PEJABAT KESIHATAN JOHOR BAHRU JOHOR

PEJABAT KESIHATAN JOHOR BAHRU
JOHOR
PROSEDUR PENGENDALIAN
PESAKIT LUAR DI KLINIK
KESIHATAN
NO.DOKUMEN : JHR-PKJB-PK-AKK-04
KELUARAN :02
TARIKH KUATKUASA : 24/11/2014
PROSEDUR PENGENDALIAN PESAKIT LUAR DI KLINIK
KESIHATAN
DISEDIAKAN OLEH
DILULUSKAN OLEH
NAMA
DR MARYEM
SOKHANDAN FADAKAR
JAWATAN
PEGAWAI PERUBATAN
DR ROHAYAH BINTI
ABDULLAH
PAKAR PERUBATAN
KELUARGA
TARIKH
17/11/2014
NO.SALINAN KAWALAN
24/11/2014
DIKELUARKAN KEPADA
NO.DOKUMEN : JHR-PKJB-PK-AKK-04
REKOD PINDAAN
TARIKH
PINDAAN
NO.KELUARAN/
NO.PINDAAN
RUJUKAN/
MUKASURAT
TERLIBAT
17/11/2014
JHR-PKJB-PK-AKK-04
KELUARAN:01/PINDAAN:00
05/01/2016
JHR-PKJB-PK-AKK-04
KELUARAN:02/PINDAAN:00
BUTIR-BUTIR
PINDAAN
DILULUSKAN
OLEH
Keseluruhan
muka surat
Perubahan /
Penambahbaikan
format Dokumen
mengikut keperluan
yang lebih mudah
Dr Rohayah
Binti Abdullah
Muka surat 1
Perluasan skop
lokasi dan
penambahan
rujukan
Dr Siti Rupeah
Togiman
NO DOKUMEN: JHR-PKJB-PK-AKK-04
KELUARAN:02
PINDAAN:01
1.0
OBJEKTIF
Prosedur
ini
menggariskan
tatacara
pengurusan
dan
perkhidmatan
pengendalian pesakit luar di Klinik Kesihatan supaya setiap pelanggan yang
datang mendapat rawatan yang optima.
2.0
SKOP
Prosedur ini digunapakai oleh petugas kesihatan di semua klinik kesihatan
dan klinik desa di Pejabat Kesihatan Johor Bahru untuk menguruskan
perkhidmatan pengendalian pesakit di Unit Pesakit Luar.
3.0
RUJUKAN
3.1
Manual Kualiti, Pejabat Kesihatan Johor Bahru (JHR-PKJB-MK-01)
3.2
Polisi Perkhidmatan Pra-Hospital Negeri Johor
3.3
Panduan Amalan Klinikal (CPG) Kementerian Kesihatan Malaysia
website : (www.moh.gov.my)
3.4
Akta Fee 1951 Pindaan 1982
3.5
Surat Pekeliling Ketua Setiausaha KKM Bil 8 Tahun 2015 Pelaksanaan
Caj Penuh bagi Perintah Fi (Perubatan) (Kos Perkhidmatan) 2014
1
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4.0
DEFINISI DAN TERMINOLOGI
4.1 Kaunter Saringan
: Kaunter untuk pemeriksaan berat, tinggi,
tekanan darah, ukur lilit pinggang dan
saringan kesihatan berdasarkan keperluan
4.2 Pengenalan Diri
: Kad pengenalan/ passport/ surat beranak/
Kad polis/ tentera/ Kad temujanji/ surat
jaminan (Guarantee Letter)/Surat Nikah
4.3 Prosedur rawatan
: Aktiviti rawatan selain konsultasi rawatan
seperti
pengambilan
x-ray,
dressing,
kemasukkan / penukaran tiub Nasogastric,
Urinary Catheter, pemberian Nebulizer,
ECG, pengambilan darah dan lain-lain
4.4 Pegawai yang Berkaitan
: Pakar-pakar
hospital,
Pegawai
Sains
Makanan, Pegawai Dietetik, Jurupulih Cara
Kerja Anggota, Pegawai Sains Sosial dan
lain-lain yang berkaitan
4.5 Kes kronik
: Kes-kes yang memerlukan rawatan jangka
panjang contoh kes diabetik, darah tinggi,
asthma, mental, HIV, TB, Methadone
4.6 Kes biasa
: Kes penyakit ringan seperti demam, batuk,
selesema,cirit birit dan lain-lain
4.7 Borang siasatan
: Borang makmal, X-ray dan lain-lain yang
berkaitan
2
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4.8 Kes-kes Kecemasan
: Kes-kes yang memerlukan rawatan awal
dan segera
4.9 Buku/Fail rawatan
: Kes-kes yang menggunakan kad / buku /
fail
5mengikut kategori kes
yang tertentu mengikut kategori kes seperti
Kes
Diabetis,
Hipertension,
Asthma,
Kesihatan Mental
4.10 CPG
: Panduan Amalan Klinikal
4.11 BSSK
: Borang Saringan Status Kesihatan Wanita
Dewasa/ Lelaki Dewasa/ Warga Emas/
Remaja
4.12 SOP
: Standard Operating Procedure
4.13 NDR
: National Diabetis Register
4.14 NCD
: Penyakit tidak berjangkit
4.15 FMS
: Pakar Perubatan Keluarga
4.16 M&HO
: Pegawai Perubatan Dan Kesihatan
4.17 PPP
: Penolong Pegawai Perubatan
4.18 JK
: Jururawat Kesihatan
4.19 JTMP
: Juruteknologi Makmal Perubatan
3
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3
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4.20 PF
: Pegawai Farmasi
4.21 PPF
: Penolong Pegawai Farmasi
4.22 JM
: Jururawat Masyarakat
4.23 PT
: Pembantu Tadbir
4.24 PPK
: Pembantu Perawatan Kesihatan
4.25 TPC
: Sistem Teleprimary Care
4.26 WP
: Waktu Pejabat
4.27 LWP
: Luar Waktu Pejabat
4
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5.0
CARTA ALIR
CARTA ALIR
Terima pelanggan
Pendaftaran
pelanggan
PROSEDUR KERJA
TANGGUNGJAWAB
5.1 Kategorikan pelanggan mengikut :
i.
Kes kronik
ii.
Kes biasa
iii. Pengambilan darah
iv. Prosedur rawatan
v. Kes-kes kecemasan – perlu
diberi rawatan awal dengan
segera di bilik kecemasan
(WP: kurang daripada 1 minit
LWP: kurang daripada 15
minit)
- Bagi Kes kronik kad perlu
dikeluarkan dan disemak
sebelum hari klinik.
PT/PPK/PPP/
JK /JM
- Senarai Semak Keskes Kecemasan
(Malaysian Triage
Category)
- Laporan Pencapaian
Kes-kes Kecemasan
5.2 Semua pelanggan perlu
didaftarkan samada secara manual
atau TPC. Kes-kes kronik perlu
didaftarkan mengikut kategori kes
atau program.
PT/PPK/PPP/
JK/JM
- Buku Daftar Kes-kes
Yang Dilihat Di Bilik
kecemasan
- Buku Daftar Perubatan
PL -101/102
- Sistem TPC
- Buku Daftar Kesihatan
Mental/Diabetis/NDR/
Methadone/TB/HIV
5.3 Perkara-perkara yang diperlukan
semasa pendaftaran:
PT/JK/JM/PPK
- Akta Fee
- Resit pembayaran
- Kad Rawatan Pesakit /
TPC
i.
ii.
iii.
iv.
Minta dokumen pengenalan
diri
Pastikan urusan pembayaran
dilaksanakan mengikut Akta
Fee.
Pesakit mendapatkan nombor
giliran
Serahkan kad rawatan pesakit
mengikut kategori kes/TPC
5.4 Lakukan
klinikal:
Saringan
pemeriksaan
klinikal
Pendidikan
kesihatan
saringan
REKOD/DOKUMEN
pemeriksaan
i.
Pengambilan berat badan /
tinggi/ suhu badan /BP /
glukometer mengikut
kategori kes kecuali bagi kes
pengambilan darah dan
prosedur rawatan terus ke
bilik-bilik berkaitan.
PPP/JK/JM
/PPK
- Kad rawatan pesakit/
TPC
- Rekod Keputusan
Verifikasi
ii.
Saringan status kesihatan
mengikut keperluan dan
lengkapkan rekod yang
berkaitan.
FMS/M&HO
/PPP/JK
- BSSK/ NCD / Saringan
Minda Sihat/ TPC
iii.
Siasatan dilakukan mengikut
kategori kes dan lengkapkan
borang yang berkaitan / TPC
FMS/M&HO
/PPP/JK
iv.
Pastikan keputusan ujian ada
sebelum atau semasa tarikh
temujanji
- Borang siasatan/TPC
Siasatan
klinikal
A
B
5
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CARTA ALIR
A
PROSEDUR KERJA
TANGGUNJAWAB
REKOD/DOKUMEN
5.5 Lakukan konsultasi, diagnosa
dan rawatan mengikut kategori
kes dan lengkapkan rekod yang
berkaitan
FMS/M&HO/
PPP/JK/JM
- Kad rawatan
pesakit/ TPC/
CPG/SOP yang
berkaitan/ Buku MC
5.6 Rujuk kes jika perlu
FMS/M&HO/
pegawai yang
berkaitan
- Surat rujukan/ TPC
5.7 Beri temujanji jika perlu
FMS/M&HO/
JM/PPK
- Kad temujanji
(Perubatan 91)
- Buku rekod
temujanji/ TPC
B
Konsultasi
rawatan
Rujuk untuk
rawatan lanjut
Temujanji
Farmasi
5.8 Pelanggan mendapatkan ubatubatan sekiranya perlu
6
PF/PPF
- Prekripsi/kad
rawatan
pesakit/TPC
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6.0
REKOD KUALITI
BIL
REKOD
TEMPOH
PENYIMPANAN
5 Tahun
LOKASI
Kaunter Pendaftaran
1.
Buku Daftar Perubatan PL101/102
2.
Buku Daftar Kes-kes Yang
Dilihat Di Bilik Kecemasan
5 Tahun
Bilik Kecemasan
3.
Buku Daftar Mengikut
Program
- Kesihatan Mental
- Diabetes(NDR)
- Methadone
- TB
- HIV
5 Tahun
Kaunter Pendaftaran / Bilik
Kad
4.
Kad Rawatan
-Pesakit Luar
- Diabetes
- Hipertensi
- Mental
-TB
-Methadone
5 Tahun
Bilik Kad
5.
BSSK Mengikut Kategori
-Remaja (BSSK/R/2008
Pind.1/2013)
-Wanita Dewasa
(BSSK/W/2008 Pind.
1/2013)
-Lelaki Dewasa
(BSSK/L/2008 Pind. 1/2013)
-Warga Emas
(BSSK/WE/2008 Pind.
1/2013)
Pind.2/2011)
1 Tahun
Kaunter Saringan / Bilik
Konsultasi / Bilik Kad
6.
Saringan NCD
1 Tahun
Kaunter Saringan / Bilik
Konsultasi / Bilik Kad
7.
Saringan Minda Sihat
1 Tahun
Kaunter Saringan / Bilik
Konsultasi / Bilik Kad
8.
Buku Resit
5 Tahun
Kaunter Pendaftaran
7
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BIL
REKOD
TEMPOH
PENYIMPANAN
5 Tahun
LOKASI
Bilik konsultasi
9.
Buku MC
10.
Buku preskripsi
2 Tahun
Bilik konsultasi
11.
Laporan Pencapaian Keskes Kecemasan
2 Tahun
Bilik kecemasan
12.
Laporan Pencapaian HbA1c
2 Tahun
Bilik diabetes
13.
Senarai Semak Kes-kes
Kecemasan (Malaysian
Triage Category)
5 Tahun
Bilik kecemasan
7.0
OBJEKTIF KUALITI
7.1
80% pesakit aktif diabetes menjalani ujian HbA1c sekurang-kurangnya
setahun sekali.
7.2
100% kes-kes kecemasan (di bawah “TRIAGE category RED - Priority
1”) yang datang ke klinik semasa waktu pejabat diberi response
(“attend”) dalam masa 1 minit.
8
LAMPIRAN 1
Daftar melalui TPC
LAMPIRAN 2
LAMPIRAN 3 (I)
LAMPIRAN 3 (II)
LAMPIRAN 3 (III)
LAMPIRAN 3 (IV)
LAMPIRAN 3 (V)
LAMPIRAN 3 (VI)
LAMPIRAN 3(VII)
LAMPIRAN 4(I)
LAMPIRAN 4(II)
LAMPIRAN 4 (III)
LAMPIRAN 4 (IV)
LAMPIRAN 4 (V)
LAMPIRAN 4 (VI)
LAMPIRAN 5 (I)
LAMPIRAN 5 (II)
LAMPIRAN 5 (III)
LAMPIRAN 5 (IV)
LAMPIRAN 6
LAMPIRAN 7
LAMPIRAN 8
LAMPIRAN 9
LAMPIRAN 10
LAMPIRAN 11 (I)
JHR-PKJB-B02-AKK-04
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LAMPIRAN 11 (II)
JHR-PKJB-B02-AKK-04
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LAMPIRAN 12
LAMPIRAN 13
MALAYSIAN TRIAGE CATEGORY
TRIAGE LEVEL – RED ZONE: DESCRIPTORS FOR CATEGORIES
Triage
Category
Response
Description of Category
Immediately Life-Threatening
RED
(Priority 1)
Immediate assessment
and treatment
Conditions that are threats to
life (or imminent risk of
deterioration) and require
immediate aggressive
intervention
Clinical Descriptions (indicative only)













Imminently life-threatening
The patient’s condition is
serious enough or
deteriorating so rapidly that
there is the potential of threat
to life, or organ-system
failure, if not treated within 15
minutes of arrival
RED
(Priority 2)
Assessment and treatment
within 5 minutes
(assessment and
treatment often
simultaneously)
OR
Important time-critical
treatment
The potential for time-critical
treatment (e.g. thrombolysis,
antidote) to make a significant
effect on clinical outcome
depends on treatment
commencing within a few
minutes of the patient’s
arrival in the ETD
Trauma shock
Cardiac arrest
Respiratory arrest
Pneumothorax – trauma / tension
Immediate risk to airway – impending
arrest
Respiratory rate <10 / min
Extreme respiratory distress
SBP < 80 (adult) or severely shocked
child/infant
Unresponsive or responds to pain only
(GCS < 8)
Ongoing / prolonged seizure
IV overdose and unresponsive or
hypoventilation
Severe burns > 30% BSA
Severe behavioral disorder with
immediate threat of dangerous influence
 Airway risk – severe stridor or drooling
with distress
 Severe respiratory distress
 Severe exacerbation of bronchial
asthma
 Circulatory compromise:

Cold and clammy skin, poor
perfusion

HR < 50/min or > 150/min (adult)

Hypotension with hemodynamic
effects

Severe blood loss
 Chest pain of cardiac nature
 Very severe pain of any cause
 Glucose level < 2 mmol/L
 Drowsy, decrease responsiveness of
any cause (GCS < 10)
 Acute hemiparesis / hemiplegia
 Fever with signs of lethargy (any age)
 Acid or alkali splash (eye – requiring
irrigation)
 Major polytrauma requiring rapid
organized team response
 Severe localized trauma – spinal
injuries, major fracture, amputation
 High-risk history::

significant sedative or other toxic
ingestion

significant dangerous
envenomation
 Severe pain suggesting PE, AAA or
ectopic pregnancy
TRIAGE LEVEL – YELLOW ZONE: DESCRIPTORS FOR CATEGORIES
Triage
Category
Response
Description of Category
Potentially Life-threatening
The patient’s condition may
progress to life or limbthreatening, or may lead to
significant morbidity, if
assessment and treatment are
not commenced within 15-30
minutes of arrival
OR
YELLOW
Assessment and treatment
starts within 15 minutes
Situational Urgency
There is potential for adverse
outcome if time-critical
treatment is not commenced
within 15-30 minutes
OR
Humane practice mandates
the relief of severe discomfort
or distress within 15-30
minutes
Clinical Descriptions (indicative only)
 Severe hypertension, asymptomatic
 Moderate blood loss – any cause
 Moderate shortness of breath with SaO2
90-95%
 Glucose level > 15 mmol/L
 Seizure (now alert)
 Any fever if immunosuppressed, e.g.
oncology patient, steroid Rx
 Persistent vomiting
 Dehydration
 Head injury with GCS > 10
 Burns <15% of BSA regardless of depth
rd
and/or <10% 3 degree burns
 Moderately severe pain – any cause,
requiring analgesia
 Chest pain likely non-cardiac and
moderate severity
 Abdominal pain without high risk
features – moderate severity or patient
age > 55 years
 Moderate limb injury – deformity, severe
laceration, crush
 Limb – altered sensation, acutely absent
pulse
 Trauma – high-risk history with no other
high-risk features
 Stable neonate
 Child at risk
 Behavioral / Psychiatric:

Very distressed, risk of self-harm

Acutely psychotic or thought
disorder

Situational crisis, deliberate selfharm

Agitated / withdrawn
 Potentially aggressive
 Poisoning / drug overdose which require
immediate procedure
TRIAGE LEVEL – GREEN ZONE: DESCRIPTORS FOR CATEGORIES
Triage
Category
Response
Description of Category
Airway secured,, ambulant,
hemodynamically stable
patients and not in respiratory
distress.
GREEN
Priority 1
The patient’s condition may
deteriorate or adverse
outcome may result, if
assessment and treatment is
not commenced within one
hour of arrival in ETD.
Symptoms moderate or
prolonged.
(G1 – Fast
Lane)
Clinical Descriptions (indicative only)













GREEN
Priority 2
(G2)
Situational Urgency
Assessment and treatment
start within 60 minutes
Require initial management or
first aid before seen by
doctors
Non-critical cases
GREEN
Priority 3
(G3)
Patients who can wait
Children < 2 years old
Senior citizen > 65 years old
Acute pain: Pain Score < 4
Non-specific abdominal pain
Mild hemorrhage
POP complications – tight cast, no
neurovascular impairment
Swollen “hot” joint
All OSCC cases (without resuscitation
needs)
Mild exacerbation of bronchial asthma
Foreign body aspiration, no respiratory
distress
Acute urinary retention
Elevated blood sugar without any major
symptoms
High Fever > 39’C
 Psychiatric complaints – without risk of
self-harm
 Minor allergic reactions
 Hospital staff with minor complaints
 Vomiting or diarrhea without
dehydration, normal mental status
 Minor trauma – not necessarily acute
 Head injury – alert, no sign and
symptom of increase intra-cranial
pressure
 Bumps and bruises
 Closed fracture of upper limbs
 Simple laceration and cuts – not
requiring sutures
 Controllable bleeding
 Closed fracture of upper limbs or ankle
without major angulation
 Chronic abdominal pain
 Menses related complaints
 General medical conditions or minor
illnesses not requiring monitoring
 Sore throat – no respiratory symptoms
 Earache
 Nail prick
 Acute infective eye conditions
GREEN
Priority 4
COLD CASES / OUT
PATIENTS
(G4)
Triage away to primary
care or another center
OR
Will be seen in ‘After
Office Hour Clinic’ in ETD
(KRPSWP)
GREEN
Priority 5
CLINICOADMINISTRATIVE
PROBLEMS
(G5)
Not seen in ETD
Non-emergency cases
The patient’s condition is
chronic or minor enough that
symptoms or clinical outcome
will not be significantly
affected if assessment and
treatment are delayed up to
two hours from arrival
Non-emergency related
conditions
 Chronic trauma injuries > 6 months
 Acute pyrexia < 38’C for adult < 65 years
of age OR children between 2 to 12
years of age
 Simple skin diseases – chronic
 All pregnancies more than 20 weeks
requiring antenatal follow-up
 Cough and cold
 Minimal pain with no high risk features
 Low-risk history and now asymptomatic
 Minor symptoms of existing stable
illness
 Minor symptoms of low-risk conditions







Missed appointments
Medications exhausted
Second opinion seeking
STO
Medical certificate
Specialist clinic cases
Medical check-up
CONCEPT OF TRIAGE:

It is a dynamic process – continuous evaluation and assessment of the patient
is required to look for any sign and/or symptoms of deterioration, thus the
decision to upgrade the patient.

It is a process to sort out / prioritizing the patients that come to Emergency
and Trauma Department to get treatment – those with higher priority (more
critical) will be seen and managed first than those with lower priority (less
critical) that will be seen later.

The officer in the Primary Triage counter will do the prioritization of all the
patients and will pass over the case to the respective clinical zones based on
his early and rapid assessment of the patient’s condition.

The officer in the Secondary Triage area/room will cater for all the Green
Zone cases and do the initial assessment and treatment of the patients; such
as taking the vital signs, do the dressing of the trauma patient, administer the
ATT injection, ordering the radiological investigations (x-rays) under the order
of the Medical Officer, requesting basic blood investigations etc. The patients
will be asked to wait in the waiting area if this basic assessment show that
they still fulfills the criteria of ‘green category’. They will be called by the
Medical Officer later for complete medical examination