MMSR Manual 2021-Standard 9 (Medical Records,Policies and Procedures).pdf

Standard 9 MEDICAL RECORDS, POLICIES AND PROCEDURES Attachments: FIGURE 9-1 Patient Treatment Daily Log FIGURE 9-2 Injury Summary Report FIGURE 9-3 Policies & Procedures FIGURE 9-4 Scope 0of Service FIGURE 9-5 Consult & Transfer to RAC...

Standard 9 MEDICAL RECORDS, POLICIES AND PROCEDURES Attachments: FIGURE 9-1 Patient Treatment Daily Log FIGURE 9-2 Injury Summary Report FIGURE 9-3 Policies & Procedures FIGURE 9-4 Scope 0of Service FIGURE 9-5 Consult & Transfer to RAC 149  ulh.11g5.o i · Johns Hopkins Aram  SURVEY AND COMPLIANCE REVIEW REPORT Instructions: Tick ()) Yes or NO or write “NA” where not Applicable Item Standards Responsible Date: Comments Code Yes No NA 9.0 MEDICAL RECORDS , POLICIES AND PROCEDURES 1. PATIENT PROCESSING AND MEDICAL RECORDS 1. The HCP shall ensure that their medical facilities have dedicated medical record/ HCP file available for every patient/ Electronic filing recommended. 2. The HCP shall ensure that their medical facilities have a tetanus immuni- zation HCP record available in the patient’s medical record/file. 3. The HCP shall ensure that their medical facilities have a process availa- ble (e.g., log book) for documenting patient’s attendance. Information listed is generally HCP nonclinical and is kept for statistics purposes and for periodic report to management. Refer to Figure 9-1 4. The HCP shall ensure that their medical facilities have a process available for HCP reporting patient Off-Duty status. 5. The HCP shall ensure that their medical facilities have printed education HCP materials/posters available. 6. The HCP shall ensure that their medical staff document each and every encounter into the medical record. At a minimum, the following information HCP is included: a. Patient’s name and ID number. b. Date of visit c. Time in and time out. d. History. e. Examination and assessment results. f. Diagnosis or impression. g. Treatment given, medications, etc h. Discharge status/sick leave/work restriction/referral. i. Discharge instructions. j. Significant Medical Data Sheet (SMDS), i.e. ordinary / occupational / work injuries. 151  SURVEY AND COMPLIANCE REVIEW REPORT Instructions: Tick ()) Yes or NO or write “NA” where not Applicable Item Standards Responsible Date: Comments Code Yes No NA 9.0 MEDICAL RECORDS , POLICIES AND PROCEDURES 2. REPORTING ON-THE-JOB/OFF-THE-JOB INJURIES The CC & HCP shall ensure that their medical facilities have a system in place for reporting on-the-job/off-the-job injuries. Injuries shall be documented recorded in a log book Refer to Figure 9-2, and all injuries are reported as per established HCP/CC regulations of MOH, MOL Law & Saudi Aramco Loss Prevention. Refer to GI 6.0005….. link 3. HEALTH CARE POLICIES, PROCEDURES AND GUIDELINES 1. Medical Staff are familiar with the location of their Health Care Policies, HCP Procedures and Guidelines. For the required Policies and Procedures. Refer to Figure 9-3 2. The HCP shall ensure that their policies and procedures are accessible to all HCP staff. At a minimum, includes but not limited to the followings Health Care Policies and Procedures: A. SCOPE OF SERVICE The HCP shall ensure that each medical facilities has a policy that defines their scope of service: Refer to Figure 9-4 1. Type of care and treatment offered at the facility. HCP 2. Eligibility of service. HCP 3. Investigations, tests and clinical procedures (diagnostic or otherwise) performed HCP in the facility. 4. Hours of operation. HCP B. MEDICAL EMERGENCY AND DRP/ MEDIVAC GUIDELINES at a minimum include, the following policies and procedures: 1. Medical Evacuation (Medivac) for medical/traumatic emergencies from Saudi CC/ HCP Aramco Aviation. Compliance to Saudi Aramco GI-1321.015. 2. Medical Emergency(s) Response /ERP. HCP 3. Disaster Response. Include Pandemics, food poisoning … etc CC/ HCP 152  SURVEY AND COMPLIANCE REVIEW REPORT Instructions: Tick ()) Yes or NO or write “NA” where not Applicable Item Standards Responsible Date: Comments Code Yes No NA 9.0 MEDICAL RECORDS , POLICIES AND PROCEDURES C. INFECTION CONTROL POLICIES AND PROCEDURES at minimum include the following policies and procedures: HCP 1. Infection Control in Medical Facility Personnel. HCP 2. Blood and Infectious Fluid Exposure. HCP 3. Employee Screening and Immunization Program. HCP 4. Hand Hygiene. HCP 5. Handling of Soiled and Clean Linen. HCP 6. Specimen Collection and Transport, where applicable. HCP 7. Cleaning of Spills. HCP 8. Sharp Injuries, what to do in the event and reporting. HCP 9. Reporting Occupational Illness/ Communicable diseases (i.e., HCP Hepatitis B/C, Tuberculosis, Chicken pox, etc.). D. GENERAL POLICIES AND PROCEDURES at a minimum include the following policies and procedures: 1. Waste Management. HCP 2. Protocols for consultation and for patient referral to the nearest hospital, or to CC/HCP an inpatient medical facility. 3. The HCP has a patient consultation, referral and transfer policy to Saudi Aramco CC/HCP remote urgent care facilities. Contractor/ HCP shall comply with the attached RAC consultation and Transfer policy Refer to Figure 9-5 4. The HCP shall ensure that their medical facilities have a policy that describes a HCP reliable alternative system of transfer in place in the absence of an ambulance. 5. The HCP shall ensure that a policy on Occupational Health Services (physicals and HCP conservation program, i.e., hearing, pulmonary, etc.) is available for their employees. 153  SURVEY AND COMPLIANCE REVIEW REPORT Instructions: Tick ()) Yes or NO or write “NA” where not Applicable Item Standards Responsible Date: Comments Code Yes No NA 9.0 MEDICAL RECORDS , POLICIES AND PROCEDURES E. SAFETY POLICIES AND PROCEDURES at a minimum include, the following policies and procedures: 1. Fire Drills and Fire Response. CC/HCP 2. Equipment Maintenance HCP 3. Adherence to GI-150.002 (First Aid Training for Employees). CC/HCP F. PATIENT CARE GUIDELINES (EXAMINATION AND TREATMENT PROTOCOL FOR NURSES) at a minimum include, the following policies and procedures: HCP 1. Protocols (steps to follow) for the treatment of common illness and HCP emergencies, from a common cold to chest pain, burns, etc. Refer to Figure 4.3 and Figure 4.4 2. Protocols for consultation and for patient referral to the nearest hospital, or to HCP an inpatient medical facility. 3. Nursing Procedures and Work Practice. HCP 4. Management of Death. HCP 5. Patient and Family Rights. HCP 6. Confidentiality of Patient Information. HCP 7. Medication Guidelines HCP at a minimum include, the following policies and procedures: a. Medication Requisition. HCP b. Prescribing, administration and dispensing of medication/ drugs in the HCP absence of a physician or pharmacist, in accordance with MOH regulation. c. Shipping and Receiving of Drugs. HCP d. Storing and Disposal of Drugs. HCP e. Prescription storage and administration of narcotics and controlled drugs. HCP 154  SURVEY AND COMPLIANCE REVIEW REPORT Instructions: Tick ()) Yes or NO or write “NA” where not Applicable Item Standards Responsible Date: Comments Code Yes No NA 9.0 MEDICAL RECORDS , POLICIES AND PROCEDURES G. COMMUNICATIONS 1. The HCP shall ensure that their medical staff keep a communication book/file HCP available at the medical facilities to maintain effective internal and external communication. 2. The HCP/CC shall ensure that their medical facilities have a notice board(s) CC/HCP available and that it contain current relevant information, e.g., safety, infection control, etc. 3. The contractor company shall ensure that their medical facilities have the CC following communication devices available: a. A landline phone with internal and external access, including direct access to emergency services. b. Global system for mobile communications (GSM) and/or other communication devices with available network and appropriate frequency for field communication. 4. The CC shall ensure that their medical facilities have a dedicated telephone CC available for internal communication and with appropriate dial access to communicate directly with the nearby Medical Designat- ed Facilities to request external medical assistance, consultation and advice. 5. The CC shall ensure that their medical facilities have a fax machine available CC either in the medical facility or in a nearby administrative office. 6. The CC shall ensure that their medical facilities have a dedicaed CC emergency communication device (110 or similar), for receiving expedient information/instructions regarding fire and/or other disaster in the camp and/or surrounding construction area. 7. The HCP shall ensure that their medical facilities where applicable, have all their CC communication equipment checked per shift. Findings must be documented and available upon request. 155 Figure 9-1 Patient Treatment Daily Log Medical Facility: Date: Date Name and Badge Number Time In Time Out Treatment Comments Report prepared by: Name: Badge No.: Signature: Date: 156  Figure 9-2 Injury Summary Report Medical Facility: Project No.: Page: of Propo- File No.: Date: nent: Brief Description of Carry Over Nature of Injury Injury Date of Acci- Days Lost this Accident. State Name Injured Badge Number Craft Yes/No and Body Part No. dent Month What, Where, How Affected and Why. # of injuries this Total days lost month Report prepared by: Title: 157  Polices and Procedures Policies and procedures are facility specific instructions and guidelines which concern the day-to-day activities / operation of the medical facility. General Guidelines 1. Each organization is responsible for developing specific policies and procedures for its medical facility. These policies must be updated and revised every three (3) years. Revisions are approved by an authorized medical representative, and dated to identify the review date. 2. Policies and procedures shall be available to all concern staff. These policies include but are not limited to: Required Policies and Procedures Organization 1-1 Organization Chart. 1. 1-2 Roles and Responsibilities. 1-3 Mission and Vision. Administrative 2-1 Job descriptions. 2-2 Manpower Requirements. 2. 2-3 Staff Qualifications. 2-4 Staff Recruitment Process. 2-5 Licensing. Staff Education Program 3-1 New Hire Orientation. 3-2 Staff Competency. 3. Safety and Loss Prevention: 2-1 Fire Safety. S 2-2 HAZCOM. 2-3 Disaster Response Plan. 4. Infection Control and Environmental Health. 5. Quality Improvement Program. Operation 6-1 Scope of Service. 6-2 Patient Eligibility of Care. 6. 6-3 Patient Registration and Health Insurance. 6-4 Consultation. 15 6-5 Referral and Transfer. 7. Medical Records Patient, Documentation and Confidentiality of Information. 8. Patient Care/Nursing Practice. 9. Treatment Protocol. 10. Equipment Management and Supplies. 11. Drugs: Prescription, Ordering, Storage, Administration, Dispensing, Shipping and Receiving of Drugs. 12. Communication. 13. Transportation: Patient’s transfer and Medivac Procedures. 14. Laboratory specimens: Handling, Storage and Transportation. Note: Should you require a sample of any of the above policies, please contact the RAC Admin. / MMSR Coordinator. Figure 9-4 Scope of Services Care Provided Care includes triage, assessment, diagnosis, first aid, treatment, stabilization and transfer or Medivac to an inpatient hospital for definitive care and response to disaster situations. Treatment Includes treatment of encounters of varying complexities, such as acute trauma, medical emergencies and prescribing medicines. Basic BLS and other first aid intervention. Use of AED, incorporating life saving measures with stabilization techniques. Investigations Investigations include any tests/procedures that can be undertaken, e.g.: 1. Dip stick urine test. 2. Test strip blood test. 3. Hearing test. 4. Pulmonary function test (PFT). 5. 12 Lead EKG/Chest lead monitoring. 6. Pulse Oximeter and SPO2. 7. Visual Acuity (Snellen chart). 8. Employees Physicals. 9. Radiology. 10. Laboratory. Patient Eligibility Clear policy statement regarding who is eligible for care and what are they eligible for, e.g.: a. For all employees. b. For general public or non-employee with potentially serious or life threatening condition. 15  Figure 9-5 Request For Emergency Consultation and Patient Transfer from Contractor Clinic 1. POLICIES A. The Contractor Medical Facility is the primary responder to all medical emergencies occurring to its work force. B. Primary response includes: initial triage, assessment, emergency care and stabilization of the patient as appropriate. C. All contractor companies will ensure that all employees are registered for care at a hospital offering in-patient and specialist care before they enter the work-site.This medical insurance cover should include first aid, emergency care, investigations and in- patient treatment and ambulance transfer. This shall be regularly verified by the Saudi Aramco Contract proponent department. D. Contractor Medical Facilities will maintain up to date data detailing relevant personal, medical and employment information on all employees. E. Contractor Medical Facilities will transfer all patients identified as life-threatening or critical expediently and directly to the nearest hospital facility. In the event that access to the nearest hospital facility is difficult or not available, when requested, JHAH / RACs will provide emergency medical support, including assistance with transfer as appropriate. The patient's transportation and escort to the RAC remains the responsibility of the Contractor clinic. F. Contractor Medical Facilities will utilize their on-site medical facilities and resources for the management of urgent, emergent and non-urgent patients prior to transferring them to another medical facility for further care if appropriate. G. Patients requiring definitive care should be transferred directly to the private company's designated in-patient medical facility. H. When a medivac is required for a Contractor patient from a RAC, the RAC Facility staff will be responsible for making flight arrangements with Saudi Aramco Aviation/JHAH DHC EMS I. Prior notice of transfer of any patient from a Contractor Medical Facility to a RAC must (circumstances permitting) be pre-arranged with the receiving RAC. 16 2. RESPONSIBILITIES A. RAC Contractor Medical and Nursing Staff shall orient Contractor Medical staff to comply with the requirements and the outlined process. B. Contractor Medical Staff shall: 1) Consult the RAC physician/nurse prior to transferring a patient to a RAC to discuss the case and appropriateness of transfer. The Contractor nurse or physician must have all assessment and clinical details including initial care given and patient's response available. 2) Provide an escort for Contractor patients if in the judgment of the RAC physician, this is required for onward transfer from the RAC to definitive care. 3) Complete appropriate clinical records including triage notes, vital signs and stabilization measures. Documentation including lqama and medical insurance card and other documents as appropriate should accompany the patient. 4) Be responsible for all post transfer follow-ups with its designated medical facilities. 5) Keep a database at the clinic with details of each of the contractor employee's medical registration and insurance. This must include medical insurance number, name and contact details of hospitals designated to provide care to the employee. C. The Contractor Company shall: 1) Ensure Contractor Medical Facilities staff must comply with the contents of this MMSR manual. 2) Ensure all their employees; have appropriate medical insurance cover including sub- contractor employees under their responsibility. 3) Where RACs assume responsibility for transferring a contractor patient onwards to a hospital facility, ensure the private company's medical designated facility is notified, is prepared to accept the patient and is aware of the ETA. Note: RAC staff is responsible for requesting Air medical evacuation per GI 1321.15. Where RACs assume responsibility for transferring a contractor patient onwards to a hospital facility, contractor company ambulance MUST accompany with their own medical staff (e.g. Shaybah-Pump Stations, as required. 4) Contractor Medical Facilities shall be responsible for arranging all transfer logistics, including flight manifest formalities, of all their routine transfers or referrals to another facility. 5) Where air transportation is involved, arrange for the receiving hospital to provide an appropriate ambulance and staff to meet the plane. 6) Ensure the Contractor Medical Facility ambulance is used where patient transfer by road is required. 7) Ensure a Contractor nurse or physician escort all their patients transferring out of RACs unless otherwise agreed by RAC. 8) When responding to off-site emergencies involving a Contractor death official certification and clearance to move the body is necessary. Company medical staff is responsible for staying with the body until it is officially released can be moved. 16  Important Links: MOH, Saudi Government National Portal http://www.moh.gov.sa/en/Pages/Default.aspx Saudi Commission for Health Specialties http://english.scfhs.org.sa/en/pages/default.aspx Saudi Food and Drug Authority http://old.sfda.gov.sa/ar/Pages/default.aspx Council of Cooperative Health Insurance http://www.cchi.gov.sa/en/Pages/default.aspx Saudi Central Board for Accreditation of Healthcare Institutions http://cbahi.securehostsite.biz/arabic/home Saudi Health Council http://www.chs.gov.sa/En/default.htm Ministry of Labor/ MOL law http://www.mol.gov.sa Protection Against Occupational Hazards, Major In dustrial Accidents and Work Injuries and Health and Social Services http://www.sagia.gov.sa/Documents/Laws/labor_law_en.pdf Send all relevant MMSR communication to MMSR Team using the following Email address: [email protected] 16