Document Type: Policy (S/P) Document Status: Control Document

Business Unit: Moe Kaung Oncology Center Created Date:

Document No.: Issued Date:
Revision: Due Date:
Subject: Initial Assessment and Reassessment of Patients

Originated by : Reviewed by: Approved by:

Name……………………………………………….. Name………………………………………………. Name………………………………………………..

( Dr. Nyan Ye Oo ) ( Prof. Dr Thein Zaw) ( Dr. Kyaw Sein Tun)

Position……..Quality Manager…………… Position……Center Director………… Position…Board of Director………

Date……………………… Date……………………… Date………………………

Document History
Version Revision and Effective Date Reason for change
Approval Date
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1. PURPOSE
To describe the guideline of initial and reassessment process for identifying any potential risks or
complications also monitor the patient's progress and response to treatment.

S/P-01-MKOC-XXX
Document Type: Policy (S/P) Document Status: Control Document
Business Unit: Moe Kaung Oncology Center Created Date:
Document No.: Issued Date:
Revision: Due Date:
Subject: Initial Assessment and Reassessment of Patients

2. POLICY
This policy establishes a baseline of the patient's health status , develop a plan of care, and make
necessary adjustments to the plan of care .Patient assessment is made with the interdisciplinary approach of
the physician, nurses, and other stuff.
3. SCOPE/PLAN
The initial assessment is designed to determine the extent of the care needed for the individual and
the need for further assessment.
4. DEFINITION
Nil.
5. DUTY AND RESPONSIBILITY
All patients at Moe Kaung Oncology Center are evaluated by a licensed provider at the time of initial
assessment and reassessment care process

6. DESCRIPTION/ PROCEDURE
6.1 The initial assessment and nursing intervention form done by nurse at Chemotherapy day care
unit, Moe Kaung Oncology Center includes at a minimum:
a) The reason for the visit
b) Chief complaint
c) Allergies

S/P-01-MKOC-XXX
Document Type: Policy (S/P) Document Status: Control Document
Business Unit: Moe Kaung Oncology Center Created Date:
Document No.: Issued Date:
Revision: Due Date:
Subject: Initial Assessment and Reassessment of Patients

d) Pain Assessment
e) Findings of the physical examination (See in History taking and initial assessment form)
f) Plan for treatment / procedure
g) Review of current medications (See in HIS and History taking and initial assessment form)
The assessment is documented and kept in the patient’s record and is signed by the licensed provider.
6.2 Pain management
Moe Kaung Oncology Center Physicain/ Nurses assesses and manages the patient’s pain. When
warranted by the patient’s condition and either conducts or refers the patient for a comprehensive pain
assessment to Moe Kaung Hoapital. The methods used to assess pain that are consistent with the patient’s age,
condition, and ability to understand. Reassesses and responds to the patient’s pain, based on its reassessment
criteria and either refers the patient for treatment then document in the initial assessment and intervention
form.

The processes to assess and to manage pain appropriately, including

a. Identifying patients with pain during initial assessment and reassessments.
b. Providing information to patients about pain that may be an expected result of treatments,
procedures, or examinations.

S/P-01-MKOC-XXX
Document Type: Policy (S/P) Document Status: Control Document
Business Unit: Moe Kaung Oncology Center Created Date:
Document No.: Issued Date:
Revision: Due Date:
Subject: Initial Assessment and Reassessment of Patients

c. Providing management of pain, regardless of the origin of pain, according to guidelines or

protocols and in conjunction with patient goals for pain management.
d. Communicating with and educating patients and families about pain and symptom
management in the context of their personal, cultural, and religious beliefs.
e. Educating health care practitioners about pain assessment and management.

6.3 Reassessment
• Reassessment occurs at the time of each subsequent visit to the Moe Kaung Oncology Center
as determined by the patient’s conditions, types of procedures being performed or to determine a patient’s
response to treatment. All information is documented in the initial assessment and intervention form at the
time of observation or assessment in order to provide for continuity in care planning.
• Given the patient’s condition and needs as determined by the assessment or reassessment of
the provider, patients may be referred for specialized care at Moe Kaung Hospital.
• Each of these assessments will also be documented in the patient’s record and reassessment
performed as needed to assure continuity and quality of patient care.
Work Instructions for Initial Assessment
1. Gather patient information. This includes the patient's medical history, current symptoms, and any
previous treatments.
2. Perform a physical examination. This should include a thorough examination of the patient's skin,
lymph nodes, and internal organs.

S/P-01-MKOC-XXX
Document Type: Policy (S/P) Document Status: Control Document
Business Unit: Moe Kaung Oncology Center Created Date:
Document No.: Issued Date:
Revision: Due Date:
Subject: Initial Assessment and Reassessment of Patients

3. Order diagnostic tests. These may include blood tests, imaging studies, and biopsies.
4. Develop a plan of care. This should be based on the patient's diagnosis, stage of disease, and
overall health status.
5. Educate the patient and family. This should include information about the patient's diagnosis,
treatment options, and potential side effects.
Work Instructions for Reassessment
1. Review the patient's medical record. This should include the patient's initial assessment, treatment
plan, and any subsequent progress notes.
2. Perform a physical examination. This should focus on any changes in the patient's health status
since the initial assessment.
3. Order diagnostic tests. These may be necessary to monitor the patient's response to treatment or to
identify any new complications.
4. Update the plan of care. This should be based on the patient's current health status and response to
treatment.
5. Educate the patient and family. This should include information about any changes to the patient's
treatment plan or any new side effects that may occur.
7. REFERENCE
Carbonu, D. M. (2009). Promoting a Holistic Multidisciplinary Team Approach to Patient
Assessment and Reassessment: Challenges and Outcomes. In Proceedings of the 17th International
Nursing Research Congress Focusing on Evidence-based Practice (pp. 19-22).

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