Dee Nez AEDS HOSPITAL MANUAL Paws Teed Date; S0pt-2007 [AMOSUP-SEAMEN'S cone NOSPITAL (Mail) PATIENT CARE PLANNING aed prea PageNe: V2 AMOSUP-SEAMEN’S HOSPITAL (Manila) provides a systematic, coordinated interdisciplinary process of screening, assessment/re-assessment, education and planning that is designed for the patient's continuing care needs. Planning includes the patient and his/her family and appropriate health care team members as well as necessary support of community services. The medical record, particularly the admission history, discharge plan, the physician progress notes and the pathway/pian of care facilitate communication of information among interdisciplinary team members actoss the continuum’ of care. Plan of care shall include order and timing of treatments as well as referrals to other specialties as may be necessary. POLICY: 4. Provisions for the following shall be made in line with the patient's care plan = Identification and assessment to meet the patient's physical, social, emotional and spiritual needs © Involvement of patient/family in assessment, planning, identification and choice of resources to be used ‘+ Education to prepare patientfamily for continuing care + Referrals, with patientfamily permission, to practitioners, settings and organizations to meet continuing care needs Transfers, with patient/family consent, of information to: such practitioners, settings land organizations, that js necessary to facilitate referral and continuing care. © Assistance to patientfamily in adaptation to the continuing care plan. + Timely movement to the next appropriate level of care. . 2. The care plan i$ developed by a multidisciplinary team of health professionals in consideration of published clinical practice guidelines, patient's values and cultural preferences as well as, medico-legal and other statutory requirements as generally mandated by the Department of Health. RESPONSIBILITIES: 4. Attending Physician is ultimately responsible for the patient's discharge and throughout the patient's course of treatment, collaborates with all parties involved in the planning for the patient's continuing care needs. 2, Professional nurse caring for the patient: 5 2.1 Assures that a continuing care plan is developed and implemented with input from the patient/family and other appropriate health care team members; 2.2 initiates data collection, assessment and planning as early as possible in the patient's continuum of care when feasible, prior to admission (clinic/physician office), no later than eight (8) hours post admission to the acute care setting:Doc. Nar ENPOS HOSPITAL MANUAL RevNe: 00 : Tomes Duc: Sept2007 a PATIENT CARE PLANNING Proparedby: OMR HOSPITAL (Manila) ‘Anproved oy: Hoop. Director Page No: 2.3. Assures follow through with the continuing care plan; 24 Seeks necessary assistance to operationalize the continuing care plan. Health Care Team Members (includes rehabilfation therapists, nutriionists and other ancillary personnel) support the continuing care planning process and contribute to the plan through Expert corisultation for patients with complex clinical, psychosocial and financial discharge issues PROCEDURE: 1. Data Collection and Assessment Process begins as early as possible in the patient's confinuum of care. Preliminary screening and assessment in the acute care setting must occur within the first eight (6) hours of SEinission. This process Is ongoing as the medical team routinely collects process and Gutcomes data in the form of treatment methods, test results and patient's condition after treatment are appropriately evaluated and feedbacks of these are given to medical team members concerned. Plan Development Planning is a joint process involving the patients, their families, members of the health care jeam as well as necessary outside agencies. Evaluation results and medical analysis of the patient's condition are made available to assist in the development of multdisciplinary plan of care Plan implementation Collaboration of the interdisciplinary health care team with the patients and their families is directed toward moving the patient to the appropriate level in the continuum of care This process occurs through exchange of written and verbal communication and hospital Guidelines. The ultimate goal is to promote continuity aver time among phases of service to the patient, to include care beyond the inpatient settings, “The patient and his/her family are given full explanation of the plan of care. If at any point, the patient refuse any treatment or nature of test, the medical team shall respect his/her decision But consequences of such refusal shall be discussed accordingly. Plan Evaluation Evaluation is an ongoing process of the interdisciplinary health care team that monitors and changes the plan as necessary. The discharge process provides for continuing care based on the patient’s re-assessed needs at the time of the discharge. Evaluation occurs through ‘exchange of written and verbal communicafions.Doe Nor HMMS HOSPITAL MANUAL Rey No: 00 Iesned Date: Sept-2007 ‘AMOSUP.SEAMEN'S. pes ‘HOSPITAL (Manila) PATIENT DISCHARGE PLANNING || Prevaoihy GME | PageNo: 12 Discharge Planning is a multidisciplinary, collaborative process involving the patient, patient's family and concemed team members and is initiated within 8 hours of all inpatient admissions. The patient and his/her family are appropriately informed of the approximate duration of the treatment, extent and/or frequency of re-assessment, likely effects of the re- assessment, the need for follow-up care after hospital discharge and other needs to continue the health care. POLICY: 1. A discharge order is required from the patient's attending physician and/or resident on duty. 2. Patient care discharge needs are re-assessed by the nurse on duty once every 24 hours and by other team members as needed, 3. Progress toward discharge is communicated in intershift report and to all identified health care team members on a daily basis. 4, The nurse is responsible for coordinating the discharge plan with other team members and verifying with the patient/patient’s family that needs are met. All members of the health-care team are expected to contribute to the plan based on identified needs. 5. Routinely anticipated patient and family discharge needs are documented on the Progress Notes/Discharge Plan which includes special care at home, resuming activity, diet, medications, how to manage discomfort and when and how to contact a health care provider. 6. Additional patient and family discharge needs are documented on the discharge plan by professional members of the multidisciplinary team. PROCEDURE: 1. The doctor confirms with the patient that he/she is to be discharged. 2. The patient's doctor writes down his/her discharge orders to discharge the patient in the Progress Notes/Doctor’s Orders and discuss with the nurse the discharge instructions. 3. Nurse carries out discharge orders of the doctor, facilitates filling up of PhilHealth form by the patient and instructs his/her family to process their final payments with the Billing section. . 4, The Midwife/Nursing Aide/Orderly returns all unused medicines to the Pharmacy. 5. Nurse prepares post charges and prépares the patient's chart for billing- z Dos Naz HMO HOSPITAL MANUAL fais: 100) Jemacd Date: Sept.2007 Prepared bj: QMR = Approved by: Hosp. Director PageNo: 22 scsur SEAMEN | PATIENT DISCHARGE PLANNING Nurse sends discharge notice to the Medical Records, Dietary, Pharmacy, Pathology, Radiology, Accounting and Security sections. Nurse facilitates completion of the patient's Discharge Summary by the doctor particularly the home medications and follow-up treatment, if necessary. Nurse records patient's discharge date and time then endorse patient's chart to the Medical Records. PATIENT DISCHARGE INSTRUCTIONS All patients and their respective families will be given written instructions for care when discharged. The Discharge Plan includes: List of follow-up appointments (provider to be seen, the provider's locations and phone number and the date and time of the appointment is indicated) List of discharge medications (the dose prescribed, route of administration, the time after discharge to take the first dose and times of subsequent doses) Discharge diet and dietary restrictions Discharge activity with specific instructions Other special instructions