Monitoring Admission and Discharge

Documentation Procedure

PREP. By habtamu.
Bsc. Nurse

08/19/2021 1
 Implement admission procedure

 Hospital Admission and Discharge

08/19/2021 2
 Learning Objectives

Upon completion of this topic, you should be able to:


Describe the Basics of Patient admission & discharge Procedures


Identify Policies and procedures of admission

Preparing and filing inpatient documentation

Verifying patient records completeness


Delivering Relevant Patients Record to Appropriate Destination

08/19/2021 3
 Hospital Admission

Admission
• It is a formal process whereby a person is
accepted by a hospital for the purpose of
hospital treatment as an inpatient.
• Admitted patient: is defined as a person
who meets the criteria for admission to the
admission category and care type
08/19/2021 4
 Cont…

• Bed management: is the allocation and

provision of beds,
• Especially in a hospital where beds in
specialist department (wards) are a scarce
resource.
• The "bed" in this context represents not
simply a place for the patient to sleep,
08/19/2021 5
 Cont…

• But the services that go with being cared

for by the medical facility:

-Admission processing,

-physician time/visit,

-nursing care, necessary diagnostic work,

-appropriate treatment, and so forth.

08/19/2021 6
 Cont…

• Outpatient (or out-patient): is a patient

who is not hospitalized for 24 hours or more
• But who visits a hospital, clinic, or
associated facility for diagnosis or
treatment.
• Treatment provided in this fashion is called
ambulatory care.
08/19/2021 7
 Inpatient (or in-patient)

• It is a patient "admitted" to the hospital and

stays overnight or for an indeterminate time,
usually several days or weeks.
• Treatment provided in this fashion is called
inpatient care.
• Inpatients usually occupy a bed in a health
care facility for at least four hours or overnight.
08/19/2021 8
 Cont…

• The time needed before a person is

declared an inpatient varies from country
to country.
• In this regard, there is no written document
in Ethiopia that specifies the time that
should be spent in hospital before it is
declared as inpatient.
08/19/2021 9
 Cont…

The admission to a hospital involves the

• Writing an admission note

• Documents the patient's status,

• Reasons why the patient is admitted for

inpatient care,
• The initial instructions for that patient's care.
08/19/2021 10
 Cont…

• Patient’s leaving of the hospital is commonly

termed as patient discharge,
• And involves a corresponding discharge note
or summary.
• Where a patient is admitted on the
expectation that he or she will remain
overnight,
08/19/2021 11
 Admission procedure

• The admission of a patient to hospital is

ordered by a doctor and carried out by an
admission clerk.
• At the time of admission, a patient already
has a medical record number and medical
record.
• Thus, a new number is not issued.
08/19/2021 12
 Cont…

• The hospital, however, needs to keep a

daily list of all admissions.
• All patients admitted, whether admitted for
the first time or not
• And other admission related information
on the appropriate recording tool.
08/19/2021 13
 Admission criteria

• The criteria for all admission categories

reflect the intended level of treatment that
the patient is to receive.
• The decision to admit is based on these
criteria, which must be considered before a
decision is made.
08/19/2021 14
 Cont…

• The decision to admit can only be made

by authorised medical officer or nurse

practitioner.

08/19/2021 15
 Cont…

A person may be admitted if one or more of

the following apply:

• The person’s condition requires clinical

management

• The person requires observation in order to be

assessed or diagnosed
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 Cont…

• The person requires at least daily assessment

of their medication needs

• The person requires a procedure/s performed

• There is a legal requirement for admission.

08/19/2021 17
 Note:
• Admission categories and classes for
additional criteria specific to each admission
type.
• One of the following criteria related to
severity of illness and intensity of service
will usually be present to warrant
admission.
08/19/2021 18
 Severity of illness

• Sudden alteration to conscious state

(unconsciousness, coma, disorientation,
confusion or unresponsiveness)
• Abnormally high or low pulse (pulse rate
outside specified range for age)
• Abnormally high or low blood pressure
(above or below limit for age)
08/19/2021 19
 Cont…

• Acute loss of sight or hearing

• Acute loss or ability to move major body part

• Persistent fever (rectal temperature>38.3 C, or

other temperature>37.8 C in Paediatric)
• Active bleeding

• Severe plasma electrolyte/acid-base/blood pH

abnormality or low Hb or packed cell volume
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 Admission status

• All admissions must have an urgency

status assigned to indicate if the
admission occurred on an emergency or
elective basis:
_Elective

_Emergency admission
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 Elective admissions

• Elective admission patients may include

cases under investigation for a non-urgent

illness,

• Or planned non-urgent procedures.

08/19/2021 22
 Cont…

• Each admission should only occur on the

basis of available beds
• Including consideration of the number and
experience of health professionals in each
shift and their current workload.

08/19/2021 23
 Cont…

• Elective patients must not be admitted

directly to the operating suite
• If there is not an appropriately designated
bed available at the time of admission.

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 Emergency admissions

• Emergency care includes patients

suffering from an acute illness or injury

that requires urgent assessment and

treatment
08/19/2021 25
 Cont…

• The Manager will contact the nursing/midwifery

coordinator requesting extra staff resources
• Where the appropriate ward has no beds or
cannot accept the patient due to insufficient
health professional resources,
• The designated officer responsible for
admissions .
08/19/2021 26
Policies and procedures of admission
• Admission and discharge procedures, along with
appropriate health professional to patient ratios,
• Are fundamental to ensuring appropriate clinical
health professional care is provided to clients
receiving care from health agencies
• which provide inpatient and/or community
facilities.
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• This policy is intended to provide a

minimum requirement guideline across all

sectors of in-patient health services.

08/19/2021 28
 Admission policy

1. All health facilities should have an admission

protocols in place.
• Such protocols are fundamental in guiding

safe,
adequate and continuing care across
health delivery contexts and to ensuring the
effective use of resources.
08/19/2021 29
 Cont…

2. Admission of people to health services

should only occur

_where there is an appropriate level and

skills mix of health professional staff

_who are rostered and available to

provide care, including specialist nursing
and/or obstetric care.
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 Cont…

3. Admission and discharge planning is an

interdisciplinary process
• Which should include all relevant health
professionals as well as the person
receiving care and their carers.

08/19/2021 31
 Admission policies should include at
least the following elements:

• A clear role statement for the health agency

• Procedures for monitoring workload capacities,

including staff patient ratios, skill-mix .
• A process in relation to emergency department
direct and elective admissions which must
adhere to these principles
08/19/2021 32
 Cont…

• Admission and discharge monitoring

mechanisms;
• Evaluation or quality management criteria;
• Provision made to involve patient/consumer
in the discharge process.

08/19/2021 33
 Checking client identity

• Identification information is an important part

of a patient's medical record and it should
include enough information to uniquely
identify an individual patient.
• Some health facilities will ask to view and/or
copy the patient’s identification card in order
to verify this data.
08/19/2021 34
• The patient identification data may be

entered into a computerized database, or

manually typed onto the outer front page

of the medical record folder.

08/19/2021 35
 The patient identification data may
include:

• The full legal name of the patient,

including

.The first name,

.Middle name and grandfather name

.And prefixes (e.g., Doctor) if any.

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 Cont…

• It is also important to collect the patient’s

_alias(nickname),

_ previous name, or middle

name, as the patient may have been seen

at the facility under another name.

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 Cont…

• Internal identification number or hospital

registration number.
• Date of birth (DD/MM/YYYY), gender, marital
status, address and phone numbers.
• Name, address and telephone number of
nearest relative (next of kin) or friend.
• Date of registration (DD/MM/YYYY)
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 Cont…

• Wristbands

• Bar coding. Some of these have proved to

be cost-effective

08/19/2021 39
 Purpose of checking patient’s
identity
• To avoid patient misidentification. Throughout
the health-care industry, the failure to correctly
identify patients continues to result in:

_medication errors,

_ transfusion errors,

_testing errors,

_wrong person procedures, and the discharge

08/19/2021 40
 Cont…

• Available interventions and strategies can

significantly reduce the risk of patient

misidentification.

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 Cont…

• The major areas where patient

misidentification can occur include
_ drug administration,
_ blood transfusions,
_and surgical interventions.

08/19/2021 42
 Cont…

• The trend towards limiting working hours

for clinical team members leads to an
increased number of team members caring
for each patient,
• There by increasing the likelihood of hand-
over and other communication problems
08/19/2021 43
 Strategies for patient's identity

The following strategies should be

considered
1. Ensure that health-care organizations
have systems in place that:
 Emphasize the primary responsibility of
health-care workers to check the identity
of patients
08/19/2021 44
 Cont…

 and match the correct patients with the

correct care (e.g. laboratory results,
specimens, procedures)
 Provide clear protocols for identifying
patients who lack identification
 And for distinguishing the identity of
patients with the same name.
08/19/2021 45
 Cont…

 Encourage patients to participate in all

stages of the process.
 Provide clear protocols for maintaining
patient sample identities throughout pre-
analytical, analytical, and post-analytical
processes.
08/19/2021 46
 Cont…

 Provide clear protocols for questioning

laboratory results
• or other test findings when they are not
consistent with the patient’s clinical history.
 Provide for repeated checking and review in
order to prevent automated multiplication of
a computer entry error.
08/19/2021 47
 Admission /Discharge recording tools

• With the reformed HMIS, there are three basic

recording tools for inpatient services:
• The Admission/discharge card, Register and
Tally.
• However, there are many clinical forms by
which healthcare providers document the entire
patient’s information captured during the
08/19/2021 48
 Admission/discharge Card

• It is very useful recording tool of the

patient’s information related to
_ personal identification,
_ ward admitted,
_admission diagnosis,

08/19/2021 49
 Cont…

_discharge diagnosis,
_condition at discharge,
_admission and discharge dates and
_other financial information related to
the inpatient services offered.

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08/19/2021 51
 Admission/Discharge Register

• The purpose of completing this register for

each inpatient service is to gather
information
• That enables the facility to identify top
causes of morbidity and mortality of
inpatient department.
08/19/2021 52
 Cont…
• In addition, the data contained by the register
helps
• To identify specific diseases or clinical
conditions of priority that are targeted for
eradication or control.
• The register is case register (not longitudinal
register) where each row is used to record
information of one patient
08/19/2021 53
 Cont...

• admission and the same row will be

completed at the time of discharge of that
patient.
• It is located at all the wards (rooms where
admitted patients receive inpatient
services).
08/19/2021 54
 Cont…

• The data to be filled in the

admission/discharge registered is available
in the medical records of each inpatient
cases
• And it will be collected and entered at the
time of admission and discharge each
case.
08/19/2021 55
 Content of Admission/ Discharge Register

• The admission/discharge register has five

basic groups of columns.
• These groups of related columns are for

_ Identification,
_ Admission,
_Provider initiated HIV testing and counseling
(PIHTC), _Discharge and finance information.
08/19/2021 56
 Cont…
• Identification includes: Medical Record
Number (MRN), Age, and Sex, woreda / sub-
city.
• Admission includes: Date of Admission,
Admission diseases classification (HMIS
diagnosis)
• PIHTC includes: HIV test offered, HIV test
performed and HIV test result
08/19/2021 57
 Cont…

• Discharge includes: date of discharge,

length of stay, condition at discharge and
discharge diagnosis (Based on HMIS
disease classification)
• Finance includes: Cost of service,
Amount paid, and Voucher Number.
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08/19/2021 59
 IPD Tally sheet
• This tally sheet is important to summarize
the inpatient services and diseases
disaggregated by age group, sex and
New/repeat status.
• It is filled by the care provider at the end of
each day. Counts should be summed and
state at the bottom the tally sheet at the
end of each month.
08/19/2021 60
Information Recorded while Admitting a patient

• Most of the documents in the health record are

clinical services and some of these clinical
forms are discussed in the previous learner
module 2 (Managing Medical Records).
• However, here we will try to describe and
summarize the most important one as follows.

08/19/2021 61
 History and physical examination
recording form/patient form

• Function: To record patient history and

physical examination findings.
• Location: Inside the Medical record folder
• Work process: When a patient is admitted
as an in-patient a full history and physical
examination should be conducted by the
attending physician.
08/19/2021 62
 Client Progress Notes

• An essential part of a Client Personal File

• Where staff and clients briefly record

details to document the client’s status or

achievements.

08/19/2021 63
 Cont…

• A tool for reflecting on a client’s movement

towards their goals as identified in their
Individual action Plans.
• It is essential that progress notes reflect
the strengths
• And recovery-focused elements of clients.
08/19/2021 64
 Cont…

• Location: Medical record folder

• Work process: When patient is seen by a

clinician, the information obtained will be
recorded with date, clinical details, and
signature of the attending clinician.

08/19/2021 65
 All progress notes should include:
• A client’s progress towards goals identified in
Individual Plans.
• Level of support provided by staff.

e.g. staff completing tasks for client.

• The client’s level of participation in and partnership
with the service.
• The clients significant achievements and changes.
08/19/2021 66
 Con…

• Referrals made.

• Any information given to clients.

• All informed consent decisions.

• Any follow-up required.

08/19/2021 67
 Important Points Regarding Progress
Notes
• Clients personal file notes including progress
notes are legal documents.
• So , it should be kept confidential.

• All client personal files must be kept in a secure

location and accessed only by authorized staff.
• Progress notes must be kept in a chronological
order.
08/19/2021 68
 Con…

• The progress notes must be recorded

during every contact or each shift

(morning, evening and night) depending

on the program.

08/19/2021 69
 Cont…

• All progress notes should be read at the start

of each shift in order to:-
-support the client’s current situation.

-what support the client will require.

- what follow-up activities need to occur during
the shift.

08/19/2021 70
 Con…

• All progress notes should be written with

reference to the previous entry.
• Client’s have the right to request to read
their own file notes.

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 Nursing Process Forms

• Nursing admission assessment form

• Nursing problem statement list
• Nursing care plan
• Nursing patient progress report

08/19/2021 72
 Cont…

• Function: To describe the nursing

assessment, care plan and outcome of
nursing care of an admitted patient.
• Location: Bed-side clip board during the
patient’s stay, but must ultimately be
included in the patient’s MR as part of the
permanent record.
08/19/2021 73
 Medication Administration Record

• Function: To record all medications

ordered and administered to a patient.
• Location: Bed-side clip board during the
patient’s stay, but must ultimately be
included in the patient’s MR as part of the
permanent record.
08/19/2021 74
 Fluid Balance Chart

• Function: To record all fluid inputs and

outputs for patients at risk of fluid overload
or dehydration.
• Location: Bed-side clip board during the
patient’s stay, but must ultimately be
included in the patient’s Medical record
folder as part of the permanent record.
08/19/2021 75
 Consent forms

• Function: The consent form outlines the

risks associated with a particular procedure.
• A signed consent form indicates that the
patient (or designated proxy) has been
informed of the risks and has authorized the
procedure.
• Location: Medical record folder
08/19/2021 76
 Referral and Feedback Form (if relevant)

• Function: To document patient history at

the hospital and to provide reason for
referral
• Location: One copy in the Medical record
folder and one copy to patient.

08/19/2021 77
• Reason for referral : (Discussed )?

08/19/2021 78
 Delivering Relevant Patients Record
to Appropriate Destination
• Note date and time

• Use appropriate forms

• Identify the client

• Write in ink (Usually all charting is written
with black ink, but each agency determines
protocol.)
• Use standard abbreviations
08/19/2021 79
 Con..

• Spell correctly

• Write legibly

• Correct errors properly

• Write on every line
• Sign each entry

08/19/2021 80
General Rules for Recording & reporting
♦ Spelling: Be sure that the patient's name,
hospital number and the ward is spelled
correctly , complete address and telephone
number, if any.

♦ Completeness: should write the date and time

as well as his/her signature On completion of any
single or "stat" order.

♦ Exactness: don’t use words you are not sure of. 81

08/19/2021
 Rules…
♦ Legibility: hand write should be readable & use
commonly accepted abbreviations

♦ Neatness: All records should be printed neatly.

Printing should be small and legible.

♦ Avoid Errors : A nurse should never record

treatment, medication or nursing care which
she/he has not done and knows nothing about it.
08/19/2021 82
Keep patients’ Medical Record During
Hospital Stay

08/19/2021 83
Monitoring and Updating Patient Information during patients hospital stay

• This part of managing medical record is

entirely done during the inpatient stay of
the patient.
• Main responsibility lay on the care
providers involved in the treatment
process of the patient.
08/19/2021 84
 Cont…
• As described earlier, most of the clinical
documents that constitute the medical records of
inpatient cases are the clinical forms.
• The HIT has to check for the:
 accuracy

 completeness

 and on-time recording of these

clinical forms on regular bases.

08/19/2021 85
 Cont…
 Accuracy

– Data that is compiled in databases and reporting

forms is accurate and reflect no inconsistency
between what is in the registers and what is in the
databases/reporting forms at facility level.

– Similarly, in case of data entered in the

computers, there is no inconsistency between the
data in the reporting forms and the computer files.
08/19/2021 86
 Cont…

 Data Completeness:

– At service delivery point, it refers to all

the relevant data elements in a
patient/client register are filled

08/19/2021 87
 Cont…
– At Health Administrative unit

• All the data elements in a database or report are

filled

• The health administrative unit has reports from

all the health facilities and/ or lower level health

administrative units within its administrative

boundary
08/19/2021 88
 Cont…

Timeliness

Data is collected, transmitted and

processed according to the prescribed
time and available for making timely
decisions

08/19/2021 89
Basic hospital statistics for inpatient services

Inpatient Death/mortality rate

• Definition: A patient who expires/died
while he/she is inpatient of a hospital.
• The term ‘mortality’ is referred as death.
• It is a ratio of all inpatient deaths for a
given period to the total number of
discharges and deaths in the same period.
08/19/2021 90
 Formula

• Inpatient death rate:

Total number of deaths of inpatient in a given period

_______________________________________x 100
Total number of discharges and deaths in the same
period

08/19/2021 91
 Cont…

N.B Inpatient death rate should be

calculated based on discharge data not
admission data.
• This is because a patient who is
hospitalized has a chance of being
discharged as died.
08/19/2021 92
computing and reporting average Length
of Stay
Average length of stay
• Definition: a length of stay for one patient is
the number of calendar days from admission to
discharge.
• The average length of stay is the average of the
sum of length of stay of any group of inpatients
discharged during a specified period of time.
08/19/2021 93
 Formula

Ave. Length of stay=

Total inpatient service days of discharged (including

deaths)Patients for a given period
___________________________________________
Total number of discharges and deaths in the same
period

08/19/2021 94
 Example
• In June, a hospital has discharged 2,086
patients (including deaths, but excluding
newborns).
• Their combined inpatient service days
were 13 654 days.
• Using the above formula, the average
length of stay of these patients was:
08/19/2021 95
 Cont…

= 13654
2086
= 6.54 or 6.5 days

That is, the average stay as inpatient during June was

6.5 days.

08/19/2021 96
 Bed occupancy rate

• Definition: the percentage of inpatient beds

occupied over a given period.
• To calculate the bed occupancy rate for
certain period,
• You need to know the number of patient
days (also known as inpatient service day)
08/19/2021 97
 Cont…

• Which is a unit of measure of denoting the

services received by one inpatient during one

24 hour period.

• A total patient day is the sum of all inpatient

service days for each of the days during a

given period.
08/19/2021 98
 Formula

Bed occupancy rate=

Total number of patient days for a given period

______________________________________X 100
Available beds X the number of days in the period

08/19/2021 99
 Example

• Black lion hospital has 500 available beds

and provided 13,250 patient days in Hidar
(November). Hidar has 30 days.
• The bed occupancy rate of the black lion
hospital was:

08/19/2021 100
 13,250
___________x 100 88.3%
500x30

08/19/2021 101
 Case fatality rate

• Definition: The case fatality rate is

defined as the number of deaths assigned
to a given cause (disease) in a certain
period, divided by the number of cases of
the disease reported during the same
period.
08/19/2021 102
 Formula

Case fatality rate of disease =

Number of deaths for a given disease y

_______________________________________x100
Number of cases of the same disease reported y

08/19/2021 103
 Cont…

• The number of days of care rendered to an

inpatient is from admission to discharge.
• The duration of an inpatient's hospitalization is
considered to be one day
• If he is admitted and discharged on the same day
and also if he is admitted on one day and
discharged the next day.
08/19/2021 104
 Cont…

• The day of admission should be counted

but not the day of discharge.

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Identifying Patient Medical Record Location

• Reading assignments

08/19/2021 106
 Apply Discharge and clearance
procedures

08/19/2021 107
 Discharging a Patient

• Discharging:

Preparation of the patient to leave the hospital after

completing obligations to the hospital and receiving

instructions for medical care.

08/19/2021 108
 Indications for discharge:

• Progress in the patient's condition

• No change in the patient's condition

•Against medical advice

• Death

08/19/2021 109
 Discharging a patient against medical advice (AMA)

• When the patient want to leave an agency without

the permission of the physician - unauthorized
discharge the following activities are indicated:
A. Ascertain why the person wants to leave the
agency.
B. Notify the physician of the client’s decision.

08/19/2021 110
 Con…

C. Offer the patient the appropriate form to complete

D. If the client refuses to sign the form, document the
fact on the form
• and have another health professional witness this
Provide the patient with the original of the signed
form and place a copy in the record

08/19/2021 111
 Con...

E. When the patient leaves the agency, notify the

physician, nurse in charge, and agency
administration as appropriate
• Assist the patient to leave as if this were a usual
discharge from the agency (the agency is still
responsible while the patient is on premises)

08/19/2021 112
 Patient leave

• Patient leave is a temporary absence from hospital

overnight, with medical approval for a period no
greater than seven consecutive days.
• If a patient is on leave for greater than seven days,
the patient should be discharged and readmitted
if/when returning from leave.

08/19/2021 113
 Leave vs. transfer

• As stated above, leave entails the intention that a

patient will return to resume care and is most often
planned.
• If, for some unforeseen reason, a patient must
receive care at another facility, a transfer must take
place.

08/19/2021 114
 Example

• A patient at hospital A falls out of bed with a

suspected fractured hip.
• Urgent transfer to hospital B is required for further
management. There are no firm plans to return as
future clinical course is indeterminate.

08/19/2021 115
 Cont…

• Therefore, hospital A records a transfer (no leave).

• If and when the patient returns it is a new

admission, regardless of the number of days that

have elapsed.

08/19/2021 116
 DISCHARGE CRITERIA

• The patient is stable

• The patient is no longer benefiting from the
available treatment.
• Information comes to light of the patient’s pre-
existing functional health status..
• Many patients recovering from critical care
08/19/2021 117
 Discharge and clearance procedures

• The hospital discharge process is initiated on the

recommendation of a physician.
• The process may vary from hospital to hospital as
hospitals have their own policies regarding
discharge.

08/19/2021 118
 Cont…

• Patients should make sure they understand any

follow-up instructions before leaving the hospital
and, if not, they should ask for clarification.
• Possible questions they might need clarification on
include:

08/19/2021 119
 Cont…

• Does the patient need a follow-up visit?

• Who should he/she see?

• Should the patient call to make the appointment or

is it already arranged?

08/19/2021 120
 Cont…

• What medications have been prescribed?

• Are there any side effects? If there are, should the

patient stop taking the medication?

08/19/2021 121
 Cont…

• Medical record staff responsible for this procedure

should be trained to ensure that the medical records
are completed promptly and correctly.

08/19/2021 122
 Completing Discharge Summaries

• A discharge summary is a summary of the patient’s

stay in hospital written by the attending doctor.
• The minimum detail provided in a discharge
summary is:

• Patient identification

• Reason for admission

08/19/2021 123
 Cont…

• Examinations and findings

• Treatments while in hospital and

• Proposed follow up/ Death summary

08/19/2021 124
 Cont…

• Upon the discharge a patient,

• The following information should be recorded on
admission/discharge register entry
• That corresponds to the particular patient
admission related information.

08/19/2021 125
 Cont…

• Date of discharge of the patient

• Length of stay (the difference of data of discharge

and date of admission)

• Condition at discharge: the possible value can be

improved or referred or dead left against medical
advice or absconded (runaway from the hospital
suddenly).
08/19/2021 126
 Cont…

• HMIS Diagnosis: Based on the HMIS disease

classification.

• Cost of the service: exact cost in terms of Birr.

• Amount Paid: the amount of money paid for the

service during stays and discharge

(see figure 8.4).

• Voucher number: from the payment receipt.

08/19/2021 127
08/19/2021 128
08/19/2021 129
Organizing Documentation of Discharged Patients

• While in hospital, the patient’s medical record

develops with the recording of clinical information by
doctors and other health professionals.
• Results of pathology tests etc. are added as they
are received.
• Nurses record daily progress notes and special
observations.

08/19/2021 130
 Cont…

• If a patient has any special tests and/or surgical

procedures, relevant information is included.
• On discharge/death of the patient the medical
record, including all forms relating to the admission
plus any previous records, should be sent to the
Medical record unit as soon as possible or within 24
hours.
08/19/2021 131
 Cont…

• Medical record staff responsible for the discharge

procedure should be trained to ensure that the
medical records are completed promptly and
correctly.
• The discharge procedure begins with the receipt of
the medical records of discharged
patients/deceased.

08/19/2021 132
 Cont…

• The medical records of discharged client/deceases

should be sent to the Medical Record Department

by the ward staff on the same day of

discharge/death or the next morning.

08/19/2021 133
 Cont…

• In some countries, a staff member from the Medical

record unit collects the medical records of
discharged/deceased from the wards at a specific
time every day.

08/19/2021 134
 Cont…

• The Medical record unit staffs are responsible for the

daily bed census, which they receive from each

ward at the beginning of the day.

08/19/2021 135
 Cont…

• From the bed census forms staff are able to record

details of discharges and deaths and prepare a daily
discharge list.
• This list is extremely important and should be
duplicated and sent to a number of sections in the
health care facility.

08/19/2021 136
Verifying Medical Records for Completeness for discharged patient

• The Medical record unit staffs are responsible for

managing the medical records of discharged
patients
• And should check to see if they have all the medical
records of discharged patients from the previous
day.
• If any are missing they should contact the ward to
find them.
08/19/2021 137
 Cont…

• Once a patient has been discharged, the medical

record should be returned promptly to the Medical
Record Unit.
• Failure to do so may result in a missing medical
record.
• Once the patient is no longer in the ward, their
medical record can easily be misplaced.

08/19/2021 138
 Cont…

• Medical record completion procedure begins with

the receipt of the medical records of completed
services, discharges and deaths.
• Those medical records should be sent to the
medical record department by the health care staff
by the end of the day and before that all the
processes should be completed from each unit.

08/19/2021 139
 Cont…

• In some cases, a staff member from the medical

record unit collects the medical records from the
health care facility wards every day.
• It is a good practice to list and send the summary of
discharged and dead patient to the medical record
unit.

08/19/2021 140
 Cont…

• The clerk in the medical record unit checks each

medical record to ensure that all the forms are in the
record.
• For example, if the patient has had an operation an
operation report should be in the record.

08/19/2021 141
 Cont…

• In addition all progress notes, pathology and x-ray

forms, nursing notes etc. should be included.
• There should also be a final discharge note made by
the attending doctor including to where the patient
has been discharged and arrangements for follow-
up.

08/19/2021 142
 Cont…

• The clerk then sorts the forms into the correct order
(if they are not already sorted).
• In the case of new patient the forms are attached to
a medical record folder with a clip or fastener.

08/19/2021 143
 Cont…

• If the patient has been in health care facility before

the old records are retrieved and the latest
admission forms are added by placing them behind
the appropriate divider or in a chronological order.

08/19/2021 144
 Cont…

• The clerk also needs to check if the doctor has

completed the lower part of the front sheet.
• That is, the HMIS diagnosis has been recorded
along with any other condition treatment while in the
facility.

08/19/2021 145
 Cont…

• The signature of the health care provider is

important as it shows that the doctor has completed
the medical record and takes responsibility for the
content.

08/19/2021 146
 Recording Information From Discharge
Summary for Follow Up and Appointment

When we appointment to follow up on a health

problem we fill the following information:

 What health problem is the reason for this return

appointment?
 What questions or concerns do I want addressed
during this appointment
08/19/2021 147
 Cont…

 What signs and symptoms should I watch for?

 When should I call to report signs and symptoms

 Treatment issues(Rx taken at the time of discharged

& new treatment at the time of appointment)

08/19/2021 148
 Cont…

• Follow-Up Appointment date and time

• Reminder Bring all the records you have been
keeping since your last visit, such as a blood sugar
record if you have diabetes

08/19/2021 149
 Policies of discharge

1.All staff must be aware of their roles and

responsibilities regarding the discharge process .

2.The patients best interests and wishes will remain

central to plans being made for discharge.

3 . Discharge is to be commenced on admission .

4 . Discharge is a multi disciplinary process .

08/19/2021 150
 Cont…

5. Communication is paramount between the patient,

relatives / carers and all members .

6. Patients will be provided with information regarding

their treatment in hospital, advice regarding future
management .

08/19/2021 151
 Cont…

7. All patients are entitled to have their ongoing needs

assessed against Continuing Health Care criteria for
Continuing Health Care Funding
8. All consumables for the patient to be obtained
24hrs prior to discharge

08/19/2021 152
 Summary of policy

• This discharge policy has been written to provide

guidance on good practice to assist the multi-

professional team in achieving safe and timely

discharge.

08/19/2021 153
 Cont…

• The policy outlines the principles and steps of

effective discharge, the responsibilities of Trust staff
and provides guidance .
• Discharge processes for Trust inpatient services are
provided as appendices to the policy.

08/19/2021 154
 Cont…

• The underpinning principles of effective discharge are:

1. Effective communication

2. Alignment of services to ensure continuity of care

3. Involvement of patients / families / carers

4. Efficient systems to support the process

08/19/2021 155
 Cont…

5. Clear clinical management plans

6. Early identification of discharge date

7. Identified named lead coordinator

8. Review and audit of practice

08/19/2021 156
 Returning Patient Document to MRU

• The Medical Record of discharged patients or the

deceased should be returned to the Medical Record
unit within 24 hours of discharge.
• The Medical Record unit should review the Medical
Record to see if all forms have been properly
signed, particularly the discharge summary.

08/19/2021 157
 Cont…

• If they are not signed, the Medical Record

Department should alert the physician on record or
case team leader to complete and sign the
discharge summary.

08/19/2021 158
Archive and Destruction of Patient Records

• If you have run out of room to store paper records

you may need to archive the original documents.
• A comprehensive archive process, with written
policies and procedures will help you meet your
professional standards and legislative requirements.

08/19/2021 159
 Cont…

• We may have inactive patient records – patients

may have deceased, left your practice, or simply

have not returned to the practice for a length of time.

08/19/2021 160
 Cont…

• The Health Information Act makes information

security provisions requiring custodians to protect
individually identifying health information in their
custody
• Or control by making reasonable security
arrangements to protect against unauthorized
access, collection, use, disclosure, or destruction.

08/19/2021 161
 Cont…

• Note: sometimes it seems that it is easier to keep

records forever rather than destroy them after the
retention periods and legislative requirements are
met.
• However, remember that you may be required to
produce or provide access to records for as long
you continue to have custody of records.

08/19/2021 162
 Destruction:

• Ensure that you have recorded which records have

been destroyed, the method of destruction, and the
date and signature of the person responsible for the
destruction.
• See the disclosure log form in the sample
procedure “Archive and Destruction of Patient
Records”.

08/19/2021 163
IPD ADMISSION/DISCHARGE REGISTER

• Archival procedures

• National and regional regulations for retention

should be observed.

08/19/2021 164
 Cont…

• If these regulations are unknown, records may be

retained in active storage for 5 years after last visit
and retained in inactive storage for 10 years after
last visit or death.

08/19/2021 165
 Routine observation chart

• Archival procedures

• National and regional regulations for retention

should be observed.

• If these regulations are unknown, records may be

retained in active storage for 5 years after last visit
and retained in inactive storage for 10 years after
last visit or death
08/19/2021 166
 IPD morbidity and mortality tally

• Archival procedures

• National and regional regulations for retention

should be observed.

• If these regulations are unknown, tally sheets

may be retained for 5 years and then discarded

08/19/2021 167
Checking client identity during discharging
(Group work)

08/19/2021 168
Compiling Admission and discharge Reports

• Organizing the reports on discharges and admission

from all health institutions.
• These reports can be represented by graphs ,tables &
own report formats
• The total number of attendances in months an
increase or decrease of the same month form the
pervious year.

• Of these, attendances at type of departments .

08/19/2021 169
08/19/2021 170
 Included data elements in reports

• How much admitted patient care was provided?

• Who used these services?

 In 2014–15, 53% of separations were for women

and girls. About41% of separations were for people
aged 65 and over.
• What services were provided?

08/19/2021 171
 Cont…

• How many procedures were performed?

• What was the safety and quality of the care?

• How was the care funded?

08/19/2021 172
 Summary

• This report draws together the direct experiences of

clients and staff to provide an updated national
picture of hospital admission and discharge practice
for people .
• It identifies examples of effective working, as well as
where improvements still need to be made.

08/19/2021 173
 Cont…

• It builds on existing guidance on hospital admission

and discharge to propose a set of standards which

can be applied regardless of the specific models of

practice in place.

08/19/2021 174
 Cont…

• Our findings reveal that while some areas have

introduced effective measures to help address
patients’ accommodation needs when they access
hospital .

08/19/2021 175
 Completing Billing and Other Required
Clearances

• When much of your facility’s billing depends on

accurate and timely use of codes that generate
Ambulatory Payment Classification (APC) groups,
you need to have a system in place to check your
billing and coding department’s work.

08/19/2021 176
 Cont…

• Accurate and complete coding is the single most

important element driving your success in the

environment of APC reimbursement.

08/19/2021 177
 Cont…

• Conducting an APC audit is a great way to ensure

that your organization identifies, monitors, and
rectifies in- appropriate billing practices, which will
benefit your bottom line while simultaneously
highlighting potential compliance issues.

08/19/2021 178
 Cont…

• Auditors should also conduct periodic follow-up

audits to ensure that the organization has
procedures in place to address issues regarding the
quality and accuracy of the coding and billing
process

08/19/2021 179
 Why perform billing and coding audits

• Improved operational efficiency. If performed

correctly, audits should identify all types of errors
and direct you to the root of any coding problems.

08/19/2021 180
 Cont…

• Audits can also increase productivity.

• If employees see auditing as a normal part of their
work process rather than as a function that
threatens their jobs, they are more likely to perform
with a higher degree of effectiveness and efficiency.

08/19/2021 181
Improved relations between HIM/billing staff and physicians

• An effective audit will identify errors caused by

physician documentation problems. Physicians
responsible for poor documentation should be
informed and educated on these issues, and receive
regular feedback from health informa- tion
management (HIM) staff.

08/19/2021 182
 Improved data quality overall

• If compliance auditing is performed appropriately,

with the necessary feedback, education, and follow-
up, it results in improved data quality.
• All data users have an inter- est in ensuring that
data is reliable.

08/19/2021 183
Correct reimbursement to the organization

• Audits should identify underpayments as well as

overpayments.
• Because of the improved operational efficiencies
that can result from auditing, many facili- ties have
seen an increase in their overall revenue base.

08/19/2021 184
 ሰውን ለመርዳት ሰው መሆን በቂ ነው‼‼
08/19/2021 185