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تقييم وإعادة تقييم المريض

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date_gregorian=2023-06-20 date_hijri=1444-12-02 document_type=guide entity=language:ar entity=format:application/pdf language=en taxonomy_l1=health taxonomy_l2=healthcare_system taxonomy_l3=hospital_regulations validity_confidence=0.0
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اداره الخدمات الطبيه
Medical Services Administration
رؤيه جامعه جده
جامعه السعوديه الحديثه
NEW SAUDI UNIVERSITY VISION
[Non-Text]
2014
جامعه جده
University of Jeddah
(059)
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<table><tr><td colspan="3">Policy Title: Patient Assessment and Reassessment</td></tr><tr><td>Department/Unit: General Clinics.</td><td>Policy Number: UOJ-MSA-GC-P/03</td><td>Replaces No:</td></tr><tr><td>Creation Date: 22/12/2022</td><td>Effective Date:</td><td>Review Date:</td></tr></table>
Revision History
<table><tr><td>Subject</td><td>Changes made</td><td>Done by</td><td>Revision date</td></tr><tr><td></td><td></td><td></td><td></td></tr><tr><td></td><td></td><td></td><td></td></tr><tr><td></td><td></td><td></td><td></td></tr><tr><td></td><td></td><td></td><td></td></tr><tr><td colspan="3">5497-313-36-kXTFBD1AS+F/KoaO+JkNw==-6/20/2023 12:37:47 PM</td><td></td></tr><tr><td></td><td></td><td></td><td></td></tr></table>
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Page 1 of 6
Enc:
الرقماء
Date:
اللغه
Ref.: UOJ-MSA-GC-P/03
المملكه العربيه السعوديه - ارسل السعوديه
Kingdom of Saudi Arabia - Ministry of Education
@Uoofjeddah
www.uj.edu.sa
+966 12 23344444
identity@uj.edu.sa
P.O. Box 80327 Jeddah 21589 21589 80327 ص.ب
5497-313-36-kXTFBD1AS+F/KoaO+NJkNw=--6/20/202354297343-B6+kXTFBD1AS+F/KoaO+NJkNw=--6/20/2023 12:37:47 PM

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اداره الخدمات الطبيه
Medical Services Administration
ريسه كامسه جده
الجامعه السعوديه الحديثه
NEW SAUDI UNIVERSITY VISION
[Non-Text]
2014
جامعه بدره
University of Jeddah
(059)
1. CONDITIONS: 1.1 All staff of General Clinics.
2. PURPOSE: 2.1 To ensure that all patients of the MSA undergo an appropriate assessment by qualified individuals based on which a plan of care can be established.
3. DEFINITIONS: N/A
4. Related N/A
Documents:
5. POLICY: 5.1 It is the policy of the MSA that all patients, receiving healthcare services, at the facility will receive a complete assessment by a qualified individual to allow development and implementation of a plan of care that will best meet the individualized health care needs of the patient.
5.2 Clinic physician and nurse will complete the initial assessment in an effort to provide a comprehensive, collaborative approach to patient care. The patient may be referred to other discipline, for more comprehensive assessment if needed based on the findings of the initial assessment.
5.3 Assessment is performed by each discipline within its scope of practice e.g. geriatric, dental, Immunization etc.
5.4 An initial medical and nursing assessment is completed in the first visit; then all patients are reassessed in the follow up visits according to discipline. The assessment may be extended to another visit, unless a procedure is to be performed for the patient during the first visit.
5.5 Trainee physicians and interns are also allowed to perform assessment, but senior member of PHC medical staff (consultant / specialist / resident) countersigns their documentation in the health record in the same clinic visit.
Page 2 of 6
Enc:
الرقم قاتن
©
@uofjeddah
[Non-Text]
www.uj.edu.sa
©
+966 12 23344444
©
identity@uj.edu.sa
المملكه العربيه السعوديه - الجزاير الج李明
Kingdom of Saudi Arabia - Ministry of Education
P.O. Box 80327 Jeddah 21589 21589 80327 ص.ب
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اداره الخدمات الطبيه
Medical Services Administration
ريسه كامسه جده
الجامعه السعوديه الحديثه
NEW SAUDI UNIVERSITY VISION
[Non-Text]
2011
جامعه بدر
University of Jeddah
(059)
6. PROCEDURES:
6.1 On the first visit, all patients will have an initial medical / nursing assessment which will be completed by the attending physician and the clinic nurse and will consist of history & physical examination.
6.2 An initial Nursing Assessment is completed to include at least:
6.2.1 Vital signs
6.2.2 Allergies & adverse drug reaction
6.2.3 Fall risk screening
6.2.4 Pain screening
6.2.5 Nutritional screening
6.2.6 Functional screening
6.2.7 Psychosocial screening
6.2.8 Body mass index
6.2.9 Waist circumference
6.2.10 Motor activity
6.2.11 Food habits 1AS+F/Koa0+NJkNw==-6/20/2023 12:37:47 PM
6.2.12 Previous history of chronic disease
6.2.13 Previous family history of chronic disease
6.2.14 Smoking status
6.2.15 Psychological screening of depression
6.2.16 Psychological screening of anxiety
6.3 An initial Medical Assessment is completed to include at least:
6.3.1 Complaint
6.3.2 Present history
6.3.3 Past history (hospital admission & surgery)
6.3.4 Family history
6.3.5 Current medications
6.3.6 Immunization status (for pediatric patients).
6.3.7 Physical examination including full body systems review
6.3.8 Early and periodic examination of the targeted disease in the medical evaluation form by age group and risk factors.
Page 3 of 6
Enc:
المرققاته
Date:
الثلاثه
Ref. [UOJ-
J-MSA-GC-P/03:الرقم
المملكه العربيه السعوديه - الجزاير
Kingdom of Saudi Arabia - Ministry of Education
P.O. Box 80327 Jeddah 21589 21589 80327 ب.م.ب
@Uofjeddah
www.uj.edu.sa
+966 12 23344444
©
identity@uj.edu.sa
5497-313-36-kXTFBD1AS+F/Koa0+NJkNw=--6/20/202354297343-B6+kXTFBD1AS+F/Koa0+NJkNw=--6/20/2023 12:37:47 PM

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اداره الخدمات الطبيه
Medical Services Administration
ريه كامه له جد
الجامعه السعوديه الحديثه
NEW SAUDI UNIVERSITY VISION
[Non-Text]
2011
جامعه بدرم
University of Jeddah
(059)
6.4 General clinic nurse performs patient's nurse assessment within 10 to 15 minutes from patient's arrival to general clinics nurse and General clinic physician performs patient's medical assessment within 10 to 20 minutes from patient's arrival to general clinics physician.
6.5 As appropriately determined by the physician performing initial assessment, other disciplines will be contacted to assess the patient as needed, e.g. social worker, dietitian.
6.6 Other points for history and physical examination will be assessed in different disciplines according to their assessment forms.
6.7 The initial assessment must end with conclusions about patient condition and plan of care (including medications and investigations).
6.8 The healthcare team reassess the patients on scheduled visit/s, its times and frequencies are determined according to clinical guidelines.
6.9 The healthcare team will reassess the patients on their return to the PHC regardless if this return is scheduled or not and the reassessment include at least:
6.9.1 Diagnosis
6.9.2 New complaint
6.9.3 Relevant symptoms & signs
6.9.4 Results of investigations done
6.9.5 Results of interventions done
6.9.6 Response to treatment given
6.9.7 Compliance to treatment given
6.9.8 Complication and side effects
6.9.9 Plan for continued treatment or completion of treatment.
6.10 The plan of care may be revised and corrected based on the results of the reassessment.
7. RESPONSIBILITIES
7.1 MSA Supervisor: To ensure the implementation of this policy and procedure in the all clinics.
7.2 MSA healthcare team: To follow the guidelines mentioned above regarding
Page 4 of 6
Enc:
الرقماء
Date:
اللاتي
Ref.:
UOJ-MSA-GC-P/03
المملكه العربيه السعوديه - الجزاير
Kingdom of Saudi Arabia - Ministry of Education
P.O. Box 80327 Jeddah 21589 21589 و0327
@Uofjeddah
www.uj.edu.sa
+966 12 23344444
identity@uj.edu.sa
5497-313-36-kXTFBD1AS+F/Koa0+NJkNw=--6/20/202354297343-B6+kXTFBD1AS+F/Koa0+NJkNw=--6/20/2023 12:37:47 PM

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اداره الخدمات الطبيه
Medical Services Administration
ريسه كامسه جده
الجامعه السعوديه الحديثه
NEW SAUDI UNIVERSITY VISION
[Non-Text]
2011
جامعه بدر
University of Jeddah
(059)
patient assessment and reassessment and to complete all required health record
forms.
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8. Appendix:
8.1 Assessment and reassessment forms
9. REFERENCES:
9.1 CBAHl resource manual
9.2 Ministry of Health Manual for general clinic.
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Page 5 of 6
Enc:
الرقماء
Date:
اللاريه
Ref.:UOJ-MSA-GC-P/03
المملكه العربيه السعوديه - الجزاير الج李明
Kingdom of Saudi Arabia - Ministry of Education
@Uoofjeddah
www.uj.edu.sa
+966 12 23344444
identity@uj.edu.sa
P.O. Box 80327 Jeddah 21589 21589 80327
5497-313-36-kXTFBD1AS+F/Ko a0+NJkNw==-6/20/202354297343-B6+kXTFBD1AS+F/Ko a0+NJkNw==-6/20/2023 12:37:47 PM

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اداره الخدمات الطبيه
Medical Services Administration
ريه كامه ل جده
الجامعه السعوديه الحديثه
NEW SAUDI UNIVERSITY VISION
[Non-Text]
2014
جامعه بدره
University of Jeddah
(059)
Prepared By: 1AS+F/Ko a0+NJkNw==-6/20/2023549734
Name: Dr. Abdullah Fawaz Khalel
Position: Quality Representative, General Clinics
Date: 22/12/2022
Signature:
Reviewed By:
Name: Dr. Eman Balbaid
Position: Supervisor, General Clinics
Date:
Signature:

Recommended By: Ko a O + NJ k N w = -6/20/2023 12:37:47 PM
Name: Mrs. Ahlam Alrefai
Position: Supervisor, Quality&Patient Safety Unit
Date:
Signature:

Approved By:
Name: Dr. Mansour Tobai g y
Position: Supervisor, Medical Services
Administration
Date:
Signature:
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Page 6 of 6
Enc:
المرققاته
Date:
الترج
Ref.: UOJ-MSA-GC-P/03
المملكه العربيه السعوديه - وزاره النقل
Kingdom of Saudi Arabia - Ministry of Education
P.O. Box 80327 Jeddah 21589 21589 د.م 80327 ب.ب
©
@uofjeddah
[Non-Text]
www.uj.edu.sa
[Non-Text]
+966 12 23344444
[Non-Text]
identity@uj.edu.sa
المملكه العربيه السعوديه - اداره التعليم
Kingdom of Saudi Arabia - Ministry of Education
P.O. Box 80327 Jeddah 21589 21589 د.م 80327 ب.ب