out patient care in hospital which is sophesticated

regarding hospital settings

1. PREPARED BY, BINCY PAUL ASSESSMENT OF OUT PATIENT

2. DEFINITION

3. PURPOSE

4. POLICY ALL PATIENTS MUST BE RECEIVE COMPREHENCIVELY OUT PATIENT CINICAL ASSESSMENT UPON THEIR FIRST VISIT. EVERY PATIENT MUST BE REASSESSED PERIODICALLY IN EACH SUBSEQUENT VISITS CINICAL ASSESSMENT MUST BE CONDUCTED WITHIN OR EQUAL TO 30 DAYS ,ALONG WITH PRIOR TO ADMISSION AND OPD PROCEDURE. ANY CHANGES IN PATITENT CONDITION SINCE THE ASSESSMENT OR NO CHAGE ARE DOCUMENTED IN THE PATIENT MEDICAL RECORD AT THE TIME OF PRIOR TO ADMISSION AND OPD PROCEDURE. IF THE MEDICAL ASSESSMENT GREATER THAN 30 DAYS THE MEDICAL HISTORY AND PHYSICAL EXAMINATION UPDATED AND REPEATED RESPECTIVEY. CLINICAL ASSESSMENT OF THE PATIENT SHALL INCLUDE THE PRESENT COMPLAINT AND ADDITIONAL ASSESSMENT SHALL BE PERFORMED WHEN NEEDED

5. EACH SPECIALITY AND SUB SPECIALITY SHOULD DO THE MOST APPROPRIATE ASSESSMENT ACC. TO THE PATIENT OWN CLINICA CONDITION AND PROCEDURE. THE ASSESSMENT OF OUT PATIENT IS THE SHARED RESPONSIBLILTY OF PHYSICIAN AND NURSE AND THE FINDINGS OF ASSESSMENT MUST BE DOCUMENTED IN THE MEDICAL RECORED OR ELECTRONICALY.THE RELEVENT INFORMATION SHALL BE OBTAINED PATIENT OR THEIR FAMILY MEMBERS

6. COMPONENTS OF PATIENT ASSESSMENT

7. PHYSICIAN GENERAL ASSESSMENT

8. NURSING GENERAL ASSESSMENT

9. PEDIATRIC OUT PATIENT ASSESSMENT BIRTH HISTORY

10. OBSTRETICS AND GYNECOLOGICAL ASSEESSMENT PHYSICIAN ASSESSMENT ANTE NATAL CARE OBSTRETICS HISTORY MEDICAL AND SURGICAL HISTORY GENETIC OR TETROLOGY SCREENING GYNECOLOGY ASSESSMENT

11. ENDOSCOPY PHYSICIAN ASSESSMENT . PRE ANSTHESIA OR PRE SEDATION ASSESSMENT ANSTHESIA OR SEDATION ASSESSMENT NURSING ASSESSMENT PERIOPERATIVE ASSESSMENT POST OPERATIVE ASSESSMENT

12. GENERAL SURGERY

13. All the components of patient assessment shall be updated every 30 days. For follow up visit is done within a period of 30 days. Validated competencies needed for to performing nursing assessment

14. OPD PHYSICIAN OPD NURSE ASSEESSMENT:Initia l assessment must be conducted by the physician in their concerned department. All assessmment should be documented in the patient record Discus regarding the treatment,alternatives,risks and complication with pt INITIA L ASSESSMENT: ALL OUT PATIENT ASSESSMENT SHOULD BE INCLUDED THE ABOVE MENTIONED POINTS UPON THE FIRST VISIT REASSESSMENT It should be done on each visit according to the condition of the patient REASSESSMENT All opd reassessment in nsg must be done in every subsequent visit include the current complaint,any changes in the patient condition and pain assessment It shoud be done if any changes occure in pt condition.