MULTI DISPLINARY CARE.

. PATIENT PHYSICIANNURSESOTHERSDIETITIANPHYSIOTHERAPIST

PURPOSE  The purpose of the MDC is to support integration and coordination of patient care activities to ensure an efficient care process and increase the likelihood of better patient outcomes

Policy in SKGH PORTAL 1 HOSPITAL DOCUMENT 2 HOSPITAL WIDE POLICY 3

SKGH shall provide uniform care to all patients using a multidisciplinary collaborative approach of care. Uniformity of care is based on:-  Accessibility and availability of services at all times i.e. emergency and inpatient services available at all times with the availability of applicable staffing to cover patients care needs.  Care provision to accommodate patients unable to afford payment as per Ministry of Health and Ministry of Presidential Affairs regulations.  Standardized level of care provided based on applicable policies to guide care processes.

.  The patient and / or their family / designee shall be involved in the planning process.  The planning and provision of care is driven by consideration of the rights of the patient to make informed decisions regarding their care, including the right to accept or refuse care.  The care planned for a patient shall be individualized and related to his or her identified needs.  The development, implementation and maintenance of a patient’s plan of care shall be an interdisciplinary process. Each health care team member providing care to the patient shall have input into the plan of care.  Integration of the plan shall be accomplished by the plan of care of the most responsible physician from daily rounds, assessment findings and post-operative orders (as appropriate) being incorporated into the care planned by the nursing and clinical support staff.  The plan of care shall be updated or revised as appropriate based on the reassessment of the patient by the health care practitioners to reflect the evolving condition of the patient.  The planned care is documented in the patients’ medical record in the form of measurable progress goals.  The planned care is provided to the patient and relevant family/ significant others.  The care provided for the patient shall be written in the patients’ “ Multidisciplinary plan of care ” form in the medical record by the healthcare professionals providing the care.  Follow up care is coordinated to ensure the patient’s needs are met or referred through the appropriate department

Development and Initiation of the Plan of Care:  On admission to SKGH, all patients shall have a plan of care developed within a maximum of 24 hours.  The initial plan of care shall be developed using the patient’s initial assessment from the physician history and physical and nursing admission assessment and reflect the patient’s principal diagnosis and identified problems.  The care planned for the patient shall be individualized and related to his/her identified needs.  The initial physician plan of care shall include an estimated length of stay.  The health care provider shall involve the patient and/or family in the development of the plan of care,  Goals set for the plan of care shall be Specific, Measureable, Attainable, Realistic and Timely (SMART).  The multidisciplinary team shall develop the plan of care using SMART goals based on the progression and ongoing plan of the most responsible physician.  Multidisciplinary team shall also incorporate their planned goals based on patient needs identified during their assessment and reassessment of the patients as well as during patient/multidisciplinary rounds / meetings and post-operative note.  In accordance with the assessment /reassessment policies all health care providers will update the plan of care to reflect the evolving condition of the patient.

Documentation of Plan of Care:  Care provided for the patient shall be documented in the patient’s Multi-Disciplinary Plan of Care by the health professional providing the care and must be acknowledged by the treating physician(s).  The plan of care is integrated by all the health care providers and must be in a measurable goals.  All the multidisciplinary Plan of care interventions must be clearly documented in the progress notes.

Patient and Family Education:  The patient and / or their family being involved in the planning process shall receive relevant education from their direct care provider to ensure understanding and collaboration to meet the patient’s goals and plan of care.  Any patient/ family education shall be documented in the patient’s medical record on the “Patient and Family Health Education Record”.

Referral and / or Transfer of Care  Referrals or transfers of care shall be incorporated into the plan of care for the patient. The referring or transferring clinician shall ensure that the patient’s current plan of care is handed over to the relevant clinician or department to ensure follow up care is coordinated.

FORM IN SKGH

MESSAGE FROM THE PATIENT TO THE TEAM