Policy for Admission, Transfer and Discharge of Patients at Maple Ward Responsible Directorate: Responsible Director:
Provider Services Robert Flack
Date Approved: Committee:
08 August 2008 Governance Committee
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Version Control. Document Title
Policy for Admission, transfer and Discharge of Patients at Maple Ward
Amanda Johnson, Caroline Summers, Gwen Ruddlesdin
Ward staff, GP Clinical Assistants
Date of Production
for Head of Provider Governance
Primary Circulation List
Staff within Maple Ward
Web address Restrictions
Standard for Better Health Map.
Core Standard Reference Performance Indicators
C4 (a/d), C6, C16 1. Review of admission documentation against admission 2. audit and review of incidents related to admission, transfer and discharge from HVMH
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Associated policies and procedures
Aims and objective
Scope of policy
Accountabilities and responsibilities
Admission, transfer and discharge processes
Monitoring and Evaluation
Equality impact assessment
Training needs analysis
Criteria for admission to Maple Ward
Patients transferring from an acute hospital setting
Access to the service
Criteria for acute admissions
Transferring patients to the Acute Trust
Flow chart for Admissions fro MAU, A+E, CDU
Documentation to be completed by referring doctor in A+E
Flow chart for Local Care Direct
Transfer of Care Proforma completed by Hospital Matron
Flow chart of process followed by Bed Flow Matron
Proforma to be completed by GP prior to admission to Maple
Flow chart for admission from GP
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Kirklees PCT Provider Services will have a systematic and planned approach to admissions, transfers and discharges from Maple Ward. This will ensure that all the appropriate information is held within a standard format that can be easily accessed by staff and that the monitoring processes are clear to all.
This policy sets out the criteria and process for the admission / transfer and discharge of patients to and from Maple Ward, Holme Valley Memorial Hospital.
Associated Policies and Procedures.
This Policy / procedure should be read in accordance with the following PCT policies, procedures and guidance. • • • • •
Incident Reporting Policy Patient Identification Policy Records Management Policy Confidentiality Policy Vulnerable Adults policy
Aims and Objectives.
Kirklees PCT Provider Services aims to provide medical, nursing, therapy care and support on Maple Ward to enable the patient to achieve their maximum level of independence. This Policy has been written to enable staff on Maple Ward to follow agreed standards when admitting, transferring and discharging patients. All admissions, transfers and discharges will be: •
Of high quality
Comply with the agreed policy and procedures
Supported with initial and supplementary staff training
This policy is intended to benefit patients, relatives and carers; general public; staff. Objectives of Maple Ward. • • •
To provide a short-term (1-6 weeks) step down / step up service within an intermediate care setting. To co-ordinate the provision of services for those patients returning to their own homes. To provide and / or co-ordinate the provision of medical, nursing, social, and therapeutic services for patients experiencing adverse changes in their lives.
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To enable the patient to establish or recover activities of daily living skills, communication skills, mobility and confidence. To provide an alternative to an acute hospital admission or long term residential or nursing home admission where the identified need is medical, nursing, or therapy intervention in a non-acute setting.
Kirklees PCT Provider Services will ensure that the service is available to all, regardless of ethnicity, gender, sexuality or religion.
Scope of the Policy
This policy must be followed by all PCT employees and staff on temporary or honorary contracts as well as bank staff and students.
Accountabilities & Responsibilities
The Director of Provider Services is lead Director with Board level responsibility for the quality of service provision on Maple Ward. Overall day to day responsibility for all aspects of patient care is the Ward Manager. The Clinical Services Manager will be responsible for ensuring that all staff conform to the standards laid out in this policy. All staff are responsible for ensuring they follow Kirklees PCT Provider Services admission, transfer and discharge criteria. If the nurse in charge of the ward has any concerns regarding the transfer of a particular patient, they must discuss this with the ward manager, manager on call, or whoever is most appropriate (for example a lack of skills or resources to meet the needs of a particular patient, so that the issues can be addressed.)
Admissions, Transfer and Discharge Processes
Kirklees PCT Provider Services has agreed criteria for admission to Maple Ward which have been developed in a procedural document. This will be reviewed on an annual basis to ensure that the criteria continue to meet patient needs and will be ratified by both the Provider Services and with commissioners. Discharge planning starts at the time of admission and will be considered at all review meetings with patients and their informal carers. Decision to Discharge • Discharge arrangements and plans will be discussed with the patient and where appropriate their carer throughout the process. • Discharge will take place on or before the predicted date of discharge. • Changes to this date will be discussed and agreed with the multidisciplinary team. • Discharge arrangements and plans will be agreed with those involved in providing care following discharge and will be advised of any changes to the plan. • Discharge will take place after planned interventions are undertaken and discharge arrangements put in place. • Arrangements for essential care at home, and equipment essential for discharge will be in place on or before the date of discharge. • Drugs to take home - Tablets to take out (TTO’s) will be ordered at least 24 hours prior to discharge and appropriate arrangements will be made to ensure that further supplies of medication can be prescribed and dispensed without delay. Page 5 of 24
The contact assessment and discharge plan will accompany the patient. This will include information relating to medication in order that all those, including General Practice, involved in post discharge care are aware of all discharge arrangements.
Discharge of Vulnerable patients Special care will be taken in planning and coordinating discharge arrangements for particularly vulnerable groups. It is essential that screening processes are in place and effective to ensure the early identification of patients who have continuing care needs. Once identified, appropriate referrals must be made to the relevant specialists and agencies.
Monitoring and Evaluation
Kirklees PCT Provider Services will have structured and robust monitoring and evaluation process in place to ensure that patient care is to a high quality standard. •
The Provider Services Quality Group will be responsible for monitoring compliance with this policy and procedure including the implementation of the document and training for staff. The Quality Group will report any deficiencies and recommendations to Provider Services Board who will performance manage any action plans.
The Ward Manager and Service Manager will be responsible for ensuring that the monitoring of the service is undertaken by reviewing the discharge and admission documentation against the standard procedures and reporting any discrepancies to the Quality Group. Any system failures which have the potential to impact on patient safety will be reported via the Trust incident reporting policies and procedures.
Patient transfers and discharges will be monitored on a continuous basis through the SITREP process, which has been set up to monitor against the established criteria and targets
An action plan will be developed and further work undertaken should it become apparent that there are problems in a particular area of noncompliance
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Equality Impact Assessment.
All public bodies have a statutory duty under the Race Relation (Amendment) Act 2000 to â€œset out arrangements to assess and consult on how their policies and functions impact on race equality.â€? This obligation has been increased to include equality and human rights with regard to disability age and gender. The PCT aims to design and implement services, policies and measures that meet the diverse needs of our service, population and workforce, ensuring that none are placed at a disadvantage over others. In order to meet these requirements, a single equality impact assessment is used to assess all its policies/guidelines and practices. This Policy was found to be compliant with this philosophy. Equality Group
Reasons for decision
Procedures will ensure that patients receive all necessary support 9
Disability Faith belief
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Training Needs Analysis.
All staff appointed to work in Maple Ward will receive training in this policy and associated procedures through the induction process. Additional training will be provided through staff meetings to ensure that staff retain familiarity with the processes and achieve full compliance. If necessary, focussed training will be provided to individuals or as a result of any compliance concerns noted through the regular reviews. Information will be circulated to all General Practices in Kirklees on an annual basis to ensure that doctors and other healthcare staff are familiar with Maple Ward procedures. Nursing staff in Maple Ward have developed good links with staff in the acute trusts. Through this network, information on Maple Ward procedures will be shared and any issues discussed.
DH (2004) Discharge from hospital â€“ pathway, process and practice
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Involvement and participation of others in the process of developing these guidelines as shown below:
Stakeholders name and designation
KPCT Policy Development Group
Chair: Tina Quinn
Clinical staff, Maple Ward
Ward Manager: Caroline Summers
Medical Practitioners for Maple Ward
Joan Booth, Locality Manager
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Procedures for Admission, Transfer and Discharge in Maple Ward
8 August 2008
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Criteria for Admission to Maple Ward
To be eligible to receive the services offered on Maple Ward, patients must meet the following criteria:• • • • • •
Be 65 or more in age (people of a lower age could be considered if appropriate) Must be a resident or temporary resident of Kirklees Have experienced a change in circumstances, thus preventing them from functioning at an appropriate and desirable level. Have received any necessary acute treatment prior to admission. Must have the realistic potential to return to increase the level of functioning through a period of rehabilitation Patient, themselves, must consent to the provision of the service.
Patients transferring from an Acute Hospital Setting
All patients transferring from an acute hospital setting will be required to fulfil the general admission criteria outlined above and in addition: • • • • • • •
Must be deemed medically stable prior to transfer. Does not require any out of hours clinical support services. Not be acutely confused. Has had all recent test results reviewed by the Consultant who perceives the patient’s medical status is such, that the Consultant will refer care back to GP. A diagnosis wherever possible has been made and a proposed management plan is in place. The transferring Consultant must be prepared to provide telephone advice / review as needed by HVMH Have 14 days supply of prescribed discharge medications
Maple Ward is unable to accept patients who have been assessed and who:• • •
Are only waiting for a longer-term service i.e specialist housing or adaptations to their own home, or permanent residential or nursing care. Have severe mental health or physical disabilities, which would prevent them from benefiting from the service. Require an emergency placement.
Whose assessed need is not clear and / or there is no explicit need for the service or clarity of why it has been requested.
Access to the Service
Kirklees PCT Provider Services will ensure that all patients are admitted through a structured process appropriate to their particular needs, as shown in the attached appendices •
Step up acute admissions via Elmwood Health Centre and Oaklands Health Centre
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Step up acute admissions via Oaklands practice from GP’s within the Kirklees area.
Step down transfers from CHT assessed by Bed Flow Matron.
Step down admissions from MAU, CDU, A+E via CHFT during hours Monday – Friday 9am-5pm (Appendix 1)
Rapid Response via patients own GP.
Patients from Acute Trusts out of area via Maple Ward and admitting GP.
Via Local Care Direct (protocol for admission in place; see Appendix 3).
The person co-ordinating the assessment should discuss and gain the authorisation of the nurse in charge prior to an admission being arranged.
It is expected that the healthcare professional assessing the patient for Maple Ward will have made explicit to the service user / or carer:• The short-term nature of the service. •
The enabling nature of the service.
The provision of the service is subject to the agreement of the Service User and where appropriate the carer.
Information regarding Maple Ward’s environment and routine (Appendix 4)
(Documentation written in partnership with Kirklees Social Services is currently under consideration for use on the ward in relation to a signed agreement of the above by the patient)
Referral Processes •
All step-down admissions can be referred directly to the Matron at HRI, by using agreed proforma. (Appendix 5)
Flow chart of process (Appendix 6)
Dr to Dr from MAU / A+E, documentation to complete initially (Appendix 2)
Flow chart for process (Appendix 1)
Acute admission referrals the patients own GP must ring 07900323989 proforma to be completed (Appendix 7)
Flow chart of process. (Appendix 8)
NHS Kirklees and the Bed Flow Matron (HRI) will be kept informed of the bed availability on Maple Ward, HVMH.
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Criteria for Acute Admissions
The patient should meet TWO or more of the following criteria: •
Acute Illness, or deterioration in chronic illness presentation, requiring high level of nursing care, medical or therapy input, but do not require high tech acute hospital assessment or investigations
May be admitted for intravenous fluids, therapy or blood transfusion. Does not requires immediate X-Ray or other radiological investigation
Requires pharmacological treatment and close monitoring.
May require pathological investigation to assist with diagnosis.
The patient requires terminal or palliative care – ongoing symptom and pain relief management and continuing psychological support, where the cause of the pain has already been diagnosed.
The patient should meet ALL of the following criteria: •
Patient agreeable to admission, goals discussed and agreed with the patient
Intervention likely to be short term, typically 1-6 weeks
Patient can not be managed at home by mainstream or alternative intermediate care services.
Prior to acute episode patient was able to manage at home with appropriate support
Patient does not require long term 24 hour or respite care
Patient is a resident of the NHS Kirklees
Where the admitting GP has any concerns regarding suitability for admission, the patient will be assessed in Huddersfield Royal Infirmary A&E department and then transferred to Maple ward.
Exclusions include: •
Acute confusional state.
Moderate or severe dementia.
Diarrhoea / vomiting of infectious origin with patients who are insulin dependant diabetics and patients with chronic renal failure.
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It is the responsibility of the nurse in charge to communicate to all staff the expected arrival of a new admission.
An appropriately situated bed must be allocated and the patients name written on the overhead board.
Once the patient arrives on the ward, the GP must be informed to visit unless they have already seen the patient at home and completed all the relevant documentation required on admission.
It is the responsibility of the nurse in charge to ensure:1. Consideration is given to the patients infection risk e.g. MRSA/C Dif (if known) and specific actions taken to reduce risks to other patients and staff. 2. Complete admission book and daily returns sheet 3. Patient’s next of kin informed of arrival to ward. 4. Base line observations are recorded. Including routine BM recordings for diabetic patients, and ward test urine for all patients. 5. If urine offensive, nitrate positive consider obtaining an MSU. 6. If MSU taken write on white board and in patients profile (back page) 7. Admission bracelets and allergy bands to be put on patients wrists. 8. The patient profile part of the admission is accurately and thoroughly completed. Document dossette box delivery, key safe numbers, home care cancelled etc. Patients admitted from their home environment should bring all prescribed medication with them. 9. Ensure names and hospital numbers are recorded on every piece of documentation. 10. Document date for TED stocking removal, catheter date changes, date for Vit B12 injections / prostatic injections etc 11. The physical and social profile is completed. 12. Patient’s property forms completed. 13. Complete multidisciplinary notes / evaluation with relevant information required eg reason for admission, management plan etc. 14. Complete individualised care plans within 24 hours. 15. Observe pressure areas on admission. 16. Complete all pressure area documentation 17. Assess suitability of mattress. 18. Complete FRASE within 72 hrs of admission. 19. Complete manual handling risk documentation. Page 14 of 24
20. Inform OT and Physio of admission, management plan, FRASE score if high. 21. Refer to other disciplines. Continence, chiropody, dietician, SALTS etc as needed. Document in referral book. 22. Once seen by GP, ensure resuscitation status, expected date of discharge, and prn medication is prescribed (forward think if prescription of prn would be useful, particularly out of hours) 23. Confirmation on the patients current medicines status i.e. what medicines they are taking is confirmed and appropriate actions taken to ensure these are prescribed and available for use on the wards. 24. If patient is in need of certain prescribed medication which is not on the ward, the nurse in charge will need to obtain this from pharmacy. (Written requests only accepted). Otherwise use patients own medication until the pharmacist next visits. Patients transferred from the acute Trust should have 14 days medication with them. 25. If IV fluids prescribed ensure accurately prescribed, also check we have enough supply. If not order more. 26. Ensure syringe drivers are documented on the syringe driver chart and on the drug chart. 27. Ensure oxygen is also prescribed correctly. 28. Use observation charts to record regular BP, P etc and keep with care plans. 29. Document on white board the need for observations to be recorded, and dressings to be done. 30. Assess if oxygen required if so inform portering staff.
Transferring patients to the Acute Trust.
If a patients condition deteriorates, it is the responsibility of the nurse in charge to contact either the GP responsible for the medical cover (in hours), or Local Care Direct (Out of Hours) to explain the nature of the problem. Depending upon the length of time it takes for the Dr to arrive on site, the nurse in charge must make clinical decisions based on how the patient is presenting. In the event of an emergency where the nursing staff are unable to wait for a medical practitioner to arrive on site a 999 ambulance must be called. The nurse in charge must collect the medical records, treatment chart and medication and formulate a brief letter (if time allows) for continuity of care. The documents must be provided to the acute Trust at time of transfer if necessary by ensuring the sealed information and medication is handed to the ambulance crew. This action must be documented. The patientâ€™s next of kin must be informed of the transfer and A+E department given a verbal hand over of the situation. Documentation in the medical records must be accurate and concise. Information of transfer must also be entered onto specific ward documentation which focuses on inpatient activity.
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The patient and, where appropriate, their carer will be at the centre of and involved in their discharge planning. For every patient, planning for discharge will begin on admission and will be identified as having started by the documentation of an ‘Estimated Date of Discharge’. Discharge plans will be designed to meet each individuals needs. A home visit will be undertaken if deemed necessary and risks will be assessed, and shared with members of the MDT. Transport arrangements are discussed at an early stage. Documentation within the medical records will show evidence of a discharge plan, which outlines the patients’ needs and associated discharge arrangements, including resources such as medication, dressings, equipment. This will include a medical / pharmacy discharge TTO sheet, submitted to pharmacy in advance (by fax) allowing time to organise and send the medication, preventing an unnecessary delay. Consideration must be given to patients with medidose / dossette boxes. These discharges require the nurse to organise weekly deliveries from the patients’ local chemist. Prior to the patient leaving the ward all their medication will be explained to them. They will be informed of any forthcoming appointments, or visits from community nurses etc. They are asked to complete a patient satisfaction survey focusing on areas of the ‘essence of care’ document. All community support practitioners, day centres etc will be informed of the patients pending date of discharge. The patients own GP will have been contacted prior to discharge and a copy of the discharge summary posted out to them once the patient has left the ward. A full discharge letter is dictated by the doctor for the patients he accepted as Acute admissions from home. Patients who wish to self-discharge can complete documentation accepting responsibility for their actions. The Dr must be informed wherever possible before the patient leaves the hospital. Again the nurse must ensure carers, GP and other appropriate agencies are aware of the patient’s actions.
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Appendix 1. Flow Chart for Admissions from MAU, A+E, CDU (Same process) Monday to Friday 9am – 5pm
Admission to Maple Ward From MAU, CDU, A+E ↓ Complete proforma (appendix 2) ↓ if patient suitable ↓ Check if bed available Tel ext 5618 and check which GP on take ↓ Medical Registrar or Consultant ↓ Telephone 345603 (Dr Akam, or GP on call) Telephone 689111 (Dr Shamsee, or GP on call) Discuss patient details ↓ GP accepts patient and informs Maple Ward staff of impending admission ↓ MAU / A+E /CDU staff arranges transport Inform patient and family of transfer Send all relevant documentation with patient (notes, treatment chart, medication)
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Appendix 2. Documentation to be completed by Dr in A+E /MAU /CDU
ASSESSMENT PROFORMA FOR DR TO COMPLETE PRIOR TO CONSIDERING TRANSFERING A PATIENT TO MAPLE WARD, HOLME VALLEY HOSPITAL. Maple Ward is a 20 bedded unit within a community hospital setting, situated in the outskirts of Holmfirth. We offer “step up” and “Step down” services, but do not accept patients who require specialist medical or technological intervention. 2 local GP practices provide “in hours” medical cover, out of hours medical cover is provided by Local Care Direct, in an emergency we ring 999. With this in mind, it is imperative that the patients who are transferred to us are medically stable and have an achievable rehabilitation goal (please have the patient reviewed by OT and PT for their assessment wherever possible). Please consider the following:1. Is the patient suitable for Maple Ward (Considering above information?) Yes No 2. Is the patient likely to improve with rehabilitation. Yes No If the patient is unlikely to improve with rehab and / or only requires extra help at home, they are NOT suitable. 3. Is the patient medically stable? Yes No 4. Have all bloods, ECG, X-Rays been checked and are normal? Yes No 5.
Is outpatient follow up required Yes No ( If yes has it been organised? Yes No ) 6. Please record patient’s mini mental score: _ Please inform GP when discussing patient.
If all the answers to questions 1,2,3,4,5, are “yes”, the patient is suitable to discuss with the Local GP practice. Please have at hand the patients MMSE to feedback to the GP and any relevant information regarding the patients cognitive ability. It is imperative that the nursing staff on maple ward receive information regarding the patient once accepted. Many thanks, Caroline Summers, Ward Manager.
PLEASE FAX THIS TO 5614 WITH PATIENTS NAME, HOSPITAL NUMBER AND DEPARTMENT. PLEASE SEND ORIGINAL ALONG WITH PATIENTS CASENOTES, TREATMENT CHART AND DRUGS.
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Appendix 3. Flow chart for Local Care Direct.
LOCAL CARE DIRECT SEES AND ASSESSES PATIENT.
Patient requires some Diagnostic intervention, i.e Blood test, X-Ray. ↓
No investigation required ↓ Rings Maple Ward to check bed availability and discuss
LCD Doctor checks bed available at HVMH,
completed proforma ↓
provisionally books bed and
LCD arranges ambulance
gives medical details
and sends proforma
(Appendix ) with patient
LCD Doctor completes
Must also send their stock
proforma (Appendix )
of medicines with them, and
indicating that if all
completed HVMH drug chart
investigations are acceptable patient can be transferred to HVMH. ↓ LCD Dr arranges ambulance To either A+E, CDU or MAU ↓ responsibility of department staff to arrange admission to HVMH following investigation.
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Appendix 4 Transfer of Care Documentation for Maple Ward Patient and Ward Team must be in agreement for transfer to Maple Ward, Holme Valley Memorial Hospital. This form, when completed needs to be faxed to Caroline Summers, Ward Manager or Nurse in Charge. Fax no: 5614. If patient accepted for transfer, original copy to be sent with all other medical documentation. Date of Referral……………………………….. Date of admission……………………………... Maple Ward Staff Only
Consultant………………… Ward……………. Name of Therapist……………………………..
Accepted. Not Accepted
Home Visit Details……………………………. Patient Details (attach sticker) Name…………………………………………..
Reason for decision
Hospital Number……………………………… Date of Birth…………………………………… Diagnosis………………………………………
Pending? (as OPA)……...
Estimated length of stay if admitted to HVMH ………………………….………………………..
Resus Status ……………………………………………………………………………
Admission MRSA Screen Date:
Date Treatment completed
Please mark ALL BOXES and fill in dotted lines where applicable. Home Situation: Alone
Accommodation : Det. House Flat Bungalow Terrace Which floor? …… Stairs
Rails in situ
Prior to admission:
Rails ordered 1. Bath
Outside step rails
Ordered Any aids
How many calls per day………. per week……….
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Independent Stick 2 sticks Frame
Unable With assistance
Independent Assist 2
Assist 1 Hoist
Mild deficit MMSE………
Reduced / pain
Reduced / pain
Diet/ feeding and swallowing
Diet / feeding and swallowing
Normal Other S/B Dietitian
Self Care. Wash/ Dress/Bathe
Self Care. Wash/ Dress/ Bathe
Colostomy Please specify………….
Colostomy Please specify……
Friable skin Pressure Ulcer
Any other referrals pending?………………………………………………………………… Rehabilitation goals: Mobility
Other please specify ………………………………………………………… Signature……………………………Name……………………………….Ext No…………………….
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Appendix 5. Flow chart of process followed by Bed Flow Matron.
Ward staff at CHFT highlight patient they believe suitable for Maple Ward and contact Bed flow Matron. ↓ Bed Flow Matron completes proforma (Appendix 4) and faxes It through to Maple Ward 5621 ↓ Nurse in Charge discuss patient’s Suitability with accepting GP and MDT ↓ Patient not suitable
↓ patient suitable bed
bed flow matron informed
flow matron informed.
reason for refusal documented
She informs ward at
CHFT to organise admission, inform patient and their carers. Discuss patient details with staff on Maple Ward. Send medical records, drug chart and medication.
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Appendix 6. Process for GP Acute admission to Maple Ward.
TO BE COMPLETED BY GP – PRIOR TO ADMISSION OF PATIENT TO HVMH NAME:
Brief history of events leading to admission Examination Outline provisional diagnosis Cognitive Capacity
Expected outcome from admission Past medical history – include any complex social needs Current medication Allergies Resuscitation Status Overnight Medical Management Plan/ Instructions for Nurses
Have you or a GP colleague visited the patient today?
When was the patient last seen :
Signature of GP…………………………………………….Date……………………. Has the patient been screened for MRSA prior to admission? Date……………………
Please complete and fax to: 01484 345614, also copy to be sent with patient Page 23 of 24
Appendix 7 Flow chart of admission process from GP
GP or GP colleague reviews patient that day ↓ Requires admission to HVMH ↓ GP rings and speaks to Qualified Nurse on 07900323989 ↓ Discuss and complete proforma, taking GP mobile number to return call. ↓ Qualified nurse discusses admission with Oaklands Duty Dr and MDT Team ↓ Ring original GP back
patient not suitable
back to own GP
Own GP rings For an ambulance
To enable a full medical assessment to take place on the day of admission, the patient MUST arrive on Maple Ward no later than 3pm.
It is also essential that you complete the admission proforma and that the patient brings this, and their current medication in with them.
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