Second part

- Nursing plan policy

Policy name

Nursing plan policy

Policy number

Issue date and number

Review Date

Number of pages

All hospital departments

Politics :

The Services Department is committed to providing nursing care according to the patient’s needs and documenting it in the nursing care plan for each patient.

The Purpose :

1. Understand the patient’s needs and meet them.

2. Provide high-quality nursing care.

Steps:

The nursing team does:

1. Conduct a nursing assessment of the patient upon admission and determine the patient’s problems.

2. Writing down the patient’s nursing problems in the nursing plan, which includes: (problems/needs - nursing intervention - evaluation - signature).

3. Write the necessary procedures to help solve nursing problems.

4. Re-evaluation to determine the extent of the patient’s response to nursing interventions.

5. The department supervisor follows up the plan and implements its procedures.

Administrator :

Department Supervisor - Charge Nurse.

Models:

Nursing care plan template.

The Reviewer :

Comprehensive hospital accreditation guides.

Preparation	Review	The trust

Nursing registration policy

Policy:

The Nursing Services Department is committed to accurate nursing registration 24 hours a day in a correct, accurate and legible manner

The Purpose:

Record all patient data.

Teaching health team members to register on nursing forms in a correct, accurate and legible manner.

Steps:

The nursing team members do:

1. Recording every activity performed by the patient from the moment he enters his form.

2. The team begins by evaluating the patient using the prepared form.

3. The patient’s main complaint is identified and needs are determined.

4. Planning the care that will be provided to the patient.

5. Implement the plan carefully to obtain the desired results.

6. Evaluate the plan each shift to identify the development of the situation.

7. Repeat any of the steps of the plan that did not improve the patient’s condition.

8. Monitor vital signs and notify the doctor when any change occurs from normal levels.

9. The necessity of working and submitting a report on any emergency incident during the work period, such as (patient falling - patient escaping - error in administering treatment).

10. The health team members must pay attention to recording the nursing progress, which includes (the patient’s condition - the doctor’s recommendations - all medical procedures, tests, rumors - and surgical interventions - nursing intervention - patient evaluation for no new signs and symptoms).

Administrator :

Nursing staff members

Models:

Nursing notes - nursing assessment - vital signs - nursing care plan - treatment charts

The Reviewer:

Operational guide for nursing services at the Ministry of Health.

Preparation	Review	The trust

Policy for assessing patients for abuse or neglect

Policy:

The hospital is committed to preventing harm or neglect to patients while they are in the hospital and dealing with these cases as soon as they occur to eliminate harm or neglect to patients while dealing with them.

Purpose:

To develop methods for dealing with patients in the event of exposure to abuse or neglect.

Mistreatment:

the patient while he is in the hospital, which leads to him being exposed to physical or psychological harm/injury, or both. There are types

Different types of mistreatment can be divided into:

Mental abuse:

By affecting the mental state.

Manifestations of mental abuse:

· Verbal assault.

· To threaten .

· Intimidation .

· isolation .

· Insult.

· Humiliation.

· Deprivation .

Physical abuse:

By affecting the patient's physical condition by exposing the patient to (beating, slapping, kicking).

Manifestations of physical abuse:

· Patient falling.

· The appearance of bed sores in the patient.

· The presence of wounds that are not well cared for.

· The presence of unexplained injuries.

· Physical pain when touched.

· The presence of marks resulting from biting, scratching, abrasions or bruises.

· Unexplained signs of dehydration and malnutrition, sickness, sunken eyes, or eye injuries.

· The presence of blood stains in the underwear.

Sexual mistreatment:

The patient is exposed to any form of sexual assault/harassment.

Physical abuse:

Manifestations of physical abuse:

· theft .

· Misuse of money and property.

· blackmail .

· scam .

· There are abnormal actions in the patient’s bank account.

· Indifference to spending money.

Negligence:

It is any negligence [dereliction of treatment] that harms a patient in need without an acceptable medical reason from a responsible person while the patient is in the hospital.

Special need:

He is a person who needs the help of another due to (a mental disability, age deficiency, or brain atrophy/dysfunction), which hinders the person’s ability to protect himself or provide his own care.

Types of negligence that the patient may be exposed to:

· Negligence in medical and nursing care.

· Neglecting to give treatment doses.

· Neglecting social and psychological needs.

· Lack of food/water.

· Placing the patient in an unsafe place or without supervision.

Procedures :

1. The doctor and nurse evaluate the patient’s condition and determine his treatment needs.

2. The doctor and nurse inform the patient of the treatment plan and how to implement it.

3. The nurse teaches the patient how to call her when needed

4. The social worker visits patients in the internal departments daily to monitor patients’ complaints in order to report them to management and those responsible for resolving their complaints.

5. In the event that a case of neglect or abuse is discovered, the patient’s treating physician shall be informed:

- The doctor evaluates the patient’s condition and identifies manifestations of mistreatment or neglect, and a report is written with a commitment to physical and psychological treatment for the cases. - The doctor asks the patient to write his complaint (for the damages inflicted on him) if he wants, with or without a signature.

The head of the medical board appoints whomever he deems appropriate to investigate and follow up on the complaint, then the results are presented to him for necessary action.

Responsible: - Doctor - Nurse - Social Worker.

Forms: - Patient Rights and Duties Form - Form for acknowledging the existence of trusts

Preparation	Review	The trust

Minimum medical history and clinical examination policy

Policy: The hospital is committed to setting the minimum requirements for a patient’s medical examination upon admission.

Purpose: To determine the minimum medical examination and medical history necessary to evaluate the patient upon admission to the hospital.

Working procedures:-

1. The department doctor takes a medical history and examines the patient upon admission according to the medical history and medical examination form, which includes:

· The patient’s personal history, which explains (full name - gender - age - profession - marital status according to the national ID card - special habits such as smoking and drinking alcohol).

· Basic complaint

· Details of current illness

· Previous hospitalization or surgery

· Sensitive

· Drug interactions

· Medications taken by the patient

· History of mental illness

· Genetic history of the disease

2. The doctor conducts a clinical examination of the patient, which includes:-

· Measuring vital signs (pressure - pulse - temperature).

· A comprehensive examination of all parts of the patient’s body.

· Local examination of the patient’s complaint using various manual examination methods.

· The doctor records the examination result and results from the date of admission and the clinical examination in the patient’s file (initial diagnosis).

· The doctor records the initial treatment plan

3. Based on his findings and according to the patient’s need, the doctor orders, in writing on the doctor’s order form, to perform the necessary tests and x-rays for the patient and determines the notes of vital signs that will be taken and the dates for their recording by the department’s nurses.

4. The doctor writes the drug treatment accurately in the treatment description and implementation form.

5. The doctor determines the type of nutrition appropriate for the patient on the doctor’s order form.

6. The nurse records the patient’s data on the food form to bring meals to the patient.

7. The treating physician informs the patient and his family of the initial diagnosis, treatment or surgery plan, potential results, expected complications, and nutritional regimen.

Responsible: The specialist physician

Forms: Sick History and Medical Examination Form - Food Form - Doctor's Orders Form.

References: Egyptian Accreditation Standards 2013.

Preparation	Review	The trust

Policy for identifying categories of hospital patients most at risk

Policy:

Critically ill patients most at risk must be identified and followed up. Then the medical team begins the evaluation process and the plan is coordinated and implemented with the patient and family.

The Purpose:

· Identifying patients most at risk, such as children, individuals with special needs, the elderly, and psychiatric patients in the hospital, and the special evaluation necessary for each of them.

· Medical cases that require special services regarding hospital care:

◾ Age 75 years or older.

◾ Change in the state of consciousness or related disorders (mental disorders).

◾ Injuries, multiple fractures, fractures of major joints.

◾ Malnutrition, dehydration, microbial poisoning.

◾ Patients with late cases.

◾ Children.

◾ Victims of abuse, neglect or injury.

◾ Dialysis patients.

◾ Intensive care patients.

◾ Patients with chronic diseases.

◾ Patients who are prone to falling.

◾ Patients exposed to bed sores.

· Patients taking sedative medications and diuretics.

Procedures:

· The medical team matches the at-risk cases to each patient within 24 hours of his admission to the hospital, and if the patient’s condition matches one of the following cases, the patient’s expected risk signs are determined.

· Doctors and nurses record current and expected problems and main and alternative solutions in care plans.

· Doctors and nurses follow up on cases and re-evaluate them according to the requirements of each case.

Preparation	Review	The trust