‫ﻗﺳﻡ ﺇﺩﺍﺭﺓ ﺍﻟﺟﻭﺩﺓ ﺍﻟﺷﺎﻣﻠﺔ‬

CBAHI PFR Standards Translated ‫ﻣﻌﺎﻳﻳﺭ ﺣﻘﻭﻕ ﺍﻟﻣﺭﺿﻰ ﻭﺫﻭﻳﻬﻡ ﺳﺑﺎﻫﻲ ﻣﺗﺭﺟﻣﺔ‬
‫ﻓﻲ ﺣﺎﻝ ﺍﻟﺧﻼﻑ ﻳﺭﺟﻊ ﺇﻟﻰ ﺃﺻﻝ ﺍﻟﻧﺹ ﺍﻹﻧﺟﻠﻳﺯﻱ‬
Total Standards: 18 |Total Sub-Standards: 74 |Total ESR Standards: 0 0:‫ | ﻣﺠﻤﻮﻉ ﻣﻌﺎﻳﻴﺮ ﺍﻷﺳﺎﺱ‬74 :‫ | ﻣﺠﻤﻮﻉ ﺍﻟﻤﻌﺎﻳﻴﺮ ﺍﻟﻔﺮﻋﻴﺔ‬18 :‫ﻣﺠﻤﻮﻉ ﺍﻟﻤﻌﺎﻳﻴﺮ‬

PFR.1 PFR.1
Hospital leaders support and protect the patient and .‫ﻗﺎﺩﺓ ﺍﻟﻣﺳﺗﺷﻔﻳﺎﺕ ﻳﺩﻋﻡ ﻭﻥ ﻭﻳﺣﻣﻭﻥ ﺣﻘﻭﻕ ﺍﻟﻣﺭﻳﺽ ﻭﺍﻷﺳﺭﺓ‬
family rights.
:‫ﺍﻟﻐﺭﺽ‬
Standard Intent: :‫ ﻭﻳﻧﺑﻐﻲ ﺃﻥ ﻳﺷﻣﻝ ﺍﻟﺩﻋﻡ ﻣﺎ ﻳﻠﻲ‬.‫ﺍﻟﻘﻳﺎﺩﺓ ﻣﺳﺅﻭﻟﺔ ﻋﻥ ﺩﻋﻡ ﻭﺇﻧﻔﺎﺫ ﺗﻧﻔﻳﺫ ﺣﻘﻭﻕ ﺍﻟﻣﺭﻳﺽ‬
Leadership is responsible for supporting and enforcing implementation of "‫ ﺗﻁﻭﻳﺭ ﻭﺇﺑﻼﻍ "ﺷﺭﻋﺔ ﺍﻟﺣﻘﻭﻕ‬
patient rights. Support should include: ‫ ﺍﻟﻣﻭﺍﻓﻘﺔ ﻋﻠﻰ ﺍﻟﺳﻳﺎﺳﺎﺕ ﺍﻟﻼﺯﻣﺔ ﻟﺗﻧﻔﻳﺫ ﺍﻟﺣﻘﻭﻕ ﻣﻥ ﻗﺑﻝ ﺍﻷﻁﺭﺍﻑ ﺍﻟﻣﻌﻧﻳﺔ ﻓﻲ ﺟﻣﻳﻊ‬/ ‫ ﻭﺿﻊ‬
 developing and communicating the "Bill of Rights" ‫ﺃﻧﺣﺎء ﺍﻟﻣﻧﻅﻣﺔ‬
 developing/approving policies required for ‫ ﺗﻌﻳﻳﻥ ﻫﻳﻛﻝ ﻣﺳﺅﻭﻝ ﻋﻥ ﺍﻷﻧﺷﻁﺔ ﺍﻟﻣﺗﻌﻠﻘﺔ ﺑﺎﻟﺣﻘﻭﻕ ﺃﻭ ﺇﺿﺎﻓﺔ ﻫﺫﻩ ﺍﻷﻧﺷﻁﺔ ﺇﻟﻰ ﻫﻳﻛﻝ ﻗﺎﺋﻡ‬
implementation of rights by relevant parties across the ‫ﻳﺗﻌﻠﻕ ﺑﺑﻌﺽ ﺟﻭﺍﻧﺏ ﺍﻟﺣﻘﻭﻕ‬
organization ‫ ﺍﺟﺗﻣﺎﻋﺎﺕ ﻟﺗﺛﻘﻳﻑ ﺍﻟﻣﻭﻅﻔﻳﻥ ﺣﻭﻝ ﺣﻘﻭﻕ ﺍﻟﻣﺭﻳﺽ‬/ ‫ ﺍﻟﺗﻭﺻﻳﻝ ﻭﺣﺿﻭﺭ ﺟﻠﺳﺎﺕ‬
 assigning a structure to be responsible for activities in
‫ﻭﺗﺷﺎﺭﻙ ﺍﻹﺩﺍﺭﺓ ﻭﺍﻟﻣﻭﻅﻔﻭﻥ ﺍﻟﺳﺭﻳﺭﻳﻭﻥ ﻭﻏﻳﺭﻫﻡ ﻓﻲ ﺗﻁﻭﻳﺭ ﺳﻳﺎﺳﺎﺕ ﻭﺇﺟﺭﺍءﺍﺕ ﺣﻘﻭﻕ‬
relation to rights or adding these activities to an
‫ ﻭﻳﺗﻡ ﺗﺩﺭﻳﺏ ﺟﻣﻳﻊ ﺍﻟﻣﻭﻅﻔﻳﻥ ﻋﻠﻰ ﺍﻟﺳﻳﺎﺳﺎﺕ ﻭﺍﻹﺟﺭﺍءﺍﺕ ﻭﻋﻠﻰ ﺩﻭﺭﻫﻡ ﻓﻲ ﺩﻋﻡ‬.‫ﺍﻟﻣﺭﺿﻰ‬
existing structure that is concerned with some aspects
‫ ﻳﺟﺏ ﺃﻥ ﻳﻛﻭﻥ ﺟﻣﻳﻊ ﺍﻟﻣﻭﻅﻔﻳﻥ ﻋﻠﻰ ﺑﻳﻧﺔ ﻣﻥ‬:‫ ﻭﻣﻥ ﺍﻷﻣﺛﻠﺔ ﻋﻠﻰ ﺫﻟﻙ‬.‫ﺣﻘﻭﻕ ﺍﻟﻣﺭﺿﻰ ﻭﺍﻷﺳﺭ‬
of rights
‫ ﻣﺎ‬،‫ ﻭﺗﻌﺯﻳﺯ ﻣﺷﺎﺭﻛﺔ ﺍﻟﻣﺭﺿﻰ ﻓﻲ ﻗﺭﺍﺭﺍﺕ ﺍﻟﺭﻋﺎﻳﺔ‬،‫ﻛﻳﻔﻳﺔ ﺍﻟﺣﻔﺎﻅ ﻋﻠﻰ ﺍﻟﺧﺻﻭﺻﻳﺔ ﻭﺍﻟﺳﺭﻳﺔ‬
 conduction and attendance of sessions/meetings to
educate staff about patient rights
.‫ﻳﺟﺏ ﺍﻟﻘﻳﺎﻡ ﺑﻪ ﺇﺫﺍ ﻛﺎﻥ ﺍﻟﻣﺭﻳﺽ ﻳﺭﻳﺩ ﻁﺑﻳﺏ ﺁﺧﺭ‬
Management, clinical staff, and others participate in developing patients’ rights
policies and procedures. All staff members are trained on the policies and
procedures and on their role in supporting patients’ and families’ rights.
Examples are: all staff should be aware on how to maintain privacy,
confidentiality, enhancing patient participation in care decisions, what to do if
a patient wants another physician. PFR.1.1
‫ﻳﻘﻭﻡ ﻗﺎﺩﺓ ﺍﻟﻣﺳﺗﺷﻔﯽ ﺑﺈﻧﺷﺎء ﻭﺍﻟﺣﻔﺎﻅ ﻋﻠﯽ ﻫﻳﮑﻝ ﻳﺷﻣﻝ ﻗﺎﺩﺓ ﺍﻟﻣﺳﺗﺷﻔﯽ ﻭﻏﻳﺭﻫﻡ ﻟﺩﻋﻡ‬
PFR.1.1 ‫ ﻭﻟﺟﻧﺔ‬،‫ ﻋﻼﻗﺎﺕ ﺍﻟﻣﺭﻳﺽ‬،‫ﻭﺍﻹﺷﺭﺍﻑ ﻋﻠﯽ ﺟﻣﻳﻊ ﺃﻧﺷﻁﺔ ﺣﻘﻭﻕ ﺍﻟﻣﺭﻳﺽ ) ﻋﻠﯽ ﺳﺑﻳﻝ ﺍﻟﻣﺛﺎﻝ‬
Hospital leaders establish and maintain a structure that involves .(‫ﺍﻟﺩﻓﺎﻉ ﻋﻧﻬﻡ‬/ ‫ﺣﻘﻭﻕ ﺍﻟﻣﺭﺿﻰ‬
hospital’s leaders and others to support and oversee all patient rights PFR.1.2
activities (e.g. patient relations, patient rights/patient advocacy .‫ ﺍﺳﺗﻔﺳﺎﺭﺍﺗﻬﻡ ﺑﺷﺄﻥ ﺣﻘﻭﻗﻬﻡ‬/ ‫ﺍﻟﻣﺭﺿﻰ ﻭﺃﺳﺭﻫﻡ ﻟﺩﻳﻬﻡ ﺇﻣﻛﺎﻧﻳﺔ ﺗﻭﺻﻳﻝ ﻣﺧﺎﻭﻓﻬﻡ‬
committee). PFR.1.3
PFR.1.2 ‫ﻳﻘﻭﻡ ﻗﺎﺩﺓ ﺍﻟﻣﺳﺗﺷﻔﯽ ﺑﺗﻁﻭﻳﺭ ﻭﺍﻟﺣﻔﺎﻅ ﻋﻠﯽ ﺑﻳﺎﻥ ﺣﻘﻭﻕ ﻭﻣﺳﺅﻭﻟﻳﺎﺕ ﺍﻟﻣﺭﻳﺽ ﺍﻟﺫﻱ ﻳﺷﻣﻝ‬
Patients and families have an access to communicate their
.‫ﺟﻣﻳﻊ ﺣﻘﻭﻕ ﻭﻣﺳﺅﻭﻟﻳﺎﺕ ﺍﻟﻣﺭﻳﺽ ﻭﺍﻷﺳﺭﺓ‬
concerns/inquiries regarding their rights.
PFR.1.4
PFR.1.3
‫ﻳﻁﻭﺭ ﺍﻟﻣﺳﺗﺷﻔﻰ ﻭﻳﻧﻔﺫ ﺍﻟﺳﻳﺎﺳﺎﺕ ﻭﺍﻹﺟﺭﺍءﺍﺕ ﺍﻟﺗﻲ ﺗﺣﻣﻲ ﻭﺗﺩﻋﻡ ﺗﻧﻔﻳﺫ ﺣﻘﻭﻕ ﺍﻟﻣﺭﻳﺽ‬
Hospital leaders develop and maintain patient rights and responsibilities
.‫ﻭﺍﻷﺳﺭﺓ‬
 ‫ﻗﺳﻡ ﺇﺩﺍﺭﺓ ﺍﻟﺟﻭﺩﺓ ﺍﻟﺷﺎﻣﻠﺔ‬
statement that includes all patient and family rights and responsibilities. PFR.1.5
PFR.1.4 ‫ﻳﻭﻓﺭ ﺍﻟﻣﺳﺗﺷﻔﻰ ﺣﻘﻭﻕ ﺍﻟﻣﺭﻳﺽ ﻭﻣﺳﺅﻭﻟﻳﺎﺗﻪ ﻟﻠﻣﺭﺿﻰ ﻭﺍﻟﻌﺎﺋﻼﺕ ﻓﻲ ﺷﻛﻝ ﻭﻟﻐﺔ ﻳﻣﻛﻥ ﺃﻥ‬
The hospital develops and implements policies and procedures that ‫ ﺗﻭﻓﻳﺭ ﻭﺛﻳﻘﺔ ﺣﻘﻭﻕ ﺍﻟﻣﺭﺿﻰ ﻭﻣﺳﺅﻭﻟﻳﺎﺗﻬﻡ ﺃﻭ ﻧﺷﺭﻫﺎ ﻓﻲ ﻏﺭﻓﺔ‬،‫ﻳﻔﻬﻣﻬﺎ ) ﻋﻠﻰ ﺳﺑﻳﻝ ﺍﻟﻣﺛﺎﻝ‬
protect and support the implementation of patient and family rights. .(‫ﺍﻟﻣﺭﻳﺽ ﻭﺍﻷﻣﺎﻛﻥ ﺍﻟﻌﺎﻣﺔ ﻓﻲ ﺟﻣﻳﻊ ﺃﻧﺣﺎء ﺍﻟﻣﺳﺗﺷﻔﻰ‬
PFR.1.5 PFR.1.6
The hospital makes patient rights and responsibilities available to .‫ﻳﺿﻣﻥ ﺍﻟﻣﺳﺗﺷﻔﻰ ﺇﺑﻼﻍ ﺍﻟﻣﺭﺿﻰ ﺑﺣﻘﻭﻗﻬﻡ ﻭﻣﺳﺅﻭﻟﻳﺎﺗﻬﻡ‬
patients and families in a format and language they can understand (e.g., PFR.1.7
providing patient rights and responsibilities document or posting in the .‫ﻳﺳﺎﻋﺩ ﺍﻟﻣﺳﺗﺷﻔﻰ ﺍﻟﻣﺭﺿﻰ ﻋﻠﻰ ﻣﻣﺎﺭﺳﺔ ﺣﻘﻭﻗﻬﻡ‬
patient’s room and public places throughout the hospital). PFR.1.8
PFR.1.6 ‫ﻳﻘﻭﻡ ﺍﻟﻣﺳﺗﺷﻔﻰ ﺑﺗﺛﻘﻳﻑ ﺍﻟﻣﻭﻅﻔﻳﻥ ﺑﺷﺄﻥ ﻣﺳﺅﻭﻟﻳﺎﺗﻬﻡ ﻓﻳﻣﺎ ﻳﺗﻌﻠﻕ ﺑﺣﻘﻭﻕ ﺍﻟﻣﺭﺿﻰ ﻭﺍﻷﺳﺭ‬
The hospital ensures that patients are informed about their rights and .(‫ ﺃﺛﻧﺎء ﺍﻟﺗﻭﺟﻳﻪ ﻭﻛﺫﻟﻙ ﺩﻭﺭﺍﺕ ﺗﺟﺩﻳﺩ ﺍﻟﻣﻌﻠﻭﻣﺎﺕ‬،‫)ﻋﻠﻰ ﺳﺑﻳﻝ ﺍﻟﻣﺛﺎﻝ‬
responsibilities. PFR.1.9
PFR.1.7 .‫ﻳﺩﺭﻙ ﺍﻟﻣﻭﻅﻔﻭﻥ ﻣﺳﺅﻭﻟﻳﺎﺗﻬﻡ ﻓﻲ ﺣﻣﺎﻳﺔ ﺣﻘﻭﻕ ﺍﻟﻣﺭﺿﻰ ﻭﺍﻷﺳﺭﺓ‬
The hospital helps patients to exercise their rights.
PFR.1.8
The hospital educates staff on their responsibilities regarding patient and
family rights (e.g., during orientation as well as refresher courses).
PFR.1.9
Staff are aware of their responsibilities in protecting patient and family
rights.
PFR.2 PFR.2
Cultural, psychosocial, religious, and spiritual needs of . ‫ﻟﻠﻣﺭﺿﻰ‬ ‫ﻭﺍﻟﺭﻭﺣﻳﺔ‬ ‫ﻭﺍﻟﺩﻳﻧﻳﺔ‬ ‫ﻭﺍﻻﺟﺗﻣﺎﻋﻳﺔ‬ ‫ﻭﺍﻟﻧﻔﺳﻳﺔ‬ ‫ﺍﻟﺛﻘﺎﻓﻳﺔ‬ ‫ﺍﻻﺣﺗﻳﺎﺟﺎﺕ‬ ‫ﻭﺩﻋﻡ‬ ‫ﺍﺣﺗﺭﺍﻡ‬ ‫ﻳﺗﻡ‬
patients are respected and supported.
Standard Intent: :‫ﺍﻟﻐﺭﺽ‬
Cultural, psychosocial, religious, and spiritual values of patients affect how ‫ﺍﻟﻘﻳﻡ ﺍﻟﺛﻘﺎﻓﻳﺔ ﻭﺍﻟﻧﻔﺳﻳﺔ ﻭﺍﻻﺟﺗﻣﺎﻋﻳﺔ ﻭﺍﻟﺩﻳﻧﻳﺔ ﻭﺍﻟﺭﻭﺣﻳﺔ ﻟﻠﻣﺭﺿﻰ ﺗﺅﺛﺭ ﻋﻠﻰ ﻛﻳﻔﻳﺔ ﺍﻻﺳﺗﺟﺎﺑﺔ‬
they respond to their care. If a person's spiritual values, beliefs, attitudes and ‫ ﺇﺫﺍ ﻛﺎﻧﺕ ﺍﻟﻘﻳﻡ ﺍﻟﺭﻭﺣﻳﺔ ﻭﺍﻟﻣﻌﺗﻘﺩﺍﺕ ﻭﺍﻟﻣﻭﺍﻗﻑ ﻭﺍﻟﻣﻣﺎﺭﺳﺎﺕ ﺍﻟﺩﻳﻧﻳﺔ ﻟﻠﺷﺧﺹ ﻻ ﺗﻣﻛﻧﻬﻡ‬.‫ﻟﺭﻋﺎﻳﺗﻬﻡ‬
religious practices do not enable them to deal satisfactorily with questions ‫ﻣﻥ ﺍﻟﺗﻌﺎﻣﻝ ﺑﺷﻛﻝ ﻣﺭﺽ ﻣﻊ ﺍﻷﺳﺋﻠﺔ ﺍﻟﻣﺗﻌﻠﻘﺔ ﺑﺎﻟﺣﻘﺎﺋﻕ ﺍﻟﻼﻧﻬﺎﺋﻳﺔ ﻭﺍﻟﻣﻌﻧﻰ ﺍﻟﻧﻬﺎﺋﻲ ﻭﺍﻟﻐﺭﺽ ﻓﻲ‬
concerning the infinite realities and ultimate meaning and purpose in life, then .‫ ﻓﺈﻥ ﻫﺫﺍ ﻗﺩ ﻳﺅﺩﻱ ﺇﻟﻰ ﺣﺎﻟﺔ ﻣﻥ ﺍﻟﻣﺭﺽ ﺍﻟﺭﻭﺣﻲ ﺃﻭ ﺍﻷﻟﻡ ﺍﻟﺭﻭﺣﻲ‬،‫ﺍﻟﺣﻳﺎﺓ‬
this may well lead to a state of spiritual disease or spiritual pain. ‫ ﻭﻫﻲ ﺗﺷﻣﻝ ﺟﻣﻳﻊ‬. ‫ﺗﻌﺑﺭ ﺍﻟﺣﺎﻟﺔ ﺍﻟﺭﻭﺣﻳﺔ ﻋﻥ ﺍﻟﻁﺭﻳﻘﺔ ﺍﻟﺗﻲ ﻳﺷﻌﺭ ﺑﻬﺎ ﺍﻟﺷﺧﺹ ﻣﻥ ﺧﻼﻝ ﺗﺟﺭﺑﺗﻪ‬
Spiritual describes the way in which a person make sense of his experience. It ،‫ ﻭﺍﻟﺿﻣﻳﺭ‬،‫ ﻭﺍﻟﻘﻳﻣﺔ‬،‫ ﻭﺍﻟﻛﺭﺍﻣﺔ‬،‫ﺟﻭﺍﻧﺏ ﺍﻟﺣﻳﺎﺓ ﺍﻟﺗﻲ ﺗﻣﻛﻥ ﺍﻹﻧﺳﺎﻥ ﻣﻥ ﺃﻥ ﻳﻛﻭﻥ ﺇﻧﺳﺎﻧﻳﺎ؛ ﻭﺍﻟﺗﻔﺭﺩ‬
includes all those aspects of life that enable a person to be human; uniqueness,
‫ ﺇﻧﻬﺎ ﺗﻌﺑﺭ ﻋﻥ ﺍﻟﺗﻌﺎﻣﻝ ﻣﻊ ﺍﻷﻟﻡ ﻭﺍﻟﻭﺣﺩﺓ ﻭﻣﻊ ﻗﺑﻭﻝ‬.‫ ﻭﺍﻟﻌﻼﻗﺎﺕ‬،‫ ﻭﺍﻟﻣﻌﺗﻘﺩﺍﺕ‬،‫ ﻭﺍﻟﻣﻭﺍﻗﻑ‬،‫ﻭﺍﻟﻘﻳﻡ‬
dignity, worth, conscience, values, attitudes, beliefs, relationships. It is about
coping with pain and loneliness and with accepting himself as he is without ‫ ﻟﻠﺗﻌﺎﻣﻝ ﻣﻊ ﺍﻟﺻﺭﺍﻉ‬،‫ ﺇﻧﻬﺎ ﺗﻌﻁﻲ ﺇﻣﻛﺎﻧﻳﺔ ﻟﻣﻭﺍﺟﻬﺔ ﺍﻹﺟﻬﺎﺩ‬.‫ﻧﻔﺳﻪ ﻛﻣﺎ ﻫﻭ ﺩﻭﻥ ﺇﺣﺭﺍﺝ ﺃﻭ ﻋﺎﺭ‬
embarrassment or shame. It makes it possible to face stress, to handle conflict, ‫ ﺍﻟﺑﻌﺩ ﺍﻟﺭﻭﺣﻲ ﻟﻠﺷﺧﺹ ﻳﺷﻣﻝ ﺍﻟﺣﺎﺟﺔ ﺇﻟﻰ ﺇﻳﺟﺎﺩ ﺇﺟﺎﺑﺎﺕ ﻣﺭﺿﻳﺔ ﻋﻠﻰ‬.‫ﻭﺍﻟﻘﻠﻕ ﻭﺍﻟﻔﺷﻝ ﻭﺍﻟﺭﻓﺽ‬
anxiety, failure and rejection. The spiritual dimension of a person encompasses .‫ﺃﺳﺋﻠﺗﻪ ﺍﻟﻼﻧﻬﺎﺋﻳﺔ ﺣﻭﻝ ﻣﻌﻧﻰ ﺍﻟﺣﻳﺎﺓ ﻭﺍﻟﻣﺭﺽ ﻭﺍﻟﻣﻭﺕ‬
the need for finding satisfactory answers to his ultimate questions about the ‫ﻣﻥ ﺍﻟﻣﻬﻡ ﺃﻥ ﻳﻔﻛﺭ ﺟﻣﻳﻊ ﺍﻟﻌﺎﻣﻠﻳﻥ ﻓﻲ ﻣﺟﺎﻝ ﺍﻟﺭﻋﺎﻳﺔ ﺍﻟﺻﺣﻳﺔ ﻓﻲ ﺃﻫﻣﻳﺔ ﺍﻟﻌﻧﺻﺭ ﺍﻟﺩﻳﻧﻲ ﻣﻥ ﺃﺟﻝ‬
meaning of life, illness, and death. .‫ﺍﻟﻣﺳﺎﻋﺩﺓ ﻓﻲ ﺇﺩﺍﺭﺓ ﺍﻟﻣﺭﺽ )ﺗﺟﺭﺑﺔ ﻓﻘﺩﺍﻥ ﺍﻟﺻﺣﺔ( ﻭﻛﺫﻟﻙ ﺍﻟﻣﺭﺽ‬
It is important that all those engaged in healthcare think about the relevance of ‫ﻭﻳﻣﻛﻥ ﺗﻭﻓﻳﺭ ﺍﻟﺭﻋﺎﻳﺔ ﺍﻟﺭﻭﺣﻳﺔ ﺍﻟﻣﺎﻫﺭﺓ ﻭﺍﻟﺣﺳﺎﺳﺔ ﻭﺍﻟﻣﻧﺎﺳﺑﺔ ﻣﻥ ﻗﺑﻝ ﻣﺟﻣﻭﻋﺔ ﻣﺗﻧﻭﻋﺔ ﻣﻥ‬
 ‫ﻗﺳﻡ ﺇﺩﺍﺭﺓ ﺍﻟﺟﻭﺩﺓ ﺍﻟﺷﺎﻣﻠﺔ‬
spirituality in order to help manage illness (the experience of losing health) as ‫ ﻭﻣﻥ ﺍﻟﺿﺭﻭﺭﻱ ﺃﻥ‬.‫ ﻭﻣﻭﻅﻔﻲ ﺍﻟﺭﻋﺎﻳﺔ ﺍﻻﺟﺗﻣﺎﻋﻳﺔ‬،‫ ﻭﺍﻟﺻﺣﺔ‬،‫ ﺑﻣﺎ ﻓﻲ ﺫﻟﻙ ﺃﻓﺭﺍﺩ ﺍﻷﺳﺭﺓ‬،‫ﺍﻟﻧﺎﺱ‬
well as disease. ‫ﻳﻛﻭﻥ ﻟﺩﻯ ﺍﻟﻣﻭﻅﻔﻳﻥ ﺍﻟﺻﺣﻳﻳﻥ ﻭﺍﻻﺟﺗﻣﺎﻋﻳﻳﻥ ﺍﻟﻣﻬﺎﺭﺍﺕ ﻭﺍﻟﻣﻌﺎﺭﻑ ﻭﺍﻟﺩﻋﻡ ﺍﻟﻼﺯﻡ ﻟﺗﻘﺩﻳﻡ ﻫﺫﻩ‬
Skilled, sensitive and appropriate spiritual care can be provided by a variety of .‫ﺍﻟﺭﻋﺎﻳﺔ ﺍﻟﺣﺳﺎﺳﺔ‬
people, including family members, health, and social care staff. It is essential ‫ ﻭﻗﺩ ﺗﻌﻁﻲ ﺍﻷﻧﺷﻁﺔ ﺍﻟﺩﻳﻧﻳﺔ‬.‫ﻳﻌﺩ ﺍﻟﺗﺩﻳﻥ ﺇﺣﺩﻯ ﺍﻟﻁﺭﻕ ﻟﺩﻯ ﺑﻌﺽ ﺍﻟﻧﺎﺱ ﻟﻠﺗﻌﺑﻳﺭ ﻋﻥ ﺍﻟﺭﻭﺣﻳﺔ‬
that health and social staff have the necessary skills, knowledge, and support to
،‫ ﻭﺣﺿﻭﺭ ﻧﺩﻭﺓ‬،‫ ﻗﺩ ﻳﺭﻏﺏ ﺍﻟﻧﺎﺱ ﻓﻲ ﺍﻟﺻﻼﺓ‬.‫ﻣﻧﻔﺫﺍ ﻟﺑﻌﺽ ﺍﻻﺣﺗﻳﺎﺟﺎﺕ ﺍﻟﺭﻭﺣﻳﺔ ﺍﻟﻣﺫﻛﻭﺭﺓ ﺃﻋﻼﻩ‬
deliver sensitive care.
Religious describes one way in which some people find expression for the
‫ﻭﺍﻟﺗﺣﺩﺙ ﺇﻟﻰ ﺭﺟﻝ ﺩﻳﻥ ﻭﻣﺎ ﺇﻟﻰ ﺫﻟﻙ ﻛﻭﺳﻳﻠﺔ ﻟﻭﺿﻊ ﺣﻠﻭﻝ ﻟﻸﺳﺋﻠﺔ ﺍﻟﺭﻭﺣﻳﺔ ﻭﺍﻻﺣﺗﻳﺎﺟﺎﺕ ﺍﻟﺗﻲ‬
spiritual. Religious activities may give an outlet for some of the spiritual needs .‫ﻳﻌﺎﻧﻭﻥ ﻣﻧﻬﺎ‬
mentioned above. People may wish to say prayers, attend a service, speak to a ‫ﻭﻣﻥ ﺍﻟﻣﻬﻡ ﺃﻥ ﻳﻌﻲ ﺟﻣﻳﻊ ﺍﻟﻌﺎﻣﻠﻳﻥ ﻓﻲ ﻣﺟﺎﻝ ﺍﻟﺭﻋﺎﻳﺔ ﺍﻟﺻﺣﻳﺔ ﺍﻟﻣﻣﺎﺭﺳﺎﺕ ﺍﻟﺩﻳﻧﻳﺔ ﻭﺍﻟﺛﻘﺎﻓﻳﺔ ﻟﻬﺅﻻء‬
minister of their faith etc. as a way of working out the spiritual questions and .‫ ﻻ ﺳﻳﻣﺎ ﻓﻳﻣﺎ ﻳﺗﻌﻠﻕ ﺑﺎﻟﺧﺻﻭﺻﻳﺔ ﻭﺍﻟﻧﻅﺎﻡ ﺍﻟﻐﺫﺍﺋﻲ ﻭﺍﻟﻭﻻﺩﺓ ﻭﺍﻟﻣﻭﺕ‬،‫ﺍﻟﺫﻳﻥ ﻳﺄﺗﻭﻥ ﺇﻟﻰ ﺍﻟﻣﺳﺗﺷﻔﻰ‬
needs which they are experiencing. :‫ﻭﻻ ﻳﻧﺑﻐﻲ ﺃﻥ ﻳﻛﻭﻥ ﺗﻘﻳﻳﻡ ﺍﻻﺣﺗﻳﺎﺟﺎﺕ ﺍﻟﺭﻭﺣﻳﺔ ﻧﻣﻁﻳﺎ ﺑﻝ ﻳﻧﺑﻐﻲ ﺃﻥ ﻳﺷﻣﻝ ﻋﻧﺎﺻﺭ ﺃﺳﺎﺳﻳﺔ ﻣﺛﻝ‬
It is important that all those engaged in health care familiarize themselves with ‫· ﺍﺳﺗﻛﺷﺎﻑ ﻛﻳﻔﻳﺔ ﻓﻬﻡ ﺍﻟﻧﺎﺱ ﻟﻣﺎ ﻳﺣﺩﺙ ﻟﻬﻡ‬
the religious and cultural practices of those who come into the hospital, ‫· ﻣﺎ ﻫﻲ ﻣﺻﺎﺩﺭ ﺍﻟﻘﻭﺓ ﺍﻟﺗﻲ ﻳﻣﻛﻥ ﺍﻻﻋﺗﻣﺎﺩ ﻋﻠﻳﻬﺎ‬
especially with regard to privacy, diet, birth and death. ‫· ﻭﻋﻣﺎ ﺇﺫﺍ ﻛﺎﻥ ﻳﺷﻌﺭ ﻫﺅﻻء ﺃﻥ ﺗﻠﻙ ﺍﻟﻣﺻﺎﺩﺭ ﺳﺗﻛﻭﻥ ﻣﻔﻳﺩﺓ ﻟﻬﻡ ﻓﻲ ﻫﺫﻩ ﺍﻟﻣﺭﺣﻠﺔ ﻣﻥ ﺣﻳﺎﺗﻬﻡ‬
Assessment of spiritual needs does not have to be structured but should include
core elements such as:
· Exploring how people make sense of what happens to them
· What sources of strength they can draw upon
PFR.2.1
· And whether these are felt to be helpful to them at this point in their life ‫ﻳﻌﺗﺭﻑ ﺍﻟﻣﺳﺗﺷﻔﻰ ﻭﻳﻭﻓﺭ ﺗﺩﺭﻳﺏ ﻟﻠﻣﻭﻅﻔﻳﻥ ﻋﻠﻰ ﺍﻻﺳﺗﺟﺎﺑﺔ ﻟﻣﻌﺗﻘﺩﺍﺕ ﺍﻟﻣﺭﻳﺽ ﺍﻟﺛﻘﺎﻓﻳﺔ‬
.‫ﻭﺍﻟﻧﻔﺳﻳﺔ ﺍﻻﺟﺗﻣﺎﻋﻳﺔ ﻭﺍﻟﺩﻳﻧﻳﺔ ﻭﺍﻟﺭﻭﺣﻳﺔ ﻭﺍﻟﻘﻳﻡ ﻭﺍﻻﺣﺗﻳﺎﺟﺎﺕ‬
PFR.2.1 PFR.2.2
The hospital recognizes and provides staff training on responding to .‫ﻳﻭﻓﺭ ﺍﻟﻣﺳﺗﺷﻔﻰ ﻣﺭﺍﻓﻕ ﻣﻧﻔﺻﻠﺔ ﻟﻠﻧﺳﺎء ﻛﻣﺎ ﺗﻘﺗﺿﻲ ﺍﻟﺣﺎﺟﺔ‬
patient’s cultural, psychosocial, religious and spiritual beliefs, values PFR.2.3
and needs. ‫ﻳﻭﻓﺭ ﺍﻟﻣﺳﺗﺷﻔﻰ ﺍﻟﻭﺻﻭﻝ ﺇﻟﻰ ﺍﻟﺭﻋﺎﻳﺔ ﺍﻟﺭﻭﺣﻳﺔ ﺃﻭ ﺍﻟﻣﺷﻭﺭﺓ ﺍﻟﺗﻲ ﺗﻠﺑﻲ ﺍﺣﺗﻳﺎﺟﺎﺕ ﻣﺧﺗﻠﻑ‬
PFR.2.2 .‫ﺍﻟﻣﺭﺍﺟﻌﻳﻥ‬
The hospital provides separate facilities for women where appropriate. PFR.2.4
PFR.2.3 .‫ﻳﻘﺩﻡ ﺍﻟﻣﻭﻅﻔﻭﻥ ﺍﻟﺭﻋﺎﻳﺔ ﻟﻠﻣﺭﺿﻰ ﺑﺎﺣﺗﺭﺍﻡ ﻭﻛﺭﺍﻣﺔ‬
The hospital provides access to spiritual care or advice that meets the
needs of the different populations served.
PFR.2.4
Staff members provide care to patients with respect and dignity.
PFR.3 PFR.3
Privacy of patients is maintained throughout the care .‫ﻳﺗﻡ ﺍﻟﺣﻔﺎﻅ ﻋﻠﻰ ﺧﺻﻭﺻﻳﺔ ﺍﻟﻣﺭﺿﻰ ﻓﻲ ﺟﻣﻳﻊ ﻣﺭﺍﺣﻝ ﻋﻣﻠﻳﺔ ﺍﻟﺭﻋﺎﻳﺔ‬
process.
:‫ﺍﻟﻐﺭﺽ‬
Standard Intent: ‫ ﻓﻳﻣﺎ ﻳﺗﻌﻠﻕ‬،‫ ﺇﻥ ﺣﻣﺎﻳﺔ ﺗﻠﻙ ﺍﻟﺣﻘﻭﻕ‬.‫ﺍﻟﺧﺻﻭﺻﻳﺔ ﻭﺍﻟﺳﺭﻳﺔ ﻫﻲ ﺍﻟﺣﻘﻭﻕ ﺍﻷﺳﺎﺳﻳﺔ ﻓﻲ ﻣﺟﺗﻣﻌﻧﺎ‬
Privacy and confidentiality are basic rights in our society. Safeguarding those ‫ ﺇﻥ ﺍﻟﻘﻳﺎﻡ‬.‫ ﻫﻭ ﺍﻟﺗﺯﺍﻣﻧﺎ ﺍﻷﺧﻼﻗﻲ ﻭﺍﻟﻘﺎﻧﻭﻧﻲ ﻛﻣﻘﺩﻣﻲ ﺍﻟﺭﻋﺎﻳﺔ ﺍﻟﺻﺣﻳﺔ‬،‫ﺑﻣﻌﺗﻘﺩﺍﺕ ﺍﻟﻔﺭﺩ ﺍﻟﺷﺧﺻﻳﺔ‬
rights, with respect to an individual’s personal beliefs, is our ethical and legal .‫ﺑﺫﻟﻙ ﻓﻲ ﺑﻳﺋﺔ ﺍﻟﺭﻋﺎﻳﺔ ﺍﻟﺻﺣﻳﺔ ﺍﻟﻳﻭﻡ ﻳﺷﻛﻝ ﺗﺣﺩﻳﺎ ﻣﺗﺯﺍﻳﺩﺍ‬
obligation as health care providers. Doing so in today’s health care ‫ﻳﺟﺏ ﻋﻠﻰ ﻣﻭﻅﻔﻲ ﺍﻟﻣﺳﺗﺷﻔﻰ ﺑﺫﻝ ﺟﻬﻭﺩ ﻟﻠﺣﻔﺎﻅ ﻋﻠﻰ ﺧﺻﻭﺻﻳﺔ ﺍﻟﻣﺭﺿﻰ ﻭﺍﺣﺗﺭﺍﻣﻬﻡ ﺃﺛﻧﺎء‬
environment is increasingly challenging.
 ‫ﻗﺳﻡ ﺇﺩﺍﺭﺓ ﺍﻟﺟﻭﺩﺓ ﺍﻟﺷﺎﻣﻠﺔ‬
The hospital staff has to exert efforts in maintaining and respecting patients’ ‫ ﺃﺧﺫ ﺍﻹﺫﻥ ﻗﺑﻝ‬،‫ ﺇﺑﻘﺎء ﺍﻟﺳﺗﺎﺋﺭ ﻣﻐﻠﻘﺔ ﺃﺛﻧﺎء ﺍﻟﻔﺣﻭﺻﺎﺕ ﺃﻭ ﺇﺟﺭﺍءﺍﺕ ﺍﻟﺳﺭﻳﺭ‬.‫ﺗﻘﺩﻳﻡ ﺧﺩﻣﺎﺕ ﺍﻟﺭﻋﺎﻳﺔ‬
privacy during provision of care services. Keeping curtains closed during ‫ ﻭﺗﻧﻔﻳﺫ ﻣﺩﻭﻧﺔ ﻗﻭﺍﻋﺩ ﺍﻟﺳﻠﻭﻙ ﻓﻲ ﻏﺭﻓﺔ ﺍﻟﻌﻣﻠﻳﺎﺕ ﻓﻲ ﺣﻳﻥ ﺃﻥ ﺍﻟﻣﺭﻳﺽ ﺗﺣﺕ‬،‫ﺃﻱ ﺇﺟﺭﺍء ﺃﻭ ﺍﻟﺗﺩﺧﻝ‬
examinations or bedside procedures, taking permission before any procedure or ‫ ﻣﻥ ﺑﻳﻥ ﺃﻣﻭﺭ ﺃﺧﺭﻯ ﺑﻌﺽ ﺍﻷﻣﺛﻠﺔ ﻋﻠﻰ ﺍﺣﺗﺭﺍﻡ‬،‫ ﻭﺍﻟﻣﻭﺍﻓﻘﺔ ﻋﻠﻰ ﺍﻟﻣﺭﻳﺽ ﻗﺑﻝ ﺗﺻﻭﻳﺭ‬،‫ﺍﻟﺗﺧﺩﻳﺭ‬
intervention, implementing the code of ethics in the operating theater while the .‫ﺧﺻﻭﺻﻳﺔ ﺍﻟﻣﺭﺿﻰ‬
patient is under anesthesia, consenting the patient prior to photograph, among
others are some examples of respecting the privacy of patients.
PFR.3.1
PFR.3.1 .‫ﺗﺣﺗﺭﻡ ﺧﺻﻭﺻﻳﺔ ﺍﻟﻣﺭﻳﺽ ﺧﻼﻝ ﺟﻣﻳﻊ ﺍﻟﻣﻘﺎﺑﻼﺕ ﻭﺍﻻﻣﺗﺣﺎﻧﺎﺕ ﻭﺍﻟﻌﻼﺟﺎﺕ‬
Patient privacy is respected during all interviews, examinations, and PFR.3.2
treatments. .‫ﻻ ﻳﺗﻡ ﺗﻌﺭﺽ ﺍﻷﺟﺯﺍء ﺍﻟﺧﺎﺻﺔ ﻟﻠﻣﺭﻳﺽ ﺩﻭﻥ ﺩﺍﻉ ﺃﺛﻧﺎء ﻋﻣﻠﻳﺔ ﺍﻟﺭﻋﺎﻳﺔ‬
PFR.3.2 PFR.3.3
Patient private parts are not exposed unnecessarily during care process. .‫ﺗﻭﺟﺏ ﺍﻟﻣﺳﺗﺷﻔﻰ ﺍﻟﺣﺻﻭﻝ ﻋﻠﻰ ﻣﻭﺍﻓﻘﺔ ﺧﻁﻳﺔ ﻋﻠﻰ ﺗﺻﻭﻳﺭ ﺍﻟﻣﺭﺿﻰ‬
PFR.3.3
The hospital mandates a written consent to photograph patients.
PFR.4 PFR.4
The hospital protects patient belongings. .‫ﻳﺣﻣﻲ ﺍﻟﻣﺳﺗﺷﻔﻰ ﻣﻣﺗﻠﻛﺎﺕ ﺍﻟﻣﺭﻳﺽ‬

Standard Intent: :‫ﺍﻟﻐﺭﺽ‬

The hospital is responsible for safeguarding patient belongings. A policy ‫ ﻳﺟﺏ ﻭﺿﻊ ﺳﻳﺎﺳﺔ ﺗﻧﻅﻡ ﻫﺫﻩ ﺍﻟﻌﻣﻠﻳﺔ ﺑﻣﺎ ﻓﻲ‬.‫ﺍﻟﻣﺳﺗﺷﻔﻰ ﻣﺳﺅﻭﻝ ﻋﻥ ﺣﻣﺎﻳﺔ ﻣﻣﺗﻠﻛﺎﺕ ﺍﻟﻣﺭﻳﺽ‬
should be in place that regulates this process including forms to be filled, the ‫ ﻭﺍﻟﺣﺎﻻﺕ ﺍﻟﺗﻲ‬،‫ ﻭﻭﻋﻲ ﺍﻟﻣﻭﻅﻔﻳﻥ‬،‫ ﻭﺍﻟﻣﻛﺎﻥ ﺍﻟﺫﻱ ﺗﺗﻡ ﻓﻳﻪ ﺍﻟﻌﻣﻠﻳﺔ‬،‫ﺫﻟﻙ ﺍﻟﻧﻣﺎﺫﺝ ﺍﻟﻭﺍﺟﺏ ﻣﻠﺅﻫﺎ‬
place where the process takes place, staff awareness, and cases when the .‫ﻳﻛﻭﻥ ﻓﻳﻬﺎ ﺍﻟﻣﺭﻳﺽ ﻏﻳﺭ ﻗﺎﺩﺭ ﻋﻠﻰ ﺍﺗﺧﺎﺫ ﺍﻟﻘﺭﺍﺭ‬
patient is unable to make a decision.

PFR.4.1
There is a process described in a policy for the protection of patient PFR.4.1
belongings. .‫ﻫﻧﺎﻙ ﻋﻣﻠﻳﺔ ﻣﻭﺻﻔﺔ ﻓﻲ ﺳﻳﺎﺳﺔ ﻟﺣﻣﺎﻳﺔ ﻣﻣﺗﻠﻛﺎﺕ ﺍﻟﻣﺭﻳﺽ‬
PFR.4.2 PFR.4.2
Patients receive information about the hospital’s responsibility for .‫ﻳﺗﻠﻘﻰ ﺍﻟﻣﺭﺿﻰ ﻣﻌﻠﻭﻣﺎﺕ ﺣﻭﻝ ﻣﺳﺅﻭﻟﻳﺔ ﺍﻟﻣﺳﺗﺷﻔﻰ ﻋﻥ ﺣﻣﺎﻳﺔ ﻭﺣﻣﺎﻳﺔ ﻣﻣﺗﻠﻛﺎﺗﻬﻡ‬
safeguarding and protecting their belongings. PFR.4.3
PFR.4.3 ‫ ﻓﺈﻥ ﺍﻟﻣﺳﺗﺷﻔﻰ ﻟﺩﻳﻪ ﻋﻣﻠﻳﺔ‬،‫ﻋﻧﺩﻣﺎ ﻳﺗﺣﻣﻝ ﺍﻟﻣﺳﺗﺷﻔﻰ ﻣﺳﺅﻭﻟﻳﺔ ﺣﻣﺎﻳﺔ ﻣﻣﺗﻠﻛﺎﺕ ﺍﻟﻣﺭﻳﺽ‬
When the hospital assumes responsibility for safeguarding patient .‫ﻟﺣﻣﺎﻳﺗﻬﻡ ﻣﻥ ﺍﻟﺳﺭﻗﺔ ﺃﻭ ﺍﻟﺧﺳﺎﺭﺓ‬
belongings, the hospital has a process to protect them from theft or loss. .‫ ﻳﺣﺩﺩ ﺍﻟﻣﺳﺗﺷﻔﻰ ﺃﻳﻥ ﻳﺗﻡ ﺍﻻﺣﺗﻔﺎﻅ ﺑﺎﻟﻣﻣﺗﻠﻛﺎﺕ ﺍﻟﺧﺎﺻﺔ ﺑﺎﻟﻣﺭﻳﺽ‬PFR.4.3.1
PFR.4.3.1 The hospital defines where the patient belongings are ‫ ﻳﺣﺩﺩ ﺍﻟﻣﺳﺗﺷﻔﻰ ﻣﻥ ﻫﻭ ﺍﻟﻣﺳﺅﻭﻝ ﻋﻥ ﺍﻟﺣﺻﻭﻝ ﻋﻠﻰ ﺍﻟﺗﻭﻗﻳﻌﺎﺕ ﺍﻟﻣﻁﻠﻭﺑﺔ‬PFR.4.3.2
kept. .‫ﻋﻠﻰ ﺍﻟﻧﻣﻭﺫﺝ ﺫﻱ ﺍﻟﺻﻠﺔ ﻋﻧﺩ ﺗﻠﻘﻲ ﻭﺗﺳﻠﻳﻡ ﻣﻣﺗﻠﻛﺎﺕ ﺍﻟﻣﺭﻳﺽ‬
PFR.4.3.2 The hospital defines who is responsible for obtaining PFR.4.4
the required signatures on the related form when receiving and ‫ﺗﺣﺩﺩ ﺍﻟﻣﺳﺗﺷﻔﻰ ﻛﻳﻔﻳﺔ ﺍﻟﺗﻌﺎﻣﻝ ﻣﻊ ﺍﻷﺷﻳﺎء ﺍﻟﺛﻣﻳﻧﺔ ﻟﻠﻣﺭﺿﻰ ﻏﻳﺭ ﺍﻟﻘﺎﺩﺭﻳﻥ ﻋﻠﻰ ﺍﺗﺧﺎﺫ ﺍﻟﻘﺭﺍﺭﺍﺕ‬
handing over the patient’s belongings. ،‫ ﻭﺍﻟﻣﺭﺿﻰ ﻓﻲ ﺣﺎﻟﺔ ﺍﻟﻐﻳﺑﻭﺑﺔ‬،‫ﺍﻟﻣﺗﻌﻠﻘﺔ ﺑﻣﻣﺗﻠﻛﺎﺗﻬﻡ ) ﻣﺛﻝ ﺍﻟﻣﺭﺿﻰ ﺍﻟﻣﺻﺎﺑﻳﻥ ﺑﺻﺩﻣﺎﺕ ﻧﻔﺳﻳﺔ‬
PFR.4.4 .(‫ ﻭﺍﻟﻣﺳﻧﻳﻥ ﻭﺍﻷﻁﻔﺎﻝ‬،‫ﻭﺍﻟﻣﺭﺿﻰ ﺍﻟﻣﺷﻭﺷﻳﻥ‬
The hospital addresses how the valuables of those patients unable to
 ‫ﻗﺳﻡ ﺇﺩﺍﺭﺓ ﺍﻟﺟﻭﺩﺓ ﺍﻟﺷﺎﻣﻠﺔ‬
make decisions regarding their belongings (e.g., traumatized patients,
patients in comatose state, confused patients, elderly and children) are
handled and safeguarded.

PFR.5 PFR.5
The hospital provides protection for patients. .‫ﻳﻭﻓﺭ ﺍﻟﻣﺳﺗﺷﻔﻰ ﺍﻟﺣﻣﺎﻳﺔ ﻟﻠﻣﺭﺿﻰ‬

Standard Intent: :‫ﺍﻟﻐﺭﺽ‬

Certain groups of patients and hospital areas require specialized protection. ‫ ﻭﻳﻧﺑﻐﻲ ﺃﻥ‬.‫ﺑﻌﺽ ﻣﺟﻣﻭﻋﺎﺕ ﺍﻟﻣﺭﺿﻰ ﻭﺍﻟﻣﺟﺎﻻﺕ ﻓﻲ ﺍﻟﻣﺳﺗﺷﻔﻳﺎﺕ ﺗﺗﻁﻠﺏ ﺣﻣﺎﻳﺔ ﻣﺗﺧﺻﺻﺔ‬
The hospital should provide extra protection measures for such groups or ‫ ﻭﻳﻧﺑﻐﻲ ﺃﻥ ﻳﺗﻠﻘﻰ ﺍﻟﻣﺭﺿﻰ‬.‫ﻳﻭﻓﺭ ﺍﻟﻣﺳﺗﺷﻔﻰ ﺗﺩﺍﺑﻳﺭ ﺣﻣﺎﻳﺔ ﺇﺿﺎﻓﻳﺔ ﻟﻬﺫﻩ ﺍﻟﻣﺟﻣﻭﻋﺎﺕ ﺃﻭ ﺍﻷﻣﺎﻛﻥ‬
places. Vulnerable patients should receive adequate assistance and protection .‫ﺍﻟﺿﻌﻔﺎء ﺍﻟﻣﺳﺎﻋﺩﺓ ﻭﺍﻟﺣﻣﺎﻳﺔ ﺍﻟﻛﺎﻓﻳﺔ ﺍﻟﺗﻲ ﻳﺣﺗﺎﺟﻭﻥ ﺇﻟﻳﻬﺎ‬
they need. .‫ﻳﻣﻛﻥ ﺃﻥ ﻳﻛﻭﻥ ﺇﺳﺎءﺓ ﻣﻌﺎﻣﻠﺔ ﺍﻟﻣﺭﻳﺽ ﻭﺇﻫﻣﺎﻟﻪ ﻭﺍﺳﺗﻐﻼﻟﻪ ﺟﺳﺩﻳﺎ ﺃﻭ ﺟﻧﺳﻳﺎ ﺃﻭ ﻋﺎﻁﻔﻳﺎ ﺃﻭ ﻣﺎﻟﻳﺎ‬
Patient abuse, neglect, and exploitation can be physical, sexual, emotional or ‫ﻭﻗﺩ ﻳﺣﺩﺙ ﺇﻫﻣﺎﻝ ﺟﻧﺎﺋﻲ ﺃﻳﺿﺎ ﻋﻧﺩﻣﺎ ﻳﻔﺷﻝ ﻣﻘﺩﻡ ﺍﻟﺭﻋﺎﻳﺔ ﻓﻲ ﺗﻭﻓﻳﺭ ﺍﻟﻌﻼﺝ ﺃﻭ ﺍﻟﺭﻋﺎﻳﺔ ﺍﻟﻼﺯﻣﺔ‬
financial. Criminal neglect may also occur when a caregiver fails to provide
‫ ﻳﺟﺏ ﻋﻠﻰ ﺍﻟﻣﺳﺗﺷﻔﻰ ﺗﺣﺩﻳﺩ ﻭﻣﻧﻊ ﺟﻣﻳﻊ ﺃﻧﻭﺍﻉ ﺍﻹﻫﻣﺎﻝ ﺃﻭ‬.‫ﻟﻠﺣﻔﺎﻅ ﻋﻠﻰ ﺻﺣﺔ ﺍﻟﻔﺭﺩ ﺃﻭ ﺳﻼﻣﺗﻪ‬
treatment or care that is necessary to maintain the health or safety of the
individual. The hospital has to identify and prevent all types of neglect or :‫ﺇﺳﺎءﺓ ﻣﻌﺎﻣﻠﺔ ﺍﻟﻣﺭﺿﻰ ﻣﺛﻝ‬
abuse of patients such as: ‫ ﺇﻫﻣﺎﻝ ﺍﻟﻣﺭﺿﻰ ﻋﻥ ﻁﺭﻳﻕ ﺍﻟﺗﻌﻣﺩ ﻓﻲ ﺗﻘﺩﻳﻡ ﺧﺩﻣﺎﺕ ﻓﻲ ﺍﻟﻭﻗﺕ ﺍﻟﻣﻧﺎﺳﺏ ﻭﻣﺗﺳﻘﺔ ﻭﻛﺎﻓﻳﺔ‬.1
1. Neglecting patients by willfully failing to provide timely, consistent, .‫ ﻣﺛﻝ ﺍﻟﺗﻐﺫﻳﺔ ﻭﺍﻟﻌﻼﺝ ﻭﺍﻟﻧﻅﺎﻓﺔ‬،‫ﻭﺁﻣﻧﺔ‬
adequate and safe services, such as nutrition, therapy, and cleanliness; ‫ ﺃﻭ ﺇﺳﺎءﺓ ﺍﺳﺗﺧﺩﺍﻡ ﺍﻟﻘﻳﻭﺩ‬،‫ ﺳﻭء ﻣﻌﺎﻣﻠﺔ ﺍﻟﻣﺭﺿﻰ ﻋﻥ ﻁﺭﻳﻕ ﺳﺭﻗﺔ ﺃﻭ ﺇﺳﺎءﺓ ﺍﺳﺗﺧﺩﺍﻡ ﺍﻷﺩﻭﻳﺔ‬.2
2. Mistreating patients by stealing or misusing medications, or misusing .‫ﺃﻭ ﺍﻟﻌﺯﻟﺔ‬
restraints or isolation; .‫ ﺃﻭ ﺍﻟﺗﺣﺭﺵ ﺑﻬﻡ‬،‫ ﺍﻫﺗﺯﺍﺯ‬،‫ ﺍﻻﻋﺗﺩﺍء ﺟﺳﺩﻳﺎ ﻋﻠﻰ ﺍﻟﻣﺭﺿﻰ ﻋﻥ ﻁﺭﻳﻕ ﺿﺭﺏ‬.3
3. Physically abusing patients by striking, shaking, or molesting them; ‫ ﺗﺯﻭﻳﺭ ﻋﻼﺝ ﺍﻟﻣﺭﻳﺽ ﺃﻭ ﺳﺟﻼﺕ ﺍﻟﺭﻋﺎﻳﺔ‬.4
4. Falsifying the patient’s treatment or care records

PFR.5.1 PFR.5.1
Patients are protected from neglect and abuse by physicians, nurses, or ‫ﻳﺗﻡ ﺣﻣﺎﻳﺔ ﺍﻟﻣﺭﺿﻰ ﻣﻥ ﺍﻹﻫﻣﺎﻝ ﻭﺇﺳﺎءﺓ ﺍﻟﻣﻌﺎﻣﻠﺔ ﻣﻥ ﻗﺑﻝ ﺍﻷﻁﺑﺎء ﻭﺍﻟﻣﻣﺭﺿﻳﻥ ﺃﻭ ﺃﻱ ﻣﻭﻅﻔﻳﻥ‬
any other staff. .‫ﺁﺧﺭﻳﻥ‬
PFR.5.2 PFR.5.2
The hospital provides appropriate security and prevents unauthorized ‫ﻳﻭﻓﺭ ﺍﻟﻣﺳﺗﺷﻔﻰ ﺍﻷﻣﻥ ﺍﻟﻣﻼﺋﻡ ﻭﻳﻣﻧﻊ ﺍﻟﻭﺻﻭﻝ ﻏﻳﺭ ﺍﻟﻣﺻﺭﺡ ﺑﻪ ﺇﻟﻰ ﺍﻟﻣﻧﺎﻁﻕ ﺍﻟﻧﺎﺋﻳﺔ ﺃﻭ‬
access to remote or sensitive areas (e.g., female wards). .(‫ﺍﻟﺣﺳﺎﺳﺔ )ﻣﺛﻝ ﺃﺟﻧﺣﺔ ﺍﻹﻧﺎﺙ‬
PFR.5.3 PFR.5.3
The hospital provides visitors with identification badges. .‫ﻳﻭﻓﺭ ﺍﻟﻣﺳﺗﺷﻔﻰ ﻟﻠﺯﺍﺋﺭﻳﻥ ﺷﺎﺭﺍﺕ ﺍﻟﺗﻌﺭﻳﻑ‬
PFR.5.4 PFR.5.4
The hospital has a process in place to protect infants/children from .‫ﻟﺩﻯ ﺍﻟﻣﺳﺗﺷﻔﻰ ﻋﻣﻠﻳﺔ ﻟﺣﻣﺎﻳﺔ ﺍﻟﺭﺿﻊ ﻭﺍﻷﻁﻔﺎﻝ ﻣﻥ ﺍﻻﺧﺗﻁﺎﻑ‬
abduction. PFR.5.5
PFR.5.5 ‫ﻟﺩﻯ ﺍﻟﻣﺳﺗﺷﻔﻰ ﻋﻣﻠﻳﺔ ﻟﺣﻣﺎﻳﺔ ﺍﻟﻣﺭﺿﻰ ﺍﻟﻣﻌﺭﺿﻳﻥ ﻟﻠﺧﻁﺭ ) ﻣﺛﻝ ﺍﻟﻣﺭﺿﻰ ﺍﻟﻣﻌﻭﻗﻳﻥ‬
The hospital has a process in place to protect vulnerable patients (e.g., .(‫ﻭﺍﻟﻣﺳﻧﻳﻥ‬
disabled and elderly patients).
 ‫ﻗﺳﻡ ﺇﺩﺍﺭﺓ ﺍﻟﺟﻭﺩﺓ ﺍﻟﺷﺎﻣﻠﺔ‬
PFR.6 PFR.6
The hospital provides assistance to patients with special .‫ﻳﻘﺩﻡ ﺍﻟﻣﺳﺗﺷﻔﻰ ﺍﻟﻣﺳﺎﻋﺩﺓ ﻟﻠﻣﺭﺿﻰ ﺫﻭﻱ ﺍﻻﺣﺗﻳﺎﺟﺎﺕ ﺍﻟﺧﺎﺻﺔ‬
needs.
:‫ﺍﻟﻐﺭﺽ‬
Standard Intent: ‫ ﻭﻳﻧﺑﻐﻲ‬.‫ﻭﻳﻧﺑﻐﻲ ﺃﻥ ﻳﺗﻠﻘﻰ ﺍﻟﻣﺭﺿﻰ ﺫﻭﻱ ﺍﻻﺣﺗﻳﺎﺟﺎﺕ ﺍﻟﺧﺎﺻﺔ ﺍﻟﻣﺳﺎﻋﺩﺓ ﺍﻟﻛﺎﻓﻳﺔ ﺍﻟﺗﻲ ﻳﺣﺗﺎﺟﻭﻧﻬﺎ‬
Special needs patients should receive adequate assistance they need. ‫ﺍﻟﻧﻅﺭ ﻓﻲ ﺍﻟﻣﺗﻁﻠﺑﺎﺕ ﺍﻟﺣﺎﺳﻣﺔ ﻟﻠﺗﻌﺎﻣﻝ ﻣﻊ ﺍﻟﻣﺭﺿﻰ ﺫﻭﻱ ﺍﻻﺣﺗﻳﺎﺟﺎﺕ ﺍﻟﺧﺎﺻﺔ ﻓﻲ ﺍﻟﺗﺧﻁﻳﻁ‬
Requirements critical to deal with special needs patients should be considered ‫ ﻭﻗﻭﻑ ﺍﻟﺳﻳﺎﺭﺍﺕ ﻭﺍﻟﻛﺭﺍﺳﻲ‬:‫ ﻭﻣﻥ ﺍﻷﻣﺛﻠﺔ ﻋﻠﻰ ﺫﻟﻙ‬.‫ﻟﺟﻣﻳﻊ ﺍﻟﻣﺭﺍﻓﻕ ﻭﺍﻟﺧﺩﻣﺎﺕ ﺍﻟﻣﺳﺗﺷﻔﻰ‬
in the planning of all hospital facilities and services. Examples are: parking, ‫ ﻭﺍﻟﻣﺳﺎﻋﺩﺓ ﻓﻲ ﺣﺎﻟﺔ‬،‫ ﻭﺍﻟﻣﺗﺭﺟﻣﻳﻥ ﺍﻟﻔﻭﺭﻳﻳﻥ ﻭﺃﺟﻬﺯﺓ ﺍﻟﺳﻣﻊ‬،‫ﺍﻟﻣﺗﺣﺭﻛﺔ ﻭﺍﻟﺣﻣﺎﻣﺎﺕ ﺍﻟﺧﺎﺻﺔ‬
wheel chairs, special bathrooms, interpreters and hearing devices, assistance in .‫ﻧﺷﻭﺏ ﺣﺭﻳﻕ‬
the event of fire.
PFR.6.1
PFR.6.1 ‫ﻳﻘﺩﻡ ﺍﻟﻣﺳﺗﺷﻔﻰ ﺍﻟﻣﺳﺎﻋﺩﺓ ﺍﻟﺿﺭﻭﺭﻳﺔ ﻟﻠﻣﺭﺿﻰ ﺫﻭﻱ ﺍﻻﺣﺗﻳﺎﺟﺎﺕ ﺍﻟﺧﺎﺻﺔ ﺣﻳﺛﻣﺎ ﺩﻋﺕ ﺍﻟﺣﺎﺟﺔ‬
The hospital provides the necessary assistance to patients with special ‫ﺇﻟﻰ ﺫﻟﻙ ) ﻣﺛﻝ ﺗﻘﺩﻳﻡ ﺍﻟﻣﺳﺎﻋﺩﺓ ﻓﻲ ﺣﺎﻻﺕ ﺍﻟﺣﺭﻳﻕ ﻭﺃﻣﺎﻛﻥ ﻭﻗﻭﻑ ﺍﻟﺳﻳﺎﺭﺍﺕ ﺧﺎﺭﺝ ﺍﻟﺷﺎﺭﻉ‬
needs where and when needed (e.g., providing assistance in case of fire, ‫ ﻭﺇﻣﻛﺎﻧﻳﺔ‬،‫ ﻭﺣﻣﺎﻣﺎﺕ ﺍﻟﻣﻌﻭﻗﻳﻥ ﺍﻟﺗﻲ ﻳﻣﻛﻥ ﺍﻟﻭﺻﻭﻝ ﺇﻟﻳﻬﺎ‬،‫ﺑﺎﻟﻘﺭﺏ ﻣﻥ ﻣﺩﺧﻝ ﺍﻟﻣﺭﺿﻰ ﺍﻟﻣﻌﻭﻗﻳﻥ‬
off-street parking spaces near the entrance for disabled patients, .(‫ﺍﻟﻭﺻﻭﻝ ﻟﻣﺳﺗﺧﺩﻣﻲ ﺍﻟﻛﺭﺍﺳﻲ ﺍﻟﻣﺗﺣﺭﻛﺔ‬
handicapped accessible bathrooms, accessibility for wheelchair users).

PFR.7 PFR.7
Staff members respect and protect patient health .‫ﻳﺣﺗﺭﻡ ﺍﻟﻣﻭﻅﻔﻭﻥ ﻭﻳﺣﻣﻭﻥ ﺳﺭﻳﺔ ﺍﻟﻣﻌﻠﻭﻣﺎﺕ ﺍﻟﺻﺣﻳﺔ ﻟﻠﻣﺭﻳﺽ ﻁﻭﺍﻝ ﻋﻣﻠﻳﺔ ﺍﻟﺭﻋﺎﻳﺔ‬
information confidentiality throughout the care
:‫ﺍﻟﻐﺭﺽ‬
process. .‫ﻳﺟﺏ ﻋﻠﻰ ﺍﻟﻣﻧﻅﻣﺔ ﺗﺣﺩﻳﺩ ﻣﺳﺗﻭﻯ ﺍﻷﻣﻥ ﻭﺍﻟﺳﺭﻳﺔ ﺍﻟﺣﻔﺎﻅ ﻋﻠﻰ ﺍﻟﻣﻌﻠﻭﻣﺎﺕ ﺍﻟﻣﺗﻌﻠﻘﺔ ﺑﺎﻟﻣﺭﻳﺽ‬
Standard Intent:
.‫ﻭﻳﺳﺗﻧﺩ ﺍﻟﻭﺻﻭﻝ ﺇﻟﻰ ﻫﺫﺍ ﺍﻟﻧﻭﻉ ﻣﻥ ﺍﻟﻣﻌﻠﻭﻣﺎﺕ ﺇﻟﻰ ﺍﻟﺣﺎﺟﺔ ﻭﻳﻌﺭﻑ ﺑﻣﺳﻣﻰ ﺍﻟﻭﻅﻳﻔﺔ ﻭﺍﻟﻭﻅﻳﻔﺔ‬
The organization must determine the level of security and confidentiality
maintained for patient related information. Access to this type of information .‫ﺗﻌﺭﻑ ﻋﻣﻠﻳﺔ ﻓﻌﺎﻟﺔ‬
is based on need and defined by job title and function. An effective process .‫ ﻣﻥ ﻟﺩﻳﻪ ﺣﻕ ﺍﻟﻭﺻﻭﻝ ﺇﻟﻰ ﺍﻟﻣﻌﻠﻭﻣﺎﺕ‬.1
defines. ‫ ﺍﻟﻣﻌﻠﻭﻣﺎﺕ ﺍﻟﺗﻲ ﻳﺳﺗﻁﻳﻊ ﺍﻟﻔﺭﺩ ﺍﻟﻭﺻﻭﻝ ﺇﻟﻳﻬﺎ؛‬-2
1. Who has access to information; ‫ ﻭ‬.‫ ﺍﻟﺗﺯﺍﻡ ﺍﻟﻣﺳﺗﺧﺩﻡ ﻟﻠﺣﻔﺎﻅ ﻋﻠﻰ ﺳﺭﻳﺔ ﺍﻟﻣﻌﻠﻭﻣﺎﺕ‬.3
2. The information to which an individual has access; .‫ ﺍﻟﻌﻣﻠﻳﺔ ﺍﻟﻣﺗﺑﻌﺔ ﻋﻧﺩﻣﺎ ﺗﻧﺗﻬﻙ ﺍﻟﺳﺭﻳﺔ ﻭﺍﻷﻣﻥ‬- 4
3. The user’s obligation to keep information confidential; and
4. The process followed when confidentiality and security are violated.
PFR.7.1
PFR.7.1 ‫ﻳﻧﻔﺫ ﺍﻟﻣﺳﺗﺷﻔﻰ ﺳﻳﺎﺳﺔ ﺗﺿﻣﻥ ﺳﺭﻳﺔ ﺍﻟﻣﻌﻠﻭﻣﺎﺕ ﺍﻟﻣﺗﻌﻠﻘﺔ ﺑﺻﺣﺔ ﺍﻟﻣﺭﻳﺽ ﻭﻛﻳﻔﻳﺔ ﺣﻣﺎﻳﺗﻪ ﻣﻥ‬
The hospital implements a policy that ensures the confidentiality of .‫ﺍﻟﺿﻳﺎﻉ ﺃﻭ ﺳﻭء ﺍﻻﺳﺗﺧﺩﺍﻡ‬
information related to the patient’s health and how to protect it from loss PFR.7.2
or misuse. ‫ﺗﺷﻳﺭ ﺍﻟﺳﻳﺎﺳﺔ ﺇﻟﻰ ﺍﻟﻅﺭﻭﻑ ﺍﻟﺗﻲ ﻳﻣﻛﻥ ﻓﻳﻬﺎ ﺍﻹﻓﺭﺍﺝ ﻋﻥ ﻫﺫﻩ ﺍﻟﻣﻌﻠﻭﻣﺎﺕ ﻭﻛﻳﻔﻳﺔ ﺍﻟﺣﺻﻭﻝ ﻋﻠﻰ‬
PFR.7.2 .‫ﺇﺫﻥ ﺍﻟﻣﺭﻳﺽ ﺇﺫﺍ ﻟﺯﻡ ﺍﻷﻣﺭ‬
The policy indicates the circumstances under which such information
may be released and how to obtain patient’s permission if required.
 ‫ﻗﺳﻡ ﺇﺩﺍﺭﺓ ﺍﻟﺟﻭﺩﺓ ﺍﻟﺷﺎﻣﻠﺔ‬
PFR.8 PFR.8
Staff members assist patients and their families to ‫ﻳﺳﺎﻋﺩ ﺍﻟﻣﻭﻅﻔﻭﻥ ﺍﻟﻣﺭﺿﻰ ﻭﺃﺳﺭﻫﻡ ﻋﻠﻰ ﺍﻟﻣﺷﺎﺭﻛﺔ ﻓﻲ ﺍﺗﺧﺎﺫ ﻗﺭﺍﺭﺍﺕ ﻣﺳﺗﻧﻳﺭﺓ ﺑﺷﺄﻥ ﻋﻣﻠﻳﺔ‬
participate in making informed decisions about the care .‫ﺍﻟﺭﻋﺎﻳﺔ ﻭﺍﻟﻌﻼﺝ ﻭﺍﻟﺧﺩﻣﺎﺕ‬
process, treatment and services. :‫ﺍﻟﻐﺭﺽ‬
Standard Intent:
‫ ﻭﻳﻧﺑﻐﻲ ﺃﻥ ﺗﺳﺗﻧﺩ ﻫﺫﻩ ﺍﻟﻘﺭﺍﺭﺍﺕ ﺇﻟﻰ‬.‫ﺗﺩﻋﻡ ﺍﻟﻘﻳﺎﺩﺓ ﻣﺷﺎﺭﻛﺔ ﺍﻟﻣﺭﺿﻰ ﻓﻲ ﻗﺭﺍﺭﺍﺕ ﺍﻟﺭﻋﺎﻳﺔ‬
The leadership supports patient participation in care decisions. These decisions
should be based on information provided by caregivers. The information ‫ ﻋﻠﻰ ﺳﺑﻳﻝ ﺍﻟﻣﺛﺎﻝ ﻻ‬،‫ ﻭﻳﻧﺑﻐﻲ ﺃﻥ ﺗﺷﻣﻝ ﺍﻟﻣﻌﻠﻭﻣﺎﺕ‬.‫ﺍﻟﻣﻌﻠﻭﻣﺎﺕ ﺍﻟﺗﻲ ﻳﻘﺩﻣﻬﺎ ﻣﻘﺩﻣﻭ ﺍﻟﺭﻋﺎﻳﺔ‬
should include, but not limited to, nature of the disease, different options of / ‫ ﻭﺍﻟﻣﺧﺎﻁﺭ ﺍﻟﻣﺣﺗﻣﻠﺔ‬،‫ ﻭﺍﻟﻣﻧﺎﻓﻊ‬،‫ ﻭﺧﻳﺎﺭﺍﺕ ﺍﻹﺩﺍﺭﺓ ﺍﻟﻣﺧﺗﻠﻔﺔ‬،‫ ﻁﺑﻳﻌﺔ ﺍﻟﻣﺭﺽ‬،‫ﺍﻟﺣﺻﺭ‬
management, benefits, and potential risks/complications including no .‫ ﻳﺗﻡ ﺗﻭﻓﻳﺭ ﺍﻟﻣﻌﻠﻭﻣﺎﺕ ﺑﻁﺭﻳﻘﺔ ﻣﻔﻬﻭﻣﺔ ﻟﻠﻣﺭﻳﺽ‬.‫ﺍﻟﻣﺿﺎﻋﻔﺎﺕ ﺑﻣﺎ ﻓﻲ ﺫﻟﻙ ﻋﺩﻡ ﻭﺟﻭﺩ ﻋﻼﺝ‬
treatment. The information is provided in a way that is understandable to the ‫ﺗﻭﻗﻳﻊ ﺍﻟﻣﺭﻳﺽ ﻳﻌﻧﻲ ﺗﻠﻘﻲ ﺍﻟﻣﻌﻠﻭﻣﺎﺕ ﺍﻟﻣﺫﻛﻭﺭﺓ ﺃﻋﻼﻩ ﻻﺗﺧﺎﺫ ﻗﺭﺍﺭ ﻣﺳﺗﻧﻳﺭ ﺑﺎﻹﺿﺎﻓﺔ ﺇﻟﻰ‬
patient. The patient's signature signifies receiving the above information to ‫ ﻳﻌﺎﻟﺞ‬. ‫ ﻗﺩ ﺃﺟﻳﺏ ﻋﻧﻬﺎ ﺑﺻﻭﺭﺓ ﻣﺭﺿﻳﺔ‬/ ‫ﺍﻟﺣﺻﻭﻝ ﻋﻠﻰ ﻓﺭﺻﺔ ﻟﻁﺭﺡ ﺍﻷﺳﺋﻠﺔ ﻭﺃﻥ ﺟﻣﻳﻊ ﺃﺳﺋﻠﺗﻪ‬
make an informed decision in addition to getting the chance to ask questions .‫ﺍﻟﻣﺳﺗﺷﻔﻰ ﺣﻕ ﺍﻟﻣﺭﻳﺽ ﻓﻲ ﻁﻠﺏ ﺭﺃﻱ ﺁﺧﺭ ﺣﻭﻝ ﺭﻋﺎﻳﺗﻪ‬
and that all his/her questions have been answered to his satisfaction. The
hospital addresses the patient right to request another opinion about his care.

PFR.8.1
Patients are informed about how they can actively participate in their
care decisions.
PFR.8.2 PFR.8.1
Patients’ choices are respected. .‫ﻳﺗﻡ ﺇﻋﻼﻡ ﺍﻟﻣﺭﺿﻰ ﺣﻭﻝ ﻛﻳﻔﻳﺔ ﻣﺷﺎﺭﻛﺗﻬﻡ ﺑﻔﺎﻋﻠﻳﺔ ﻓﻲ ﻗﺭﺍﺭﺍﺕ ﺍﻟﺭﻋﺎﻳﺔ ﺍﻟﺧﺎﺻﺔ ﺑﻬﻡ‬
PFR.8.3 PFR.8.2
Staff members provide patients and, when appropriate, their families .‫ﻳﺗﻡ ﺍﺣﺗﺭﺍﻡ ﺧﻳﺎﺭﺍﺕ ﺍﻟﻣﺭﺿﻰ‬
with honest, accurate and reasonable information in a manner they can PFR.8.3
understand about their illness, the proposed treatment and other ‫ ﻣﻌﻠﻭﻣﺎﺕ ﺻﺎﺩﻗﺔ ﻭﺩﻗﻳﻘﺔ ﻭﻣﻌﻘﻭﻟﺔ ﺑﻁﺭﻳﻘﺔ‬، ‫ ﻭﻷﺳﺭﻫﻡ ﻋﻧﺩ ﺍﻟﺣﺎﺟﺔ‬،‫ﻳﻭﻓﺭ ﺍﻟﻣﻭﻅﻔﻭﻥ ﻟﻠﻣﺭﺿﻰ‬
alternatives, potential benefits, potential complications and likelihood of ،‫ ﺍﻟﻔﻭﺍﺋﺩ ﺍﻟﻣﺣﺗﻣﻠﺔ‬،‫ ﻭﺍﻟﻌﻼﺝ ﺍﻟﻣﻘﺗﺭﺡ ﻭﺍﻟﺑﺩﺍﺋﻝ ﺍﻷﺧﺭﻯ‬،‫ﻳﻣﻛﻧﻬﻡ ﻓﻬﻣﻬﺎ ﺣﻭﻝ ﻣﺭﺿﻬﻡ‬
success of treatment. .‫ﺍﻟﻣﺿﺎﻋﻔﺎﺕ ﺍﻟﻣﺣﺗﻣﻠﺔ ﻭﺍﺣﺗﻣﺎﻝ ﻧﺟﺎﺡ ﺍﻟﻌﻼﺝ‬
PFR.8.4 PFR.8.4
When it is medically inadvisable to provide the patient with such ‫ ﻳﺗﻡ ﺗﻘﺩﻳﻡ‬،‫ﻋﻧﺩﻣﺎ ﻳﻛﻭﻥ ﻣﻥ ﻏﻳﺭ ﺍﻟﻣﺳﺗﺻﻭﺏ ﻁﺑﻳﺎ ﺗﺯﻭﻳﺩ ﺍﻟﻣﺭﻳﺽ ﺑﻣﺛﻝ ﻫﺫﻩ ﺍﻟﻣﻌﻠﻭﻣﺎﺕ‬
information, the information is provided to a legally authorized person .‫ﺍﻟﻣﻌﻠﻭﻣﺎﺕ ﺇﻟﻰ ﺷﺧﺹ ﻣﺭﺧﺹ ﻟﻪ ﻗﺎﻧﻭﻧﻳﺎ ﺃﻭ ﺷﺧﺹ ﻳﻌﻳﻧﻪ ﺍﻟﻣﺭﻳﺽ‬
or a person designated by the patient. PFR.8.5
PFR.8.5 ‫ﻳﺗﻡ ﺩﻋﻡ ﺍﻟﻣﺭﺿﻰ ﻟﻣﻧﺎﻗﺷﺔ ﺧﻁﻁ ﺍﻟﺭﻋﺎﻳﺔ ﺍﻟﺧﺎﺻﺔ ﺑﻬﻡ ﻣﻊ ﺍﻟﻣﻭﻅﻔﻳﻥ ﺍﻟﻣﺳﺅﻭﻟﻳﻥ ﻭﻳﺗﻡ ﺃﺟﺎﺑﺔ‬
Patients are supported to discuss their plans of care with the responsible .‫ﺟﻣﻳﻊ ﺃﺳﺋﻠﺗﻬﻡ‬
staff members and have all their questions answered. ‫ ﻳﺗﻡ ﺗﺯﻭﻳﺩ ﺍﻟﻣﺭﻳﺽ ﺑﺎﻻﺳﻡ ﻭﺍﻟﻭﺿﻊ ﺍﻟﻣﻬﻧﻲ ﻟﻠﻁﺑﻳﺏ ﺃﻭ ﻏﻳﺭﻩ ﻣﻥ ﺍﻟﻣﻬﻧﻳﻳﻥ‬PFR.8.5.1
PFR.8.5.1 The patient is provided with the name and the .‫ﺍﻟﺫﻳﻥ ﻳﺗﺣﻣﻠﻭﻥ ﺍﻟﻣﺳﺅﻭﻟﻳﺔ ﺍﻟﺭﺋﻳﺳﻳﺔ ﻋﻥ ﺇﺩﺍﺭﺓ ﻋﻣﻠﻳﺔ ﺍﻟﺭﻋﺎﻳﺔ‬
professional status of the physician or other professional who has ‫ ﻳﻘﻭﻡ ﺍﻟﻣﻭﻅﻔﻭﻥ ﺑﺗﻌﺭﻳﻑ ﺃﻧﻔﺳﻬﻡ ﻟﻠﻣﺭﺿﻰ ﻣﻥ ﺧﻼﻝ ﺗﻘﺩﻳﻣﻬﻡ ﻷﻧﻔﺳﻬﻡ‬PFR.8.5.2
the primary responsibility for managing the care process. .‫ﻭﻋﺭﺽ ﺑﻁﺎﻗﺔ ﺍﻻﺳﻡ‬
PFR.8.5.2 Staff members identify themselves by introduction PFR.8.6
and by displaying the name. .‫ﻳﺗﻡ ﺇﻋﻼﻡ ﺍﻟﻣﺭﺿﻰ ﻛﻳﻔﻳﺔ ﺍﻻﺗﺻﺎﻝ ﻣﻘﺩﻣﻲ ﺍﻟﺭﻋﺎﻳﺔ ﻓﻲ ﺣﺎﻟﺔ ﺍﻟﻁﻭﺍﺭﺉ‬
 ‫ﻗﺳﻡ ﺇﺩﺍﺭﺓ ﺍﻟﺟﻭﺩﺓ ﺍﻟﺷﺎﻣﻠﺔ‬
PFR.8.6 PFR.8.7
Patients are informed of how to contact care providers in case of .‫ﻳﺳﺗﺟﻳﺏ ﺍﻟﻣﻭﻅﻔﻭﻥ ﺑﺷﻛﻝ ﻣﻧﺎﺳﺏ ﻟﻁﻠﺑﺎﺕ ﺍﻟﻣﺭﺿﻰ ﻟﻠﺣﺻﻭﻝ ﻋﻠﻰ ﺭﺃﻱ ﺛﺎﻥ ﺇﺫﺍ ﻟﺯﻡ ﺍﻷﻣﺭ‬
emergency. PFR.8.8
PFR.8.7 ‫ﻳﺣﺗﺭﻡ ﺍﻟﻣﺳﺗﺷﻔﻰ ﻣﻁﺎﻟﺏ ﺍﻟﻣﺭﺿﻰ ﻭﺍﺣﺗﻳﺎﺟﺎﺗﻬﻡ ﺑﻣﺎ ﻓﻲ ﺫﻟﻙ ﺗﻔﺿﻳﻼﺗﻬﻡ ﻓﻲ ﺍﻟﻘﺿﺎﻳﺎ ﺍﻟﺷﺧﺻﻳﺔ‬
Staff members respond appropriately to patients’ requests of a second .‫ﻣﺛﻝ ﺍﻟﻁﻌﺎﻡ ﻭﺍﻟﺷﺭﺍﺏ ﻭﺍﻟﻣﻼﺑﺱ ﻭﺍﻟﺭﻋﺎﻳﺔ ﺍﻟﺫﺍﺗﻳﺔ‬
opinion if necessary.
PFR.8.8
The hospital respects patients’ demands and needs including their
preferences in personal issues such as food, drink, clothing, and self-
care.
PFR.9 PFR.9
The hospital informs patients, and families as .‫ ﺑﻧﺗﺎﺋﺞ ﺍﻟﺭﻋﺎﻳﺔ‬،‫ ﺣﺳﺏ ﺍﻻﻗﺗﺿﺎء‬،‫ﻳﻘﻭﻡ ﺍﻟﻣﺳﺗﺷﻔﯽ ﺑﺈﺑﻼﻍ ﺍﻟﻣﺭﺿﯽ ﻭﺍﻷﺳﺭ‬
appropriate, of the outcome of care.
Standard Intent: :‫ﺍﻟﻐﺭﺽ‬
It is one of the patient’s rights to be honestly informed about the outcome of ‫ ﻟﻬﺎ ﺇﻣﺎ ﺇﻳﺟﺎﺑﻳﺔ ﺃﻭ‬/ ‫ﻭﻣﻥ ﺣﻘﻭﻕ ﺍﻟﻣﺭﻳﺽ ﺃﻥ ﻳﻛﻭﻥ ﻋﻠﻰ ﻋﻠﻡ ﺑﺻﺭﺍﺣﺔ ﻋﻥ ﻧﺗﺎﺋﺞ ﺧﻁﺔ ﺍﻟﺭﻋﺎﻳﺔ ﻟﻪ‬
his/her care plan either positive or negative. A just culture of safety in the ‫ ﺛﻘﺎﻓﺔ ﻋﺎﺩﻟﺔ ﻟﻠﺳﻼﻣﺔ ﻓﻲ ﻣﻛﺎﻥ ﺍﻟﻌﻣﻝ ﺍﻟﺻﺣﻲ ﺍﻟﺣﺩﻳﺙ ﺗﺷﺟﻊ ﻭﺗﻁﻭﻳﺭ ﺍﻟﻣﻌﺭﻓﺔ ﻭﺍﻟﻣﻬﺎﺭﺍﺕ‬.‫ﺳﻠﺑﻳﺔ‬
modern healthcare workplace encourages and develops the knowledge, skills, ‫ ﻳﻌﻣﻝ ﺍﻷﻁﺑﺎء‬.‫ﻭﺍﻻﻟﺗﺯﺍﻡ ﻣﻥ ﻣﻘﺩﻣﻲ ﺍﻟﺭﻋﺎﻳﺔ ﺍﻟﺻﺣﻳﺔ ﻟﺗﻘﺩﻳﻡ ﺍﻟﺭﻋﺎﻳﺔ ﺍﻟﺻﺣﻳﺔ ﻟﻠﻣﺭﺿﻰ‬
and commitment of healthcare providers to deliver safe patient care. Physicians ‫ﻭﺍﻟﻣﺭﺿﻰ ﻓﻲ ﺷﺭﺍﻛﺔ ﻣﻊ ﻣﻘﺩﻣﻲ ﺍﻟﺧﺩﻣﺎﺕ ﻭﺍﻹﺩﺍﺭﻳﻳﻥ ﺍﻵﺧﺭﻳﻥ ﻟﺗﺣﺳﻳﻥ ﺍﻟﺭﻋﺎﻳﺔ ﻭﺗﺣﻘﻳﻕ ﺃﻓﺿﻝ‬
and patients work in partnership with other providers and administrators to .‫ﺍﻟﻧﺗﺎﺋﺞ ﺍﻟﺳﺭﻳﺭﻳﺔ ﺍﻟﻣﻣﻛﻧﺔ‬
optimize care and achieve the best possible clinical outcomes. ‫ ﻗﺩ ﻻ ﺗﻛﻭﻥ ﺍﻟﻧﺗﺎﺋﺞ ﺍﻟﺳﺭﻳﺭﻳﺔ ﻛﻣﺎ ﻫﻭ‬،‫ﻋﻠﻰ ﺍﻟﺭﻏﻡ ﻣﻥ ﺍﻻﻟﺗﺯﺍﻡ ﺑﺗﻭﻓﻳﺭ ﺃﻓﺿﻝ ﺭﻋﺎﻳﺔ ﻣﻣﻛﻧﺔ‬
Despite the commitment to provide the best care possible, clinical outcomes ‫ ﻳﺗﻡ ﺍﻟﺗﻌﺭﻑ ﻋﻠﻰ ﺍﻷﺣﺩﺍﺙ ﺍﻟﺳﻠﺑﻳﺔ ﻭﺍﻷﺧﻁﺎء ﺍﻟﻁﺑﻳﺔ ﺍﻟﺗﻲ ﺗﺅﺛﺭ ﻋﻠﻰ‬.‫ﻣﻁﻠﻭﺏ ﺃﺻﻼ ﺃﻭ ﺍﻟﻣﺗﻭﻗﻊ‬
may not be as originally desired or anticipated. Adverse events and medical ‫ ﻭﻗﺩ ﻫﺩﺩ ﻓﺷﻝ ﺍﻟﻌﺎﻣﻠﻳﻥ ﻓﻲ ﻣﺟﺎﻝ‬.‫ﺭﻋﺎﻳﺔ ﺍﻟﻣﺭﺿﻰ ﺩﻭﻟﻳﺎ ﺑﺎﻋﺗﺑﺎﺭﻫﺎ ﻣﺷﺎﻛﻝ ﺭﺋﻳﺳﻳﺔ ﻓﻲ ﺍﻟﻁﺏ‬
errors affecting patient care are recognized internationally as major problems
‫ﺍﻟﺭﻋﺎﻳﺔ ﺍﻟﺻﺣﻳﺔ ﻭﺍﻟﻣﻌﺎﻫﺩ ﺍﻟﺻﺣﻳﺔ ﻓﻲ ﺍﻟﺗﺻﺩﻱ ﻟﻬﺫﻩ ﺍﻟﻣﺷﻛﻠﺔ ﺑﺗﻘﻭﻳﺽ ﺛﻘﺔ ﺍﻟﺟﻣﻬﻭﺭ ﻓﻲ ﻧﻅﺎﻡ‬
in medicine. The failure of health care professionals and health institutes to
address this problem has threatened to undermine public confidence in the
.‫ﺍﻟﺭﻋﺎﻳﺔ ﺍﻟﺻﺣﻳﺔ ﻛﻛﻝ‬
health care system as a whole. ‫ﻳﺟﺏ ﺃﻥ ﺗﻛﻣﻝ ﺍﻟﺟﻬﻭﺩ ﺍﻟﺭﺍﻣﻳﺔ ﺇﻟﻰ ﻣﻧﻊ ﺍﻟﻧﺗﺎﺋﺞ ﺍﻟﺳﻠﺑﻳﺔ ﻟﻠﺭﻋﺎﻳﺔ ﺑﺳﻳﺎﺳﺎﺕ ﺯﻳﺎﺩﺓ ﺍﻟﺻﺩﻕ ﻭﺍﻻﻧﻔﺗﺎﺡ‬
Efforts to prevent negative outcomes of care must be supplemented by policies ‫ ﺍﻹﻓﺻﺎﺡ ﻋﻥ ﺍﻟﻧﺗﺎﺋﺞ ﺍﻟﺳﻠﺑﻳﺔ ﻳﺗﻁﻠﺏ ﺍﻟﻠﺑﺎﻗﺔ‬.‫ﻣﻊ ﺍﻟﻣﺭﺿﻰ ﻭﺃﺳﺭﻫﻡ ﺣﻭﻝ ﺍﻟﺣﻭﺍﺩﺙ ﺍﻟﺳﻠﺑﻳﺔ‬
of increased honesty and openness with patients and their families about ‫ ﻳﺟﺏ ﻋﻠﻰ ﻣﺅﺳﺳﺎﺕ ﺍﻟﺭﻋﺎﻳﺔ ﺍﻟﺻﺣﻳﺔ ﺗﻭﻓﻳﺭ ﺍﻟﺗﺩﺭﻳﺏ ﻟﻸﻁﺑﺎء ﻓﻲ ﻫﺫﺍ‬.‫ﻭﻣﻬﺎﺭﺍﺕ ﺍﻻﺗﺻﺎﻝ ﺍﻟﺟﻳﺩﺓ‬
adverse incidents. Disclosure of negative outcomes requires tact and good ‫ ﻳﻧﺑﻐﻲ ﺇﺑﻼﻍ ﺍﻟﻣﺭﺿﻰ ﺑﺎﻟﺣﻭﺍﺩﺙ ﺍﻟﺳﻠﺑﻳﺔ ﻏﻳﺭ ﺍﻟﻣﺗﻭﻗﻌﺔ‬،‫ ﻭﻛﻘﺎﻋﺩﺓ ﻋﺎﻣﺔ‬.‫ ﺇﺫﺍ ﻟﺯﻡ ﺍﻷﻣﺭ‬،‫ﺍﻟﻣﺟﺎﻝ‬
communication skills. Healthcare institutions should provide training for the .‫ﻓﻲ ﺃﻗﺭﺏ ﻭﻗﺕ ﻣﻣﻛﻥ‬
clinicians in this area, if necessary. As a general rule, patients should be :‫ﻭﺗﺷﻣﻝ ﻣﻛﻭﻧﺎﺕ ﺍﻹﻓﺻﺎﺡ ﺍﻟﺗﻲ ﺗﻬﻡ ﻣﻌﻅﻡ ﺍﻟﻣﺭﺿﻰ ﻣﺎ ﻳﻠﻲ‬
informed of unexpected adverse incidents as soon as possible. ‫ ﺍﻟﻛﺷﻑ ﻋﻥ ﺟﻣﻳﻊ ﺍﻷﺧﻁﺎء ﺍﻟﺿﺎﺭﺓ‬
Components of disclosure that matter most to patients include: ‫ ﺷﺭﺡ ﺳﺑﺏ ﺣﺩﻭﺙ ﺍﻟﺧﻁﺄ‬
 Disclosure of all harmful errors ‫ ﻛﻳﻑ ﺳﻳﺗﻡ ﺗﻘﻠﻳﻝ ﺁﺛﺎﺭ ﺍﻟﺧﻁﺄ‬
 An explanation as to why the error occurred ‫ ﺍﻟﺧﻁﻭﺍﺕ ﺍﻟﺗﻲ ﺳﻳﺗﺧﺫﻫﺎ ﺍﻟﻁﺑﻳﺏ )ﻭﺍﻟﻣﻧﻅﻣﺔ( ﻟﻣﻧﻊ ﺗﻛﺭﺍﺭﻫﺎ‬
 How the error's effects will be minimized
 Steps the physician (and organization) will take to
prevent recurrences
 ‫ﻗﺳﻡ ﺇﺩﺍﺭﺓ ﺍﻟﺟﻭﺩﺓ ﺍﻟﺷﺎﻣﻠﺔ‬
PFR.9.1 PFR.9.1
The hospital has a defined process for informing patients, and families ‫ ﺑﻧﺗﺎﺋﺞ‬،‫ ﺣﺳﺏ ﺍﻻﻗﺗﺿﺎء‬،‫ﻟﺩﻯ ﺍﻟﻣﺳﺗﺷﻔﻰ ﻋﻣﻠﻳﺔ ﻣﺣﺩﺩﺓ ﻟﻺﻓﺻﺎﺡ ﻹﻋﻼﻡ ﺍﻟﻣﺭﺿﻰ ﻭﺍﻷﺳﺭ‬
as appropriate, of the outcome of care including adverse events or .‫ﺍﻟﺭﻋﺎﻳﺔ ﺑﻣﺎ ﻓﻲ ﺫﻟﻙ ﺍﻷﺣﺩﺍﺙ ﺍﻟﺳﻠﺑﻳﺔ ﺃﻭ ﺍﻟﻧﺗﺎﺋﺞ ﺍﻟﺳﻠﺑﻳﺔ ﻏﻳﺭ ﺍﻟﻣﺗﻭﻗﻌﺔ‬
unanticipated negative outcomes. PFR.9.2
PFR.9.2 .‫ﻳﺗﻡ ﺗﻭﺛﻳﻕ ﻋﻣﻠﻳﺔ ﺍﻹﻓﺻﺎﺡ ﺗﻠﻙ ﻓﻲ ﺍﻟﺳﺟﻝ ﺍﻟﻁﺑﻲ ﻟﻠﻣﺭﻳﺽ‬
The disclosure process is documented in the patient’s medical record.
PFR.10 PFR.10
Informed consent is obtained prior to high risk .‫ ﺍﻹﺟﺭﺍءﺍﺕ ﻋﺎﻟﻳﺔ ﺍﻟﻣﺧﺎﻁﺭ‬/‫ﻳﺗﻡ ﺍﻟﺣﺻﻭﻝ ﻋﻠﻰ ﺍﻟﻣﻭﺍﻓﻘﺔ ﺍﻟﻣﺳﺗﻧﻳﺭﺓ ﻗﺑﻝ ﺍﻟﻌﻼﺟﺎﺕ‬
treatments/procedures.
Standard Intent: :‫ﺍﻟﻐﺭﺽ‬
The hospital should maintain an updated list of procedures/treatments requiring ‫ ﺍﻟﻌﻼﺟﺎﺕ ﺍﻟﺗﻲ ﺗﺗﻁﻠﺏ ﺍﻟﻣﻭﺍﻓﻘﺔ‬/ ‫ﻳﺟﺏ ﻋﻠﻰ ﺍﻟﻣﺳﺗﺷﻔﻰ ﺃﻥ ﻳﺣﺗﻔﻅ ﺑﻘﺎﺋﻣﺔ ﻣﺣﺩﺛﺔ ﻣﻥ ﺍﻹﺟﺭﺍءﺍﺕ‬
informed consent. Patients and families have the right to know which .‫ ﺍﻟﻌﻼﺟﺎﺕ ﺍﻟﺗﻲ ﺗﺗﻁﻠﺏ ﻣﻭﺍﻓﻘﺗﻬﻡ‬/ ‫ ﻟﻠﻣﺭﺿﻰ ﻭﺍﻟﻌﺎﺋﻼﺕ ﺍﻟﺣﻕ ﻓﻲ ﻣﻌﺭﻓﺔ ﺍﻹﺟﺭﺍءﺍﺕ‬.‫ﺍﻟﻣﺳﺗﻧﻳﺭﺓ‬
procedures/treatments require their consent. In general, all cases receiving ‫ ﻳﺟﺏ ﺃﻥ ﻳﺗﻡ ﺍﻟﺗﻭﻗﻳﻊ ﻋﻠﻰ ﺟﻣﻳﻊ ﺍﻟﺣﺎﻻﺕ ﺍﻟﺗﻲ ﺗﺗﻠﻘﻰ ﺍﻟﺗﺧﺩﻳﺭ ﺃﻭ ﺟﻣﻳﻊ ﺍﻟﺣﺎﻻﺕ ﺍﻟﺗﻲ‬،‫ﺑﺷﻛﻝ ﻋﺎﻡ‬
anesthesia or all cases having procedures that involve invasion of skin or .‫ ﻣﻭﺍﻓﻘﺔ ﻣﺳﺗﻧﻳﺭﺓ‬،‫ﺗﻧﻁﻭﻱ ﻋﻠﻰ ﺇﺟﺭﺍءﺍﺕ ﺗﻧﻁﻭﻱ ﻋﻠﻰ ﻏﺯﻭ ﺍﻟﺟﻠﺩ ﺃﻭ ﻓﺗﺣﺔ ﺍﻟﺟﺳﻡ ﺍﻟﻁﺑﻳﻌﻲ‬
natural body orifice, an informed consent should be signed. Additionally, a .‫ ﻳﻠﺯﻡ ﺍﻟﺣﺻﻭﻝ ﻋﻠﻰ ﻣﻭﺍﻓﻘﺔ ﺧﻁﻳﺔ ﻋﻧﺩﻣﺎ ﻳﻁﻠﺏ ﺍﻟﻣﻭﻅﻔﻭﻥ ﺍﻟﺗﺻﻭﻳﺭ‬،‫ﺑﺎﻹﺿﺎﻓﺔ ﺇﻟﻰ ﺫﻟﻙ‬
written consent is required when photography is requested by staff. ‫ ﺃﻱ‬.‫ ﻋﻼﻣﺎﺕ ﻫﺎﻣﺔ ﺃﺧﺭﻯ ﻋﻠﻰ ﺍﻟﻧﻣﻭﺫﺝ‬/ ‫ ﻓﺈﻥ ﺍﻟﻣﺭﻳﺽ‬،‫ﺑﻌﺩ ﺇﺟﺭﺍء ﻋﻣﻠﻳﺔ ﺍﻟﻣﻭﺍﻓﻘﺔ ﺍﻟﻣﺳﺗﻧﻳﺭﺓ‬
After conduction of the informed consent process, the patient/significant other ‫ ﻋﻼﻣﺎﺕ ﺍﻟﺷﺎﻫﺩ ﻋﻠﻰ ﻫﻭﻳﺔ ﺍﻟﻣﺭﻳﺽ ﻭﻟﻳﺱ‬.‫ﻣﻭﻅﻑ ﻓﻲ ﺍﻟﻣﺳﺗﺷﻔﻰ ﻳﻣﻛﻥ ﺃﻥ ﻳﻛﻭﻥ ﺷﺎﻫﺩﺍ‬
signs the form. Any hospital employee can be a witness. The witness signs for .‫ ﻳﺟﺏ ﺃﻥ ﺗﻛﻭﻥ ﺍﻟﻛﺗﺎﺑﺔ ﻣﻘﺭﻭءﺓ ﻣﻊ ﻋﺩﻡ ﻭﺟﻭﺩ ﺍﺧﺗﺻﺎﺭﺍﺕ‬،‫ ﻓﻲ ﺟﻣﻳﻊ ﺍﻟﺣﺎﻻﺕ‬.‫ﻟﻣﺣﺗﻭﻯ ﺍﻟﻣﻭﺍﻓﻘﺔ‬
the patient identity and not for the content of the consent. In all cases, the
writing should be legible with no abbreviations.

PFR.10.1
The hospital has a policy and form(s) for obtaining the informed consent
from the patient or a legal representative prior to starting high risk PFR.10.1
treatments and procedures. ‫ﻟﺩﻯ ﺍﻟﻣﺳﺗﺷﻔﻰ ﺳﻳﺎﺳﺔ ﻭﺷﻛﻝ ) ﺃﺷﻛﺎﻝ( ﻟﻠﺣﺻﻭﻝ ﻋﻠﻰ ﻣﻭﺍﻓﻘﺔ ﻣﺳﺗﻧﻳﺭﺓ ﻣﻥ ﺍﻟﻣﺭﻳﺽ ﺃﻭ ﻣﻥ‬
PFR.10.2 .‫ﺍﻟﻣﻣﺛﻝ ﺍﻟﻘﺎﻧﻭﻧﻲ ﻗﺑﻝ ﺑﺩء ﺍﻟﻌﻼﺟﺎﺕ ﻭﺍﻹﺟﺭﺍءﺍﺕ ﻋﺎﻟﻳﺔ ﺍﻟﻣﺧﺎﻁﺭ‬
The informed consent process includes explanation of the nature of the PFR.10.2
treatment or procedure, expected benefits and risks, alternative courses ‫ ﻭﺍﻟﻣﻧﺎﻓﻊ ﻭﺍﻟﻣﺧﺎﻁﺭ‬،‫ﻭﺗﺗﺿﻣﻥ ﻋﻣﻠﻳﺔ ﺍﻟﻣﻭﺍﻓﻘﺔ ﺍﻟﻣﺳﺗﻧﻳﺭﺓ ﺷﺭﺣﺎ ﻟﻁﺑﻳﻌﺔ ﺍﻟﻌﻼﺝ ﺃﻭ ﺍﻹﺟﺭﺍء‬
of action, and the likely consequences of not undergoing the treatment. .‫ ﻭﺍﻟﻌﻭﺍﻗﺏ ﺍﻟﻣﺣﺗﻣﻠﺔ ﻟﻌﺩﻡ ﺇﺟﺭﺍء ﺍﻟﻌﻼﺝ‬،‫ ﻭﺍﻟﻁﺭﻕ ﺍﻟﺑﺩﻳﻠﺔ‬،‫ﺍﻟﻣﺗﻭﻗﻌﺔ‬
PFR.10.3 PFR.10.3
The informed consent is always obtained before any invasive surgery/ / ‫ ﻭﻗﺑﻝ ﺍﻟﺗﺧﺩﻳﺭ‬، ‫ ﺇﺟﺭﺍء ﺗﺩﺍﺧﻠﻲ‬/ ‫ﻳﺗﻡ ﺍﻟﺣﺻﻭﻝ ﻋﻠﻰ ﺍﻟﻣﻭﺍﻓﻘﺔ ﺍﻟﻣﺳﺗﻧﻳﺭﺓ ﺩﺍﺋﻣﺎ ﻗﺑﻝ ﺃﻱ ﺟﺭﺍﺣﺔ‬
procedure, sedation/ anesthesia, and transfusion of blood and blood .‫ ﻭﻗﺑﻝ ﻧﻘﻝ ﺍﻟﺩﻡ ﻭﻣﻛﻭﻧﺎﺕ ﺍﻟﺩﻡ‬،‫ﺍﻟﺗﻬﺩﺋﺔ‬
components. PFR.10.4
PFR.10.4 ‫ﻳﺣﺩﺩ ﺍﻟﻣﺳﺗﺷﻔﯽ ﻗﺎﺋﻣﺔ ﺑﺎﻟﻌﻼﺝ ﻭﺍﻹﺟﺭﺍءﺍﺕ ﺫﺍﺕ ﺍﻟﻣﺧﺎﻁﺭ ﺍﻟﻌﺎﻟﻳﺔ ﺍﻟﺗﻲ ﺗﺗﻁﻠﺏ ﻣﻭﺍﻓﻘﺔ ﻣﺳﺗﻧﻳﺭﺓ‬
The hospital identifies a list of high risk treatments and procedures that :‫ﺑﻣﺎ ﻓﻲ ﺫﻟﻙ ﻋﻠﯽ ﺳﺑﻳﻝ ﺍﻟﻣﺛﺎﻝ ﻻ ﺍﻟﺣﺻﺭ ﻣﺎ ﻳﻠﻲ‬
require informed consent including, but are not limited to, the following: ،‫ ﺗﻧﻅﻳﺭ ﺍﻟﻘﺻﺑﺎﺕ‬،‫ ﺗﻧﻅﻳﺭ ﺍﻟﻘﻭﻟﻭﻥ‬،‫ ﺍﻟﺗﻧﻅﻳﺭ ﺍﻟﺩﺍﺧﻠﻲ ) ﻋﻠﻰ ﺳﺑﻳﻝ ﺍﻟﻣﺛﺎﻝ‬PFR.10.4.1
PFR.10.4.1 Endoscopy (e.g., colonoscopy, bronchoscopy, .(‫ ﺍﺳﺗﺋﺻﺎﻝ ﺍﻟﻛﻠﻳﺔ‬،J ‫ ﻭﺿﻊ ﺃﻧﺑﻭﺏ‬،‫ﺗﻧﻅﻳﺭ ﺍﻟﻣﺛﺎﻧﺔ‬
cystoscopy, J-tube placement, nephrostomy). ،‫ ﺍﻟﻛﻠﻰ‬،‫ ﺍﻟﻛﺑﺩ‬،‫ ﺍﻟﺛﺩﻱ‬،‫ ﻧﺧﺎﻉ ﺍﻟﻌﻅﺎﻡ‬،‫ ﺧﺯﻋﺔ ) ﻋﻠﻰ ﺳﺑﻳﻝ ﺍﻟﻣﺛﺎﻝ‬PFR.10.4.2
.(‫ﺍﻟﺑﺭﻭﺳﺗﺎﺗﺎ‬
 ‫ﻗﺳﻡ ﺇﺩﺍﺭﺓ ﺍﻟﺟﻭﺩﺓ ﺍﻟﺷﺎﻣﻠﺔ‬
PFR.10.4.2 Biopsy (e.g., bone marrow, breast, liver, kidney, .‫ ﻓﺣﺹ ﺷﻌﺎﻋﻲ ﻣﻘﻁﻌﻲ ﻣﻊ ﺍﻟﺗﺑﺎﻳﻥ‬PFR.10.4.3
prostate). .‫ ﺍﻟﻔﺣﺹ ﺑﺎﻟﺭﻧﻳﻥ ﺍﻟﻣﻐﻧﺎﻁﻳﺳﻲ ﻣﻊ ﺃﻭ ﺑﺩﻭﻥ ﺍﻟﺗﺑﺎﻳﻥ‬PFR.10.4.4
PFR.10.4.3 CT examination with contrast. ،‫ ﺗﺻﻭﻳﺭ ﺍﻷﻭﻋﻳﺔ‬،‫ ﺍﻹﺟﺭﺍءﺍﺕ ﺍﻹﺷﻌﺎﻋﻳﺔ ﺍﻟﻐﺎﺯﻳﺔ ) ﻋﻠﻰ ﺳﺑﻳﻝ ﺍﻟﻣﺛﺎﻝ‬PFR.10.4.5
PFR.10.4.4 MRI examination with or without contrast. .(‫ ﺗﺻﺭﻳﻑ ﺧﺭﺍﺝ ﺗﺣﺕ ﺗﻭﺟﻳﻪ ﺷﻌﺎﻋﻲ ﻣﻘﻁﻌﻲ‬،‫ﻗﺳﻁﺭﺓ‬
PFR.10.4.5 Invasive radiological procedures (e.g., angiography, ‫ ﺍﻟﻁﻣﻭﺡ ﻋﻥ ﻁﺭﻳﻕ ﺍﻟﺟﻠﺩ ﻣﻥ ﺳﻭﺍﺋﻝ ﺍﻟﺟﺳﻡ ﺃﻭ ﺍﻟﻬﻭﺍء ﻣﻥ ﺧﻼﻝ ﺍﻟﺟﻠﺩ‬PFR.10.4.6
angioplasty, drainage of an abscess under CT guidance). ‫ ﺃﻧﺑﻭﺏ‬،‫ ﺛﻘﺏ ﻗﻁﻧﻲ‬،‫ ﻁﻣﻭﺡ ﻧﺧﺎﻉ ﺍﻟﻌﻅﺎﻡ‬،‫ ﻣﻔﺻﻠﻲ‬،‫)ﻋﻠﻰ ﺳﺑﻳﻝ ﺍﻟﻣﺛﺎﻝ‬
PFR.10.4.6 Percutaneous aspiration of body fluids or air through .(‫ ﺑﺯﻝ‬،‫ﺍﻟﺻﺩﺭ‬
the skin (e.g., arthrocentesis, bone marrow aspiration, lumbar .‫ ﺍﻟﺣﻘﻥ ﺗﺣﺕ ﺍﻟﺟﺎﻓﻳﺔ ﻭﺍﻟﺗﺧﺩﻳﺭ‬PFR.10.4.7
puncture, chest tube, paracentesis). .‫ ﺍﻟﻌﻼﺝ ﺑﺎﺳﺗﺧﺩﺍﻡ ﺍﻟﻌﻼﺝ ﺍﻟﻛﻳﻣﻳﺎﺋﻲ ﻭﺇﺟﺭﺍءﺍﺕ ﺍﻷﻭﺭﺍﻡ ﺍﻹﺷﻌﺎﻋﻳﺔ‬PFR.10.4.8
PFR.10.4.7 Epidural injections and anesthesia. .‫ ﺍﺳﺗﻌﻣﺎﻝ ﺍﻟﻣﻭﺍﺩ ﺍﻟﻣﺷﻌﺔ ﺍﻟﻧﺷﻁﺔ‬PFR.10.4.9
PFR.10.4.8 Treatment with chemotherapy and radiation .‫ ﻭﺿﻊ ﺍﻟﺧﻁ ﺍﻟﻣﺭﻛﺯﻱ‬PFR.10.4.10
oncology procedures. PFR.10.5
PFR.10.4.9 Use of radio-active material. ‫ ﺍﻟﻘﺻﺭ ﺃﻭ‬،‫ﻋﻧﺩﻣﺎ ﻳﻛﻭﻥ ﺍﻟﻣﺭﻳﺽ ﻏﻳﺭ ﻗﺎﺩﺭ ﻋﻠﻰ ﺇﻋﻁﺎء ﺍﻟﻣﻭﺍﻓﻘﺔ ﺍﻟﻣﺳﺗﻧﻳﺭﺓ )ﻋﻠﻰ ﺳﺑﻳﻝ ﺍﻟﻣﺛﺎﻝ‬
PFR.10.4.10 Central line placement. ‫ ﻳﺗﻡ ﺍﻟﺗﻣﺎﺱ ﺍﻟﻣﻭﺍﻓﻘﺔ ﻣﻥ ﺃﻗﺭﺏ ﺃﻗﺭﺑﺎء ﺍﻟﻣﺭﻳﺽ ﺃﻭ ﺍﻟﻭﺻﻲ‬،(‫ﺍﻟﻣﺭﺿﻰ ﻏﻳﺭ ﺍﻟﻣﺅﻫﻠﻳﻥ ﻋﻘﻠﻳﺎ‬
PFR.10.5 .‫ﻋﻠﻳﻪ‬
When a patient is incapable of giving informed consent (e.g., minors or
mentally incompetent patients), consent is sought from the patient’s next
of kin or guardian.
PFR.11 PFR.11
The hospital has a policy to deal with patients who .‫ﻟﺩﻯ ﺍﻟﻣﺳﺗﺷﻔﻰ ﺳﻳﺎﺳﺔ ﻟﻠﺗﻌﺎﻣﻝ ﻣﻊ ﺍﻟﻣﺭﺿﻰ ﺍﻟﺫﻳﻥ ﻳﺭﻓﺿﻭﻥ ﺃﻭ ﻳﺗﻭﻗﻔﻭﻥ ﻋﻥ ﺍﻟﻌﻼﺝ‬
refuse or discontinue the treatment.
Standard Intent: :‫ﺍﻟﻐﺭﺽ‬
The hospital communicates to a patient about his right to refuse or discontinue ‫ ﻓﻲ ﺣﺎﻟﺔ‬.‫ﻳﺗﻭﺍﺻﻝ ﺍﻟﻣﺳﺗﺷﻔﯽ ﻣﻊ ﺍﻟﻣﺭﻳﺽ ﺣﻭﻝ ﺣﻘﻬ ﻓﻲ ﺭﻓﺽ ﺍﻟﺭﻋﺎﻳﺔ ﺍﻟﻣﻘﺭﺭﺓ ﺃﻭ ﺍﻟﺗﻭﻗﻑ ﻋﻧﻬﺎ‬
the planned care. In case the patient/significant other refuses or request ‫ ﻳﺷﺭﺡ ﻟﻬﻡ ﺍﻟﻣﻭﻅﻔﻭﻥ ﺍﻟﻣﻌﻧﻳﻭﻥ ﻋﻭﺍﻗﺏ‬،‫ ﻏﻳﺭﻩ ﺃﻭ ﻁﻠﺏ ﺍﻟﺗﻭﻗﻑ ﻋﻥ ﺍﻟﺭﻋﺎﻳﺔ‬/ ‫ﺭﻓﺽ ﺍﻟﻣﺭﻳﺽ‬
discontinuation of care, relevant staff explains to them the consequences of .‫ ﻳﺟﺏ ﺗﻭﺛﻳﻕ ﺍﻟﻌﻣﻠﻳﺔ ﺑﺭﻣﺗﻬﺎ ﻓﻲ ﻣﻠﻑ ﺍﻟﻣﺭﻳﺽ‬.‫ﻫﺫﺍ ﺍﻟﺭﻓﺽ ﺃﻭ ﺍﻟﺗﻭﻗﻑ ﻭﻳﺷﺭﺡ ﺑﺩﺍﺋﻝ ﺃﺧﺭﻯ‬
such refusal or discontinuation and explains other alternatives. The whole
process should be documented in the patient's file.

PFR.11.1 PFR.11.1
There is a policy and procedure that addresses the patient’s right to .‫ﻫﻧﺎﻙ ﺳﻳﺎﺳﺔ ﻭﺇﺟﺭﺍءﺍﺕ ﺗﻌﺎﻟﺞ ﺣﻕ ﺍﻟﻣﺭﻳﺽ ﻓﻲ ﺭﻓﺽ ﺃﻭ ﺇﻳﻘﺎﻑ ﺍﻟﻌﻼﺝ ﺍﻟﻣﻘﺩﻡ‬
refuse or discontinue treatment offered. PFR.11.2
PFR.11.2 .‫ﻳﺗﻡ ﺷﺭﺡ ﻋﻭﺍﻗﺏ ﺭﻓﺽ ﺍﻟﻌﻼﺝ ﻟﻠﻣﺭﻳﺽ‬
The consequences of treatment refusal are explained to the patient. PFR.11.3
PFR.11.3 .‫ﻳﺗﻡ ﺇﻋﻼﻡ ﺍﻟﻣﺭﺿﻰ ﺣﻭﻝ ﺍﻟﺑﺩﺍﺋﻝ ﺍﻟﻣﺗﺎﺣﺔ ﻟﻠﺭﻋﺎﻳﺔ ﻭﺍﻟﻌﻼﺝ‬
Patients are informed about available care and treatment alternatives. PFR.11.4
PFR.11.4 .‫ ﻳﺷﺎﺭﻙ ﺃﻓﺭﺍﺩ ﺍﻷﺳﺭﺓ ﻓﻲ ﺍﻟﻌﻣﻠﻳﺔ‬،‫ﻛﻠﻣﺎ ﻛﺎﻥ ﺫﻟﻙ ﻣﻼﺋﻣﺎ‬
Whenever appropriate, family members are involved in the process. PFR.11.5
PFR.11.5 .‫ﻳﺗﻡ ﺍﺣﺗﺭﺍﻡ ﺧﻳﺎﺭﺍﺕ ﺍﻟﻣﺭﺿﻰ ﻭﺍﻟﻌﺎﺋﻠﺔ‬
 ‫ﻗﺳﻡ ﺇﺩﺍﺭﺓ ﺍﻟﺟﻭﺩﺓ ﺍﻟﺷﺎﻣﻠﺔ‬
Patient and family choices are respected. PFR.11.6
PFR.11.6 .‫ﻳﺗﻡ ﺗﻭﺛﻳﻕ ﺍﻟﻣﻧﺎﻗﺷﺔ ﺫﺍﺕ ﺍﻟﺻﻠﺔ ﻓﻲ ﺍﻟﺳﺟﻝ ﺍﻟﻁﺑﻲ ﻟﻠﻣﺭﻳﺽ‬
The relevant discussion is documented in the patient’s medical record.
PFR.12 PFR.12
The hospital has a policy regarding withholding .‫ﻟﺩﻯ ﺍﻟﻣﺳﺗﺷﻔﻰ ﺳﻳﺎﺳﺔ ﺗﺗﻌﻠﻕ ﺑﻭﻗﻑ ﺟﻬﻭﺩ ﺍﻹﻧﻌﺎﺵ‬
resuscitation efforts.
Standard Intent: :‫ﺍﻟﻐﺭﺽ‬
Withholding resuscitation efforts for terminally ill or dying patients is an ‫ﺇﻥ ﺣﺟﺏ ﺟﻬﻭﺩ ﺍﻹﻧﻌﺎﺵ ﻟﻠﻣﺭﺿﻰ ﺍﻟﺫﻳﻥ ﻳﻌﺎﻧﻭﻥ ﻣﻥ ﺃﻣﺭﺍﺽ ﺧﻁﻳﺭﺓ ﺃﻭ ﺍﻟﻣﻭﺕ ﻫﻭ ﻗﺿﻳﺔ‬
ethical and legal issue. A policy should be in place to regulate such decisions .‫ ﻭﻳﻧﺑﻐﻲ ﻭﺿﻊ ﺳﻳﺎﺳﺔ ﻟﺗﻧﻅﻳﻡ ﻫﺫﻩ ﺍﻟﻘﺭﺍﺭﺍﺕ ﻭﻓﻘﺎ ﻟﻠﻔﺗﻭﻯ ﺫﺍﺕ ﺍﻟﺻﻠﺔ‬.‫ﺃﺧﻼﻗﻳﺔ ﻭﻗﺎﻧﻭﻧﻳﺔ‬
according to related Fatwa.

PFR.12.1 PFR.12.1
There is a written (No Code) policy that is implemented and consistent ‫ﻫﻧﺎﻙ ﺳﻳﺎﺳﺔ ﻣﻛﺗﻭﺑﺔ ) ﻻ ﻳﻭﺟﺩ ﻗﺎﻧﻭﻥ( ﻳﺗﻡ ﺗﻧﻔﻳﺫﻫﺎ ﻭﺗﻣﺷﻳﺎ ﻣﻊ ﺍﻟﻘﻭﺍﻧﻳﻥ ﻭﺍﻟﻠﻭﺍﺋﺢ ﻟﺣﺟﺏ ﺟﻬﻭﺩ‬
with laws and regulations for withholding resuscitation efforts for the .‫ﺍﻹﻧﻌﺎﺵ ﻟﻠﻣﺭﺿﻰ ﺍﻟﺫﻳﻥ ﻳﻌﺎﻧﻭﻥ ﻣﻥ ﺃﻣﺭﺍﺽ ﻁﺎﺭﺋﺔ ﺃﻭ ﻧﻬﺎﻳﺔ ﺍﻟﻌﻣﺭ‬
terminally ill or end of life patients. PFR.12.2
PFR.12.2 .‫ ﺍﻷﺳﺭﺓ ﺣﻭﻝ ﺃﻣﺭ ﺇﻋﺎﺩﺓ ﺍﻹﻧﻌﺎﺵ ﻓﻲ ﺍﻟﺳﺟﻝ ﺍﻟﻁﺑﻲ ﻟﻠﻣﺭﻳﺽ‬/ ‫ﻳﺗﻡ ﺗﻭﺛﻳﻕ ﻗﺭﺍﺭ ﺍﻟﻣﺭﻳﺽ‬
Patient/family decision about the resuscitative order is documented in
the patient’s medical record.
PFR.13 PFR.13
The hospital informs patients about their .‫ﻳﻘﻭﻡ ﺍﻟﻣﺳﺗﺷﻔﻰ ﺑﺈﺑﻼﻍ ﺍﻟﻣﺭﺿﻰ ﺑﻣﺳﺅﻭﻟﻳﺎﺗﻬﻡ‬
responsibilities.
Standard Intent: :‫ﺍﻟﻐﺭﺽ‬
To ensure that patient responsibilities towards themselves, others and the ‫ ﻭﻣﻥ‬.‫ ﻳﺗﻡ ﺇﺑﻼﻍ ﺍﻵﺧﺭﻳﻥ ﻭﺍﻟﻣﺳﺗﺷﻔﻰ ﻟﻠﻣﺭﺿﻰ‬،‫ﻟﺿﻣﺎﻥ ﺃﻥ ﻣﺳﺅﻭﻟﻳﺎﺕ ﺍﻟﻣﺭﻳﺽ ﺗﺟﺎﻩ ﺃﻧﻔﺳﻬﻡ‬
hospital are communicated to patients. Examples are: :‫ﺍﻷﻣﺛﻠﺔ ﻋﻠﻰ ﺫﻟﻙ‬
 Follow the plan of care, inform staff about any changes ‫ ﻭﺇﺑﻼﻍ ﺍﻟﻣﻭﻅﻔﻳﻥ ﻋﻥ ﺃﻱ ﺗﻐﻳﻳﺭﺍﺕ‬،‫ ﺍﺗﺑﻊ ﺧﻁﺔ ﺍﻟﺭﻋﺎﻳﺔ‬
 Respect the privacy of other patients ‫ ﺍﺣﺗﺭﺍﻡ ﺧﺻﻭﺻﻳﺔ ﺍﻟﻣﺭﺿﻰ ﺍﻵﺧﺭﻳﻥ‬
 Follow hospital policies (e.g. smoking, safety, infection (‫ ﻭﻣﻛﺎﻓﺣﺔ ﺍﻟﻌﺩﻭﻯ‬،‫ ﻭﺍﻟﺳﻼﻣﺔ‬،‫ ﺍﺗﺑﻊ ﺳﻳﺎﺳﺎﺕ ﺍﻟﻣﺳﺗﺷﻔﻳﺎﺕ )ﻣﺛﻝ ﺍﻟﺗﺩﺧﻳﻥ‬
control)

PFR.13.1
Patients are provided with appropriate information regarding their PFR.13.1
responsibilities. .‫ﻳﺗﻡ ﺗﺯﻭﻳﺩ ﺍﻟﻣﺭﺿﻰ ﺑﺎﻟﻣﻌﻠﻭﻣﺎﺕ ﺍﻟﻣﻧﺎﺳﺑﺔ ﻓﻳﻣﺎ ﻳﺗﻌﻠﻕ ﺑﻣﺳﺅﻭﻟﻳﺎﺗﻬﻡ‬
PFR.13.2 PFR.13.2
Patient responsibilities require the patient to: :‫ﻣﺳﺅﻭﻟﻳﺎﺕ ﺍﻟﻣﺭﻳﺽ ﺗﺗﻁﻠﺏ ﻣﻥ ﺍﻟﻣﺭﻳﺽ‬
PFR.13.2.1 Provide complete and accurate information about his ‫ ﺑﻣﺎ ﻓﻲ ﺫﻟﻙ ﺍﻷﺩﻭﻳﺔ‬،‫ ﺗﻭﻓﻳﺭ ﻣﻌﻠﻭﻣﺎﺕ ﻛﺎﻣﻠﺔ ﻭﺩﻗﻳﻘﺔ ﻋﻥ ﺻﺣﺗﻪ‬PFR.13.2.1
health, including medications, dietary supplements, and any .‫ ﻭﺃﻱ ﺣﺳﺎﺳﻳﺔ‬،‫ﻭﺍﻟﻣﻛﻣﻼﺕ ﺍﻟﻐﺫﺍﺋﻳﺔ‬
allergies. .‫ ﺍﺗﺑﻊ ﺧﻁﺔ ﺍﻟﺭﻋﺎﻳﺔ ﺍﻟﺗﻲ ﻳﺣﺩﺩﻫﺎ ﻣﻘﺩﻡ ﺍﻟﺭﻋﺎﻳﺔ‬PFR.13.2.2
PFR.13.2.2 Follow the plan of care prescribed by his provider. .‫ ﺃﻥ ﺗﺣﺗﺭﻡ ﺟﻣﻳﻊ ﺍﻟﻣﻭﻅﻔﻳﻥ ﻭﻛﺫﻟﻙ ﺍﻟﻣﺭﺿﻰ ﺍﻵﺧﺭﻳﻥ‬PFR.13.2.3
 ‫ﻗﺳﻡ ﺇﺩﺍﺭﺓ ﺍﻟﺟﻭﺩﺓ ﺍﻟﺷﺎﻣﻠﺔ‬
PFR.13.2.3 Be respectful to all staff as well as other patients. ‫ ﻭﻋﺩﻡ‬،‫ ﺍﺣﺗﺭﺍﻣﺎ ﻟﺳﻳﺎﺳﺎﺕ ﻭﺇﺟﺭﺍءﺍﺕ ﺍﻟﻣﺳﺗﺷﻔﻰ ) ﻣﺛﻝ ﺳﺎﻋﺎﺕ ﺍﻟﺯﻳﺎﺭﺓ‬PFR.13.2.4
PFR.13.2.4 Be respectful to the hospital policies and procedures ‫ ﻭﺳﻼﻣﺔ‬،‫ ﻭﺍﺳﺗﺧﺩﺍﻡ ﺍﻷﺟﻬﺯﺓ ﺍﻟﻛﻬﺭﺑﺎﺋﻳﺔ‬،‫ﻭﺟﻭﺩ ﺳﻳﺎﺳﺔ ﻟﻠﺗﺩﺧﻳﻥ‬
(e.g., visiting hours, no smoking policy, use of electrical .(‫ﺍﻟﻣﻣﺗﻠﻛﺎﺕ‬
appliances, and safety of belongings). ‫ ﻳﻛﻭﻥ ﻣﺳﺅﻭﻻ ﻋﻥ ﺍﻻﺳﺗﺧﺩﺍﻡ ﺍﻵﻣﻥ ﻟﻣﺭﺍﻓﻕ ﺍﻟﻣﺳﺗﺷﻔﻰ ﻭﻣﻌﺩﺍﺗﻪ‬PFR.13.2.5
PFR.13.2.5 Be responsible for the safe use of the hospital’s facilities
and equipment
PFR.14 PFR.14
The hospital has an effective process to respond to .‫ﻟﺩﻯ ﺍﻟﻣﺳﺗﺷﻔﻰ ﻋﻣﻠﻳﺔ ﻓﻌﺎﻟﺔ ﻟﻠﺭﺩ ﻋﻠﻰ ﺷﻛﺎﻭﻯ ﺍﻟﻣﺭﺿﻰ‬
patient complaints.
Standard Intent: :‫ﺍﻟﻐﺭﺽ‬
Patients have a right not only to complain and to have those complaints ‫ﻭﺍﻟﻣﺭﺿﻰ ﻟﻳﺱ ﻟﻬﻡ ﺍﻟﺣﻕ ﻓﻘﻁ ﻓﻲ ﺗﻘﺩﻳﻡ ﺍﻟﺷﻛﺎﻭﻯ ﻭﺃﻥ ﻳﺗﻡ ﺍﺳﺗﻌﺭﺍﺽ ﻫﺫﻩ ﺍﻟﺷﻛﺎﻭﻯ ﻭﺣﻠﻬﺎ ﻭﻟﻛﻥ‬
reviewed and resolved but also to receive information about the complaint ‫ ﻳﺟﺏ ﻋﻠﻰ ﺍﻟﻘﻳﺎﺩﺓ ﺩﻋﻡ ﻫﺫﺍ ﺍﻟﻧﻅﺎﻡ ﺍﻟﺫﻱ ﻳﺿﻊ‬.‫ﺃﻳﺿﺎ ﺍﻟﺣﺻﻭﻝ ﻋﻠﻰ ﻣﻌﻠﻭﻣﺎﺕ ﻋﻥ ﺁﻟﻳﺔ ﺍﻟﺷﻛﻭﻯ‬
mechanism. Leadership should support such a system that sets a mechanism ،‫ ﻭﺑﺎﻹﺿﺎﻓﺔ ﺇﻟﻰ ﺫﻟﻙ‬.‫ ﺗﻠﻘﻲ ﺍﻟﺷﻛﺎﻭﻯ ﻭﺣﻠﻬﺎ‬،‫ﺁﻟﻳﺔ ﻹﻋﻼﻡ ﺍﻟﻣﺭﻳﺽ ﺣﻭﻝ ﺍﻟﺣﻕ ﻓﻲ ﺗﻘﺩﻳﻡ ﺷﻛﻭﻯ‬
for informing the patient about the right to complain, complaint receiving and ،‫ ﺑﻣﺎ ﻓﻲ ﺫﻟﻙ ﺇﻧﺷﺎء ﻗﺎﻋﺩﺓ ﺑﻳﺎﻧﺎﺕ‬،‫ﻳﻧﺑﻐﻲ ﻟﻠﻘﻳﺎﺩﺓ ﺃﻥ ﺗﺧﺻﺹ ﻫﻳﻛﻼ ﻟﻺﺷﺭﺍﻑ ﻋﻠﻰ ﺍﻟﻧﻅﺎﻡ ﺑﻛﺎﻣﻠﻪ‬
resolution. Additionally, the leadership should assign a structure to oversee the .‫ ﻭﻣﻥ ﺛﻡ ﺍﺗﺧﺎﺫ ﺇﺟﺭﺍءﺍﺕ ﺍﻟﺗﺣﺳﻳﻥ‬،‫ﻭﺻﻳﺎﻏﺔ ﺗﻘﺎﺭﻳﺭ ﻣﺟﻣﻌﺔ ﺗﺷﻳﺭ ﺇﻟﻰ ﺍﻻﺗﺟﺎﻫﺎﺕ ﻭﺍﻷﻧﻣﺎﻁ‬
whole system including establishment of a data base, formulation of ‫ ﻭﻳﻧﺑﻐﻲ ﻭﺿﻊ ﺳﻳﺎﺳﺔ ﺗﻔﻲ‬.‫ﻭﻳﻧﺑﻐﻲ ﺗﻘﻳﻳﻡ ﻓﻌﺎﻟﻳﺔ ﺇﺟﺭﺍءﺍﺕ ﺍﻟﺗﺣﺳﻳﻥ ﻣﻥ ﺧﻼﻝ ﺍﻻﺗﺟﺎﻫﺎﺕ ﻭﺍﻷﻧﻣﺎﻁ‬
aggregated reports that indicate trends and patterns and hence taking .‫ﺑﺟﻣﻳﻊ ﻋﻧﺎﺻﺭ ﺍﻟﻣﻌﻳﺎﺭ‬
improvement actions. Effectiveness of improvement actions should be
evaluated through the trends and patterns. A policy should be in place that
satisfies all elements of the standard.
PFR.14.1
PFR.14.1 .‫ﻫﻧﺎﻙ ﺳﻳﺎﺳﺔ ﻭﺇﺟﺭﺍءﺍﺕ ﻟﻺﺩﺍﺭﺓ ﺍﻟﻌﺎﺩﻟﺔ ﻟﺷﻛﺎﻭﻯ ﺍﻟﻣﺭﺿﻰ ﻓﻲ ﺇﻁﺎﺭ ﺯﻣﻧﻲ ﻣﻌﻘﻭﻝ‬
There is a policy and procedure for the fair management of patient PFR.14.2
complaints in a reasonable timeframe. ‫ ﻋﻼﻗﺎﺕ ﺍﻟﻣﺭﺿﻰ( ﻣﺳﺅﻭﻝ ﻋﻥ‬،‫ﻳﻌﻳﻥ ﺍﻟﻣﺳﺗﺷﻔﻰ ﻭﺣﺩﺓ ﺃﻭ ﺷﺧﺹ ﻣﻌﻳﻥ ) ﻋﻠﻰ ﺳﺑﻳﻝ ﺍﻟﻣﺛﺎﻝ‬
PFR.14.2 .‫ﺇﺩﺍﺭﺓ ﺷﻛﺎﻭﻯ ﺍﻟﻣﺭﺿﻰ‬
The hospital assigns a specific unit or person (e.g., patient relations) PFR.14.3
responsible for managing patients’ complaints. ‫ﻳﺿﻣﻥ ﻗﺎﺩﺓ ﺍﻟﻣﺳﺗﺷﻔﻳﺎﺕ ﺍﺗﺧﺎﺫ ﺗﺣﺳﻳﻧﺎﺕ ﻧﻭﻋﻳﺔ ﻭﺇﺟﺭﺍءﺍﺕ ﺍﺳﺗﺭﺍﺗﻳﺟﻳﺔ ﺍﺳﺗﻧﺎﺩﺍ ﺇﻟﻰ ﺗﺣﻠﻳﻝ‬
PFR.14.3 .(‫ ﻛﻝ ﺛﻼﺛﺔ ﺃﺷﻬﺭ ﻭﺳﻧﻭﻳﺎ‬،‫ﺍﺗﺟﺎﻫﺎﺕ ﺍﻟﺑﻳﺎﻧﺎﺕ )ﻋﻠﻰ ﺳﺑﻳﻝ ﺍﻟﻣﺛﺎﻝ‬
Hospital leaders ensure taking quality improvement and strategic actions
based on trended data (e.g., quarterly and annually).
PFR.15 PFR.15
The hospital seeks feedback from patients regarding the .‫ﻳﺳﻌﻰ ﺍﻟﻣﺳﺗﺷﻔﻰ ﻟﻠﺣﺻﻭﻝ ﻋﻠﻰ ﺍﻟﺗﻐﺫﻳﺔ ﺍﻟﻣﺭﺗﺩﺓ ﻣﻥ ﺍﻟﻣﺭﺿﻰ ﻓﻳﻣﺎ ﻳﺗﻌﻠﻕ ﺑﺎﻟﺧﺩﻣﺎﺕ ﺍﻟﻣﻘﺩﻣﺔ‬
services provided.
Standard Intent: :‫ﺍﻟﻐﺭﺽ‬
Satisfied patients comply better with physician's instructions. The hospital ‫ ﻳﺟﺏ ﻋﻠﻰ ﺍﻟﻣﺳﺗﺷﻔﻰ ﺗﺻﻣﻳﻡ ﻧﻅﺎﻡ‬.‫ﻣﺭﺿﻰ ﻣﺭﺿﻰ ﺍﻻﻣﺗﺛﺎﻝ ﺑﺷﻛﻝ ﺃﻓﺿﻝ ﻣﻊ ﺗﻌﻠﻳﻣﺎﺕ ﺍﻟﻁﺑﻳﺏ‬
should design a system that measures the satisfaction of patients and provide a ‫ ﻭﻳﻧﺑﻐﻲ ﺍﺳﺗﺧﺩﺍﻡ ﻫﺫﻩ ﺍﻟﻣﻌﻠﻭﻣﺎﺕ ﻟﺗﻭﺟﻳﻪ‬.‫ﻳﻘﻳﺱ ﺭﺿﺎ ﺍﻟﻣﺭﺿﻰ ﻭﺗﻭﻓﻳﺭ ﺗﺩﻓﻕ ﻣﻧﺗﻅﻡ ﻟﻠﻣﻌﻠﻭﻣﺎﺕ‬
regular flow of information. This information should be used to guide ‫ ﻭﻳﻧﺑﻐﻲ ﺃﻥ ﺗﺭﺍﻋﻲ ﺍﺳﺗﻘﺻﺎءﺍﺕ ﺍﻟﺭﺿﺎ‬.‫ﺍﻹﺩﺍﺭﺍﺕ ﻭﺍﻟﻠﺟﺎﻥ ﺣﺳﺏ ﺍﻻﻗﺗﺿﺎء ﻟﺑﺩء ﺃﻧﺷﻁﺔ ﺍﻟﺗﺣﺳﻳﻥ‬
departments and committees as appropriate to initiate improvement activities. .‫ ﻗﺩ ﺗﻛﻭﻥ ﻋﺎﻣﺔ ﺃﻭ ﻣﻭﺟﻬﺔ ﺇﻟﻰ ﺧﺩﻣﺔ ﻣﺣﺩﺩﺓ ﺃﻭ ﻋﺩﺩ ﻣﻌﻳﻥ ﻣﻥ ﺍﻟﻣﺭﺿﻰ‬.‫ﺍﻟﻌﻳﻧﺎﺕ ﺍﻟﺳﻠﻳﻣﺔ‬
The satisfaction surveys should consider proper samples. It may be general or
 ‫ﻗﺳﻡ ﺇﺩﺍﺭﺓ ﺍﻟﺟﻭﺩﺓ ﺍﻟﺷﺎﻣﻠﺔ‬
directed to specific service or specific patient population.

PFR.15.1 PFR.15.1
The hospital conducts patient satisfaction surveys on a regular basis. .‫ﻳﻘﻭﻡ ﺍﻟﻣﺳﺗﺷﻔﻰ ﺑﺈﺟﺭﺍء ﺍﺳﺗﻘﺻﺎءﺍﺕ ﺑﺷﺄﻥ ﺭﺿﺎ ﺍﻟﻣﺭﺿﻰ ﻋﻠﻰ ﺃﺳﺎﺱ ﻣﻧﺗﻅﻡ‬
PFR.15.2 PFR.15.2
The hospital makes improvements based on the patient satisfaction .‫ﻳﻘﻭﻡ ﺍﻟﻣﺳﺗﺷﻔﯽ ﺑﺈﺟﺭﺍء ﺗﺣﺳﻳﻧﺎﺕ ﻋﻠﯽ ﺃﺳﺎﺱ ﻧﺗﺎﺋﺞ ﺍﺳﺗﻁﻼﻉ ﺭﺿﺎ ﺍﻟﻣﺭﻳﺽ‬
trended survey results.
PFR.16 PFR.16
The hospital has an effective system for clinical research .‫ﻟﺩﻯ ﺍﻟﻣﺳﺗﺷﻔﻰ ﻧﻅﺎﻡ ﻓﻌﺎﻝ ﻷﻧﺷﻁﺔ ﺍﻟﺑﺣﻭﺙ ﺍﻟﺳﺭﻳﺭﻳﺔ‬
activities.
:‫ﺍﻟﻐﺭﺽ‬
Standard Intent: ‫ﺟﺯء ﻣﻥ ﺍﻟﺗﺯﺍﻡ ﺍﻟﻣﺳﺗﺷﻔﻰ ﺑﺳﻼﻣﺔ ﺍﻟﻣﺭﺿﻰ ﻭﺍﺣﺗﺭﺍﻡ ﺣﻘﻭﻕ ﺍﻟﻣﺭﺿﻰ ﻫﻭ ﺗﻧﻅﻳﻡ ﺟﻣﻳﻊ ﺍﻷﻧﺷﻁﺔ‬
Part of the hospital commitment to patient safety and respecting patients’ rights :‫ ﻭﺍﻟﺗﻲ ﺗﺷﻣﻝ‬،‫ﺍﻟﻣﺗﻌﻠﻘﺔ ﺑﺎﻟﺑﺣﻭﺙ ﺍﻟﺗﺩﺧﻠﻳﺔ ﻓﻲ ﺍﻟﻣﺳﺗﺷﻔﻰ‬
is to regulate all activities related to the interventional researches in the ،‫ ﺍﻟﺗﺄﻛﺩ ﻣﻥ ﺍﻟﻌﻣﻠﻳﺎﺕ ﺍﻟﻣﺗﻌﻠﻘﺔ ﺑﺎﺳﺗﻌﺭﺍﺽ ﺑﺭﻭﺗﻭﻛﻭﻻﺕ ﺍﻟﺑﺣﻭﺙ؛ ﻭﻭﺯﻥ ﺍﻟﻣﺧﺎﻁﺭ ﻭﺍﻟﻣﻧﺎﻓﻊ‬
hospital, which include: ‫ ﻭﺍﻷﺳﺎﻟﻳﺏ ﺍﻟﻣﺳﺗﺧﺩﻣﺔ ﻟﺣﻣﺎﻳﺔ ﺳﺭﻳﺔ ﺍﻟﻣﺭﺿﻰ ﻭﺳﻼﻣﺗﻬﻡ‬،‫ﻭﺍﻹﺷﺭﺍﻑ ﻋﻠﻰ ﺍﻟﺗﺟﺎﺭﺏ ﺍﻟﺳﺭﻳﺭﻳﺔ‬
 To make sure the processes related to the review of ‫ ﻭﻗﺩ ﻳﺗﺧﺫ ﻫﺫﺍ ﺷﻛﻝ ﻟﺟﻧﺔ ﺃﻭ ﺗﻌﻳﻳﻥ ﻣﺳﺅﻭﻟﻳﺎﺕ ﻷﻁﺑﺎء ﻣﻌﻳﻧﻳﻥ ﻭﻏﻳﺭﻫﻡ ﻣﻥ ﺃﺧﺻﺎﺋﻳﻲ‬.‫ﻭﺗﻁﻭﻳﺭﻫﺎ‬
research protocols; the weighing of risks and benefits, the .‫ﺍﻟﺭﻋﺎﻳﺔ ﺍﻟﺻﺣﻳﺔ‬
oversight of the clinical trial, and the methods used to ،‫ ﻳﺣﻕ ﻟﻠﻣﺭﻳﺽ ﺍﻟﺣﺻﻭﻝ ﻋﻠﯽ ﻣﻭﺍﻓﻘﺔ ﻣﺳﺗﻧﻳﺭﺓ ﻗﺑﻝ ﺍﺧﺗﻳﺎﺭ ﺍﻟﻣﺷﺎﺭﮐﺔ ﻓﻲ ﺍﻷﺑﺣﺎﺙ ﺍﻟﺳﺭﻳﺭﻳﺔ‬
protect patients’ confidentiality and safety are developed .‫ ﻭﺍﻟﺗﺟﺎﺭﺏ‬،‫ﻭﺍﻟﺗﺣﻘﻳﻕ‬
and implemented. This may take the form of a committee ،‫ ﻭﺍﻟﺗﺣﻘﻳﻘﺎﺕ‬،‫ ﻟﻠﺗﺄﻛﺩ ﻣﻥ ﻭﺟﻭﺩ ﻣﻭﺍﻓﻘﺔ ﻣﺳﺗﻧﻳﺭﺓ ﻗﺑﻝ ﻣﺷﺎﺭﻛﺔ ﺍﻟﻣﺭﻳﺽ ﻓﻲ ﺍﻟﺑﺣﻭﺙ ﺍﻟﺳﺭﻳﺭﻳﺔ‬
or assigned responsibilities to designated physicians and .‫ﻭﺍﻟﻣﺣﺎﻛﻣﺎﺕ‬
other health care professionals. .‫ ﺍﻟﺗﺄﮐﺩ ﻣﻥ ﺗﻭﺛﻳﻕ ﻗﺭﺍﺭﺍﺕ ﺍﻟﻣﻭﺍﻓﻘﺔ ﻭﺗﺎﺭﻳﺧﻬﺎ ﻭﺗﺣﺩﻳﺩ ﺍﻟﺷﺧﺹ ﺍﻟﺫﻱ ﺣﺻﻝ ﻋﻠﯽ ﺍﻟﻣﻭﺍﻓﻘﺔ‬
 The patient has right to informed consent prior to choosing
to participate in clinical research, investigation, and trials.
 To make sure there is informed consent prior to the patient
participating in clinical research, investigation, and trials. PFR.16.1
 To make sure that consent decisions are documented, ‫ﻳﻘﻭﻡ ﺍﻟﻣﺳﺗﺷﻔﯽ ﺑﺗﻧﻔﻳﺫ ﺍﻟﺳﻳﺎﺳﺎﺕ ﻭﺍﻹﺟﺭﺍءﺍﺕ ﻭﻣﺩﻭﻧﺔ ﺃﺧﻼﻗﻳﺎﺕ ﺍﺧﺗﻳﺎﺭ ﻭﻣﺷﺎﺭﮐﺔ ﺍﻟﻣﺭﺿﯽ ﻓﻲ‬
dated, and identify the person who obtained the consent. .‫ﺃﻧﺷﻁﺔ ﺍﻟﺑﺣﺙ‬
PFR.16.1 PFR.16.2
The hospital implements policies, procedures, and code of ethics for the ‫ﺍﻟﺳﻳﺎﺳﺎﺕ ﻭﺍﻹﺟﺭﺍءﺍﺕ ﺍﻟﺗﻲ ﺗﻭﺟﻪ ﺍﻷﻧﺷﻁﺔ ﺍﻟﺑﺣﺛﻳﺔ ﺍﻟﺗﺟﺭﻳﺑﻳﺔ ﻭﻓﻘﺎ ﻟﻠﻘﻭﺍﻧﻳﻥ ﻭﺍﻟﻠﻭﺍﺋﺢ ﻭﺍﻟﻣﻌﺎﻳﻳﺭ‬
selection and participation of patients in research activities. .‫ﺍﻟﻣﻬﻧﻳﺔ ﻭﻣﺩﻭﻧﺎﺕ ﻗﻭﺍﻋﺩ ﺍﻟﺳﻠﻭﻙ‬
PFR.16.2 PFR.16.3
The policies and procedures that guide experimental research activities ‫ﻟﺩﻯ ﺍﻟﻣﺳﺗﺷﻔﻰ ﻟﺟﻧﺔ ﺑﺣﺛﻳﺔ ﺃﻭ ﻫﻳﻛﻝ ﺁﺧﺭ ﻟﻺﺷﺭﺍﻑ ﻋﻠﻰ ﺟﻣﻳﻊ ﺍﻷﻧﺷﻁﺔ ﺍﻟﺑﺣﺛﻳﺔ ﻭﺿﻣﺎﻥ‬
are in accordance with laws and regulations, professional standards, and .‫ﻣﻼءﻣﺗﻬﺎ ﻭﺳﻼﻣﺗﻬﺎ‬
codes of conduct. PFR.16.4
PFR.16.3 .‫ﻳﺗﻡ ﺍﻟﺣﺻﻭﻝ ﻋﻠﻰ ﻣﻭﺍﻓﻘﺔ ﺍﻟﻣﺭﻳﺽ ﻋﻥ ﻋﻠﻡ ﻗﺑﻝ ﺍﻟﺩﺧﻭﻝ ﻓﻲ ﺑﺭﻭﺗﻭﻛﻭﻝ ﺍﻟﺑﺣﻭﺙ‬
The hospital has a research committee or another structure to oversee all PFR.16.5
research activities and ensure their appropriateness and safety. ‫ﻳﻘﻭﻡ ﺍﻟﻣﺳﺗﺷﻔﻰ ﺑﺈﺑﻼﻍ ﺍﻟﻣﺭﺿﻰ ﺑﺣﻘﻬﻡ ﻓﻲ ﺭﻓﺽ ﺍﻟﻣﺷﺎﺭﻛﺔ ﻓﻲ ﺍﻟﺑﺣﻭﺙ ﺍﻟﺗﺟﺭﻳﺑﻳﺔ ﺩﻭﻥ ﺍﻟﺗﺄﺛﻳﺭ‬
 ‫ﻗﺳﻡ ﺇﺩﺍﺭﺓ ﺍﻟﺟﻭﺩﺓ ﺍﻟﺷﺎﻣﻠﺔ‬
PFR.16.4 .‫ﻋﻠﻰ ﺍﻟﺣﺻﻭﻝ ﻋﻠﻰ ﺍﻟﺭﻋﺎﻳﺔ ﺃﻭ ﻋﻠﻰ ﻧﻭﻋﻳﺔ ﺍﻟﺭﻋﺎﻳﺔ ﺍﻟﻣﻘﺩﻣﺔ ﻭﻳﺣﺗﺭﻡ ﺭﻏﺑﺎﺗﻬﻡ‬
Patient's informed consent is obtained before entering in a research PFR.16.6
protocol. .‫ﻳﻧﻔﺫ ﺍﻟﻣﺳﺗﺷﻔﻰ ﻧﺗﺎﺋﺞ ﺍﻟﺑﺣﻭﺙ ﻟﺗﺣﺳﻳﻥ ﺧﺩﻣﺎﺗﻪ‬
PFR.16.5
The hospital informs patients of their right to refuse participation in
experimental research with no effect on access to care or the quality of
care provided and respects their wishes.
PFR.16.6
The hospital implements the research outcomes to improve its services.
PFR.17 PFR.17
Hospital leaders develop and adopt ethical standards in ‫ﻳﻘﻭﻡ ﻗﺎﺩﺓ ﺍﻟﻣﺳﺗﺷﻔﻳﺎﺕ ﺑﺗﻁﻭﻳﺭ ﻭﺍﻋﺗﻣﺎﺩ ﻣﻌﺎﻳﻳﺭ ﺃﺧﻼﻗﻳﺔ ﻓﻲ ﺍﻟﺗﻌﺎﻣﻝ ﻣﻊ ﺍﻟﻣﺭﺿﻰ ﻭﺩﺍﻋﻣﻳﻬﻡ‬
dealing with patients and their supporters and .‫ﻭﻣﻥ ﻳﺭﻋﺎﻫﻡ‬
sponsors. :‫ﺍﻟﻐﺭﺽ‬
‫ﻳﻘﻭﻡ ﻗﺎﺩﺓ ﺍﻟﻣﺳﺗﺷﻔﻰ ﻛﺟﺯء ﻣﻥ ﺇﺩﺍﺭﺓ ﺍﻟﻣﺳﺅﻭﻟﻳﺎﺕ ﺍﻷﺧﻼﻗﻳﺔ ﻭﺍﻟﻘﺎﻧﻭﻧﻳﺔ ﻟﻠﻣﺭﺿﻰ ﺑﺗﻁﻭﻳﺭ ﺍﻟﻭﺛﺎﺋﻕ‬
Standard Intent:
The hospital leaders as part of managing ethical and legal responsibilities to ‫ﻣﻥ‬ ‫ ﻣﺩﻭﻧﺔ ﻗﻭﺍﻋﺩ ﺍﻟﺳﻠﻭﻙ ﻭﺍﻟﺳﻳﺎﺳﺎﺕ( ﻭﺁﻟﻳﺔ )ﻣﺛﻝ ﺍﻹﺣﺎﻟﺔ ﺇﻟﻰ ﻟﺟﻧﺔ( ﻳﻣﺎﺭﺱ ﺍﻟﻣﺳﺗﺷﻔﻰ‬،‫)ﻛﺭﺳﺎﻟﺔ‬
patients develop documents (as mission. Code of conduct, policies) and a .‫ ﺍﻟﻔﻭﺗﺭﺓ ﻭﺍﻟﺗﺳﻭﻳﻕ ﻭﺗﺿﺎﺭﺏ ﺍﻟﻣﺻﺎﻟﺢ‬:‫ ﻭﻣﻥ ﺍﻷﻣﺛﻠﺔ ﻋﻠﻰ ﺫﻟﻙ‬.‫ﺧﻼﻟﻬﺎ ﻫﺫﻩ ﺍﻟﻣﺳﺅﻭﻟﻳﺎﺕ‬
mechanism (like referral to a committee) through which the hospital exercises ‫ﺑﺗﻭﻓﻳﺭ‬ ‫ﻳﺗﻌﻠﻕ‬ ‫ﺟﺯء ﻣﻥ ﺍﻟﻣﺳﺅﻭﻟﻳﺎﺕ ﻫﻭ ﺍﻟﺗﺄﻛﺩ ﻣﻥ ﺃﻥ ﺍﻟﻣﺳﺗﺷﻔﻰ ﻳﻧﻔﺫ ﺳﻳﺎﺳﺔ ﻭﺯﺍﺭﺓ ﺍﻟﺻﺣﺔ ﻓﻳﻣﺎ‬
these responsibilities. Examples are: billing, marketing and conflict of interest. .‫ﺍﻟﺭﻋﺎﻳﺔ ﺍﻟﻁﺎﺭﺋﺔ ﻋﻧﺩ ﺍﻟﺣﺎﺟﺔ ﺑﻐﺽ ﺍﻟﻧﻅﺭ ﻋﻥ ﻋﺩﻡ ﺍﻟﻘﺩﺭﺓ ﻋﻠﻰ ﺍﻟﺩﻓﻊ‬
Part of responsibilities is to ensure that the hospital implements the MOH
policy regarding provision emergency care when needed regardless of inability
to pay. PFR.17.1
‫ﺗﻘﺩﻡ ﺍﻹﺭﺷﺎﺩﺍﺕ ﻟﻠﻣﻭﻅﻔﻳﻥ ﺍﻟﺳﺭﻳﺭﻳﻳﻥ ﻭﻏﻳﺭ ﺍﻟﺳﺭﻳﺭﻳﺔ ﺍﻟﺗﻲ ﺗﻐﻁﻲ ﺍﻟﺿﻭﺍﺑﻁ ﺍﻷﺧﻼﻗﻳﺔ ﻟﺭﻋﺎﻳﺔ‬
PFR.17.1 .‫ﺍﻟﻣﺭﺿﻰ ﻭﻏﻳﺭ ﺍﻟﻣﺭﺿﻰ‬
Guidance is provided for clinical and non-clinical staff covering patient- PFR.17.2
care and non-patient care ethical issues. .‫ﺍﻟﻣﺳﺗﺷﻔﻰ ﺗﺩﻗﻕ ﻓﻭﺍﺗﻳﺭ ﺍﻟﺧﺩﻣﺎﺕ‬
PFR.17.2 PFR.17.3
The hospital accurately bills for services. .‫ﻳﺻﻭﺭ ﺍﻟﻣﺳﺗﺷﻔﻰ ﺧﺩﻣﺎﺗﻪ ﻟﻠﻣﺭﺿﻰ ﺑﺷﻔﺎﻓﻳﺔ ﻭﺻﺩﻕ‬
PFR.17.3 PFR.17.4
The hospital honestly portrays its services to patients. .‫ﻳﺣﺎﻓﻅ ﺍﻟﻣﺳﺗﺷﻔﻰ ﻋﻠﻰ ﺍﻟﺗﺳﻭﻳﻕ ﺍﻷﺧﻼﻗﻲ‬
PFR.17.4 PFR.17.5
The hospital maintains ethical marketing. ‫ﻟﺩﻯ ﺍﻟﻣﺳﺗﺷﻔﻰ ﻋﻣﻠﻳﺔ ﻭﺍﺿﺣﺔ ﻟﺗﻭﻓﻳﺭ ﺍﻟﺭﻋﺎﻳﺔ ﻟﻠﻣﺭﺿﻰ ﺍﻟﻔﻘﺭﺍء ﺍﻟﺫﻳﻥ ﻳﻌﺎﻧﻭﻥ ﻣﻥ ﺣﺎﻻﺕ‬
PFR.17.5 .‫ﻁﺎﺭﺋﺔ‬
The hospital has a clear process to provide care for impoverished PFR.17.6
patients presenting with emergent situations. .‫ﻳﺗﻡ ﺍﺳﺗﻌﺭﺍﺽ ﻧﺗﺎﺋﺞ ﺍﻻﻋﺗﺑﺎﺭﺍﺕ ﺍﻷﺧﻼﻗﻳﺔ ﻭﺗﺣﺳﻳﻥ ﺍﻟﻧﻅﻡ ﻭﻓﻘﺎ ﻟﺫﻟﻙ‬
PFR.17.6
Outcomes of ethical considerations are reviewed and system
improvements are made accordingly.
 ‫ﻗﺳﻡ ﺇﺩﺍﺭﺓ ﺍﻟﺟﻭﺩﺓ ﺍﻟﺷﺎﻣﻠﺔ‬
PFR.18 PFR.18
Hospital leaders ensure that patients, families, and staff ‫ﻳﺿﻣﻥ ﻗﺎﺩﺓ ﺍﻟﻣﺳﺗﺷﻔﻳﺎﺕ ﺃﻥ ﻳﺗﻡ ﺇﺑﻼﻍ ﺍﻟﻣﺭﺿﻰ ﻭﺍﻷﺳﺭ ﻭﺍﻟﻣﻭﻅﻔﻳﻥ ﺑﺧﻳﺎﺭﺍﺕ ﻭﺇﺟﺭﺍءﺍﺕ ﺍﻟﺗﺑﺭﻉ‬
members are informed about the choices and .‫ﺑﺎﻷﻋﺿﺎء‬
procedures of organ donations. :‫ﺍﻟﻐﺭﺽ‬
‫ ﺗﺗﻭﻓﺭ ﺍﻟﻔﺗﻭﻯ ﺍﻟﻣﺗﻌﻠﻘﺔ ﺑﺎﻟﺗﺑﺭﻉ‬.‫ﻭﻳﺷﺟﻊ ﺍﻟﻣﺳﺗﺷﻔﻰ ﺣﻕ ﺍﻟﻣﺭﻳﺽ ﻓﻲ ﺍﻟﺗﺑﺭﻉ ﺑﺎﻷﻋﺿﺎء ﻭﺍﻷﻧﺳﺟﺔ‬
Standard Intent:
The hospital promotes the patient right to donate organs and tissues. The Fatwa ‫ﺑﺎﻷﻋﺿﺎء ﻣﻥ ﺷﺧﺹ ﻣﻳﺕ ﺃﻭ ﺣﻲ ﻋﻠﻰ ﺍﻟﻣﻭﻗﻊ ﺍﻹﻟﻛﺗﺭﻭﻧﻲ ﻟﻠﻣﺭﻛﺯ ﺍﻟﺳﻌﻭﺩﻱ ﻟﻠﺗﺑﺭﻉ ﺑﺎﻷﻋﺿﺎء‬
related to organ donation from a dead or living person is available on the .‫ ﺍﻟﻣﻭﺍﺩ ﺍﻷﺧﺭﻯ ﺍﻟﻣﺗﻌﻠﻘﺔ ﺑﺎﻟﻣﻭﺕ ﺍﻟﺩﻣﺎﻍ ﻭﻋﻣﻠﻳﺎﺕ ﺍﻟﺗﺑﺭﻉ ﺍﻟﻣﻧﺎﺳﺑﺔ ﻭﺗﺗﻭﻓﺭ ﺃﻳﺿﺎ‬.(S.C.O.T)
website of The Saudi Center for Organ Donation (S.C.O.T). Other materials ‫ﺍﻟﺧﺎﺹ‬ ‫ ﻭﺗﺻﻣﻳﻡ ﻧﻅﺎﻣﻬﺎ‬S.C.O.T ‫ ﻭﺍﻟﺗﻌﺎﻭﻥ ﻣﻊ‬،‫ﻳﺟﺏ ﻋﻠﻰ ﺍﻟﻣﺳﺗﺷﻔﻰ ﻣﺭﺍﺟﻌﺔ ﻫﺫﻩ ﺍﻟﻣﻭﺍﺩ‬
related to brain death and proper donation processes are also available. The . ‫ﺍﻟﻧﻅﺎﻡ‬ ‫ﻫﺫﺍ‬ ‫ ﻭﻳﻧﺑﻐﻲ ﺗﺩﺭﻳﺏ ﺍﻟﻣﻭﻅﻔﻳﻥ ﻋﻠﻰ ﺗﻧﻔﻳﺫ‬.‫ﺍﻟﺗﻲ ﻳﻧﺑﻐﻲ ﺃﻥ ﺗﻛﻭﻥ ﻣﺗﺳﻘﺔ ﻣﻊ ﺍﻟﻘﺎﻧﻭﻥ ﻭﺍﻟﻠﻭﺍﺋﺢ‬
hospital should review these materials, cooperate with S.C.O.T and design its
own system that should be consistent with law and regulations. Staff should be
trained in implementing that system. PFR.18.1
.‫ﻳﻘﻭﻡ ﺍﻟﻣﺳﺗﺷﻔﯽ ﺑﺈﻋﻼﻡ ﺍﻟﻣﺭﺿﯽ ﺃﻭ ﺍﻷﺳﺭ ﺑﺧﻳﺎﺭﺍﺕ ﺍﻟﺗﺑﺭﻉ ﺑﺎﻷﻋﺿﺎء‬
PFR.18.1 PFR.18.2
The hospital makes patients or families aware of the options of organ ‫ﻳﻌﻳﻥ ﺍﻟﻣﺳﺗﺷﻔﻰ ﺍﻟﻣﻭﻅﻔﻳﻥ ﺍﻟﻣﺩﺭﺑﻳﻥ ﻹﺑﻼﻍ ﺍﻟﻣﺭﺿﻰ ﻭﺍﻷﺳﺭ ﻋﻥ ﺍﻟﺗﺑﺭﻉ ﺑﺎﻷﻋﺿﺎء ﺑﻁﺭﻳﻘﺔ‬
donation. .‫ﺣﺳﺎﺳﺔ ﻟﺣﺎﻟﺗﻬﻡ ﻭﺍﺣﺗﺭﺍﻡ ﻣﻌﺗﻘﺩﺍﺗﻬﻡ ﻭﺭﻏﺑﺎﺗﻬﻡ‬
PFR.18.2 PFR.18.3
The hospital assigns trained staff to inform patients and families about ‫ ﻭﻣﻥ ﻳﻣﻛﻧﻪ‬،‫ﻳﻭﻓﺭ ﺍﻟﻣﺳﺗﺷﻔﻰ ﻟﻠﻌﺎﺋﻠﺔ ﺟﻣﻳﻊ ﺍﻟﻣﻌﻠﻭﻣﺎﺕ ﺍﻟﻼﺯﻣﺔ ﺣﻭﻝ ﻣﺎ ﻳﻣﻛﻥ ﺍﻟﺗﺑﺭﻉ ﺑﻪ‬
organ donation in a manner that is sensitive to their situation and .‫ ﻭﺍﻹﺟﺭﺍءﺍﺕ ﺍﻟﻣﺗﻌﻠﻘﺔ ﺑﺎﻟﺗﺑﺭﻉ‬،‫ ﻭﻛﻳﻔﻳﺔ ﺍﻟﺗﺑﺭﻉ‬،‫ﺍﻟﺗﺑﺭﻉ‬
respectful of their beliefs and wishes. PFR.18.4
PFR.18.3 ‫ﻳﻭﻓﺭ ﺍﻟﻣﺳﺗﺷﻔﻰ ﻟﻠﻌﺎﺋﻠﺔ ﺟﻣﻳﻊ ﺍﻟﻣﻌﻠﻭﻣﺎﺕ ﺍﻟﻼﺯﻣﺔ ﻋﻥ " ﺍﻟﻔﺗﻭﻯ" ﺍﻟﺭﺳﻣﻳﺔ ﺑﺷﺄﻥ ﺍﻟﺗﺑﺭﻉ‬
The hospital provides the family with all the necessary information .‫ﺑﺎﻷﻋﺿﺎء‬
about what can be donated, who can donate, how to donate, and the
procedures involved in donation.
PFR.18.4
The hospital provides the family with all the necessary information
about the official” Fatwa” regarding organ donation.

1438 ‫ﺗﻡ ﺑﻌﻭﻥ ﷲ ﻓﻲ ﺗﻣﺎﻡ ﺍﻟﺳﺎﻋﺔ ﺍﻟﺛﺎﻟﺛﺔ ﻭﺍﻟﻧﺻﻑ ﻣﺳﺎءﺍ ﻣﻥ ﺍﻟﻳﻭﻡ ﺍﻟﺧﺎﻣﺱ ﻭﺍﻟﻌﺷﺭﻭﻥ ﻣﻥ ﺭﻣﺿﺎﻥ‬

‫ﺍﻟﻠﻬﻡ ﺗﻘﺑﻝ ﻣﻧﺎ‬

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