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Existing Patient: Admit to Ward

Existing Patient: Admit to Ward. Option One Ward Administrator: Gives Family Form 2* To Family on Admission. Option Two Waiting List Manager: Sends Family Form 2* To Family for Admission or Pre-Admission Clinic. Family: Completes Family Form 2* on Admission or

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Existing Patient: Admit to Ward

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  1. Existing Patient: Admit to Ward Option One Ward Administrator: Gives Family Form 2* To Family on Admission Option Two Waiting List Manager: Sends Family Form 2* To Family for Admission or Pre-Admission Clinic Family: Completes Family Form 2* on Admission or Completes at Pre-Admission Clinic or Brings completed on Admission To Nurse • Ward Administrator: • Obtains Medical Record • Ensures in Medical Record: • Birth History • Immunisation and • Infectious Disease Record • - Patient Assessment Form Nurse or Health Care Assistant: Reviews Family Form 2* with Family Annotates Family Form 2 as necessary or Completes Family Form 2 by interviewing Family Files at bedside in Nursing Record N.B. Checked by supervising nurse Ward Administrator: Updates PiMS with changes noted on Family Form 2* Doctor or Other Competent Professional: Reviews Family Form 2 Commences Patient Assessment or Completes Patient Assessment Records on Patient Assessment Form Updates: Birth History Immunisation & Infectious Disease Record Nurse or Health Care Assistant: Commences Patient Assessment or Completes Patient Assessment Records on Patient Assessment Form Updates: Birth History Immunisation & Infectious Disease Record N.B. Checked by supervising nurse Doctor or Other Competent Professional: Writes Management Plan for Discharge Refers to Multi-disciplinary Team Records on Patient Assessment Form Multi-disciplinary Team: Annotates: Family Form 2* & Patient Assessment Form To Ward Administrator to update PiMS with any changes Nurse or Health Care Assistant: Negotiates care plan with Child & Family Refers to Multi-disciplinary Team N.B. Checked by supervising nurse * = Family Form 2 may be re-used for subsequent admissions for up to one year Option One: The ward administrator gives Family Form 2 to the family to complete on admission. The ward administrator checks the patient’s records to ascertain if there is an existing current Family Form 2. If the child has significantly changed, or the form has become illegible due to repeated admissions, the parents may be asked to complete a new form. The ward administrator will ask the nurse who is the most appropriate person to issue the form. It may be issued by nurses, health care assistants or ward administrators. The nurse will use their professional judgment to decide if the patient or their parents should be asked to complete Family Form 2 or if they should be interviewed. When an existing patient is to be admitted to a ward, the following process takes place…

  2. Existing Patient: Admit to Ward Option One Ward Administrator: Gives Family Form 2* To Family on Admission Option Two Waiting List Manager: Sends Family Form 2* To Family for Admission or Pre-Admission Clinic Family: Completes Family Form 2* on Admission or Completes at Pre-Admission Clinic or Brings completed on Admission To Nurse • Ward Administrator: • Obtains Medical Record • Ensures in Medical Record: • Birth History • Immunisation and • Infectious Disease Record • - Patient Assessment Form Nurse or Health Care Assistant: Reviews Family Form 2* with Family Annotates Family Form 2 as necessary or Completes Family Form 2 by interviewing Family Files at bedside in Nursing Record N.B. Checked by supervising nurse Ward Administrator: Updates PiMS with changes noted on Family Form 2* Doctor or Other Competent Professional: Reviews Family Form 2 Commences Patient Assessment or Completes Patient Assessment Records on Patient Assessment Form Updates: Birth History Immunisation & Infectious Disease Record Nurse or Health Care Assistant: Commences Patient Assessment or Completes Patient Assessment Records on Patient Assessment Form Updates: Birth History Immunisation & Infectious Disease Record N.B. Checked by supervising nurse Doctor or Other Competent Professional: Writes Management Plan for Discharge Refers to Multi-disciplinary Team Records on Patient Assessment Form Multi-disciplinary Team: Annotates: Family Form 2* & Patient Assessment Form To Ward Administrator to update PiMS with any changes Nurse or Health Care Assistant: Negotiates care plan with Child & Family Refers to Multi-disciplinary Team N.B. Checked by supervising nurse * = Family Form 2 may be re-used for subsequent admissions for up to one year Option Two: The waiting list manager sends an admission date to the patient/parents. This date is normally negotiated with the patient/parents. Some specialists have pre-admission clinics. If this is the case, the waiting list manager will send an appointment for a pre-admission clinic to the patient/parents. This appointment may also have been negotiated. The waiting list manager will send Family Form 2 to the patient/parents for them to complete and bring to the pre-admission clinic. The family would complete Family Form 2 and give it to the nurse on admission or at the pre-admission clinic. Communication support needs must be assessed to enable full participation in the assessment process and a complete assessment to be made. The patient should be actively engaged whenever possible, encouraged to provide information for themselves, and to be involved in the assessment process.

  3. Existing Patient: Admit to Ward Option One Ward Administrator: Gives Family Form 2* To Family on Admission Option Two Waiting List Manager: Sends Family Form 2* To Family for Admission or Pre-Admission Clinic Family: Completes Family Form 2* on Admission or Completes at Pre-Admission Clinic or Brings completed on Admission To Nurse • Ward Administrator: • Obtains Medical Record • Ensures in Medical Record: • Birth History • Immunisation and • Infectious Disease Record • - Patient Assessment Form Nurse or Health Care Assistant: Reviews Family Form 2* with Family Annotates Family Form 2 as necessary or Completes Family Form 2 by interviewing Family Files at bedside in Nursing Record N.B. Checked by supervising nurse Ward Administrator: Updates PiMS with changes noted on Family Form 2* Doctor or Other Competent Professional: Reviews Family Form 2 Commences Patient Assessment or Completes Patient Assessment Records on Patient Assessment Form Updates: Birth History Immunisation & Infectious Disease Record Nurse or Health Care Assistant: Commences Patient Assessment or Completes Patient Assessment Records on Patient Assessment Form Updates: Birth History Immunisation & Infectious Disease Record N.B. Checked by supervising nurse Doctor or Other Competent Professional: Writes Management Plan for Discharge Refers to Multi-disciplinary Team Records on Patient Assessment Form Multi-disciplinary Team: Annotates: Family Form 2* & Patient Assessment Form To Ward Administrator to update PiMS with any changes Nurse or Health Care Assistant: Negotiates care plan with Child & Family Refers to Multi-disciplinary Team N.B. Checked by supervising nurse * = Family Form 2 may be re-used for subsequent admissions for up to one year • The ward administrator obtains and ensures the medical record contains: • The Birth History Form and the Immunisation & Infectious Disease Record which are filed in the Birth, Immunisation & Family Form 1 section. • The Patient Assessment Form (PAF) which is filed in the Clinical Records – Medical section. The nurse reviews the information provided by the parents/patient on Family Form 2 and completes any outstanding aspects. The form is filed in the Nursing Record at the bedside. The patient should be actively engaged whenever possible, encouraged to provide information for themselves, and to be involved in the assessment process. The doctor also reviews the information provided by the parents/patient on family Form 2 to inform the assessment of the patient.

  4. Existing Patient: Admit to Ward Option One Ward Administrator: Gives Family Form 2* To Family on Admission Option Two Waiting List Manager: Sends Family Form 2* To Family for Admission or Pre-Admission Clinic Family: Completes Family Form 2* on Admission or Completes at Pre-Admission Clinic or Brings completed on Admission To Nurse • Ward Administrator: • Obtains Medical Record • Ensures in Medical Record: • Birth History • Immunisation and • Infectious Disease Record • - Patient Assessment Form Nurse or Health Care Assistant: Reviews Family Form 2* with Family Annotates Family Form 2 as necessary or Completes Family Form 2 by interviewing Family Files at bedside in Nursing Record N.B. Checked by supervising nurse Ward Administrator: Updates PiMS with changes noted on Family Form 2* Doctor or Other Competent Professional: Reviews Family Form 2 Commences Patient Assessment or Completes Patient Assessment Records on Patient Assessment Form Updates: Birth History Immunisation & Infectious Disease Record Nurse or Health Care Assistant: Commences Patient Assessment or Completes Patient Assessment Records on Patient Assessment Form Updates: Birth History Immunisation & Infectious Disease Record N.B. Checked by supervising nurse Doctor or Other Competent Professional: Writes Management Plan for Discharge Refers to Multi-disciplinary Team Records on Patient Assessment Form Multi-disciplinary Team: Annotates: Family Form 2* & Patient Assessment Form To Ward Administrator to update PiMS with any changes Nurse or Health Care Assistant: Negotiates care plan with Child & Family Refers to Multi-disciplinary Team N.B. Checked by supervising nurse * = Family Form 2 may be re-used for subsequent admissions for up to one year The nurse, health care assistant, doctor or other health care professional will commence the assessment of the patient and records the assessment on the Patient Assessment Form (PAF). The Birth History the Immunisation & Infectious Disease Records are updated as required. The ward administrator records any changes from Family Form 2 onto PiMS. Different professionals, according to their competence and confidence, may complete the assessment of the patient. Each section of the form has a box to be completed that illustrates who completed that part of the assessment. Any additional admission assessment of the patient by another health care professional is to be recorded on the appropriate part of PAF. All entries on the Patient Assessment Form must be signed and dated according to hospital policy.

  5. Existing Patient: Admit to Ward Option One Ward Administrator: Gives Family Form 2* To Family on Admission Option Two Waiting List Manager: Sends Family Form 2* To Family for Admission or Pre-Admission Clinic Family: Completes Family Form 2* on Admission or Completes at Pre-Admission Clinic or Brings completed on Admission To Nurse • Ward Administrator: • Obtains Medical Record • Ensures in Medical Record: • Birth History • Immunisation and • Infectious Disease Record • - Patient Assessment Form Nurse or Health Care Assistant: Reviews Family Form 2* with Family Annotates Family Form 2 as necessary or Completes Family Form 2 by interviewing Family Files at bedside in Nursing Record N.B. Checked by supervising nurse Ward Administrator: Updates PiMS with changes noted on Family Form 2* Doctor or Other Competent Professional: Reviews Family Form 2 Commences Patient Assessment or Completes Patient Assessment Records on Patient Assessment Form Updates: Birth History Immunisation & Infectious Disease Record Nurse or Health Care Assistant: Commences Patient Assessment or Completes Patient Assessment Records on Patient Assessment Form Updates: Birth History Immunisation & Infectious Disease Record N.B. Checked by supervising nurse Doctor or Other Competent Professional: Writes Management Plan for Discharge Refers to Multi-disciplinary Team Records on Patient Assessment Form Multi-disciplinary Team: Annotates: Family Form 2* & Patient Assessment Form To Ward Administrator to update PiMS with any changes Nurse or Health Care Assistant: Negotiates care plan with Child & Family Refers to Multi-disciplinary Team N.B. Checked by supervising nurse * = Family Form 2 may be re-used for subsequent admissions for up to one year The doctor or any other competent professional writes a management plan to enable discharge in the PAF. The patient may also be referred to the multi-disciplinary team. The nurse identifies and negotiates the plan of care with the patient and their parents. This is recorded on the patients care plan. Concerns arising from the assessment of the patient should be communicated to the person responsible for the patient’s admission and treatment. The patient should be actively engaged whenever possible, encouraged to provide information for themselves, and to be involved in the assessment process.

  6. Existing Patient: Admit to Ward Option One Ward Administrator: Gives Family Form 2* To Family on Admission Option Two Waiting List Manager: Sends Family Form 2* To Family for Admission or Pre-Admission Clinic Family: Completes Family Form 2* on Admission or Completes at Pre-Admission Clinic or Brings completed on Admission To Nurse • Ward Administrator: • Obtains Medical Record • Ensures in Medical Record: • Birth History • Immunisation and • Infectious Disease Record • - Patient Assessment Form Nurse or Health Care Assistant: Reviews Family Form 2* with Family Annotates Family Form 2 as necessary or Completes Family Form 2 by interviewing Family Files at bedside in Nursing Record N.B. Checked by supervising nurse Ward Administrator: Updates PiMS with changes noted on Family Form 2* Doctor or Other Competent Professional: Reviews Family Form 2 Commences Patient Assessment or Completes Patient Assessment Records on Patient Assessment Form Updates: Birth History Immunisation & Infectious Disease Record Nurse or Health Care Assistant: Commences Patient Assessment or Completes Patient Assessment Records on Patient Assessment Form Updates: Birth History Immunisation & Infectious Disease Record N.B. Checked by supervising nurse Doctor or Other Competent Professional: Writes Management Plan for Discharge Refers to Multi-disciplinary Team Records on Patient Assessment Form Multi-disciplinary Team: Annotates: Family Form 2* & Patient Assessment Form To Ward Administrator to update PiMS with any changes Nurse or Health Care Assistant: Negotiates care plan with Child & Family Refers to Multi-disciplinary Team N.B. Checked by supervising nurse * = Family Form 2 may be re-used for subsequent admissions for up to one year Members of the multi-disciplinary team record any additional assessment of the patient on Family Form 2 and the PAF as appropriate. The Ward Administrator will record any additional personal data onto PiMS. You have now reached the end of this demo

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