TITLE: GUIDELINE FOR COMPLETION OF THE MULTIDISCIPLINARY ADMISSION/DISCHARGE DATABASE

EXCEPTIONS:  Nursery areas will continue to utilize the assessment and discharge planning tools specified for their patient population.

INSTRUCTIONS FOR PAGE ONE:

Unlicensed personnel may assist in completing page one of the MADD form.

1. Attach patient identification label to the upper left-hand corner of the first page.
2. Indicate the date and time the form is initiated.
3. Indicate the location from which the patient was admitted.
4. Indicate from whom the information is derived.
5. Indicate who will be the emergency contact person for the patient.
6. Indicate the contact person’s relationship to the patient.
7. Indicate the phone number of the contact person (locally or at primary residence, or a work number).
8. Patient's Perception of problem/reason for hospitalization:  Provide information in this section regarding the patient's description of his/her illness and reason for hospitalization.
9. Collect and record the following baseline date:  height, weight, temperature, pulse, respirations, blood pressure.
10. Personal Property:  Document the valuables and articles of clothing in the patient's possession at the time of admission or if sent home with family members, their name, or if sent to sate, attached receipt to the D/C Summary Sheet.
11. Special Assist Devices:  Document any special assist devices the patient may use and the disposition of these devices at the time of admission.
12. Medication Review:  List all medications patient is currently taking.  Include name of medication, dose, frequency, and time of last dose.
13. Teaching/Learning Needs:  Indicate level of patient's education.  Mark the areas that patient will need more instruction on:  diet, disease/illness, health maintenance, medications, equipment, risk factors and/or procedures.
14. Immunizations:  Indicate the dates of when the patient received these immunizations  Hepatitis, Pneumococcal, H-Flue.
15. Spiritual Needs:  Indicate the spiritual needs of the patient by asking the questions listed on the form.  Indicate the primary language of the patient and whether or not an interpreter will be needed.
16. Pain Screening:  Indicate the pain needs of the patient by asking the questions listed on the form.  If "yes" is given to any of the questions, the RN must complete and document a more thorough pain asssessment.
17. Fall Risk Screening:  Based on the patient's risk factors, complete the tool with a score.  If patient scores a 7 or greater, implement the Nursing Falls Protocol.

INSTRUCTIONS FOR PAGE TWO:

1. Nutritional Screening:  Complete the information regarding the patient's nutritional status.
2. Advanced Directives:  Indicate the Advanced Directives for the patient and whether or not a copy of the Directive is placed on the chart.
3. Allergies:  Indicate the patient's known allergies, reaction/symptoms experienced, when they occurred and how they were treated.  If "no allergies", write "N/A" in this space.  If allergies are noted, the chart must be labeled with the allergies and an allergy band is placed on the patient's wrist (same wrist as Patient ID Band).
4. Patient's Pre-Admission Living Situation/Resources:   Indicate the information listed in this section by asking the questions listed.
5.  Transportation Plans at Discharge:  Indicate the information by asking the questions listed in this section.
6. Comments/Additional Information:  Write out any additional information or comments that are is not covered in any section of the MADD Form.
7. Required Signatures:  Person completing the form is to sign on the Completion into Access Center line.  Any person(s) helping to complete the form is to sign on the Assisted in Completing Form line.

INSTRUCTIONS FOR PAGE THREE:  HISTORY

1. In each of the sections, review the descriptors/diseases/symptoms listed and mark all that are applicable to the patient.
2. If there is a disease/symptom/descriptor not listed that the patient mentions in the particular section, write it out in the lines provided under the section.
3. If there are "No History of Problems", mark the "No History of Problems" box.
4. The following sections will be included in the History Sections:  Neurological/EENT, Cardiovascular, Respiratory, Gastrointestinal/Endocrine, Genitourinary, Integument, Psychosocial,
5. Hemodynamic, Musculoskeletal/Activity/Rest, Gynecological, and Pain.

INSTRUCTIONS FOR PAGE FOUR:  BIOPHYSICAL ASSESSMENT:

This part of the MADD form must be completed by a Licensed Nurse.

For findings consistent with the normal assessment descriptors in the boxes, mark WNL box.  For abnormal findings, write the exception in the space provided.

1. The Biophysical Assessment will include the following: Neurological/EENT Assessment, Cardiovascular Assessment, Respiratory Assessment, Gastrointestinal/Endocrine Assessment, Genitourinary Assessment, Psychosocial Assessment, Integumentary Assessment, Musculoskeletal Assessment and Maternal (Pregnancy) Assessment.
2. The Licensed Nurse who completed the Biophysical Assessment sections signs on the line for RN signature.
3. Indicate Date and Time Biophysical Assessment section was completed.
4. Licensed Nurse reviews all information and initiates the Plan of Care for the patient.

RESOURCE PERSON(S):  Pam LaBorde, RN, MSN; Joyce Randof, RN, MSN

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