232a1 approprlaLe professlonals perform coordlnaLed and sequenced paLlenL assessmenL Lo reduce

wasLe and unnecessary repeLlLlon

ollcles and rocedures on conducLlng lnlLlal assessmenL ln an efflclenL and sysLemaLlc manner

1 ConducLlon of lnlLlal assessmenL for paLlenL from ouLslde source (ouLpaLlenL) wlll be a comblne
sLraLeglc assessmenL of Lhe resldenL physlclan and nurse on duLy (L8 personnel)
2 lmperaLlve deLalls and lnformaLlon wlll be recorded on paLlenL lnformaLlon charL as basls for
furLher evaluaLlon and assessmenL
3 lnlLlally Lhe L8 personnel (nurse/Lralnee) wlll collecL Lhe necessary daLa such as paLlenL's full
name age gender welghL (pedlaLrlc cllenLs) address conLacL number blrLhday and chlef
complalnLs lurLhermore Lhere's a need Lo relLeraLe cerLaln drugs and medlcaLlon LhaL has been
prevlously Laken (eg malnLenance medlcaLlon)
4 Concluslve and lnlLlal vlLal slgn or perLlnenL medlcal assessmenL should be noLed and lf
necessary lmmedlaLely refer Lo Lhe resldenL physlclan
3 AfLer all Lhe daLa has been collecLed Lhe resldenL physlclan wlll do Lhe compleLe medlcal hlsLory
and perLlnenL physlcal assessmenL (cephalocaudal) All of Lhe slgnlflcanL and non slgnlflcanL
flndlngs wlll be collecLed and noLed Lo Lhe paLlenL cllnlcal summary card as legal medlcal hlsLory
6 lf Lhere are necessary and slgnlflcanL laboraLory workup lL should be well documenLed ln Lhe
paLlenL cllnlcal summary (form) as basls for fuLure medlcal reference 1he orlglnal copy should
be glven Lo Lhe paLlenL ln cases LhaL boLh slgnlflcanL flndlng were noL able Lo be reLrleved Lhe
laboraLory deparLmenL should have a backup copy ln Lhelr sysLem
7 All flles of ouLpaLlenL cllenLs should be flled ln a sysLemaLlc manner followlng Lhe alphabeLlcally
asslgned area for ease access and flllng All paLlenL daLa LhaL needs follow should be placed ln
Lhe followup box for easy and accesslble reLrleval
8 1he L8 logbook whlch conslsL of Cu/lnaLlenL/ uead on Arrlval/vehlcular AccldenL cases
should be accompllshed wlLh accuracy 1hls wlll serve as basls for fuLure medlcal reference
9 All slgnlflcanL assessmenL accompllshed by Lhe nurse should be reporLed and verlfled by Lhe
resldenL physlclan lL should be properly reporLed and documenL ln Lhe paLlenL cllnlcal summary
lndlcaLlng Lhe Llme daLe and Lhe seLLlng
10 1here should be only one person collecLlng slgnlflcanL daLa from Lhe paLlenL for lnlLlal
assessmenL Lo prevenL dlsLurbances or amblgulLy ln Lhe parL of Lhe paLlenL glvlng lmporLanL
lnformaLlon





236a1 assessmenL are performed regularly and are deLermlned by paLlenL's evolvlng response Lo care
ollcles and rocedure LhaL ldenLlfy paLlenLs wlLh speclal needs
1 aLlenL wlLh speclal need requlres speclflc Lype of aLLenLlon dependlng on Lhe level and exLend
of one's dlsablllLy or deflclency Lhus Lhese Lype of paLlenL needs much more aLLenLlon and
dellcaLe care
2 ln order Lo ldenLlfy paLlenL wlLh speclal needs we should conslder assesslng Lhe paLlenL
1herefore lL requlres lmmedlaLe and Lhorough response llrsL we should conslder Lhelr level of
undersLandlng and ablllLy Lo comprehend one's lnsLrucLlon Lhls ls very vlLal ln Lhe process due
Lo Lhe reason LhaL lL wlll affecL our ablllLy Lo seL poslLlve relaLlonshlp Lo Lhe paLlenL
3 Second Lhelr physlcal prowess Lhls wlll subsLanLlaLe Lo our ablllLy Lo ldenLlfy Lo Lhelr medlcal
aldlng maLerlals (eg wheelchalr/ sLreLcher eLc)
4 lourLh ls Lhelr supporLlve mechanlsm (eg parenLs/ slgnlflcanL oLhers) Lhls wlll glve us an ldea
Lhe paLlenL ls ln facL ln need of furLher medlcal asslsLance 1he mere acL of someone aldlng Lhem
ln Lhelr behalf slmply denoLes Lhelr dlsablllLy/ deflclency
3 Speclal medlcal records should be glven Lo Lhem ln cases LhaL Lhey have prevlous medlcal
asslsLance from Lhe hosplLal 1hls wlll ald ln ldenLlfylng Lhelr prevlous medlcal LreaLmenL and we
can furLher evaluaLe Lhe effecLlveness and Lhe LreaLmenL remedy
ollcles and rocedure LhaL ldenLlfy Lhe speclflc Lype of assessmenL approprlaLe Lo Lhe needs of Lhe
paLlenL wlLh speclal needs
1 1he Lype of assessmenL approprlaLe for paLlenL wlLh speclal needs and ordlnary cllenLs are [usL
buL Lhe same ln core buL may dlffer ln Lhe amounL of Llme and efforL and level of dellverlng Lhe
response (communlcaLlon)
2 ln cases of menLal reLardaLlon Lhe assessmenL enLalls Lhe gap dlfference ln age and maLurlLy
Lhe effecLlveness of Lhe assessmenL wlll be dependenL on Lhe lmperaLlve lnformaLlon LhaL Lhe
slgnlflcanL oLhers/ relaLlves wlll ald Lhe medlcal Leam slnce Lhey are Lhe one who can mosL
relaLe/observe Lhe behavlor of Lhe cllenL
3 ln cases of physlcal dlsablllLy Lhelr speclflc assessmenL wlll be on Lhe speclflc physlcal
affecLaLlon SlgnlflcanL flndlngs LhaL are vlLal ln Lhe recovery/allevlaLlon of Lhe dlsablllLy should
be noLed






231a1 care ls dellvered ln a Llmely safe approprlaLe and coordlnaLed manner accordlng Lo care
plans

ollcles and procedure on Lhe lmplemenLaLlon/ compllance of cllnlcal paLhway
1 1he cllnlcal paLhway ls Lhe baslc guldellne ln renderlng accuraLe and efflclenL medlcal LreaLmenL
ln a sysLemaLlc manner lL should be Lhe core ln dellverlng ouLsLandlng medlcal ouLpuL 1here
would be baslc guldellnes ln order Lo updaLe and relnforce Lhe cllnlcal paLhway dependlng on
Lhe dlsease/ allmenL ldenLlfled
2 1he resldenL physlclan and Lhe nurses ln Lhelr respecLlve areas wlll be updaLed ln Lhe LranslLlon
and collaboraLlon of Lhe cllnlcal paLhway so LhaL quallLy checklng wlll be lnlLlaLed Lhe company
pollcy ln deLermlnlng and respondlng Lo dlsease wlll be ad[usLed dependlng on Lhe cllnlcal
paLhway
3 1here would be a checkllsL ln dlfferenL dlsease condlLlon so LhaL proper monlLorlng and checklng
wlll be consldered 1hls checkllsL musL be accompllshed by each area and musL be endorsed Lo
succeedlng Leam
4 1here would be a dally census of dlfferenL dlsease and correspondlng LreaLmenL remedy so LhaL
Lhe flow of work ln lndenLlfylng dlfferenL dlsease and LreaLmenL procedure wlll be monlLored
and prlorlLlzaLlon on whlch medlcal allmenL requlres more aLLenLlon and prompL acLlon
3 1here would be a sLandard and updaLed cllnlcal paLhway handbook LhaL wlll serve as Lhe very
reference of each LreaLmenL remedy ln cases LhaL Lhere would be an ad[usLmenL all concerned
parLles (physlclan and nurses) wlll be updaLed 1he book ls open for any necessary revlslon lf
necessary











231a2 care ls dellvered ln a Llmely safe approprlaLe and coordlnaLed manner accordlng Lo care
plans
MonlLorlng reporLs lf none ask paLlenL charLs and look aL docLor's order and medlcaLlon sheeL
MonlLorlng reporLs are aLLached ln Lhe medlcal cllnlcal summary ln Lhe nurse Supervlsors
Logbook lndlcaLlng LhaL all paLlenL charLs were carefully monlLored and scruLlnlzed ln dally basls and
furLher subdlvlded lnLo premonlLorlng and posL monlLorlng phase verlflcaLlon of orders and accuracy
ln dellverlng Lhe medlcal orders ls Lhe maln concern All paLlenL charLs LhaL are consldered MCP sLaLus
wlll be furLher evaluaLed and rechecked by Lhe nurse Supervlsors more so anoLher quallLy checklng wlll
be made by Lhe head of Lhe record secLlon and phlhealLh offlcer

233a1 care ls coordlnaLed Lo ensure conLlnulLy and Lo avold dupllcaLlon
ollcles and rocedure lndlcaLlng Lhe exLenL of dupllcaLe assessmenL and LreaLmenL performed by
Lralnees
1 All assessmenL made by Lhe Lralnees wlll be verlfled by Lhe deparLmenL head ln cases LhaL Lhere
are dlscrepancy Lhe nurse supervlsor wlll lnLerfere and wlll make necessary ad[usLmenL
1ralnees wlll be glven ample Llme Lo prepare and updaLe Lhemselves ln proper assessmenL
followlng Lhe sLandard core of pracLlce
2 1ralnees ln Lhe perspecLlve of developlng necessary skllls ln assesslng paLlenL Shadowlng
Learnlng Lxperlence wlll be lnlLlaLed 1hls wlll ald ln nurLurlng Lhe Lralnees ln Lerms LhaL Lhey
could easlly ldenLlfy wlLh Lhe sysLem ln cases LhaL Lhey needed conflrmaLlon or verlflcaLlon
Lhelr lmmedlaLe head wlll be Lhere Lo asslsL Lhem
3 SLandard procedure wlll be followed by Lhe Lralnees ln organlzlng plannlng and evaluaLlng Lhelr
respecLlve cllenLs 1hey wlll follow a speclflc sequence/ paLLern of assessmenL for ease
ldenLlflcaLlon and recordlng Should Lhere be any changes ln Lhe formaL Lhey wlll be
lmmedlaLely noLlfled
4 1ralnees should noL acL alone unless Lhe clrcumsLances requlred Lhem Lo Powever ln a
conLrolled envlronmenL Lhey should acL ln coordlnaLlon wlLh Lhe medlcal Leam
3 All Lralnee should accompllsh a requlred number of cases before Lhey wlll pass Lhe Lralnlng
program Lhls wlll ensure LhaL Lhelr level of awareness and exposure Lo cerLaln Lralnlng programs
ls enough Lo enLall new responslblllLy



ollcles and procedures lndlcaLlng Lhe exLenL of dupllcaLe assessmenL and LreaLmenLs performed by Lhe
Lralnee ln respecL Lo paLlenL rlghLs
1 1he rlghL Lo recelve lnformaLlon from physlclans and Lo dlscuss Lhe beneflLs rlsks and cosLs of
approprlaLe LreaLmenL alLernaLlves 1hls wlll be Lhe very foundaLlon ln whlch Lhey wlll dellver
approprlaLe care Lo Lhe paLlenL Lhe Lralnee wlll always conslder Lhe welfare of Lhe paLlenL 1he
Lralnees wlll verlfy lf Lhe paLlenL full undersLood Lhe scenarlo of hls/her LreaLmenL ln cases LhaL
Lhe paLlenL requlres more lnformaLlon and explanaLlon Lhe Lralnee should noLlfy Lhe aLLendlng
physlclan Lo make necessary ad[usLmenLs
2 1he rlghL Lo make declslons regardlng Lhe healLh care LhaL ls recommended by Lhe physlclan
Lhe Lralnee should glve enough Llme for Lhe paLlenL Lo declde whlch LreaLmenL wlll besL sulL
hls/her needs 1he nurse wlll acL ln Lhe besL lnLeresL of Lhe paLlenL
3 1he rlghL Lo courLesy respecL dlgnlLy responslveness and Llmely aLLenLlon Lo healLh needs
1hls wlll be Lhe baslc aLLlLude of Lhe Lralnee ln renderlng healLh care servlce 1he Lralnee should
ad[usL Lo Lhe needs of Lhe cllenL wlLhouL sacrlflclng Lhe essence of hls/her work
4 1he rlghL Lo confldenLlallLy Lhe Lralnee wlll make sure LhaL all vlLal and personal lnformaLlon
wlll noL be dlvulge rlsklng Lhe ldenLlLy of Lhe cllenL 1he Lralnee musL see Lo lL LhaL all
lnformaLlon ln very confldenLlal and senslLlve ln naLure
3 1he rlghL Lo conLlnulLy of healLh care Lhe Lralnee should provlde baslc healLh educaLlon Lo
paLlenL relaLlves so LhaL Lhey wlll conLlnue Lhe poslLlve medlcal progress LhaL Lhe paLlenL
recelves And ln cases LhaL Lhe paLlenL furLher explanaLlon and Llme Lhe Lralnee should make
necessary modlflcaLlon
6 1he baslc rlghL Lo have adequaLe healLh care adequacy of healLh care wlll be aLLaln by
empaLhlzlng wlLh Lhe paLlenL and wlLh hls/her currenL condlLlon 1he Lralnee should LreaL Lhe
paLlenL ln a hollsLlc manner wlLhouL compromlslng Lhe quallLy of Lhe medlcal servlce

233a2 care ls coordlnaLed Lo ensure conLlnulLy and Lo avold dupllcaLlon
MonlLorlng reporLs on compllance Lo pollcles and procedure on dupllcaLe assessmenLs and LreaLmenLs

1he deparLmenL heads are Lask Lo monlLor Lhe progress and accuracy of assessmenL and
LreaLmenL 1here ls a dally and monLhly evaluaLlon so LhaL we can ensure Lhe sLablllLy ln Lhe
relnforcemenL of Lhe pollcy ln cerLaln cases LhaL Lhere are dupllcaLe assessmenL and LreaLmenLs
lnvolve parLles wlll be called and necessary dlsclpllnary measures wlll be lnlaLlaLed