Prioritizing health and well-being during the patient experience should be the main focus of all a hospital's processes: having optimized systems, updated protocols, prepared supplies, and trained staff will create a cohesive system that will provide a seamless and calm experience that will prevent complications, clinical negligences or administrative barriers.
The patient's experience begins from admission, which, despite its immediacy, represents a critical point that requires special attention.
First, it is essential to have an identified admission area within the hospital where patient information can be recorded promptly. It is recommended that this task be done through automated electronic health records software in order to avoid inconsistencies or loss of documents. In addition to the identification data, the software must identify if they have specific medical insurance, if it is their first admission, or if they have already been treated before, and it is even essential to report whether they arrived at the organization alone or accompanied.
In addition, the hospital must have a medical triage protocol that evaluates whether it has the appropriate infrastructure, specialized staff, and the necessary equipment to provide quality and safe care. Likewise, it is essential to consider what procedures to follow in case no beds are available or the required equipment is not operational, even incorporating the referral process to other healthcare centers.
EHR as a source of patient traceability
Hospital care and quality must remain constant throughout the patient's stay. To achieve this, all collaborators must communicate effectively within the institution. In the age of technology, having an electronic health record (EHR) has become fundamental for healthcare organizations. This type of software records information about the staff, services, and areas and allows detailed monitoring of the services provided.
In the EHR, all crucial data and movements of the patient during their stay are recorded:
- The responsible treating physician and their requests for studies or procedures, as necessary, are recorded.
- The medical indication functionalities allow clear and accessible documentation in the clinical record, ensuring adequate traceability and minimizing the risks of confusion, misinterpretation, or negligence.
- It is allowed to attach the patient's informed consent before any surgery, as well as any request for additional material or equipment for monitoring and control.
- Requests for consultations between specialties, observations by nursing staff, and completed, pending, or scheduled administration of medications are documented.
Patient transport by ambulance
Transferring patients between hospital establishments is a crucial process that must be approached with the highest attention and care. In many organizations, especially those part of a healthcare network, protocols and procedures are usually established to carry out scheduled or emergency transfers.
The key to successful transfers relies on establishing formal agreements with receiving hospitals and other healthcare service providers that ensure their adherence to current local standards and legislations, facilitate the transfer process, and commit to providing coordinated care.
The institution must monitor the quality and safety of ambulance services, whether provided directly by the hospital or through subcontracting. This topic includes response time, patient care, trained personnel, safety and necessary equipment, and the response to complaints or claims related to services.
When a transfer is made, it is necessary to have detailed documentation that outlines the patient's care summary, diagnosis, treatment received to date, procedures performed, therapeutic indications, treating physicians, and any additional relevant information. This documentation is shared with the receiving hospital to ensure a smooth transition and continuity of care.
Patient discharge and follow-up
When a patient is discharged, it is essential to follow precise procedures and document all instructions provided, including medication intakes, physical therapies, rehabilitation, diet, and suggested physical activity, among others.
In particular situations, such as temporary departures or special permits, the associated risks and specific indications must also be recorded in the electronic health record. The patient and their family must be fully informed about the reason for discharge, the schedule, the doctor, and relevant instructions.
The pillar in this final stage of the process is a complete discharge note. This should include the reason for discharge, a summary of the evolution of the case, the final diagnosis, medications administered, the patient's condition at the time of discharge, prognosis, management and treatment plan, advice for outpatient surveillance, and any other details relevant to the continuity of care.
From admission through care and transfer to discharge and post-hospitalization indications, communication between medical collaborators is notable, with the electronic health record being the source of basic information that will be used for all stages during the patient's stay. The appropriate linking of the areas will ensure adequate services and careful monitoring that will significantly contribute to your long-term recovery and well-being.
