Second part
- A brief overview of the policies
The policies that will be presented are just a model, and the hospital has the right to make the policy in accordance with its work system.
The policy is reviewed every three years unless there is any change in it during those three years.
At the beginning of each policy, fill out the table as follows:
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At the end of each policy, fill out the table as follows:
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Evaluation policies
Evaluation areas and content policy according to each department
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Politics :
The hospital is committed to clarifying the areas and contents of the evaluation according to each department.
The Purpose :
Clarifying the areas and contents of the evaluation according to each section, which helps provide appropriate medical care to the patient, reach an accurate diagnosis, and develop a treatment plan.
Working procedures:
First: The treating physician:
1- The initial patient evaluation must include identifying the personal history, the patient’s complaints, and the patient’s family history.
2- The initial patient evaluation must clarify the patient’s medical history and medical examination, which includes (vital signs - examination of body systems according to specialty and condition).
3- Review the results of any evaluation performed on the patient outside the hospital (medical report) before admitting the patient for treatment inside the hospital.
4- Identify the patient’s previous treatments and the extent of his response to them in order to:
· Determine the initial diagnosis.
· Determine the research required for the patient.
· Develop an appropriate treatment plan.
· Identify the patient’s medical care needs and choose the best care for him.
5- The doctor re-examines the patient clinically after reviewing the patient’s complete medical history, within 24 hours of the patient’s admission to the hospital, according to the medical history and medical examination form.
6- Each of the departments determines the content of the medical evaluation according to the specialty and clinical work guides (heart, women, dialysis, premature infants).
7- The doctor records the diagnosis, examination results, and medical history in the patient’s file and signs it with the date and time.
8- The doctor re-evaluates the patient based on the results of the tests and examinations and the progress of his health condition. He registers and signs, writing the date and time in the patient’s file.
Secondly, nursing:-
· The nurse evaluates the patient upon admission to the hospital using the nurse evaluation form.
· The initial information and data are recorded when the patient enters the department on the nurse’s patient evaluation form:
- Vital signs (pressure - pulse - respiratory rate - temperature).
- Weight and height.
- Having an allergy.
- Pain assessment
- Evaluation of skin condition
- Assess the patient regarding the possibility of a fall
- Nutritional assessment.
- Evaluation of motor activity.
- The patient’s need for restraint or isolation.
- Informing the patient of his rights, responsibilities, and hospital policy within 24 hours of admission.
Third, anesthesia:
The anesthesiologist evaluates the patient's condition:
1- Before administering anesthesia according to a pre anesthesia sheet form showing the type of anesthesia planned.
2- Observing and evaluating the patient during anesthesia according to the form prepared for this purpose.
3- Evaluate the patient before leaving the recovery room according to the recovery model.
Fourth: Physiotherapist (evaluation of motor, functional, and rehabilitative activity in case the patient needs it).
Fifth: The treating physician evaluates the nutritional needs of patients, especially the cases that are sorted according to the nursing evaluation upon admission.
Sixth: The social worker, according to his job description (he verifies patients’ satisfaction, and conducts social research when the patient needs financial, material, educational, or social support).
Responsible:
Doctor - Nurse - Social Worker.
Forms:
(medical report - patient ticket - emergency form - nursing evaluation - anesthesia sheet - physical therapy form - patient satisfaction questionnaire).
References:
Egyptian Accreditation Standards 2013.
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Timeframe policy for completing the assessment
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Politics :
· The hospital is committed to evaluating the patient and determining his complete needs within 24 hours of his admission to the hospital.
The Purpose :
· Determine sufficient and permissible time to complete the patient’s assessment and determine his needs.
Working procedures:
1. The resident doctor evaluates the patient’s condition upon admission to the hospital.
2. Emergency surgery patient. The treating physician evaluates his condition immediately before performing the operation.
3. The nurse completes the nursing assessment when the patient is admitted to the hospital.
4. The patient is evaluated for physical therapy when he needs it, and this is decided by the treating physician.
5. The consultant evaluates the patient whose presentation is scheduled within a period not exceeding 24 hours for stable cases / anesthesia presentations in the internal department.
6. The anesthesiologist evaluates the patient in cases of emergency operations immediately before performing the operation.
7. The department supervisor calls the patient’s social worker when he needs him.
References:
Egyptian Accreditation Standards 2013
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Minimum frequency policy and re-evaluation content
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Policy:
Re-evaluation of patients in critical and non-critical cases that require long-term (chronic) treatment.
Purpose:
To ensure that patient care and assessment are properly monitored and continued
Working procedures :
First: In acute cases (critical units):
The treating physicians in the departments evaluate and determine the following
1- Degree of awareness and awareness.
2- Vital signs.
3- The occurrence of complications.
4- The results of the tests and treatment or (surgical interventions).
5- The extent of response to treatment.
o The nursing evaluation rate is continuous, and the alternate doctor is called when a critical result is issued (physiological - laboratory - x-ray) and when there is pain, and the doctor re-evaluates.
o The re-evaluation of the patient is documented and a follow-up note is recorded at least once per shift (every 24 hours), and any procedures resulting from a call or emergency or important events for the patient are recorded with the date and hour.
Second: In non-acute cases:-
Treating doctors evaluate patients in non-acute cases and ensure...
· Vital Signs .
· Complications occur
· The results of the tests and treatment
· Patient compliance with treatment and medical instructions.
This is done every 12 hours for the internal department by the specialist or doctor on duty, unless the clinical evidence requires less than that and this is documented in the patient’s file.
Third: Conditions that require long-term treatment (chronic diseases)
The doctors treating the departments that care for patients who need long-term or (chronic) treatment ensure that:
· Vital Signs .
· Complications occur.
· Results of tests and treatment.
· The extent of the disease.
The frequency of re-evaluation shall be once a day by the doctor on duty or as required by clinical evidence and documented in the patient’s file.
1. The specialist doctor re-evaluates the patient from various specialties while the patient is in the hospital to determine the extent of the response to the treatment and its effectiveness.
2. The on-duty nurse re-evaluates the patient each shift to determine the patient’s needs.
Fourth: Cases that need to be re-evaluated
· The treatment plan developed for the patient Individualized care plan
· Change in patient condition
· Diagnosis Patient diagnosis
· Expected outcome of care, treatment or service
· The extent of the patient’s response to previous treatment
3. The re-evaluation is documented in the patient’s file
The patient should be re-evaluated immediately before anesthesia is administered
Fifth: Content of re-evaluation for nursing
1- Vital signs: every 6 hours in inpatient departments, every 2 hours in care and premature care, after blood transfusion, before surgical operations, during recovery, and when the patient complains that requires re-measurement, or according to the doctor’s instructions.
2- Pain:
3- The possibility of the patient falling: every shift.
4- Skin condition: all skin color during recovery.
5- Nutritional evaluation: when the patient needs it according to the doctor’s orders.
6- Measuring blood sugar: according to the doctor’s instructions.
7- The patient’s need for restraint or isolation: according to the doctor’s orders.
Forms: Medical follow-up form.
References: Egyptian Accreditation Standards 2013
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Pain assessment, re-evaluation and management policy
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Policy:
The hospital is committed to a process of assessment, re-evaluation and pain management.
Purpose:
To explain the process of assessing, re-evaluating, and treating pain.
Procedures :
1- The responsible nurse assesses the pain (according to the following table), determines its severity, describes the pain and its frequency by asking the patient and looking at the patient’s facial expression (in the event that he is unable to speak or in the event that he is a child), and this is recorded in the pain assessment form and kept in the patient’s file when Admission of the patient to the hospital.
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2- The treating physician develops a pain treatment plan and records this in the patient’s medical file.
3- The responsible nurse implements the treatment and follow-up plan according to the pain model and the doctor’s instructions.
4- The responsible nurse re-evaluates the pain and records it in the previous form and completes it with each nursing shift. It is possible to re-evaluate more than that depending on the patient’s condition:
1. The charge nurse reassesses pain once before surgical operations, after surgical operations, once every hour for 3 hours, then every shift, or according to the doctor’s orders.
2. The charge nurse reassesses pain if pain is present and one hour after pain medication is given.
Responsible: Nursing staff members - Doctor.
Forms : Pain Assessment Form .
References:- Approved Egyptian Accreditation Standards 2013
Attachments : Clinical evidence for the indications for medications used to treat pain
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