromised

All above patients require specialized assessment.