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HOSPITAL FRONT VIEW PHOTO

No. of Pages : 30

Date Created : DD/MM/YYYY

Date of Implementation : DD/MM/YYYY

Prepared By : Signature :
Name :
Designation : NABH Coordinator
Approved By : Signature :
Name :
Designation : Medical Director
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AMENDMENT SHEET

S. No Section no & Details of the Reasons Signature of Signature

page no amendment the of the
preparatory approval
authority authority
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CONTROL OF THE MANUAL

The holder of the copy of this manual is responsible for maintaining it in good and safe condition and in a
readily identifiable and retrievable.

The holder of the copy of this Manual shall maintain it in current status by inserting latest amendments as and
when the amended versions are received.

Accreditation coordinator is responsible for issuing the amended copies to the copyholders, the copyholder
should acknowledge the same and he /she should return the obsolete copies to the Accreditation coordinator.

The amendment sheet, to be updated (as and when amendments received) and referred for details of
amendments issued.

The manual is reviewed once a year and is updated as relevant to the hospital policies and procedures. Review
and amendment can happen also as corrective actions to the non-conformities raised during the self-assessment
or assessment audits by NABH.

The authority over control of this manual is as follows:

Preparation Approval Issue

Accreditation coordinator Medical Director Accreditation coordinator

The procedure manual with original signatures of the above on the title page is considered as ‘Master Copy’,
and the photocopies of the master copy for the distribution are considered as ‘Controlled Copy’.

Distribution List of the Manual:

S. No Designation

1 Medical Director
2 Accreditation Coordinator
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CONTENTS
SL. No. Topics Page Number
AAC 01 Policy and procedure on Registration 5
AAC 02 Policy and procedure on Admission 7
AAC 03 Policy and procedure on Admission of patients in ICU, EMERGENCY 12
AAC 04 Policy and procedure on Non Availability of Beds – ICU 15
AAC 05 Policy and procedure on Assessment policy-ICU, Emergency, Operation 16
Room & Ward
AAC 06 Policy and procedure on Transfer of Patients –Stable, Unstable Patients 20
AAC 07 Policy and procedure on Laboratory services, Quality assurance & Safety 23
Programme
AAC 08 Policy and procedure on Imaging services & Safety Programme 24
AAC 09 Policy and procedure on Patient Education on Expected Cost 26
AAC 10 Policy and procedure on Discharge Summary 27
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AAC 01 – POLICIES AND PROCEDURE ON REGISTRATION

Purpose:

To have a uniform registration of patients and to maintained the records of patients coming to our hospital.

Scope:

Scope of registration includes all patients in OPD and Emergency Department.

Policy:

All patients are registered with a unique registration number (OPD Number). Registration shall be done for
OPD consultation, Investigations and Emergency care.

Emergency care has to be provided 24 hrs a day and 365 days a year.

Following timing is followed for registration and OPD consultation

Registration in OPD: -

OPD consultation –time morning 9AM to 9 PM

Emergency registration and emergency services – 24 hours

Patients are registered only if the treatment requirement is within the scope of services of the hospital (as
detailed in scope of service document No. (AAC/01). If patient’s requirement is outside hospital’s scope, patient
shall be informed on same.

Unidentified patient:

Patient coming or brought to the hospital, whose details (name, address etc.) cannot be identified are termed as
unidentified patients. In case of unidentified patient brought to the hospital, he/she shall be registered in
emergency and as MLC. The registration detail of such patients shall clearly show the unidentified status of the
patient. The identification details shall be updated as soon as the identification of the patient is confirmed.
In case of confusion as to whether to register or not, Medical Superintendent shall be contacted.
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Procedure
S. Procedural steps Responsibility
No.

1. Check if the patient is a new patient or a follow up patient OPD Staff

2. For follow up patient enter the OPD number of patient in HMIS OPD Staff
and take print of case paper

3. For new patients, ask details of the patient Name, Age, Address OPD Staff
and Problems.

4. Enquire for referral letter OPD Staff

5. Register for the specialty as asked by patient or as per referral slip OPD Staff

6. In case specialty is not known, take the patient to MS. Follow the OPD executive
decision of MS for registering in a particular specialty

7. Enter the details, in the computer software OPD Staff

8. Enter the service to be rendered OPD Staff

9. If patient is coming for only Investigation, check the investigation Causality staff
order on referral slip / investigation slip and enter into the service

10. In case of confusion in entering investigation, check it from Causality staff

‘checklist of service’

11. Print case paper having registration details of the patient Causality staff

12. Hand over the Case paper to the patient / relatives and Send to Nursing
concerned doctor

13. Direct the patient to consultation room Nursing staff

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AAC-02 POLICIES AND PROCEDURE ADMISSION

Purpose:

To define the process of admitting patient to an inpatient Nursing Unit.

Policy:

To ensure that the patient gets right treatment immediately on admission based on initial nursing assessment
& consultant’s order

Attachments: Medical Data Sheet, Patient Valuable form, Doctor Visit Sheet, Ward Procedure Sheet

Responsibility: Reg. / Adm. Department, Nursing Unit, Billing, ER

Time Limit: Within 10 mins. in ICUs & within 30 mins. in Wards

Schedule of new admission

Patient admitted from admission dept except emergency cases from 8a.m to 8 p.m. After that each and every
patient gets admitted from Emergency room.

Registration Procedure (In admission dept.)

 The patient comes with a consultant/admission note at the time of admission.

 The Casualty Medical Officer of ER explains the patient about the proposed care, expected results and
possible outcome.

 During admission, name of both admitting and attending consultants has to be written according to the
admission note brought by the patient from the consultant.

 If the patient does not come with the consultant note, the admission officer has to take information from
the patient or his relative about the referring doctor and call him to enquire about the admitting and
attending consultant.

 If the patient comes directly to the hospital i.e. he/she does not come with any referral note or through
phone call, then he will be referred to ER- where the ER Registrar has to- asses the patient and the
consultant on emergency schedule will be called, and thereafter the patient will be recommended further
for admission if required.

 After completion of admission procedure, an inpatient no. is allotted to the patient.

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 An admission slip is generated and filed in the patient’s medical record file.

 Admission fee is collected from the patient at the time of admission.

 An identification band is issued to the patient for easy identification (Refer policy for ID bands).

 The admission officer has to explain the patient/relative about the services available at the hospital to
make an inform decision.

The information includes:

 Rights and responsibilities of the patient

 Minimum deposit at the time of admission

 Class of room & their charges

 Number of patients per room

 Facilities available to patient in each class

 The surcharge applicable to particular class

 Charges for I.C.U.

 Visit fees of consultant

 Visitor’s policy

 Upgrading or degrading of class, i.e. if the patient upgrades the class, the charges for the higher class
will be applicable form the day of admission.

 Grade of surgeries and other associated charges

 Other necessary information

 Patient who has come for the package treatment are given additional information regarding :

 The different types of packages,

 Information regarding the inclusions & exclusions of package.

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 Room facilities

 Bed is allotted to the patient on the basis of choice of class & speciality unit (List enclosed).

 No Consultant or the Nurse Administrator has the right to allocate bed to the patient. This authority lies
with the Admission department only.

Advance Room Booking:

 If the patient wants to get the room booked in advance for his/her admission, the admission officer takes
the complete details from the patient and allots the class and room according to the choice of the
patient/Guardian.

 The hospital has right to change the room no. in case of unavailability of the same room at the time of
admission but the class will remain same.

 A booking confirmation no., date and time of admission is given to the patient. (Annexure- Booking
Form).

 The patient is clearly explained that the hospital has right to cancel the booking in unforeseen
conditions.

 For the booking of room patient has to pay the booking charge at the admission office/IP billing.

 In unforeseen conditions the hospital has right to cancel the booking with prior information to the
patient.

 Patient is shifted to the room accompanied by an attendant, who carries the patient’s admission file and
hand over it to the floor nurse administrator.

 The unit nurse of the patient ensures that the patient is admitted in the right room and the initial
assessment is done immediately in the given time frame (Refer Nursing Policy & Procedure).

B. Admission Procedure:

The patient can be admitted in the hospital from Emergency Room, as direct In-patient or can be
referred from outpatient department for admission.

1. Routine admission

 Admission officer has to inform the concern-nursing unit and PRO about new admission.
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 Housekeeping dept has to arrange the unit and intimate to admission dept regarding readiness of the
unit.

 Admission officer has to inform the nursing unit about the details of new admission. It includes
patient’s name, gender, and class, treating consultant & case type.

 Nurse administrator has to assign the staff for new admission patient.

 According to the patient’s clinical condition primary nurse has to arrange the unit.

 Nurse Administrator has to make sure that room is prepared with necessary bedside equipments as per
case type before receiving the patient.

 The moment patient get admitted, admission officer accompany the patient to the respective unit along
with the admission file. The file contains record file with “Patient admission Form,” Medical Data
Sheet, Doctor Visit sheet, & Service given to patient sheet.

 Primary Nurse has to check the details in “Patient admission Form,” and if any discrepancy is found,
get it corrected from the Admission officer.

 Admission officer has to explain about the details of hospital facility

 Admission officer has to orient the patient and relative about necessary services.

 Primary nurse has to start initial assessment within 15 minutes but not later than 30 minutes.

 If any abnormality of condition noticed by the primary nurse during assessment she has to inform the
medical officer immediately for necessary management.

 If written treatment orders are already there, she has to initiate the treatment according to medication
administration policy.

 If any written investigation orders are there, she has to sent requisition accordingly.

 Primary Nurse has to hand over valuables to patient’s relatives and take their signature in Patient
Valuable form. (Refer Valuable Policy)

 Medical Officer has to inform to the Admitting and Attending consultant about patient arrival time.
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If the patients’ admission time is different from this schedule then primary nurse has to send a-la-
carte order according to the patients order.

 Primary Nurse has to prepare Nursing plan as per consultant’s order and nursing assessment.

 Primary nurse has to reassess the patient continuously, till the patient gets stabilized.

 Primary Nurse has to prepare patient file according to the sequence of MRD sheet.

 Patient Admission form

 History sheet

 Treatment sheet

 Progress sheet

 Consultant sheet

 ICU chart

 Vital Signs and I/O Chart

 Nursing treatment sheet

 Service Sheet

 Doctor visit sheet

 Primary Nurse has to transfer the documents from In-patient record file (received from Admission

Dept.) to ward file.

 Primary Nurse has to enter required details in the Admission Book.

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AAC-03 POLICIES AND PROCEDURE ADMISSION OF PATIENT IN ICU

Purpose
To smooth down the process of admitting the patient so that patient can safely be admitted.
Scope
All patients need to be admitted to our hospital.
Responsibility
Admission officer, staff nurse, Nurse Administrator, PRO, Asst. Manager, Medical officer, consultant
Policy
 Policy of the hospital invites all the patients irrespective of their race, color, religion, ancestry,
financial class or national origin
 Patients shall be admitted under any fulltime or visiting consultant of the hospital solely by
patient’s preference.
 All TPA and credit patients are subject to authorization letter.
 Admission department is working for 24*7.
 Hospital protocols shall be informed to patients at the time of admission only.

Types of admission:
Planned Admission
In this kind of admission, admission of a patient is pre-planned. Patient is given a scheduled date and
time for the admission. If patient wish to opt for credit facility (like, Mediclaim, TPA etc), essential
paper work like permission letter, authorization letter etc formalities are finished before the patient
comes for the admission. On the day of admission patient comes to the admission department and
admission procedure is done as per given below Procedure for planned admission.

Admission from OPD Clinics

Anytime if need arises for the admission, for the OPD patient immediately after consultation, in such
cases, consultant shall fill the admission request form and send the form to admission dept and escort the
patient and/or relatives to admission department. After finishing the necessary process, patient will be
transferred to the allotted room.

Admission From Emergency Room(ER)

When patient from Emergency room agrees for the admission, casualty medical officer shall fill in the
admission request form and send the form to admission department along with one relative of the
patient. Immediately after necessary admission process, admission officer shall inform the allotted bed
no to ER. And patient shall be shifter to room directly from ER.

Admission of the outpatient observation :

A patient who requires a temporary stay on OPD bases for the observation, patient’s consultant shall
send the duly filled admission request form to admission department and after coordinating with ER
staff, admission department shall allot the bad to the patient.
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Procedure
Patient enters for the admission process after undergoing initial assessment by the consultant in case of
planned/OPD patients and by CMO in case of emergency. Patient and relatives are well explained by
consultant regarding proposed care, expected results and expected cost of care. If patient gets agreed for
the admission, doctor write downs admission instruction and send the patient to the admission
department for the selection of room and other formalities.
Procedure For Planned Admissions
i. Patient comes to the hospital with the OPD file carrying the appointment date / admission request letter
given by admitting consultant, for the admission.
ii. Admission officer confirms the appointment and if it’s not scheduled, ask to Asst. Manager OPD for the
confirmation of the admission.
iii. Primarily package details shall be explained by the person, giving the appointment to the patient.
iv. At the time of admission, admission officer shall explain different class of rooms available and rate per
day accordingly.
v. Admission officer shall check for the availability of the room of the desired class and admit the patient
only on the bases of any one valid ID proof (Driving license/PAN card/ Voting ID/ Valid passport)
vi. Admission officer shall send the patient to Billing department to deposit the admission deposit as
mentioned in deposit policy.
vii. Admission officer shall inform the nursing staff on respective floor regarding arrival of the new patient.
viii. Nursing staff shall inform the PRO to confirm that room is ready to receive the patient.
ix. Patient shall reach the designated room along with the admission file accompanied by GRE.
x. GRE shall handover the patient to staff nurse on the floor.
xi. Staff nurse and nurse administrator shall welcome the patient and give him/her comfortable position on
the allotted admission bed.
xii. Staff nurse shall take admission assessment and Medical officer shall take proper clinical history of the
patient and inform the admitting doctor regarding arrival of the patient.
xiii. Within 30 minutes of patient’s arrival, PRO shall meet the patient and ensure that non-medical
requirement of the patient is fulfilled.
xiv. Admission department shall explain following things to the patient and relatives and get informed
admission as well as explanation consent.
 Persons allowed with the patient as per their class
 Provision given to relatives at night. Like one pillow and blanket for one relative in case of twin
sharing, two pillows and blankets for two relatives in premier etc.
 Outside eatables are not allowed in the hospital premises.
 Any visitor, who wants to come to see the patient, required to take the visitor pass and then only can
come.
 Accompanies relative must have to keep their attendant’s pass with them every time and show it to
security whenever demanded.
 Services included and excluded in the package, if packaged patient.
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 Patient and relatives are solely responsible for their belongings and valuables, hospital authority shall
not be responsible for any loss or damage.
 Detailed information about the room allotted to the patient and respective floor PRO’s
information shall be provided to the patient at the time of admission.

Procedure for Emergency Admission

i. In case or emergency patients are directed to ER for the life saving procedures. And at least
OPD no. is being created by the ER executive.
ii. Once the patient receive emergency services and in ER, and if admission if required, patient and
relatives are explained by the treating consultant for the requirement of admission and estimated
expenditure.
iii. Once treating consultant explains everything, patient is being escorted to admission department.
iv. Admission department shall inform the allotted bed to ER staff so that patient’s shifting can be
made as soon as possible.
v. If patient need to be admitted in ICU, ER shall inform to ICU for the preparation of unit with all
equipments required for the patient. (Ventilator, Monitor, Bi PAP, Defibrillator etc.)
Admission officer shall follow the procedure for informing relatives and taking consent as mentioned below.
i. Once the bed is allotted to the patient, ER staff shall accompany the patient to the designated
room and handover the patient to the unit nurse.
ii. ER staff shall finish the formalities of posting the charges, for the treatment given in ER.
iii. ER staff shall inform to admitting consultant regarding shifting of the patient.
iv. After receiving the patient in the wards nurse shall do all the formalities as mentioned in
PLANNED ADMISSIONS
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AAC-04 POLICIES AND PROCEDURE NON AVAILABILITY OF BEDS

Purpose
To establish an overall management plan to provide appropriate and consistent inpatient access during periods
of high volume.

Scope
All inpatient areas

Responsibility
Nurse administrators, PRO s, Admission dept, Sr. Manager, Medical Director.

Procedure
 Patients are allocated, based on their choice of particular class of facility: Economy, twin sharing,
premier, and suite.
 In case of non-availability of the particular class of bed, patients are temporary being allotted lower or
higher class whichever is vacant; after their consent, and as soon as their choice of bed gets vacant they
are being shifted to particular class of bed.
 If the patient from another facility is to be transferred to the hospital and beds are occupied, the other
facility shall be asked to hold on to the transfer for particular time period.

Non availability of beds in ICU:

Beds in ICU are assigned according to the following guidelines

a) ICU bed allocation will be prioritized as per ICU prioritize criteria.
b) ICU nurse administrator is informed in advance in case of admission and prior to major surgeries.

The priority for bed allocation includes:

a) Patients who are already admitted in the hospital are given the first priority for bed assignment to
ICU in case of deterioration in the patient's conditions.
b) Patients external to the hospital are placed in Emergency ICU in case of non-availability.
c) Emergency and critical patients are given first priority.
d) In case there is no bed available in the ICU then the patient will be transferred in the following
order:
- To other ICU
- To the Emergency ICU
- To other Unit
- To an outside center with the required facilities.
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AAC-05 POLICIES AND PROCEDURE ASSESSMENT POLICY

Purpose

To define the system for initial assessment & reassessment at the time of admission, for initiating treatment and
nursing care plan provided to the patient.

Policy: To ensure initial assessment within the given time frame, by primary nurse for appropriate nursing
intervention.

Area for Patient Assessment:

 ICU patient assessment.
 Ward patient assessment.
 Emergency patient assessment.
 Operation room patient assessment.

Attachments:
 Nursing admission assessment
 Nursing treatment sheet
 Vital sign and intake output chart
 Clinical History
 Nutritional Screening Form

Department involve:

 Nursing department
 Medical staff

Responsibility
 Primary nurse
 Nurse administrator
 Clinical supervisors

Time limit:

Initial assessment: Within 15 to 30 minutes.

Reassessment: Every 4 hour or as per Consultant orders.

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Procedure

A. Patient assessment is an ongoing process that begins when the patient gets admitted and continues
throughout the tenure of hospitalization.

B. Once the patient arrives in the unit, primary nurse has to do an initial assessment within a moment the
first 15-minute to determine immediate care.

C. Initial assessment has to complete by primary nurse.

 The nurse administrator has to assigned staff to patient according to the patient’s condition.
 Primary nurse has to take history from in Nursing Assessment form from Patient and relatives.
 Primary nurse has to record chief complaints and brief history for the patient during their
assessment, e.g. blood in sputum blood in vomiting, or bed sore.
 Primary nurse has to write patient condition and any legal status about the patient, in nursing
treatment sheet. e.g. MLC case.
 After initial assessment, she is fully responsible to inform medical officer or consultant about the
patient details.
 For reassessment, primary nurse has to check again all-important criteria like initial assessment.
 During reassessment if primary nurse noticed any deviation from the normal assessment, she has to
inform on duty medical officer immediately.
 Primary nurse has to start medical treatment at earliest possible.
 Primary nurse has to document results of the initial assessment and reassessment in each patient’s
medical record.
 The assessment of infants, children and adolescent patients is individualized to the patient’s age and
needs
 The scope and intensity of any further assessment will be based on the patient's diagnosis and
condition.

In Emergency Room

Time limit:
Initial assessment: Immediate on arrival
Reassessment: Every minute, and as per consultant instruction

Procedure
The initial assessment of the patient it means to identify patient life-threatening problems---AIRWAY,
BREATHING, and CIRCULATION.
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 Primary nurse has to check first the level of the consciousness, if the patient is conscious primary
assessment can be performed at a glance.
 If patient is not fully conscious, primary assessment should process step by step, like airway,
breathing, circulation, disability and expose.
 Primary nurse has to check patient for neck or spinal cord injury.
 If patient have any head or spinal injury primary nurse has to provide immediate immobilization of
the spine while performing assessment.
 Initiate for IV assess and check blood pressure.
 For re assessment primary nurse has to check every 15 minute and as per patient condition and she
has to mention in nurses treatment sheet.
 Primary nurse has to record patient intake output chart.
In CCU’s
Initial assessment: immediate on arrival
Reassessment: Every 15 minutes, and as per consultant instruction
D. Once the patient arrives on the treatment area, primary nurse has to do an initial assessment immediate
on arrival
E. Initial assessment has to complete by primary nurse

 Primary nurse has to write mention criteria within time limit.

 The nurse administrator has to assigned staff to patient according patient condition.
 Primary nurse has to take detailed history from patient & relatives
 Primary nurse has to record chief complaints and brief history during their assessment, e.g. blood in
sputum blood in vomiting, or bed sore.
 Primary nurse has to write patient condition and any legal status about patient, in nursing treatment
sheet. e.g. MLC case.
 CCUs registrar has to take medical history, past history and history about any addiction.
 After initial assessment primary nurse is fully responsible to inform medical officer or consultant.
 For reassessment, primary nurse has to check again all-important criteria like assessment and she has
to write down in CCU chart.
 During reassessment if primary nurse noticed any deviation from normal assessment, she has to
inform on duty medical officer immediately.
 Primary nurse has to start medical treatment at earliest possible.
 Primary nurse has to document results of the initial assessment and reassessment in each patient’s
medical record.
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At OPEATION ROOM

Pre operative phase:

Initial assessment: Within 15-30 minutes
Reassessment: Every 2 hours and as per consultant orders.

 Primary nurse has to informed patient and their relatives that what procedure has been going on.
 Determine the following during initial assessment of the patient’s physical and psychological status
like patient’s past and present medical history.
 Primary nurse has to informed house officer about patient condition if she/he having fever, cold or
any other physical discomfort.
 Do not ingest food or fluid from mid night previous to day of surgery.
 Do not wear make –up or nail polish.
 Wear Patient’s Uniform
 Clear procedure for valuables or jewelry.
 Check that one responsible adult person is with patient.

Post operative
Initial assessment: Immediate on arrival
Reassessment: Every 2 hourly and as per Consultant orders.
 Primary nurse has to verify the patient’s identify the operative procedure and the surgeon who
performed the procedure.
 Primary nurse has to evaluate the following vital sign of patient
 Respiratory status.
 Circulatory status.
 Pulse, Temperature, Oxygen saturation level, Hemodynamic values.
 Primary nurse has to check patient level of consciousness and stimuli.
 Primary nurse has to evaluate the patient’s any lines, tubes, or drains estimated blood loss, condition
of the wound.
 Primary nurse has to evaluate the patient’s comfort and safety by indicators such as pain and
protective reflexes.
 Primary nurse has to perform safety checks to verify that padded side rails are in place, and restraints
properly applied, as needed, for infusions, transfusions etc.
 Primary nurse has to evaluate activity status; movement of extremities.
 Review health care provider orders.
 Primary nurse has to change patient’s position and progress activity like—LOC, dizziness, and
nausea.
 Primary nurse has to orient to patient about time, place and person when he/she become the
conscious.
Note: it is important for the nurse to know the patients native language to provide an accurate assessment.
Interpreters can also solve the problem.
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AAC-06 POLICIES AND PROCEDURE TRANSFER OF PATIENTS

1.0 PURPOSE:

To have a procedure for quick and safe transfer of patients from our hospital to another health centre.

2.0 SCOPE:

All patients in IPD and OPD.

3.0 POLICY ON UNSTABLE PATIENTS

POLICY

To provide a mechanism to facilitate the appropriate transfer of medically unstable patients.

DEFINITIONS

Medically unstable condition- the term “medically unstable condition” means-

A medical condition manifesting itself by acute symptoms of sufficient severity (including severe
pain) such that the absence of immediate medical attention could reasonably be expected to result
in-placing the health of the individual (or, with respect to a pregnant women, the health of the
woman or her unborn child) in serious jeopardy,

Serious impairment of bodily functions

Serious dysfunction of any bodily organ or part

Stabilized – the term “stabilized” means with respect to a medically unstable condition,
Which no material deterioration of the condition is likely, within reasonable medical
Probability, to result from or occur during the transfer of the individual from a facility.

3.1 PROCEDURE

a. Requests from other health care providers to transfer patients who have an emergency medical
condition and require emergency and tertiary level medical care not available at that facility should
be immediately approved when services, space, facilities, and personnel are available to provide
appropriate care.
b. When the facility making the transfer request is capable of providing the necessary care, that facility
must stabilize the emergency medical condition prior to transfer.
c. When the transferring facility is requesting the transfer of an unstable patient, the following
conditions must be met:
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 Physician certification that the expected benefits of transfer outweigh the risks of
Transfer.
 Patient or family consent when possible
 Attempts made by the transferring hospital, within its capability, to stabilize the
patient in order to minimize any risks of the individual during transfer
 Our capacity and capability to treat the transferred patient
 Delivery of all appropriate medical records
 Transfer shall be made with qualified personnel and transportation equipment.
d. If an emergency patient requires services not available at the Hospital, the transfer shall be refused
with a recommendation to contact another facility with the necessary capability.
e. Transfer of patients shall be made by the referring physician contacting senior consultant/consultant/
Resident Medical Officer of The Hospital.
f. The Hospital staff member shall obtain the details of the patients’ emergent medical condition and
contact Admitting Desk. Admitting Desk shall verify that beds are available.
g. All departments who receive requests for transfer of patients shall maintain this policy and procedure
statement in a place accessible to medical staff, and other personnel to ensure that physicians who are
involved in transfers adhere to its content. Questions shall be referred to Director Medical Services.
h. Similarly, when resources matching the patient needs are not available at the Hospital patients shall
be transferred Another Hospital that can meet the patient’s needs. The consultant / Residential
Medical Officer shall contact the faculty of the receiving hospital to ensure that eligibility guidelines
are met. Transportation arrangements and a medical escort (if needed) shall be made through the
Residential Medical Officer.
i. Indications for transfer to another facility:
 Psychiatric condition
 No beds are available at all
 Patient desires to be transferred to another facility
 Services are not available at the hospital
j. Patients being transferred from The Hospital shall be accompanied by a transfer summary that shall
include details of the patient medical condition, interventions done and the ongoing needs of the
patient.
k. Such transfers shall be accompanied by the residential medical officer.
l. Stabilization prior to transfer shall include securing the airway (if needed), intravenous access,
appropriate fluid replacement and pain control
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4.0 POLICY ON STABLE PATIENTS

1.0 POLICY
To provide a mechanism to facilitate the “appropriate transfer” of stable, non-emergent patients who
request such a transfer.

2.0 DEFINITIONS

An “appropriate transfer” is defined as one in which:

The receiving facility has available resources and agrees to accept the transfer and provide necessary
treatment, and the transferring facility provides the receiving hospital with a complete copy of the patient’s
records and other information (such as discharge summary, copies of X-rays, etc.), and the transfer is effected
through qualified personnel and transportation equipment, including use of necessary and medically appropriate
life support measures during the transfer.

PROCEDURE

 It is the policy of The Hospital to accept the transfer of stable, non-emergent patients when space,
facilities, and personnel are available. Every effort shall be made to accept patients when the sending
facility does not have the space, facilities or personnel to provide safe and appropriate care.
 Transfers of stable, non-emergent patients to higher referral centre may be made by
contacting a consultant physician of the Hospital.
 Stable, non-emergent transfers shall be directly admitted to hospital units.
 Acceptance of stable, non-emergent patients for transfer to The Hospital shall be made contingent
upon verification of available resources.
 Transportation arrangements for patients to be transferred from The Hospital shall be made through
the Residential Medical Officer.

RECORDS

Registration Form
Admission Note
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AAC-07 POLICY AND PROCEDURE ON LABORATORY SERVICES, QUALITY ASSURANCE

AND SAFETY PROGRAMME

PURPOSE
To provide guidelines for laboratory services as per the requirements of the patients.
SCOPE

All the patients those who avail laboratory services, the hospital ensures availability of laboratory services
commensurate with the health care service offered
RESPONSIBILITY

 Head of the department,

 Senior Staff
 Laboratory technicians,

POLICY

 24 hours laboratory services are provided.

 Laboratory services are in consonance with the hospital scope of the services:
 Hospital clinical laboratory will engage competent personnel for technical work which includes
technologist and Professionals. The Hospital ensures that all staff of Laboratory Services is
appropriately trained.
 The clinical laboratory services sets out the acceptance criteria for samples received to ensure quality
and safe service.
 Without written request from the treating doctor, sample shall not be drawn from the patient and Criteria
for written request are as follows: Name of the patient; Age/Sex; MR. no (IP No.); Test examinations
clearly indicated; Doctor’s Name, Signature, date and time.
 Criteria for labeling the samples.
 All samples must be labeled with Name of the patient, sex, age, IP.No, date and time of sample taken.
 All samples are discarded as per Biomedical Waste Management Handling Rules, 1998 (2000).
 Turnaround time for each tests are defined. Laboratory results are issued within the defined time frame-
Critical results are defined and displayed. Critical results if any are reported to the concerned doctor
through intercom these are recorded. It is the responsibility of the laboratory staff to communicate any
critical test results to the concerned doctor.
 Laboratory personnel are trained in safe practices and are provided with appropriate safety equipment /
devices. Tests not done in the hospital are outsourced to an approved outside lab. A “Outsourced Test
Register” is maintained.
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AAC 08 - POLICY AND PROCEDURE ON IMAGING SERVICES AND SAFETY

PROGRAMME

PURPOSE

To provide guide lines for identification and safe transportation of patient for imaging services within the
imaging departments.

SCOPE

All patients who receive services from imaging department.

RESPONSIBILITY

 Radiologist,
 Radiography Technicians

POLICY

Compliance with legal requirement:

 AERB / BARC approval for imaging unit has been obtained after inspection and the licenses are
displayed in their respective areas to prove compliance on these issues
 All the workers of the imaging services have been provided with TLD badges for monitoring of their
individual exposures to radiation as part of radiation safety program. Regular monitoring of these badges
has been out sourced and a record for the same is maintained in the radiology department.
 Proper sign posting has been done in the radiology department.
 Training of department staff.

Diagnostic Imaging includes the following:

 Computerized Radiography
 Mobile Radiography.

Identification of patient:
 Hospital shall ensure that all the patients are identified prior to carrying out their investigations.
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 All those patients who require assistance will be transported safely without causing any injury to them in
the process.
 Where applicable patient shall be advised for pre-test preparation and appointment shall be scheduled
for the test when pre-test preparation deserves time more than a day.
 The cases shall be taken up on first come first serve basis, unless otherwise there is requirement to give
priority for specific patients for clinical or other valuable reasons.
 Technician shall orient the patient for taking shots based on to film/equipment positions/process norms
and diagnostic requirements on request of medical practitioner.

Safe transportation of patients: The hospital shall ensure the safe transportation of patients to the imaging
services. For patient’s transportation the Inter – Hospital transfer procedure shall be followed. The medical
staffs arranging transportation is responsible for this task.

Time frame for all results: Imaging results shall be available within the defined time frame. Imaging results
shall be made available on a prefixed schedule of timing. In case of critical patients the results shall be
intimated as immediate as possible.
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AAC- 09 POLICIES AND PROCEDURE PATIENT EDUCATIONS ON EXPECTED COST

Policy:
The patients and family shall be explained in detail about the expected cost of the treatment. This shall be given
in written as estimated expenses of the treatment. (Preferably at the time of admission)

The patient’s estimated expenses shall be calculated on the basis of uniform pricing policy and schedule of
charges.

The tariff list shall be made available to patient if requested for.

In case of change in patient condition or plan of treatment or treatment setting which has financial implications,
same shall be intimated to the patient / relative in advance. This also shall be given in written if requested for.

Procedure

S. No. Procedural steps Responsibility

At the time of admission room charges for various categories is PRO
1.
informed to patient or his/her custodian.
Patient shall be informed regarding Consultant visit charges at the PRO
2.
time of admission.
Patient shall be informed about the detailed procedure & its PRO
3.
associated charges whenever it is planned for.
Patient shall be informed about investigation & Pharmacy charges as PRO
4.
and when required.
Any other charges as and when required shall be informed to the PRO
5.
patients.
If patient requires ICU care the charges for the same and charges for PRO
6.
the critical care area shall be informed before shifting to ICU.
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AAC- 10 POLICIES AND PROCEDURE DISCHARGE SUMMARY

Purpose
To streamline the entire discharge process for maximum efficiency
Scope
All patients getting discharged from the wards
Responsibility
Consultant / Medical Officer / Staff Nurse / Nurse Administrator/ Nursing Supervisor / Assistant
Manager
Definitions and Abbreviations:
Nil
Procedure
a. Discharge advised & documented in the patient’s record by consultant.
b. Nursing staff shall inform the same to the respective PRO and MT for the posting formalities and
discharge summary.
c. Patient & relatives explained about the discharge procedure by PRO.
d. Medical officer has to prepare manual discharge summary and MT shall type it.
e. Drug return sent to pharmacy (If any) by nurse.
f. PRO has to check with the relatives the mode of transportation. If needed help them to arrange
for an ambulance.
g. Nurse keeps the patient record ready with all the reports and arranges the patient’s in file as per
MRD check list.
h. Once all the formalities get finished from floor level, nurse send the file to Pharmacy department
and at last to billing department for the clearance.
i. Nurse has to do follow up with the billing department and send the relatives for the final bill
settlement to billing department.
j. On receipt of discharge slip, Nurse Administrator and medical officer have to explain discharge
medicine to the patient.
k. Nurse hands over discharge file with Discharge summary and other reports to patient or relative
and signature taken in the discharge documents handover form.
 Nurse ensures that the aftercare treatment is clear to the patient & relativeOnce the
patient and relative are ready to leave, hospital attendant accompanies the patient to the
Lift/ Ambulance.
 Ensure that no patient is discharged unless accompanied by a relative.
 Nurse checks that all the records are complete and kept for dispatch to Medical records
department.
 Ensure that the terminal disinfection of the unit is done and the unit is kept ready to
receive the next patient.
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DISCHARGE PROCESS IN CASE OF UNPLANNED DISCHARGE

Senior nurse/medical officer/PRO

Return medicines two hour prior to schedule discharge

Prepare file according to MRD Sheet immediately after returning medicines

Get all forms and reports photo-copied

Start preparing patient
For physical discharge

Prepare both the files (MRD File, patient file) and check for posting status and pharmacy clearance

Send file to billing department

After receiving authorization slip/clearance memo do PHYSICAL DISCHARGE

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DISCHARGE PROCESS IN CASE OF PLANNED DISCHARGE

Complete file documentation one day in advance before schedule date of discharge

Inform relative one day in advance and check inventory of used and unused medicines and document it.

First arrange the file according to MRD Check list, get all forms and reports photocopied and then mark
discharge check list on the day of schedule date and get it counter signed by Asst. Manager- wards.

Return medicines to pharmacy along with the file immediately after countersignature by Asst. Manager—
wards.

After receiving pharmacy clearance, start preparing patient for physical discharge and asst. Manager wards to
inform PRO

Send the file to billing department for final settlement of bill

After receiving file from billing, verify billing clearance and then do physical discharge
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NOTES

 Separate record is to be maintained regarding time of sending file to billing and receiving back
 Separate record is to be maintained regarding time of sending medicine and obtaining pharmacy
clearance.
 To make sure authorization slip/clearance memo is received in duplicate.
 Signature of the patient/relative is to be obtained regarding receiving of reports and all necessary
documents on authorization slip/clearance memo
 File must be prepared as per MRD SHEET attached.
 Security guard to check room just prior to physical discharge of patient and to put signature on
authorization slip/clearance memo.
 Turn over time for entire discharge process is 2 hours.
 Ward in charge to ensure complete and properly filled MRD file reaches MRD on day to day
basis.
 There should be proper record of hospital property used for patient and must be received back
with proper record.