Admission process

The admission process may commence in any of the following forms:

  1. Emergency patient
  2. Patient from primary care with aspects needing inpatient care
  3. Patient under observation in A&E
  4. Elective patient booked in for procedure
  5. Day care post-operative case retained for overnight observation

THE ADMITTING DOCTOR

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Once the decision to admit has been made, an admitting doctor must be assigned to perform the initial assessment which includes taking patient identification details and medical history, physical examination, investigations and also formulate a provisional diagnosis which is all documented on the admission note and admission sheet. The date and time of admission must be indicated as well as the reason for admission.

The admitting doctor is also responsible for indicating whether additional precautions need to be taken in the care of a particular patient for example patients requiring additional infection control measures. The admitting doctor must advise on the unit onto which the patient will be admitted based on the initial assessment.

THE ADMITTING NURSE

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The patient will then be handed over to the admitting nurse within the respective department, who has the responsibility of performing the functional assessment (the guide is) found at the back of the admission sheet; the admitting nurse also obtains patient’s consent to the admission using the pre-designated form. The admitting nurse will then confirm the mode of payment with the patient and the biller on duty and then advise the patient/patient minder on the payment plan recommended for their category. If the patient is covered by insurance, the relevant forms will be completed at this stage.

The admitting nurse will then by phone inform the unit to which the patient is to be admitted and prepare for transfer. Prior to transfer any investigations ordered by the admitting doctor must be initiated and it should be clearly indicated on the admission note if the samples have been collected or particular imaging has been done.

PATIENT TRANSFER

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The transfer of patients to the admitting unit must be done in a manner that promotes patient safety, privacy and dignity. This implies that the admitting nurse must pay attention to detail like fall prevention, patient comfort and preference.

Once on the ward, the admitting nurse should hand over the patient records generated so far to the receiving nurse on the unit and also give a verbal handover to the receiving nurse covering all the important aspects of the patient being admitted. The receiving nurse should then transfer the patient to a bed/room prepared for the patient and give a brief orientation to the patient and patient minders on the facilities such as washrooms, lights, etc. and also on the level of clinical care expected during their stay. A ward information leaflet is given to the patient for reference. All admitted patients should have a follow up assessment by a doctor within 4 hours of arrival onto the admitting unit to ensure that care on the unit has been initiated promptly and to respond to any patient concerns.

Documentation requirements during admission

    ADMISSION (FACE) SHEET INDICATING PATIENT IDENTIFICATION DATA

    including legal name, hospital number, date of birth/age, sex, nationality, residential address, email, and phone contact; details of next of kin-as determined by the patient; emergency contact person details if di erent from NoK. If patient is not able to communicate, only the emergency contact details will be maintained. This is to be completed by the admitting doctor. Where possible, the patient must view and verify that these details are correct. If the patient is unable to do so, the next of kin/legal guardian/care giver may undertake this responsibility.

    FUNCTIONAL ASSESSMENT

    is completed by the admitting nursing showing respiratory, cardiovascular, neurological, nutritional, mobility, waste elimination, social and psychological assessment, and communication, pain, and sleep assessment. The assessing nurse must indicate their name in the provided space.

    PAYMENT INFORMATION

    is captured on the admission sheet and should be verified by the biller on duty. Patient/ patient minder should commit in writing that they will settle the hospital bills in the case of cash paying patients, or partial payment by insurance.

    CONSENT FORM FOR ADMISSION

    indicating that the patient/patient minders freely chose to get care from C-Care IHK and that care will be provided reasonably by C-Care IHK doctors and staff , that they understand the reason(s) for their admission, that they authorize the hospital designated sta to provide the relevant information to their insurance, that they will ensure safety of their personal property while in hospital in addition to security offered by the hospital.

    ADMISSION NOTE

    indicating initial assessment: - patient identification data, medical history, physical examination, investigations, provisional diagnosis, and management plan. The admitting doctor must clearly indicate their name and signature in the space provided. Patient Identification documents, currently in the absence of national identity card, patients will be requested to present some form of identification at admission to ascertain their identity and legal name. When the national ID project is completed, all Ugandans will be required to present the ID on admission, foreign patients are required to present a passport. A copy of this document will be made and kept on file. In the case of minors, the parent/guardian’s documents will be captured.