New Referral Received: Admit to Ward Ward Administrator: Gives Family Form 1 Gives Family Form 2 To Family Family: Completes Family Form 1 To Ward Administrator Completes Family Form 2 To Nurse Ward Administrator: Family Form 1 on PiMS Signs Family Form 1 that PiMS record updated Prepares Medical Record to contain: Family Form 1 Birth History Immunisation & Infectious Disease Record Patient Assessment Form Nurse or Health Care Assistant: Reviews Family Form 2* with Family Annotates Family Form 2 as necessary or Completes Family Form 2 by interviewing Family Files at bedside in Nursing Record N.B. Checked by supervising nurse Nurse or Health Care Assistant: Commences Patient Assessment or Completes Patient Assessment Records on Patient Assessment Form Creates: Birth History Immunisation & Infectious Disease Record N.B. Checked by supervising nurse Doctor or Other Competent Professional: Reviews Family Form 2 Commences Patient Assessment or Completes Patient Assessment Records on Patient Assessment Form Creates: Birth History Immunisation & Infectious Disease Record Doctor or Other Competent Professional: Writes Management Plan for Discharge Refers to Multi-disciplinary Team Records on Patient Assessment Form Nurse or Health Care Assistant: Negotiates care plan with Child & Family Refers to Multi-disciplinary Team N.B. Checked by supervising nurse Multi-disciplinary Team: Annotates: Family Form 2* & Patient Assessment Form To Ward Administrator for PiMS updating * = Family Form 2 may be re-used for subsequent admissions for up to one year When a newly referred patient is to be admitted to a ward, the following process takes place… When a newly referred patient is admitted as an emergency admission to a ward, the ward administrator gives Family Form 1 to the parents to complete. Although the patient is newly referred they may have previously been an in-patient. Where this occurs, the ward administrator checks the patient’s records to ascertain if there is an existing current Family Form 2. If the child has significantly changed, or the form has become illegible due to repeated admissions, the parents may be asked to complete a new form. The ward administrator will ask the nurse who is the most appropriate person to issue the form. It may be issued by nurses, health care assistants or ward administrators. The nurse will use their professional judgment to decide if the patient or their parents should be asked to complete Family Form 2 or if they should be interviewed.

New Referral Received: Admit to Ward Ward Administrator: Gives Family Form 1 Gives Family Form 2 To Family Family: Completes Family Form 1 To Ward Administrator Completes Family Form 2 To Nurse Ward Administrator: Family Form 1 on PiMS Signs Family Form 1 that PiMS record updated Prepares Medical Record to contain: Family Form 1 Birth History Immunisation & Infectious Disease Record Patient Assessment Form Nurse or Health Care Assistant: Reviews Family Form 2* with Family Annotates Family Form 2 as necessary or Completes Family Form 2 by interviewing Family Files at bedside in Nursing Record N.B. Checked by supervising nurse Nurse or Health Care Assistant: Commences Patient Assessment or Completes Patient Assessment Records on Patient Assessment Form Creates: Birth History Immunisation & Infectious Disease Record N.B. Checked by supervising nurse Doctor or Other Competent Professional: Reviews Family Form 2 Commences Patient Assessment or Completes Patient Assessment Records on Patient Assessment Form Creates: Birth History Immunisation & Infectious Disease Record Doctor or Other Competent Professional: Writes Management Plan for Discharge Refers to Multi-disciplinary Team Records on Patient Assessment Form Nurse or Health Care Assistant: Negotiates care plan with Child & Family Refers to Multi-disciplinary Team N.B. Checked by supervising nurse Multi-disciplinary Team: Annotates: Family Form 2* & Patient Assessment Form To Ward Administrator for PiMS updating * = Family Form 2 may be re-used for subsequent admissions for up to one year The parents complete Family Form 1 and give it to the ward administrator. The parents complete Family Form 2 and give it to the nurse. Family Form 2 may be reused for up to one year and annotated for subsequent admissions. The patient should be actively engaged whenever possible, encouraged to provide information for themselves, and to be involved in the assessment process. Communication support needs must be assessed to enable full participation in the assessment process and a complete assessment to be made.

New Referral Received: Admit to Ward Ward Administrator: Gives Family Form 1 Gives Family Form 2 To Family Family: Completes Family Form 1 To Ward Administrator Completes Family Form 2 To Nurse Ward Administrator: Family Form 1 on PiMS Signs Family Form 1 that PiMS record updated Prepares Medical Record to contain: Family Form 1 Birth History Immunisation & Infectious Disease Record Patient Assessment Form Nurse or Health Care Assistant: Reviews Family Form 2* with Family Annotates Family Form 2 as necessary or Completes Family Form 2 by interviewing Family Files at bedside in Nursing Record N.B. Checked by supervising nurse Nurse or Health Care Assistant: Commences Patient Assessment or Completes Patient Assessment Records on Patient Assessment Form Creates: Birth History Immunisation & Infectious Disease Record N.B. Checked by supervising nurse Doctor or Other Competent Professional: Reviews Family Form 2 Commences Patient Assessment or Completes Patient Assessment Records on Patient Assessment Form Creates: Birth History Immunisation & Infectious Disease Record Doctor or Other Competent Professional: Writes Management Plan for Discharge Refers to Multi-disciplinary Team Records on Patient Assessment Form Nurse or Health Care Assistant: Negotiates care plan with Child & Family Refers to Multi-disciplinary Team N.B. Checked by supervising nurse Multi-disciplinary Team: Annotates: Family Form 2* & Patient Assessment Form To Ward Administrator for PiMS updating * = Family Form 2 may be re-used for subsequent admissions for up to one year The ward administrator records the information from Family Form 1 onto PiMS. The administrator prepares the medical record: The Birth History Form, the Immunisation & Infectious Disease Record and Family Form 1 are filed in the Birth, Immunisation & Family Form 1 section. The Patient Assessment Form (PAF) is filed in the Clinical Records – Medical section. The nurse reviews the information provided by the parents/patient on Family Form 2 and completes any outstanding aspects. The form is filed in the Nursing Record at the bedside. The doctor also reviews the information provided by the parents/patient on Family Form 2 to inform the assessment of the patient. The patient should be actively engaged whenever possible, encouraged to provide information for themselves, and to be involved in the assessment process.

New Referral Received: Admit to Ward Ward Administrator: Gives Family Form 1 Gives Family Form 2 To Family Family: Completes Family Form 1 To Ward Administrator Completes Family Form 2 To Nurse Ward Administrator: Family Form 1 on PiMS Signs Family Form 1 that PiMS record updated Prepares Medical Record to contain: Family Form 1 Birth History Immunisation & Infectious Disease Record Patient Assessment Form Nurse or Health Care Assistant: Reviews Family Form 2* with Family Annotates Family Form 2 as necessary or Completes Family Form 2 by interviewing Family Files at bedside in Nursing Record N.B. Checked by supervising nurse Nurse or Health Care Assistant: Commences Patient Assessment or Completes Patient Assessment Records on Patient Assessment Form Creates: Birth History Immunisation & Infectious Disease Record N.B. Checked by supervising nurse Doctor or Other Competent Professional: Reviews Family Form 2 Commences Patient Assessment or Completes Patient Assessment Records on Patient Assessment Form Creates: Birth History Immunisation & Infectious Disease Record Doctor or Other Competent Professional: Writes Management Plan for Discharge Refers to Multi-disciplinary Team Records on Patient Assessment Form Nurse or Health Care Assistant: Negotiates care plan with Child & Family Refers to Multi-disciplinary Team N.B. Checked by supervising nurse Multi-disciplinary Team: Annotates: Family Form 2* & Patient Assessment Form To Ward Administrator for PiMS updating * = Family Form 2 may be re-used for subsequent admissions for up to one year The nurse, health care assistant, doctor or other health care professional will commence the assessment of the patient and records the assessment on the Patient Assessment Form (PAF). The birth part of this history is recorded on the Birth History Form. The patient’s immunisation & infectious disease history is recorded on the Immunisation & Infectious Disease Record. Different professionals, according to their competence and confidence, may complete the assessment of the patient. Each section of the form has a box to be completed that identifies who completed that part of the assessment. Any additional admission assessment of the patient by another health care professional is to be recorded on the appropriate part of PAF. All entries on the Patient Assessment Form must be signed and dated according to hospital policy. Concerns arising from the assessment of the patient should be communicated to the person responsible for the patient’s admission and treatment. The patient should be actively engaged whenever possible, encouraged to provide information for themselves, and to be involved in the assessment process.

New Referral Received: Admit to Ward Ward Administrator: Gives Family Form 1 Gives Family Form 2 To Family Family: Completes Family Form 1 To Ward Administrator Completes Family Form 2 To Nurse Ward Administrator: Family Form 1 on PiMS Signs Family Form 1 that PiMS record updated Prepares Medical Record to contain: Family Form 1 Birth History Immunisation & Infectious Disease Record Patient Assessment Form Nurse or Health Care Assistant: Reviews Family Form 2* with Family Annotates Family Form 2 as necessary or Completes Family Form 2 by interviewing Family Files at bedside in Nursing Record N.B. Checked by supervising nurse Nurse or Health Care Assistant: Commences Patient Assessment or Completes Patient Assessment Records on Patient Assessment Form Creates: Birth History Immunisation & Infectious Disease Record N.B. Checked by supervising nurse Doctor or Other Competent Professional: Reviews Family Form 2 Commences Patient Assessment or Completes Patient Assessment Records on Patient Assessment Form Creates: Birth History Immunisation & Infectious Disease Record Doctor or Other Competent Professional: Writes Management Plan for Discharge Refers to Multi-disciplinary Team Records on Patient Assessment Form Nurse or Health Care Assistant: Negotiates care plan with Child & Family Refers to Multi-disciplinary Team N.B. Checked by supervising nurse Multi-disciplinary Team: Annotates: Family Form 2* & Patient Assessment Form To Ward Administrator for PiMS updating * = Family Form 2 may be re-used for subsequent admissions for up to one year The doctor or any other competent professional writes a management plan to enable discharge in the PAF. The patient may also be referred to the multi-disciplinary team. The nurse identifies and negotiates the plan of care with the patient and their parents. This is recorded on the patients care plan. Members of the multi-disciplinary team record any additional assessment of the patient on Family Form 2 and the PAF as appropriate. The Ward Administrator will record any additional personal data onto PiMS. You have now reached the end of this demo