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تقييم المرضى

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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=mixed 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
الجامعه 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</td></tr><tr><td>Department/Unite:Nursing Unit.</td><td>Policy Number:UOJ-MSA-NR-P/11</td><td>Replaces No:</td></tr><tr><td>Creation Date: 10/12/2022</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>5497-313-36-Wh1wYqyR6Z66k9yaEP+ylg==-6/20/2023 11:18:40 AM</td><td></td><td></td><td></td></tr></table>
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Enc:
المرقاقات
Date:
اللاريه
Ref.:[OJ-MSA-NR-P/11]
المملكه العربيه السعوديه - لسعوديه الحالي
Kingdom of Saudi Arabia - Ministry of Education
©
@uofjeddah
[Non-Text]
www.uj.edu.sa
©
+966 12 2334444
©
identity@uj.edu.sa
P.O. Box 80327 Jeddah 21589 21589 80327
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اداره الخدمات الطبيه
Medical Services Administration
رؤيه جامعه جده
الجامعه السعوديه الحديثه
NEW SAUDI UNIVERSITY VISION
[Non-Text]
2014
جامعه جده
University of Jeddah
(059)
1. CONDITIONS:
2. PURPOSE:
1.1 All Patient of Medical Services Administration.
2.1 To identify the patient problems and plan for suitable care. To identify and prioritize care and treatment as consequence of the assessment within identified time.
2.2 To determine and promote the persistent of advanced and standard care, services and plan.
2.3 To establish discharge Planning, decision and activities
3. DEFINITIONS:
3.1 Initial Patient Assessment definition: initial patient assessment at his arrival to the center to detect patient needs for suggested care. Documentation of time, patients' information, needed treatment in the medical record.
3.2 Reassessment: reassessment of patients by all different methods are important to identify patients reaction to treatment and to review the planned care, when indicated, the frequency of patients assessment, its onset, and its time, should be documented in the patient medical record.
4. Related
N/A
Documents:
5. POLICY:
5.1 It is the policy of MSA \( ^{®} \) that all patients cared for in the University Medical Services Administration should have their health care needs identified and documented through an established assessment and reassessment process.
6. PROCEDURES:
6.1 All patients' care needs identified through assessment and reassessment which are performed and documented in the patient file.
6.2 Assessment and reassessment are the duties of the nurses and physician.
6.3 The initial assessment should include:
6.3.1 Medical History.
6.3.2 Present Complaint.
6.3.3 Date of Present Complaint.
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Enc:
المرقاقات:
Date:
اللاريه
Ref.:UOJ
JSA-NR-P/11:الرقم
المملكه العربيه السعوديه - الجزاير
Kingdom of Saudi Arabia - Ministry of Education
P.O. Box 80327 Jeddah 21589 21589 و.م.م
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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)
6.3.4 Current Medications and Allergies.
6.3.5 Past Medical and Surgical History.
5497-313-36-Wh1wYqyR6Z66k 6.3.6 Social and Family History. 8:03A36-Wh1wYqyR6Z66k9yaEP-y1g==-6/20/2023 11:18:40 AM
6.3.7 Vital Signs Including Height and Weight.
6.3.8 Pain Assessment.
7. RESPONSIBILITIES 7.1 All staff of Nursing Unit.
8. Appendix: 8.1 Physician Order Sheet
8.2 Nurse's Notes
9. REFERRANCES: 9.1 Ministry of Health Manual for Nursing Unit.
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<PAGE>Page 3 of 5
Enc:
المرقاقات
Date:
اللاريه
Ref.:[OJ-MSA-NR-P/1]الرقم
المملكه العربيه السعوديه - الجعتها
Kingdom of Saudi Arabia - Ministry of Education
©
@uofjeddah
[Non-Text]
www.uj.edu.sa
©
+966 12 2334444
©
identity@uj.edu.sa
P.O. Box 80327 Jeddah 21589 21589 80327
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اداره الخدمات الطبيه
Medical Services Administration
رؤيه جامعه جده
الجامعه السعوديه الحديثه
NEW SAUDI UNIVERSITY VISION
[Non-Text]
2014
جامعه جده
University of Jeddah
(059)
Prepared By:
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Name: Mrs. Esraa Saady
Position: Quality Representative, Nursing Unit
Date: 10/12/2022
Signature: S. Lago
Name: Mrs. Ahlam Alrefai
Position: Supervisor, Quality&Patient Safety Unit
Date:
Signature:

Reviewed By:
Name: Mrs. Areej Saymaldaher
Position: Supervisor, Nursing Unit
Date: 01/05/2023
Signature:

Approved By:
Name: Dr. Mansour Tobaigy
Position: Supervisor, Medical Services
Administration
Date:
Signature:
Reviewed By:
Name: Dr. Eman Balbaid
Position: Supervisor, General Clinics
Date:
Signature:

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Page 4 of 5
Enc:
المرقاقات:
Date:
اللاريه
Ref.:U
OJ-MSA-NR-P/11:الرقم
المملكه العربيه السعوديه - الجزء
Kingdom of Saudi Arabia - Ministry of Education
P.O. Box 80327 Jeddah 21589 21589 80327 ب.ب
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اداره الخدمات الطبيه
Medical Services Administration
رؤيه جامعه جده
الجامعه السعوديه الحديثه
NEW SAUDI UNIVERSITY VISION
[Non-Text]
2014
جامعه جده
University of Jeddah
(059)
Appendix 1
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Serial No:
Date :
Name :
Diagnosis :

جامعه جده
University of Jeddah
(0.5%)
ER Order
□ Blood Sagar
□ Dressing
□ Ihj.
□ Nebulizer
□ Oxygen
□ Tab.
□ V.S
□ Other
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Notes:
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طبيبك العمر الطر الطي الباطي
السم:
التويع:

© © © © © © © © © © © © © © © © © © © © © © © © © © © © © © © © © © © ©
طالبان الژيلي - دەرەمني لەرەت
Mingdom of Saudi Arabia - Ministry of Education
P.D. Box 80327 Jeddah 21099 21099 8067 8077
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Enc:
المرقاقات
Date:
اللاريه
Ref.: [OJ-MSA-NR-P/1] ٢٠١١
المملكه العربيه السعوديه - ارسل العربيه
Kingdom of Saudi Arabia - Ministry of Education
P.O. Box 80327 Jeddah 21589 21589 80327
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