Kingdom of Saudi Arabia

TNEMSESSAER DNA TNEMSSESSA S’TNEITAP

Ministry of Health
Baish General Hospital
Quality Management and Patient Safety
Patient Safety Committee

MEDICAL STAFF AND PROVISION OF CARE

ADMINISTRATIVE POLICY AND PROCEDURE
Medical & Nursing
POLICY NUMBER: BGH-MS-005 APPLIES TO: Staff

APP TITLE: PATIENT’S ASSESSMENT AND REASSESMENT

APPROVAL DATE: January 1, 2018 EFFECTIVE DATE: January 15, 2018

Version 1
DUE FOR REVIEW: January 1, 2020 NUMBER OF PAGES: 1 of 7

1- DEFINITION

TERMS DEFINITIONS
Emergency This category of patients includes those who have serious
Admission medical 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
Urgent Admission who 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
Routine Admission at risk of substantial injury to their health if not admitted within 24
hours.
The study of the forces involved in the circulation of blood.
Hemodynamics
The process of informing a patient about a health matter to
Patient Education secure informed consent, patient cooperation, and a high level of
patient compliance.

2- OBJECTIVE
To ensure that all patients of the hospital undergo an appropriate assessment by qualified
individuals on the basis of which a plan of care can be established.

3- POLICY
3.1 It is the policy of Beish General Hospital (BGH) that all patients, receiving Inpatient,
Outpatient or Emergency Services, at the facility will receive a complete head to toe assessment
by a qualified individual to allow development and implementation of a plan of care that will best
meet the individualized health care needs of the patient. The assessment of the care and/or
treatment needs of the patient will be continuous throughout the patient’s hospitalization.

3.2 All disciplines deemed necessary upon initial or ongoing assessment by Nursing Services or
by physician order, will participate in the assessment process in an effort to provide a
MS
 Kingdom of Saudi Arabia

TNEMSESSAER DNA TNEMSSESSA S’TNEITAP

Ministry of Health
Baish General Hospital
Quality Management and Patient Safety
Patient Safety Committee

MEDICAL STAFF AND PROVISION OF CARE

ADMINISTRATIVE POLICY AND PROCEDURE
Medical & Nursing
POLICY NUMBER: BGH-MS-005 APPLIES TO: Staff

APP TITLE: PATIENT’S ASSESSMENT AND REASSESMENT

APPROVAL DATE: January 1, 2018 EFFECTIVE DATE: January 15, 2018

Version 1
DUE FOR REVIEW: January 1, 2020 NUMBER OF PAGES: 2 of 7

comprehensive, collaborative approach to patient care.

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
4.1 Most Responsible Physician (MRP)/ team

4.1.1 The admitting consultant is the leader of the patient care team in the planning and
provision of care throughout the continuum.

4.1.2 Admitting specialist or ROD will have an initial assessment of each patient for
physical and medical status of the patient, to identify appropriate care needs or the need
for further assessment.

4.1.3 Reassessment is done by designated specialist or ROD (in case of evening and
night shift) throughout the continuum of care with the consultant’s daily review of care
plan and patient’s progress.

4.2 Assigned Nurse Is responsible for initial assessment and reassessment of the patient for
vital parameter status, mental status, nutritional assessment and physiotherapeutic needs in ER,
Ward and ICU.

5- PROCEDURES
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 Kingdom of Saudi Arabia

TNEMSESSAER DNA TNEMSSESSA S’TNEITAP

Ministry of Health
Baish General Hospital
Quality Management and Patient Safety
Patient Safety Committee

MEDICAL STAFF AND PROVISION OF CARE

ADMINISTRATIVE POLICY AND PROCEDURE
Medical & Nursing
POLICY NUMBER: BGH-MS-005 APPLIES TO: Staff

APP TITLE: PATIENT’S ASSESSMENT AND REASSESMENT

APPROVAL DATE: January 1, 2018 EFFECTIVE DATE: January 15, 2018

Version 1
DUE FOR REVIEW: January 1, 2020 NUMBER OF PAGES: 3 of 7

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 Initial assessment will also include, as appropriate:

5.4.1 Primary nutritional assessment for nutritional status and nutritional risk, documented
in Nursing Assessment form and Nutritional Assessment form.

5.4.2 Pain assessment, documented in Admission Assessment Sheet, which includes an

appropriate assessment of the patient’s condition i.e. intensity, frequency, location,
duration, character of pain (e.g. throbbing, sharp/dull.), aggravating and relieving factors,
effects on activities of daily living, sleep patterns. (Refer to Pain Assessment &
Reassessment Management policy)

5.4.3 Diagnostic testing procedures which includes laboratory and invasive/non-invasive

procedures for diagnostic imaging

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 Kingdom of Saudi Arabia

TNEMSESSAER DNA TNEMSSESSA S’TNEITAP

Ministry of Health
Baish General Hospital
Quality Management and Patient Safety
Patient Safety Committee

MEDICAL STAFF AND PROVISION OF CARE

ADMINISTRATIVE POLICY AND PROCEDURE
Medical & Nursing
POLICY NUMBER: BGH-MS-005 APPLIES TO: Staff

APP TITLE: PATIENT’S ASSESSMENT AND REASSESMENT

APPROVAL DATE: January 1, 2018 EFFECTIVE DATE: January 15, 2018

Version 1
DUE FOR REVIEW: January 1, 2020 NUMBER OF PAGES: 4 of 7

5.4.4 Pre-anesthesia assessment with appropriate assessment scores as needed.

5.4.5 Condition specific or department specific assessments:

5.4.5.1 EMERGENCY DEPARTMENT (ER)

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:

5.4.5.1.1.1 Patient complaints

5.4.1.1.1.2 Vital signs
5.4.1.1.1.3 Allergies
5.4.1.1.1.4 Treatment prior to arrival to the ER
5.4.1.1.1.5 Initial and continued treatment during stay in ER.

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

5.4.5.2.1 Within the first 30 minutes, a complete assessment is done.

5.4.5.2.2 Department-specific forms supplement the assessment, and provide
additional assessment and documentation as it pertains to operative/invasive
procedures.

5.4.5.3 PEDIATRIC PATIENTS ( infants, children & adolescents): Regardless of

unit, pediatric patients will have the following elements assessed: length/height,
weight, head circumference in children under 2 years of age, and current
immunization status

5.4.5.4 PHYSIOTHERAPY & REHABILITATION

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 Kingdom of Saudi Arabia

TNEMSESSAER DNA TNEMSSESSA S’TNEITAP

Ministry of Health
Baish General Hospital
Quality Management and Patient Safety
Patient Safety Committee

MEDICAL STAFF AND PROVISION OF CARE

ADMINISTRATIVE POLICY AND PROCEDURE
Medical & Nursing
POLICY NUMBER: BGH-MS-005 APPLIES TO: Staff

APP TITLE: PATIENT’S ASSESSMENT AND REASSESMENT

APPROVAL DATE: January 1, 2018 EFFECTIVE DATE: January 15, 2018

Version 1
DUE FOR REVIEW: January 1, 2020 NUMBER OF PAGES: 5 of 7

5.4.5.4.1 The physiotherapist's initial assessment strives to identify problem areas

contributing to or having the potential to contribute to functional losses.
Accordingly a treatment plan is developed.

5.4.5.4.2 A physiotherapy assessment is completed within 24 hours of referral.

5.5 Assessments will be carried out within the following time frames depending on the scope of
hospital services and condition of the patient.

Category Assessment by in-house Assessment by

staff Consultant on Call
Emergency Immediate Within 30 minutes
Urgent Within 1/2 hour Within 04 hours
Routine Within 3 hours Within 24 hours

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

TNEMSESSAER DNA TNEMSSESSA S’TNEITAP

Ministry of Health
Baish General Hospital
Quality Management and Patient Safety
Patient Safety Committee

MEDICAL STAFF AND PROVISION OF CARE

ADMINISTRATIVE POLICY AND PROCEDURE
Medical & Nursing
POLICY NUMBER: BGH-MS-005 APPLIES TO: Staff

APP TITLE: PATIENT’S ASSESSMENT AND REASSESMENT

APPROVAL DATE: January 1, 2018 EFFECTIVE DATE: January 15, 2018

Version 1
DUE FOR REVIEW: January 1, 2020 NUMBER OF PAGES: 6 of 7

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
6.1 Pulse oximeter
6.2 Stethoscope
6.3 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

TNEMSESSAER DNA TNEMSSESSA S’TNEITAP

Ministry of Health
Baish General Hospital
Quality Management and Patient Safety
Patient Safety Committee

MEDICAL STAFF AND PROVISION OF CARE

ADMINISTRATIVE POLICY AND PROCEDURE
Medical & Nursing
POLICY NUMBER: BGH-MS-005 APPLIES TO: Staff

APP TITLE: PATIENT’S ASSESSMENT AND REASSESMENT

APPROVAL DATE: January 1, 2018 EFFECTIVE DATE: January 15, 2018

Version 1
DUE FOR REVIEW: January 1, 2020 NUMBER OF PAGES: 7 of 7

7.2 Doctor’s Progress Notes

7.3 Physician Order Sheet
7.4 Admission Assessment Sheet
7.5 Pain Assessment and Reassessment form
7.6 Daily patient in their assessment/reassessment sheet
7.7 Nutritional Assessment form
Social Worker’s Notes 7.8
Pre-anesthesia assessment form (as needed) 7.9

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

TNEMSESSAER DNA TNEMSSESSA S’TNEITAP

Ministry of Health
Baish General Hospital
Quality Management and Patient Safety
Patient Safety Committee

MEDICAL STAFF AND PROVISION OF CARE

ADMINISTRATIVE POLICY AND PROCEDURE
Medical & Nursing
POLICY NUMBER: BGH-MS-005 APPLIES TO: Staff

APP TITLE: PATIENT’S ASSESSMENT AND REASSESMENT

APPROVAL DATE: January 1, 2018 EFFECTIVE DATE: January 15, 2018

Version 1
DUE FOR REVIEW: January 1, 2020 NUMBER OF PAGES: 8 of 7

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