Management Of Information. (MOI)

The Medical Record will be arranged in a reverse Chronological Order (i.e. the most recent admission/ outpatient visit will be first).

Inpatient Diagnoses & Outpatient Procedures will be coded using the ICD-10-AM. They are used to help the organization to identify the top Diagnoses and Procedures performed, facilitate Clinical Research and participate in outside databases/ registries.

Be aware of validity of documentation in the patient medical records i.e. eligibility, etc.

Any Errors: must be crossed out with a single horizontal line, and initialled. “Error” must be written next to it. No Erasers, correction pens to be used.

Late Entry: When a pertinent entry was missed or not written in a timely manner. Identify the new entry as a “Late Entry”. Enter the current date and time. ” Do Not” attempt to give the appearance that the entry was made on a previous date or an earlier time. The entry must be signed. Identify or refer to the date and circumstance for which the late entry is written.

An Addendum: is another type of late entry that is used to provide additional information in conjunction with a previous entry. (Follow the same procedure of late entry)

Any Patient: who remains in the hospital for more than Forty- Eight (48) hours including patients held in the Emergency Department (ED) will require a dictated Discharge Summary.

A Discharge Summary must be completed within fourteen (14) Days after discharge.

Death Summary must be completed within fourteen (14) Days after patient death.

Monitoring of MR Content & Completeness: Regular open patient MR review must be conducted by every MRP, as Two (2) files review per month. Please note that: We needs evidence of four (4) month MR reviews before the date of JCI Accreditation - April (This 4 month rule applies for any task requires evidences of documentation and implementation).

Facility Management and Safety (FMS)

a. Major Disaster You must know the Major Disasters Codes: Code Yellow: Stand-By - Code Red: Full Alert - Code Green: Stand Down

Our hospital is involved in Major Disaster Category (A) For aeroplanes crashes, terrorism attaches and also covers North Riyadh Area.

Participates in the Major Disaster Category (B) with Ministry of Health such as water floods, sand storms & other Riyadh areas.

Agreed by Hospital Administration, receiving (25) patients/causalities at a time is considered a Major Disasters.

During Major Disaster : Staff to ask for and ensures availability of the following Elements: Required medications, Bloods/Products, Infection Control, Utilities.

Do not talk to any Media (Radio, TV, and Journalist), it is the responsibility of the Hospital Administration.

b. Fire Events You must know Fire Code: Code F and The ext. (555) to activate Code F

In event of fire: Your answer will be I use, Standard Fire Orders: R.A.C.E. (You must be familiar with). Do not explain what is R.A.C.E. unless you are asked.

R = RESCUE: Any patient in immediate danger from the fire, if it does not endanger your life. A = ALARM: Sound the alarm for “Code F”, by calling ext. “555” and activating a pull station alarm box. C = CONFIN E: The fire by closing all doors and windows. E = EXTING UISH: The fire with a fire extinguisher, or EVACUATE the area if the fire is too large for a fire extinguisher.

Patients’ evacuation from fire area is Horizontal, if no fire exit in the receiving area patients’ evacuation will be Vertical. During evacuation do not forget to look for patients/staff in toilets (may not heard F Code). You have to ensure your safety as well.

Must know the fire alarm sites in your area and how to use them. Must know the fire free zones area and collection zone in your area. Must know the location of fire extinguisher in your area, and if it is stabile to be used for all types of fires.

In case no fire extinguisher available, you can use any Powders for miner fires.

You may be asked to demonstrate how to use the fire extinguisher: you must be familiar with (P.A.S.S.) procedure.

P = PULL the pin on the fire extinguisher. A = AIM the extinguisher nozzle at the base of the fire. S = SQUEEZE or press the handle. S = SWEEP from side to side until the fire appears to be out.

You must know the location of ‘Medical Gas Valve’ in your area, and you know how and when to close it. In case you are required to do so (It is Charge nurse responsibility). your answer will be: Must ensure that patients requiring oxygen are placed on portable oxygen before closing the valve, to ensure patients safety.

Must know the fire hose location in your area and if you can use it. If it is a low water pressure you can use, but if it is a high water pressure to be used only by hospital foremen. This is to avoid harming yourself and the others.

Child Abduction Code Pink : you will receive training on how to activate code pink, and each staff responsibilities.

INSHALAH WE WILL PASS,,,,,JCI SURVEY... ALL I BEST DR AMAL MOSTAFA NEONATOLOGIST