INTERDEPARTTIENTAL POLIC}' & PROCEDURE (IPP)
Policy
Title: MULTIDISCIPLINARY PLAN OF CARE
Applies To: All AMCH Staff
Policy No.: AMCH/IPP/P002(2)
Lllolrillg 6i!q rl L0rl . on i,l,,r,
Issue Date:
01 September
2016
Abh. Matemi, & ChlldRn Horphil
Effective Date:
01 July 2024
Valid Until :
0l July 2027
Review I)ue:
01 June 2027
1. PURPOSE:
1.1 To ensure that a comprehensive multidisciplinary plan ofcare is documented in the medical
record file of every patient admitted in Abha Matemity and Children's Hospital (AMCH).
2. DEFINITIONS:
2.1 The multidisciplinary care plan is
2.1.1 A strategy that is developed based on data gathered during patient assessment. This
2.1
.2
care plan determines the needs ofthe patient and establishes protocols to meet those
needs. The objective ofthe plan is offer patient care in a seamless continuum.
A treatment plan especially designed for individualized patient care. The healthcare
staff develops the plan with input from the family and communication with each other.
3. RESPONSIBILITIES:
3.1 The Assistant for medical services monitors the following:
3.1.1 Daily morning rounds on hospital wards.
1.1
.2 Routine meetings with department heads, medical and other Healthcare staff.
3.1.3 Medical record review results.
3.1.4 Patientcomplaints.
3.2 The Assistant for nursing services monitors the following:
3.2.1 Daily moming rounds on hospital wards.
3.2.2 Routine meetings with head nurses and nursing stafl
3.2.3 Medical record review results.
3.3 Quality and Patient Safety Department - monitors the implementation of the policy,
responsible in informing all affected personnel prior to the date ofthe policy.
3.4 Physicians, Nurses and other Healthcare staff (Social care, dietician, Physical Therapist, etc.)
are responsible for the application ofthe policy.
4. POLICY:
4.1 It is policy of AMCH to provide an individualized multidisciplinary plan of care for patients
through the assessment and reassessment process ofthe healthcare team. Plan ofcare is
constructed on updated Clinical Practice Guidelines.
4.2 The plan of care is developed, implemented and evaluated through a collaborative approach
between the healthcare team(s), patient, and family and aimed to meet all patients' needs.
4.2.1 The plan of care is based on the assessment findings'
4.2.2 The patient and family are involved in developing the plan of care.
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of5
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AMCH/APP/FOO I
INTERDEPARTMENTAL POLICT' & PROCEDURE (IPP)
&
Polic-v-
Title: MULTIDISCIPLINARY PLAN OF CARE
Polic"r No.: AMCIVPP/P002(2)
JL!]rilig orlqll l4ri. q.,i,,,, ^
Abha M.t€miry & Children Hospilal
Issue I)ate:
0l September
2016
Effective Date:
01 July 2024
Applies To: All AMCH Staff
Valid Until :
0l July 2027
Review Due:
01 June 2027
4.2.3 The plan of care contains the measurable goals/desired outcomes towards discharge.
4.2.4 The plan of care is initiated within four (4) hours for Intensive care admissions and
eight (8) hours for ward admissions and is completed sTithin 24 hours of admission or
earlier based on the patient's condition and needs. The plan of care is reviewed by the
most responsible physician on a daily basis.
4.2.5 The plan of care is modified as appropriate upon any significant change in the
patient's condition or when new treatments are added or discontinued.
4 .2
The plan of care includes a provisional date of discharge set within 24 hours of
admission.
4.2.7 For consultations - the consulting physician approves and follows up the
implementation of the plan of care as set by the consulted physician.
.6
4.1 Patients who are admitted for surgery have medical assessment performed and plan of care
documented prior to surgery.
4.3.1 Each patient has a post-operative plan of care.
4.3.2 A post-operative plan of care is written /enter by the responsible surgeon in the
physician note . The post-operative plan of care includes:
4.3.2.1 Post-operative monitoring parameters and its frequency.
4.3.2.2 Wound care.
4.3.2.3 Care of drains and catheters.
4.3.2.4 Special patient positioning requirements.
4.3.2.5 Nutritional instructions.
4.1.2.6 When to start mobilization.
4.3.2.7 Special refenals (e.g. physical therapy, respiratory therapy)
4.3.2.8 A new order for all required medications.
4.3.2.9 Any other post-operative care needed including required follow up.
43.3 The post-operative plan ofcare is available in the patient's electronic medical record
before discharge from recovery.
4.4 The dietitian, in collaboration with ottrer clinical staff, develops an appropriate nutritional plan
ofcare for patients with nutritional disorders.
4.5 The social worker works collaboratively with clinical staff (physicians, nurses, and other
clinical staff) to develop a suitable plan of care that meets the psychosocial needs ofthe patient
and ensures the continuity ofcare. Social worker plan of care includes goals and interventions
such as counseling, education, and facilitation ofresources.
4.6 Patients with fi.nctional disorder(s) have an appropriate plan of care that meets their needs.
4.6.1 The physiotherapist, in collaboration with other clinical staff, develops a suitable plan
ofcare for patients with frnctional disorders.
4.6.2 The plan of care meets the medical needs ofthe patient and has measurable goals.
4.6.3 Patients are educated about the plan ofcare and the procedures and rehabilitative
exercises.
AIl4Ct I
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AMC}{/APP/FOO I
I
@
Policy
NTERDEP,{RTMENT-{L POLI('}' & PROCEDT RE ( I PP)
Title: MULTIDISCPLINARY PLAN OF CARE
Policy No. : AMCH/IPP/P002(2)
Jlorollg orlq! l{ri !5r-od.iJi-o
Abh. Mat€mity & children Hospital
Issue Date:
01 September
2016
Effective Date:
0l Juty 2024
Applies To: All AMCH Staff
Valid Until :
0l Jnly 2O27
Review Due:
Ol .ltne 2O27
4.7 Patients are reassessed by the healthcare team at regular intervals to ensure effectiveness of
care, their response to the plan of care is monitored, and adjustments are made accordingly.
4.8 The plan ofcare is documented in the patient's medical record and coordinated between the
different services as part of multidisciplinary team planning.
5. PROCEDURE:
5.1 A multidisciplinary plan of care is written/enter in medical record for all patients admitted in
AMCH.
5.2 Assess the patient and identifr their needs (refer to AMCH/APP/P103 - Patient Assessment
and Reassessment).
5.3 Referrals and consultations will be sent based on the patient needs and assessment findings
(refer to AMCH/APP/P040 - Consultation)
5.4 Plan of care is initiated within 4 hours for intensive care admissions and 8 hours for ward
admissions by the attending physician based on the assessment findings. It should be completed
within 24 hours or earlier based on the patient's conditions and needs. The multidisciplinary
plan of care includes but not limited to the following:
5.4.1 Physicians treatment plan, investigations needed and progress notes;
5.4.2 Expected length of stay
5.4.3 Dischargeplanning
5.4.4 Information on any surgical operation / procedure required and the associated benefits
and risks.
5.4.5 Postoperative care needed.
5.4.6 Consultations and recommendations after consultation.
5.4.7 Nursing care plans
5.4.8 Socio economic plans
5.4.9 Nutritional plan
5.4.10 Functional plan
5.4.1I All patient education provided to the patient on his/her plan of care and the
anticipated outcomes.
5.5 All disciplines involved in the care ofa patient collaborate to develop the patient's plan ofcare.
5.6
Each healthcare team member provides input into the plan ofcare. The
patient/family/significant other is included in the development, implementation, maintenance,
planning and evaluation of the care provided.
The attending physician sees and evaluates his/her patient and progress notes are written at
least daily and for any change or deterioration in the patient's medical condition. They include
the provisional diagnosis, treatment options, and the plan of care.
5.7 Document the plan of care (AMCII/APP/F189- Multidisciplinary Plan of Care Form)
5.7
.l Date and time
Ai4CH
Page 3 of 5
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AMCI]/APP/FOO I
INTERDEPARTMENTAL POLICY & PROCEDURE (IPP)
&
Policy
Policy No. : AMCH/IPP/P002(2)
Issue Date:
0l September
2016
,lLol,illq d:!q! l.gJi .lro,,,,,,,-o
Abha Matemity & Childrcn Hosphal
5.7.2
5.7.3
5.7.4
5.7.5
5.7.6
Title: MULTIDISCIPLINARY PLAN OF CARE
Effective Date:
0l Jnly 2024
Applies To: All AMCH Staff
Valid Until :
Review Due:
01 Ju\ 2027
0l Ju,ae2027
Problem (ldentify high priority)
Goals/ Target Date
Intervention Plan
Responsible Team
Evaluation & Follow up (Date & Time).
5.8 Patients are reassessed by the healthcare team at regular intervals to ensure effectiveness of
care, their response to the plan ofcare is monitored, and adjustnents are made accordingly
5.8.1 Reassessment is done to determine:
5.8.1.1 response to treatment,
5.8.1.2 compliance with trcatment,
5.8.1.3 complications and side effects
5.8.1.4 Plans for continued or completion of treatment
5.8.2 The patient goavmeasurable outcome and plan of action are updated by the individual
who identified the problem, or by other healthcare team members according to their
expertise and credentials.
5.9 A healthcare team member utilizes clinical practice guidelines, standardized plans of care, or
other such documents as a reference. Note: The document used as a reference must be a
permanent part ofthe medical record and must be individualized for the patient. These
documents will be filed in the progrcss note section of the medical record.
6. CROSSREFERENCES:
6.1
6.2
6.1
AMCFYAPP/P040 - Consultation.
AMCH/APP/PIO3 - Patient Assessment and Reassessment.
AMCHAIR/P039-Nursing Documentation,Care plan.
7. EQUPMENT&MATERIALS:
7
.l
Multidisciplinary Plan of Care Form -AMCIVAPPIF 189
8. REFERENCE:
8.1 CBAHI National Hospital Standards, 3rd Edition, 2015, page 61,69-70,76,83,95,102, 1ll,
113, 122, 126, 160, 161, 163-164, 166 ar,d 177.
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AMCtIi APP/FOO I
INTERDEPARTMENTAL POLICY & PROCEDTIRE (IPP)
Policy
Title: MULTIDISCPLINARY PLAN OF CARE
Applies To: All AMCH Staff
Policy No.: AMCH/IPP/P002(2)
utt-o.tciltq
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Issue Date:
01 September
2016
Valid Until:
0l July 2027
0l June2027
Name & Position
Signafure
Date
Prepared By:
Dr. Mohammed Badawi
Medical Staff Quality Coordinator
(€ C--'
L -oL,"y
Reviewed
Ms. Zahra Talaa
Patient and Family Education Head
g*U'>
4 . oC -1,'az.l
&
Mr. Bader Assiri
Abha Matemity & Children Hospital
Effective Date:
01 July 2024
Review Due:
9.
Approved
By
, ( - oj-ZDrt
Patient Experience Department Head (
qlu,,
Mr. Aisha Assiri
Medical Record Department Head
Mr. Mousa Al Malki
Respiratory Services Head
6r
Ms. Nassar Al Hattan
Social Care Department Head
Mr. Najwa Abuallam
Ms. Abdulrahman Al Shehr{
Dietary Department Head 4 -ffi:
Ms. Amal Al Asmari
tLlob fwbt
Dr. Hussein Mohd Etwadi
Assistant for Medical Services
,lb
Mr. Saeed Yahya Shatfan
Quality and Patient Safety Director
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Assistant for Nursing Services
Dr. Ali Mohammed Asiri
Hospital Director
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wlouf
Physiotherapy Department Head
Final
Approval
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Page 5 of5
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