天坛医院

Inpatient

Patient admission process and quality control standards

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I. Process

1. After receiving the notification of patient admission, the doctor in charge will identify the bed, inform the charge nurse to receive the admitted patients, and place them appropriately and reasonably to avoid long waiting times for patients.

2. The charge nurses take the initiative to introduce themselves and carefully verify the patient's hospitalization card and wristband information with the supervisor nurse. After confirming the correct information, nurses should put the patient's wristband on their wrist and adequately place the patient in the hospital.

3. The charge nurse leads the patient to the bedside and assists in placing the items brought. The nurse shows the admission introduction, including ward environment, facilities, doctor and nurse in charge, working hours, meal service, visiting companionship, safety management, and other rules and regulations. The nurse learns patient needs, actively answer patient questions, and assists.

4. Measure and record the patient's consciousness, body temperature, blood pressure, pulse, respiration, weight, height, and other data. At the same time, observe the condition of acute and critical patients, check the pipeline and skin and other states, and record accurately.

5. Nursing first consults and assesses the patient's vital signs, state of consciousness, self-care ability, skin, diet, sleep, cleanliness, potential nursing risks, psychological and social conditions, etc. Ask or check whether the patient has loose teeth, wears dentures, or has an oral disease, and make nursing records.

6. Provide nursing care measures such as primary care, observation of condition, safe care, and psychological support to patients according to the assessment results. Inform patients and families of existing nursing risks, provide nursing education, and promptly communicate with the supervising physician about the patient's condition.

7. Follow medical advice to complete specimen collection and examination appointments in a planned and timely manner and assist physicians in implementing timely and effective therapeutic measures.

8. Neonates, acute and critical cases, and special patients must be treated promptly according to the patient's specific situation and medical advice.

9. Create nursing record sheets, assessment sheets, etc., fill in relevant items according to the "Quality Control Standards for Nursing Document Writing," and perform key condition handover.

II. Quality control standards

1. The bed unit and related items are adequately prepared.

2. Serve actively and enthusiastically, use standardized service language, and do not delay in receiving medical treatment.

3. Transport the patient to the designated bed and place the patient appropriately.

4. Monitoring vital signs is standardized and recorded in a timely and accurate manner.

5. Detailed and comprehensive admission orientation and preaching.

6. Nursing assessments are accurate, and nursing measures are developed to be relevant and implemented in depth.

7. Satisfactory service evaluation by patients and families.

8. Nursing records meet the requirements of the Quality Control Standards for Nursing Document Writing.

9. Handover is detailed, accurate, and comprehensive.

10. Timely management of patients with acute and critical illnesses.


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