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2. The planning considers all available assessment information.
3. An appropriate surgery is planned based on the assessment.
4. Prior to the procedure, a preoperative diagnosis is documented.
21.3.2 Standard
The risk, benefits and alternative options are discussed with the patient and his or her families or those who make decisions for the patients.
Intent of 21.3.2
1. Patient and their families or decision makers, receive adequate information
to participate in the case decisions and provide the informed consent. 2.
The information includes a.
The surgical and non surgical options. b.
The risks of the planned procedure and remedial measures. c.
Side effects of the surgery, for example loss of fertility, amenorrhoea and surgical menopause which can affect the quality of life of the
patient. d.
Other complications for example wound breakdown and infections. e.
Adjuvant treatment, for example chemotherapy, and the side effect of this treatment.
f. The type of surgical scar
g. The possible need to transfuse blood and blood products, and its
complication. These could range from minor allergic reactions to the risk of
transmission of infectious diseases, even though remote, are informed.
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3. This information is provided to the patients or their relatives by the gynae-
oncologist or any other individual qualified to do so. The gynae-oncologist is also responsible for obtaining consent, for the surgery. Patient at added
risk, due to associated medical co-morbid are required to sign high risk consent. This consent is obtained from the family members. All the
information provided and queries answered are documented in the patient’s case notes.
Measurable elements of 21.3.2
1. Adequate preoperative counselling is provided and options discussed.
2. Consent for the surgery is taken by the gynae-oncologist or the fellow in
training. 3.
High risk consent is required for those at added risk. 4.
The whole process is documented.
Compliance with practice protocols Std: 100 21.3.3 Standard
The surgery performed is documented in the case notes.
Intent of 21.3.3
The findings during surgery are very important, both for the short and long term management of the patient and it must be correctly written. The patients operative
notes includes :- a.
the post-operative diagnosis, b.
a description of the surgical procedure and the findings. c.
the surgical specimens sent. d.
the names of the surgeon, assistant, and staff-nurse must be written.
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e. the date, time of commencement and completion of surgery must be
documented. f.
post operative instructions will include the intravenous fluid regime, analgesia, antibiotics if any with its dosage.
Measurable elements of 21.3.3
1. A post operative diagnosis is documented
2. A description of the surgical procedure, findings, and any surgical specimen
sent, is documented 3.
The names of the surgeon and surgical assistants are documented.
Compliance with practice protocols Std: 100 21.3.4 Standard
Patient care after surgery is planned and documented.
Intent of 21.3.4
Each patients post surgical care is different, and therefore it is important that it is carefully planned out. The Post operative instructions include the intravenous fluid
regime, analgesia, antibiotics if any, with its dosage. The post operative planned care is documented in the case notes.
Measurable elements of 21.3.4
1. Each patients post operative care is planned.
2. The plan is documented in the patient’s record.
Compliance with practice protocols Std: 100
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21.4 CHEMOTHERAPY SERVICES 21.4.1 Standard
Chemotherapy services are available to meet patient’s needs, and all such services meet applicable local and national standards, laws, regulations and professional
standards.
Intent of 21.4.1
The department provides both in-ward and day-care chemotherapy for patients. These services meet all the applicable local and national standards, laws and
regulations and professional standards.
Measurable elements of 21.4.1
1. Chemotherapy services meet applicable local and national standards, law and
regulations 2.
Chemotherapy services are available to meet patient needs. 3.
Both in-patient and day care services are provided.
Compliance with practice protocols Std: 100 21.4.2 Standard
A qualified Gynae-oncologist is responsible for managing the chemotherapy services.
Intent of 21.4.2
Chemotherapy services are under the directive of a qualified gynae-oncologist who has been gazetted by the Ministry of Health Malaysia. He assumes professional
responsibility for the chemotherapy services provided. Responsibilities include: a
Developing and updating Chemotherapy protocols b
Maintaining quality control programs
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c Individualizing the type of chemotherapy needed for a particular
individual d
Attending to any complications from chemotherapy e
Preparing statistics pertaining to chemotherapy administration.
Measurable elements of 21.4.2
1. Chemotheraphy services are under the direction of a qualified Gynae-
oncologist 2.
Responsibilities includes those elements from a through e in the intent statement.
Compliance with practice protocols Std: 100 21.4.3 Standard
Department protocols guides the care of patients undergoing chemotherapy.
Intent of 21.4.3
1. Chemotherapy poses risk to patients, and thus needs to be provided using
clear definitions policies and procedures. Chemotherapy may cause life threatening anaphylaxis, myelo-suppression and various other complications.
Important consideration includes the patient’s ability to withstand the toxicities, availability of life saving medications and resuscitation set-up.
Chemotherapy protocols outlines :- a.
Indication and type of chemotherapy for a particular condition b.
Hematological and biochemical criteria’s to be fulfilled before administrating chemotherapy
c. Drug dosages calculation formulas
d. Patient monitoring, criteria’s.
e. Dosage and frequency of drugs.
f. Hydration regimes
