2.2.02 Findings on admission Estimated reading: 1 minute 60 views Authors Goal and purpose The aim of the assessment must be to make a highly reliable decision as quickly as possible as to whether the patient requires inpatient treatment or not. The interview and physical examination should be problem-orientated. The questioning and examination are initially aimed at establishing a diagnosis, but also serve to identify other problems at an early stage. Separation into medical admission, nursing admission and anamnesis by social services must be avoided. The data should be collated and ranked as a problem list. Special preferences and needs - even those that the patient is not aware of - should be discovered and documented. The protection of personal privacy must be guaranteed. Area of application Description of the Documentation Resources Responsibility and qualification Notes and comments Applicable documents Literature Terms Attachments No attachments 2.2 Planning for the individual patient - Previous 2.2.01 Admission of a patient Next - 2.2 Planning for the individual patient 2.2.03 Findings brought along: utilisation
