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Call us: 012 808 0940   ED: 012 808 0911

KAUST Health Policies and Procedures

Management of Referrals
  • All referrals will be made to a named service and not to a specific physician, unless it is deemed necessary or beneficial for the patient health outcome by the referring physician
  • All external referrals shall be routed through the KAUST Health Referral Coordinator

Booking for a referral:

For the internal referral:

  • The nurse will book the patient directly with the needed service or via receptionist and pass on the insurance information to that specialty clinic nurse, if applicable

For external referral to (DSFH facilities):

  • The nurse will direct the patient to the referral coordinator who will follow the attached guidelines
  • The Referral Coordinator will prepare a copy of any related medical investigation results (e.g. lab & radiology reports) as required and provide them to the patient to take to their referral appointment
  • Non- Urgent: within 72 hours
  • Urgent: Within 24-48 hours

Referral Feedback:

  • On the next visit, the physician will ask the patient about referral feedback reports
  • Any report will be handed to the medical record technician by the receptionist to be scanned
  • To insure continuity of care the healthcare provider responsible for the patient’s care needs to be clearly identified in the electronic medical records (EMR)
  • Each appointment visit will have a KAUST Health healthcare provider that has been identified in the EMR during the appointment and registration process
  • The patient has the right to choose the KAUST Health healthcare provider during the appointment and registration process. All efforts will be made to accommodate the request.
  • The responsible KAUST Health healthcare provider may be different with each visit depending on the assigned doctor for the visit
  • There is no one specific KAUST Health healthcare provider responsible for the entire care of the patient
  • All KAUST Health patients who wish to be seen by a physician to get a service at outpatient, emergency room must be registered to the Health Information System
  • Unique identifier will be created for each patient during his/her first visit at the KAUST Health, the medical record number with the patient’s full demographic details
  • The issued medical record number shall be identified with a computer generated serial number unique to each patient and shall be used for the subsequent visits
  • General consent will be obtained by the receptionist at the registration points and form should be signed by all patients or their legal representatives once only during their first visit to the clinic

Registration:

  • At first encounter at KAUST Health whether in Emergency Room or at outpatient clinics, every patient must complete the registration process at the reception areas. By completion of the required demographic data “Electronic Patient Profile digital form” that includes:
    • Patient's full name i.e. (patient name, father name, and family name)
    • Gender (Sex)
    • Patients’ National Identification Number for Saudis and (Resident ID / Passport) “Unique Identifier”
    • Patient's Phone number (Mobile, home and work)
    • E-mail address if available
    • Patient’s Nationality
    • Patient’s KAUST ID
    • Contact details of designee and to be registered under additional information on YASASII

Signing the general consent form:

  • Upon registration on the first visit, a copy of the 1. KAUST Health Patient rights and responsibilities statement will be given by the registration staff to each patient, and will answer all patients’ inquiries about their rights and responsibilities 2. Welcome to KAUST booklet which includes KAUST Health Scope of Services/Working hours/Contact information, etc.
  • The patient or his/ her legal representative should complete and sign the general consent form. This consent will be obtained once during the first visit upon registration

Booking registration:

  • Patients calling for booking an appointment through the central booking and do not have medical records, will be asked for full information required for registration similar to the normal registration procedure, and will be given a “registration number” that will be used by the patient later on during his/ her 1st visit to the KAUST Health, patients will come to Registration customer service officers and complete the registration of the medical file and will sign the general consent and will be given their medical records numbers

Newborns in KAUST Health:

  • Receptionist will open medical file for the patient under the mother information, patient will be named “Baby of ***”. Until the new born has an ID (passport, National ID or resident ID) then the receptionist will replace “Baby of***” with the patient’s full name

The Physician-Approved Medical Taxi is available for KAUST eligible personnel and their dependents.  KAUST eligible personnel include the following:

  • KAUST employees and their dependents
  • KAUST students and their dependents
  • KAUST faculty and their dependents
  • KAUST Post Docs and their dependents
  • Patients who do not qualify for the Physician-Approved Medical Taxi will be assisted in arranging a taxi, to be paid for by the patient, if requested
  • The decision to use a Physician-Approved Referral Taxi is based on the decision of the KAUST Health physician and the acuity level of the patient
  • For a patient seen in the ER, the ER nurse will provide documentation for the patient to bring on the disposition of the patient within the patient’s medical record
  • For a patient seen in the Out-Patient Department (OPD) and authorized by the physician for a Physician Approved Referral Taxi, the OPD nurse will provide a referral letter from the physician

The ER/OPD nurse ensures the patient is given the following before leaving KAUST Health:

  • Medical report with discharge summary from the ER physician / Referral letter from the OPD physician
  • Information that this is a one-way taxi only with the advice given to the patient to consider arrangements for the return trip back to KAUST
  • All appointment requests received from outside the clinic are made through the Central Booking unit
  • Internal referrals/requests may be made in each clinic’s reception
  • There are several clinical departments wherein bookings are made through their respective departments and reception such as Dental, Physiotherapy and Radiology appointments
  • SMS notifications are sent to the patients’ mobile number upon booking appointments
  • Patients will call 0128080940 when using a mobile number and 940 when using a KAUST Landline

Cancelling appointments:

Patients may cancel their appointment through the following means:

  • Call center
  • H-connect
  • Any reception area
  • E-mail address

Dental Appointments:

  • The slots will be booked as per timing needed for procedures

Dental Hygienist Appointment:

  • All patients who are to receive scaling, root planning, or prophylaxis at KAUST Health should have an oral examination, including a periodontal examination, by a dentist at least once per year
  • Those patients who have not had a dental examination in the past year will be appointed for examination by a dentist before their scheduled appointment for scaling, root planning, or prophylaxis

Late Patients:

  • Patient will be considered late if he or she comes late up to 9 minutes from the appointment time for all the Outpatient clinics
  • If patient is seen by the doctor, the doctor will explain to him/ her that he/she will have care only for the remaining time for the appointment slot

No Show Patients:

  • Patient is required to cancel or change a scheduled appointment up to a minute before the appointment. Otherwise, will be considered No show if they do not attend
  • A failure to present at the 10th minute of a scheduled appointment will be recorded in the patients as a “no show”
  • It is the policy of KAUST Health that any ambulance transport service provided conforms to the highest standards in meeting patient care needs as well as meeting Ministry of Health (MOH) and accreditation standards
  • A decision to transfer a patient, the mode of transport, and the skill set of the transfer crew is the responsibility of the Emergency Room (ER) physician
  • The patient and family members are informed of need to transfer to secondary care and verbal consent will be acquired and recorded by the ER physician in the EMR medical record
  • The ER physician will speak with the physician in charge at the receiving hospital to transfer the case. The receiving physician will be given a full verbal description of the patient’s condition. At that time advice can be requested on any treatment needed before transfer
  • The patient and family members are informed of the planned transfer date and time
  • In case the clinical needs of the transferred patient warrants medical care at a medical center with a higher level of care than KAUST Health, the decision to which medical center to transfer the patient will be determined by the ER physician and will be based mostly on the acuity and severity of the patient’s clinical situation and patient and family involvement in the decision making
  • The new appointment should be made as soon as possible and preferably before the next doctor’s appointment if possible
  • Patients will be seen as per their appointments with the exception of urgent cases
  • Report and CD are provided upon the request of the patient or treating physician
  • Many patients with acute pain, such as children and adults with coexisting medical conditions, have special needs. Specialized technology is often required to relieve pain. Chronic pain has a huge impact on the individual and society as a whole. It is the primary reason for delayed recovery. Most chronic pain problems start with an acute nociceptive pain episode. Therefore, effective early care is paramount in managing chronic pain. Given the importance of pain in healthcare, it is presently the subject of intensive scientific research which in turn has generated a growing evidence base regarding the diagnosis, treatment and management of painful conditions

Pain Screening:

  • Screening for pain is performed by healthcare staff during each visit
  • The staff select the appropriate standardized scale to assess the patient’s pain intensity, depending on the patient’s ability to express their pain. All scales are designed to rate pain using the 0-10 concept with “0” representing no pain and “10” representing worst pain experience
  • Water quality from the dental chair shall be assessed on monthly basis
  • Cleaning, Sterilization and disinfection of dental instruments are done in dental CSSD
  • KAUST Health is not liable for loss of, or damage to, personal property occurring on KAUST Health premises as a result of negligence on the part of the owner
  • All found items to be turned in to Patient relations during regular working hours, after hours it can be placed in safekeeping with the ER
  • All patient or visitor inquiries about a lost item, are referred to the Patient Relation Coordinator during regular business hours
  • All found articles are placed in a clear plastic bag or envelope and marked with the owner’s name and contact details (if known), date and area found
  • Patient items left behind in any areas such as ER/lab/Rad where ownership of the found object is known – ER personnel are to contact the patient directly. If the patient is unable to pick up an item that day, please forward to the Patient Relation coordinator during regular business hours
  • When a lost item is received, attempt to locate the owner by:
    • Observing any identification found on the lost item and make contact if details are available
  • All found items are tagged with the date and area where the item was found and then stored in the secured Patient relation Lost and Found locker
  • For Expensive jewelry, cellular phones, other valuable electronics, and prescription glasses, the Patient Relations coordinator contact security department at 922, to collect the items ASAP for safe keeping or disposal (within 24 Hours)
  • Medication: Will be handed over to the Pharmacy immediately
  • Non-valuable items: items include clothing, hats, gloves, scarves, clean beverage containers and sunglasses will be turned over to KAUST Housing Office Lost & Found desk (within 24 Hours)
  • Keys: will be turned over to the KAUST Housing Office (Lost & Found desk)
  • Illegal or illicit items: will be turned over to KAUST Security immediately
  • Library books: will be returned to designated libraries straight away

Claiming items or the release of thing

  • Individuals who claim their things must do so in person and provide a valid ID 
  • If you are not able to collect the item in person, a representative may be appointed, but they may be required to provide a letter of permission from the owner
  • KAUST Health promotes good health and is committed to raising awareness of the dangers of smoking, passive smoking, and its associated risks
  • The NO Smoking Policy seeks to guarantee all employees, patients, visitors, and contractors the right to work in an air free of tobacco smoke
  • Tobacco smoking includes cigarettes (manufactured or otherwise), cigars, tobacco pipes, and bubbly smoke devices, and e-cigarettes
  • To reduce the impact of smoking on patients, visitors and staff KAUST Health regularly host smoking cessation programs to encourage smokers to stop
  • Smoking is a significant contributor to the starting of uncontrolled Fires
  • The use of tobacco products is prohibited in all part of KAUST Health facility except in the designated smoke area, located at the south end of the building

Disciplinary Action:

  • Visitors and patients are informed by KAUST Health staff, that if they don't adhere to the KAUST Health No smoking policy, they will be requested to leave the facility
  • KAUST Health administration will take appropriate disciplinary action against any person that violates for further action
  • Security personnel will be notified and asked to escort the person from the facility, if necessary
  • Smoking is only allowed in designated smoking areas, identified by “Smoking Area” sign. Smoking near an open window or doors are not permitted. Smoking is also not permitted within a radius of at least 8 meters from the building
  • All employees of KAUST Health have the right to a safe, secure and violence-free work environment. KAUST Health recognizes this right and acknowledges that nothing is more important than the safety and security of its employees and patients
  • KAUST Health’s prohibition against violent, threatening, or intimidating behavior applies to all persons involved in its operations. As such, KAUST Health shall protect its patients, staff, and visitors against acts of violence, threatening or intimidating behavior that may occur in the work environment
  • KAUST Health has established a policy that offers “zero tolerance” for actual or threats of violence against co-workers, patients, visitors, or any other persons who are either on our premises or have contact with employees in the course of their duties

Workplace Violence: Workplace violence is defined as actions or words that endanger employees or result in employees having a reasonable belief that they are in danger.

Such activities include:

  • Verbal or physical harassment
  • Verbal or physical threats
  • Assaults or other violence
  • Any other behavior that causes others to feel unsafe (e.g., bullying, sexual harassment

Escalating any reported violations with Human Resources and adopting an evident zero tolerance for workplace violence.

  • It is the policy of KAUST Health that ensure all patients are identified correctly prior to any procedure, treatment, administration of blood or medication, or specimen collection
  • KAUST Health uses 2 unique identifiers for every patient
  • Upon the initial visit and any subsequent visit to KAUST Health it is essential that the patient is identified correctly
  • At the point of registration to the clinic or Emergency Room, patients wishing to register for care and open a file must provide an approved means of identification to the KAUST Health reception staff. Accepted documents for registration are:
    • Mandatory documents: Passport or Iqama (Saudi residence permit) Or Hafiza (Saudi National ID)

General patient identification procedures:

  • Stating their full name (at least 3 names; first name, father’s name and family name except some nationalities who only have 2 names in their passport). Names must not be abbreviated
  • KAUST Health Medical Record Number
  • National ID/Iqama ID
  • Passport Number
  • Date of Birth

Creating and applying an ID Band:

  • All ER patients will be required to wear an ID band
  • The ID band will be created and applied in the ER triage room or applied at the bedside if the patient is too unwell to be seen in the triage room

Removal of ID band:

  • The ID band must remain on the patient during their stay in the ED and only be removed as part of the formal discharge process
  • To outline standardized procedure of hand hygiene at KAUST Health thereby providing a high level of protection to patients, healthcare workers (HCW) and visitors against healthcare-associated infections (HAI) and their related events
  • Hand hygiene: A general term that applies to hand washing, antiseptic hand wash, antiseptic hand rub, or surgical hand antisepsis. Hand hygiene remains as the single most effective measure in reducing and preventing healthcare-associated infections
  • Hand washing: washing hands with plain soap and water
  • Alcohol-based hand rubs: an alcohol-containing preparation designed for application to the hands for reducing the number of viable microorganisms on the hands which should be at least 70% alcohol
  • Antiseptic agent: Antimicrobial substances that are applied on the skin to reduce the number of microbial flora. Examples include alcohols, chlorhexidine, chlorine, hexachlorophene, iodine, chloroxylenol (PCMX), quaternary ammonium compounds, and triclosan
  • Antiseptic hand wash: Washing hands with water and soap or other detergents containing an antiseptic agent
  • Surgical hand antisepsis: is an antiseptic hand wash or antiseptic hand rub performed preoperatively by surgical team to eliminate transient flora and reduce resident hand flora. The recommended time for surgical hand washing is 2-5 minutes
  • Unnecessary touching of surfaces in close proximity to the patient during the delivery of healthcare is avoided to prevent both contamination of clean hands from environmental surfaces and transmission of pathogens from contaminated hands to surfaces
  • Hands are washed with antimicrobial soap or water when visibly dirty, contaminated with proteinaceous material, when it is visibly soiled with blood and body fluids or when contact with patient and patient’s environment positive with spore forming organisms. (e.g., Clostridium dificille)
  • If hands are not visibly soiled, decontaminate hands with alcohol based hand rub
  • Wash hands with non-antimicrobial or antimicrobial soap and water if contact with spores is likely to have occurred
  • A patient who is conscious and has decisional capacity or legal guardian of minor has a right to refuse any medical care. The treating physician shall advise the patient of the risks involved in discontinuing treatment or refusing investigations and encourage the patient to continue in his or her prescribed course of medical treatment
  • If the patient insists on his/ her choice, the physician must document that patient was advised against discontinuing treatment, and should get the patient’s signature as acknowledgement of the patient’s awareness of the risks on the Refusal Form
  • Informed consent: Agreement or permission accompanied by full information on the nature, risks, and alternatives of a medical procedure or treatment before the physician or other health care professional begins the procedure or treatment. After receiving this information, the patient then either consents to or refuses such a procedure or treatment. Any adult, male or female, defined by a legal age of eighteen (18) Hijra years or older for Muslims, or eighteen (18) Gregorian years or older for non-Muslims whose countries follow the Gregorian calendar, may sign for themselves, except in special situations (listed below) where the approval of another party is required:
    • Minors (i.e. patients under the age of eighteen (18) years
    • Mentally incompetent patients
    • Temporarily incompetent to make decisions, i.e. unconscious, comatose, in severe pain
  • Emancipated Minor:  a person younger than 18 years of age who is free of parental care and is financially responsible for himself or herself
  • The attending physician has to advise the patient of the potential consequences of discontinuing medical treatment. The attending physician should convince the patient to stay and receive treatment. If after this discussion the patient still decides to refuse the treatment the attending physician will ask the patient to read and sign the Against Medical Advice (AMA) Form
  • If the patient refuses to sign the Against Medical Advice (AMA) Form, the attending physician or nurse has to read the form to the patient and document the patient's refusal to sign the form in the progress notes. One staff member shall also sign the Form to prove that the patient decided to leave after being informed of the possible consequences of such a decision as witness
  • Patient Relations will then follow up with the patient to facilitate any further care required within the next working day for non-urgent life threatening cases

For non-life threatening cases requesting AMA:

  • If an adult patient or the patient’s representative still insists on AMA discharge/refuses care, the matter shall be referred to the Patient Relations department during administrative hours for any additional assistance required
  • Follow-up care or an appointment should be arranged and adequate supplies of medicines should be provided so ongoing medical care is not compromised before the patient leaves before AMA.  ER nurses will coordinate the follow up care

For life threatening cases requesting / insisting for AMA:

  • If an adult patient or the minor’s guardian/ legal representative or substituted decision maker (SDM) insists on AMA, the appropriate service e.g. pediatrician, OB/GYN and or the Chief of Staff must be referred to during administrative hours and after administrative hours
  • The patient and or the minor guardian will be seen by the referred physician.  Every effort will be made through regular discussion, the involvement of senior staff, KAUST Health Director and of necessary escalated to the VP, Community Life if the patient is still insisting on AMA
  • Parents/patients’ mental capacity should be assessed should by the primary physician to assist in the decision process to establish whether the patients has the mental capacity to make such a decision.  Any such decision should be documented
  • Medication prescriptions would be refilled AND coordinated by the family medicine department
  • Medication refills for medications prescribed by other specialties including Pediatrics and Ob-Gyn will be forwarded to the appropriate departments to review and complete
  • Applies only to medications previously prescribed by a KAUST Health doctor
  • The medication refill process will not include controlled, narcotic medications or acute care medications
  • Patient request will be processed by the refill team from Sunday to Thursday between 8am and 5pm and takes 3 working days to be processed
  • Patient initiates medication refill request not more than a week before their last refill is due to finish by sending a request to KAUST Healthrefill@fakeeh.care with the following details:
    • Patient name
    • KAUST Health medical record number
    • KAUST ID
    • Contact number
    • Medication details (Name, Dose, Frequency and Duration)
  • All completed medication refill requests are then forwarded to the pharmacist who liaises with the insurance coordinators for the approval of the prescribed medication
  • If approved, the pharmacist will prepare the requested medication within the allotted 3 days
  • The pharmacist can keep the medication for up to one week. After this period the medication is no longer available and the patient will need to initiate another refill request
  • If the medication is not approved or available, the pharmacist will inform the patient directly when the patient comes to collect their medication. The patient will then need to liaise with their respective insurance providers regarding approval of their medications
  • As we are the only healthcare provider in the community, sometimes we identify needs for patient care that no one else can provide
  • External physicians: a physician who is practicing in a facility outside of KAUST Health. This includes DSFH. It also includes clinical scenarios whereby a visiting specialist who is primarily based at a facility outside of KAUST Health, but who has scheduled outpatient clinics at KAUST Health and has seen the patient previously but is not on site to provide the prescribing and administration request of the patient at the time that the patient presents to KAUST Health

Patient Requesting Medication Prescriptions:

  • A patient requesting prescription and supply of a medication originally prescribed by an external physician, or requesting that a medication prescribed but not dispensed at DSFH or any other Health Care facility outside of KAUST Health be dispensed at KAUST Health, should make an appointment with a KAUST physician in the relevant specialty
  • The patient should provide a Medical report and external prescription, where possible, from the external physician explaining the diagnosis and the management plan
  • The consulting physician should establish the indication for the medication as determined by the external physician. The consulting physician should decide within the limits of their competency and privileges if they are qualified and willing to prescribe the medication
  • If the physician decides not to proceed to prescribing the medication then he/she may suggest an alternative therapy if clinically appropriate or should advise the patient to return to the external physician or refer/direct to an alternative qualified specialist

Patient Requesting Administration of Medication Already In Their Possession:

  • A patient might present to KAUST Health (outpatient or ER) with a medication provided by an external physician and request administration of the medication by clinical staff of KAUST Health. These patients should provide evidence of the external prescribing physician’s order which should be scanned onto the patient medical record
  • The medication shall not be administered in KAUST Health without a KAUST Health physician order issued and recorded in the patients’ medical record by a KAUST physician in the outpatient department or in the ER
  • If the physician decides not to proceed to issuing the order to administer medication then he/she may suggest an alternative therapy if clinically appropriate or should advise the patient to return to the external physician or refer/direct to an alternative qualified specialist

Storage of External Medication:

  • Medicines originally prescribed and dispensed by an external provider shall not be stored at KAUST Health. It is the patient’s responsibility to store and transport the medicines as per manufacturer instructions

Monitoring:

  • If the medication requires monitoring (including clinical response, biological markers, and radiological response) then the patient and the physician must agree on a plan for the monitoring and identify who the lead physician responsible for acting upon the results is

The purpose of Adverse Drug Reaction (ADR) reporting program at KAUST Health are to:

  • Promote reporting, and documentation
  • Prevent or minimize the occurrence and the extent of harm and injury that results from ADRs
  • Provide information to physicians on ADRs in order that regulatory action can be taken based on the ADRs received and an appropriate care can be delivered
  • Provide a mechanism for monitoring the safety for drug use
  • Participate and contribute towards ADRs reporting system mainly to Ministry of Health (MOH)
  • Encourage post marketing surveillance of drugs
  • An ADR may or may not be a medication error and does not necessarily reflect poor patient care
  • ADR will be submitted to Saudi Food and Drug Authority by assigned pharmacist
  • Adverse Drug Reaction (ADR): Any response to a drug which is noxious and unintended, and which occurs at doses normally used in man for prophylaxis, diagnosis, or therapy, or for the modification of physiological function.  (Definition of World Health Organization)
  • ADR history shall be obtained from the patient before medications ordering by the attending physician and recorded in patient EMR
  • All KAUST Health and DSFH staff members are responsible for the privacy of the patient and the confidentiality of his/her information.

All requests for release of information must:

  • Specify the data to be released, the dates of the episodes of care of which the data will be released and who will be receiving it; his/her full name, relationship and contact details be signed by the patient and/or their designated SDM 
  • Completed and signed requests for release of patient information must be submitted in person or through the designated e-mail (Patient-Relations@KAUST.EDU.SA) to the Patient Relations Office on the official Authorization for Release of Information form (form 1)
  • Only the following can be released to the patient or his/her authorized person: Medical reports, Sick Leaves, Diagnostic investigation results and reports
  • No authorization needed from the patient for release of medical data for; healthcare provision activities, quality improvement activities and reporting to the governmental agencies of incidents of public health or public safety issues
  • Any release of information to governmental agencies and or the Media needs the involvement and approval of the KAUST Health Director
  • Any violation of the patient's right to confidentiality and the security of their healthcare related information will be subjected to investigation and disciplinary action, as per KAUST Health Rules and Regulations

Release of Information of Medical Data from KAUST Health:

  • Any individual requesting medical data related to his/her medical care will fill and sign a “Consent For Release of Patient’s Medical Reports and Medical Information Form”. This is available by email from Patient-Relations@kaust.edu.sa or can be picked up in person from the Patient Relations office
  • The following services will be ready in one to three working days where possible upon the time of receiving the request. Some of the tests/reports may take longer
    • Outpatient Attendance and Sick Leave Report
    • Copies of Investigation Results (X-Ray & Lab. Results)
    • Comprehensive Medical Report

Summary for exit Medical Report:

The form includes:

  • Patient's full name, address, gender and KAUST ID
  • Name of the individual receiving the information and their National Identification number
  • Write “self” if the person receiving will be the patient him/her self
  • Type of information that the patient requesting “Medical report, summary report, sick leave form, Radiology CD and Reports, and Lab results and reports.
  • If the patient will not be receiving the medical data themselves, they should clearly state that
  • The name of the designated person, his/her official National Identification and the relationship to the patient
  • Purpose or need for the information
  • Nature of the information to be released, including exclusive dates of treatment
  • Signature of patient or legal representative
  • If the release of medical data is requested by e-mail, the requestor should:
    • fill and sign the form completely
    • Scan it after signature
    • Scan the national ID or passport or Iqama for non-Saudi and KAUST Health Medical Record card
    • Forward the signed scanned documents above back to the Patient Relations to the Patient Relations Office by e-mail to Patient-Relations@kaust.edu.sa
  • In case the patient is a minor, his/her substitute decision maker’s authorization and signature must be obtained on the form and the patient's and substitute decision maker's IDs MUST be presented
  • When the patient or his/her designated person receives the requested medical data, he/she needs to show official ID and sign for receipt
  • If the information requested is not picked up by patient or designee within 14 days, the medical data will be returned to Medical Records for filing for three months. If the information requested is not picked up by patient or designee after 3 months, the Medical Records Officer will destroy these papers

Release of Information from other Health Organizations:

  • If the data or information requested is owned by DSFH in Jeddah, the official Authorization for Release of Information Form for DSFH will be required to be completed and signed.  This form is available by email from Patient-Relations@kaust.edu.sa or can be collected in person from the Patient Relations office at KAUST Health
  • If the data or information requested is owned by another health care organization (e.g. International Medical Centre (IMC)); the requestor will have to provide consent for release of information directly to that specific organization using their Release of information form

Release of Information to the Employer/Human Resource Department:

Employee Medical Queries are limited to the Human Resource’s  (HR) request for information regarding his or her employee's work limitation and or duty status, the response to such queries is confined to work related health aspect of the employee's condition and any KAUST Health employee receiving such requests will direct the request to the KAUST Health occupational Health Physician

 

Release of Information to share with KAUST School or Psychology Clinic at KAUST (HWC program):

  • The release of patient Medical Information to KAUST school or HWC needs to fill an authorization form by the patient/ the guardian & should be signed to ensure agreement for sharing the information

Release of Information required by MOH:

  • The release of patient Medical Information to the MOH as required by law for infectious and communicable diseases will be done by the Infection control practitioner. KAUST Health administration will be notified of any communicable disease (Class I and Class II) 

Release of Information required not covered by law and regulations:

  • Any request of patient information from a third party not covered by law and regulation shall be raise to Chief of Staff and KAUST Health Director for approval
  • After the request has been approved, Patient Relations Officer will contact the patient to grant permission by filling the Consent for release of patients medical reports and medical information form 

Release of Original Medical Records outside KAUST Health:

Medical records hardcopies shall only be released from the KAUST Health facilities after approval of the KAUST Health Director if requested by one of the following:

  • The KAUST legal department upon advice confirming the tender of a properly issued subpoena or court order
  • KAUST Government Affairs services department upon advice confirming of a request for information from the Saudi Arabian Government 

Medical Reports for Outpatients:

  • The Medical report (MR) is requesting b the requestor by completing a form in Patient Relations Office
  • The assigned physician has the right to request to see the patient if further information is required to complete the report

For Medical Reports requested in Arabic (mostly for governmental purposes):

At KAUST Health all medical reports are released in English. If the patient needs the report written in Arabic then he will be advised to take the report written in English to an official & authenticated translation office to be translated to Arabic. For KAUST Health employees & student, the service is available to them though the KAUST Government Affairs office.
  • To ensure the privacy and confidentiality of electronic communication among KAUST Health staff & electronic communication between patients and KAUST Health staff
  • To ensure the patient’s right to review his/her electronic medical record related information   using secured DSFH information system
  • To inform and facilitate the access of patients to their health information and released health records and booking appointments with physicians at KAUST Health
  • To ensure that patient information is released to patient only or his/her guardian with using valid activation PIN code

H – Connect:

Patient will be consented for using H – Connect when he /she 1st registers to KAUST Health. Registered Patient will visit H - connect through DSFH website.  https://kmchconnect.fakeeh.care.

Steps for Creating account on H – connect:

  • Patient will enter the Medical Record Number
    • In  case  the  patient  doesn’t  have  the  Medical  Record Number,  Patient  cannot  be  registered  on H - connect
    • If Medical Record Number is valid, the system require ID Type (Iqama, KAUST ID, Passport, etc)
  • Patient will enter the ID Number
  • Patient will enter the Username and Password
  • Patient will accept the terms and conditions at the time of signing the General Consent Form (see form 1) for Patient Portal
  • Patient will receive PIN code on the mobile phone number that is already registered in the patient Electronic Medical Record
  • Patient will enter the username and password for accessing H - connect services
  • H - connect is capable of providing complete audit trial of all key activities performed

Email:

For Minor:

  • Patient’s Father
  • Patient’s Mother
  • Patient’s Paternal Grandfather
  • Patient’s Brother
  • Patient’s Uncle

For Mentally Incompetent Male Patient:

  • Patient’s Father
  • Patient’s Paternal Grandfather
  • Patient’s Son
  • Patient’s Brother
  • Patient’s Paternal Uncle

For Young Wife (under 18 years of age):

  • Patient’s Husband
  • Patient’s Father
  • Patient’s Paternal Grandfather
  • Patient’s Brother
  • Patient’s Paternal Uncle

For Mentally Incompetent Female Patient (under 18 years of age):

  • Patient’s Husband
  • Patient’s Father
  • Patient’s Paternal Grandfather
  • Patient’s Son
  • Patient’s Brother
  • Patient’s Paternal Uncle
  • To delineate the steps needed to follow Saudi Arabia regulations of reporting notifiable cases that are diagnosed or suspected within KAUST Health Clinic
  • To provide documentation and monitoring of the process of reporting notifiable cases
  • To delineate steps that would enable Saudi Arabia health authorities to:
    • Promptly identify public health problems or conditions
    • Provide optimal care and follow up of patients and their contacts with prompt application of appropriate precautionary measures to prevent spread or transmission of contagious disease
    • Gather enough information on the incidence and prevalence of a notifiable communicable disease or condition necessary to control and/or eradicate them
    • The notifiable cases to be reported are determined by Ministry of Health (MOH) mandates and are dependent on MOH case definitions for communicable diseases
    • Confidentiality of patient information shall be maintained throughout the reporting process
  • On a monthly basis or if a dental unit is not in use for more than 7 days water samples for culture will be taken from the KAUST Health dental units by dental assistant staff
  • Evaluation of microbial testing shall be based on  Center for Disease Control  (CDC) and American Dental Association (ADA) for quality of dental unit water reference standards namely that coolant water used in non-surgical dental procedures ≤ 500 colony forming units of heterotrophic bacteria per milliliter of water (CDC 2003 & ADA 2012)
  • The dental units will be disinfected on a minimum of a monthly basis (or whenever recommended by infection control coordinator) by the dental assistant staff using only approved solution. Only competent dental assistants shall be allowed to perform this procedure
  • To provide guidelines in preventing the spread of disease and outbreaks involving toys and to ensure that toys and play area are cleaned and disinfected on a regular basis
  • Toys brought in by families must not be shared
  • Cleaning of the play area will be the responsibility of the housekeepers and will be logged on a daily basis
  • Play area will be cleaned and disinfected every two hours
  • If a patient with suspected or obvious droplet or airborne precaution symptoms uses the play area, pediatric or emergency room staff nurse will immediately isolate the used toys and calls the housekeeper to do cleaning and disinfection of the area
  • If any toys are “mouthed” by a patient, these toys are to be cleaned after use

Play areas:

  • Play areas are cleaned on a daily basis every 2 hours or if there’s a need to
  • High touch areas are cleaned and disinfected regularly every 2 hours
  • Deep cleaning of the play area done on weekly basis

Toys for isolation Room:

  • Toys will be disinfected with approved disinfectant before and after use in the isolation room
  • If toys with porous surfaces (e.g., stuffed animals) that cannot be effectively cleaned are given to children in isolation, these toys must be kept by the child and taken home upon discharge or discarded

Books and posters:

  • Pages laminated and easily cleaned
  • Wipe with approved disinfected after each use

All staff exercise at all times to the utmost extent the principles of standard precaution to ensure safety of all staff, patient and visitors. All staff comply with the implement the following practices:

  • Hand hygiene Proper donning and doffing of Personal Protective Equipment (PPE)
  • Standard precautions
  • Respiratory hygiene
  • Implementation of transmission-based precaution
  • Proper waste management
  • All equipment disinfected following the guidelines outlined in the equipment care policy
  • Linen management 
  • KAUST Health health care providers ensure appropriate patient and family education that helps patients/families better understand and participate in their care and make informed decisions using appropriate and evidence-based knowledge, materials and educational resources
  • KAUST Health health care providers will assess patient and family education and learning needs and how the learning can best occur, taking into account patient’s and family member’s health care literacy, educational level and language skills, emotional barriers and willingness to learn, physical and cognitive limitation, religious, cultural values and learning preferences
  • Patient and family are encouraged to ask questions and to speak as an active participant in the education process
  • KAUST Health Health promotion specialist plans annually for community teaching activities based on community health profile from KAUST Health Health Information System (HIS) of the most common disease in KAUST, World Health Days, and may consider the request of patients through social media campaigns, and as per healthcare providers’ recommendations

Topics / teaching interventions may include but are not limited to subjects such as:

  • Patient rights and responsibility
  • Plan of care, treatment and procedures
  • Medical condition
  • Basic health practices and safety
  • The safe and effective use of medications
  • Safe and effective use of medical equipment or supplies when provided by KAUST Health (e.g. Wheelchairs, Crutches, Inhalers, Glucometers etc.)
  • Rehabilitation techniques to help them reach maximum independence possible.
  • Nutrition Interventions
  • Dental health
  • Immunization information
  • Lactation Support
  • Pain management/Coping mechanisms
  • Health maintenance and disease prevention
  • Smoking Cessation interventions/support

If the patient is not able to understand English, healthcare provider shall arrange an interpreter as per the Translation and Interpretation policy. 

Educational resources and materials

Educational materials will be provided to patients to facilitate teaching and patient’s understanding if needed and consistent with patient/family’s learning preference (e.g. procedure preparation, disease management information etc.).
  • To ensure that all patient care information will be provided to the patient and/or his/her family in a language they can understand and thus assist in the involvement of the patient in their care management and facilitate informed decision-making
  • Confidentiality should be maintained at all times 
  • In the event where interpreter is not on the list of the KAUST Health List of Interpreter/Translator, a website link of the list of embassies, which can be, contacted to assist in translation is available
  • The patients presenting to the KAUST Health shall be notified of their right to interpreter services at no charge for medical communication if needed
  • A list of volunteer KAUST Health staff as interpreters of different languages other than English is available at each reception and triage room of each department
  • Whenever appropriate, patient’s verbal consent should always be obtained prior using an interpreter except during emergency situation
  • Whenever possible, staff volunteer interpreters should be the first options for providing interpretation. A family member or friends may assist with providing limited, simple interpreting/translation services or in emergency situations when an interpreter is not immediately available to provide appropriate language assistance in person or over the telephone
  • When patients/patient representatives insist upon the use of a friend or family member to provide them with interpreting service, KAUST Health personnel shall additionally retain a healthcare interpreter if available to participate in the exchange to ensure that it represents an accurate portrayal of the information to KAUST Health staff and patients
  • If a patient declines a KAUST Health volunteer interpreter, the reason for declining the service should be recorded in the patient’s medical record if applicable, especially when patient agreement and signature of consents will be required. The name of the person who interprets for the patient and her/his relationship to the patient (e.g. wife, friend, etc.) shall also be recorded
  • A confidentiality agreement will be maintained with any used interpreters
  • Before the interpreter finishes the session they should check with both the patient and the doctor that they understand everything and do not have any other questions
  • To ensure that all KAUST Health patients get equal and fair treatment regardless of age, race, gender, religion and disability at all times and under all conditions
  • KAUST Health leadership advocates all principles of Patient, Family Rights and Responsibilities through defining Patient Rights, adopting a Patient, Family Rights and Responsibilities statement, and implementing the related policies and systems
  • All concerned staff will ensure that “Patient, Family Rights and Responsibility statement” is available to all patients and their families and displayed clearly in all patients areas
  • All Patients and Families will be educated about their Rights and Responsibilities during the care encounters at KAUST Health and made aware of how to pursue them in order to ensure the provision of compassionate care that guarantees their personal dignity and autonomy
  • KAUST Health develops and implements process to identify vulnerable patient groups at additional risk and protect them from these risks to safety

Awareness:

All patients and their families or their legal representative(s) have the right to be informed about their rights and responsibilities and to receive a copy of KAUST Health Bill of Rights and Responsibilities so:

  • All KAUST Health patients upon registration on their first visit will receive a copy from the statement of rights and responsibilities in a brochure from Receptionist

Access to Care:

  • All Individuals will be afforded impartial access within the clinic scope of services to treatment that are available and medically indicated based on the patient’s need and according to the clinic’s mission, vision, and capability to provide needed services regardless of race, color, age, disability, creed, sex, marital status, national or ethnic origin, religion, sexual orientation or source of payment
  • Patients and their families will be informed by the treating physicians about the alternative sources of care if the service required is not available at KAUST Health
  • Patients have the right to choose their physicians and to be transferred to another treating physician, if they do not wish to remain under the care of their current physician upon justifiable
  • Patients have the right to request a second opinion that can be from another KAUST Health physician or from external licensed physicians. For seeking for second opinion from outside KAUST Health, patients or their relatives should notify the attending physician or his/her designee
  • Patients and their legal representatives have the right to be informed about the expected costs of any recommended treatment. Patients who are requesting to know the financial obligations will be directed to the Reception Desk
  • Provision of care will not be affected by the patient’s inability to pay, So all critically ill patients or those cases brought to the ER as victims accidents will be managed and treated without delay at the clinic as indicated and required

Respect and Dignity:

  • Patients have the right to considerate; respectful care at all times and under all circumstances, with recognition of their personal dignity and worth
  • Patients’ dignity is maintained at all times, for example patient identification occurs using his/her name, privacy maintained, pain management, communication, choice and control and equality
  • Patients have the right to wear appropriate personal clothing, religious, cultural or other symbolic items as long as they do not jeopardize his / her safety, modesty or hinder and interfere with diagnostic procedures or treatment

Personal Safety and Security:

  • Patients have the right to be protected from any verbal or physical abuse by any KAUST Health staff or others individuals
  • Patients have the right to expect reasonable safety in so far as the clinic practices and environment are concerned
  • Vulnerable patients will be taken care of according to KAUST Health policies
  • A No-Smoking policy is adopted in KAUST Health
  • More details about Confidentiality can be found in Confidentiality Policy

Care provider’s identity:

  • Patients have the right to know the identity and professional status of individuals providing service to them, and to know which physician or other practitioner is primarily responsible for their care
  • Patients have the right to know the qualifications and the experience of their attending physicians, and they can get the required information from the Patient Relations

Privacy:

  • Persons not directly involved in patient care will not be allowed to attend the patient's examination unless patient approved their stay
  • Non-life-threatening patients will not be examined in entrances or waiting areas
  • Patients will be placed in protective privacy when considered necessary for personal safety
  • Patients have the right to refuse to be photographed, recorded or being part of KAUST Health administrative or educational activities
  • Male/Female specific waiting areas might be arranged based on the patient request.
  • Appropriate chaperon may be provided upon patient request

Confidentiality:

  • Unless mandated by law, all discussions or consultations involving a patient case will be conducted discreetly and that individuals not involved in direct care will not be present without permission of the patient, all discussion with family members in front of the patient will be conducted in a volume sufficient for the patient to hear
  • Unless mandated by law, Medical records is read only by individuals directly involved in treatment, research or monitoring of quality, and by other individuals only on authorization by the patient or that of his/her legally authorized representative
  • Unless mandated by law, all communications and other records pertaining to his/her care, including the source of payment for treatment, are treated as confidential

Condition-related Information:

  • Patients have the right to obtain from the practitioners responsible for coordinating their care, complete, accurate, updated information concerning their diagnosis, treatment( including the benefits, risks and expected outcomes), pain management, and any expected prognosis
  • Patients have the right to have information about the alternative treatment options and modalities (if available) and the expected benefits, risks and complications of each option
  • This information will be communicated in terms the patients can reasonably be expected to understand
  • Patients have the right to request an interpreter, if they do not understand the language spoken by the health care providers
  • When it is medically advisable, as documented by the attending physician in the patient medical record, the information will be given to the patient's designee(s) or to the legally authorized individual
  • The patient has the formal right of access to his/her medical records

Informed Consent:

  • The patient has the right to reasonably informed participation in decisions involving his/her care by treating physician
  • This participation will be based on a clear, concise explanation of his/her condition and of all proposed technical procedures, including the possibilities of any risk of mortality or serious side effects, problems related to healing, and probability of success
  • The patient will not be subjected to elective specific procedures (none life threatening procedures) without his/her voluntary, competent, and informed consent, or that of his/her legally authorized representative
  • Where medically significant alternatives for care or treatment exist, the patient will be so informed by treating physician
  • The patient has the right to know who is responsible for performing the procedures or treatment
  • If a patient is unconscious or is determined to be mentally incompetent and no consent can be obtained from an appropriate family member, an alternative treatment or procedure which does not require obtaining an informed consent can be carried on

Informed Refusal:

  • The patient may refuse a recommended treatment or diagnostic or therapeutic procedure
  • If the procedure or the treatment is urgent, the said treatment or procedure will be carried on without consent according to the clinic policy for informed consent
  • Refusal of diagnostic or treatment plan will not affect the professionalism of the medical care provided by KAUST Health

Pain Assessment and Management:

  • The patient has the right to be properly assessed and has effective pain management
  • The patient has the right to be educated and have information about pain, pain relief measures and available options
  • The patient has the right to have time allocated for pain assessment, prevention and management

Participation of planning treatment:

  • KAUST Health guarantees to all patients the right to participate in their care planning. This right includes and not limited to; the opportunity to discuss treatment and alternatives with individual care provider, the opportunity to request and participate in formal care consultation
  • Patients have the right to request a family member or other representative(s) to be involved in such consultation
  • If the patient is unable to communicate and take decisions, KAUST Health shall make reasonable efforts to notify the legal representatives, a family member or a designated person(s) identified in writing by the patient
  • KAUST Health encourages the participation of family members in the care process of their patients, unless KAUST Health has a written request from the patient not to involve certain person(s)

Transfer and Continuity of Care:

  • The patient will not be transferred to another facility unless he/she has received a complete explanation of the need for the transfer and the alternatives to such a transfer, and unless the transfer is acceptable to the other facility
  • The patient has the right to be transferred safely and comfortably to the facility that agrees to provide treatment for him/her. KAUST Health will arrange for the transfer by its staff and ambulance which will be prepared with all required equipment and escorting staff according to patient’s needs. Privacy will be maintained during transfer
  • Patient has the right to decide upon his/her request if he/she wants to be transferred by the ambulance and the escorting team

Complaint/Feedback Process:

All patients, and their family members have the right to express their opinions, suggestions, concerns and to submit an official complaint regarding their personal experience and any unmet reasonable expectations as regards the care or services provided to them and have the right to know information regarding the clinic process and the approved mechanism for the initiation, review and resolution of such complaints.

Patient Responsibilities:

Full disclosure of health information:

  • The patient is responsible for providing to the best of their knowledge, accurate and complete information about medical complaints, past illnesses, hospitalizations, medications, pain, and other matters relating to their health
  • The patient is responsible for answering fully the questions of the health care team
  • The patient is responsible for making sure that he/she is understanding the medical and clinical information given to him/her
  • The patient is responsible for reporting pain to their treating physicians and nurses, discussing relief options to develop pain management plans, telling the treating physician or nurses if their pain is not relieved and reporting any concerns they may have about taking pain medications

Cooperation during examinations and procedures:

  • The patient is responsible for following the treatment plan recommended by those responsible for their care to the best of their ability. This may include following the instructions of the nurses and health professions as they carry out the coordinated plan of care implement the responsible practitioner’s orders and enforce the applicable rules and regulations
  • The patient is responsible for compliance with instructions for self-care including taking medications and attending follow-up visits
  • Patients and, as appropriate their families, should express their ability to follow the agreed upon treatment care plan
  • Accepting the consequences of refusing treatment or not following the health care team’s instructions, and they should respect and comply with the clinic regulations
  • The patient is responsible for keeping appointments and, when he/she is unable to do so for any reason, for notifying the central booking. Patient might be liable for fine or a penalty in case of not showing up for their appointment
  • The patient is responsible for making sure that their bills are paid as promptly as possible
  • Being considerate of the rights of other patients by:
    • Maintain a quiet atmosphere and observe no smoking policy and infection control regulations
    • Not using the personal properties of other patients
    • Being considerate of the rights of the clinic staff
    • Taking care of KAUST Health properties at all times

Special Conditions:

Children:

  • Children have the right to be assessed and managed safely by specialized staff, using  adjusted tools and equipment
  • Child patients have the right to receive care when they are accompanied by a guardian
  • KAUST Health hold the responsibility of providing vaccinations based on the MOH schedule.
  • An abuse and neglect policy is adopted
  • Specific room is designated as a play ground
  • All used electrical plugs are safe for children

Psychological/mental/disabled patients:

  • Dignity is maintained at all times
  • Environment is adjusted for their safety
  • Specific parking spots for physically disabled patient

In certain circumstances where patients are unable to protect their own valuables due to their clinical condition, KAUST Health will be responsible for safeguarding the patient valuables. These circumstances include:

  • Patients who arrived unconscious
  • Victims involved in road traffic accidents and suffer from severe trauma
  • KAUST Health will remain to shoulder responsibility for valuables for the above patients until the patient requests the valuables to be returned
  • In all cases, patients should be encouraged, where appropriate, to ask relatives to take unnecessary valuables off KAUST Health premises
  • Patient for transfer to external facilities. During the handover of patient belongings of KAUST Health ER Staff to an external facility, 2 copies of Patient belongings form must be signed and acknowledged by the receiving staff. One copy will be retained to the external facility, and the second copy will be returned by the KAUST Health transferring staff to KAUST Health ER department for scanning and archiving
  • For other departments (Radiology, Rehabilitation, and Minor Surgery):
    • Patients are advised to store their belongings in the approved lockers in their respective areas

Dealing with belongings of deceased patients:

  • The clinic will handle the property of deceased patients promptly
  • Management of death in ER : if any valuables items are requested by the relatives once the body is in the morgue, 2 witnesses will witness the removal of the items from the deceased and record the recipient’s name and ID number (if available) in the morgue log book. Personal belongings form must also be completed
  • When removing any personal belongings from the body, the ER nurse will give it to the person who will legally collect the body (Police case and non-police case)

Refunded Cash:

If there will be any cash to be refunded to patient for financial discrepancy, this should be done as following:

  • Receptionists will document the refund and get the patient signature before handling the cash, and will give one copy to the patient and one to Insurance coordinator at end of the shift
  • If patient already left KAUST Health, receptionist will give the cash and the form to Insurance coordinator to keep it in safety box, and when patient comes back to KAUST Health, will get the cash and form from Insurance coordinator
  • The Patient Relations are directly responsible for coordinating all patients/visitors complaints
  • Patient Relations Officers shall call the patients with pending cases every 5 business days to keep him informed about his complaints
  • This policy does not cover medico-legal complaints

The patient should be offered the opportunity to formalize the Complaint in writing if they wish to do so.

Initiation of a complaint:

  • Formal complaints may be clinical or non-clinical related, however, the process for initiating complaints is the same whether clinical or non-clinical in nature
  • Patient Relations staff actively gives the patients the opportunity to express dissatisfaction or to complain if they wish to do so
  • Complaints can be sent by email or in writing on the Complaint form (see attached form 1) or verbal to the Patient Relations Office
  • During working hours, Patient Relations should be contacted to intervene whenever a patient or family member indicates that they wish to complain
  • Out of hours, patients and family members wishing to complain should email Patient Relations at patient-relations@kaust.edu.sa
  • Acknowledgement of receiving the complaint will happen within 48 working hours
  • Once a complaint has been raised by any of the above mechanisms a member of the Patient Relations Department will contact the complainant during their duty hours, or during the next working day if out of hours, to discuss the complaint and take more details if needed

Non-Clinical Complaints:

  • The complaint is forwarded to the relevant organizational unit leader for investigation
  • Non-clinical complaints must be fully investigated  and resolved by the concerned organizational unit within 5 business days

Clinical Complaints:

  • The clinical complaint is forwarded to the Medical Director along with the Quality and Risk Manager for investigation
  • Clinical complaints must be fully investigated and resolved by the concerned organizational unit within 7 business days where possible
  • If the complaint needs to be reviewed by a Committee, the result of the investigation must be communicated to the patient within 40 days
  • All clinical complaints are discussed in the Committee for their further action and improvement

Response to Patients:

  • The Patient Relations will contact the patient to provide feedback concerning the actions taken to resolve the complaint on the telephone number or contact information provided in the written complaint within (5 working days for non clinical – 7 working days for clinical)
  • If the patient is not satisfied with the result of the investigation and the feedback given, the case will be referred to the Chief of Staff office along with informing the KAUST Health Director, Chief of Staff office will convene an independent team to review it
  • Patient Relations will inform the complainant that the complaint will be reviewed independently and that feedback will be provided following the review
  • It is the policy of KAUST Health to obtain General Consent from any legally-consented person coming to receive care on their registration
  • It is the policy of KAUST Health to obtain a specific informed consent from legally-consented persons, before performing certain specific diagnostic, therapeutic or surgical procedures or administration of special kinds of treatment, transfusion of blood or blood products, and disposal of tissues or body parts
  • The physician who will perform the proposed diagnostic, surgical or medical intervention on a patient is responsible for obtaining the informed consent
  • Taking medical photography is non-applicable at KAUST Health
  • Informed Consent: The process of informing a patient about a procedure, treatment, or clinical trial/research study so that the patient can make a voluntary, informed decision to accept or refuse to have the procedure or treatment. The patient must be fully informed and understand the information that he/she is provided before giving consent. The elements of informed consent include, but are non-limited to information about, and potential benefits and risks of the proposed procedure, treatment, clinical trial/research study and possible alternatives to the procedure and treatment
  • Legally-Consented Persons: all  adult patients with decision-making capacity or from their substitute decision makers / legally authorized persons / legal guardians of minors and incompetent adults
  • Informed: Means having been given information.
  • Verbal Consent: shall be obtained for simple procedures such as insertion of peripheral I.V. line; however the attending physician may elect to obtain it for documentation purpose
  • Telephone Consent: is permission given by telephone from a parent or legal representative. The telephone consent is only accepted in extra ordinary conditions and emergency situations if the patient is minor or incapable of consenting for himself/herself
  • Written Consent: is consent in writing, and may be given by the patient, his/her designee or legally authorized person
  • Thumbprint: A thumbprint is acceptable in lieu of a signature. A clinician or nurse must document this and sign as witness and clarify in his/her notes which hand is used
  • Adult patients: A person/patient who has reached the age of 18 years. They have a moral, ethical and legal entitlement to make decisions regarding their treatment, and to be provided sufficient information in order to make informed decisions regarding their healthcare
  • Minor - A person who is under the age of 18 years (legal competence) is presumed not to have legal capacity to make health care decision. A parent or legal guardian must make health care decision for the child. However, a child younger than 18 years old is considered to possess legal capacity to sign inform consent without the consent of anyone else in the following conditions:
    • Has given birth to a child
    • Is married
  • Decision making capacity/ competency (DMC): The ability to understand and appreciate the nature and consequences of a decision regarding medical or surgical procedure or treatment and the ability to select and choose a particular decision. DMC is a dynamic state that may change quickly; moreover, DMC is decision specific
  • Informed consent decision maker: Patients who have been determined to possess DMC should make their own health care decisions, whereas patients determined to lack DMC should be protected from    making bad and sometimes irreversible decisions. Those lacking DMC will not be accepted as informed consent decision makers and thus require a substitute decision maker
  • Substitute Decision Maker: A person who may act as the consent giver in the event that the patient is unable to do. This person is usually a close relative and should have familiarity with the patients presumed wishes regarding medical care
  • Competent Patients: Those are patients possessing DMC and could be one of the following:
  • Competent Adult: an adult male or female patient (18 years or older) and has been determined to possess decision making capacity (DMC)
  • Incompetent/ Incapacitated Patient: person may be judged incompetent if, for any reason, it is felt that he/ she is unable to understand the information provided in the process of obtaining consent. Reasons for declaring incompetence may include, but are not limited to, the following conditions: inadequate age, mental disability, impairment of judgment by drugs or medications and acute disturbances of consciousness, reasoning or memory caused by disease
  • Witness: means to attest or verify. The signature of a KAUST Health employee(s) or the external physicians affiliates on a consent form as a witness(s) is indicating only:
    • That the correct person is signing the consent
    • That the witness is satisfied that consent is freely given
    • That the witness is satisfied that the patient judgment is not impaired by sedatives or other medications (i.e. that the patient knows what is going on)
    • The witness has no responsibility or liability regarding the nature of information given, received or understood by the patient or his/her representative(s)
    • Next of Kin/Surrogate: The first- degree legal guardian in accordance to the list in “Attachment No.2” when a patient cannot consent for medical or examination as described in the policy. The first-degree male relative must be an adult
    • Therapeutic Privilege: Is the health care practitioner’s right to withhold information based on clinical decision making skills with the anticipation that the truth will impair the outcome of the patient’s condition, treatment and recovery
    • General informed consent is to be obtained at the time of registering of the patient for the clinic by the Customer Service Officer (CSO)
    • The patient or his/ her legal representative should complete and sign the General Consent form (see attached). This consent will be obtained once during the first visit upon registration


Validity of Consent:

  • Informed Consent form can be obtained and signed within 30 days prior to the date of performing the planned elective procedure(s)
  • A single consent form may be signed for the entire course of treatment (not to exceed 6 months) in certain therapeutic programs involving a course of multiple in Dental Department

The consent remains valid and in effect until one of the following events occur:

  • If, for any reason, the procedure is delayed beyond 30 days.
  • If the patient or his/her representative(s) withdraws the consent prior to the procedure. (A verbal revocation should promptly be documented in the patient’s medical record by the treating physician).
  • If the medical condition of the patient significantly changed or becomes mentally incompetent
  • If the treating physician will not be able to perform the procedure him/herself or will not be available for any emergency reasons.
  • If any of the above mentioned events occurred, the consent form will become null and void and a new consent form must be signed prior to performing the medical or surgical procedure.

Conditions for waiving the mandate of “Informed Consent”:

  • There are situations where Informed consent policy doesn’t apply; the procedures may be performed without patient consent:
  • Immediate action must be taken to preserve the patient’s life
  • Immediate action must be taken to prevent a possible serious impairment of a body organ
  • Immediate action must be taken to prevent deterioration of the patient’s health
  • As part to KAUST Health commitment to provide the best health care and maintain community engagement and customer service excellence, it will provide patients with the opportunity to share, express and evaluate their experiences with offered satisfaction surveys
  • KAUST Health will use this information to improve its service or discover other opportunities in which to better serve our patient and family needs
  • Patients’ satisfaction surveys data will:
    • Initiate Performance Improvement Projects, help KAUST Health to learn where to improve and will lead us to exceed our patient’s expectations
  • Patient satisfaction survey will be automatically disseminated via online to patients who were seen in KAUST Health
  • KAUST Health uses the Press Ganey survey as the tool for patient satisfaction measurement
  • KAUST Health Provides its patients with Satisfaction Survey Tools through a contractor company called “Health.Links” Licenced by Press Ganey Associates, Inc.
Health.Links will send SMS notifications with designated links to all patients who visited KAUST Health with the exception of (same day visits, follow ups, procedures and Allied health services).

Once the CSO identifies the presence of a special needs patient at the reception desk, the CSO shall serve the patients by following the below process:

  • Come out of his/her desk and talk to the patient face to face
  • Take all the needed information to register the patient
  • Escort the patient to the waiting area
  • Process patient arrival at HIS
  • Inform the staff nurse about the availability of the special needs patient at the waiting area
  • The patient will remain at the waiting area until the staff nurse calls the patient for his/her appointment
  • Lab technicians and radiology technicians will perform CSO’s tasks in their areas
  • KAUST Health offers the service of loaning hospital grade electronic breast pumps to patients in need
  • The loan of the hospital grade electronic breast pumps is offered as a temporary solution to an acute breast feeding issue for continued and on-going use
  • Patient must either purchase their own pump or contact other service providers for on-going rental purposes after the completion of the approved loan duration mentioned in Equipment Educational Materials Loan Form

The electronic hospital grade breast pump is considered medically necessary for any of the following conditions:

  • Unsuccessful experience and insufficient breast milk after a trail using manual or standard breast pumps
  • Treat breast engorgement
  • Treat mastitis
  • When a breast feeding infant has a procedure or congenital condition (respiratory, cardiac, cleft palate) that interferes with breast feeding
  • Mothers with multiple births
  • Re-lactation
  • Unplanned/unexpected return to work
  • All hospital grade breast pump requests shall be facilitated through KAUST Health Ob/Gyn Charge Nurse and/or Health Educator
  • Attachments for the hospital grade electronic can be purchased through KAUST Health pharmacy

To establish criteria for minor patient's care when not accompanied by their parents or guardians in an outpatient/ER

This policy doesn’t apply on ER categories 1, 2 &3, safe guarding issues, rehab, speech therapy, psychology and psychiatry. Invasive procedures in outpatient departments shall not be done without parent’s presence.

  • Minor Adolescents will not be seen without parental permission
  • Minor Children will not be seen without legal guardian (parents). Maids or siblings will not be considered as standing in loco parentis (in place of the parent)
  • Minor Child: The charge nurse will check to see if the parent is present. If not the patient will not be seen. The charge nurse will ring the parent or guardian and explain the situation to them. The minor and anyone accompanying them will be informed of this policy. The next available appointment will be offered if the parent is not immediately available
  • Minor Adolescent: The minor will be asked to give a telephone number at which the parent or guardian is present. A note will not be acceptable
  • The charge nurse will ring the parent or guardian and explain the situation to them. If the parent or guardian is ready to give consent they should be told that they will have to pass an ID check before they can do that. If they fail, the minor will not be seen
  • Parent ID check: The parent should be able to identify themselves by giving the following personal details about themselves (not the minor) as per the patient identification policy
  • Parent ID's Minor Adolescent: The parent should be able to identify the Minor Adolescent as follows:
    • Full name
    • KAUST ID
    • KAUST Health Medical record number
    • Age or date of birth
    • Telephone number as recorded in HIS
  • Treating physician would assess the child competency. If child is found to be competent than he/she can be seen after parental consent
  • To define and ensure the importance of confidentiality of information as a basic right for all KAUST Health patients and that this right is always preserved
  • It is the policy of KAUST Health to maintain and respect individual’s right to privacy and confidentiality of information
  • KAUST Health has implemented processes to ensure the confidentiality of data and information
  • Confidential Information: Verbal, written, pictorial images, or electronic information that includes information generated by KAUST Health or information received from other health care providers, that identifies the individual patient, includes medical, diagnostic, treatment, and prognosis information on the patient

Patients Involvement:

  • Patients are requested to sign a General Consent Form upon their first encounter to KAUST Health which specifies that they understand that information is to be shared with other service providers
  • Release of medical information will be strictly to the patient himself/ herself or to his/ her designee or legally authorized person as per Release of Patients Medical Information
  • It is the policy of KAUST Health to maintain a profound respect for human dignity and, in doing so, requires the patient's right to privacy be upheld at all times
  • Each person's privacy needs, preferences and expectations should be identified and maintained
  • Use every opportunity to verbalize the importance of patient privacy
  • Provide patients with a clear recourse should they feel their privacy has been compromised
  • When providing care for patients, room door must be kept closed and bed curtains will be drawn to provide privacy
  • All conversations with the patient regarding his/her care will be conducted in a low volume and confidential manner. All discussions with family members in front of the patient will be conducted in a volume sufficient for the patient to hear
  • The patients’ clinical condition will not be discussed with anyone other than those individuals who have the “right to know” such as immediate family, other care providers and legal representatives
  • Patient will not be examined in hallways or waiting areas under any circumstances
  • The nurse and treating physician will ensure that the patient is properly covered, especially in front of family
  • Ask patients if they would prefer their family member wait outside the room while certain tests are being conducted
  • Requesting a family member to be involved in discussion about the patient’s medical condition shall be done after completing the examination and covering the patient

KAUST Health Facility offers the service of loaning medical equipment, medical devices, educational materials, and/or wheelchairs to patients when needed through the following process:

  • Treating physician and/or health educator shall approve form after identifying the medical need
  • For all loan requests, cash deposit must be paid by patient following the below process:
    • During operational hours - Sunday to Thursday from 8 to 5 pm, payment must be made to KAUST Health Finance representative/Business Manager or his/her designee
    • After operational hours (after 5 pm) and during weekends, payment must be done to KAUST Health Emergency Room Receptionist who should pass the amount of money to KAUST Health Business Manager on the next operational working day

The deposits are as following:

Item Fee
Medical equipment loans such as, but not limited to, nebulizer, breast pumps, blood pressure (Holter Moniter Device is not included as it is always ordered by physicians)  devices, glucometer…etc. 2,000 SAR
Wheelchairs 700 SAR
Educational material 80 SAR
  • Cash deposit is fully refundable to patients if the loaned item is returned back to KAUST Health in a good working condition
  • Loan duration is 7 days starting from the day of receiving the item
  • Patient will be able to extend the loan duration for an additional 7 days after maintaining the approval of the treating physician and/or health educator
  • All extended requests must be approved by KAUST Health Business Manager or his/her designee after maintaining the treating physician and/or health educator approval
  • In case of any damage or loss to the loaned item, the patient shall shoulder the cost as per the price listed on the purchase order, processed by KAUST Health
  • Patient shall be refunded the deposit back in cash after completing KAUST Health-Refund billing and finance - KAUST Health-0502017
  • KAUST Health recognizes the important role which voluntary activity plays in complementing the work of its staff and therefore values, supports and encourages the efforts of those individuals who give freely of their time and energy to benefit KAUST Health
  • KAUST Health volunteers may come from the KAUST community or may be someone who applies through Fakeeh.Care
  • KAUST Health volunteers will complete an application form (form 1) and undergo an interview for the position which they are volunteering and interview form will be completed (form 2)
  • KAUST volunteers who have already been through a vetting process with other KAUST departments e.g. HR and do not require to have an interview but are required to complete an application form
  • Final approval for volunteers will be given by KAUST management
  • Volunteer placements of any length will be accepted at KAUST Health
  • Volunteers will not have any access to patient medical records
  • Volunteers will not participate in any direct patient care activities
  • Volunteers will complete a health assessment form which will be reviewed by the Staff Health Physician and action taken as necessary
  • Volunteers below the age of 18 require parental consent
  • Volunteer: Someone who freely gives regular, unpaid help that either enhances the services that KAUST Health staff can provide or helps KAUST Health to improve and develop its services
  • Individual interested in volunteering at KAUST Health will be asked to complete a volunteer application form
  • Successful volunteer candidates will be given a start date at KAUST Health and are required to sign a volunteer job description a confidentiality agreement and a volunteer agreement
  • The volunteer will participate in clinic wide orientation including but not limited to quality, patient safety and infection control subjects. The volunteer will also undergo fire training
  • A certificate for the specified volunteer hours will be given to all volunteers who successfully complete the volunteer period