Elements and Performance Criteria
- Assess the inpatient
- Admit client to the inpatient care facility in accordance with organisation policies and procedures
- Prepare for inpatient assessment in accordance with clinical guidelines, codes and organisation policies and procedures
- Obtain and record client history in order to gather data to contribute to the inpatient assessment
- Follow personal hygiene and infection control procedures
- Conduct physical examination in order to gather data to contribute to the inpatient assessment
- Formulate an inpatient diagnosis
- Analyse data gathered during the inpatient assessment in order to recognise abnormal trends for comparison with normal health patterns
- Interpret analysed data to establish what information has clinical significance in relation to the client's health status
- Organise data of clinical significance into meaningful clusters to focus on correct identification of any health problem(s)
- Formulate inpatient diagnosis based on the analysis, interpretation and clustering of clinically significant data and determined health problem(s)
- Formulate the inpatient care plan
- Establish inpatient care goals to determine the objectives for the inpatient care plan
- Establish expected outcomes of inpatient care to measure the progress of the inpatient care plan
- Establish priorities for inpatient care to anticipate and sequence therapeutic interventions
- Determine therapeutic interventions considering activities of daily living, care priorities and expected outcomes
- Integrate special needs of the client into the inpatient care plan
- Use relevant clinical pathways in the inpatient care plan
- Determine discharge plan considering expected outcomes, support systems and ability to meet activities of daily living
- Obtain authorisation of inpatient care plan by clinical supervisor
- Implement inpatient care
- Coordinate activities of the client, health care providers and significant others in order to implement the inpatient care plan
- Implement care in accordance with the inpatient care plan, therapeutic interventions, clinical guidelines, codes and organisation policies and procedures
- Monitor and record client response to inpatient care in accordance with organisation policies and procedures
- Report inpatient response other than expected outcomes to clinical supervisor
- Evaluate inpatient care
- Measure therapeutic interventions against the goals and expected outcomes in order to amend the inpatient care plan
- Measure inpatient progress against goals and expected outcomes of the inpatient care plan
- Amend inpatient diagnosis based on inpatient progress and response to therapeutic interventions
- Reformulate inpatient care plan based on amended inpatient diagnosis