clinical-inpatient/SOPs/Patient-Care/SOP-INP-001-Admission-Discharge.md

# Standard Operating Procedure: Patient Admission and Discharge

| Document ID | SOP-INP-001 |
|-------------|-------------|
| Title | Inpatient Admission and Discharge Process |
| Revision | 1.0 |
| Effective Date | [DATE] |
| Author | [AUTHOR] |
| Approved By | [APPROVER] |
| Department | Patient Care Services |

---

## 1. Purpose

To establish standardized procedures for the admission and discharge of inpatients to ensure safe, efficient transitions of care and compliance with regulatory requirements.

## 2. Scope

This procedure applies to all inpatient admissions and discharges including:
- Elective admissions
- Emergency admissions
- Transfers from other facilities
- Same-day discharges
- Transfer to other levels of care

## 3. Responsibilities

### 3.1 Admitting Staff
- Complete registration and insurance verification
- Assign appropriate bed based on admission type
- Communicate with receiving unit

### 3.2 Nursing Staff
- Conduct admission assessment
- Implement physician orders
- Complete discharge education
- Ensure safe handoff

### 3.3 Attending Physician
- Complete admission orders
- Document admission H&P
- Authorize discharge
- Complete discharge summary

### 3.4 Case Management/Social Work
- Assess discharge needs
- Coordinate post-acute care
- Arrange equipment and services

## 4. Definitions

| Term | Definition |
|------|------------|
| Admission | Formal entry into inpatient status with expectation of overnight stay |
| Observation | Outpatient status with close monitoring (not admission) |
| Discharge | Formal release from inpatient care |
| Readmission | Return to inpatient status within 30 days of prior discharge |

## 5. Procedure

### 5.1 Admission Process

#### 5.1.1 Pre-Admission (Elective)
1. **Scheduling**
   - Confirm surgery/procedure date
   - Verify insurance authorization
   - Complete pre-admission testing as ordered

2. **Pre-Admission Call**
   - Review arrival instructions
   - Confirm medication list
   - Review NPO requirements
   - Verify transportation plans

#### 5.1.2 Emergency Admission
1. **ED Assessment Complete**
   - Stabilization and workup completed
   - Admission decision made by physician
   - Bed request placed

2. **Bed Assignment**
   - Match patient needs to unit capabilities
   - Consider isolation requirements
   - Prioritize by acuity

#### 5.1.3 Registration and Consent
1. **Patient Registration**
   - Verify demographic information
   - Confirm insurance/payer
   - Issue identification band
   - Provide patient rights information

2. **Consent**
   - General consent for treatment
   - HIPAA acknowledgment
   - Advance directive inquiry
   - Specific procedure consents as applicable

#### 5.1.4 Nursing Admission Assessment

| Assessment Component | Documentation |
|---------------------|---------------|
| Vital signs | T, HR, RR, BP, SpO2, Pain |
| Allergies | Drug, food, environmental, reactions |
| Current medications | Name, dose, frequency, last taken |
| Medical/surgical history | Complete review |
| Chief complaint | Current presentation |
| Fall risk | Validated tool score |
| Pressure ulcer risk | Braden or similar scale |
| Nutritional screen | Weight, recent changes, intake |
| Pain assessment | Intensity, quality, location |
| Functional status | ADLs, mobility, cognition |
| Psychosocial | Social support, barriers |

3. **Safety Checks**
   - [ ] Fall risk interventions implemented
   - [ ] Allergies documented and visible
   - [ ] Appropriate ID band (allergy band if indicated)
   - [ ] Code status verified and documented
   - [ ] Valuables secured

#### 5.1.5 Physician Admission Orders
Required elements:
- [ ] Diagnosis/reason for admission
- [ ] Level of care
- [ ] Diet orders
- [ ] Activity orders
- [ ] Vital sign frequency
- [ ] Medication orders (reconciled)
- [ ] IV fluids (if applicable)
- [ ] Labs and tests
- [ ] Consults
- [ ] VTE prophylaxis
- [ ] Nursing orders

### 5.2 Discharge Process

#### 5.2.1 Discharge Planning
**Initiate at Admission:**
- Anticipated length of stay
- Likely discharge disposition
- Early identification of barriers
- Case management referral if complex needs

**Ongoing Assessment:**
- Daily review of discharge readiness
- Multidisciplinary rounds participation
- Family/caregiver engagement

#### 5.2.2 Discharge Criteria
Patient must meet all applicable criteria:
- [ ] Medical condition stable or appropriately managed
- [ ] Discharge orders written by physician
- [ ] Patient/caregiver education completed
- [ ] Medications available/filled
- [ ] Follow-up appointments scheduled
- [ ] Post-acute care arranged (if needed)
- [ ] Transportation arranged
- [ ] Patient/caregiver verbalize understanding

#### 5.2.3 Medication Reconciliation
1. **Compare Lists**
   - Pre-admission medications
   - Inpatient medications
   - Discharge medications

2. **Reconciliation Actions**
   - Continued unchanged
   - Dose changed
   - New medication
   - Discontinued (with reason)

3. **Patient Education**
   - New medications explained
   - Changes to existing medications explained
   - Written medication list provided
   - Teach-back confirmed

#### 5.2.4 Discharge Education

**Required Topics:**
| Topic | Completed | Patient Verbalized Understanding |
|-------|-----------|----------------------------------|
| Diagnosis/condition | ☐ | ☐ |
| Medications | ☐ | ☐ |
| Activity restrictions | ☐ | ☐ |
| Diet restrictions | ☐ | ☐ |
| Wound/device care | ☐ | ☐ |
| Warning signs to watch for | ☐ | ☐ |
| When to call doctor | ☐ | ☐ |
| When to seek emergency care | ☐ | ☐ |
| Follow-up appointments | ☐ | ☐ |

#### 5.2.5 Discharge Documentation

**Discharge Summary** (by physician):
- Admission diagnosis and reason
- Hospital course summary
- Significant findings
- Procedures performed
- Discharge diagnosis
- Discharge condition
- Discharge plan and instructions
- Follow-up care

**Nursing Discharge Note:**
- Discharge date and time
- Mode of transport
- Condition at discharge
- Patient/family understanding confirmed
- Discharge supplies/equipment provided
- Prescriptions given
- Follow-up appointments confirmed

### 5.3 Special Situations

#### 5.3.1 Against Medical Advice (AMA)
1. Physician discusses risks with patient
2. Document patient capacity to make decision
3. Attempt to address patient concerns
4. Complete AMA form if patient insists
5. Provide discharge instructions despite AMA status
6. Offer follow-up options

#### 5.3.2 Transfer to Another Facility
1. Accepting facility and physician confirmed
2. Complete transfer summary
3. Send copies of relevant records
4. Ensure safe transport
5. Call report to receiving unit

## 6. Documentation

- FRM-INP-001 Admission Assessment
- FRM-INP-002 Discharge Checklist
- Medication Reconciliation Form
- AMA Discharge Form (if applicable)
- Transfer Summary (if applicable)

## 7. Quality Metrics

| Metric | Target |
|--------|--------|
| Admission assessment completed within 8 hours | >95% |
| Discharge instructions documented | 100% |
| Medication reconciliation completed | 100% |
| 30-day readmission rate | Per benchmark |
| Patient satisfaction with discharge | Per benchmark |

## 8. References

- CMS Conditions of Participation
- The Joint Commission Standards
- State licensing regulations
- Institutional policies

---

## Revision History

| Rev | Date | Description | Author |
|-----|------|-------------|--------|
| 1.0 | [DATE] | Initial release | [AUTHOR] |