In this session, you will learn about reception of the patient in the hospital and recording personal and medical data of the patient. You will also study primary medical examination performed by IPD and OPD Department. At the end of the session, you will acquire the knowledge of the role of GDA in preliminary observation and admission of patient in the hospital.
Admission of patient means, allowing a patient to stay in the hospital for observation, investigations and treatment of the disease he is suffering from.
The admission of a patient to a hospital can be either emergency or routine. The emergency admission means that the patients are admitted in acute conditions requiring immediate treatment, e.g. clinets with heart attack, accidents, acute appendicitis, posionings, labour pains, diarrhoea, dysentery, hyperpyrexia, haematemesis, dyspnoea , shock etc. in emergency admission, every moment is precious. Therefore, the patients should be admitted to the casualty department or emergency ward and the immediate treatment is initiated to save the life or the patient.
Routine admission means that the patients are admitted for investigations and planned treatments and surgeries, e.g. the patients with hypertension, diabetes chronic appendicitis, jaundice, hernia, cirrhosis of liver, chronic renals failure, nephritis, bronchitis etc.
RECEPTION OF THE PATIENT
Since the first impression are likely to be vivid and not easily erased. It is specially important that the patient and those who are with him receive the most courteous attention and care in the outpatient department. The personnel in the admitting department should greet him and make him at ease. In emergency conditions, no time should be lost to initiate the treatment. The manner in which the nurse and the physician receive and treat the patient is after all most important aspect of his reception and admission to the hospital.
RECORDING OF PERSONAL AND MEDICAL DATA
The clerk in the record section is responsible for recording certain data that are essential for identification of the patient. He question the patient or his family members to get the name, address, age, sex, religion, occupation, income, marital status, the business address, telephone number and name and address of the nearest relative, if any. He records it in the outpatient record. patients too ill to answer questions should be admitted immediately and the necessary data is supplied by the family or friends at the first opportunity.
In order to assign the patient the proper service and to give the immediate care needed, it is necessary to know the diagnosis or suspected diagnosis. The duration of illness, the name of the physician to whom he is referred to. This can be obtained by appropriate questioning of the patient.
The patient is given the outpatient number which he keeps with him for the future reference. He is given the necessary direction how to proceed further.
MEDICAL EXAMINATION
A detailed social and medical history of the patient is taken by the physician and is recorded. The patient’s temperature, pulse, respirations and blood pressure etc., are recorded. A through examination of the body from head to foot will reveal any deviation from normal structure and functions which will help the physician to diagnose the disease. The necessary investigations such as X-ray, laboratory test etc., are also made to diagnose the disease and to prescribe the treatment.
Relatives of friends who bring the patient to the hospital often want to meet, and talk to the physician about the patient.
The GDA should make arrangement for relatives to meet the physician as far as facilities of the institution allow.
INPATIENT DEPARTMENT( I.P.D)
The patients who are suffering from mild ailments are sent home with necessary treatment. Others are admitted to the hospital for further investigations and treatment.
Transporting the patient from OPD to IPD
Patients who are not very ill and are allowed to walk are escorted to the clinical division by a GDA or an attender. Wheel chairs should be available for those who are too sick, weak or lame to walk.
Patient who are brought to the hospital in the ambulance should be carried to their respective wards on the stretchers. A seriously ill patient should never be left in the hands of a untrained personnel. A female patient should never be left with a male attender.
RECEPTION OF THE PATIENT BY THE GDA
The GDA admitting the patient should introduce herself and greet the patient and his relatives with friendliness, making special effort to establish and effective GDA – patient relationship. Her behavior should be such that she gains the confidence and cooperation of the patient.
If the patient is very sick, she/he should put him to bed immediately. The relatives are treated with courtesy and are given special consideration in this trying period, consistent with the hospital regulations. The patient who is not very ill is allowed to move about and can be taken for a round in the ward. Introduce the other patients to him and vice versa, and also with nursing personnel working in the ward. Orientate the patient to the whole ward, duty room, the toilet rooms and the unit prepared for him.
PRELIMINARY OBSERVATION OF THE PATIENT
The first few moments of contact with a new patient will reveal a great deal about him to an observant GDA. The patient’s general facial expression will denote not only his emotional reactions but the presence of pain or fatigue. Any decolouration of the skin such as jaundice or cyanosis, facial paralysis, nourishment etc. is noted without difficulty. Further observations can be made while giving care to the patient.