Discharge Standard DISCHARGE, REFERRAL AND FOLLOW UP

35 Operation Policy In Obstetrics and Gynaecology Services Intent of 8.5.1 i. Patients shall be charged according to the Fees Medical order. ii. No leave of absence shall be granted to patients. iii. Patients who wish to leave the hospital against medical advice need to do so in writing in an appropriate form. iv. The minimum length of stay for the uncomplicated postnatal primigravida mothers and their babies shall be up to 24 hours. For multiparas mothers, minimum stay should not be less than 12 hours. v. Postnatal patients with complications and delivered operatively shall be discharged appropriately not less than 48 hours after delivery. vi. Mothers should have been able to pass urine before discharge. The newborn should have been able to pass urine and have their bowels opened before discharge. vii. Mothers shall be discharged together with their babies unless the babies require prolonged stay in the hospital. viii. Identification, verification of babies and relevant administrative matters education, shall be carried out by the nursing staff before leaving the ward. A checklist shall be filled up. ix. Physically disabled and mentally incompetent patients shall be discharged to the legal custodian with written acknowledgement. OPERATIONAL POLICIES 36 Operation Policy In Obstetrics and Gynaecology Services x. The police shall be informed, through the hospital police counter, of any patient found missing, after all efforts to trace the patients have failed. Such cases shall be informed to the specialist, sister in charge and the Head of Department. Discharge shall be done after 24 hours of the patient being noted to be missing. xi. All discharges of antenatal and postnatal mothers shall be recorded in the antenatal card – ‘Home based antenatal card Rekod Kesihatan Ibu KIK1a96. xii. Discharge summary for antenatal or postnatal patients should be done by house officer medical officer. A copy of the discharge summary shall be attached to the antenatal card for the patient the Health officers responsible for the patient’s continued and follow up care. xiii. Discharge summary shall include the following: a. Reason for admission. b. Significant diagnoses and co morbidities. c. Diagnostic and therapeutic procedures performed. d. Significant medications and other treatment. e. The patient’s condition on discharge. f. Discharge medication. g. Follow up instructions. xiv. The medical records shall be dispatched to medical record department within 72 hours after the discharge. OPERATIONAL POLICIES 37 Operation Policy In Obstetrics and Gynaecology Services Measurable elements of 8.5.1 1. Patient shall be appropriately referred and or discharge. 2. Discharge summary shall be prepared at discharge by a qualified person, containing relevant information and follow up instructions, for patients and their practitioner responsible for the patient’s continuation of care. Dispatch of records to Records Office within 72 hours Std: 100 Survey of patients to ensure clear discharge instructions Std: 100

8.5.2 Referral Standard

Appropriate referral of patients. Intent of 5.5.2 1. The department shall cooperate with health care practitioner and outside agencies to ensure timely and appropriate referral 2. A referral shall be made appropriately to other departments or for outside agencies if necessary 3. Interdepartmental referral shall be decided at the specialist consultant level. 4. All interdepartmental referral shall have an input from the specialist consultant. 5. A referral letter, containing the summary of the patient’s problem and care shall be given to patient for the next practitioner. OPERATIONAL POLICIES 38 Operation Policy In Obstetrics and Gynaecology Services 6. Transport arrangement shall be made for transfer to other departments hospital. Measurable elements of 8.5.2. 1. Referral shall be made appropriately when necessary Referral of patients at specialist level Std: 100 8.5.3 Follow-up Standard Patients and as appropriate, their families shall be given understandable follow-up instructions at referral or discharge Intent of 8.5.3 1. The name and location of sites for continuing care shall be informed to patient and family. 2. Appropriate appointment dates shall be given to patient if any return to for the services in the department is needed. 3. The instruction shall be explained to patient and family and provided in writing. Measurable elements of 8.5. 1. Follow up instructions shall be provided in an understandable form and manner verbal and written to patient and or family.

8.6 TRANSFER OF PATIENT

8.6.1 Standard

Transfer for patient to another organisation for continuation of care. OPERATIONAL POLICIES