polisi operasi unit kejururawatan hospital sungai siput

POLISI OPERASI UNIT KEJURURAWATAN HOSPITAL SUNGAI SIPUT

Nombor Polisi : HS 001 Tarikh Semakan : 31 Mei 2019

Versi : 02/2019 Muka Surat : 1/34

1. VISI DAN MISI KEMENTERIAN KESIHATAN MALAYSIA

1.1. VISI

Negara menggembleng tenaga ke arah kesihatan yang lebih baik.

1.2. MISI

Misi Kementerian Kesihatan adalah untuk menerajui dan berusaha bersama-sama :

i) Untuk memudahkan dan membolehkan rakyat :

Mencapai sepenuhnya potensi mereka dalam kesihatan

Menghargai kesihatan sebagai asset paling berharga

Mengambil tanggungjawab dan tindakan positif demi kesihatan mereka

i) Untuk memastikan system kesihatan berkualiti tinggi iaitu :

Mengutamakan pelanggan

Saksama

Tidak membebankan

Cekap

Wajar mengikut teknologi

Boleh disesuaikan mengikut persekitaran

Inovatif

ii) Dengan menekankan :

Sifat penyayang, profesionalisme dan kerja berpasukan

Sifat menghormati maruah insan

Penglibatan masyarakat




2. VISI, MISI DAN OBJEKTIF HSOPITAL SUNGAI SIPUT

2.1. VISI HOSPITAL SUNGAI SIPUT

Menyediakan perkhidmatan kesihatan yang cekap, efisyen dan berkualiti.

2.2. MISI HOSPITAL SUNGAI SIPUT

Memberi perkhidmatan kesihatan yang berkualiti, komprehensif, selamat dengan

semangat berpasukan dan profesionalisme.

2.3. OBJEKTIF HOSPITAL SUNGAI SIPUT

Memberi perkhidmatan rawatan dan pemulihan yang berkualiti berteraskan elemen-

elemen budaya korporat supaya setiap individu mencapai dan mengekalkan satu taraf

kesihatan bagi membolehkan menjalani kehidupan ekonomi dan sosial yang produktif.

3. MATLAMAT

3.1 Untuk memberi perkhidmatan kejururawatan yang bersesuaian,kompeten dan efisen.

4. OBJEKTIF

4.1. Memberi perawatan kejururawatan yang berkualiti.

4.2. Memberi etika dan tingkah laku yang professional sentiasa diamalkan dikalangan para

jururawat.

4.3. Memastikan perawatan yang diberi boleh diterima,selamat dan optima.

4.4. Pengurusan sumber manusia kejururawatan dan anggota sokongan yang berkaitan

4.5. Memastikan semua anggota kejururawatan mendapat pendidikan dan latihan yang

sesuai supaya dapat menjalankan tanggungjawab mereka dengan berkesan.

4.6. Unit beroperasi mengikut waktu pejabat dan syif.

4.7. Unit menyediakan perkhidmatan penyeliaan kejururawatan 24 jam melalui Ketua

Jururawat atas panggilan.

4.8. Menguruskan CSSU.




5. CARTA ORGANISASI

:P/J U36

:KJ U32

:JT U29/32 (KUP)

:JM U24

:JM U19

:PEN JT U14

PETUNJUK :

:JM U19




6. DESKRIPSI POLISI

6.1. Unit Kejururawatan akan mengesyorkan penempatan dan pengagihan anggota

kejururawatan serta anggota sokongan yang berkaitan.

6.2. Unit Kejururawatan akan memastikan semua jururawat mempunyai Sijil Pengamalan

Tahunan yang sah.

6.3. Perkhidmatan kejururawatan yang berkualiti sentiasa dikekalkan dengan mengikut

aktiviti :

6.3.1. Induksi dan perkembangan profesionalisma yang berterusan.

6.3.2. Kepastian kualiti.

6.3.3. Pemantauan dan penilaian amalan kejururawatan.

6.3.4. Audit kejururawatan.

6.3.5. Perkembangan senarai semak kejururawatan, garis panduan, Protokol dan

Prosedur Operasi.

6.3.6. Pemantauan pendidikan pesakit dan kaunseling.

6.3.7. Penyelia Jururawat dan Ketua Jururawat bertindak sebagai penyelaras

bagi pengalaman klinikal pelatih.

6.4. Untuk memberi kaunseling kepada jururawat dan anggota sokongan berkaitan.

6.5. Pengurusan Unit sucihama mematuhi polisi operasi Unit.

6.6. Penyelia jururawat memastikan semua Unit dibawah penyeliaannya mengekalkan dan

mengemaskini inventori peralatan dan aset Unit.




7. PENYELENGGARAAN PERALATAN

7.1 Penyelia jururawat memastikan peralatan di selenggara berkala oleh Perkhidmatan

Sokongan Hospital swasta mengikut Hospital Spesific Indicator Performance (HSIP)

/Technical Requirement Key Performace Indicator (TRKPI) yang ditetapkan.

8. ASPEK UTAMA KESELURUHAN POLISI HOSPITAL

8.1 Semua aspek polisi hospital yang berkaitan perlu dipatuhi.

9. VISI UNIT KEJURURAWATAN HOSPITAL SUNGAI SIPUT

9.1 Memberi khidmat perawatan holistic bagi meningkatkan status kesihatan yang berkualiti

dengan berlandaskan Budaya Penyayang.

10. MISI UNIT KEJURURAWATAN HOSPITAL SUNGAI SIPUT

Kami akan berkerja berpasukan dengan anggota kesihatan yang lain, pesakit,keluarga

dan masyarakat untuk memberi perawatan yang berkualiti. Kami juga akan memberi

layanan yang mesra,perkhidmatan dan perawatan yang selamat dan suasana selesa

kepada semua pesakit. Kami bertanggung jawab untuk melaksanakan peraturan dan etika

kejururawatan dengan cemerlang.




NURSING SERVICE POLICY HOSPITAL SUNGAI SIPUT

1. INTRODUCTION

1.1. Nurses form the largest workforce in Hospital Sungai Siput, Perak, Nurses contribute to

the healthcare of individual, families and community through theHealth system that

promote quality healthcare. All nurses are registered withNursing Board of Malaysia.

Each nurse is required to have her annual practicing certificate renewed annually.

1.2. The Nursing Service is headed by a Matron as depicted in the Organization Chart of

Nursing Service. (Appendix 1.) The Matron is directly responsible to the hospital director

(Appendix 1A) Organisational Chart Hospital). And is overall responsible for nursing

administrations and nursing services.

2. SCOPE OF NURSING SERVICE

Primary roles and responsibilities of nursing service is to provide holistic care through

teamwork, caring and professionalism. Nurses work collaboratively with other members of the

health care team to ensure continuous individualized care. Placement of nursing personnel is in

the various units / wards which encompass obstetrics & gynecology, general medicine,

pediatric, hemodialysis, emergency, and outpatient nursing services and other support services,

that is central sterile supply services, infection control and quality unit. Nursing Service provides

24 hours coverage of nursing care by three shifts schedule. On-call Nursing Sisters are

assigned in two shifts daily and one matron rotate to stand call every week and weekend.

2.1. Administrative Roles and Responsibilities

2.1.1. Placement and deployment of staff, training and professional development.

2.1.2. Planning and resource requisition.

2.1.3. Daily operation of the unit to ensure uninterrupted patient care including:

2.1.3.1. Sufficient supply of linen and drugs, consumables.

2.1.3.2. Conducive and safe environment




2.1.3.3. Functioning and safe equipment.

2.1.4. Clinical roles and responsibilities

2.1.4.1. Monitoring of nursing care standards, quality of care.

2.1.4.2. Nursing documentation

2.1.4.3. Compliance to policies and procedures by nursing personnel.

2.1.4.4. Clinical nursing audit.

2.1.4.5. Enhancing therapeutic nurse-patient relationship.

2.1.4.6. Patients education and sharing information

3. VISION, MISSION, PHILOSOPHY, OPERATIONAL OBJECTIVES

3.1. Vision

To provide holistic safe quality care through teamwork and caring service provided by a

professional work force facilitated by information technology

3.2. Mission

We will work as a team with other health care providers, patient, family and community

in providing quality care. We will also provide caring, comfortable, safe and conducive

environment for all clients. We are committed to create an ethical discipline and

competent work force.

3.3. Philosophy

The nursing service practice the Cooperate Culture of Ministry of Health and the 10s

concept Senyum, Salam, Segera, Sentuh, Sensitif, Sopan, Segak, Selia, Selidik, and

Semangat.




3.4. Operational Objectives

3.4.1. Provide safe, quality individualized care by collaborating with patient and

families.

3.4.2. Provision of care shall be performed by competent nurses.

3.4.3. Ensure adequate supervision and teaching of nursing personnel in each

ward/unit.

3.4.4. Upgrade standard of care through continuous quality improvement programmed.

3.4.5. Improve knowledge and skills of work force through continuous professional

development programmed.

3.5. Clients’ Charter

3.5.1. Every client shall be treated equally with respect, dignity and human kindness

regardless of race, religion and beliefs.

3.5.2. Every client shall be attended to promptly and professionally at all time

according to his / her needs.

3.5.3. Patient safety and comfort shall be our priority.

3.5.4. All nursing procedures shall be explained to clients before it is carried out.

4. CODE OF PROFESSIONAL CONDUCT FOR NURSES/ MIDWIFES

4.1. Nurses shall practice in accordance to the Code of Professional Conduct for Nurses

First Edition April (1998).

4.2. Midwifes shall practice in accordance to the Code of Professional Conduct and Practice

of a Midwife.




5. CORPORATE GOVERNANCE

5.1. Administration, Letters and Documents Management

5.1.1. Nursing service shall comply with the hospital policy with regards to all

incoming and outgoing letters as stipulated in the Arahan Perkhidmatan Bab 3.

5.1.2. Personal records of staff shall be maintained at the relevant unit levels. This

includes : personal record on biodata, copy of relevant certificate, updated

annual practicing certificate, record of privileges, record of all training / CPD

/log books and record of leave.

5.1.3. Statistical records such as human resource management, quality initiatives,

ward census / workload / staff placement and deployment are also kept and

updated at the nursing department and all various units.

5.2. Finance And Budget Allocation

5.2.1. Nursing service shall plan and apply for budget requirement for purchase of

resources and human resource development on a yearly basis and upon

requests by the hospital.

5.2.2. Nursing Service work in collaboration with all various departments with regards

to selection and request for purchase of equipment.

5.2.3. Nursing service is also involved in the technical assessment of equipment and

consumables.

5.3. Human Resource Management

5.3.1. Staff allocation is determined by the Human Resource Department, Ministry of

Health and distribution is done by the nursing administration at the state level.

5.3.2. At the hospital level, the chief matron shall do placement of nursing personal.

Categories of nursing personnel are:

5.3.2.1. Chief Matron

5.3.2.2. Area Matron

5.3.2.3. Nursing Sister (Nurse Manager)

5.3.2.4. Registered Nurse

5.3.2.5. Community Nurse




5.3.3. Staff placement and deployment shall take into consideration:

5.3.3.1. Patient acuity level and workload of the specific ward / unit,

5.3.3.2. Qualification and experience of individual staff.

5.3.3.3. Contingency for absenteeism, Medical leave and emergency leave.

5.3.4. Nursing Service shall plan and request for staff requirement based on patient

acuity level / workload and expansion and extension of services.

5.3.5. Nursing service shall plan the requirement of manpower needs with post basic

training / specialty training to meet the services of the hospital.

5.3.6. Reshuffle of staff with no specialty training / post basic training is done every 5

years upon request and whenever necessary for purpose of staff enrichment.

5.3.7. Nurses shall be provided with written and dated job description which defines

roles and responsibilities for their designated position: and is reviewed and

updated regularly.

5.3.8. Nurses shall be registered with Nursing Board, Malaysia and has current

practicing certificate.

5.3.9. Midwife shall be registered with the midwifery Board, Malaysia.

5.4. Staff Discipline

5.4.1. Nurses / midwives are to abide by the Professional Code of Conduct and to all

rules and regulations stipulated in the Government General Orders (chapters

A to G) and the Service Circular and Code of Conduct- Peraturan 4.

5.4.2. Nurses / midwives with ethical issues shall be addressed to Ethical Committee

and appropriate action shall be taken according to Nurses Act / Midwife Act.

5.4.3. Nurses / midwives with disciplinary issues shall be subjected to Disciplinary

Action based on Buku Panduan Pengurusan Tatatertib, Bahagian Sumber

Manusia Kementerian Kesihatan Malaysia.

5.4.4. Nurses / midwives shall wear their uniform at all times while on duty.

5.4.5. Any staff entering /participating in patient care in the Labour Room, CSSU and

ED shall abide by the staff attire protocol.




5.5. Rostering

5.5.1. Nursing service provides 24 hours coverage for in- patient care and ensures

sufficient numbers of staffs are available to provide holistic care.

5.5.2. Ward/unit nursing sister shall be responsible to plan a two weekly staff work

schedule for shift and on-call duty. Generally nurses work in three shifts

consisting of:

5.5.2.1. Am duty, from 7.00am to 2.00pm

5.5.2.2. Pm duty, from 2.00pm to 9.00pm

5.5.2.3. Night duty, from 9.00pm to 7.00am

5.5.3. There shall always be a senior/experienced nurses working in each shift to

supervise and guide the junior staff.

5.5.4. Newly graduated and transfer-in staffs shall be assigned to a mentor for a

minimum period of 3 months.

5.5.5. Whenever there is insufficient staff due to emergency leave/medical leave,

matrons / nursing sisters shall re-arrange the roster to meet the service needs.

5.5.6. The matrons/nursing sister shall plan and grant the staff’s annual leave

accordingly.

5.5.7. Staff on-call shall be contactable at all times.

5.5.8. Roster for nursing sister working shift duty shall be planned by the respective

Area Matron and submitted to be coordinated with the general call roster.

5.5.9. Nursing service shall establish an on-call schedule for matron and nursing sister

to provide 24 hours nursing administration coverage.

5.6. Administrative roles for matron and sister on call.

5.6.1. Shall monitor and ensure continuity of quality patient care.

5.6.2. Shall monitor staff patient ratio and determine redeployment as need arises.

5.6.3. In the event when the ward are full, the practice of flexi bed allocation shall be

initiated by the matron / sister on call.




5.7. Human Resource Development

5.7.1. Nursing staff are required to attain continuing professional development (CPD)

points according to their categories.

5.7.2. Nursing services shall identify training needs, plan continuing nursing

education (CNE) program and monitor achievement of CPD points for nursing

staff.

5.7.3. Continuing Professional Development (CPD) program shall include short

courses / seminars / workshops / clinical attachment either organized by wards

/ units / department / hospital or externally.

5.7.4. Nurses shall be encouraged to go for post basic courses / higher education for

self enrichment.

5.7.5. Nursing service shall establish the maximum number of staff number that can

be approved to attend post basic courses/higher education without

compromising delivery of services.

5.7.6. Nurses shall maintain a logbook of training record for the year.

5.8. Training of Nursing Students

5.8.1. Placement of nursing students in the clinical areas shall be in accordance to

MOU between the College and Ministry of Health. This is to ensure optimal

clinical exposure and no overcrowding of students.

5.8.2. The clinical instructors shall be available at all times to supervise nursing

students.

5.8.3. Nursing Service shall determine the maximum number of students allowed in

each clinical area. Feedback shall be given to the college when number of

student exceed.

5.9. Orientation

5.9.1. There shall be a planned orientation program for all categories of newly

appointed / transfer in nurses and student nurses.

5.9.2. Nursing Service shall establish structured module for staff orientation.

5.9.3. Orientation module shall be reviewed and updated regularly to meet the

current role changes of nursing staff.




5.10. Staff Appraisal

5.10.1. Appraisal documents shall be established with the involvement of staff and

reviewed to assess performance / progress, identify training needs and to

motivate staff when necessary.

5.10.2. Staff appraisal shall be done at the end of the year and results shall be

informed to staff concerned for further improvement.

5.10.3. Staffs receive written evaluation of their performance annually.

5.11. Credentialing and Privileging

5.11.1. Nursing service shall establish a mechanism and criteria for credentialing and

privileging of nursing staff and coordinate application for approval by the

Hospital Credentialing and Privileging Committee.

5.11.2. The criteria for credentialing and privileging of nursing staff shall include

current registration and documentation of appropriate training.

5.11.3. Clinical privileges shall be granted for a period of 3 years.

5.11.4. Nurses are allowed to appeal to the appellate committee when their

application is rejected.

5.11.5. Ongoing periodic structured competency assessment shall be conducted for

the purpose of evaluation and re-privileging.

5.12. Staff Welfare and Safety

5.12.1. Nursing department practice ‘open door concept’ where staff are allowed to

discuss or ventilate problems they have encountered.

5.12.2. Internal transfer shall be considered for staffs who wish to practice in their

area of interest.

5.12.3. Nurses after post basic / attachment training are required to serve in the

areas that they are trained in.

5.12.4. Nurses after post basic midwifery shall be placed in the Obstetric

&Gynecology wads / unit for a minimum period of 2 years after which they

are allowed to apply for internal transfer.




5.12.5. Attachment of staff to related discipline to acquire hands-on knowledge and

skills for the purpose of enriching knowledge and skills shall be scheduled a

required.

5.13. Facility and Equipment Management

5.13.1. In view of assuring a safe, efficient integrated support services that facilitate

delivery of quality patient care, nursing service shall work in partnership

withFEMS & FEMS personnel to ensure continuous management of

equipment, compliance to policies and provision of user training program.

5.13.2. The nurse managers of the respective wards / units, supervised by the area

matron shall be responsible:

5.13.2.1. For the care, maintenance and storage of the equipment in their

area.

5.13.2.2. To ensure equipment are readily available and functional for use

at all times.

5.13.2.3. To conduct inventory as scheduled and reports sent to the asset

manager.

5.13.2.4. For periodical updates for condemned equipment and to send

report to the hospital asset manager.

5.13.2.5. To monitor PPM schedule is being complied and proper

references made.

5.13.2.6. To report faulty equipment to Hospital Support Service.

5.13.2.7. To liaise with HSS ( Hospital Support Personnel ) personnel for

any clarification in regards to maintenance and repair.

5.13.2.8. To report failure of Hospital Support Service to comply with HSIP

for the initiation of deduction formula being put into effect.

5.13.2.9. To update KEW-PA records at all times.




5.13.3. Cleansing Service

5.13.3.1. Maintain a clean, safe and healthy environment at all times.

5.13.3.2. Monitor to ensure cleansing shall be carried out according to

schedule.

5.13.3.3. Cleansing complaints are to be made without any compromise for

the benefit of deductions.

5.13.3.4. Monitor the cleansing reagents used as according to KKM

standards.

5.14. Management of Store

5.14.1. Store shall be kept neat and tidy at all time.

5.14.2. Record in and out items in the respective bin cards.

5.14.3. All items should be arranged as first in first out system (FIFO).

5.14.4. Items shall be arranged accordingly.

5.15. Information Communication Technology ( ICT )

5.15.1. Nurses shall take appropriate security measure to avoid unauthorized

access, alteration, disclosure and accidental loss of data.

5.15.2. Nurses shall follow strictly good ethical email in accordance to the hospital

policy.

5.16. Quality Management System

5.16.1. The head of nursing service shall be a member of the hospital quality

assurance committee.

5.16.2. Area matron and ward / unit nurse manager shall monitor quality

performance in their respective wards / units.




5.16.3. To cultivate and install quality culture among all nursing personnel and to

ensure continuous improvement in the quality of patient care nursing service

shall:

5.16.3.1. Conduct nursing audits periodically.

5.16.3.2. Monitor and report all untoward incidences and carry out

Improvement measures and prevent future occurrence.

5.16.3.3. Compile NIA / KPI and Hospital Quality Objective data for Quality

improvement purposes.

5.16.3.4. Conduct HSA studies to improve patient care service.

5.16.3.5. Monitoring and feedback mechanism shall be established in the

hospital to ensure dissemination of performance. (This is done

twice a year by the Quality Unit)

5.16.3.6. All nurse manager of the respective wards / units shall collect,

compile and analyze their own data / statistics and submit their

performance to the Quality Unit.

5.16.3.7. All untoward incidences and sentinel events shall be investigated

and root cause analysis conducted.

5.17. Incident Reporting

5.17.1. Nurses shall report all incidences and untoward events and submit to

Hospital Director, Chief Matron and respective area matron.

5.17.2. Nurse managers are to report all incidences that occur in their respective

wards /units within 24 hours of the incident.

5.17.3. Nurse managers are to investigate all incidences that occur in their respective

wards / units and send report to the head of nursing unit.

5.17.4. All sentinel events must be investigated and root cause analysis conducted.




5.18. Disaster Plan

5.18.1. The Nursing Service shall establish plan for internal and external disaster

corresponding to the hospital disaster plan (Refer : Pelan Tindakan Bencana

Hospital and Pelan Tindakan Bencana Kejururawatan)

6. CLINICAL GOVERNANCE

6.1. Nursing Care Delivery System

6.1.1. A combination of patient care delivery system which encompasses team and

functional nursing is practiced. Team nursing is preferred as it allows optimal

use of nursing personnel of various categories with varied skill mixed and

competency. Functional assignment is instituted based on needs and priorities

of the various units.

6.2. Standard of Care

6.2.1. Nurses is expected to provide a good standard of nursing care in the following

manner:

6.2.1.1. Conscientiously assesses the physical, psychosocial and spiritual

needs of each patient.

6.2.1.2. Provides compassionate and competent nursing care to meet each

patient’s needs.

6.2.1.3. Intervenes appropriately and promptly to prevent complications.

6.2.1.4. Maintain accurate and proper documentation of care given to each

patients.

6.2.1.5. Gives correct information and education to each patient according to

the needs.

6.2.1.6. Evaluate each patient’s response to treatment at regular intervals.

6.2.2. Nurses shall work collaboratively and co-operatively with other members of

the health care team. She does not hesitate to consult appropriate

professional colleagues when needed.




6.3. Communication during Handing Over Shift

6.3.1. Nursing Service shall practice hand-off communication during shift changes and

as required:

6.3.1.1. Daily by Nursing Sister on-call to the teams of matrons.

6.3.1.2. At end of shift change between the on-call Nursing Sister

6.3.1.3. End of shift changes by the team leader

6.3.2. Nurses shall practice effective hand-off communication during shift changes and

when requires by passing over and taking over reports of all patients from bed to

bed by providing up to date information regarding patient’s condition, allergy,

care, treatment, medication, records, reports and patient’s property.

6.3.3. Nurses shall pass over Dangerous Drug Act (DDA) key / drug, patient’s property

(if any), any incidence, any current circulars, important messages and MC book.

6.3.4. Nurses shall communicate with other support services such as imaging,

physiotherapy, Laboratory, Pharmacy, Food services, Administration, Clinics

and other hospitals, in regards to patient care and treatment.

6.4. Nursing Documentation

Electronic Nursing documentation being part of the electronic medical records comprises

of nursing assessment, care plan, nursing kardex (nursing notes), nursing progress

report, and various flow sheets(result sections).

6.4.1. Nursing assessment of patient shall be carried out within the first two hours of

admission and care plan documented within twenty four hours.

6.4.2. Client’s progress report shall be documented and communicated during passing

over of shift.

6.4.3. Nurses shall refer to the general and specific care plan and modify to meet

individual patient’s need.

6.4.4. Narrative and focus charting shall be the preference for writing the patient’s

progress report.

6.4.5. Implement and document care given.

6.4.6. Maintain accurate and proper documentation of care given to each patient.




6.4.7. Nursing sisters of wards/ units shall conduct documentation audit and send

report to Nursing Cara Plan Committee.

6.4.8. Nursing sisters shall analyze and provide feedback to staff to improve nursing

documentation.

6.5. Admission

6.5.1. All clients on admission shall be acknowledged on arrival to the ward.

6.5.2. All clients shall be assigned to their beds according to their condition.

6.5.3. Implement immediate nursing intervention to client’s condition and needs.

6.5.4. The doctor in charge shall be informed regarding the admission.

6.5.5. Orientation shall be given to all patients and their accompanying family member.

6.5.6. Patient’s property shall be managed as stipulated in hospital policy. (refer to

hospital policy on care of patient’s property).

6.6. Transfer of Patients

6.6.1. Patients and next of kin shall be informed of the transfers.

6.6.2. The receiving ward within the hospital or referred hospital, shall be informed in

advance before the patient is transferred over.

6.6.3. Practice effective hand-off communication by providing up to date information

regarding client’s condition, allergy, care, treatment, medications, records,

reports and patient’s property, during handing over to the receiving staff.

6.7. Abscondment

6.7.1. Patients who fail to turn up for admission to the ward of leave the hospital

premise without permission is considered absconded and shall be discharged

after 24 hours from the ward census.

6.7.2. The ward staff shall inform the next of kin and report to the police within 24

hours.




6.8. Discharge

6.8.1. Discharge package shall be prepared and given upon discharge. (Medication,

appointment card and medical certificate (if any).

6.8.2. Advise on discharge shall be given to patient and family at time of discharge.

6.9. Discharge At Own Risk (AOR)

6.9.1. Patient requesting AOR discharge shall be informed of the risk by the doctor /

specialist in-charge.

6.9.2. Patient / next of kin, shall sign the AOR discharge form and be given a discharge

package. (Refer to the hospital policy).

6.9.3. Dangerously ill patients shall be allowed to be discharge (AOR) upon request.

6.10. Death

6.10.1. Nurse shall notify mortuary staff and request for burial permit upon

confirmation of death by the doctor.

6.10.2. All deceased shall be respected and their dignity maintained at all time

regardless of ethnicity, religious beliefs and social status.

6.10.3. The relatives shall be allowed to performed religious ritual without disturbing

other patient.

6.10.4. Last Office shall be performed and body tagged correctly accordingly to work

instruction for management of deceased before transferring to mortuary. (Refer-

Arahan Kerja : Pengurusan Mayat…)

6.10.5. Burial permit shall be dispatch to the mortuary for the release of the body.

6.10.6. The deceased shall be transferred to the mortuary within an hour after

confirmation of death.

6.10.7. Practice effective hand-off communication by providing up to date information of

the deceased as stipulated on body tag, client’s property (if any), during handing

over to the receiving mortuary staff.




6.11. Patient And Family Rights

6.11.1. Nurses shall ensure privacy and confidentiality of patients is maintain.

6.11.2. Family members shall be included in the plan of care and decision making

process.

6.11.3. Patients shall be informed about their treatment and progress.

6.11.4. Patients shall be educated on the treatment and have the right to ask if

doubtful.

6.11.5. Patients shall be respected and addressed by name.

6.11.6. Patients have the right to decline participation in research studies and

clinical trials.

6.11.7. Patients have the right to receive appropriate pain relief.

6.11.8. The patient shall be allowed to practice his /her cultural and spiritual belief

without disturbing other patients.

6.11.9. Patients have the right to refuse physical examination by nursing students

without supervision.

6.12. Patients Safety Practice

6.12.1. The Safety Culture of Nursing service shall focus on patients, staffs,

visitors and all client who are directly or indirectly involved in patient care.

The safety practices include:

6.12.2. Identify patients correctly using two identifiers by asking their name and

check their MRN.

6.12.3. Practice effective communication on receiving orders or test result by:

6.12.3.1. Writing it down

6.12.3.2. Read back

6.12.3.3. Confirm order

6.12.4. Prior procedure/ surgery, nurses shall verify:

6.12.4.1. to ensure valid consent obtained from patient / next of kin.

6.12.4.2. to confirm patient’s identity using two identifiers.

6.12.5. Reduce the risk of healthcare-associated infection by complying with

infection control practices and observing the five moments of hand

hygiene.




6.12.6. Reduce the risk of patient harm from fall by complying with policy on

Prevention and Management of Patient Fall.

6.12.7. Practice effective hand-off communication by providing up to date

information regarding client’s condition, allergy, care treatment,

medications, record, reports and patient’s property during handing over to

the receiving staff.

6.12.8. Use only approved abbreviation.

6.12.9. Comply with safety practices when serving medication by observing the

6R.

6.12.10. Educate patient on hand hygiene, respiratory ethic, contact precaution

practices, regarding their illness, medication and diet.

6.12.11. Monitor patients regularly to identify changes in patient’s condition and

respond accordingly.

6.12.12. Monitor patient to identify suicidal risk.

6.12.13. Manage spillage in accordance to Prosedur Kualiti Operasi (PK(O)(27).

6.12.14. Manage patient or family complain in accordance to the guideline on

Management of Complains from the Central Government and Ministry of

Health.

6.12.15. Nurse shall be familiar and follows protocol when encountering fire and

internal disaster.

6.12.16. Nurse shall be familiar and follows protocol on initiation of Hospital

Emergency Code, Hospital Medical Alert Code and external disaster.

6.13. Grievance Mechanism and Complaints Management

6.13.1. Management of complaints shall be carried out in accordance with Guideline

on the Management of Complaints and Medico-legal Cases, Medical

Practice Division, Ministry Of Health, March 2007.




6.14. Infection Control Practices

6.14.1. Nurses shall be familiar and comply with Infection Control Practices in

accordance to Policy And Procedure Of Infection and Antibiotic Control,

Ministry of Health and Pocket Guideline for Standard Precaution,

Occupational Health Unit, Ministry of Health (3rd Edition, 2007).

6.14.2. Patient and relatives shall be educated on the importance of compliance to

performing hand hygiene.

6.14.3. Nurse managers shall monitor the availability of hand rubs.

6.14.4. All nurse managers and link nurses in each ward / unit are to monitor correct

control practices.

6.14.5. To provide continuous nursing education program and infection control

updates to all staff in the hospital.

6.14.6. Proper Isolation Precaution practices shall be observed when managing

infectious cases.

6.14.7. Visitors shall be restricted and educated to comply with Isolation Precaution

practices while in the ward.

6.15. Dangerously III Patient (DIL)

6.15.1. Nurse shall take note of the patients deemed as seriously ill in the ward/unit

and shall allow relative to be at patient’s bedside towards the end of life.

6.16. Management of Placenta

6.16.1. All placentas shall be checked by the midwife conducting the delivery for

completeness and findings documented.

6.16.2. Disposal of placentas shall be in accordance as clinical waste.

6.16.3. For non-infected cases, placentas shall be release upon request for cultural

belief practices. (Refer: Pocket Guideline for Standard Precautions (3rd

edition 2007).




6.17. Discharge of Mother and Baby in Obstetric and Paeds.

6.17.1. Nurses shall ensure tagging of mother and their baby as in accordance to

Pekeliling Ketua Pengarang Kesihatan Bil 1/2007 – Garispanduan Sistem

Kawalan Keselamatan Bayi di Hospital-Hospital :

6.17.1.1. On tagging before and during delivery (Rujuk Fail Meja MO 1.2),

Pengurusan Ibu Mengandung dan Kelahiran Bayi di Unit

Obstetrik)

6.17.1.2. During discharge process (Refer to Arahan Kerja – Arahan Kerja

Discaj Ibu dan Anak di Hospital Sungai Siput).

6.17.2. Nurses in Obstetric and Paeds shall ensure safety of babies as in

accordance to Pekeliling Ketua Pengarah Kesihatan Bil 1/2007

GarispanduanSistem Kawalan Keselamatan Bayi.

6.17.3. Health Education shall be given to mothers prior discharge.

6.17.4. On discharge, parents shall be informed of the exit route to be allowed for

security purpose. (Refer to Arahan Kerja A.K.HS.JR.18-Arahan Kerja Discaj

Ibu dan Anak di Hospital Sungai Siput).




7. NURSING CARE STANDARD

Nursing Service shall work towards the achievement of high quality care through effective

assessment, planning, intervention and evaluation of patient care. High standard of care

shall be maintained at all times.

7.1. STANDARD 1 :

Nursing care shall be planned for each patient based on documented assessment of

their needs. Pre-planned nursing care plan are available for reference in the J drive.

Criteria:

i. The nursing assessment and nursing care plan shall commence within two hours

of admission. If the assessment and care plan is not completed during the

admission shift, the next shift shall complete the care plan within 24 hours of

admission. Plan of care shall then be carried out immediately.

ii. The patient / family members shall be involved when formulating nursing care

plan.

iii. Nursing intervention shall be evaluated from time to time and patient progress

documented.

iv. Nursing progress notes which include the patient progress or regress shall be

documented from shift to shift.

v. Nursing notes which includes all patient treatment and procedures carried out

shall be documented accordingly.

vi. The discharge care plan which includes patient education on various aspect of

care, shall commence soon upon admission.




7.2. STANDARD 2:

The patient’s safety will be maintained during hospitalization.

Criteria: Nurse shall implement safety measures to ensure :

i. Accurate patient identification.

ii. Prevention of Healthcare Associated infection.

iii. Prevention of falland harm.

iv. Prevention of Medication Errors.

v. Prevention of surgical fires / Burns.

vi. Accurate and complete reconcile medications across continuum of care.

vii. Prevention of wrong patient, wrong procedure and wrong site surgery.

viii. The nursing assessment shall include details of the patient’s physical disability

which may impinge on the safety of the patient while in hospital.

ix. The ward environment shall be safe from mechanical hazards.

x. All equipment shall be functioning and safe for use.

xi. Nursing staff shall be informed of patients’ whereabouts.

xii. Patients shall inform the ward staff should there be a need to leave the ward

xiii. Any incidence of fire, all patient are evacuated to safe area (refer Hospital Fire

Guideline)

7.3. STANDARD 3 :

The patient shall be clean and kept comfortable during hospitalization.

Criteria :

i. The patient shall have :

A daily bath / shower/ sponge.

Teeth cleaned twice daily or mouth toilets 4 hourly.

Hair kept clean, tidy and well groomed.

Hair washed shall be carried out when necessary.

Nails kept short and clean.




7.4. STANDARD 4:

The patient shall be clean and kept comfortable during hospitalization.

Criteria:

i. The patient’s hospital clothing changed daily or P.R.N. when soiled.

ii. The bed linen will be changed daily and P.R.N. when soiled.

iii. Bed ridden patient shall be attended to their personal hygiene and positioning

shall be carried out two hourly and pressure area care shall be performed every

four hours unless contraindicated.

iv. The patient shall be maintained as pain free as possible at all times.

v. In the pre-operative / procedural phase, the patient shall receive physical and

emotional care so as to minimize the onset of complications.

vi. Incidents or accidents involving patients shall be documented, investigate and

corrective action implemented.

vii. The ward sister or a senior registered nurse shall assign nursing staff with

necessary knowledge and skills to provide safe and effective care to patient.

viii. The patient’s emotional, social and intellectual needs shall be met during

hospitalization.

7.5. STANDARD 5:

The patient shall be assisted to achieve and maintain hydration status during

hospitalization.

Criteria :

i. The nursing assessment will include aspects of the patient’s hydration status,

usual and current intake and output which shall be reflected in the nursing care

plan if a problem is identified.

ii. The nursing care plan shall include aspects of care relevant to the patient’s

fluid and nutritional needs.




iii. The fluid balance chart shall indicate all intake and output over a 24 hour period

and shall be maintained for patient.

Less than nine months of age.

Who are failing to thrive.

Who have conditions affecting intake and /or output’

e.g., vomiting, diarrhea, renal disorder.

Who are receiving I.V.Fluids.

Elderly > 60 years of age.

7.6. STANDARD 6 :

The patient shall be assisted to achieve and maintain optimal respiratory function

during hospitalization.

Criteria :

i. The nursing assessment shall include aspects of patient’s usual and current

respiratory status which shall be reflected in the nursing care plan if a problem is

identified.

Color

Air entry

Use of accessory muscles

Respiratory rate

Presence of stridor or wheeze

ii. Changes in the respiratory status of the patient shall be reported promptly.




7.7. STANDARD 7:

In the pre- operation/ procedure phase, the patient shall receive physical and emotional

care so as to minimize the onset of complications.

Criteria:

i. Prior to the procedure:

ii. The patient shall receive an explanation of the proposed procedure and

anticipate nursing care using language that is understand by patient.

iii. The patients / next of kin shall have the care explained and shall be given the

opportunity to ask questions regarding the proposed nursing care.

iv. The patient shall be fasted as pre Hospital Policy unless other wise specified

by the doctor.

v. Pre-op preparation shall be carried out as per department policy.

vi. The patient shall be dressed in OT gown.

vii. The patient’s safety shall be maintained by:

Verification of identify bands with operative check and medical record

by two people (at least one registered nurse) prior to leaving the ward

and on arrival at the reception area.

Visual observation during transfer.

7.8. STANDARD 8:

Incidents or accidents involving patients shall be documented, investigated and

corrective action implemented.

Criteria :

i. The nurse involved in or discovering an * accidents or incident to a patient

shall notify the M.O. of the ward immediately and shall document the details

on the appropriate forms.

ii. The M.O. who attends the patient shall complete the details in the incident

form.

iii. A record of the incident shall also be decomented by the nurse and the doctor

in the progress notes.




iv. The Area Matron shall be given the complete report during the shift the

incident occurred.

v. The Area Matron shall ensure any corrective action is initiated and shall

document this in the report.

vi. The completed report shall be sent to the Chief Matron who notes the incident,

the subsequent action, and follows up as necessary.

vii. A photocopy of the report shall be sent to Head of Department and Director of

Hospital.

viii. Details of all incident reports shall be compiled by the QA Nursing Coordinator

anda report distributed each month. Six monthly reviews of all incidents shall

also be compiled.

ix. All medications incidents will be reviewed by the Chief Matron, Nursing QA

coordinator and a report and recommendations forwarded to the QA

committee.

Accidents and incidents deemed reportable include :

i. Anytime trauma is sustained.

ii. Equipment failure.

iii. Any disruption to a patient’s treatment regime.

iv. Patient vs patient incident, absconding patients.

v. Falls from bed, cots, wheelchair etc.

vi. Any drug omission or greater than flour hours and other error involving wrong

drug, route, person, time, dose.

vii. Error involving I.V, rates, lines, solution, or infiltration where damage has

occurred.

viii. Staff vs patient / visitors incidents.

ix. Details of all incident reports shall be compiled by the QA Nursing Coordinator

and report distributed each month. Six monthly reviews of all incidents shall

also be compiled.

x. All medications incidents will be reviewed by the Chief Matron, Nursing QA

coordinator and a report and recommendations forwarded to the QA

committee.




7.9. STANDARD 9 :

The Ward Sister or a Senior Registered Nurse will coordinate the rostering of the nursing

staff to allow each patient to receive safe and effective care from nurses who have the

necessary knowledge and skills.

Allocate patients according to nursing care needs and the level of knowledge

and skills of the nurse rather than the geographical layout of the wrad.

Allocate the number of patients assigned to each nurse according to the

amount of nursing care require by each patient.

Plan meal break relief so that patient care is maintained at a safe level. This

will require at least two-third of the staff to be present on the ward at all times.

In all shifts an appropriate resource person is allocated for nurses who are in

formal student programmes.

Plan for the appropriate number and level or staff for each shift.

Promote effective communication between the nursing staff and also between

the nursing and other health care team members.

Keep the Area Matron or Matron on call informed of serious changes in the

condition of any patient and staffing changes.

7.10. STANDARD 10 :

The nurse allocated to care for each patient will receive current and ongoing

information about that patient troughout the shift.

Criteria :

i. a concise handover of all ward / unit patients will be attended by all oncoming

staff at beginning of each shift.

ii. The nurse taking over the patient care will read the patients current

documentation.




iii. When a nurse leaves the ward during the shift, a handover of patients will

occur from bed to bed. The nurse handling over the patients must have

completed all observations due.

iv. The patient’s allocated nurse will have the opportunity to contribute to the

round / discussion with the health care team.

v. The nurse will be kept informed of any changes in treatment.

7.11. STANDARD 11 :

The patient’s emotional, social and intellectual needs will be met during

hospitalzation.

Criteria :

i. The nursing assessment will include aspects of the patient’s emotional, social

and intellectual status which will be reflected in the nursing care plan if a

problem is identified.

ii. The patient will be encourage to utilize available materials and facilities

appropriate in their recovery.

iii. The patient will be reffered to the appropriate health care team e.g., social

medical officer if required.

iv. All the pediatric patients will have acces to play through the ward play leaders

and nursing staff.

v. The patient will be cared for in an age appropriate environment. The pediatric

patient will be provided with age appropriate tots and activities including

television programmed.




7.12. STANDARD 12 :

The next of kin will be kept informed of the patient’s progress and the family will be

involved in the care of the patient where appropriate.

Criteria :

i. The nursing assessment will include aspects of the family’s availability and

desired involvement in the patients care.

ii. Nursing staff will introduce themselves, by name and designation, to the

relatives or whenever they are present.

iii. The nursing staff will arrange for relative / next of kin to speak with other

members of the health care team when requested to do so.

iv. Nursing staff will be responsible for the patient’s care and will support and

guide the family to give care if they elect to do so.

v. Nursing staff will encourage relatives / next of kin who spend long periods of

their time with the patient to recognize their own need for rest, meals, hygiene,

and other family commitments

vi. Relatives will be referred to the Medical Social Worker or appropriate

personnel accommodation if required.

vii. Nursing staff will ensure the relatives have access to the patient whenever

appropriate.

viii. Patients / Relatives will be reffered to special support services as appropriate,

Medical Social Worker, Community Nursing Services, SOCSO, Hospice etc.

Care after discharge.

ix. Teaching plans for patients and significant others will be developed and

implemented as soon as possible after admission so as facilitate effective care

after discharge.

x. Relevant phamplets and written instructions will be available for parents /

family members / significant other in each ward / department.

xi. Information about patient support groups will be given to patients / relatives as

appropriate.




7.13. STANDARD 13 :

All patients and / or families will be discharge with the necessary knowledge, skills

and / or an appropriate support service to continue the management of remaining

nursing problems.

Criteria :

i. A discharge care plan will be commenced within 24 hours of admission.

ii. The discharge care plan will be updated as appropriate, according to the

patient’s progress.

iii. The discharge care plan will include a teaching plan, which is designed to

facilitate progressive patient / family learning before the patient is discharged.

iv. Before discharge the patient / family will :

express acceptance of the responsibility for home care.

describe the necessary actions and their rationale.

demonstrate relevant techniques and procedures.

v. At discharge, all remaining nursing care problems will have been addressed

in the discharge care plan.

vi. The discharge care plan will include details of support services, referrals and

appointments.

vii. Equipment and medication for continuing care following discharge will be

obtained and education regarding their use and / or administration will be

completed prior to discharge.

viii. The timing of discharge will be determined according to the progress of the

discharge care plan.