Ga. Comp. R. & Regs. R. 111-8-40-.19 - Patient Assessment and Treatment

All patient care services provided by the hospital shall be under the direction of a member of the medical staff or a licensed physician, dentist, osteopath, or podiatrist who has been granted hospital privileges.

(a) Patient Assessment/Screening on Admission. The hospital shall provide each inpatient with an appropriate assessment of the patient's condition and needs at the time of admission. Such assessments shall be provided by personnel authorized by hospital policy or the medical staff bylaws and/or rules and regulations and shall be designed to trigger referral for further assessment needs.

1. A history and physical examination shall be completed within the first twenty-four (24) hours after admission. A history and physical examination completed by either the patient's physician or the appropriate practitioner operating under the direction of the physician as authorized by law no more than thirty (30) days prior to the admission may be accepted but must be updated to reflect the patient's condition at the time of admission. Where the patient is admitted solely for oromaxillofacial surgery, such history and physical may be completed by the oromaxillofacial surgeon.

2. A basic nursing assessment to include at least evaluation of physical and psychological status sufficient to develop an initial plan of care shall be completed within the first twelve (12) hours after admission. Within twenty-four (24) hours after admission, a comprehensive nursing assessment will be completed to include at least:

(i) Screening and referral for further assessment of patient needs related to social, nutritional, and functional status; and

(ii) Screening of educational and potential post-hospitalization needs.

3. Inquiry as to the status of any advance directives for the patient shall be made at the time of admission.

(i) If a patient has an advance directive in place that the patient wishes to invoke, but the written directive is not available at the time of admission, there shall be a mechanism in place to trigger a recheck by hospital personnel for the document within a reasonable period of time.

(ii) If the patient does not have an advance directive in place, admissions procedures shall require that designated hospital personnel will offer information regarding advance directives according to hospital policy and timelines.

(b) Patient's Plan of Care.

1. On admission, the plan of care shall be initiated by the designated hospital staff for each patient to meet the needs identified by the initial assessments. The initial plan of care shall be placed in the patient's record within twelve (12) hours of admission.

2. As the patient's treatment progresses, the plan of care shall be updated to reflect any changes necessary to address new or changing needs.

(c) Reassessments of the Patient's Condition. Reassessment of the patient's condition shall be performed periodically at appropriate intervals and defined in hospital policy. In addition, reassessments shall occur at least as follows:

1. During and following an invasive procedure;

2. Following a change in the patient's condition or leve l of care;

3. During and following the administration of blood and blood products;

4. Following any adverse drug reaction or allergic reaction; and

5. During and following any use of physical restraints or seclusion.

(d) Other Treatment Requirements.

1. All patients shall be given the opportunity to participate, or have a designated representative participate, in decisions regarding their care.

2. Patients shall be provided treatment free from physical restraints or involuntary seclusion, unless utilized solely for protection during brief transport to a specified destination or authorized by a physician's order, for a limited period of time, to protect the patient or others from injury. Policies and procedures shall be in place to require that a patient's physical comfort and safety needs are addressed during any period of required physical restraint or confinement. A positioning or securing device used to maintain the position, limit mobility, or temporarily immobilize during medical, dental, diagnostic, or surgical procedures is not considered a restraint.

3. Patients shall receive care in a manner free from all forms of abuse or neglect.

4. Patients shall receive treatment in an environment that respects their personal privacy, both of their physical person and their treatment information.

5. The hospital shall establish and enforce policies and procedures that require that all personnel providing direct care to the patient identify themselves to the patient by name and title or function.

Notes

Ga. Comp. R. & Regs. R. 111-8-40-.19

O.C.G.A. § 31-7-2.1.

Original Rule entitled "Patient Assessment and Treatment" adopted. F. Feb. 20, 2013; eff. Mar. 12, 2013.