Professional Documents
Culture Documents
Patient's Assessment and Reassesment
Patient's Assessment and Reassesment
Ministry of Health
Baish General Hospital
Quality Management and Patient Safety
Patient Safety Committee
1- DEFINITION
TERMS DEFINITIONS
Emergency This category of patients includes those who have serious medical
Admission problems, and may be at risk of death or serious injury to their health if
not admitted as soon as possible.
This category includes patients with serious medical problems who
Urgent Admission may be at risk of substantial injury to their health if not admitted within
24 hours.
Includes patients with no serious medical problems who are not at risk
Routine Admission of substantial injury to their health if not admitted within 24 hours.
The study of the forces involved in the circulation of blood.
2- OBJECTIVE
To ensure that all patients of the hospital undergo an appropriate assessment by qualified individuals on the basis of w
3- POLICY
It is the policy of Beish General Hospital (BGH) that all patients, receiving Inpatient, Outpatient or Emergency Services,
All disciplines deemed necessary upon initial or ongoing assessment by Nursing Services or by physician order, will pa
MS
Kingdom of Saudi Arabia
Ministry of Health
Baish General Hospital
Quality Management and Patient Safety
Patient Safety Committee
3.3 The assessment should include the patient’s social and psychological needs.
3.4 The MRP must attend patients within 24 hours- for routine admissions, within 4 hours- for urgent
cases, and within 30 minutes- for emergencies.
3.5 Consultants must attend their patients for reassessment at least daily for routine patient needs; and
anytime if there is a significant change (deterioration) in the patient’s condition.
The contents of the history and physical examination are determined by the department 3.6
.heads according to the needs
4- RESPONSIBILITIES
Most Responsible Physician (MRP)/ team
The admitting consultant is the leader of the patient care team in the planning and provision of care throughout the con
Admitting specialist or ROD will have an initial assessment of each patient for physical and medical status of the patie
Reassessment is done by designated specialist or ROD (in case of evening and night shift) throughout the c
Assigned Nurse Is responsible for initial assessment and reassessment of the patient for vital parameter status, men
5- PROCEDURES
MS
Kingdom of Saudi Arabia
Ministry of Health
Baish General Hospital
Quality Management and Patient Safety
Patient Safety Committee
5.1 At the time of admission, all patients will have an initial physical, psychological and social status
assessment completed by MRP or ROD and Registered Nurse.
5.2 As appropriately determined by the physician performing initial assessment, other disciplines will be
contacted to assess the patient. The initial assessment for in-patients is completed and documented within
8 hours. The following are authorized to perform assessments related to their functional areas:
5.2.1 Physicians
5.2.2 Nurses
5.2.3 Dietitians
5.2.4 Physiotherapists
5.2.5 Clinical Pharmacists
5.2.6 Social Workers
5.3 Upon completion of the collaborative, interdisciplinary assessment, a plan of care will be developed
by all healthcare team members, in consultation with the patient/family as appropriate and possible.
5.4.1 Primary nutritional assessment for nutritional status and nutritional risk, documented in
Nursing Assessment form and Nutritional Assessment form.
MS
Kingdom of Saudi Arabia
Ministry of Health
Baish General Hospital
Quality Management and Patient Safety
Patient Safety Committee
5.4.5.1.1 All patients presenting for treatment in the emergency department will receive a
medical screening/ assessment by the ER physician on duty, in order of priority based
upon their condition or change in condition, which will include but is not limited to:
5.4.5.1.2 The ER physician assesses and evaluates each patient prior to making any
referrals or decisions regarding disposition.
5.4.5.2 ICU/CCU
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Kingdom of Saudi Arabia
Ministry of Health
Baish General Hospital
Quality Management and Patient Safety
Patient Safety Committee
5.5 Assessments will be carried out within the following time frames depending on the scope of hospital
services and condition of the patient.
5.6 REASSESSMENT: The scope and intensity of any further assessments are determined by the
patient’s diagnosis, care setting, the care the patient is seeking, the patient’s consent to treatment and
his/her response to previous care rendered.
5.6.1 Any significant change in the patient’s diagnosis and/or condition necessitates an
immediate reassessment with changes in the plan of care reflecting the change in diagnosis or
condition.
5.6.2 Patients are reassessed after treatment, therapy or educational sessions to determine the
effectiveness (extent of improvement) of the interventions undertaken by the healthcare team.
Time frames for reassessment are dependent upon the type of treatment or therapy and/or the
intensity of the educational session provided.
5.6.3 Reassessment may also occur if members of the healthcare team become aware of issues in
the patient’s social/home environment which may impact his/her condition/treatment/care e.g. the
day after admission, the patient’s daughter arrives at the
MS
Kingdom of Saudi Arabia
Ministry of Health
Baish General Hospital
Quality Management and Patient Safety
Patient Safety Committee
facility and informs that the patient has recently increased his/her alcohol intake significantly; an
issue previously undetected by staff and unmentioned by the patient during initial assessment,
social services assessment and subsequent reassessments.
5.6.4 Reassessment of the patient shall be performed at regular intervals during the course of
care by medical and nursing staff; and documented at least every 24 hours in general care units,
and every 8 hours in critical care units by medical staff and every 8 hours in every ward by
nursing staff, daily patient in their assessment/reassessment sheet.
5.6.5 Ancillary services involved in the patient’s care also perform reassessment as
dictated by patient’s needs.
5.7 The plan of care will be reviewed regularly in consultation with appropriate members of the
healthcare team and the patient/ family. The plan of care will be revised as appropriate to the patient’s
condition and the ongoing assessment process.
5.8 Discharge planning needs will be included in the initial assessment and reassessment process,
throughout the patient’s hospitalization. The patient/family will be involved in the discharge
planning process as appropriate.
5.9 Appropriate education shall be provided to patient and/or family about the patient’s progress.
6- EQUIPMENTS
Pulse oximeter
Stethoscope
ECG strip/ ECG machine/ Cardiac Monitor Sphygmomanometer (BP Apparatus) 6.4
7- FORMS
7.1 History and Physical Examination form
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Kingdom of Saudi Arabia
Ministry of Health
Baish General Hospital
Quality Management and Patient Safety
Patient Safety Committee
8- REFERENCES
Rafha Central Hospital, Medical Staff Policy Version 3, 2015 8.1
Ministry of Health 8.2 CBAHI Standards 8.3
MS
Kingdom of Saudi Arabia
Ministry of Health
Baish General Hospital
Quality Management and Patient Safety
Patient Safety Committee
MS