1. Patient Identification
The patient's name and date of birth should be verified before any treatments or procedures are administered. This helps to ensure that the correct patient is receiving care and that any allergies or other medical information is known.
2. Assessment of the Patient
The patient's condition should be assessed in order to determine the best course of treatment. This may include taking vital signs, reviewing lab results, and assessing symptoms.
3. Medical History
It is important to review the patient's medical history in order to gain a better understanding of their current condition. This information can help to rule out any potential causes of the patient's symptoms.
4. Review of Systems
The patient's overall health should be examined, including any potential issues with their respiratory system, cardiovascular system, etc. This can help to identify any potential problems that may need to be addressed before discharge.
5. Physical Examination
A physical examination should be performed in order to assess the patient's current condition. This may include checking the patient's pulse, blood pressure, and temperature, as well as looking for any signs of injury or infection.
6. Diagnostic Studies
Diagnostic studies may be ordered in order to help diagnose the patient's condition. This could include x-rays, CT scans, or blood tests.
7. Treatment Plan and Orders
Once a diagnosis has been made, a treatment plan should be created with orders for any necessary medications or treatments. This will help to ensure that all of the necessary steps are taken for the patient's care.
8. Discharge Planning
Discharge planning begins once a diagnosis has been made and a treatment plan has been created. The goal of discharge planning is to ensure that the patient has everything they need before leaving the hospital, including a list of follow-up care instructions.
9. Follow-up Care Instructions
It is important for patients to follow up with their doctor after leaving the hospital. This could include returning for additional tests or appointments, taking medications as prescribed, etc.