Dr. Ram Manohar Lohia
Combined Hospital , Lucknow
Quality Operating Process
Document No :
RML/IAP/01
Manual of Operations
Initial assessment an
Reassessment of patient
Date of Issue :
15/1/2008
Service Name :
Initial Assessment and
Reassessment of Patient
Operational Policy
Date Created :
15-01-2008
Chief Medical Superintendent
Approved By :
Name
:
Signature :
Medical Superintendent
Reviewed By :
Name :
Signature :
Director
Issued By :
Name :
Signature :
Head of the Department
Responsibility of Updating :
Name :
Signature :
1
Manual of Operation
Dr. Ram Manohar Lohia
Combined Hospital , Lucknow
Quality Operating Process
Document No :
RML/IAP/01
Manual of Operations
Initial assessment an
Reassessment of patient
Date of Issue :
15/1/2008
Page of Contents:
Sl.Order Particulars
A
Purpose
B
Scope
C
Policy
1. Out patient Assessment
2. Assessment After Admission
3. Responsibility Matrix
2
Manual of Operation
Dr. Ram Manohar Lohia
Combined Hospital , Lucknow
Quality Operating Process
Document No :
RML/IAP/01
Manual of Operations
Initial assessment an
Reassessment of patient
Date of Issue :
15/1/2008
A. Purpose: To assure care provided to each patient is based on an assessment of the patient's
relevant physical, psychological, and social status needs.
B. Scope: Hospital Wide
C. Policy:
1. Outpatient Assessment: Outpatient are assessed during the clinical visit by the treating
consultant. Initial assessment includes:
a. Physical examination of the patient
b. Recording patient’s previous medical history
c. Nutritional Screening, identify patient at nutritional risk
d. Developing a plan of care
Based on the initial assessment of patient and established plan of care, reassessment are
performed and documented throughout the care process and follow up appointments.
2. Assessment after Admission: Each patient upon admission shall be assessed by qualified
individuals for appropriate care or treatment needs / need for further assessment. The physical
and psychological status of each inpatient shall be assessed.
The scope and intensity of the assessment shall be determined by:
a. The patient's condition/diagnosis
b. The care setting
c. The patient's response to any previous care and the patient’s consent to treatment.
d. The patient shall be assessed and the records shall be documented.
Documented plan of care is drawn
A. Documented plan of care is drawn on the basis of initial assessment.
i. Frequency of assessment:
a. A duly registered and credentialed doctor shall document patient assessment within 24
hours of admission.
b. The nursing assessment shall be performed and documented in the patient record within 24
hours of admission.
c. The nutritional and functional assessments shall be completed within 24 hours of admission
of the patient.
3
Manual of Operation
Dr. Ram Manohar Lohia
Combined Hospital , Lucknow
Quality Operating Process
Document No :
RML/IAP/01
Manual of Operations
Initial assessment an
Reassessment of patient
Date of Issue :
15/1/2008
d. Continued reassessments shall be documented throughout in the patient’s medical record.
e. Reassessment of the patient shall be performed at regular intervals in the course of care by
medical and nursing staff.
f. Reassessments shall be performed to determine a patient’s response to care/treatment.
g. Reassessment shall take place when there is a significant change in a patient’s condition or a
change in diagnosis.
h. Nursing staff shall reassess patients at least once in every shift.
i. Medical staff shall reassess patients at least once daily
j. More frequent reassessments shall be done by both nurses and doctors as per the clinical
condition of the patient.
The plan of care shall be reviewed regularly in consultation with or from written information
provided by other members of the health care team and the patient/family. The plan of care will
be revised as appropriate to the patient’s condition and the ongoing assessment process.
4
Manual of Operation
Dr. Ram Manohar Lohia
Combined Hospital , Lucknow
Quality Operating Process
Document No :
RML/IAP/01
Manual of Operations
Initial assessment an
Reassessment of patient
Date of Issue :
15/1/2008
3. Responsibility Matrix - Initial Assessment of the patient.
Initial assessment
At Admission –
Medical
Doctor
Nurse
Dietician
Nursing
Nutritional
Responsibility Matrix - Reassessment of the patient
Reassessment
Doctor
Physiotherapist
Nurse
Dietician
Medical
Nursing
Nutritional
Functional
8. Qualified professionals performing assessment will be registered as applicable under the law
of the land:
Professional
Basic Qualification
Registration
Medical
M.B.B.S
Registered with the Centre / State
Medical Council.
Nursing
Diploma / Degree in Nursing
Registered with the Centre / State
Nursing Council.
Dietician
Bachelor’s Degree in Dietetics
Physiotherapist
Bachelor’s Degree in Physiotherapy Not required
5
Not required
Manual of Operation