admissions, transfers, and discharge chapter 9

Unit 1 Safe, effective Care environment

Section Management of Care

Chapter 9 Admissions, Transfers, and Discharge

Overview
●● Responsibilities of nurses include ensuring continuity of care throughout the processes of
admission, transfers, and discharge. Client information is organized and kept in a logical
order for easy dissemination between nurses and other members of the health care team as
clients are admitted, transferred, and discharged.

●● The admission assessment provides baseline data to use in the development of the nursing
care plan. Baseline data are compared with future assessments to monitor client status and
response to treatment.

●● Many clients experience anxiety and fear of the unknown at the time of admission to
the hospital or health care facility. The feeling of independence and self-identity may be
lost. Children may experience separation anxiety if parents are not present during the
hospitalization. When nurses recognize clients’ concerns and provides respectful, culturally
sensitive care, the clients’ experiences will be more positive.

●● Discharge planning is an interdisciplinary process that is started by the nurse at admission.

Nurses conduct discharge planning with both the client and client’s family for optimal
results.

●● Nurses establish the ability of clients to participate in the admission assessment. Clients
in distress or with mental status changes may need to have a family member provide
necessary information.

●● Nurses begin establishing the therapeutic relationship with clients and families during the
admission process.

●● Nurses promote professional communication between health care providers.

●● Nurses use the nursing process as a guide to plan teaching and interventions for clients
during discharge.

Admission Process
●● Equipment

◯◯ Prior to arrival of the client, take necessary equipment into the room. This should
include appropriate documentation forms, equipment to obtain vital signs, pulse
oximeter, and hospital attire for the client.

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●● Procedure

◯◯ Introduce yourself to the client.

◯◯ Explain the roles of other nursing staff.
◯◯ If in a semiprivate room, introduce the client to his roommate.
◯◯ Provide hospital attire and assist the client as necessary.
◯◯ Position the client comfortably.
◯◯ Apply the client’s identification bracelet and allergy band, if needed.
◯◯ Provide facility-specific brochures and informational material.
◯◯ Provide information about advance directives.
◯◯ Document the client’s advance directives status in the medical record. (Place a copy in
the medical record if it is available.)
◯◯ Assess/collect the following data:
■■ Baseline data – Vital signs, height, weight, allergy status, home medications
■■ Biographical information on the client
■■ The client’s reason for seeking health care
■■ Present illness and symptoms
■■ Health history of:
☐☐ Current illness
☐☐ Current medications (prescription and over-the-counter)
☐☐ Prior illnesses, chronic diseases
☐☐ Surgeries
☐☐ Previous hospitalizations
☐☐ Other relevant data
■■ Family history (hypertension, cancer, heart disease, diabetes mellitus)
■■ Psychosocial assessment
☐☐ Alcohol, tobacco, drug, and caffeine use
☐☐ History of mental illness
☐☐ History of abuse or homelessness
☐☐ Home situation/significant others
■■ Nutrition
☐☐ Current diet, any chewing or swallowing problems
☐☐ Recent weight gain/loss

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■■ Spiritual health/quality-of-life concerns:

☐☐ Religion
☐☐ Advance directives/living will
■■ Review of systems
■■ Safety assessments:
☐☐ History of falls
☐☐ Sensory impairments (vision, hearing)
☐☐ Use of assistive devices (walker, cane, crutches, or wheelchair)
■■ Discharge information
☐☐ Family members in the home
☐☐ Transportation for discharge
☐☐ Any relevant phone numbers
☐☐ Medical equipment needs at home
◯◯ Inventory any personal items brought by the client to the facility.
■■ Items to be inventoried usually include clothing, jewelry, money, credit cards,
assistive devices (hearing aids, cane, dentures), medications, and religious articles.
■■ Document how items are disposed of to include leaving items at the bedside,
storing items in the client’s room closet, sending items home with family
members, and locking up valuables in the facility’s safe. The client should be
discouraged from keeping valuables at the bedside.
◯◯ Orient the client and family to the room/facility. Share information with the client,
including:
■■ Call light operation
■■ Electric bed operation
■■ Telephone services/television controls
■■ Overhead lighting operation
■■ Smoking policy
■■ Restroom locations
■■ Waiting areas
■■ Meal times
■■ Usual time for physician visits
■■ Dining/vending services
■■ Visiting policies

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Transfer and Discharge Process

●● Indications for Transfer and Discharge

◯◯ The client’s level of care has changed. For example, health status has improved so that
intensive care is no longer needed.
◯◯ Another setting is required to provide necessary care for the client. For example, the
client is transferred from the medical unit to the surgical suite.
◯◯ The facility does not offer the type of care the client now requires. For example, after
the acute phase of a stroke, the client now requires care in a skilled facility.
◯◯ The client no longer needs inpatient care and is ready to return home.
●● Discharge Planning

◯◯ This should begin when the client is admitted to the facility, unless the facility is to be
the client’s permanent residence (long-term care).
◯◯ Assess whether or not the client will be able to return to his previous residence.
◯◯ Determine whether or not the client will need and/or have someone to assist him at
home.
◯◯ Assess the residence to see if adaptations or specific equipment are required to
accommodate the client prior to discharge.
◯◯ Make a referral to the social worker to arrange for community services required by the
client at discharge.
◯◯ Communicate client health status and needs to community service providers.
◯◯ The client’s provider provides written documentation that the client may be
discharged. Some clients leave the facility prior to being discharged. A client who
is legally competent has the legal right to leave the facility at any time. The nurse
notifies the client’s provider, and if possible, has the client sign the proper forms and
provides discharge teaching.
●● Discharge Education

◯◯ Discharge instructions are discussed with the client and written down for the client to
have a copy at home.
◯◯ Instructions should use clear, concise language that the client will understand.

View Media Supplement: Discharge Teaching (Video)

◯◯ Standards for discharge education include:

■■ Identifying safety concerns for the client at home.
■■ Reviewing signs and symptoms of potential complications and when to contact
either emergency care or the provider.
■■ Providing the phone number of the provider.

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■■ Providing names and phone numbers of community resources that will give care
at the client’s residence.
■■ Step-by-step instructions for performing continuing treatments, such as dressing
changes.
■■ Dietary restrictions and guidelines, including those that pertain to medication
administration.
■■ Amount and frequency of therapies the client is to perform to support continued
independence at home.
■■ Directions on how to take medications and explanations for why each one is
being prescribed.
●● Equipment

◯◯ Items to be transferred/discharged with the client include:

■■ The client’s personal belongings at the bedside (flowers, books, clothing, personal
care items)
■■ Valuables from the safe (if leaving the facility)
■■ Medications (especially those belonging to the client or those that cannot be
returned to the pharmacy for credit)
■■ Assistive devices
■■ Medical records or a transfer form
●● Procedure

◯◯ Responsibilities of the nurse include:

Transferring/Discharging the Client Receiving the Transferred Client
• On the day/time of transfer, confirm that • Have any specialized equipment ready.
the receiving facility/unit is expecting the • If appropriate, inform the client’s
client and that the room/bed is available. roommate of the impending admission/
• Communicate the time the client will transfer.
transfer to the receiving facility/unit. • Inform other health care team members of
• Complete documentation (medical the client’s arrival and needs.
records, transfer form). • Meet with the client and family on arrival
• Give a verbal transfer report in person or to complete the admission process and
via telephone. orient the client/family to the new facility/
• Confirm the mode of transportation unit.
the client will be using to complete the • Assess how the client tolerates the transfer.
transfer/discharge (cart, wheelchair, • Review transfer documentation.
ambulance). • Implement appropriate nursing
• Make sure the client is dressed interventions in a timely manner.
appropriately if going outside the facility.
• Account for all of the client’s valuables.

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◯◯ Transfer documentation – Transfers within a facility usually require that the chart and
other documentation accompany the client. Information should include:
■■ Client medical diagnosis and care providers
■■ Client demographic information
■■ Overview of the client’s health status, plan of care, and recent progress
■■ Any alterations that may precipitate an immediate concern
■■ Notification of any assessments or client care that will be needed within the next
few hours
■■ Most recent set of vital signs and medications including PRN given
■■ Allergies
■■ Diet and activity orders
■■ Presence of or need for special equipment or adaptive devices (oxygen, suction,
wheelchair)
■■ Advance directives and emergency code status
■■ Family involvement in care and health care proxy if applicable
◯◯ Discharge documentation – Each client record should be closed with a discharge
summary to include discharge instructions. Nursing documentation at discharge
includes:
■■ Type of discharge (ordered by the provider, against medical advice [AMA])
■■ Actual date and time of discharge, who went with the client, and how the client
was transported (wheelchair to a private car, stretcher to an ambulance)
■■ Where the client was discharged to (home, long-term care facility)
■■ A summary of the client’s condition at discharge (steady gait, ambulating
independently, in no apparent distress)
■■ A description of any unresolved difficulties and procedures for follow-up
■■ Disposition of valuables, client’s medications brought from home, and/or
prescriptions
■■ A copy of the client’s discharge instructions
◯◯ Discharge instructions – The client’s discharge instructions should include:
■■ Step-by-step instructions for procedures to be done at home
■■ Precautions to take when performing procedures or administering medications
■■ Signs and symptoms of complications that should be reported
■■ Names and numbers of health care providers and community services the client/
family can contact
■■ Plans for follow-up care and therapies

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Chapter 9: Admissions, Transfers, and Discharge

Application Exercises

1. Which of the following is a primary source for client data during the admission process?

A. The client
B. The family
C. The emergency department staff
D. The provider

2. A nurse is performing an admission assessment for an older adult client. After gathering the
assessment data and performing the review of systems, which of the following actions is a priority for
the nurse?

A. Orient the client to his room.

B. Conduct a client care conference.
C. Review the client’s medical orders.
D. Develop a plan of care.

3. When transferring a client with a fractured radius from the emergency department to the orthopedic
unit, which of the following information should the nurse include in the transfer report?

A. The name of the client’s partner

B. Where the client was when the fracture occurred
C. The time received and the amount of the last pain medication dose
D. The client’s occupation

4. Which of the following information should be included in a transfer report? (Select all that apply.)
The client is alert and oriented.
The client does not like spinach.
The client has an allergy to shellfish.
The client needs morphine every 4 hr.
The client has two cats at home.

5. Who is responsible for making sure all documentation is finished prior to transfer of a client to a new
health care facility?

A. Provider
B. Certified nursing assistant
C. Nurse transferring the client
D. Social worker who set up the transfer

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6. When does discharge planning begin in an acute care facility?

A. Two days from discharge

B. The day of discharge
C. When the nurse gets the order for discharge
D. When the client is admitted

7. What data should be included in a client’s discharge summary? (Select all that apply.)
Interventions performed by the physical therapist 2 days ago
Where the client needs to go for follow-up care
Instructions given on medication and treatments
Summary of the client’s condition at time of discharge
The phone number of the home health agency that will be making home visits

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Chapter 9: Admissions, Transfers, and Discharge

Application Exercises Answer Key

1. Which of the following is a primary source for client data during the admission process?

A. The client
B. The family
C. The emergency department staff
D. The provider

The client is a primary source of data and is usually the best source of information. The
family, the emergency department staff, and the provider will have valuable information to
contribute, but only the client is a primary source for information.

NCLEX® Connection: Health Promotion and Maintenance: Techniques of Physical

Assessment

2. A nurse is performing an admission assessment for an older adult client. After gathering the
assessment data and performing the review of systems, which of the following actions is a priority for
the nurse?

A. Orient the client to his room.

B. Conduct a client care conference.
C. Review the client’s medical orders.
D. Develop a plan of care.

The greatest risk to this client is injury from unfamiliar surroundings; therefore, the priority
action is to orient the client to the room. Before the nurse leaves the room, the client should
know how to use the call light and other equipment at the bedside. Conducting a client
care conference, reviewing the client’s medical orders, and developing a plan of care are all
important, but are not the priority action for the nurse at this time.

NCLEX® Connection: Management of Care: Continuity of Care

3. When transferring a client with a fractured radius from the emergency department to the orthopedic
unit, which of the following information should the nurse include in the transfer report?

A. The name of the client’s partner

B. Where the client was when the fracture occurred
C. The time received and the amount of the last pain medication dose
D. The client’s occupation

It is important for the receiving nurse to know when and how much pain medication the
client last received. The other information is not relevant to his immediate care at this time.

NCLEX® Connection: Management of Care: Continuity of Care

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4. Which of the following information should be included in a transfer report? (Select all that apply.)
X The client is alert and oriented.
The client does not like spinach.
X The client has an allergy to shellfish.
X The client needs morphine every 4 hr.
The client has two cats at home.

The client’s level of consciousness, allergies, and need for pain medication are relevant
to evaluating the client’s health status and maintaining safety and comfort. Personal
preferences, such as the client not liking spinach and keeping cats as pets, may sometimes
be helpful, but neither is clinically significant for a transfer report.

NCLEX® Connection: Management of Care: Continuity of Care

5. Who is responsible for making sure all documentation is finished prior to transfer of a client to a new
health care facility?

A. Provider
B. Certified nursing assistant
C. Nurse transferring the client
D. Social worker who set up the transfer

The nurse who is transferring the client needs to complete the required documentation. The
provider may write transfer orders for the client at the new facility. The certified nursing
assistant can assist with the physical transfer of the client or belongings, but she cannot
complete the transfer documentation. The social worker may assist in finding placement for
the client, but the forms need to be completed by the nurse.

NCLEX® Connection: Management of Care: Continuity of Care

6. When does discharge planning begin in an acute care facility?

A. Two days from discharge

B. The day of discharge
C. When the nurse gets the order for discharge
D. When the client is admitted

Discharge planning needs to begin when the client is admitted. Due to short hospital
stays, this will allow for the maximum amount of time available to make all necessary
arrangements and provide any necessary teaching.

NCLEX® Connection: Management of Care: Continuity of Care

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 admissions, transfers, and discharge

7. What data should be included in a client’s discharge summary? (Select all that apply.)
Interventions performed by the physical therapist 2 days ago
X Where the client needs to go for follow-up care
X Instructions given on medication and treatments
X Summary of the client’s condition at time of discharge
X The phone number of the home health agency that will be making home
visits

All of the above information, with the exception of interventions performed by the physical
therapist 2 days ago, is pertinent information that should be included in the discharge
summary. The physical therapist should have written a progress note on the day of care.

NCLEX® Connection: Management of Care: Continuity of Care

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