Standard 3.1 Implementation of clinical services

CHAPTER III ORGANIZATION OF INDIVIDUAL HEALTH EFFORTS (UKP), LABORATORIES, AND PHARMACY

1. Standard 3.1 Implementation of clinical services

The implementation of clinical services from the process of receiving patients to discharge is carried out by taking into account patient needs and quality of service.

The process of admission to discharge of patients is carried out by meeting patient needs and quality of service supported by facilities, infrastructure and environment.

a. Criterion 3.1.1

The provision of clinical services starting from patient reception is carried out effectively and efficiently in accordance with the patient's needs, as well as taking into account the patient's rights and obligations.

1) Main Thoughts:

a) The health center is obliged to ask for general consent from service users or their immediate families, approval for low-risk procedures, diagnostic procedures, other medical treatment, predetermined limits, and other approvals, including rules and regulations and explanations of rights and obligations of service users.

b) The closest family is the husband or wife, biological father or mother, biological children, siblings or guardians.

c) General consent is requested when the service user comes for the first time, either for outpatient or inpatient treatment, and observation or stabilization is carried out.

d) Acceptance of inpatients is preceded by filling out an additional general consent form which contains storage of personal items, determination of food and drink choices, activities, interests, privacy and visitors.

e) Patients and the public receive information about service facilities, including rates, types of services, registration process and flow, service process and flow, referrals, and availability of beds for treatment/inpatient health centers. This information is available at the registration site or conveyed using other mass communication methods in a clear, accessible and easy to understand manner for patients and the public.

f) Heads of Community Health Centers and those in charge of clinical services must understand their responsibilities and work together effectively and efficiently to protect patients and prioritize patient rights.

g) Patient safety must be considered from the first time the patient registers at the health center and contacts the health center, especially in terms of patient identification, with at least two identities that remain relatively unchanged, namely full name, date of birth, or medical record number, and must not use the patient's room number or location of the patient being treated.

h) Information about referrals must be available in the registration document, including the availability of a cooperation agreement (PKS) with advanced referral health facilities (FKTRL) which contains the types of services provided.

i) Explanation of medical procedures includes at least

(1) goals and prospects for success;

(2) procedures for the medical action to be carried out;

(3) risks and possible complications;

(4) other available alternative medical procedures and their risks;

(5) disease prognosis if action is taken; And

(6) diagnosis.

j) The patient and next of kin obtain an explanation from authorized personnel about which tests/actions, procedures and treatments require consent and how the patient and family can give consent (for example, given orally, by signing a consent form, or by other means) . The patient and family understand the contents of the explanation and who has the right to give consent other than the patient.

k) The patient or the closest family member who makes decisions on behalf of the patient, may decide not to continue the planned service or treatment or continue the service or treatment after the activity has begun, including refusing to be referred to a more adequate health facility.

l) Service providers are obliged to inform patients and next of kin about their rights to make decisions, the potential outcomes of those decisions and their responsibilities regarding those decisions.

m) If the patient or close family refuses, then the patient or family is informed about alternative services and treatment, namely alternative service or treatment measures, for example a patient with diarrhea who refuses an IV drip, then the patient is educated to drink water and ORS according to the patient's body condition.

n) Puskesmas serves various community populations, including patients with obstacles and/or special needs, including: toddlers, pregnant women, disabilities, the elderly, language barriers, culture, or other obstacles that can result in obstacles or not optimal assessment processes. and providing clinical care. For this reason, it is necessary to identify patients with risks, obstacles and special needs and work on their needs.

o) To prevent the transmission of infection, health protocols are implemented which include: use of personal protective equipment, maintaining distance between one person and another, and arrangements to avoid crowds of people, starting from registration and in all service areas.

b. Assessment Elements:

a) Policies and procedures are available that regulate the identification and fulfillment of the needs of patients with risks, obstacles and special needs (R).

b) Registration is carried out in accordance with established policies, guidelines, health protocols and procedures by informing about rights and obligations and paying attention to patient safety (R,O,W,S).

c) Puskesmas provides clear, easy to understand and easily accessible information about rates, types of services, registration process and flow, service process and flow, referrals and availability of beds for inpatient (O,W) Puskesmas.

d) General consent is requested the first time the patient is admitted to outpatient care and every time he is admitted to inpatient care (D, W).