Standard 3.2 Assessment, plan of care, and delivery of care.

Standard 3.2 Assessment, plan of care, and delivery of care.

Assessment, care planning and provision of care are carried out in a complete manner.

Patient studies are carried out in a comprehensive manner to support the planning and implementation of services by professional health workers and/or inter-professional health teams which are used to formulate clinical service decisions. The implementation of patient/family care and education is carried out in accordance with the plans prepared, guided by policies and procedures, and in accordance with applicable regulations.

a. Criterion 3.2.1

The screening and initial assessment process is carried out in a comprehensive manner, covering the various needs and expectations of the patient/family, as well as preventing the transmission of infection. Patient care is carried out based on medical, nursing and other clinical care plans taking into account patient needs and guided by clinical practice guidelines.

1) Main Thoughts:

a) Screening is carried out from the beginning of patient admission to sort patients according to the possibility of infection transmission, patient needs and emergency conditions, guided by standardized screening procedures.

b) The patient review process is a continuous and dynamic process, both for outpatients and inpatients. The patient review process determines the effectiveness of the care that will be provided.

c) Patient studies include:

(1) collect data and information about physical, psychological conditions, social status and disease history. To obtain this data and information, an anamnesis was carried out (subjective data = S) as well as a physical examination and supporting examinations (objective data = O);

(2) analysis of data and information obtained that produces problems, conditions, and diagnoses to identify patient needs (assessment or analysis = A); And

(3) create a care plan (care planning = P), namely developing solutions to overcome problems or meet patient needs.

d) When a patient is first received, an initial study is carried out, then a continuous review is carried out on both outpatients and inpatients according to developments in their health condition.

e) Initial studies are carried out by medical, nursing/midwifery personnel, and personnel from other disciplines including physical/neurological/mental status, psychosociospiritual, economics, health history, allergy history, pain assessment, fall risk assessment, functional assessment (impaired bodily functions ), nutritional risk assessment, educational needs, and discharge planning.

f) During the initial assessment, it is also necessary to pay attention to whether the patient is experiencing pain or discomfort. Pain is a form of unpleasant sensory and emotional experience that is associated with tissue damage or a tendency for tissue damage to occur or a condition that indicates tissue damage.

g) Patient assessment and diagnosis should only be carried out by competent professionals. Competent professional staff are staff who in carrying out their professional duties are guided by professional standards and codes of ethics and have competence in accordance with their education and training which can be proven by a competency certificate.

h) The study process can be carried out individually or if necessary, carried out by an inter-professional health team consisting of doctors, dentists, nurses, midwives and other health care providers according to the patient's needs. If providing care requires a health team, coordination must be carried out in preparing an integrated care plan.

i) Patients have the right to make decisions regarding the care they will receive.

j) One way to involve patients in making decisions about the services they receive is by providing information that refers to statutory regulations (informed consent). In the event that the patient is a minor or an individual who does not have the capacity to make appropriate decisions, the party giving consent refers to statutory regulations. Providing information that refers to statutory regulations can be obtained at various points in time in the service, for example when a patient is admitted to inpatient care and before a certain risky action or treatment. This information and explanation is provided by the doctor in charge who will carry out the procedure or another doctor if the doctor in question is unavailable, but still with the knowledge of the doctor in charge.

k) The patient or the patient's closest family is given the opportunity to collaborate in preparing the clinical care plan that will be carried out.

l) The care plan is prepared based on the results of the study which are expressed in the form of a diagnosis and the care to be provided, taking into account the biological, psychological, social and spiritual needs, as well as taking into account the cultural values possessed by the patient, also including communication, information and education for the patient and his family.

m) Changes to the care plan are determined based on the results of further studies in accordance with changes in patient needs.

n) Medical personnel can delegate authority in writing to carry out certain medical or dental procedures to nurses, midwives or other health care providers. This delegation of authority can only be carried out in cases where medical personnel are not present and/or due to limited availability of medical personnel.

o) The delegation of authority to carry out medical procedures is carried out with the following conditions.

(1) The actions delegated include the abilities and skills possessed by the recipient of the delegation.

(2) The implementation of delegated actions remains under the supervision of the delegatee.

(3) The delegater remains responsible for the delegated action as long as the implementation of the action is in accordance with the delegation given.

(4) The action delegated does not include taking clinical decisions as the basis for carrying out the action.

(5) The action delegated is not continuous.

p) Patient care is provided by personnel in accordance with the graduate's competence with clarity regarding the details of authority according to statutory regulations.

q) In certain conditions (for example in cases of tuberculosis (TB) with malnutrition, it requires integrated treatment from doctors, nutritionists, and the person in charge of the TB program. Patients need integrated care which includes medical care, nursing care, nutritional care, and health care others according to patient needs.

r) To improve optimal clinical outcomes, there needs to be cooperation between health workers and patients/patient families. Patients/patient families need to receive health education and education related to the patient's disease and clinical needs using an interpersonal communication approach between the patient and health workers and using language that is easy to understand so that they can play an active role in the care process and understand the consequences of the care provided.

2) Assessment Elements:

a) Complete initial screening and assessment is carried out by competent personnel to identify service needs in accordance with clinical practice guidelines, including pain management and recorded in the medical record (R,D,O,W).

b) In certain circumstances, if medical personnel are not available, written authority can be delegated to nurses and/or midwives who have undergone training, to carry out initial medical studies and provide medical care in accordance with the delegated authority given (R,D).

c) Care plans are made based on the results of the initial assessment, implemented and monitored, and revised based on the results of further studies in accordance with changes in patient needs (D, W).

d) Patient care is carried out, including if necessary, collaborative care in accordance with the care plan and clinical practice guidelines and/or clinical care procedures so that they are recorded in the medical record and unnecessary repetition does not occur (D,W).

e) Health counseling/education and evaluation and follow-up are carried out for patients and families using methods that can be understood by patients and families (D,O).

f) The patient or patient's family obtains information regarding certain risky medical actions/treatments that will be carried out before giving consent or refusal (informed consent), including the consequences of the decision to refuse (D).