Bure Yohannes Internal Medicine Speciality Center Protocol for Admitted Patient Services
1. Purpose
To ensure comprehensive, patient-centered care for admitted patients through systematic history-taking,
24-hour nursing, regular physician evaluations, and seamless referrals, aligning with national healthcare
standards.
2. Scope
Applies to physicians, nurses, allied health professionals, and administrative staff involved in inpatient
care.
3. Services for Admitted Patients
A) Comprehensive History, Examination & Workup
1. Admission Process:
- Psychiatric History: Use a structured interview (e.g., Mini International Neuropsychiatric
Interview (MINI)) for mood, behavior, and substance use.
- Medical History: Document via HPI (History of Present Illness) and past medical/surgical
history.
- Social History: Assess housing, occupation, support systems, and high-risk behaviors.
2. Physical Examination:
- Perform a head-to-toe assessment using SOAP (Subjective, Objective, Assessment, Plan) format.
- Specialized exams (e.g., neurological for stroke patients).
3. Diagnostic Workup:
- Labs: CBC, electrolytes, renal/liver function, toxicology, cultures.
- Imaging: X-ray, CT, MRI as indicated.
- Other: ECG, EEG, lumbar puncture (if meningitis suspected).
4. Reassessment: Repeat workups for clinical changes or unresolved symptoms.
B) 24-Hour Nursing Care
1. Shift Structure:
- 3 Shifts: Day (7 AM–3 PM), Evening (3 PM–11 PM), Night (11 PM–7 AM).
- Nurse-Patient Ratio: 1:4 for general wards; 1:1–2 for ICU.
2. Core Responsibilities:
- Monitoring: Vital signs every 4–6 hours (or hourly for critical patients).
- Medication Administration: Follow 5 Rights (patient, drug, dose, route, time).
- ADL Support: Bathing, feeding, mobility assistance.
- Pain Management: Assess using Wong-Baker FACES Scale; titrate analgesics.
3. Compliance:
- Hourly rounding for high-risk patients (e.g., fall risks).
- Document interventions in EHR under “Nursing Notes.”
C) Detailed Physician Rounds (Twice Weekly)
1. Round Structure:
- Pre-Rounds: Resident/junior doctor reviews charts, labs, and updates.
- Attending Rounds:
- Bedside evaluation with patient/family.
- Review care plan, adjust medications, and set discharge goals.
- Post-Rounds: Update EHR, order tests, and consult specialists.
2. Documentation:
Bure Yohannes Internal Medicine Speciality Center Protocol for Admitted Patient Services
- Use APACHE II or SOFA scores for ICU patients.
- Document progress in “Physician Progress Notes.”
D) Referral Services
1. Internal Referrals:
- Consult in-house specialists (e.g., cardiology, psychiatry) via EHR.
2. External Referrals:
- Process:
- Complete Referral Form with clinical summary.
- Contact receiving facility to confirm bed/availability.
- Arrange transport (ambulance for unstable patients).
- Follow-Up: Track referral outcomes via Referral Log and obtain feedback.
4. Compliance & Quality Assurance
- Audits**: Monthly chart reviews for completeness of histories, nursing documentation, and round
compliance.
- Training:
- Nurses: Annual BLS/ACLS certification.
- Physicians: Workshops on history-taking and care planning.
- Patient Feedback: Surveys on nursing responsiveness and physician communication.
Approved By:
Dr. Yifru Andualem, Medical Director
Effective Date:15/3/2025 | Revision: Annual
