Assessment - Reassessment Policy

Hill Country Memorial Health System

Fredericksburg, Texas

Originating Department:

 

TITLE:  Assessment/Reassessment

POLICY#:

AFFECTED DEPARTMENTS: Patient Care Services

APPROVED: Care Oversight Comm.

EFFECTIVE DATE: January 1999

REVISED DATE: 8/26/99, 02/06/02

 

I. STATEMENT OF PURPOSE:

 

To ensure that all patients receive the appropriate assessment (including Initial/screening and reassessment) provided by qualified individuals within the organizational setting. The assessment process will be a continuous collaborative effort with all departments functioning as a team.  Patient assessment is a multidisciplinary function.  The importance of input by various members of the health care team is valued and supported by the organization.

 

II. STATEMENT OF POLICY:

 

A. The goal of the Assessment/Reassessment process is to provide the patient the best care and treatment possible.

 

B. All patients at Hill Country Memorial Health System receiving inpatient, outpatient or emergency services will have an initial assessment and appropriate follow up assessments based upon their individual needs including physical, psychological and social- cultural status.

 

C. This assessment process will determine the need for care and/or treatment, the type of care to be provided and the needs through the continuum of care.

 

D. Care and/or treatment provided by all health care professionals will be based on each patient's specific needs with respect to each patient's right to privacy.

 

E. All relevant biophysical, psychosocial, and nutritional, self-care, educational, environmental and discharge planning needs will be the determining factor for the assessment process.

 

F. All assessments provided by health care professionals will be based upon and include:

  1. Data collected to assess the needs of the patient.

  2. Data analyzed to create the information necessary to develop a plan to meet the patient's care or treatment needs.

  3. Decisions made regarding patient care or treatment are prioritized based on the analysis of the information collected.  

  4. Information will be provided to patients, and when appropriate to families, to assist them to make a knowledgeable decision regarding whether to seek care and/or availability of care.  

 

II. PROCEDURE:

 

The assessment framework will be structured around two components.  Initial screening and assessment/reassessment of all patients as appropriate to the clinical discipline and individual patient condition changes.

 

A. Emergency Department

 

  1. Upon presentation to the Emergency Department each patient shall have an initial assessment performed by a RN as outlined in the EMTALA policy.  This assessment shall include, but not be limited to:

  1. brief review of chief complaint and related history

  2. vital signs (no BP check for children less than two years old)

  3. pain - if pain present, assess degree, quality duration, site, precipitating factors and alleviating factors

  4. weight, for pediatric patients

  5. height/length, as applicable

  6. allergy status

  7. current medications

  1. Initial assessment (triage) data are used to determine triage level.  

  1. Emergent: Patients who have conditions that may result in loss of life or limb if not treated immediately.

  2. Urgent: Patients that require urgent care, but will not generally cause loss of life or permanent severe impairment if left untreated for several hours.

  3. Non-urgent: Patients in this category generally need evaluation and treatment, but time is not a critical factor

  1. The following data are gathered by the nurse or physician during the subsequent assessment, unless to delay immediate treatment would be detrimental to the patient's prognosis:

  1. brief physical assessment based on chief complaint

  2. developmental age

  3. head circumference for all patients below the age of two

  4. immunization status (childhood disease immunization status if less than 18 years old, influenza and tetanus immunization status for all ages)

  5. cognitive abilities and communications skills (omit for infants and children less than two years old)

  6. social status

  7. signs of abuse

  1. In the event this data cannot be gathered before treatment is initiated, it is gathered as soon as the patient's condition has been medically stabilized.  Situations that preclude this data gathering include, but are not necessarily limited to:

  1. cardiopulmonary arrest

  2. cardiogenic shock

  3. precipitous delivery

  4. acute psychosis

  5. major trauma to vital organs

  6. poisoning

  7. drug overdoes

  8. exsanguination

  9. coma

 

B. Outpatient Services

 

  1. A RN will assess each patient presenting to the Outpatient Department prior to the scheduled procedure utilizing the Outpatient Patient Assessment and History Form.

  2. Patients will be reassessed by a RN if a significant change in the patient's condition is noted or the patient returns from a procedure.

 

C.  Inpatients

 

  1. Department patient assessment will be guided by the data to be collected, the scope of the assessment, mechanisms designed to analyze the data collected, and the framework for decision making based upon the analysis of data.

  1. All departments will assume the responsibility to review those aspects of the patient's medical record that directly relate to each department's scope of care and clinical involvement with the patient.

  2. Information generated via a patient's assessment will be integrated with other disciplines to identify and prioritize the patients needs for care and treatment.

  3. The various disciplines will share and provide information about their portion of the patient assessment relevant to their scope of care.

  4. Areas of concern or patient's special needs may be identified by specific clinical disciplines.  All departments, patients and family members may request consultations for specific needs and/or question areas.

  5. The patient assessment will be age specific (neonatal, pediatric, adolescent, adult or geriatric) and should include educational, social, nutritional, spiritual preferences and daily activities of the patient.

  6. The expectations of the family and/or guardian will be taken into account for their involvement in the assessment process, treatment and/or continuous care of the patient.  

  7. Initial assessment of patients needing nursing care in all settings (departments) will be performed by a Registered Nurse.  Further assessment and reassessment will be based on a collaborative effort.

  8. The assessment process will be collaborative to facilitate, identify, and prioritize the patient's needs and determine care.

  1. Scope and Responsibility of Involved Disciplines

  1. Patient Registration - the Admitting/Registration clerk initiates the assessment process for patients entering the hospital except in Emergency situations.

  1. Determination of any advance directive or medical or legal Power of Attorney and/or referral to social services and/or patient relations for the patients with any questions.

  2. Determination of need for financial assistance.

  1. Medical Staff

  1. Each patient will have an initial assessment by a medical staff member, who will assess the physical, psychological and social status of the patient and identified appropriate care/or the need for further assessment as outlined in Medical Staff policies and procedures.  The attending physician is the leader in the planning and provision of care throughout the continuum.

  2. The physician completes a history and physical according to the Medical Staff policy.

  3. There is a Pre-Anesthesia assessment of each patient for whom any level of sedation or anesthesia above minimal sedation (anxiolysis) is contemplated.  Immediately before the induction of anesthesia/moderate sedation the patient is re-evaluated.  

  1. Patient Care Staff

  1. At the time of admission, each patient will have his or her needs assessed by a Registered Nurse (RN) utilizing the Patient Assessment and History form.  The Licensed Vocational Nurse (LVN) may perform certain aspects of data collection (history).

  2. The RN will complete the admission assessment and history as soon as possible upon arrival to the nursing unit, but shall not exceed established parameters for each unit.  Patient condition upon arrival may warrant immediate assessment.  Unit specific time frames:

 

AREA

COMPLETION TIMES

Medical/Surgical Units

8 hours

Nursery

8 hours

Postpartum

8 hours

Intermediate Care Unit

8 hours

Critical Care

4 hours

L & D

4 hours

 

  1. All patients admitted for treatment will be screened for nutritional, functional rehabilitation and respiratory therapy needs at the time the RN completes the admission history and assessment.  The RN uses screening criteria listed on the admission assessment and history form developed in coordination with the involved disciplines.  After receiving a referral from the RN the following time frames for assessment completion are followed:

 

DISCIPLINE

COMPLETION TIMES

Nutrition (High Risk)

48 hours

Nutrition (Low Risk)

72 hours

Functional Rehab - Physical Therapy

48 hours

Functional Rehab - Occupational Therapy

72 hours

Functional Rehab - Speech Therapy  (High Risk)

24 hours

Functional Rehab - Speech Therapy  (Low Risk)

72 hours

Respiratory Therapy

24 hours

Discharge Planning

72 hours

 

  1. All patients admitted for treatment will be screened for possible abuse or neglect at the time the RN completes the admission history and assessment.  The RN uses screening criteria listed on the admission assessment and history form developed in concert with the social worker.  Patients identified as possible victims of abuse or neglect will be referred to the social worker and he/she will conduct a more detailed assessment within eight hours.  The social worker will then offer direction as to notification of authorities, and any further assessment necessary.

  2. All patients admitted for treatment will be screened for alcohol abuse at the time the RN completes the admission history and assessment.  The RN uses screening criteria listed on the admission assessment and history form developed in concert with the social worker.  Patients identified to have alcohol abuse will be referred to the social worker and he/she will conduct a more detailed assessment within eight hours.  Refer to the Identification of Possible Victims of Abuse Policy.

  1. Reassessment

  1. Each patient is to be reassessed according to the guidelines established by the clinical discipline and/or a significant change in patient condition and/or diagnosis.  Specifically, a RN will conduct, at a minimum, a reassessment every 24 hours including but not limited to the review and update of the Plan of Care.

  2. Reassessment is to be ongoing and may be triggered by key decision points and at any intervals specified by the departments/ancillary disciplines directly involved in providing patient treatment and/or care.

  3. Reassessment of discharge planning needs occurs at least once a week at the Discharge Planning meeting.

  4. Reassessment may be at specified/regular interval related to:

  1. Plan of Care

  1. The RN is responsible for coordinating and prioritizing the Plan of Care after review of the nursing admission assessment and history and assessments performed by other involved disciplines.

  2. All involved caregivers are responsible for communication of patient care needs and goal status through out the patient's stay.