Second part

- Medical files (anticipated events policies)

Policy for uniform and consistent content of the patient's medical file

Policy: 

Staff familiarity with the established composition of the patient’s medical record.

The Purpose :

·   Having a medical record for every patient examined and treated.

·   The fixed composition of the patient’s medical record contains sufficient information such as:

◾ Identify the patient by name - address - file number.

◾ Allows continuity of care.

◾ Confirm the diagnosis.

◾ Justifications for treatment.

◾ Documenting treatment steps and results.

·   The components of hospital patient medical records are standardized and have a specific format, and doctors and nurses are committed to using the forms optimally and containing:

 ◾ Writing treatment orders in a unified manner and in the same place.

·   Department nurses are obligated to familiarize the patient with all patient record forms, which contain:

  ◾ Patient’s name in quadruplicate - standard number

·    It is done with examination reports, rumors, the medical report, and a copy of the discharge summary in the patient’s file.

·   The medical team corrects or amends one of the data recorded in the medical record by placing parentheses around the inaccurate data, taking into account ensuring that it is still readable, signing in front of him, and recording the date and time of making the correction, as it is not permissible to erase or delete incorrect data.

·   Availability of data related to consultations as evidence that the consulting physician reviewed the patient’s medical record and the results he reached when conducting the medical examination on him, as well as the consulting physician’s opinion and recommendations.

·   Issuing verbal diagnostic and therapeutic orders to a qualified nurse. The orders must be signed within twenty-four (24) hours, and all orders must bear the date, time, signature, and procedures applied.

·   The clinical data recorded in the medical record and any other data and signatures are clear and legible.

·   Send a referral form with the patient when he is transferred to another hospital, while keeping a copy in the patient’s file.

·   Giving the patient a discharge summary with complete information.

Procedures:

Nurses ensure that the file contains the following data upon entry:

·   Patient’s full name - uniform number - age.

·   Name, address and telephone number of a relative of the patient or someone who can be contacted in case of emergency.

·   Nurses do the following:

·   Writing the patient’s name in full and his uniform number on all pages of the medical file.

·   Recording the vital signs and medical condition of the patient in the vital signs record and the nurse’s notes record

·   Modify the treatment implementation plan according to the doctor’s amendment on the doctor’s orders page.

·   Doctors do the following:

·   Complete the patient examination record and the record contains the following data:

·   The type of allergy the patient suffers from, if any.

·   Whether the patient suffers from any chronic infectious disease such as hepatitis.

·   Diagnosis when the patient enters the hospital.

·   The patient’s complete medical history: previous, current, and family medical history.

·   A detailed statement of the patient’s clinical examination, a statement of the results drawn, and the action plan.

·   Mention the results of laboratory tests and x-rays

·   Write the type of treatment applied clearly on the doctor’s orders page.

·   Request all required examinations or tests on the clinical progress page

·   Recording all types of follow-up, consultations, and routine and special treatments appropriately in the appropriate forms.

·   Take notes on the development of the condition at least daily for patients with serious conditions, as well as for patients whose conditions are difficult to diagnose or control their clinical problems. Notes of the development of the condition must also be recorded at the time of the observation to allow for continuity of care and the possibility of transferring the patient from one department to another. Also, as much as possible, it must be determined Each problem that the patient suffers from should be clearly stated in the case progress notes and linked to the orders issued regarding it, as well as the results of examinations and treatment. On the other hand, comprehensive notes about the development of the condition during the surgical procedure and immediately after the completion of the surgery must be recorded in the record. This is done for the purpose of providing correct information for use by any caregiver who subsequently assumes responsibility for caring for the patient

·   Writing all surgical reports immediately after the end of the surgical operation, provided that they include the patient’s full name, medical file number, date of the surgical operation, diagnosis before and after the surgical operation, the name of the surgeon and his assistant, the name of the surgical operation, and a detailed statement of the results and methods used during the operation and anesthesia. The samples taken, the amount of fluid secreted, complications, reasons for surgery, and the patient’s condition before the operation.

Writing a summary of discharge or death in all medical files of patients admitted to the hospital, which includes:

 ◾ Entry and exit dates.

 ◾ Initial diagnosis - final diagnosis.

 ◾ Analysis.

 ◾ Actions taken.

 ◾ Medical drugs and other treatments.

 ◾ The patient’s condition and the next stop upon discharge.

 ◾ Discharge instructions, including food, medication, and follow-up instructions.

 ◾ The name of the doctor who discharged the patient.

Complete the referral form as follows:

 ◾ Reason for referral

 ◾ The required means of transportation and follow-up

 ◾ Description of the case

 ◾ Next stop

The emergency patient's medical file contains:

 ◾ Patient arrival time and discharge time.

 ◾ Final results at the end of treatment.

 ◾ The patient’s condition upon discharge.

 ◾ The patient’s destination upon discharge.

 ◾ Medical care instructions for patient follow-up.

 ◾ Documentation of the discharge order from the treating physician.

Responsible: 

Nursing and medical staff members.

Forms: 

Patient records - content of the medical file for each department.

References: 

Ministry of Health Medical Records Guide.

The policy of who has the authority to write in the patient’s medical file

Policy: The medical team, including nurses and treating doctors, is authorized to write in the patient’s medical file their names, clear and legible, and their job titles, provided that the information is clear and in legible handwriting, with the date and hour written.

Purpose: Determine who has the authority to write in the medical file.

Procedures:

·   When recording their performance in patient files, nurses are obligated to write their names (first name) and record the date and hour.

·   When registering in patient files, doctors are obligated to write their names (first and last names), use clichés, and write the date and time.

·   All research, examinations, and treatments requested for the patient must be signed by the treating physician, with his name written in triple and his stamp.

·   The person performing the medical tests and x-rays signs the results of the tests and x-ray reports with his or her full name and the date and hour.

Administrator:

Nursing and medical staff members.

The policy of who has the right to view the patient’s medical file to ensure the confidentiality of the information

Politics:

·      The medical record is considered a legal document, and therefore its confidentiality must be maintained, and this confidentiality is the basis of the legal aspect of the medical record.

·      Establish controls to maintain the confidentiality of information and determine who has the right to view the medical record and what data they are permitted to view.

Purpose: 

To maintain and protect the confidentiality of patient information and data.

Procedures:

·      All hospital employees sign a declaration of confidentiality of patient information.

Circumstances in which access to information in the medical file is permitted:

·      If the file is requested from the medical team to view the patient’s examinations or information of clinical value, the doctor writes a request to extract the previous file in the current file, and the doctor signs it clearly and with the date, then submits the file to the medical records official to extract the medical file.

·      In the event that the sick applicant is himself, his legal representative, or external parties such as (the Administrative Prosecution - the Public Prosecution - Inspection Bodies - the Ministry of Health), the hospital director or medical director shall review the request and provide the information in one of the following ways:

◾        Orally.

◾         An exact copy of the file.

◾        Summary of the case.

◾         The original file. In this case, a representative from the hospital will refer the file and return it after the decision on it is completed.

·      If the patient is transferred to another hospital, the specialist doctor fills out the transfer form, which includes a summary of the case (diagnosis - reason for transfer).

·      In the event of requesting a medical report on a case, the patient or his legal representative submits an oral request to the official of the Medical Records Office to contact the treating physician to write the report on the case. This is done on the same day and delivered to the applicant.

·      The hospital has the right to withhold some medical information about the patient in the event that the information represents harm to the patient, such as (  the patient’s knowledge of the nature of the patient’s medical condition may affect his psychological state and lead to the deterioration of his condition).

·      List of persons authorized to view the hospital’s medical file:

◾         The doctor responsible for the case.

◾         Doctors from other departments who are consulted about the patient’s condition.

◾         The nurse in charge of the case.

◾         The patient or his legal representative with the authorization of the patient.

◾         Hospital Director.

◾         Medical Director  .

◾         Quality and performance improvement coordinator.

◾         Judicial and supervisory authorities and the Ministry of Health when needed.

◾         Medical statistics officer.

◾         Accounts Officer.

Responsible: All hospital staff.

Forms: Declaration of confidentiality of information

Policy for protecting medical records and information from loss, damage, tampering, and unauthorized use or access

Policy: Protect medical records and information from loss, damage, tampering and unauthorized use

Purpose: To ensure that the medical file is preserved from loss or damage and to ensure that the patient’s medical information is preserved so that it can be retrieved when needed.

Procedures:

The hospital’s medical records room meets the following specifications:

·      Ventilation is adequate.

·      Lighting is sufficient.

·      Protection against fires.

·      Intact storage shelves.

·      Offices for employees.

·      Entry to the file storage area is not permitted to anyone other than authorized persons (patient affairs employees only).

·      The medical records office administrator files the patient's medical records on a shelf in the order of the month for each department.

·      The Medical Records Office official shall repair all records with loose papers or torn covers immediately before important information recorded in them is exposed to further loss or damage.

·      The official in the medical records office keeps all reports related to diagnosis, examinations, etc., such as medical reports, laboratory results, etc., in the medical file, except for x-rays, which are kept in the radiology department.

·      There is a record of requests recorded in the place where files are kept, which includes the borrowed files and the person borrowing the file from the persons authorized to view the file.

·      The medical records clerks assigned to work in the filing area are responsible for maintaining the cleanliness of the area and the proper ordering of files on the shelves.

Responsible : Medical Records Office

Policy for disposing of medical files and the duration of keeping records and files

Purpose: 

To clarify the disposal of medical files by legal means and to clarify the legal period for keeping records and files.

Politics:

·      Dispose of records within the specified period in accordance with regulations and laws.

·      Dispose of records completely to prevent anyone from viewing them or extracting identical copies of them.

·      Records may not be disposed of except based on an administrative order issued by the hospital director general.

Procedures:

·      Inactive medical records may be disposed of after a certain period of time determined by the Ministry of Health guidelines.

·      Records scheduled for disposal should be registered according to the patient's name, medical file number, and last date of activity.

·      Records must be completely destroyed to prevent anyone from viewing them or extracting duplicate copies of them.

·      The medical records official and clerk shall, on the first of December of each year, review the medical records to extract what has expired and is worthy of being permanently disposed of, in accordance with the guiding policies of the Egyptian Ministry of Health website.

·      The medical records officer shall keep all records related to lawsuits or other investigations of a confidential or serious nature and shall not dispose of them until after the lawsuits are completed.

·      The Medical Records Officer, on the first of January of each year, examines the discarded documents and after verifying the authenticity of the discarding, they are packed into bags by the department’s workers to be delivered to the Directorate of Health Affairs  for disposal in accordance with the ‘archives list’.

·      The following is the schedule for maintaining medical files and records.

The Reviewer :

·      Accredited Egyptian Accreditation Standards 2013

Policy of information given to the patient and family upon admission to the hospital

Policy: The hospital is committed to informing and informing the patient and his family upon admission of the necessary information to make the appropriate decision to treat the patient.

Purpose: To determine the information that is given to the patient and his family upon admission to the hospital, which helps in making the appropriate decision to treat the patient, n. 8, and achieves the preservation of patients’ rights, facilitates the period of stay and obtaining the required medical care, and informs patients of their responsibilities towards the hospital, which achieves the satisfaction of patients and their families.

Working procedures:

·   When the patient enters the hospital, the receptionist or admission office employee introduces the patient and his family:

·   Patients’ Bill of Rights.

·   Patients’ duties and responsibilities document.

·   Hospital instructions regarding visits, food, and/or smoking ban.

·   The receptionist/admission office employee informs the patient of the cost of accommodation and treatment and reviews the price list, in accordance with Ministerial Resolution No. 186 of 2001.

The treating physician acquaints the patient and his family with the necessary information that will help them make an informed decision, including:

·   Nature of the disease and diagnosis.

·   Expected result of treatment.

·   Planned date of discharge from the hospital.

·   Suggested treatment steps.

Responsible: treating physician - nursing staff members.

Forms: Conversion form. 

References: Approved Egyptian Accreditation Standards 213

Patient management policy in the event that there is no available space for the required medical service

Policy: The hospital is committed to finding an alternative solution for the patient in the event that there is no room for the required service in the hospital.

Purpose: To know how to act in the event that there is no room for the required service in the hospital.

Working procedures:

·      When a case is discovered for which there is no available place to provide the required medical service in the hospital, the treating physician provides  first aid to the patient and writes a report on the case.

·      The hospital helps the patient and his family to find an alternative place through the emergency department and the directorate, and provides a report to the patient’s family about the situation.

·      After confirming the approval of the hospital to which the transfer will be made, the doctor responsible for completing the transfer procedures shall.

·      By providing an equipped means of transportation suitable for the patient’s condition.

·      The treating physician writes the private data in the referral form and keeps a copy of it and attaches it to the report on the patient’s condition while providing an appropriate companion for the patient.

·      The treating physician provides medical instructions to the patient and his companion during transportation.

Responsible:  Attending physician          -  Nursing staff members

Forms : Conversion form

The Reviewer :

·      Accredited Egyptian Accreditation Standards 2013

The policy of coordination and cooperation between all departments 

(including doctors and nursing staff) through the internal departments

Policy: The hospital is committed to providing means of coordination and cooperation between all departments.

Purpose: To know how to coordinate the provision of medical care to all patients.

Working procedures:

·      Coordination between doctors and nurses.

·      Implement nursing and physician orders in a timely manner.

·      Record delivery and receipt for each category and carry out follow-up and required orders.

·      Medical consultation.

·      Coordination between departments during transportation or requesting diagnostic services:

·      Use policies that determine the appropriateness of transporting the patient within the hospital:

·      Surgical and non-surgical treatment services after conducting a medical consultation and accepting the case.

·      Diagnostic services and therapeutic services.

·      Emergency services and internal department.

Responsible : Attending physician         -   Nursing staff members

The director, his deputy or the administrative representative

Forms : Conversion form.

References: Egyptian Accreditation Standards 2013

Patient entry and exit policy

Policy: The hospital is committed to providing means of coordination and cooperation between all departments.

Purpose: To know how to coordinate the provision of medical care to all patients.

Working procedures:

·   Coordination between doctors and nurses.

·   Implement nursing and physician orders in a timely manner.

·   Recording the delivery and receipt for each category and implementing the required follow-up and orders.

·   Medical consultation.

·   Coordination between departments during transportation or requesting diagnostic services:

·   Use policies that determine the appropriateness of transporting the patient within the hospital:

·   Surgical and non-surgical treatment services after medical consultation and acceptance of the case.

·   Diagnostic services and therapeutic services.

·   Emergency services and the internal department.

Responsible: treating physician - nursing staff members

The director, his deputy or the administrative representative

Forms: Conversion form.

References: Egyptian Accreditation Standards 2013

Patient entry and exit policy

Policy: The hospital is committed to providing means of entry and exit for patients.

Purpose: Unifying the standards for entry and exit of patients to ensure a distinguished level of service without wasting capabilities or differentiation in the provision of medical service.

Procedures:

First: Login procedures:

·   The specialist of other specialized units is responsible for the decision to admit and discharge the patient after reviewing the consultant, if necessary, while adhering to the specifications included in the clinical work manuals approved by the unit director and compiled in the policy attachments.

·   The qualified anesthesiologist has the right to request a reservation for a patient if he discovers the patient’s need during the patient’s evaluation before elective surgeries. The physician notifies the existing specialist of the need for an empty bed for the patient on the day before the surgical operation.

·   The qualified anesthesiologist has the right to request that a patient be detained in intensive care if it becomes clear to him that the patient’s need is during the patient’s evaluation before urgent surgical operations. The treating physician notifies the specialist doctor in intensive care of the need for an empty bed for the patient before the patient enters the operating room.

·   The qualified anesthesiologist has the right to request that a patient be detained in intensive care if he discovers the patient’s need during the surgical procedure if an emergency occurs. The specialist physician in the intensive care unit shall be notified immediately.

·   The treating physician/anesthesiologist makes the request by filling out the medical consultation form.

·   The treating physician in any department must provide a medical consultation with the care physician if the patient’s condition meets the specifications for admission to intensive care.

Second: Specifications of leaving care

·   Stability of the patient's vital signs.

·   Respiratory rate stabilized and blood gas levels improved well.

·   The patient does not need medications that are difficult to administer outside intensive care, such as cardiac stimulants and others that are given intravenously using devices such as a solution pump and a solution syringe.

·   Accompanying cardiac arrhythmia and no serious heart disorders.

·   Stable nervous condition and no convulsions.

·   Removal of circulatory catheters.

·   The patient does not need high-level nursing services, such as care for a throat tube or a laryngeal incision.

Responsible: the treating physician - intensive care doctors - anesthesiologist - head of the premature infants department - head of the dialysis department

Models:

· Specifications established on a physiological and diagnostic basis for admission to intensive care.

· Specifications established on a physiological and diagnostic basis for admission of premature infants.

· Specifications established on a physiological and diagnostic basis for admission to dialysis.

The Reviewer :

· Egyptian Quality Standards 2013

Policy for terminally ill patients

Policy: The hospital is committed to providing medical services of a special nature to a terminally ill patient.

Purpose: Providing medical services of a special nature to a terminally ill and near-death patient that keeps him free from pain while providing psychological, social, and spiritual support to the patient and his family.

Procedures:

·   The treating physician signs a careful medical examination and carefully reviews the patient’s file, including analyses, x-rays, and examinations, to determine the patient’s final condition.

·   The treating physician presents the results of the clinical examinations and analyzes to the consultants in the appropriate specialties to determine the patient’s health condition and ensure the futility of any progressive treatment provided to him.

·   After the consultants decide that this condition is incurable, a list of the symptoms accompanying the patient and how to treat them is written so that the patient is in a healthy state free of pain, even if this requires general anesthesia for the patient.

The patient's family is interviewed and the case is explained in detail by the consultants and the director of the unit caring for them, and moral support is provided to them.

·   Conduct health education for them on how to deal with the condition.

The hospital is committed to providing and facilitating social support by consulting the citizen service office employee and providing the opportunity for the patient, if he requests, to have a clergyman attend for religious and spiritual support for the patient or his family.

Administrator :

· The treating physician and the treating consultant - employee of the Citizens Service Office.

The Reviewer :

· Egyptian Quality Standards 2013 - Joint Commission International Standards 2014.

Patient transfer, referral and discharge policy 

Policy: The hospital is committed to maintaining the patient’s security and safety and identifying those responsible during the process of his transfer, referral, or discharge from the hospital.

Purpose: Defining what is meant and the situations in which a patient is transferred/transferred/discharged.

Establishing the foundations that ensure maintaining the patient’s security and safety and identifying those responsible for transferring, referring and discharging the patient inside and outside the hospital.

The Definition :

Patient transfer is the formal transfer of responsibility for patient care from:

·   One care unit to another.

·   One medical service to another.

·   A specialist doctor for another.

·   One institution to another.

Patient referral is sending a person from:

·   One doctor to another or one specialist.

·   One department or service to another or different resources either for advice or care that is not provided by the referring entity or because it is not qualified to provide this service.

The patient is discharged home

Working procedures:

      First: Planning for transfer or transfer of the patient and discharge when developing a treatment and care plan for the patient

·   The treating physician develops a medical care plan for the patient upon his admission to the hospital, completes the medical examination and required tests, diagnoses the condition, and provides first aid to the patient.

·   The patient’s need for transfer or referral is determined when developing a medical care plan for the patient according to his condition and to ensure continuity and continuity of medical care.

The patient's medical care plan must include the patient's planned discharge date.

   Second: Discussing the reason for the referral/transfer/discharge of the patient with the patient and his family

·   The treating physician explains the reasons for making the transfer/referral/discharge decision to the patient and his family.

·   This is done when making a decision, at the beginning of developing a treatment plan, or when clinical and diagnostic results appear that are not available in the hospital.

·   The doctor records the reason for transferring or transferring the patient inside or outside the hospital in the medical file.

  Third: Follow correct and safe methods when transporting or referring a patient

·   The doctor records the required procedure within the patient’s medical file and ensures that all file data is completed, mentioning the reason for referral/transfer/or the patient’s condition upon discharge.

·   In the case of referral, the referral form is completed explaining the patient’s condition/reason for referral/required procedure.

·   In the case of consultation, the consultation form is completed in accordance with the medical consultation policy.

The method of transferring/referring the patient is determined according to his health condition.

When transporting/transferring a patient using a wheelchair or bed, the following measures must be taken:

·   Inspect the bed/chair and ensure its safety.

·   Make sure the sides of the bed are in place.

·   The department supervisor contacts the referral/transfer location to ensure the availability of the required service for the patient, and the hour and result of the call are documented in the nursing status book in the case of internal referral/transfer.

·   The responsible nurse notifies the admission and hospital accounts office to take the necessary measures for the transfer/transfer/discharge process.

·   The nurse reviews the patient’s complete data and ensures that the recorded data is correct.

      Fourth: Transferring a patient to another facility, cases of referring a patient to another facility:

·   In the event that the service is not available in the hospital.

·   Patient’s request for transfer to another facility.

·   The specialist doctor provides first aid to stabilize the patient’s condition, if necessary.

·   The specialist doctor determines the patient’s condition.

·   The specialist doctor notifies the patient or his companions of the non-availability of the necessary service for the patient in the hospital.

·   The treating physician ensures that there is a place suitable for the patient’s condition before transferring him by contacting the place receiving the patient and explaining the patient’s condition.

·   The treating physician notifies an ambulance to transport the patient, accompanied by the ambulance doctor and ambulance nurse, or transport the patient according to his desire after writing an acknowledgment from him or his family.

·   The treating physician completes the patient referral form

·   The nurse and ancillary services worker transport the patient in a safe manner, as mentioned previously.

·   The nurse makes sure to send a copy of the patient’s examination, procedures performed, research results, diagnoses, and treatment...with him to the place he is transferred to.

Fifth: Discharge of a patient:

·   When the patient’s medical condition improves and stabilizes, the consultant/specialist determines the patient’s discharge date, the treatment plan at home, the type of nutrition, and the date of follow-up in the outpatient clinic.

·   The doctor completes the discharge form for the patient and completes all the data in clear writing, and the patient is given the original discharge form and keeps a copy in the file.

·   The specialist doctor explains the instructions that will be implemented during the recovery period to the patient and his family, including the method of taking medications, the method of dealing with the medical condition, ways to obtain rehabilitative services, methods of proper therapeutic nutrition, and follow-up appointments in the outpatient clinic.

·   The nurse hands the patient his discharge form.

·   The department supervisor ensures that the financial settlement is completed.

·   The nurse removes the cannulas from the patient’s hand, if any, before leaving the department.

The nurse reviews the patient's discharge plan to determine his method of discharge.

·   The assistive services worker transports the patient from the department using a wheelchair or trolley according to the patient’s need until the patient is discharged.

Responsible for implementation:

· Doctor - nursing staff - service worker.

Models:

· Exit form - Transfer form.

The Reviewer :

· Egyptian accreditation standards approved 2013.

· Regulations and governing laws.

Hospital medical emergency response policy

Policy: The hospital is committed to responding to medical emergencies.

Purpose: Preparing departments to deal with emergency situations that require emergency dealing, while developing a system to respond to calls for emergency cases.

Procedures:

·   The nursing supervisor for each floor prepares an emergency vehicle with life-saving medications and tools according to the attached list that specifies the components and arrangement of the emergency vehicle, provided that the vehicle is close and available for use 24 hours a day.

A female supervisor in each role reviews these vehicles daily.

·   The hospital’s pharmacists’ department assigns a pharmacist to visit the emergency vehicle and verify its contents and suitability on a daily basis.

·   The medications used from the emergency vehicle are replaced immediately after they are used from the emergency cabinet of the department that used them. If these medications are not available in the emergency cabinet of any department, they are replaced from the intensive care emergency cabinet until they are dispensed from the hospital pharmacy.

·   The hospital (training officer) is committed to holding training courses on cardiorespiratory resuscitation for all employees (doctors and nurses) in the hospital on a one-day basis every two years. Those who have completed the course are given a certificate stating this, and their direct supervisor is responsible for monitoring the workers’ access to the courses.

·   Any hospital employee who suspects a case of cardiac arrest calls the cardiorespiratory resuscitation team by telephone to the intensive care unit and the floor nurse or by the switch to make a call and mention the floor/department and the room number to which you want to move.

·   The floor nurse calls the rest of the team if the switch is not available.

·   In cases of cardiac arrest that occur in intensive care, the care physician is called and the cardiorespiratory resuscitation team is not requested unless the care physician requests it, and his responsibility is to supervise the patient’s resuscitation.

·   Cases of cardiac arrest that occur in operating rooms and units where the patient is supervised by an anesthesiologist. The cardiorespiratory resuscitation team is not called unless the anesthesiologist requests it, and he is responsible for supervising the patient’s resuscitation.

·   The first person to reach the patient performs cardiac resuscitation.

·   The cardiorespiratory resuscitation team consists of an intensive care physician, a care nurse, in addition to a case doctor, a floor/department or room nurse, and a security personnel (according to the established schedule).

·   It is the responsibility of the nurse to bring the emergency vehicle for the role in which the cardiac arrest occurred.

·   The team leader is the intensive care physician who is responsible for administering electric shocks, obtaining a clear airway and breathing, and participating in cardiac resuscitation.

·   The case doctor is responsible for explaining the medical condition, reviewing the patient’s files, and informing the team leader of any information he needs. He also participates in the work of cardiac resuscitation. He is responsible for communicating with the patient’s family, informing them of developments in the patient’s condition, and involving them in any medical decision that requires their participation.

·   The intensive care nurse is responsible for giving medications and taking samples requested by the team leader and assisting the rest of the team members according to the team leader’s instructions.

·   The floor/department nurse is responsible for recording the events of cardiac arrest, the dates for giving medications, the shape of the heartbeat, and the time the heart returns to beating on the form designated for that. She is also responsible for giving breathing to the patient in the manner determined by the team leader.

·   The security personnel provides the appropriate atmosphere for the team’s work and is present when informing the patient’s family of any developments in his condition.

·   We must work to provide care places on an ongoing basis in order to receive post-cardiac arrest cases that may occur in the hospital floors, after first aid has been provided in the internal department and his condition has been stabilized.

·   The medical team in the care is trained to respond quickly and immediately when called upon, and all members of the medical team must be present in the room where the emergency is and deal with the case in accordance with the cardiorespiratory resuscitation policy.

·   The call system is tested suddenly by the unit director/quality coordinator in the hospital to ensure that doctors and nurses respond to the call and the time between the call and the response is calculated as a form of performance evaluation within the unit, with the results being submitted to the quality coordinator in the hospital.

·   Cardiorespiratory resuscitation is performed according to the attached protocol.

·   All hospital employees are trained to deal with cardiac arrest cases (basic level), while care and anesthesia doctors are trained at the advanced level.

Administrator:

· All hospital staff - CPR team.

Models:

Table of contents and arrangement of the emergency vehicle

Monthly CPR team schedule

Cardiorespiratory resuscitation protocol

The Reviewer:

Egyptian quality standards 2013.

Cardiorespiratory resuscitation protocol

Health education policy for patients and their families

Policy: Providing health education to patients visiting the hospital and their families ensures that patients are provided with important information that will help them recover and protect them from diseases when they enter the hospital, during their stay in the hospital, and after discharge. This is evident in the hospital’s commitment to educating the patient and his family regarding the following:

·   Pathological diagnosis of the patient.

·   Tests, diagnostic examinations and treatment.

·   Use of medications and possible side effects.

·   Nutrition.

·   Interactions between food and medicine.

·   Physical therapy and rehabilitation.

·   Special information on how to reduce the risk of diseases through nutrition.

·   The harms of smoking and the necessity of staying away from active and passive smoking.

·   Exercise and health-related behaviors.

·   The relationship between the patient and society.

·   Exit and follow-up instructions.

Purpose: Improving health care outcomes by educating the patient and his family to aid in recovery and upholding the value of healthy behavior by providing health information about the various medical specialties necessary for the patient.

Procedures:

·   According to Professional Ethics Regulation No. 238 of 2003, health education for patients and their families is considered one of the duties and responsibilities of the doctor and the medical team.

·   The treating physician and the responsible nurse use a special record/form to educate patients and their families.

·   The treating physician, the responsible nurse, and the patient’s medical service provider evaluate the patient’s educational level and determine the educational needs upon admission.

·   Any department participating in the educational seminars records its own seminar with its signature and date in the patient educational record

·   If abbreviations are used, an explanation is provided for each abbreviation to clarify the information.

·   The treating physician and the responsible nurse ensure that the patients’ educational record includes the type of information provided to the patient, to whom the information was provided, the extent of the response of the patient or his family, and a summary of the educational session that was conducted for the patient.

·   The treating physician and the responsible nurse ensure that the forms for the departments participating in the educational seminars are placed in the patients’ educational record.

·   The treating physician and the responsible nurse make sure that the patient’s questions are given the opportunity.

·   The treating physician and the responsible nurse ensure that the patient understands the discharge instructions and follow-up steps, and this is recorded in the patient’s file.

·   The hospital provides a special place to receive educational seminars for patients in the internal departments and outpatient clinics.

·   The hospital is committed to developing a unified educational material for chronic diseases/dialysis patients.

Administrator:

·   The treating physician - nursing staff - medical service provider from any department involved in patient education

Models:

·   Patient and family education model

The Reviewer :

·   Professional Ethics Regulations - Egyptian Quality Standards 2013.