Ad 036-02 Writting Policies and Procedures and Numbering Sys

Kingdom Of Saudi Arabia ‫اﻟﻤﻤﻠﻜﺔ اﻟﻌﺮﺑﯿﺔ اﻟﺴﻌﻮدﯾﺔ‬
Ministry Of Health ‫وزارة اﻟﺼﺤــﺔ‬

Directorate Of Health Affairs – Taif ‫ﻣﺪﯾﺮﯾﺔ اﻟﺸﺌﻮن اﻟﺼﺤﯿﺔ ﺑﻤﺤﺎﻓﻈﺔ اﻟﻄﺎﺋﻒ‬
King Abdul Aziz Specialist Hospital ‫ﻣﺴﺘﺸﻔـﻰ اﻟﻤﻠﻚ ﻋﺒﺪ اﻟﻌﺰﯾﺰ اﻟﺘﺨﺼﺼﻲ‬
Policy & Procedures ‫اﻟـﻨـﻈـﻢ و اﻹﺟــﺮاءات‬

Department Hospital wide No of Pages 1 Of 6
Policy No. AD 036/02
Policy Title WRITING POLICIES & PROCEDURES Effective Date 1/6/1432 H
(P&P’s) and Numbering System Review Date 1/5/1434 H
Purpose :
To provide guidelines for writing policies & procedures ,standardized format, and numbering system .
Definitions:
• Writing Internal Policies and/or Procedures shall mean the process by which policies and
procedures are to be developed.
• A policy and procedures is document that outlines steps to accomplish a certain task. It provides
a uniform standard of accomplishment for one or more individual(s) identified in it.
Comments:
• A Policy and Procedures should be written for each frequent and significant function of the
Department.
• It is the responsibility of each department head or equivalent to develop Policy & Procedure
(P&P).If necessary, the Organization and management may provide assistance to a department
in the development of P&Ps to ensure that established guidelines are followed.
Procedure:
• Propose to the Supervisor/Department Head the documentation of significant task, or the revision
of an existing P&Ps (employee).
• Review the proposal and designate an employee to write/revise the particular P&Ps (Department
Head).
• Prepare the initial draft of P&Ps following the prescribed outline, submit the P&P to Department
Head (Designated Employee).
• Review the draft IPP; circulate to the concerned employees for comments. Return the draft P&Ps
to the designated employee for modification/finalization (Department Head).
• Re-write/edit incorporating comments and corrections, if the P&Ps using the P&Ps form
attachment, submit to the department head for approval. (Designated Employee).
• Approved the final P&Ps, obtain the approval of the immediate supervisor and other department
heads if required presents the P&Ps to the employees of the department on regular bases for
their information and compliance. Place a copy of the P&Ps in the department IPP Manual for
employee’s reference in a reachable place.
TQM Stamp
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• Review P&Ps each 2 years during. (Department Head/Designated Employee).
• Every employee must perform in accordance with approved P&Ps, all employees are encouraged
to explore ways to improve or simplify P&Ps.
• Any P&Ps may become effective with sole approval of Program Director or Assistant Program
Director for Medical Affairs for Medical P&Ps and Assistant Program Director for Administrative
Affairs (for Administrative P&Ps).
• All Departmental Policies and Procedures shall comply with the standard format included in this policy.
• All departments P&P Should be stamped from the TQM dept. to become effective .
• All departments P&P originals should be in the TQM dept. .
Follow the guidelines to develop & complete the contents of the Policy & Procedure:
• Suggested Font: Arial 11
• Heading: Arial 11 bold

Department NAME OF THE DEPARTMENT No of Pages No of pages X of
Y
Policy No. Number of policy
in the system /
Version NO.
Policy Title What is this process/procedure about? Effective Date Date of making
( USING the policy into
HIGERY action , After the
CALENDAR ) Reviewed date
within 2 weeks .
Review Date Date OF THE
(USING HIGERY ANNUAL
CALENDAR) REVISION , after
2 years
Heading Definition
Purpose A description of why the policy is in place (e.g. The purpose of this policy is
to reduce error, identify process, assure appropriate input and obtain
correct and necessary agreement by the responsible administration person
prior to implementing any administrative or practice change.
Definitions Explain new or unusual terms.
TQM Stamp

Policy a written document which outlines the rules and expected performance of
staff within the hospital.
Accountabilities A statement of what exactly each person involved in the procedure will be
responsible for.
Procedure A step-by-step description of how the policy will be carried out.
Forms Any forms will be used to implement this policy, should be attached to the
policy.
References Include any and all references to support the policy including but not
limited to Joint Commission International JCI.
Approval 1. Inter-departmental (IPP) – approval is obtained from the highest
authority in both departments (directors/chairpersons) and/or divisions
(chiefs).
2. Signature of all required parties. Policies, involving medical staff
providers, shall be signed off by the medical director.
Approval:
Name Signature Date TQM Stamp
Prepared by USING
HIGERY
CALENDAR
Reviewed by After the
Prepared
date within
5 days
Approved By After the
Reviewed
date within
5-7 days
Writing
1- Writing must be clear and suited to the reading skills of the audience and as free of jargon as
possible.
2- Minimize use of abbreviations. On the first reference, always write the full name, with the
abbreviation in parenthesis. The abbreviation alone may be used in later references.
3- Writing in the present tense is preferred.
TQM Stamp

Numbering System: AAA – XXX / VV
AAA = Originating Department acronym (e.g. LB= Laboratory, QM = Quality Management).
XXX = Refers to the sequential numbering of the IPP’s .
VV= Refers to the version number of the IPP’s .
Only approved IPPs should be in the IPP Manual and should not include any Draft IPPs.
For departments that do have sections: AAA- BB – XXX/ VV
BB = Refers to the Departmental section
Accountabilities:
• Programme Director
• Assistant Programme Director for Medical Affairs
• Assistant Programme Director for Administrative Affairs
• Medical Director
• Department Heads
• All Hospital Staff
ALPHABETICAL CODE FOR POLICY AND ‫اﻟﺮﻣﻮز اﻷﺑﺠﺪﯾﺔ ﻷدﻟﺔ اﻟﺴﯿﺎﺳﺎت واﻹﺟﺮاءات‬
PROCEDURE MANUAL
CODE MEANING ‫اﻟﺘﻌﺮﯾﻒ‬ ‫اﻟﺮﻣﺰ‬

AD ADMINISTRATION ‫اﻹدارة‬ ‫إدارة‬
MRR MEDICAL STAFF RULES AND ‫اﻷﻃﺒﺎء وﻣﮭﺎﻣﮭﻢ‬ ‫أﻃﺒﺎء‬
REGULATION
NR NURSEING ‫اﻟﺘﻤﺮﯾﺾ‬ ‫ﺗﻤﺮﯾﺾ‬
QM QUALITY MANAGEMENT ‫إدارة اﻟﺠﻮدة‬ ‫ﺟﻮدة‬
MD MEDICAL DEPARTMENT ‫ﻗﺴﻢ اﻟﺒﺎﻃﻨﮫ‬ ‫ﺑﺎﻃﻨﮫ‬
SD SURGICAL DEPARTMENT ‫ﻗﺴﻢ اﻟﺠﺮاﺣﺔ‬ ‫ﺟﺮاﺣﺔ‬
L&D Labour & Delivery ‫ﻗﺴﻢ اﻟﻨﺴﺎء واﻟﻮﻻدة‬ ‫ﻧﺴﺎء‬
AN Anesthesia ‫ﻗﺴﻢ اﻟﺘﺨﺪﯾﺮ‬ ‫ﺗﺨﺪﯾﺮ‬
ICU ADULT INTENSIVE CARE UNITE , ‫ﻗﺴﻢ اﻟﻌﻨﺎﯾﺔ اﻟﻤﺮﻛﺰة ﻟﻠﻜﺒﺎر‬ ‫ﻋﻨﺎﯾﺔ ك‬
NICU NEONATE INTENSIVE CARE ‫ﻗﺴﻢ اﻟﻌﻨﺎﯾﺔ اﻟﻤﺮﻛﺰة ﻟﺤﺪﯾﺜﻲ اﻟﻮﻻدة‬ ‫ﻋﻨﺎﯾﺔ ط‬
UNITE ,
OR Operating Room ‫ﻗﺴﻢ اﻟﻌﻤﻠﯿﺎت‬ ‫ﻋﻤﻠﯿﺎت‬
HM Haemodialysis ‫ﻗﺴﻢ اﻟﻜﻠﻰ‬ ‫ﻛﻠﻰ‬
ER Emergency Room ‫ﻗﺴﻢ اﻟﻄﻮارئ‬ ‫ﻃﻮارئ‬
RD Radiology ‫ﻗﺴﻢ اﻷﺷﻌﺔ‬ ‫أﺷﻌﺔ‬
BC Burn Care ‫ﻗﺴﻢ اﻟﺤﺮوق‬ ‫ﺣﺮوق‬
SC Social Workers ‫اﻟﺨﺪﻣﺔ اﻻﺟﺘﻤﺎﻋﯿﺔ‬ ‫اﺟﺘﻤﺎﻋﯿﺔ‬
RH Rehabilitation ‫ﻗﺴﻢ اﻟﻌﻼج واﻟﺘﺄھﯿﻞ اﻟﻄﺒﻲ‬ ‫ﺗﺄھﯿﻞ ﻃﺒﻲ‬
TQM Stamp

DT Dietary Service ‫اﻟﺘﻐﺬﯾﺔ‬ ‫ﺗﻐﺬﯾﺔ‬

AM Ambulatory Care ‫اﻟﻌﯿﺎدات اﻟﺨﺎرﺟﯿﺔ‬ ‫ﻋﯿﺎدات‬
CIC Computer& Information Center ‫إدارة اﻟﻤﻌﻠﻮﻣﺎت‬ ‫ﻣﻌﻠﻮﻣﺎت‬
MR Medical Records ‫اﻟﺴﺠﻼت اﻟﻄﺒﯿﺔ‬ ‫ﺳﺠﻼت‬
IC Infection Control ‫ﻣﻜﺎﻓﺤﺔ اﻟﻌﺪوى‬ ‫ﻋﺪوى‬
CSSD Central sterilization & supply ‫اﻟﺘﻌﻘﯿﻢ اﻟﻤﺮﻛﺰي‬ ‫ﺗﻌﻘﯿﻢ‬
Dept.
PH Pharmacy ‫اﻟﺼﯿﺪﻟﯿﺔ‬ ‫ﺻﯿﺪﻟﺔ‬
LB Laboratory ‫اﻟﻤﺨﺘﺒﺮ‬ ‫ﻣﺨﺘﺒﺮ‬
RA RELIGOUSE AFFAIRE ‫اﻟﺸﺆون اﻟﺪﯾﻨﯿﺔ‬ ‫دﯾﻨﯿﺔ‬

PA PATIENT AFFAIRE ‫ﺷﺆون اﻟﻤﺮﺿﻰ‬ ‫ش ﻣﺮﺿﻰ‬
MRP MEDICAL REPORT ‫اﻟﺘﻘﺎرﯾﺮ اﻟﻄﺒﯿﺔ‬ ‫ﺗﻘﺎرﯾﺮ‬
GS GENERAL SERVICES ‫اﻟﺨﺪﻣﺎت اﻟﻌﺎﻣﺔ‬ ‫ﺧﺪﻣﺎت‬
ES ENGENERING SUPERVISION ‫اﻹﺷﺮاف اﻟﮭﻨﺪﺳﻲ‬ ‫ھﻨﺪﺳﻲ‬
PM Pio-MEDICAL ‫اﻟﺼﯿﺎﻧﺔ اﻟﻄﺒﯿﺔ‬ ‫ﺻﯿﺎﻧﺔ ط‬
SAF Safety ‫اﻟﺴﻼﻣﺔ‬ ‫ﺳﻼﻣﺔ‬
HM HOUSING MANAGEMENT ‫اﻹﺳﻜﺎن‬ ‫إﺳﻜﺎن‬
REC RECREATION CENTER ‫اﻟﻤﺮﻛﺰ اﻟﺘﺮﻓﯿﮭﻲ‬ ‫ﺗﺮﻓﯿﮫ‬
FAA FINANCE & ADMINISTRATION ‫اﻟﺸﺆون اﻟﻤﺎﻟﯿﺔ واﻹدارﯾﺔ‬ ‫ﻣﺎﻟﻲ‬
AFFAIRES
STC STOCK CONTROAL ‫ﻣﺮاﻗﺒﺔ اﻟﻤﺨﺰون‬ ‫ﻣﺨﺰون‬
MES MEDICAL SUPLY ‫اﻟﺘﻤﻮﯾﻦ اﻟﻄﺒﻲ‬ ‫ﺗﻤﻮﯾﻦ‬
ODM ON DUTY MANAGER ‫اﻟﻤﺮاﻗﺐ اﻟﻤﻨﺎوب‬ ‫ﻣﺮاﻗﺐ‬
SEC SECURITY ‫اﻷﻣﻦ‬ ‫أﻣﻦ‬
‫ﻋﻼﻗﺎت ﻣﺮﺿﻰ‬ ‫ م‬- ‫ ع‬-‫س‬
T& D TRAINING & DEVOLOPMENT ‫اﻟﺘﺪرﯾﺐ واﻟﺘﻄﻮﯾﺮ‬ ‫ﺗﺪرﯾﺐ‬
‫اﻟﺼﯿﺎﻧﺔ اﻟﻌﺎﻣﺔ‬ ‫ﺻﯿﺎﻧﺔ‬
‫اﻟﺼﺤﺔ اﻟﻌﺎﻣﺔ‬ ‫ﺻﺤﺔ‬
‫اﻟﻤﻐﺴﻠﺔ‬ ‫ﻣﻐﺴﻠﺔ‬
‫ﺳﻨﺘﺮال‬ ‫اﻟﺴﻨﺘﺮال‬
‫اﻟﺘﺸﻐﯿﻞ وﺻﯿﺎﻧﺔ اﻟﻨﻘﻞ‬ ‫ﺣﺮﻛﺔ‬
‫اﻟﻌﻤﻠﯿﺎت اﻻﺳﻠﻜﯿﺔ‬ ‫ﻻﺳﻠﻜﻲ‬
‫اﻟﻤﺘﺎﺑﻌﺔ اﻟﻔﻨﯿﺔ واﻟﺘﻔﺘﯿﺶ اﻟﻌﻼﺟﻲ‬ ‫ﻣﻔﺘﺶ‬
TQM Stamp

Form:
No form needed
Reference:
CBAHI
Approval:
Name Signature Date TQM Stamp
Prepared by Dr. Ahmed Al-khotani 16/5/1432
Reviewed by Dr. Abdullatiff Mahyoub 17/5/1432
Approved By Dr. Ma'atouq Al-osaimi 21/5/1432
TQM Stamp

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Kingdom Of Saudi Arabia ‫اﻟﻤﻤﻠﻜﺔ اﻟﻌﺮﺑﯿﺔ اﻟﺴﻌﻮدﯾﺔ‬

Ministry Of Health ‫وزارة اﻟﺼﺤــﺔ‬

Policy & Procedures ‫اﻟـﻨـﻈـﻢ و اﻹﺟــﺮاءات‬

Policy & Procedures ‫اﻟـﻨـﻈـﻢ و اﻹﺟــﺮاءات‬

• Review P&Ps each 2 years during. (Department Head/Designated Employee).

Policy & Procedures ‫اﻟـﻨـﻈـﻢ و اﻹﺟــﺮاءات‬

Policy & Procedures ‫اﻟـﻨـﻈـﻢ و اﻹﺟــﺮاءات‬

Policy & Procedures ‫اﻟـﻨـﻈـﻢ و اﻹﺟــﺮاءات‬

Numbering System: AAA – XXX / VV

AAA = Originating Department acronym (e.g. LB= Laboratory, QM = Quality Management).

XXX = Refers to the sequential numbering of the IPP’s .

VV= Refers to the version number of the IPP’s .

BB = Refers to the Departmental section

CODE MEANING ‫اﻟﺘﻌﺮﯾﻒ‬ ‫اﻟﺮﻣﺰ‬

Policy & Procedures ‫اﻟـﻨـﻈـﻢ و اﻹﺟــﺮاءات‬

DT Dietary Service ‫اﻟﺘﻐﺬﯾﺔ‬ ‫ﺗﻐﺬﯾﺔ‬

RA RELIGOUSE AFFAIRE ‫اﻟﺸﺆون اﻟﺪﯾﻨﯿﺔ‬ ‫دﯾﻨﯿﺔ‬

Policy & Procedures ‫اﻟـﻨـﻈـﻢ و اﻹﺟــﺮاءات‬

Approved By Dr. Ma'atouq Al-osaimi 21/5/1432

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