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TABLE OF CONTENT
2. Outpatient Examination 3
3. Admission 4
ANNEXURE
1.3. Responsibility
The Section In-charge to ensure the implementation of the instructions and other
procedures laid down.
Note* -For all the general nursing procedures refer OP- nursing department
operating manual
2. OUTPATIENT EXAMINATION
2.1.1. Patients who come after the registration are called in according to their „queue‟
number.
2.1.2. They are then seen either by the consultants or by the junior medical staff depending
upon the type of registration made PC/By-choice/general.
2.1.3. They are then quizzed in detail about their complaints subsequently, a good clinical
examination is done provisional diagnosis made and relevant investigations asked
for. The protocol for the history taking and examination is made according to
standard text books of clinical examination. E.g. .Hutchison‟s clinical method.
Patients requiring expert opinion are seen by consultants in addition to the residents.
2.1.4. Patient is then prescribed medication and asked to come back for reports the same
afternoon or the next day to come to a definite diagnosis.
2.1.5. Additional medications are prescribed if necessary.
2.1.6. For any patient who deserves and requests concession the pink social service form is
filled where category (A, B, C, D, E) is to be written by consultants. This sheet and
prescription is sent to social worker with the chart through the OPD aid. After
categorization by social worker, the category is written on the prescription and
countersigned by the HOD and the prescription given to the patient to buy
medicines from the hospital pharmacy. If concession is approved, medicines can be
given for 2 weeks only.
3. ADMISSION
3.1. Inpatient admission:
3.1.1. Patients who are sick and need admission are either seen in the casualty or in the OP
department.
3.1.2. The admitting doctor follows the procedure as given above.
3.1.3. He then fills up the doctor‟s order sheet in the following order.
a. Admission to appropriate ward notified
b. General condition stated
i. Frequency of monitoring the vital signs indicated
ii. Type of diet specified
c. Appropriate investigation mentioned
d. Drugs to be administered are specified in these generic form and the route of
administration is indicated e.g. Parental / intramuscular / IV etc and the frequency
specified Q4H or Q6H.
e. STAT medications are given before shifting.
f. Allergies to any drug is highlighted in the given column.
3.2. Emergency admission
3.2.1. A patient who is wheeled into the casualty is first seen by the sister on duty and the
casualty doctor on call is intimated.
3.2.2. The casualty doctor intimates the respective department duty doctor as and when
needed.
3.2.3. The duty doctor takes a detailed history and a detailed examination is conducted.
3.2.4. A provisional diagnosis is made and relevant investigations and asked for and
treatment instituted after consultations is made with the on call consultant.
3.2.5. Following this the patient is either admitted to the appropriate ward or discharged,
Name: ……………………………………………
Age…………………… Sex……………………..
Address…………………………………………..
Telephone No…………………………………….
TRAVEL KIT
Sl.No Item Quantity
1 EYE PAD 1
2 COTTON ROLL 1
3 BAND AID 2
4 ADHESIVE TAPE 1
5 COTTON BALLS 1
6 TRIANGULAR BANDAGE 1
7 GAUZE PADS 2
8 GAUZE 7.5x7.5 cms 2
9 GAUZE 5 x 5 cms 4
10 GLOVE PACKAGE PAIR 2
11 TOURNQUET 1
12 TWEEZER 1
13 SAVLON 1
14 FIRST AID TAPE 1
15 SURGICAL COMBINED DRESSING 7.5 X 7.5 cms 1
16 STERILE DRESSING WITH GAUZE PAD 18 X 18 cms 1
17 TRIANGULAR BANDAGE 1
18 LATEX GLOVE PAIR 1
19 WOUND WIPERS 2
20 CPR SHIELD 1
21 STRETCHED BANDAGE 5cm x 3mts 1
22 FIRST AID GUIDE 1
TRAVEL KIT
Signature: Signature:
ANNEXURE I
1. ROLE OF HEADS OF DEPARTMENTS
1.1. HODs of all departments will conduct random weekly checks (chart audits) of the OP
chart to monitor.
1.1.1. Time at which patient is seen to determine waiting time.
1.1.2. History taking and examination.
1.1.3. Appropriate tests.
1.1.4. Accurate diagnosis.
1.1.5. Justified, Accurate, Cost effective & complete treatment.
(HODs of single consultant departments shall conduct the monthly audits of at least 5
charts together with the Chief/Asst. Chief of Medical staff)
These random weekly checks shall be recorded in an Out-patient/Casualty chart audit
register.
1.2. HODs of all Departments will conduct weekly checks (chart audits) of a discharged
patient chart to monitor.
1.2.1. Accuracy of treatment.
1.2.2. Cost effectiveness of treatment.
(HODs of single consultant departments shall conduct the monthly audits of at least
5 charts together with the Chief/Asst. Chief of Medical staff)
These random weekly checks shall be recorded in an In-patient chart audit register.
1.3. The HODs will also be part of the Quality Assurance Committee conducting quarterly
review of
1.3.1. The Out-patient/Casualty chart audit registers.
1.3.2. The In-patient chart audit registers
1.3.3. The Appointment time check register.
2. ROLE OF DOCTORS/CONSULTANTS
2.1. Consultations
2.1.1. Consultants should see PC (Private Consultation) patients within 30 minutes of
appointment time.
2.1.2. Doctors should enter the time of starting the consultation in the chart below the date
stamp and the nurse‟s time.
2.1.3. Doctors should take a comprehensive history as appropriate and should write it
down in the chart.
2.1.4. The need for appropriate tests should be explained to the patient, and then ordered
by the doctors.
2.1.5. The Doctors should make a provisional or actual diagnosis and explain it to the
patient.
2.1.6. The Doctor should prescribe medication that is justified, cost-effective and this
should be explained to the patient.
2.2. Admissions
2.2.1. On admitting the patient, the Doctors should write the orders clearly.
2.2.2. The time of admission should be entered in the admission/discharge time sheet.
2.2.3. Routine PC patients and Emergency patients should be placed in bed within half an
hour of being admitted by the doctor.
2.2.4. Routine General patients should be placed on bed as soon as bed is available as
admitted by the doctor
2.2.5. Doctors should ensure that the in-patient treatment is accurate, precise, properly
documented, and that the list/procedures are appropriate and cost-effective.
2.3. Discharges
2.3.1. All routine planned discharges shall be done the previous day.
2.3.2. Only emergency discharges, discharge against medical advice, transfers, 24 -24
hour admissions and discharges on request shall be done the same day.
2.3.3. When discharging a patient, doctors should also mention the time of discharge in
the admission/discharge time sheet.
2.3.4. Doctors should write the discharge summary in time; it should also be accurate and
informative.
2.4. Casualty
2.4.1. Casualty – Doctors should attend a patient prioritized as critical emergency within 5
minutes of arrival of the patient in the casualty.
2.4.2. The doctor should make as accurate a diagnosis as possible and enter it in the order
sheet.
2.4.3. Patient and relatives should be informed in detail regarding the condition of the
patient and treatment plan. This shall be entered in the Doctors orders sheet as
“explained condition and treatment to patient and relatives”.
Annexure II
Organogram
Director
Deputy Director
HOD
Nursing Aide
House keeping