Management Of Information.(MOI)

• The Medical Record will be arranged in a reverse Chronological Order

• (i.e. the most recent admission/ outpatient visit will be first).

• Inpatient Diagnoses & Outpatient Procedures will be coded using the ICD-10-AM.

• They are used to help the organization to identify the top Diagnoses and Procedures performed, facilitate Clinical Research and participate in outside databases/ registries.

• Be aware of validity of documentation in the patient medical records i.e. eligibility, etc.

Any Errors:

• must be crossed out with a single horizontal line, and initialled. “Error” must be written next to it.

• No Erasers, correction pens to be used.

Late Entry:• When a pertinent entry was

missed or not written in a timely manner.

• Identify the new entry as a “Late Entry”.

• Enter the current date and time. ” Do Not” attempt to give the appearance that the entry was made on a previous date or an earlier time.

• The entry must be signed. • Identify or refer to the date and

circumstance for which the late entry is written.

• An Addendum: • is another type of late

entry that is used to provide additional information in conjunction with a previous entry.

• (Follow the same procedure of late entry)

• Any Patient: who remains in the hospital for more than Forty-Eight (48) hours including patients held in the Emergency Department (ED) will require a dictated Discharge Summary.

• A Discharge Summary must be completed within fourteen (14) Days after discharge.

• Death Summary must be completed within fourteen (14) Days after patient death.

• Monitoring of MR Content & Completeness: Regular open patient MR review must be conducted by every MRP, as Two (2) files review per month.

• Please note that: We needs evidence of four (4) month MR reviews before the date of JCI Accreditation - April 2015. (This 4 month rule applies for any task requires evidences of documentation and implementation).

Facility Management and Safety (FMS)

a. Major Disaster

• You must know the Major Disasters Codes:

• Code Yellow: Stand-By - Code Red: Full Alert - Code Green: Stand Down

Our hospital is involved in Major Disaster Category (A)

For aeroplanes crashes, terrorism attaches and also covers North Riyadh Area.

Participates in the Major Disaster Category (B)

• with Ministry of Health such as water floods, sand storms & other Riyadh areas.

• Agreed by Hospital Administration, receiving (25) patients/causalities at a time is considered a Major Disasters.

During Major Disaster

• : Staff to ask for and ensures availability of the following Elements: Required medications, Bloods/Products, Infection Control, Utilities.

Do not talk to any Media

• (Radio, TV, and Journalist), it is the responsibility of the Hospital Administration.

b. Fire Events

• You must know Fire Code:

• Code F and The ext. (555) to activate Code F

In event of fire:

• Your answer will be I use, Standard Fire Orders: R.A.C.E. (You must be familiar with).

• Do not explain what is R.A.C.E. unless you are asked.

R = RESCUE:

Any patient in immediate danger from the fire, if it does not endanger your life.

A = ALARM:

Sound the alarm for “Code F”, by calling ext. “555” and activating a pull station alarm box.

C = CONFINE:

The fire by closing all doors and windows.

E = EXTINGUISH:

The fire with a fire extinguisher, or EVACUATE the area if the fire is too large for a fire extinguisher.

• Patients’ evacuation from fire area is Horizontal,

• if no fire exit in the receiving area patients’ evacuation will be Vertical.

• During evacuation do not forget to look for patients/staff in toilets (may not heard F Code). You have to ensure your safety as well.

• Must know the fire alarm sites in your area and how to use them.

• Must know the fire free zones area and collection zone in your area.

• Must know the location of fire extinguisher in your area, and if it is stabile to be used for all types of fires.

• In case no fire extinguisher available, you can use any Powders for miner fires.

• You may be asked to demonstrate how to use the fire extinguisher:

• you must be familiar with (P.A.S.S.) procedure.

P = PULL the pin on the fire extinguisher.

A = AIM the extinguisher nozzle at the base of the fire.

S = SQUEEZE or press the handle.

S = SWEEP from side to side until the fire appears to be out.

• You must know the location of ‘Medical Gas Valve’ in your area, and you know how and when to close it.

• In case you are required to do so (It is Charge nurse responsibility).

• your answer will be: Must ensure that patients requiring oxygen are placed on portable oxygen before closing the valve, to ensure patients safety.

• Must know the fire hose location in your area and if you can use it.

• If it is a low water pressure you can use, but if it is a high water pressure to be used only by hospital foremen.

• This is to avoid harming yourself and the others.

Child Abduction

• Code Pink : you will receive training on how to activate code pink, and each staff responsibilities.

INSHALAH WE WILL PASS,,,,,JCI SURVEY...

ALL I BEST

DR AMAL MOSTAFA NEONATOLOGIST