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TAKLIMAT 3 MSQH

10 April 2025

Khamis

Auditorium HSAS

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SCAN QR CODE FOR ATTENDANCE

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Standard 7: HIMS

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HEALTH INFORMATION MANAGEMENT SYSTEM (HIMS)

STANDARD 7

7.1 Organisation and management

7.2 Human Resource Development and Management

7.3 Policies and Procedures

7.4 Facilities and Equipment

7.5 Safety and Performance Improvement Activities

7.6 Special Requirements

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ORGANIZATION AND MANAGEMENT

Topic 7.1

The Health Information Management System (HIMS) Services shall be organized and administered to facilitate the collation, aggregation and analysis of Facility demographic data through an established system which includes confidentiality, safe keeping and retrieval of medical records and documents both paper based and electronic related to patient care.

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HUMAN RESOURCE DEVELOPMENT AND MANAGEMENT

Topic 7.2

The Health Information Management System (HIMS) Services shall be directed by and staffed with suitably qualified and trained personnel to achieve the goals and objectives of the services.

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POLICIES AND PROCEDURES

Topic 7.3

Written policies and procedures shall reflect current standards of practice for HIMS Services, and the serve as standard operating procedures to meet the information needs of all those providing clinical services, management and external sources that may require data and information from the Facility.

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7.3.1.6

A single record for every patient is maintained with integrated recording system by healthcare providers.
A single record is a record that is a composite of all data on a given patient whether as an inpatient, ambulatory care or emergency patient. Their entire medical record is in one folder under one medical record reference number. The record of psychiatric patients shall be retained as according to statutory requirements.

Integrated record is a system of joint recording by various healthcare providers who record information around the patient (patient based) according to sequence of events.

1. A single record system is implemented for inpatient and outpatient.
2. Integrated records are practiced.

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7.3.1.11 CORE

The patient’s medical record contains documentation of patients’ valid consent for all procedures.

A valid consent may be dispensed with a surgeon believes that any delay caused in obtaining the consent would endanger the life of a patient, provided that a consensus of the surgeon and another registered medical practitioner is obtained and they jointly sign a statement stating that the delay would endanger the life of the patient.

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7.3.1.14

The medical practitioners, nurses and allied health professionals are responsible for the completeness and timely completion of medical records by ensuring:
Clinical history and examination are available within 24 hours of admission and prior to surgical procedures
Reports of operations or procedures are recorded immediately after completion of the procedure, dated and signed
All medical reports shall be completed by medical practitioner within 28 working days
All records are indexed and coded within one month of the patient’s discharge.

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FACILITIES AND EQUIPEMENT

Topic 7.4

Adequate physical facilities and equipment are available for the efficient operations of the HIMS Services.

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7.4.1.1 CORE

The facility is designed to facilitate safe and adequate storage, prompt retrieval, distribution and accessibility of medical records.

On site inspection of storage areas ensures records are stored safely.
Preventive measures for possible destruction of records by fire, water and pest.
Access control for authorized personnel.
Policy on distribution of medical records addresses the issues of confidentiality and security.

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SAFETY AND PERFORMANCE IMPROVEMENT ACTIVITIES

Topic 7.5

The head of HIMS Services shall ensure the provision of quality performance with staff involvement in the continuous safety and performance improvement activities of the HIMS Services.

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7.5.1.4 CORE

The tracking and trending of specific performance indicators :
1. Percentage of medical reports prepared within the stipulated period : <4 weeks
2. Percentage of case summaries that were completed within 72 working hours of discharge

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SPECIAL REQUIREMENTS

Topic 7.6

An accurate patient’s medical record is maintained to facilitate optimal patient care and allow for evaluation of the care provided.

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7.6.1.1

The patient’s medical record contains sufficient details to enable :
a. the patient to receive effective continuing care
b. effective communication among the members of the healthcare team
c. medical practitioners to have access to the information required for further consultation and treatment
d. another medical practitioner or other healthcare personnel to assume the care of the patient
e. carrying out concurrent or retrospective evaluation of patient care

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7.6.1.2 CORE

Entries into the records are made only by healthcare professionals of the facility. Each entry is dated with time and signed by the care provider with name and designation written down.

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7.6.1.3

All entries in the record including alterations to the record shall be legibly written in ink or typewritten or recorded on a computer terminal which is designed to receive such information and if recorded and stored in computer, it may be stored on in any device suitable for the storage data.

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7.6.1.4 CORE

Only the abbreviations and symbols which have been approved by the Medical Record Committee are used.

*Mesyuarat JK Rekod Bil.2/2024 bertarikh ………. - Ahli mesyuarat bersetuju abbreviation yang boleh digunapakai di Hospital Shah Alam ialah berdasarkan abbreviation yang dikeluarkan oleh KKM sahaja yang boleh didapati di laman web KKM.

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7.6.1.5

All original or copies of reports by medical, nursing and allied health professionals from whatever source of origin are filed in the patient’s medical record.

7.6.1.6

Entries to the medical record shall be timely and made in a way that prevent unauthorized alteration.

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7.6.1.7

Corrections which are dated and initialed by the author are only made to the medical record by the use of a single line through the incorrect entry. The correction is also put as close to the ‘struck out’ incorrect entry as possible, indicating that the correction is the intended and correct information. ‘White out’ or other types of correction materials or erasure of entries shall not be used to correct incorrect entries.

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7.6.2.2

The admission form is completed at the time of admission or when the relevant information is available.

7.6.2.3 CORE

An “alert” notation for conditions such as allergic responses and drug reactions shall be documented by the examining doctor and prominently displayed in the medical records and in the appointment card.

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7.6.2.4

The patient’s medical record contains on admission a written provisional diagnosis by the admitting medical practitioner.

7.6.2.5

The patient’s medical record contains patient’s history pertinent to the condition being treated, including relevant details of :
a. Present and past medical history
b. Family history
c. Social history
d. Examination, assessment including results of investigations
e. Observation
f. Treatment

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7.6.2.6

Drug orders are written directly in the drug prescription form in the patient’s medical record by medical practitioner.

7.6.2.7

Therapeutic orders and orders for special diagnostic tests are documented in the patient’s medical record.

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7.6.2.9

There is evidence that the care plans are documented in the patient’s medical record.

7.6.2.8

Progress notes, observations and consultation reports are written by medical, nursing and paramedical staff to record all significant events such as changes in the patient’s condition and responses to treatment. These are written as events occur with date and time and give a pertinent chronological repost of the patient’s progress.

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7.6.2.10

The medical practitioner records the preoperative diagnosis and there is an operative report immediately after surgery, including :
a. date, time and duration
b. description of the findings
c. the procedure performed

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7.6.2.11

The patient’s medical record contains information particularly relating to anaesthesia including:

Date, time and duration
Informed consent of anaesthesia
Evidence of a preoperative assessment by an anaesthetist, preferably by the attending anaesthetist
Drugs and doses given during anaesthesia and route of administration
Monitoring data
Intravenous fluid therapy if given
Post anaesthetic instructions, where appropriate
Name and signature of attending anaesthetist

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7.6.2.12

7.6.2.13

All diagnoses and procedure are recorded using relevant terminology of a current version of the International Classification of Diseases (ICD)

Discharge summary that is completed within 72 hours of the patient’s discharge ; a copy of which is filled in the patient’s medical record.

The discharge summary shall accompany the patient being transferred to another facility under the cluster programme.

The discharge summary are not allowed to be given to the patient.

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ALL THE NECESSARY NEEDED TO COMPLY THE STANDARDS

The knowledge of handling the medical records.
The importance of knowing the safe and confidentiality of medical records and documents both paper based and electronic related to patient care.

Thank you

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EMERGENCY CODES HSAS

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CODE BLUE

Dr Nareshiman Subramaniam-

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INTRODUCTION

Emergency codes are used worldwide to alert staff and members of the public for various emergency situations in hospitals

Minimize misunderstanding to the health care personnel

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There may be visitors, staff or patients that require immediate medical care in hospital, in cases such as cardiac arrest or seizure

Rapid response team will be deployed from the nearest clinical area then supported by an advance team if required

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TWO-PRONGED APPROACH

The response system is in 2 phases:

Initial response is by personnel in vicinity of patient-BLS trained

Secondary response is by a well equipped and trained team appointed by the hospital to respond to the particular area

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WHEN TO ACTIVATE CODE BLUE?

First person: public, not medically trained

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WHEN TO ACTIVATE CODE BLUE?

First person: public, not medically trained

Primary responder: Local BLS team

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WHEN TO ACTIVATE CODE BLUE?

First person: public, not medically trained

Primary responder: Local BLS team

Secondary responder: Emergency dept ALS team

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CODE BLUE EQUIPMENT

*primary responder

Gloves
Guerdel/Oropharyngeal airway
Bag valve mask
LMA
Stethoscope
Gouze, Gamgee
Crepe bandage

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CODE BLUE EQUIPMENT

*secondary responder

AED/Defibrillator
Oxygen tank and tubing
Bag mask valve/Pocket mask
Portable suction
Intubation equipment- laryngoscope/ETT
Intravenous drip setup- cannula, tubing, IV fluids
Syringes and needles
Resuscitation drugs
Stethoscope
Gloves

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No	MAIN BUILDING	Coverage Area
No	Primary Responder team	Coverage Area
1.	VVIP Ward	Level 13
2.	Pediatric Ward	Level 12
3.	Orthopedic Ward/ Satellite Pharmacy	Level 11
4.	Medical Ward	Level 10
5.	Surgical Ward	Level 9
6.	Obstetrics & Gynaecology Ward	Level 8
7.	CSSD/RHU	Level 7
8.	Operation Theatre	Level 6
9.	Intensive Care Unit	Level 5
10.	Maternity OT	Level 4 maternity waiting area
11.	Neonatal Intensive Care Unit (NICU)	Level 4 NICU waiting area
12.	Emergency & Trauma Department	Level 3, PAC and public car park in front of hospital, road leading to roundabout, Radiology department

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13.	Hemodialysis Unit	Haemodialisis unit waiting area and nearby corridor, Inpatient Pharmacy Department
14.	Pathology Department	Level 2 corridor nearby
15.	Administrative Office	Office area and Auditorium, Inpatient Pharmacy
17.	Quality Unit *After hour office and weekend: Emergency Dept	On call complex
18.	Psychiatry Clinic *After hour office and weekend: Emergency Dept	Cafeteria, Main Lobby, Revenue and Registration Counter, Mini Mart, Education Unit, Security Unit
	Public Health Unit	Counselling Unit, Library, IT Unit, Specialist parking
20.	Forensic Department	Dietetics Unit, area at the back of Hospital, Ambang Wira office
23.	Rehabilitation Unit *After hour office and weekend: Emergency Dept	Level 1 nearby corridor, Logistic Pharmacy, Main Lobby, Specialist Clinic Registration Counter, Specialist Clinic Pharmacy, Staff parking
Bil	Specialist Clinic Building	Coverage Area
Bil	Primary Responder Team	Coverage Area
1.	Rehabilitation Unit	Level 1
2.	Opthalmology/Surgical Clinic	Level 2
3.	Orthopedic/Medical Clinic	Level 3
4.	Pediatric/Obstetrics & Gynaecology Clinic	Level 4
5.	Oral & Maxilofacial/Otorhinolaryngology Clinic	Level 5
6.	Complex of Specialist Offices	Level 6

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AUDIT FORM

Only true method of tracking the volume and for future improvement

Must be filled up for each Code Blue encounter

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CODE YELLOW

PELAN TINDAKAN BENCANA

TUMPAHAN BAHAN KIMIA

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CODE YELLOW �Chemical Spill Disaster Action Plan

Pelan tindakan ini disediakan sebagai rujukan bagi mengendalikan semua jenis tumpahan bahan kimia berbahaya yang mungkin dihadapi oleh warga HSAS, untuk memastikan keselamatan pesakit, kakitangan, dan pengunjung hospital apabila berlaku insiden tumpahan bahan kimia.

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CODE YELLOW �Chemical Spill Disaster Action Plan

Pelan tindakan ini bertujuan untuk:

Melindungi keselamatan pesakit, kakitangan, pengunjung, dan persekitaran hospital.
Meminimumkan risiko dan kesan negatif daripada insiden tumpahan bahan kimia.
Memastikan proses tindak balas yang cepat, berkesan, dan sistematik.
Memastikan pemulihan dan pembaikan segera dengan mengekalkan kelancaran operasi hospital.

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DEFINISI

Bahan Kimia Berbahaya

Bahan atau sediaan yang berupaya menyebabkan kemudaratan sama ada melalui sifat fizikal dan kimia atau ketoksikannya.

Ia boleh wujud dalam bentuk habuk, gas, cecair, sebatian atau campuran; semula jadi atau sintetik.

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DEFINISI

Tumpahan Bahan Kimia

Kejadian di mana bahan kimia dikeluarkan atau tertumpah secara tidak terkawal dalam kawasan hospital, termasuk kawasan klinik, makmal, farmasi, bilik pembersihan, dan wad.

Insiden ini merangkumi apa-apa bahan kimia yang berpotensi membahayakan kesihatan, menyebabkan kebakaran, atau merosakkan peralatan dan persekitaran.

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DEFINISI

Risalah Data Keselamatan (Safety Data Sheet-SDS)

Dokumen yang menyediakan maklumat terperinci mengenai bahan kimia berbahaya
mengandungi 16 seksyen standard seperti yang ditetapkan oleh sistem GHS (Globally Harmonized System)

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Risalah Data Keselamatan (Safety Data Sheet-SDS)

Pengenalan produk dan syarikat
Pengenalpastian bahaya
Komposisi / maklumat kandungan bahan kimia
Langkah pertolongan cemas
Langkah-langkah pemadaman kebakaran
Accidental release measures
Pengendalian dan Penyimpanan

Kawalan Pendedahan / Perlindungan Diri
Sifat Fizikal dan Kimia
Kestabilan dan Kereaktifan
Maklumat Toksikologi
Maklumat Ekologi
Kaedah pelupusan
Maklumat Pengangkutan
Maklumat Peraturan
Maklumat Lain

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KATEGORI BAHAN KIMIA

The Globally Harmonized System (GHS) of Classification and Labelling of Chemicals

piawaian yang dipersetujui antarabangsa yang diuruskan oleh Pertubuhan Bangsa-Bangsa Bersatu (PBB)
ditubuhkan untuk menggantikan pelbagai jenis klasifikasi dan skim pelabelan bahan berbahaya yang sebelum ini digunakan di seluruh dunia

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KATEGORI BAHAN KIMIA

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KATEGORI BAHAN KIMIA

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KATEGORI BAHAN KIMIA

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BAHAN KIMIA LAZIM DIGUNAKAN �DI HOSPITAL�(Guidelines On Chemical Management In Health Care Facilities, 2010. Ministry Of Health, Malaysia)

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BAHAN KIMIA LAZIM DIGUNAKAN �DI HOSPITAL�(Guidelines On Chemical Management In Health Care Facilities, 2010. Ministry Of Health, Malaysia)

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Source: CHRA Findings (3rd & 29th Oct 2024)

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Source: CHRA Findings (3rd & 29th Oct 2024)

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KESIAPSIAGAAN MENGHADAPI KEJADIAN TUMPAHAN BAHAN KIMIA

Penaksiran Risiko
Langkah Pencegahan
Mengemaskini Pelan Lantai Hospital
Penyediaan Kit Tumpahan Bahan Kimia
Latihan
Mewujudkan Jawatankuasa Pengurusan Tumpahan Bahan Kimia (JK CODE YELLOW)

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Kit Tumpahan Bahan Kimia

Setiap Jabatan/Unit yang menyimpan, mengendalikan dan/atau menggunakan bahan kimia perlu menyediakan kit tumpahan bahan kimia di kawasan kerja.
Pastikan kit tumpahan bahan kimia yang ada di Jabatan/Unit masing-masing masih belum mencapai tarikh luput.
Kit yang sudah diguna pakai juga perlu diganti dengan kit tumpahan yang baru.

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Kit Tumpahan Bahan Kimia

Kit hendaklah disemak dan diselenggara setiap bulan bagi memastikan ianya cukup dan dapat digunakan jika perlu.
Kit hendaklah dilabel dengan jelas dan memastikan semua kakitangan di Jabatan/Unit maklum dengan ketersediaan kit tumpahan bahan kimia di lokasi kerja masing-masing.

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JAWATANKUASA CODE YELLOW

Satu pasukan yang ditubuhkan untuk menangani insiden melibatkan bahan kimia berbahaya.
Bertanggungjawab merancang, menyelaras, dan memantau tindakan pengurusan tumpahan bahan kimia bagi memastikan keselamatan pekerja, pesakit, pelawat, aset serta persekitaran hospital.

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PERANAN UTAMA JAWATANKUASA CODE YELLOW

Menyediakan Pelan Tindakan Kecemasan yang merangkumi prosedur tumpahan bahan kimia.
Melaksanakan latihan kepada semua kakitangan berkaitan pengurusan tumpahan bahan kimia serta mengadakan simulasi (drill) secara berkala.
Memastikan penyimpanan bahan kimia mematuhi piawaian keselamatan.
Melakukan pemeriksaan berkala terhadap peralatan kecemasan seperti alat pelindung diri (PPE), pancuran keselamatan, dan penyerap tumpahan.
Menyiasat insiden tumpahan dan memastikan tindakan pembetulan dilaksanakan.
Merekod dan menyimpan semua laporan berkaitan insiden.

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KLASIFIKASI TUMPAHAN BAHAN KIMIA

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