FUNCTION: Assessment of Patients TITLE: Assessment/Reassessment _________________________________________________________________ PURPOSE: To ensure that all patients receive the appropriate assessment (including initial/screening and reassessment) provided by qualified individuals within the organizational setting. The assessment process will be a continuous, collaborative effort with all departments functioning as a team. Patient assessment is a multi-disciplinary function. The importance of input by various members of the health care team is valued and supported by the organization. POLICY: 1. All patients at YOUR HOSPITAL HEREreceiving inpatient, outpatient or Emergency services will have an initial assessment and appropriate follow-up assessments based upon their individual needs including physical, psychological and social/cultural status. 2. This assessment process will determine the need for care and/or treatment, the type of care to be provided and the needs through the continuum of care. 3. The goal of the assessment/reassessment process is to provide the patient the best care and treatment possible. 4. Care and/or treatment provided by all health-care professionals will be based on each patient's specific needs with respect to each patient's right to privacy. 5. All relevant biophysical, psychosocial, and nutritional, selfcare, educational, environmental and discharge planning needs will be the determining factors for the assessment process. 6. All assessments provided by health-care professionals will be based upon and include: a. Data collected to assess the needs of the patient. b. Data analyzed to create the information necessary to develop a plan to meet the patient's care or treatment needs. c. Decisions made regarding patient care or treatment are prioritized based on analysis of the information collected. d. Information will be provided to patients, and when appropriate to families, to assist them to make a knowledgeable decision regarding whether to seek care and/or availability of care. When costs can be ascertained, referral will be made to the business office manager or patient accounts manager. APPLIES TO: All inpatients and outpatients of all age groups. RESPONSIBILITY: All disciplines involved in direct patient care. PROCEDURE: ASSESSMENT FRAMEWORK The assessment framework will be structured around two components. Initial screening and assessment/reassessment of all patients as appropriate to the clinical discipline and individual patient condition changes. I. General Department patient assessment will be guided by the data to be collected, the scope of the assessment, mechanisms designed to analyze the data collected, and the framework for decision making based upon the analysis of data. A. All departments will assume the responsibility to review those aspects of the patient's medical record that directly relate to each department's scope of care and clinical involvement with the patient. B. Information generated via a patient's assessment will be integrated with other disciplines to identify and prioritize the patient's needs for care and treatment. a. The various disciplines will share and provide information about their portion of the patient assessment relevant to their scope of care. b. Areas of concern or patient's special needs may be identified by specific clinical disciplines. All departments, patients and family members may request consultations for specific needs and/or question areas. c. The patient assessment will be age specific (neonatal, pediatric, adolescent, adult or geriatric) and should include educational, social, nutritional, spiritual preferences and daily activities of the patient. d. The expectations of the family and/or guardian will be taken into account for their involvement in the assessment process, treatment and/or continuous care of the patient. e. Initial assessment of patients needing nursing care in all settings (departments) will be performed by a RN. Further assessment and reassessment will be based on a collaborative effort. II. Initial/Screening Assessment The following considerations are followed by health-care providers in the design of a discipline specific assessment. The assessment process will be collaborative to facilitate, identify, and prioritize the patient's needs and determine care. A. The patient's diagnosis B. The treatment setting C. Duration and length of care D. The patient's desire for treatment E. The patient's response to previous treatment F. Nutritional status as appropriate G. The patient's functional assessment specifically for rehabilitation services and as appropriate to other ancillary departments H. Age, developmental needs, and immunization status I. Diagnostic testing procedures which includes: 1. Laboratory 2. Invasive/non-invasive procedures for diagnostic imaging J. Pre-anesthesia assessment if appropriate to include: 1. Appropriate candidate 2. Post induction re-evaluation 3. Assessment prior to discharge K. Potential victims of abuse L. Cultural needs/spiritual preferences M. Discharge planning N. Educational requirements III. Reassessment A. Each patient is to be reassessed according to the guidelines established by the clinical discipline. B. Reassessment is to be ongoing and may be triggered by key decision points and at any intervals specified by the departments/ancillary disciplines directly involved in providing patient treatment and/or care. C. Reassessment may be at specified/regular intervals related to: 1. The patient's treatment 2. The patient's response to treatment 3. Significant change in the patient's condition 4. Significant change in the patient's diagnosis 5. Discharge planning where appropriate in the scope of care of the department involved. IV. Scope and Responsibilities of Involved Disciplines A. ADMISSIONS 1. The Admitting/ER Registration Clerks initiate the assessment process for patients entering the hospital except in emergency situations. a. Identification of special needs, e.g., blindness, hearing impairment, language barriers, disabilities, spiritual preference and any other condition that may require special accommodations. b. Determination of any advance directive or Medical or Legal Power of Attorney and/or referral to Social Services for the patients with any questions. c. Informing patients of their rights and responsibilities. B. MEDICAL STAFF 1. Each patient will have an initial assessment by a medical staff member, who will assess the physical, psychological and social status of the patient and identified appropriate care/or the need for further assessment. The medical staff member is the leader of the patient care team in the planning and provision of care throughout the continuum. a. The physician completes a history and physical according to the Medical Staff Rules and Regulations. (1) Inpatient history and physical is completed within the first 24 hours of admission (2) A complete history and physical is completed and recorded in the patient's medical record prior to a surgical or invasive procedure. EXCEPTION: Emergency situations require at least a brief note and preoperative diagnosis. b. Written consent for treatment is required at the time of admission and prior to any operative or invasive procedure. EXCEPTION: Emergent situations c. Physician orders, consults, and progress notes serve as a mechanism for the Medical Staff to communicate the patient's care, treatment needs, response to treatment, patient instruction, discharge plans and continued care requirements as appropriate. d. There is a pre-anesthesia assessment of each patient for whom anesthesia is contemplated. Immediately before the induction of anesthesia, the patient is reevaluated. C. EMERGENCY DEPARTMENT 1. All patients presenting for treatment in the emergency department will receive a medical screening by the Emergency Department physician on duty. 2. Patients seeking medical care are seen by the ER physician in order of priority based upon their condition or change in condition. a. Emergent: Patients who have conditions that may result in loss of life or limb if not treated immediately. b. Urgent: Patients that require urgent care, but will not generally cause loss of life or permanent severe impairment if left untreated for several hours. c. Non-urgent: Patients in this category generally need evaluation and treatment, but time is not a critical factor. 3. Nursing personnel triages to determine if the patient is a non-urgent, urgent or emergent unless the patient is taken immediately to the treatment area for treatment due to condition/status or the availability of open treatment area. 4. The ER physician assesses and evaluates each patient prior to making any referrals or decisions regarding disposition. 5. An assessment will be performed by the registered nurse for each patient. The assessment recorded on the Emergency Room Record will include, but is not limited to: a. Patient complaint b. Allergies c. Vital signs d. Treatment prior to arrival to the ER e. Initial and continued treatment during ER admission 6. Reassessments are performed by RN's and physicians when: a. There is a change in the patient's status b. There is a change in the patient's vital signs c. As indicated by the patient's condition and/or treatment 7. Patients requiring a service not offered here are transferred via ground transportation after acceptance by a physician in another facility. 8. Cardiology, Respiratory Care, Laboratory, Pharmacy, Diagnostic Imaging and Surgical Services are available 24 hours per day. 9. Employees of this department along with all departments throughout the hospital that interact with patients, share responsibility in identifying possible victims of alleged or suspected abuse or neglect. D. NURSING 1. At the time of admission, each patient will have their needs assessed by a RN. The LVN and UAPs (Unlicensed Assistive Personnel) may perform certain aspects of data collection as outlined by policy and procedures. 2. The nursing admission history will be completed by the RN as soon as possible upon arrival to the nursing unit, but shall not exceed established parameters for each unit. Patient condition upon arrival may warrant immediate assessment. Unit specific time frames: AREA INITIAL TIMES COMPLETION TIMES Med/Surgery, Tele, 4 hours 8 hours Nursery, Postpartum Critical Care/L&D, 30 minutes 4 hours Special Care Nursery Emergency Department Upon Triage 60 minutes Endoscopy Lab/Cath Lab 30 minutes prior to procedure Surgical Services 30 minutes 60 minutes 3. Employees of this department along with all departments throughout the hospital that interact with patients, share responsibility in identifying possible victims of alleged or suspected abuse or neglect. 4. Patients admitted through Day Surgery will be contacted by phone. The physical assessment will be conducted on admission. Changes in the patient condition that have occurred between pre-admission documentation and admission to the hospital will be recorded. a. Data collection regarding systems, history, nutritional needs, functional needs, environmental, teaching needs, psychosocial and discharge planning will be completed by a RN. b. When the initial assessment identifies a patient at risk nutritionally, the dietician will be notified. c. When the patient has functional needs, e.g., speech, the nurse will notify the attending physician for further orders. d. When a discharge planning need is identified, Clinical Case Managers will be notified. e. Following assessment, the problems will be identified and goals set. f. The information generated through the analysis of assessment data is integrated to identify and prioritize the interventions. 5. Unit specific criteria have been established to reflect differences in patient care requirements. Medical/Surgical/TCU/Tele/Nursery/Postpartum 1) The initial assessment is completed by the RN within eight hours of admission. 2) Reassessment is performed by a RN or LVN every shift or more frequently as indicated by the patient's condition. 3) The reassessment is based upon but not limited to the following systems status related to the medical diagnosis, patient care needs or team problem identification/nursing diagnosis identified in patient care plan, response to treatment or change in condition. 4) Reassessment is documented on the patient care record. Patients undergoing surgical and/or invasive procedures 1) If admitted from Day Surgery area, patient will have a nursing admission history assessed by a RN. 2) When a patient comes from a nursing floor, the preoperative checklist, which includes the nursing history, is utilized for the surgery areas to assess the patient's preparation and condition during the preoperative stage. 3) Assessment data is collected prior to all invasive procedures to include consent and validation of operative site. 4) Variations identified during this preoperative/ pre-procedure nursing assessment are noted on the documentation forms and anesthesia, surgeons and other referring physicians are notified as appropriate. 5) The plan of care is individualized after completion of the initial admission assessment. Recovery (PACU/Day Surgery) 1) Initiates a plan of care based on the assessment of patient's individualized needs. 2) During the recovery phase, the patient is reassessed a minimum of every fifteen minutes and upon discharge from the area. Assessment is more frequent as the patient's condition warrants. 3) Post operative reassessments on the nursing units are done upon arrival q 30 minutes x 2, q 1 hr x 2, q 4 hr x 2 then q shift or as ordered by the physician. ICU/CCU/SICU 1) Within the first 30 minutes, a biophysical, vital signs, and allergies assessment is completed. 2) The psychosocial, educational, functional and discharge assessments are completed within eight (8) hours. 3) Reassessment of the patient is performed a minimum of every four (4) hours. Assessment occurs more frequently if ordered or as the patient's condition indicates. 4) Reassessment is documented on the flow sheet and includes a review of systems as appropriate to the patient's diagnosis. 5) Department specific forms supplement and provide additional assessment and documentation as it pertains to operative/invasive procedures. Labor/Delivery/Postpartum 1) Within the first 30 minutes, a biophysical assessment is completed. 2) Routine vital signs are done upon admission and every 4 hours or every 2 hours with rupture of membranes. 3) During active labor (1st stage) - BP, P, R every hour, FHT and uterine contraction frequency, duration and character on the labor record every hour or as condition warrants. 4) During active labor (2nd stage) - Delivery, BP, P, R every 15 minutes, FHT every 15 minutes post contraction until delivery. 5) Recovery/Postpartum Checks - C-section Delivery assess/reasses, BP, P, R, fundal/lochia checks and I and O's - q 15 min x 4, then q 30 min x 2, then q 1 hr x 2, then q 4 hrs x 48, then routine as condition warrants. When stable transfer to postpartum care. 6) Vaginal Delivery - q 15 min x 4 until stable, then transferred to postpartum. Initial assessment on post partum is 1 hr x 1 then q 4 hr x 24, then routine as condition warrants. Newborns 1) Apgar is assessed at 1 and 5 minutes or as indicated. 2) Vital signs are performed upon admission and q 1 hr while under the radiant heater; and/or until stable and then q 8 hrs. 3) Upon delivery, the nurse assesses general appearance, color, respiratory pattern, cardiac status and notes any physical abnormalities. 4) Daily newborn reassessments are performed every shift until discharge, unless baby's condition warrants more frequent observation such as in Special Care Nursery. 5) Reassessment in Special Care Nursery includes a system review every 4 hours or as warranted by the newborn's condition. Pediatric patients (infants, children and adolescents) 1) Regardless of unit, pediatric patients will have the following elements assessed: developmental age, length/height, head circumference in children under 2, weight, consideration of educational needs and daily activities (inpatients), current immunization status and family and/or guardian's needs and expectations. Transitional Care Unit 1) Patients are admitted after they have been evaluated for TCU admission criteria. 2) The initial assessment and plan of care is completed within 8 hours of admission. 3) Reassessment is done by an RN q 24 hours or more as indicated by the patient's condition. 4) Reassessment is based upon the patient's response to treatment, patient care needs, significant changes in condition and diagnosis, collaborative care plans and functional disabilities. E. DIETITIANS All patients admitted to YOUR HOSPITAL HERE will have a nutritional screen completed by nursing staff at the time of admission. Clinical dietitians will provide nutritional assessments, and reassessments, establish goals and monitor response to nutritional care at defined intervals. Nutritional care and support will be provided by a multidisciplinary healthcare team. F. SOCIAL WORKERS/CLINICAL CASE MANAGERS Each patient will be assessed through the use of high risk screening criteria to identify the need for social service intervention or discharge planning needs. The initial screening criteria will be applied on the first working day following admission, record review and patient/family assessment will occur within 24 hours of the screening. 1. Admission Screening Criteria for Discharge Planning includes amputation, cerebral vascular accident, decreased functioning, decreased mentation, diagnosis of cancer, end stage disease, head injury, hip fracture (age 65+ and/or living alone), total joint replacement, severe malnutrition, multiple trauma, suspicion of neglect or abuse (child or adult), spinal cord injury, suicide attempt, drug overdose, nursing home patient, sexually assaulted, unable to care for self with no family and/or living alone, readmission or multiple admissions, age 80+, uninsured, single parent, pregnant less than 17 years of age, and special care nursery. 2. Indications for referral for discharge planning include any illness or situation which has the potential of impacting the patient's post-hospitalization needs such as: a. Adult or child who has no one to provide needed assistance with activities of daily living b. Adult or child who has no one to provide needed supervision c. Patients hospitalized because of non-compliance with medical regime d. Family behavior adversely affecting patient e. Adult or child whose hospital treatment will necessitate a change in lifestyle, educational plans, employment, or role in the family. f. Patient who may not be able to return to the pre-hospitalization environment safely without added support systems g. Disruptive emotional reactions of patient or family related to diagnosis, treatment or recommendations 3. The criteria utilized by the UR Committee/Clinical Case Managers will be Milliman and Robertson Criteria. a. Medicare/Medicaid patients are screened for intensity of service acuity and illness criteria on the first working day following admission and at weekly case rounds. b. The at-risk patients are identified by policy and in the Utilization Review Plan 1) Referrals for intervention may be obtained from any member of the health care team, family members, and patients 2) These needs may be communicated through the Meditech system, by phone or in writing 4. Assessments by the Social Workers will focus on identifying cultural and psychosocial needs and providing counseling and referrals to promote quality of life. 5. Assessments by the Clinical Case Managers and Social Workers will address discharge planning needs and assessments for transfers to other levels of care, internal and external. 6. Reassessments will be performed: a. As changes in condition occur b. New needs are communicated by the patient, family or members of the health care team c. Periodically as determined necessary by the Social Worker, Clinical Case Manager or any members of the healthcare team. d. Planning will occur until the time of discharge in an effort to adapt to the changes that may occur during hospitalization and to make appropriate arrangements to meet the needs of the patient/family and to effectively communicate with the next level of care providers. G. REHABILITATION The Rehabilitation Therapist's initial assessment involves evaluation of the medical record and social history as well as observations and tests. Assessment strives to identify problem areas contributing to or having the potential to contribute to functional losses. Goals are established and a treatment plan is developed. The patient is continuously reassessed regarding progress towards goal achievement. The assessments are recorded on the patient's permanent medical record and the information generated through the analysis of assessment data is integrated into the collaborative care plan. Employees of this department along with all departments throughout the hospital that interact with patients, share responsibility for identifying possible victims of alleged or suspected abuse or neglect. The referral request and all available medical data will be reviewed prior to initiating the evaluation. For inpatients, the patient chart will be reviewed including doctor's orders, nursing progress note/collaborative care plans, history and physical, consultations, lab and radiology reports, social services report, other pertinent information. Outpatients will complete an outpatient medical data form upon arrival including patient identification, information, current medical condition, hospitalizations, prior treatment for this condition and past medical history. 1. A rehabilitation therapy assessment is completed the day of referral if the referral is received by 1500 (weekends and holidays are excluded). 2. Outpatients are seen within 24-48 hours or at the convenience of the patient. 3. Physical Therapy addresses the following items to make a functional assessment: a. Manual muscle examination b. Transfers c. Goniometer joint measurement d. Activities of daily living e. Functional examination f. Posture g. Flexibility h. Gait analysis i. Tenderness j. Swelling k. Progressive activity tolerance l. Sensory m. Muscle tone n. Reflexes o. Motor planning p. Wound 4. Occupational Therapy assessment will include but is not limited to the following tools: a. General evaluation b. Homemaking skills assessment c. Performance skills assessment d. Range of motion assessment e. Manual muscle examination f. Sensory evaluation g. Motor free visual perceptual test h. Wound i. Activities of daily living j. Pain and tenderness k. Functional capacity evaluation l. Specific hand evaluation m. Progressive activity tolerance n. Feeding skills 5. Speech Therapy evaluation tools include: a. Bedside swallow b. Modified barium swallow (with a radiologist) c. Oral peripheral evaluation d. Voice evaluation e. Speech articulation evaluation f. Language g. Fluency h. Auditory comprehension i. Augmentative and alternative communication 6. Reassessments are performed based upon goals developed during initial evaluation to: a. Allow for modification of the treatment plan and goals b. Justify continued care c. Establish what discharge therapy is indicated, error in collaboration with family and discharge planner as appropriate 7. Factors which trigger reassessment are: a. Changes in the patient's status b. Prior to transferring the patient to another unit within the hospital c. Discharge from the facility 8. Family members and/or significant others will be involved in the assessment/reassessment process as appropriate. 9. Reassessments will include: a. Summary of patient progress and response to treatment b. Assessment of goal achievement to date and the effectiveness of treatment provided c. Goal revision as needed d. An assessment of the patient's perception of the effectiveness of the therapy received e. Estimate of further rehab potential H. RESPIRATORY CARE A Respiratory Care Practitioner assesses the patient's need for and response to respiratory care procedures in all settings in the facility except surgery. Care is taken to address the patient and family education needs for patients that are on ventilators. 1. The Respiratory Care Practitioner's assessment is age specific and addresses considerations unique to the age group. 2. Evaluation of the patient's cardio-pulmonary status through Arterial Blood Gases, Pulmonary Function Studies, lung sounds, x-ray results and sputum production is of special interest to the RCP. Panic Value Reporting a. Panic values are all results that fall outside of the defined therapeutic range. b. All panic values MUST be reported from the bench by the therapist performing the analysis, to the attending physician, patient's RN and therapist as soon as results are known. c. If unable to contact the ordering physician, the Medical Director MUST be notified of results. Ranges for Blood Gases Adults and Children CRITICAL LIMITS CLINICAL "NORMALS" THERAPEUTIC RANGES ARTERIAL/CAPILLARY pH 7.35-7.45 mmHg 7.32-7.55 >7.60 - <7.25 PACO2 35-45 mmHg 25-65 <45.0 mmHg P02 80-100 >60 <60mmHg w/pH<7.30 HCO3 22-26 22-26 3. Newborns and preterm by capillary stick After the first 48 hours of life, capillary blood samples that have adequate arterialization will correlate to arterial pH, PaC02 and HC03. Oxygenation as a rule does not correlate to arterial samples. Crying and pain alters reported values. Improper sampling technique may invalidate all test results. NORMAL PRETERM NORMAL TERM CRITICAL LIMITS ARTERIAL/CAPILLARY pH 7.29-7.40 7.30-7.45 <7.30 - >7.45 PAC02 39-56 32-45 <32 - >45 P02 52-67 60-80 <52 - >80 HC03 22-23 18-24 <18 - >24 Umbilical Cord Blood ARTERIAL VENOUS pH 7.28-7.40 7.30-7.40 pC02 35-45 35-45 p02 25-35 28-38 4. Assessment of patients on other therapies addresses a. Breath sounds before and after therapy b. Respirations c. Heart rate as indicated d. Cough e. Sputum production f. Toleration g. Work of breathing h. Adverse reactions i. Indications/Contraindications 5. Reassessment and recommendations for changes in therapy are based upon the patient's response to the therapy given and the results of the therapist's assessment. a. Patients on ventilators are assessed every hour x 24 hours, then every 2 hours thereafter. b. Patients on routine therapy are assessed every treatment c. Patients in respiratory distress are assessed and reassessed as their condition warrants and anytime a request is received from the physicians or nurses. d. New patients are assessed during the initial treatment and repeat assessments occur before and after each treatment. 6. The assessments are recorded on the patient's permanent medical record and the information generated through the analysis of assessment data is integrated into the plan of care. 7. Employees of this department, along with all departments throughout the hospital that interact with patients, share responsibility in identifying possible victims of alleged or suspected abuse or neglect. I. RADIOLOGY Diagnostic testing, including appropriate use of radiological, electrodiagnostic and other functional tests and imaging technologies are an integral part of patient assessment. An ongoing and continual assessment of radiology findings to identify abnormal values and clinical indicators to assist the Radiologists in correlation of diagnostic information with referring physicians is completed. All patients will have an initial assessment and appropriate follow-up assessment based upon their individual needs including physical, psychological and social factors. This assessment process will determine the need for care and/or treatment type of care to be provided and the need for any further care. It is the responsibility of the technologist performing the examination to review relevant portions of the medical record that relate directly to the Radiology Department's scope of care and clinical involvement. At all times, the patient's right to privacy and confidentiality will be respected and observed. Radiologists will also review the patient's medical record as necessary prior to diagnostic examinations to ensure medical appropriateness, ensure patient safety, and gain information to assist in the interpretation of radiographs. It is the responsibility of both technologists and Radiologists to relay any information obtained via the assessment process to the appropriate department in the collaborative environment. This process will assist other disciplines to identify and prioritize the patient's needs for care and treatment. The patient assessment in Radiology will be age specific and include the following: a. Daily activities b. Expectations of the family and/or guardian will be taken into account for their involvment in the assessment process, treatment and continuous care of the pediatric patient c. Assessment of patients requiring nursing care in all settings will be performed by RN's where nursing care is provided, ie., special procedures performed in Radiology. The following considerations need to be followed and considered in the Radiology Department for appropriate assessment of each patient: a. date procedure is to be performed b. diagnostic indication for procedure to be performed c. patient's diagnosis d. the treatment setting (portable, surgery, diagnostic room) e. patient's desire for treatment f. patient's previous response to testing (IVP Dye, etc.) g. nutritional status of the patient h. patient's functional assessment i. type of diagnostic procedure to be performed j. will sedation be potentially involved? k. pregnancy assessment for all female patients age 13 to 50 l. is the patient a potential victim of an abusive situation? m. properly performed preparation For patient procedures requiring IV contrast assessment will also include: a. allergies b. previous history of reactions c. lab work including BUN, Creat as indicated d. medication history Procedure prioritization is as follows: a. First Priority: Operating Room b. Second: Nursery c. Third: Emergency Room d. Fourth: ICU-CCU e. "As Soon As Possible": Patients that are NPO f. Routine Orders The reassessment process will be ongoing and maybe triggered by key decision points and at any interval specified by department policy. Allergic reactions are included in the reassessment. STAT results, abnormal results identified are reported to the patient care unit and/or the physician. Reports are available in the Meditech system. Hard copies are available in the patient chart. Out-patient reports are faxed or mailed to the physician offices. A report is called to the physician when requested. J. LABORATORY All patients receiving laboratory specimen collection procedures will have an initial assessment and appropriate follow-up assessment based upon their individual needs including physical, psychological and social. This assessment process will determine the need for care and/or treatment, the type of care to be provided and the need for any further care. Employees of this department, along with all departments throughout the hospital that interact with patients, share responsibility in identifying possible victims of alleged or suspected abuse or neglect. All laboratory results will be assessed by laboratory personnel for critical values requiring immediate notification of the physician/RN, correlation with the previous laboratory results and/or other testing performed on the patient, and results indicating the need for follow-up testing. Pathologists will also be directly involved in the patient assessment process using their specific medical training to note directly and to also function as an advisor to the technologists as needed. The assessments will include the following parameters: a. age of the patient, neonate, child, adolescent, adult, geriatric patient b. expectations of family or guardian to account for their involvement in the assessment process, treatment and/or continuous care of the patient Assessment of the patient needing nursing care in all settings will be referred to and performed by RN's where nursing care is provided. The phlebotomist performing procedures will assess patients for identification (checking ID band) prior to obtaining a specimen, carefully inspect the site before obtaining a blood sample (specimens should not be obtained below an IV site) and after obtaining a blood sample to make sure the bleeding has stopped. All laboratory results shall be routinely reviewed by the reporting technologist, the pathologist, the chief technologist and/or lab supervisors for clerical errors, absurd results, or results requiring notification. Results reported on the evening or night shifts when a supervisor is not on duty shall be reviewed the next working day by the section supervisor or the chief technologist. The pathologist shall be immediately notified of any laboratory results which indicate a potentially life-threatening condition. Information required to perform laboratory tests include: 1. Patient name 2. Patient location 3. Medical Record and Hospital Number Requests are transmitted electronically and the initials of the individual requesting the test are traceable Outpatient request are accompanied by: 1. A copy of the order 2. Name of physician ordering the test 3. Date, time and priority of the procedure to be performed 4. Procedure requested and special information needed Blood transfusions require a complete transfusion request and an identification armband 1. Transfusion reactions are noted and reported to the blood bank and the physician. Panic values have been established which require STAT referral to the RN in charge of the patient's care. Outpatient panic values are called to the respective physician's office. K. PHARMACISTS Pharmacists, in collaboration with other members of the heathcare team will be responsible for the assessment of medication therapy. All orders except as delineated in medication use policy will be assessed by a pharmacist for appropriateness prior to implementation. Monitoring of medication effects and reassessment will be done by an interdisciplinary healthcare team. L. CARDIAC REHAB An assessment of all patients receiving cardiac rehab exercise therapy will be performed as appropriate. The assessment/ reassessment will be documented in the inpatient medical record for all Phase I patients. Prior to any initial exercise, the following will be assessed as appropriate: a. Respiratory rate b. Heart rate c. History (for all new patients in any phase) d. Diagnosis e. Observation for color, level of consciousness, mobility, edema, incision if a surgical patient f. Blood Pressure g. Patient/families understanding of treatment Treatment of the patient will be appropriate to the findings of such assessment and will be communicated to the physician when significant change occurs. Reassessment of the patient will be performed when: a. Signs of symptoms of adverse reaction or side effects are present b. At the completion of the procedure c. During the exercise session as indicated. d. When additional reassessment is warranted by a change in the patient's condition.