2. ASSESSMENT : The systematic and continuous
collection , organization, validation and documentation
of data (information). It includes patients perceived
needs ,health problems, related health practices, values
and life styles.

5. 1. To identify interdisciplinary assessment
parameters(data elements and time requirement)and
define responsibilities to plan and deliver the
appropriate level of care to meet the patients needs,
evaluate the response of care, support community
care, and plan a safe discharge from hospital.
2. To establish unified process of assessment and
reassessment of patients admitted to the units.

6. 4.Admission physical assessment shall be done with in
four hour in general unit
5.Admission physical assessment shall be done with in
one hour in special care unit
6.All data collected are entered on the Nursing
Admission Assessment Sheet and available to all those
involved in the care of the patient.
7.Data that is not obtainable with in 4 hours of
admission should be documented at the end of shift by
the assigned nurse.

7. 8.The RN assigned to the patient is responsible to
ensure that the form is completed with in the time
frame specified.
9. Documentation should be in permanent ink(blue or
black).
10.The nurse should write her/his name, RN and
signature.

8. The registered nurse will give patient care based on
documented assessment and reassessment of patient’s
needs/current status.
1.Admission physical assessment
2. Data received from the patient as well as from the
family/ significant others are include in the
assessment.
3.The Nursing Admission Assessment Sheet will be
completed on all patients by a Registered Nurse.

9. REASSESSMENT
1.The reassessment of the outcome of care/and or
treatment needs of the patient will be continuous
throughout the patient’s hospitalization.
2.Reassessment shall be done to determine patients
response to the treatment or if a significant change in
the patient’s condition .
3.Prior to discharge from the unit ,all patients shall be
reassessed to determine if they are fit for discharge.
4.Consultation of medical staff other than nursing shall
be done to determine the validity of initial data
collection and the on-going reassessment.

10. PROCEDURE
NURSING ADMISSION ASSESSMENT
1.At the time of admission , the registered Nurse
performs complete assessment of the patient.
2.Enter patient’s name, medical record number and age
at the upper left corner of the form.
3.Enter date and time of admission, medical diagnosis
and chief complaint in the appropriate spaces in the
form.
4.Document the source of information (patient, family,
caregiver or health care person or significant person).

11. 5.Chek and document if patient has previous
hospitalization and write patient history including past
major illnesses.
6.Indicate if patient was admitted from ER, home, clinic,
other and accompanied by whom.
7. Take patients vital signs(temperature, pulse,
respiration ),height ,weight .
8.Asess and document the location and the severity of
the pain using the pain scale.

12. 9.Document if patient has history of allergy, if yes,
check ,whether its due to medication , food or others.
10.Document patient brought medicine to the hospital.
If yes, check whether it was send to pharmacy.
11.Document if patient and family has valuables
brought to the hospital . If yes , check it was sent to
admission office.
12.At the time of arrival to the room , patient and
family will be given orientation to the unit , an
explanation to the patients rights and responsibilities.
13.Check the activities of daily living and need of
mobility aid.

13. 14.REVIEW OF SYSTEM.
• LOC and speech
NEUROMUSCULAR • pupils: reaction, appearance
• extremity movement
• Heart sounds and rhythm
CARDIOVASCULAR • neck vein
• pulse
• presence of edema
• extremity coolness
• capillary refill
• cyanosis and others.
RESPIRATORY • Breath sounds and breathing pattern
• Quality of cough
• character of sputum

15. GASTROINTESTINAL
• Abdomen and bowel sounds
• Nausea, vomiting, diarrhea
• Presence of urinary device
• Character of voiding
GENITOURINARY • Urinary discharge
• vaginal or penile discharge
• Turgor and integrity
INTEGUMENTARY
• Colour and temperature

16. FALL RISK ASSESSMENT
• 45 or above
• Fall risk sign
PSYCHOSOCIAL SCREENING
• Any ‘yes’ answer requires referral to
attending physician
• Need sitter or watcher
NUTRITIONAL SCREENING
• Appetite
• Change in body weight
• ?Nutritional consultation

17. DISCHARGE PLANNING
• MODE OF TRANSPORT
• ACCOMPANIED BY
• FUNCTIONAL STATUS

18. MAY BE WE ARE ON OUR TOES

19. BE HONEST ...
LEGAL
RESPONSIBILITY CAN NOT BE
DENIED