Admission to the inpatient department
Patients arriving at the ward are received by the assistant preparing the documentation. The medical chart is compiled in the office or the ambulatory unit on the basis of the outpatient medical record containing the details of the scheduled surgery, which the treating physician signs and stamps. After that, the nurse prepares the nursing documentation at the ward and assigns the patient to a bed. It is compulsory to use the hospital gown available in the storeroom. The patient is informed about the in-house rules and regulations. The nurse on the shift makes sure the patient receives the prescribed therapy.
Temperature chart
Taking the temperature: as prescribed in the Hospital’s Rules for Health Documentation Management, in the case of patients with fever temperature must be taken until the fever has subsided. This must be marked in blue on the temperature chart. A heart rate curve must also be recorded at least once a day in case of patients indicated by the physician or based on individual assessment. The heart rate curve must be marked in red on the fever chart.
Record of findings: Abnormal findings will be recorded in the chart by the ward physician depending on the type of the disorder.
Bedside nursing handover
At the beginning of the shift. In the form of verbal bedside handover and also in writing recorded in the documentation.
Rules on consultations
Consultations for outpatients take place at specialist outpatient care. Inpatients’ consultations are bedside consultations involving the physician appointed to hold the consultation or the head surgeon on duty.
Surgery consultation involving a chief physician
Held by the Head of Department (chief physician) or his/her delegate (based on the provisions of the job description).
In case of surgery consultations involving a chief physician, it is reasonable to expect a specialist of a similar position from the related division.
On-duty/ stand-by
See the effective on-duty regulations of the hospital.
As scheduled in advance, there is 1 surgery specialist head surgeon (on duty), 1 resident/trainee specialist on duty, 1 surgery specialist on-call and 1 vascular surgery specialist on-call, on the basis of the monthly on-duty schedule prepared in advance. Should there be any changes in the schedule, the Head of Department (chief physician) and the Medical Director shall be informed in advance.
Patient examinations shall be carried out by the surgery specialist on duty. Acute patients arriving with or without a referral to the General Surgery Division shall register at the ambulatory unit of the Emergency Care Division.
The physician(s) working there assess the patient’s condition (physical, etc.) and perform the necessary examinations. If needed, the physician will initiate surgery-specific examinations.
Non-transportable patients requiring urgent surgical interventions are cared for at the General Surgery Division at all times. The surgery specialist on duty will assess the need for an operation, and the emergency room physician on duty will decide together with the surgery specialist on the transportability of the patient. Outside regular working hours inpatients are attended to by the physician on duty.
During regular working hours, until the beginning of the on-duty time, these tasks are carried out by the physician at the outpatient department or the consulting physician allotted to the specialized consultation.
Events happening in the course of work during on-duty time shall be recorded in writing in the “Event Reporting Register” found in the on-duty room or reported verbally to the physician responsible for on-duty care.