VAKRATUNDA HOSPITAL PRIVATE

LIMITED

POLICY ON REGISTRATION, ADMISSION,

TRANSFER OR REFERRAL OF PATIENTS
 NABH Manual Document Number:
VHPL/NABH/AAC/02
Access Assessment & Continuity of Date of Issue:
Care 15 March
Name of Policy Registration, Admission, Transfer Or Rev Number:00
Referral Of Patients

A. PURPOSE:
To define Policy & Procedure for Registration, Admission and transfer/referral of
patients at Vakratunda Hospital Pvt. Ltd

B. SCOPE:
This Policy & procedure is applicable to patient who undergoes Registration &
Admission or transfer/referral of patients at Vakratunda Hospital Pvt. Ltd

RESPONSIBILITY:
Front Office staff /reception, Nursing In charge, OPD staff are responsible to implement
this Policy and Procedure in consultation with Director.

C. POLICY:
 Patients are admitted only if the Hospital can provide the required services to
the patient.

 All patients, out-patients, in-patients and emergency who are willing to avail
services at Vakratunda Hospital Pvt. Ltd should undergo Registration /
Admission process.

 In case of Emergency, the same to be carried out in parallel to treatment.

 Patient shall be registered only if they match the hospital services

 When there is no provision to treat the patient in the hospital, assist to transfer
the patient to other hospitals where provision exists. For this a list of nearby
Hospitals shall be maintained at the Front Office.

1) REGISTRATION PROCEDURE -
 Patient approaches Reception to avail consultation.

Controlled Copy Master Copy

 NABH Manual Document Number:
VHPL/NABH/AAC/02
Access Assessment & Continuity of Date of Issue:
Care 15 March
Name of Policy Registration, Admission, Transfer Or Rev Number:00
Referral Of Patients

 Reception staff to check with patient whether it is patient’s first visit or subsequent
visit.
 If the Patient is new then he/ she is asked about the Name, age, address, contact No.
etc.... and this information is entered in software to generate the unique Hospital ID.
 If it is not first visit, reception staff asks patient for the registration number.

2) OPD CONSULTATION PROCEDURE

 Patient waits for his turn to visit the Consultant.
 Consultation done by consultant and examination is done patient counseled
about treatment & expenses
 Entry of the same is made in the OPD notes and prescription generated.
 Investigation- Based on the medical condition, patient is advised for Lab
Investigation.
 Patient is directed to the lab collection area
 Patient visits the concerned lab collection area with the OPD Prescription
 Sample for lab investigations are collected by the Lab Technician in the
collection room. The user charges for the investigation are collected in the
lab.
 The details of the patient and the investigations required are entered into the
Lab Register and the software.
 Patient collects the reports as per the scheduled time given by the concerned
department and revisits the consultant with the reports if required
 Based on his findings and the investigation reports, the consultant writes the
prescription for the patient on the OPD prescription. The patient is directed
to the Pharmacy.
.
3) ADMISSION OF PATIENT IN HOSPITAL:
Patients can be admitted from the following areas:
 Admission from Outpatient Clinics: Patients may be directly admitted from
one of the Outpatient Clinics.
 Admissions from the Casualty: Emergency Room patients requiring inpatient
admission must have the Admission recommendation by treating medical
practitioner.

Controlled Copy Master Copy

 NABH Manual Document Number:
VHPL/NABH/AAC/02
Access Assessment & Continuity of Date of Issue:
Care 15 March
Name of Policy Registration, Admission, Transfer Or Rev Number:00
Referral Of Patients

 Admission of Outpatient Observation Patients: When an observation patient

is determined to require inpatient care, based on recommendation by
medical practitioner the patient can be admitted.
 Transfer of stable patients: Admission of stable patients transferred from
other facilities.
 Transfer of unstable patients: Admission of unstable patients transferred
from other facilities.

3.1 Procedure:
1. All patients who are to be admitted should complete registration process.
2. Admissions are referred from OPD department, Referrals and Causality.
3. The doctor advices for the admission on the OPD paper for OPD patients.
4. The Admission counter staff explain the tariff details and availability of type
of bed.
5. Patient is admitted based on their choice and availability of type of beds and
entry of the same is made in the IPD Register to generate IPD Number.
6. Every patient is provided unique Inpatient Number at the time of admission.
7. Admission of patients having health insurance policy patients are directed to
mediclaim department to proceed with claim procedure.
8. In case of unidentified patient coming to casualty, All possible efforts to be
taken by the hospital staff to find the identification of patient; if patient is
unidentified then the patient is to be shifted to Civil Hospital through security
department (also Police to be intimated) or if admitted, the patient is to be
identified by the Inpatient number till patient name is identified as
appropriate.
9. If the staff handling registration and admission needs any clarification on the
services provided by hospital, they should contact Hospital administrator for
necessary information.
10. The patient along with the Admission paper is taken to the specific ward by the
ward boy, Mavashi or OPD attendant who submits the Admission paper to the
respective ward nurse.
11. Patient is received in the bed by the ward nurse and made comfortable.
Treatment as indicated in the Admission paper is immediately initiated.

Controlled Copy Master Copy

 NABH Manual Document Number:
VHPL/NABH/AAC/02
Access Assessment & Continuity of Date of Issue:
Care 15 March
Name of Policy Registration, Admission, Transfer Or Rev Number:00
Referral Of Patients

4.) MANAGING PATIENTS DURING NON-AVAILABILITY OF BEDS

1. Patients shall be offered a choice of patient rooms / beds.
2. In case of non-availability of bed, the admission staff informs Hospital
Administrator to decide on arranging / adding more beds within the
available space (converting single room to sharing room) and the concerned
treating doctor is informed.
3. In the event of non-availability of the room of choice, the patient shall be
allotted the best alternative rooms available.
4. Hospital has different kinds of room categories such as general ward, semi
special room, special rooms, and deluxe room.
5. The concerned treating doctor to decide on postponement or cancellation of
admission in coordination with patient.
6. If no bed is available and patient requires to be admitted, decision regarding
transfer to other hospital should be taken on consultation with Hospital
administrator, Consultant, patient and the hospital administration where he
is to be transferred.
7. All staff handling registration and admission is to be trained on this
Procedure (New Staff, Changes in duties / tariff plans etc.).

5) ADDRESSING MLC CASES

In case of patients involved in medico legal cases the procedure enumerated
below shall be followed.
1. All accidents / assaults / suspicious cases / poisoning and RTA related
brought dead cases shall be enlisted as MLC and recorded in the case
sheets and maintained separately.
2. The recording shall be done in MLC Register.
3. All such Cases are to be informed to the police on phone by the
Residential Medical Officer after informing police station the allotted MLC
no and police constable ID number is noted on case sheet and the MLC
register.
4. MLC Certificate is handed over to the representative of the police station
and the name and buckle no of the constable is recorded in the MLC
Register. A copy of the same is retained.

Controlled Copy Master Copy

 NABH Manual Document Number:
VHPL/NABH/AAC/02
Access Assessment & Continuity of Date of Issue:
Care 15 March
Name of Policy Registration, Admission, Transfer Or Rev Number:00
Referral Of Patients

5. A list of MLC cases are shown below:

a. Road accidents / Industrial accidents
b. Injury with sharp object / fire arms.
c. Death / Injury in a woman
d. Death / Injury in a woman.
e. Conditions which require notification as per the laws for time being in
force.
f. Any other conditions where there is a suspicion of some foul play
g. Where the cause of death is not certain.
h. Poisoning.
i. Drowning.
6 .If in certain cases relatives do not want to register a police case then it should
be noted down and relatives consent is taken for it , for example Domestic accidents.

6) REFERRAL /TRANSFER OF PATIENT TO OTHER CENTRE

If there is no possibility of bed availability or if the patient is not agreeable to be

admitted in another class, then the treating doctor is asked to possibly defer the
admission of the patient or refer the patient to another Centre.

Transfer of unstable Patient-

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 -
Serious impairment of bodily functions
Serious dysfunction of any bodily organ or part
Unstable Patient is transferred to another organization through the ambulance,
accompanied by ambulance driver, helper and Medical officer and the nursing
staff.

Transfer of stable Patient-

Controlled Copy Master Copy

 NABH Manual Document Number:
VHPL/NABH/AAC/02
Access Assessment & Continuity of Date of Issue:
Care 15 March
Name of Policy Registration, Admission, Transfer Or Rev Number:00
Referral Of Patients

Stable Patient is transferred to another organization through the ambulance,

accompanied by ambulance driver, helper

7) TRANSFER OF PATIENTS
Patients are transferred to other facilities if
 In case of diagnostic facilities are not available with the hospitals, patients
are transferred to such facilities for undergoing such diagnostic evaluations.
 Facilities needed for treatment of patient are not within the scope of services
provided by hospital.

a) Transfer for diagnostic purpose

1. In case of diagnostic facilities are not available with the hospitals, patients are
transferred to such facilities for undergoing such diagnostic evaluations.
2. The diagnostic Centre where such facilities exists, are contacted by the
consultants or by the clinical assistant (if instructed by the consultants) and an
appointment fixed.
3. Before sending the patient, the reception is informed which makes the
necessary arrangements for ambulance and staff.
4. In case of critical patients a Medical Officer or nurse accompanies the patient
to and fro from the Diagnostic Center otherwise the patient is accompanied by
a hospital attendant.
5. Transfer for diagnostic procedure consent is taken from patient/relatives
before shifting patients
6. After the test is done, the patient is transferred back to the hospital.

b) Transfer to another facility for treatment

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

Controlled Copy Master Copy

 NABH Manual Document Number:
VHPL/NABH/AAC/02
Access Assessment & Continuity of Date of Issue:
Care 15 March
Name of Policy Registration, Admission, Transfer Or Rev Number:00
Referral Of Patients

Transfer procedure

 Decision to shift out the patient by the consultant

 Transfer out process initiated by the MO/consultant.
 Ensure availability of bed / other required facilities with the casualty
emergency medical officer of the transferring hospital. Details of the patient
should be communicated
 Entry of the Patient details, name of the organization and reason for referral
are entered in the referral register.
 Referral form is filled
 Ambulance driver informed
 Ambulance equipment to be checked, drugs to be checked. Ambulance check
list signed by the nurse in case of life threatening condition of the patient
 Nurse to be arranged by the nursing in charge for patient care during the
transfer
 To check all the required documents-Referral form, Case summary,
investigation reports to be handed over to the patient/patient attendant.
 Details of the transferring hospital (if available) to be filled in the patient
medical record.
 Patients referral form to be filled by the shifting doctor and copy of the same
retained
 Entry to make in patient referral register.
Records –
1. Registration form
2. Admission paper
3. MLC register
4. IPD Register
5. Transfer consent
6. Patient referral form
7. Patient Referral Register

Controlled Copy Master Copy

 NABH Manual Document Number:
VHPL/NABH/AAC/02
Access Assessment & Continuity of Date of Issue:
Care 15 March
Name of Policy Registration, Admission, Transfer Or Rev Number:00
Referral Of Patients

Process Flow chart: Patient Flow in OPD

Patient comes To Registration counter

Patient/ relative gives the details at the

reception

Patient gets registered directed to OPD

Consultation Done

No Investigation Advised OPD Assistant fill the investigation requisition Slip

Patient pays the charges & Exits From OPD Patient Guided To Diagnostic/lab Area
for the collection of medicine at the medicine
dispensing counter
Diagnostic/lab Services Provided

Obtains reports at scheduled time

Takes consultation with the

doctor along with the reports

Controlled Copy Master Copy

 NABH Manual Document Number:
VHPL/NABH/AAC/02
Access Assessment & Continuity of Date of Issue:
Care 15 March
Name of Policy Registration, Admission, Transfer Or Rev Number:00
Referral Of Patients

Process Flow Chart: ADMISSION PROCESS

Patient through OPD Patient through Emergency

Doctor assesses the patient and advises admission

Patient / patient relatives go to admission counter

Inpatient number is allotted and patient is guided to concerned ward.

Controlled Copy Master Copy

 NABH Manual Document Number:
VHPL/NABH/AAC/02
Access Assessment & Continuity of Date of Issue:
Care 15 March
Name of Policy Registration, Admission, Transfer Or Rev Number:00
Referral Of Patients

Process Flow Chart: PATIENT REFFERAL

Duty Doctor informs nurse about referring the

patient out

Nurse informs relatives of the patient and takes

the consent

Medical Officer liaises with receiving

hospital/Diagnostic Center

Reception counter arranges for ambulance

Patient is transferred to other hospital

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