Dr. K.G.

Deshpande Memorial Centre Doc No KGDMCH/AAC/03

Issue No 01
for Open Heart Surgery, Thoracic &
Rev No. 00
Vascular Surgery
Date 28/9/ 2019

Page 1 of 6
Document Title :Patients Assessment Policy

PREPARED BY: ---------------------------------------------

QUALITY COORDINATOR

APPROVED BY: --------------------------------------------

DIRECTOR

SUMMARY This document provides instruction and guidance to clinical and

Nursing staff on initial assessment and periodical reassessment of

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Name Name

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 Dr. K.G.Deshpande Memorial Centre Doc No KGDMCH/AAC/03
Issue No 01
for Open Heart Surgery, Thoracic &
Rev No. 00
Vascular Surgery
Date 28/9/ 2019

Page 2 of 6
Document Title :Patients Assessment Policy

the patients in outpatient, inpatient and emergency settings to

determine the initial treatment plans and its subsequent
modifications.
All HODs throughout the hospital are required to instigate action to
ensure the successful implementation of the policy within their
area(s) of control.
DISTRIBUTION To all departments, units and wards through the Hospital Manual

INTRODUCTION
Patient Assessments is a key process in ensuring comprehensiveness of medical and
nursing care for the patients. The patient assessments form a continuous process
consisting of pre-admission assessment, initial assessment on admission and periodic
reassessments throughout the patients stay at the hospital.
The overall assessment process covers the patient’s physical, psychological, social,
and rehabilitation needs and supported by additional assessments of nutritional needs
and nursing care needs of the patients to ensure a holistic and multidisciplinary care.
PURPOSE AND SCOPE
The purpose of this policy is to;
 Outline a systematic process for gathering pertinent information about each
patient.
 Establish a comprehensive information base for decision making about each
patient’s care.
 Provide patients with the right care at the time it is needed.
RESPONSIBILITIES
Clinical Staff
All doctors are responsible for following the procedural guidelines to ensure an
appropriate and timely completion of the various assessments.

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Name Name

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 Dr. K.G.Deshpande Memorial Centre Doc No KGDMCH/AAC/03
Issue No 01
for Open Heart Surgery, Thoracic &
Rev No. 00
Vascular Surgery
Date 28/9/ 2019

Page 3 of 6
Document Title :Patients Assessment Policy

Nursing Staff
Ward/ Unit Nurses responsible for tracking the timely completion of the various
assessments and for notifying the responsible doctor/ dieticians/ health providers in the
event that required information appears to be missing or incomplete.
POLICIES
Patient assessment at Dr. K.G.Deshpande Memorial Centre for Open Heart Surgery,
Thoracic & Vascular Surgery is an ongoing process that begins before the patient is
admitted and continues throughout treatment.
In case of OPD – the institution follows a policy that the patient in the outpatient
department information shall be received in the following manner,
 The initial assessment of the patient is done using the Initial Assessment form/ in
electronic forms by assisting Consultant / Sr. Consultants.
 Initial Assessment need not be performed for patients coming for follow ups and
regular reviews.
 Any patient who has not undergone a consultation with in last 6 months needs to
undergo a fresh initial assessment process.
In case of OPD, patient assessment shall be done within a time frame of 4 hrs.
Pre-admission information as well as observations made at the time of admission will be
used to determine the patient’s admission unit (intensive care/ wards) in the hospital. In
cases of admissions for elective surgeries patients are prescribed various tests/
evaluations to assess their condition/ preparedness for undergoing the surgery. A
detailed assessment shall be performed based on these investigations/ evaluations and
recorded in the OPD case sheets prior to admission of the patient.
OPD information as well as observations made at the time of admission will be used to
determine the patient’s admission unit (intensive care/ wards) in the hospital. In cases of
admissions for elective surgeries patients are prescribed various tests/ evaluations to
assess their condition/ preparedness for undergoing the surgery through physician
fitness. If the Physician finds the patient fit the date for elective surgery is given.

IN case of IP - Once the patient arrives on the treatment ward, an initial

assessment shall be performed within 24 hours of his admission. This initial
assessment may be performed in two steps;
 An initial assessment is performed by a Duty doctor attached to the admitting
unit/ departments within 3 hours of the patient admission.

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Name Name

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 Dr. K.G.Deshpande Memorial Centre Doc No KGDMCH/AAC/03
Issue No 01
for Open Heart Surgery, Thoracic &
Rev No. 00
Vascular Surgery
Date 28/9/ 2019

Page 4 of 6
Document Title :Patients Assessment Policy

 The same is validated within 24 hours by a Consultant or above from the

department who countersigns the respective assessment form.
More details assessments to determine each patient’s psychological, social, and
rehabilitation needs may be conducted as per recommendations of the treating doctors.
Any patient who has undergone a detailed initial assessment at OP within seven days
prior to his admission need not undergo an initial assessment in the IP. A copy of the
initial assessment performed in OP may be added to IP case sheets for reference.
Analysis of information from these basic assessments drives initial treatment plans and
continues up to discharge planning.
PROCEDURE (S)
A. Pre-admission Assessment:
1. Pre-admission assessment begins when a patients is recommended for admissions.
The pre-admission assessment is informal in nature and is coordinated by the
admitting physicians with support of OPD nursing staff.
2. In case of elective admissions especially in case of planned / elective surgeries the
pre- admissions assessment consists of a list of pre-determined tests and evaluation
by cardiologists / general medicine specialist for fitness for undergoing surgery.
3. The details of the assessment is documented in the OP case sheet of the patient
and used for
 To determine the appropriateness of the admission to Hospital based on the
patient’s psychiatric and physical health status,
 To determine the unit / ward for admission,
 As preliminary information for the receiving treatment team.
 Circumstances which precipitated the pending admission,
 Diagnosis and medication history
 Additional physical health problems,
 Legal status
During the process the patients is also briefed about his rights as patient of Dr.
K.G.Deshpande Memorial Centre for Open Heart Surgery, Thoracic & Vascular
Surgery Hospital and clearly educate them regarding the importance of their decision

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 Dr. K.G.Deshpande Memorial Centre Doc No KGDMCH/AAC/03
Issue No 01
for Open Heart Surgery, Thoracic &
Rev No. 00
Vascular Surgery
Date 28/9/ 2019

Page 5 of 6
Document Title :Patients Assessment Policy

making. Once the patient decides to go ahead with admission the general consent form
for admission is obtained and then the patient is shifted to the area of care.
The general consent forms are in two formats – adults and pediatrics. The patients are
expected to read the form and understand its content (in case of doubt they shall
contact the front office and get their doubts cleared) and then sign it prior to their/child’s
admission. This particular consent is not an informed consent.
B. Initial Assessment:
1. An initial assessment will be completed by a Resident from the admitting unit
within three hour of the time each patient is received by the ward staff. This initial
assessment will be checked and validated with 24 hours of the patients being
received in the wards by the Consultant or above from the admitting department /
specialty.
2. Results of the initial assessment are documented in each patient’s medical
record using initial assessment forms (as per department specific formats).
3. All patients admitted the hospital will undergo a Nutritional Assessment by a
dietician within 24 hours of admission where such an assessment is deemed
necessary based on the nutritional screening tool.
4. A nursing assessment will be performed by the nursing staff within the shift
during which the patients was received by the wards / units. Analysis of nursing
assessment information results in documentation of patient strengths, a needs
assessment summary, and nursing care plan.
5. In cases when patients refuse and/or patient’s condition precludes obtaining a
complete initial assessment, the reason for delay and plan for completion is
documented in the medical record.
D. Additional Assessments & Reassessments:
1. Admission assessment procedures may trigger a need to further examine actual
or potential areas of need for treatment.
2. Additional patient assessments are initiated by a doctor’s order and
accomplished by:
 internal referral and/or
 Referrals to outside specialists/consultants.

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Name Name

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 Dr. K.G.Deshpande Memorial Centre Doc No KGDMCH/AAC/03
Issue No 01
for Open Heart Surgery, Thoracic &
Rev No. 00
Vascular Surgery
Date 28/9/ 2019

Page 6 of 6
Document Title :Patients Assessment Policy

3. Internal Referrals: Focused assessments administered by Dr. K.G.Deshpande

Memorial Centre for Open Heart Surgery, Thoracic & Vascular Surgery Hospital
clinical and Paramedical staff include:
 Nutritional - Dietitian (On Call)
 Functional – Physiotherapy / rehabilitation staff (On Call)
E. Assessment Tools and Documentation:
1. Assessment tools and formats for documentation will be developed by the clinical
disciplines responsible for the specific evaluation. All evaluation tools will be
approved by the department HOD prior to use with patients.
2. Formats for Nursing, Nutrition and Functional will be standardized throughout the
Hospital.
MONITORING
The nursing staff of each ward monitors the timely completion of the various types of
assessments and coordinates with various categories of professionals for timely
completion.
REFERENCE
A. Standard Reference: AAC- 4
B. Document Reference:
i. Policies and Procedures for Medical Record Review
ii. Clinical Manuals/ procedures of various departments/ specialties
iii. Nursing Manuals and protocols
iv. Nutrition and Dietary Services Manual
v. Initial Assessment Form

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