2.2.02 Findings on admission

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 minimum data set for the collection of findings by doctors, nurses and other clinical disciplines must be defined. The data set can also be defined in relation to the speciality or the problem (leading symptom).
Separate data sets should be defined for individual patient groups, e.g. for children, adolescents, the frail, the dying, pain patients, pregnant women, psychiatric patients, addicts, victims of violence and abuse, patients with communicable diseases, patients undergoing chemotherapy or radiotherapy.
For each indication (especially surgical interventions), a findings status should be defined, which must be available as a minimum.
If possible, the assessment concludes with a treatment plan.
The initial assessment should be completed 24 hours after admission, or earlier if necessary.
Requirements for the qualifications of the persons who collect the findings must be defined.
Definition of a general screening programme (examinations to be carried out on every patient before admission).
Questioning about pain
Definition of special screening programmes (examinations to be carried out on individual patient groups, e.g. patients with diarrhoea or at risk of MRSA).
The protection of personal privacy must be guaranteed.

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