Patient Care Services Manual Samples

PATIENT CARE SERVICES POLICY AND PROCEDURE MANUAL TABLE OF CONTENTS

Ref. # Approval/Signature Sheet Introduction A-B Abdominal Surgery - Care of Patient (TJC PC.02.01.01 EP1, PC.02.01.03 EP7) Abdominal Paracentesis - Assisting with (TJC PC.02.01.01 EP1, IC.02.01.01 EP2) (NIAHO IC.1) Admission Policy (TJC PC.01.01.01) Admission Criteria - Critical Care (TJC PC.01.01.01 EP2) Admission from the Emergency Department (TJC PC.01.01.01 EP2) Admission Guidelines - Patients with Acute Coronary Syndrome or Possible Impending M.I. (TJC PC.02.01.01 EP1, PC.02.01.03 EP7) Assessment and Reassessment (TJC PC.01.02.01 EP1, PC.01.02.01 EP2, PC.01.02.01 EP4, PC.01.02.01 EP23) Admission Assessment Form (TJC PC.01.02.01 EP1, PC.01.02.01 EP2, PC.01.02.01 EP4, PC.01.02.01 EP23, RC.02.01.01 EP2) Assessment for Self-Harm (TJC NPSG.15.01.01 EP1) Assessment of the Critical Care Patient (TJC PC.01.02.01 EP1, PC.01.02.01 EP2, PC.01.02.01 EP4, PC.01.02.01 EP23) Allen's Test (Verification of Ulnar Circulation) (TJC PC.02.01.01 EP1) Angiography of the Head and Neck (TJC PC.02.01.01 EP1)
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Patient Care Services Manual Samples SUBJECT: ADMISSION GUIDELINES - PATIENTS WITH ACUTE CORONARY SYNDROME OR POSSIBLE IMPENDING M.I. REFERENCE #1006 PAGE: ii OF: 6 EFFECTIVE: APPROVED BY: PURPOSE: To provide appropriate guidelines for admission of the cardiac patient to Critical Care. POLICY: REVISED:

DEPARTMENT: PATIENT CARE SERVICES

Admission Guidelines:

The most expedient route to an adequate environment is strongly recommended. These include:
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Direct transport to Critical Care (i.e., ambulance gurney to Critical Care): A physician with Critical Care admission privileges to the hospital's Critical Care may gain direct Critical Care admission for his/her out-of-hospital patient. The admitting physician will assure notification of the Administrative Supervisor of admission. The admitting process will be completed after the patient is being monitored in Critical Care.

Admission from Emergency Department criteria: When the initial ED patient contact suggests a presumptive diagnosis of MI, a suspected MI, or a patient with unstable angina, the patient needs immediate attention and cardiac monitoring. Risk stratification to identify patients with possible acute coronary syndrome that would include a brief history with positive TIMI risk factors that dictate the necessity for Critical Care admission. (EKG and enzymes at this point may be normal.) Examination findings that validate the need for admission to Critical Care are (but not limited to) hypotension, pulmonary edema, diaphoresis, valvular regurgitation, rales, history of known coronary artery disease.
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SUBJECT:

INVASIVE PROCEDURE SITE IDENTIFICATION (OUTSIDE OF THE OR)

DEPARTMENT: PATIENT CARE SERVICES APPROVED BY: POLICY:

REFERENCE #1109 PAGE: iii OF: 6 EFFECTIVE: REVISED:

__________________ Hospital shall identify those procedures that require markings of the incision or insertion site. The correct patient, procedure and site will be verified by the patient and/or family, the patient care RN, LIP performing the procedure, and the anesthetist as applicable immediately prior to the initiation of the invasive procedure.

PROCEDURE:

The invasive procedure and site/side will be verified by the following means:

Patient identified using two (2) patient identifiers Verbal identification by the patient and/or family Invasive procedure informed consent History and Physical Physician's orders

The above documents along with patient/family identification must indicate the same type and site/side of procedure. The LIP and patient care RN will identify the patient and verify the invasive procedure and site/side in the department where the procedure is to be performed.

The patients identity is re-established if the practitioner leaves the patients location prior to initiating the procedure.

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Patient Care Services Manual Samples

SUBJECT:

TRANSFERRING PATIENT TO A WHEELCHAIR

DEPARTMENT: PATIENT CARE SERVICES APPROVED BY: EQUIPMENT:

REFERENCE #1171 PAGE: iv OF: 6 EFFECTIVE: REVISED:

Wheelchair Pillow Cotton pillowcase Patients bathrobe and slippers Blankets

POLICY:

__________________ Hospital has a uniform method of transferring a patient to a wheelchair. Patients who require assistance will be transferred to a wheelchair maintaining patient safety and proper patient body alignment techniques.

PROCEDURE:

Place the wheelchair parallel to the patients bed, with the back of the wheelchair facing the foot of the bed. Lock the wheels of the wheelchair. Fold up footrest of wheelchair. Place blanket over wheelchair. If a pillow is necessary, place the pillow in the back of the wheelchair with the open end of the pillow case down, or place the pillow in the seat. Place Chux over the pillow, if needed. Ensure the patient's bed is in the lowest position and the wheels are locked.
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SUBJECT:

PSYCHIATRIC EVALUATION OF A MEDICAL SURGICAL PATIENT

DEPARTMENT: PATIENT CARE SERVICES APPROVED BY: POLICY:

REFERENCE #1150 PAGE: v OF: 6 EFFECTIVE: REVISED:

__________________ Hospital is a non-psychiatric receiving hospital. Any patient accessing care at this facility who requires psychiatric treatment (emotional illness, alcoholism or drug abuse) is managed through referral and transfer to a behavioral health facility and/or management through consultative psychiatric services on a temporary basis, until the patients clinical condition has stabilized to allow for psychiatric facility transfer. For Patients Accessing the Hospital Through the Emergency Department:

The Emergency Department physician will evaluate the patient and determine the need for a psychiatric evaluation. If the patient is deemed in need of psychiatric treatment, the following criteria is assessed and documented:
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All medical complaints are stabilized: The patient must be medically cleared prior to transfer to appropriate behavioral healthcare

If the patient is a danger to self, staff or others, a security officer will be requested to continually observe the patient. Call Emergency Psychiatric Evaluation Team (PET). Maintain patient safety. Utilize restraints when needed, per policy and procedure. Call local law enforcement agency, if there is potential danger to patient, staff or others.

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Assessment and documentation includes:

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Patient history History from family member or others with whom the patient resides or other clinicians involved in the patients care
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