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Discussion

out patient procedures

I admit that my history as a hospital nurse was mostly acute care Units and ER. So med-Onocology nursing in still a bit new to me. The pt's are not that different as far as the challenges and providing the care. It's mostly the procedures and protcols that seem to baffle me at times. Our unit does out patient procedures like chemo, blood transfusions, IV iron infusions, and today procrit. I was always under the understanding that when ever a patient is in the hospital that you are required to do a nursing history, an assessmnet, vital signs, document plan of care, med-rec, and discharge instructions. So today this pt who had they went to the MD office would be in and out in very little time actually was with me about 3 hrs. I did the blood draw, sent the CBC to lab, waited for the results then had to call the MD the results, and then fax the order to pharmacy. Give the med then let the pt go. No document of discharge instructions. Does this meet standards of practice according medicare ? or JCHA ?

thanks

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My experience with out patient infusion clinic visits are that they are just that- a clinic visit. The clinic just happens to be located within the hospital rather than a free standing location.

The people seen are patients of the clinic, not the hospital.

Clinic patients are different than outpatient procedure patients. Some hospitals update the records on the patient monthly. They have an outpatient assessment (just the basics) which includes their meds, allergies, history, assessment, plan of care etc that is updated monthly. As we do computer charting and usually the patient's condition hasn't changed its just same old, same old and just takes a minute to update. As far as discharge teaching goes keep in mind that if it is medication that you are giving the patient (Procrit, Iron, etc) you can provide the patient with a medication sheet and teaching on the initial visit. After that most patients feel comfortable in their understanding although further teaching may be needed.

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