Medications, Care Plans, and Discharge Planning (Nursing)

00:04 Okay, guys, we're almost halfway down this list.

00:07 I know there's a lot of topics in admission history assessment, but as you can see, as we move through how important all these pieces of information are.

00:16 And here is another biggie, is the patients medications.

00:20 It's really important to confirm the medications that the patient takes at home prior to the arrival in the hospital.

00:28 Now, we want to make sure we have the right medication, the right dose, also when do they even take it last.

00:34 We want to be conscious to make sure we continue with that treatment and prevent double dosing for example and even verify compliance.

00:43 Just because it's on the patient's medication list, for example, doesn't mean the patient's taking it, so this is important to screen here.

00:51 Now, let's talk about patient's belongings.

00:54 So sometimes your patient may come in with a suitcase, with purses, wallet, jewelries, clothing, all of these stuff is so important that we make sure that we document, and sometimes the patient may need those belongings at bed side for comfortability.

01:10 Now, sometimes, the patient could have really important valuables, those may need to be send to security for example, but you want to make sure that you followed your agency protocol.

01:20 And, one really important thing to note, is if we lose any of those patient belongings, as a hospital we are indeed liable, so it's important to make sure we inventory these correctly, and just keep in mind that we want to keep these safe.

01:36 Now, don't forget about patient education.

01:39 As you can imagine, throughout their stay, there is so many opportunities for patient education, so we want to make sure we do it in the appropriate language and the appropriate method of learning for the patient.

01:51 We've got to gather a baseline teaching plan for the patient to reinforce really important information, for compliance and success on their treatment.

02:00 Now, during this time, we've had a lot of interview questions for the patient, we've done their initial physical assessment; this is a great time to formulate their initial care plan.

02:11 Now, this must be documented about every 24 hours by a registered nurse.

02:16 And, lastly, we are finally at discharge planning, and you may be asking yourself, "Okay, did the patient just admit here, why do we need to talk about discharge planning?" Well, you will hear time and time again, that discharge starts at admission.

02:32 Meaning, we've got to look at any barriers to discharge.

02:36 Where's their anticipated discharge needs? Where are they going to go? Do they have a partner or a spouse or children that can provide care after they go home? These are all important points to note and work with your case management or your social work and the physician, for good discharge planning and to meet the needs of the patient.

02:56 Now, lastly, in most electronic medical records, we had all these information that we just collected.

03:02 Usually there's a profile summary on this electronic medical record and it provides a great summary page and a quick overview of that patient information.

03:12 Now, in a nut shell, a couple of points to leave you with about admission history assessment in admission for a patient.

03:19 Now, this history assessment provides really pertinent patient information for planning care such as the medication history or those daily medications that they had, the patient's medical history for example, and you notice there's so many screening tools that are so useful and triggering specific consults for patient needs.

03:39 And just note, that when we're talking about a patient admission, this is typically completed by the registered nurse or the RN.

03:47 Thank you for watching.