Patient Admission Procedure

What is patient admission?

Patient admission is a structured process in a healthcare facility where a patient is formally accepted for care and treatment. This procedure involves several steps, such as recording patient information, medical history, and consent for treatment. 

The first part of admission, known as patient intake, specifically refers to collecting key demographic, social, and clinical data. Intake also involves obtaining insurance details and any necessary payments. The entire process ensures that all relevant data is collected to support the patient's treatment plan and that regulatory requirements are fulfilled. Ultimately, a smooth admission process contributes to effective patient care and satisfaction.

Step-by-step admission process

When admitting a patient, follow this process:

Patient Intake

1. Welcome the patient warmly and guide them through the intake process. Maintain a professional, empathetic demeanor.
2. Collect demographic information, including name, date of birth, contact details, and emergency contacts.
3. Obtain clinical data, including the patient's medical history, current medications, allergies, and the reason for admission.
4. Record social information, such as occupation, living conditions, and any pertinent lifestyle factors.
5. Secure consent forms for treatment, privacy practices, release of medical information, and other procedures as required.
6. Request insurance information and facilitate any necessary payments. Inform the patient of their financial responsibilities, such as deductibles, copays, or self-pay amounts.

Medicare and Medicaid Requirements

1. For patients covered by Medicare or Medicaid, ensure compliance with the guidelines of the Centers for Medicare & Medicaid Services (CMS).
2. Complete the necessary CMS certification, confirming that hospital admission is required and justified for the patient. A physician must certify that the hospitalization is required for further diagnostic study or therapeutic treatment.
3. Document the reasons for admission, the estimated time the patient will need to stay in the hospital, and the plans for post-hospital care.
4. Order forms must be completed promptly and must include sufficient information to support the decision for admission.
5. Review and verify all documentation for completeness and accuracy. Keep updated on CMS regulatory changes to maintain compliance.

Patient Education and Communication

1. Inform the patient about the purpose and process of their admission, the expected duration of their stay, their rights and responsibilities, visiting hours, and other relevant details.
2. Discuss the care plan with the patient and their family, ensuring they understand their diagnosis, planned treatments, possible risks, and expected outcomes.
3. Provide written materials as a reference for the patient and family, including a hospital handbook, informational brochures about their condition, and emergency contact information.
4. Create an open line of communication. Encourage the patient and their family to ask questions and express any concerns. Provide clear, straightforward answers, using non-medical language whenever possible.
5. Engage in shared decision-making, involving the patient and their family in decisions about their care as much as possible.

Final Note: Maintain patient privacy and confidentiality throughout the admission process. Use patient information only for the intended purposes and store it securely. Remember to document all information accurately in the patient's medical record for reference and continuity of care.

Revision: Review this SOP periodically to ensure that it remains in line with current best practices and regulations. Training and assessment should be conducted regularly to ensure that healthcare personnel understand and can carry out this SOP correctly.