How to Receive a New Patient

A new patient usually comes into the wards either from emergency or from out-patient department (OPD). Following things need to be carried out when receiving a patient:

1. Initial Assessment

• Take vitals of the patient — BP, Pulse, Temperature, Respiratory Rate
• If you find anything serious or unexpected (e.g., fits in a patient of stroke, or high blood sugar in a patient admitted for a routine hernia operation), inform your senior on call immediately

2. Review Admission Notes

• Carry out any urgent advice written on the emergency chart or on the admission slip
• Review the reason for admission and preliminary diagnosis

3. Create Ward Chart

• Make a new chart for the patient — the ward chart
• Fill in the patient's Biodata with date and time of admission
• Append the admission slip (if from OPD) or the emergency chart to the new ward chart

4. Write Receiving Notes

• Under "Receiving Notes", document:
  • Vital signs
  • Current clinical status (e.g., "patient is in respiratory distress and is irritable")
  • Any immediate concerns

5. Baseline Investigations

• If admitted through OPD, send baseline investigations:
  • CBC (Complete Blood Count)
  • RBS (Random Blood Sugar)
  • RFTs (Renal Function Tests)
  • LFTs (Liver Function Tests)
• If patient is above 40, diabetic, or has known heart disease: ECG
• If patient has cardio-respiratory problem or needs general anaesthesia: Chest X-ray

6. Emergency Investigations

• If the patient came from emergency, ensure all investigation reports are collected
• Review the reports and notify your senior of any abnormal findings
• Append reports to the patient's chart and take necessary action

7. Drug Chart

• Write drug chart according to the Ward Advice written on the emergency chart
• When in doubt, ask your Postgraduate (PG)
• Ensure the new patient receives first doses of prescribed medicines

8. Special Considerations

• A large number of drugs that are otherwise used routinely may be contraindicated or need dose modification in patients who are:
  • Pregnant or lactating
  • Have renal and/or hepatic impairment
• Be very careful when writing drug charts for these patients
• If in doubt, consult the pharma guide and your seniors

9. Pregnancy Check

• In female patients of childbearing age, ascertain if she is pregnant
• If the patient is not sure, consider a pregnancy test
• Investigations involving radiation exposure (X-rays, CT scans, contrast studies, radionuclide scans) are generally contraindicated during pregnancy