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inpatient client checklist
Admission Process
Assess client medical history and current medications.
Complete initial health assessment and vital signs check.
Assign client to a room and provide orientation to the facility.
Safety and Security
Conduct safety assessments for potential hazards.
Ensure personal belongings are documented and secured.
Review and implement any necessary precautions (e.g., fall risk).
Verify emergency contact information and advance directives.
Care Plan Development
Collaborate with the multidisciplinary team to create a care plan.
Identify client goals and expected outcomes.
Determine necessary interventions and resources.
Schedule follow-up assessments and evaluations.
Daily Living and Activities
Assess client’s ability to perform activities of daily living (ADLs).
Provide orientation to daily schedule and routines.
Ensure availability of necessary assistive devices.
Encourage participation in therapeutic activities as appropriate.
Medication Management
Review and verify medication orders with pharmacy.
Educate client on prescribed medications and potential side effects.
Monitor and document medication administration.
Schedule regular medication reconciliation.
Nutritional Assessment
Conduct a dietary assessment to evaluate nutritional needs.
Plan and provide meals according to dietary restrictions and preferences.
Monitor food intake and weight changes.
Collaborate with a dietitian as needed.
Discharge Planning
Assess readiness for discharge based on clinical criteria.
Develop a discharge plan including follow-up appointments and referrals.
Provide client and family education on post-discharge care.
Ensure transportation and support systems are in place for discharge.
Documentation
Keep accurate and up-to-date medical records.
Document all assessments, interventions, and client responses.
Review and sign off on all necessary forms and reports.
Ensure confidentiality and security of client information.
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