BURAIDAH C ENTRAL H OSPITAL

Department: NURSING SERVICE Policy Index: PP-BCH-NR/GNR-027-DPPE Title: ASSESSMENT AND RE- ASSESSMENT OF PATIENT Effective Date: Applies to: 01-01-1432 H All Nursing Staff New

B. C. H.

DPP

Replace Number : XXXXX

Number of Pages: 3 Review Due: 01-12-1433 H

1. PURPOSE:

1.1 To describe the process by which initial patient assessment and re-assessment are done
by the members of health care team.

1.2 To provide the necessary information to plan, coordinate, delegate and supervise the care
of patient.

2. DEFINITION :
2.1 It is a process of gathering and documenting information concerning the health conditions, problems / needs of a patient, re-evaluating / re-appraisal of the health conditions / needs as deemed necessary.

3. POLICY: 3.1 To assess patients for actual or potential health care problems or needs.The assessment is conducted by members of the health care team through an interdisciplinary and collabo rative approach to ensure continuity of care in compliance with CBAHI standard. 3.2 Each admitted patients initial assessment is conducted within a time frame identified by the service. Re-assessment occurs throughout the care process and the purposes. Key re assessment point and / or time intervals are defined . 3.3 An assessment is performed by each discipline within its scope of practice, applicable re gulation.
Prepared by: Magdalena Venzuela Nurse Supervisor Approved by: Ahmad Abdulla Al-Omar Hospital Director Page Number: 1/3 Approval Stamp

Form Index: BCH-QM-009-E

3.4 A registered nurse shall assess the patients need for nursing care in all setting where nursing care is provided based on individual patient requirements. 3.5 Care decisions will be based upon data and information gathered in assessment and re assessment. This data will be utilized in prioritizing patient care needs and selecting a ppropriate interventions.

4. PROCEDURES: 4.1 Initial assessment will be performed by a registered nurse and it includes the following : 4.1.1 Physical Status. 4.1.2 Psychological Status. 4.1.3 Neurological Status. 4.1.4 Social Status. 4.1.5 Cultural Status. 4.1.6 Nutritional Status. 4.1.7 Functional Screen 4.1.8 Skin Assessment 4.1.9 Pain assessment. 4.1.10 Environmental / Functional needs. 4.1.11 Risk for Injury ( Fall Risk Assessment ). 4.2 Assessment for Infants, Children and Adolescent patient includes : 4.2.1 Emotional, cognitive, communication, educational social and daily activity needs. 4.2.2 Immunization status. 4.2.3 Family expectations for and involvement in the care and treatment of the patient. 4.2.4 Developmental age, height and weight. 4.2.5 Effect of the family or guardian on the patients condition and vice versa. 4.3 Family involvement in the admission process will be facilitated by the admitting registered nurse whenever possible. 4.4 The admission assessment will be documented on the admission data base. The scope and intensity of the assessment will be determined by : 4.4.1 Patients diagnosis. 4.4.2 Care setting to which the patient is admitted. 4.4.3 Patients desire for care and interventions. 4.4.4 Patients response to treatments, procedures and interventions. 4.5 Re-assessment : 4.5.1 The patient will be re-assessed : 4.5.1.1 To determine response to treatment / procedures. 4.5.1.2 When there is a significant change in condition. 4.5.1.3 When there is a change in the level of care. 4.5.1.4 Minimally every shift and at unit specified intervals related to the care setting and course of treatment. 4.5.2 Documentation of the re-assessment will be located on the unit specific nursing flowsheet and / or progress note. 4.5.3 Re-assessment are completed by registered nurse, in addition, information for re-assessment will be gathered from patients, families other health care professionals and physician input. 4.6 Integration of Assessment And Re-assessment : 4.6.1 Datas gathered from the various clinical disciplines is integrated into the patient
Policy Number: PP- BCH-NR/GNR-027-DPP-E Title: Page Number : ASSESSMENT AND RE - ASSESSMENT OF PATIENT 2/3 Approval Stamp

Form Index: BCH-QM-009-E

medical record to assure that the patient needs are appropriately identified and service is effectively coordinated. 4.6.2 The patient plan of care is based on the integration of assessment and prioritization of the patients problem identified by members of the health team.

5. FORMS AND EQUIPMENTS : 5.1 Admission Assessment Form, BCH.

6. REFERENCES : 6.1 Windows Internet Explorer 6.2 Wikipedia.

7. APPENDIX : 7.1 N/A.

8. APPROVAL :

Name Prepared by: Magdalena Venzuela 1. Abdulla Obeid Al-Harby Reviewed by: 2.Ehab El Husseiny Ibrahim 3. Manae Al- Belaihy Approved by: Ahmad Abdulla Al-Omar

Position Nurse Supervisor Nursing Director QM Director Medical Director Hospital Director

Signature

Date
22-11-1431 H 24-11-1431 H 29-11-1431 H 29-11-1431 H 01-12-1431 H

Policy Number: PP- BCH-NR/GNR-027-DPP-E

Title: Page Number : ASSESSMENT AND RE - ASSESSMENT OF PATIENT 3/3

Approval Stamp

Form Index: BCH-QM-009-E

Policy Number: PP- BCH-NR/GNR-027-DPP-E

Title: Page Number : ASSESSMENT AND RE - ASSESSMENT OF PATIENT 4/3

Approval Stamp

Form Index: BCH-QM-009-E