Reception and registration of patients

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Reception Room Functions

1. Reception and registration of patients.

2. Examination and diagnosis of patients.

3. Sanitary treatment of patients.

4. Qualified medical care.

5. Transportation of patients to medical departments according to the disease profile.

Obligations of the nurse of the admission department:-

1. Registration of medical documentation

2. The provision of emergency first aid.

3. The implementation of medical appointments.

4. Invitation, if necessary, of medical consultants.

5. Sanitization of the patient,

6. Thermometry - measurement of body temperature.

7. Determination of indicators of physical condition (pulse, blood pressure, NPV, anthropometric data - height, weight, chest circumference, etc.).

8. Inspection and, if necessary, anti-pedicular measures.

9. Informing the sanitary and epidemiological surveillance centers about the identification of an infectious patient or a patient with pediculosis, when a patient bites with a tick, a dog - issuing an emergency notice about the detection of an infectious disease.

10. Maintenance and observance of sanitary and anti-epidemic measures in various departments of the admission department.

11. Transportation of patients to medical departments.

12. Monitoring the condition of patients in the isolation ward and timely execution of doctor's prescriptions for their examination and treatment.

13. Further training, strict observance of labor discipline.

Admission Office Documentation :-

1. Medical record of a hospital patient (f.003 / y);

2. Statistical map of a retired patient (form No. 066/y).

3. Stationary journal;

4. The register of applicants for medical care;

5. Magazine general cleaning;

6. The register of admissions of patients and refusals in hospitalization (f.0001 / U);

7. Emergency notice of an infectious disease (form No. 001 / y).

8. The journal of observation of patients in the diagnostic chamber;

9. Journal of injury records;

10. The register of industrial injuries (communication to the production);

11. Journal of accounting for criminal injuries;

12. The register of alcohol surveys;

13. The journal of the account of infectious diseases

14. Journal of anti-rabies care accounting

15. The journal of emergency tetanus prophylaxis

16. Journal of accounting for pediculosis “On Strengthening Measures for the Prevention of Typhus and the Control of Pediculosis”);

17. Emergency notice (to be completed in case of infectious diseases);

18. The journal of medicine;

19. The journal of accounting for ambulatory manipulations;

20. Journal of accounting for ethyl alcohol 96˚ and a solution of medical antiseptic 70˚ (order of the Ministry of Health of the Russian Federation No. 245 of 08/30/91);

21. The dressing journal

22. Journal of ECG accounting in the receiving department;

23. The log of the temperature regime of the

refrigerator;

24. The journal of the transfer of information to the fire department;

25. Journal of accounting for the operation of quartz lamps.

The sister draws up medical documentation after examining the patient by a doctor, informing the need for inpatient treatment and obtaining consent to hospitalization.

In the “Hospital Patient Medical Record”, “Statistical Record of the Outpatient,” “Emergency Report of an Infectious Disease,” the sister fills in the title page.

The nurse's responsibilities also include filling out the title page of the medical history: passport, date and time of admission, diagnosis of the referring institution, statistical coupon for the patient.

All medical documentation is drawn up by the sister of the admission department after examining the patient by a doctor and deciding on his hospitalization in this medical institution, or on an outpatient basis.

The nurse measures the patient’s body temperature and writes information about the patient in the “Patient Admission (Hospitalization) and Denial of Hospitalization” Journal (form No. 001 / y): last name, first name, middle name of the patient, year of birth, insurance policy data, home address, from where and by whom it was delivered, the diagnosis of the referring institution (clinic, ambulance), the diagnosis of the emergency department, and also to which department it was sent. In addition to registering the patient in the "Patient Admission Register", the sister draws up the title page of the "Hospital Patient Medical Record" (form No. 003 / y). It records practically the same information about the patient as in the "Hospitalization Journal", records the insurance policy data (in the case of planned hospitalization, it is mandatory when taking the patient). Here you should write down the telephone number (home and office) of the patient or his immediate family.

Upon admission to the hospital, the nurse measures the patient’s body temperature, blood pressure, counts the pulse and respiratory rate. The nurse writes down the patient's last name, first name, middle name of the patient, year of birth, home address, who the patient was referred to, and preliminary or accurate diagnosis of the referring institution to which department the patient is referred to in the register of admissions of patients and refusals of hospitalization.

The nurse draws up the title page of the hospital patient’s medical record, that is, records:

Conclusion:

In conclusion, admission and discharge standardization and therefore length of stay are largely in our control. There is a significant opportunity to redesign patients’ pathways and improve patient flow to create important benefits for bed management and hospital throughput, which ultimately improve quality and the safeness of patient care.

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