1

CONTENTS
Page
List of Acronyms i
Foreword iii
1. Emergency Tray 5
1.1. Emergency Tray Equipments for all units 5
1.2. Emergency Tray Medicines for all Units 6
2. Admissions 8
2.1. Admission to in-patient Care in the Ward 8
2.2. Admission for operation 8
3. Prescription of Drugs 11
4. Administering Drugs 12
4.1. Administering Oral Drugs 12
4.2. Administering intravenous drugs 12
4.3. Administering Chemotherapy 13
5. Operation Theatres 14
5.1. Patient Preparation for Operation 14
5.2. Administering Anesthesia 15
5.3. Operation Theatre 16
5.4. Postoperative Care 16
6. Labor Room 17
7. Discharging the Patients 19
8. In-patient Consultation Between Different Units of the Hospital 20
9. Private Rooms 21
10. Out Patient Department (OPD) 22
10.1. General OPD 22
10.2. Ante Natal Care OPD 22
11. Ward Round 24
12. Clinical Audit 25
13. Online indenting of Medicine and Medical
and Surgical Disposables from Pharmacy 26
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14. Zakat 28
15. Baitul Mal 29
16. Indenting of Store items 30
16.1. Indenting of Main Store items 30
16.2. Indenting of Stationary and P & D store items 30
17. Record Room 31
18. Ward Cleanliness and Maintenance 32
19. ICU 34
20. Department of Accident and Emergency Department 35
20.1. Emergency cover in A & E 35
20.2. Emergency Cover in units/wards 36
21. Gastro Intestinal Endoscopies 38
22. Cardiological Procedures 39
23. Radiological Procedures 40
24. Laboratory Investigation 41
24.1. Online Laboratory Investigation 41
25. TMOs/MOs Duty 43
25.1. Duty Rotas 43
25.2. Guidelines for TMOs/MOs Duty 43







3

i


Acronyms

SOP : Standing Operating Procedure
IV : Intravenous
BD : Bis Die (Twice a Day)
CVP : Central Venous Pressure
ECG : Electro Cardiac Gram
HO : House Officer
SMO : Senior House Officer
TMO : Trainee Medical Officer
MO : Medical Officer
CMO : Casualty Medical Officer
JR : Junior Registrar
SR : Senior Registrar
OPD : Out Patient Department
OT : Operation Theatre
ICU : Intensive Care Unit
CT : Computerized Tomography (Refined X-Ray scan)
MRI : Magnetic Resonance Imaging
ANC : Ante Natal Care
ETT : Exercise Tolerance Test
TEE : Trans Esophageal Echo Cardiography
BP : Blood Pressure
PT : Prothobim Time
APTT : Activated Partial Thromboplastin Time
ICT : Amino Chromatographic Technique
HIV : Human Immunodeficiency Virus
MLC : Mixed Lymphocyte Culture
LP : Local Purchaser
VS : Visiting Surgeon
VP : Visiting Physician
VG : Visiting Gynecologist
KUB : Kidney Ureters & Bladder
KCL : Postassium Chloride
4

ii
FOREWORD
To comply with clinical governance requirements, we as healthcare professions are
required to put in place strategies for risk management and harm minimisation. The
strategies should allow for the continual improvement of standards of service and provide
evidence of commitment to protecting patients. Standard Operating Procedure specify in
writing what should be done, when, where and by whom. The benefits of SOPs are that
they help to assure the quality and consistency of the service, ensure that good practice is
achieved at all times, provide an opportunity to fully utilize the expertise of all members
of the team, help to avoid confusion over who does what (role clarification), provide
advice and guidance to new and inexperienced staff and provide a contribution to the
audit process.
The SOPs in this booklet are general in nature and all the head of the departments
and section in charge are advised to prepare SOPs related to their specific sphere of work.
Every clinical unit has its peculiar specialty and the SOPs will need to reflect this. The
SOPs under normal circumstances, be applicable at all times, i.e. not dependent on the
presence of the unit head / professor under whose authority the procedure was prepared.
There may be exceptional circumstances where it is necessary to work outside a SOP,
e.g. in the event of computer breakdown. In these situations the professional judgement
of the doctor in charge must remain paramount. The unit heads and DMSs in charge of
sections should anticipate situations where changed circumstances will apply and
accordingly prepare separate SOPs to be followed in the event of predictable
circumstances, e.g. procedures to be followed in the event of computer breakdown.
SOPs should also be clearly marked with the date of preparation/ amendment and
should be kept up to date and relevant at all times by the senior registrar who is in day to
day charge of the unit/ward. Finally, when SOPs are first drafted, the staff may be asked
to sign to say they have read and understood them because besides clarifying staff roles,
this can also offer an opportunity for staff training and development.

Dr Aftab Akbar Durrani
Chief Executive
Dated: 1
st
Nov, 2010
5

SOP 1: Emergency Tray

1. Every unit will have an emergency medical tray with purpose built portable trolley.
2. Medical emergency tray will be kept in an accessible place & routinely monitored by
staff nurse to ensure that all supplies are replaced & weekly checked by registrar &
monthly by hospital inspection team.
All the equipment will be in working condition & emergency life saving drugs up-to-
date.
SOP 1.1: Emergency Tray Equipments for all units
Following equipment will be present in the emergency tray in working condition at all
times.
1. Ambu bag at least two, checked for physical integrity once a week.
2. Masks of different types & sizes
3. Flash light with extra batteries
4. Portable small size oxygen cylinders with proper gauge & masks
5. Swabs, sponges, cotton & adhesive taps
6. Gloves
7. Stethescope, blood pressure set of good quality
8. Laryngoscope
9. Disposable oral airways of various sizes
10. Scissors
11. Glucometer with strips(2)
12. Catheters & naso gastric tubes of various sizes
13. CVP lines
14. Lumber puncture needles of different sizes
15. Cat gut, silk & artery forceps
16. Small portable sucker machine
17. Defibrillator(01)
18. ECG machine (01)
19. Nebulizers(02)
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20. Chest tube with under water seal(03)
21. Ophthalmoscope(1)
SOP 1.2: Emergency Tray Medicines for all Units
1. Inj Adrenaline 5
2. Antihistamine 10
3. Atropine Sulphate 5
4. Inj Hypertonic 10
5. Soda bicarbonate & Calcium gluconate vial 5 each
6. Injection Dobutamine & Dopamine 5 each
7. Inj. Hydrocortisome different strength 5 each
8. Inj. Dexamitheseme 10
9. Inj.Lignocaine 5
10. Inj. Diazepam 5
11. Inj lanoxin 10 each
12. Tab. Asprin 10 each
13. Cylyceryltrimitsate 10 each
14. Inj. Frusemide 10
15. Inj. Nalaxone 10
16. Gelation Polypeptide 05
17. Potassium Chloride 05
18. Inj. Isosorbide dimitrate 05
19. Inj. Vitamin K 05
20. Inj. Ranitidine 05
21. Inj. Tranxamic acid 05
22. Solution Salbulamol 01
23. Inj. Aminophyline 250 mg 05
24. Oxygen key 01
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25. I.V Cannula 02



26. Syrinjes 5cc 05
27. Cutter 01
28. Airway 01
29. Inj Dimenhydrinate 01
30. Inj Oxytocin 01
31. Inj Methylergometrine 01
8

SOP 2: Admissions

SOP 2.1: Admission to in-patient Care in the Ward
1. Admission from OPD shall be done by the ward registrar or any senior doctor.
2. Admission through casualty shall be done by on call member of the team (SHO/
TMO) after proper referral from CMO (Patient shall receive emergency treatment in
the casualty, stabilized & only then referred to ward on call).
3. If SHO/ TMO believe there is sufficient reason, the patient shall be admitted.
4. If SHO/ TMO can not make a decision, the patient shall be put under observation &
the registrar & seniors shall be called while starting requisite treatment of the patient.
5. Casualty shall not be used as OPD nor as portal of admission of non emergency
patients to ward on call.
6. Referral from other hospitals and consultants private clinics shall be admitted via
casualty.
7. On admission, detail history shall be taken by the house officer on arrival, followed
by a summary of the patient by the TMO on duty.
8. For medico-legal cases proper official referral & presence of police shall be
mandatory
9. Proof of identity shall be must for every patient.
10. Afghans with out registration cards shall be separately marked
SOP 2.2: Admission for operation
1. Surgical patients shall have a pre-operative assessment and a provisional diagnosis
documented prior to surgery.
2. An informed consent shall be obtained by a qualified member of the surgical team
prior to the procedure on formal consent forms of hospital.
3. A quality assurance program will be followed for the surgical services.
4. The plan shall also include monitoring of surgical site infection rates.
5. Patients shall be admitted to the ward with the permission of JR and above.
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6. In evening round investigations, patient fitness and OT medicine shall be checked.
7. Deficiencies shall be corrected and those found unfit will be postponed from
operation.
8. Children, elderly, diabetic and seriously ill patient will be given priority on OT list.
9. Minor cases, stable patient, infected and hepatitis patient will be put last on OT list.
10. For high risk patient needing ICU care, a bed in ICU will be arranged a day before.
11. For high risk patient anesthetist will be informed a day before.
12. Diabetic patients will be converted to injectable insulin after consultation with an
Endocrinologist for major operation.
13. Blood will be arranged a day before surgery and will be made available in the theatre
before operation.
14. When the patient arrives in theatre, the consent form, investigations and OT
medicine will be again checked by the HOs / Junior doctor authorized by the I/C
unit.
15. Patient needing major gut surgery will be admitted 2 days before surgery
and bowel preparation will be done in ward.
16. In operation theatre investigations, consent and site of operation will again be
checked by the operating surgeon.
17. Pre op antibiotics will be given at the time of induction of anesthesia.
18. Detailed operation notes will be written by operating surgeon in patient chart and
also written in operation register. Post operative treatment shall be written clearly in
capital letters on treatment chart.
19. After completion of surgery, patient will be shifted to recovery room in supervision
of first assistant until fully recovered.
20. Only after anesthetist consent the patient will be shifted to ward.
21. After operation, SR along with TMOs and HOs will conduct a post op round at 2
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pm.
22. Evening round will be again conducted by SR/SMO/TMO/HO at 8:30 pm
23. Patient undergoing minor procedure will be mobilized and orally allowed by
evening.
24. During induction of anesthesia the first assistant shall be present in the OT with the
anesthetist.

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SOP 3: Prescription of Drugs

1. Documented policies and procedures shall exits for prescription of medications.
2. Medication orders shall be clear, legible dated, timed, named and signed.
3. The unit shall define high risk medications orders which shall be verified prior to
dispensing.
4. A list of high risk medications shall be defined by the unit / ward.
5. To prescribe a drug is to take responsibility to relieve the suffering of a patient by a
doctor.
6. Prescription shall be written in clear hand writing and preferably capital letters. Poor
hand writing can result in lethal mistakes. The doctor shall sign each prescription with
his/ her name written beneath his/her signature.
7. The drug advised shall be easily available, economical & effective. The word
effective means that the drug is considered effective by the institution or the Deptt. or
the unit
8. The doctor shall be well versed with the use, interactions & side effects of the drug
prescribed
9. The strength of drug, dosage, mode of administration & duration of use shall be
clearly mentioned in English / universal technical language, on the in-patient
treatment sheet. For out patient prescription, preferably, local language/ urdu shall be
used.
10. A leading zero may be used (e.g. .5 mg may be written as 0.5 mg). Avoid using
trailing zero which may be misread ( e.g. 5.0mg may be read as 50 mg)
11. The doctor shall also know the cost of medicine prescribed & tailor it according to the
socio- economic status of the patient, as it may be the only cause of non-compliance.
12. Drugs available in hospital pharmacy shall be given priority.
13. Drugs from outside the hospital shall only be prescribed when utterly required.
14. Regarding items 7,8,9 & 11 there will be a reference text book to consult. i.e pharma
guide, lying in the emergency cupboard of every unit/ward.
12

SOP 4: Administering Drugs

SOP 4.1: Administering Oral Drugs
Nurse shall administer oral drugs with attention to the following points
1. Identify the patient
2. Ask the patient about history of adverse reaction to the drug being given
3. Check the name, strength & expiry date of the drug with a team member( nurse)
4. Those shall be verified from the prescriptions prior to administration.
5. Medications administration shall be documented.
6. The patient and family shall be educated about the estimated cost of treatment.
7. Patients and family shall be informed about the financial implications when there is a
change in the patient condition or treatment setting.
SOP 4.2: Administering intravenous drugs
First dose of IV drug shall be given by the doctor on duty with attention to the following
1. Identify the patient
2. Ask the patient about history of adverse reaction to the drug being given
3. Check the name, strength & expiry date of the vial with a team member (Doctor or
Nurse).
4. Intradermal test dose
5. Make sure adrenaline, hydrocortisone & antihistamine injections are at hand
6. Document that 1
st
. dose was given (time, date, doctor name with designation &
signature) with no adverse reaction. In case of adverse reaction, a detail account must
be documented.
7. If a drug needs to be given frequently after the 1
st
. dose( on the same admission) it
shall be given by a nurse who shall follow steps (a-d) document in the nursing note/
treatment sheet
8. If an IV line is blocked, the nurse on duty shall inform SHO/TMO to replace it so that
the patient can be given prescribed drug.

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9. Only recognized brands of drugs agreed upon in the unit shall be allowed to be
prescribed. Junior doctors and consultants will not prescribe drugs other than
authorized trade name.
10. IV valium, IV KCL & other drugs like digoxin shall be checked by the house
officer & nurse together.
SOP 4.3: Administering Chemotherapy

1. Shall be prescribed by senior registrar and above.
2. Any change in the therapy regime shall be made after discussing with senior
colleagues.
3. Supportive therapy like I/V antibodies, blood transfusion as well as prophylactic
therapy ESP of tumor.
4. Lysis syndrome shall be observed strictly by all the doctors in the ward.
5. No chemotherapy shall be done after 1 pm.
6. Chemotherapy vials, shall be checked by medical officer and junior registrar before
the start of administering by staff nurse.
7. Administering of chemotherapy shall always be supervised by concerned doctor.
8. The timing of injection mesna and injection levocovorin shall be reminded every time
by the doctor to the nurse.
While administering intrathecal therapies the trolley shall only be having injection I/V
lignocane on one side and injection mtx, solucortif, and injection citosar on the other side
prepared by a doctor along with a staff nurse.





14

SOP 5: Operation Theatres

SOP 5.1: Patient Preparation for Operation
1. A written, informed consent is a must, duly signed by the patient, his/her immediate
relative & the HO or MO on the formal consent form of the hospital.
2. Certain aspects must be made in writing, e.g. enucleation, evisceration, exentration &
shall be explained to patient & the relatives.
3. Common complications shall also be mentioned in the consent form.
4. Should the patient refuse surgery this shall be in writing in the presence of a relative &
signed by the patients, relative & doctor.
5. The site of the body to be operated upon shall be marked.
6. The nurse shall make sure that the site to be operated on is shaved, jewelry & dentures
removed & all valuables left to a relative. She shall know which patients are due for
surgery & that they are shifted to the OT in time. All pre medications & investigations
such as fasting blood sugar & early morning KUB shall be positively done & sent with
patients. The HO concerned shall make sure that the patients are prepared properly. The
HO staying in the ward on OT day shall be present early in the ward & make sure that
all these steps are carried out.
7. Any patient who is absent from bed the night before surgery or has no medicines etc,
shall be dropped from the list.
8. During the evening round before the OT day, the registrar shall make sure that the
patient has the necessary requirements for surgery and calls to any department made
if necessary are made.
9. A tentative OT list shall be intimated to the I/C Anesthesia department after OPD and
one of the anesthetists shall carry out a round on the day before surgery, so that
necessary requirements are fulfilled. The anesthetist shall carry out his round with the
registrar at a time convenient to all.
10. All preoperative investigations including hepatitis and HIV screening shall be carried
out in the morning after the patient is admitted so that they are ready for timely

15



intervention if needed. This will prevent unnecessary delays, wastage of time and
resentment on part of the patients for having the surgery deferred.
11. Containers for specimens shall be available with patients and shall be properly
marked beforehand by the House Officer concerned showing the name, bed number,
ward and specimen name in case of biopsy & scraping for microscopy etc.
12. Informed consent is obtained for donation and transfusion of blood and blood
products. Informed consent also includes patient and family education about
donation.
13. Transfusion reactions are analyzed for preventive and corrective actions.
14. A brief operative note is documented prior to transfer out of patient from recovery
area.
15. The operating surgeon documents post operative plan of care.
SOP 5.2: Administering Anesthesia
1. A documented policy and procedure shall exit for administration of Anesthesia.
2. All patients for anesthesia have a pre-anesthesia assessment by a qualified individual.
3. The pre-anesthesia assessment results in formulation of an anesthesia plan which is
documented.
4. Informed consent for administration of anesthesia is obtained by a qualified member
of the anesthesia team.
5. During anesthesia monitoring shall include regular and periodic recording of heart
rate, cardiac rhythm, respiratory rate, blood pressure, oxygen saturation, airway
security and patency and level of anesthesia.
6. Each patients post anesthesia status is monitored and documented.
7. All adverse anesthesia events are recorded and monitored.
The Anesthetist shall be responsible for
Checking anesthesia machine, oxygen supply, anesthesia circuits, laryngoscope,
suction machine, monitors etc.
Labeling syringes of anesthesia drugs

16




Ensuring stand-by supply of oxygen cylinder, emergency drugs, ambu bag,
defibrillator etc.
Setting I/V line & starting I/V fluids
Setting monitors-SpO2, BP, ECG etc.
Pre-medication
Induction & maintenance of anesthesia as planned
Recovery of patient
Shifting the patient from the recovery to ward or ICU according to the patient
clinical status
Consultation with seniors in difficult situation/complication
SOP 5.3: Operation Theatre
1. All OT notes shall be completed and then recorded in an OT register.
2. The House Officers shall ensure that all specimens are sent and received in the ward.
3. The chief OT technician shall be responsible for the cleanliness and discipline of the
OT.
4. Swab & cotton patties count shall be maintained at all times by one member of the
operating team i.e. an OT nurse or OT tech. This shall be written on a board.
5. A House Officer and Trainee of the ward shall be present in the recovery room and
ward to respond to unforeseen mishaps.
6. All post operative patients shall be monitored.
7. Patients with Hepatitis B or C shall be operated according to set protocol which shall
be developed by the Surgical Department and the administration.
SOP 5.4: Postoperative Care
1. One house officer and TMO shall be available in the ward 24hours a day for care of
the patient.
2. The TMO batch on call shall come after O.T for postoperative round.
3. The registrar on call shall do a postoperative round after O.T.
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4. Postoperative round shall be documented with date and time by H.O, M.O, registrar
& consultant on call.
5. There shall be a protocol for resuscitation in case of any complication & immediate
contact of senior as per protocol.

18

SOP 6: Labor Room


1. Handing and taking over shall be done at 7:45 am. 3
rd
year TMO & House officer
batch on call will do labor room round at 8:00 am along with senior registrar. Batch
on call in labor room will stay in labor room for 24 hours. A 4
th
year TMO along with
her batch on call will do round at 1:00pm along with the registrar
2. Labor room round will be done by batch on call of TMOs & senior registrar at 8.00
am.
3. Every 3 hours patient will be assessed by senior TMO on call.
4. Between 1-2 pm registrar / consultant on call will do round of labor room.
5. Evening round at 8.30 pm will be carried out by on call batch together with SR / AP
on call.
6. All patients considered high risk shall be discussed with consultant on call. Any
adverse events & near misses shall be discussed at the time & then audited the next
morning by Head of the Department.
7. Labor ward shall be used only for patients in labor & occasionally for monitoring
very high risk pregnancies (not in labor) e.g Fulminating PET, severe clan III, IV
cardiac disease, severe hepatitis etc.
8. Post-op / C-Section patients shall be observed in postnatal chamber for at least 6
hours.
9. All patient discharged from labor room will be given a discharged card & asked to
report for check up within 10 days to the relevant OPD.
10. The decision of surgery shall be taken only after discussion with registrar / consultant.
11. All high risk patients shall be discussed with the consultant on call.
12. The consultant on call shall also inform about the progress of high risk patients.
13. The head nurse shall make sure that the labor room is clean all the times as it is a
place of quick patient turn over. This includes the delivery rooms, instruments,
autoclave, drugs, linens, floors, beds, toilets etc. The registrars of the two units shall
work in collaboration for maintenance and cleanliness of the labor room.
19





14. The Head nurse and the registrar of the Gynae unit on call shall make sure that the
emergency tray in the labor room is complete and up-to-date at all times in order to face
any sort of emergency.

20

SOP 7: Discharging the Patients

1. Patient shall be discharged by senior registrar or above
2. The decision of discharging the patient shall be taken a day earlier with intimation to
patient & his/ her relatives
3. Discharge summary shall be prepared by the SHO & checked by TMO/ Junior
registrar/ SR with particular attention to the following details
Patient name
Admission number
Date of admission
Date of discharge
Diagnosis
Details of investigations & treatment given
Details of intra or interdepartmental consultation
Details of treatment to be taken at home
Details of follow up
4. There particulars shall be entered by the SHO/TMO in the computer software
provided on the nursing counter.
5. Computer generated discharge slip shall be issued to the patient on the software
provided to each clinical unit in the hospital.
6. Every patient shall be given a patient registration/ hospital identity number that
should be quoted/ used for future visits/ admissions.





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SOP 8: In-patient Consultation Between Different Units
of the Hospital

1. Call for consultation to other units will be sent before 11 am.
2. Call in emergency or off hours will be directed to JR/SR
3. Each call to ward/unit will be properly written with clearly identified purpose of
consultation along with all investigations.
4. During working hours, SR/ Asstt Prof. will write call to VS, VP or VG and then
follow it up to ensure that calls are appropriately written & attended to with desired
help to the patient.
5. After working hours, the concerned 3
rd
. year post graduate trainee, JR/MO will write
the call & follow it up
6. The consultant/SR of the call receiving unit shall attend the call. In case of their non
availability the JR/MO/TMO shall attend the call with information to the
consultant/SR.
7. For very sick patient a junior doctor or a nurse will accompany the patient.
8. Once a unit has taken over a patient through a call then it shall follow that patient
through out his/her stay in the hospital & later on through OPD when necessary







22

SOP 9: Private Rooms


Admission Criteria:
1. Patient shall be hemo-dynamicaly stable
2. Patient does not require frequent monitoring( monitory devices)
3. Patient does not have violent behavioral issues/ suicidal thoughts.
Admission Process:
1. Private Room admission will be done on single occupancy basis.
2. Only SR and above can admit patients in private room through DMS (Private
Rooms).
3. Consultant/SR can shift in-patients from the ward to private room through DMS
(Private Rooms).
4. After admission, MO of private room shall take history, send investigations & start
treatment as directed by the doctor concerned.
Private Rooms Services:
1. One MO shall be present in each duty shift of private rooms.
2. One staff nurse shall be present in each duty shift on each side of private room.
3. 24 hours laboratory & radiological services shall be available
4. Each room shall be connected to nursing station via telecom services
5. Each section shall have emergency trolleys fully equipped with emergency medicines
& instruments & placed at an accessible area of the nursing station.
6. The consultant/ SRs shall be authorized to shift the patient from private room to
respective ward if needed.
7. The consultant /SRs of the respective unit will conduct the morning round of the
respective patients in private room while the JR of the respective unit will conduct the
evening round.
23

SOP 10: Out Patient Department (OPD)


SOP 10.1: General OPD
1. Patient will receive an OPD chit of the concerned OPD from OPD counter.
2. Patient will be examined properly and evaluated in general OPD. If the case is not
complicated, medicines will be prescribed and patient will be disposed off.
3. In case the patient requires further investigations, he/she will be referred to OPD lab.
4. In OPD lab samples will be taken. Routine and simple tests will be done at OPD lab,
whereas more elaborate investigations will be sent to the main lab.
5. Cases will be referred to consultant OPD if their condition so demands.
6. Record of referral will be kept at general OPD & a copy sent to the consultant OPD.
7. Patient shall be given time & date to see a consultant under intimation to the
consultant.
8. Investigations advised by consultant shall be reported upon before 1.00 PM so that
patient does not have to come back the second time to get treatment.
9. If the patient needs to come to the OPD again, he/she will be clearly guided with the
day and date given on the prescription chit for their next appointment with the
consultant at OPD.
SOP 10.2: Ante Natal Care OPD
1. All doctors shall be available in the OPD (except the on call batch in Labor room).
2. The Dispenser & Khala shall make sure that the OPD is clean, the instruments
sterilized, disposables available and all equipment and lights etc in working order.
3. The staff nurse shall make sure that patients are asked to wait for their turn to
prevent unnecessary chaos.
4. Relevant information shall be written on the OPD chit and signed.
5. All patients due for surgery shall be assessed for co morbid conditions, their BP and


24





6. pulse noted and chest examined. They shall be referred for an assessment for fitness
if needed.
7. All patients due for surgery shall be advised investigations before admission. These
shall be seen and corrected if possible, before the patient is admitted.
8. A waiting list according to the priorities shall be maintained by each ward ideally
mentioning the patients contact number and address if possible. Unforeseen delays
shall preferably be communicated to the patient.












25

SOP 11: Ward Round


1. Medical staff up to SR level will start seeing patients at the start of their working
hours(8.00 am).
2. Consultant along with the whole team will start ward round at 9.00 am.
3. Senior most consultant ( Prof. / I/C of unit) in the team will conduct the ward round.
The morning round shall be a teaching round.
4. Other consultant of the team will extend help in the management by giving their
opinion on the signs & symptoms of the patient.
5. Evening ward round will be conducted at around 8 pm.
6. Evening ward round will be conducted by Assistant Professor or SR and will be a
follow up round of the morning orders.
7. In the evening ward round, the following will be ensured:
Instructions in the morning ward round are carried out.
In the light of new findings, shall the treatment be changed on emergency basis
or it can be waited for till next morning when the whole team is around.
If the patient has improved and is ready to be discharged, instruction regarding
discharge shall be given as to be included in the discharge summary which
shall be ready by next morning.





26

SOP 12: Clinical Audit


1. Statistical record of the ward shall be maintained and regularly checked by the
registrar / S.R.
2. Fortnightly or monthly clinical audit meeting shall be conducted in the ward &
supervised by the Professor in-charge of the ward.
3. Annual appraisal of each unit shall be carried out regarding practices, performances
and issues by the S.Rs who shall be trained for conducting audits.
4. Nurses, paramedics and class-IV staff shall also be involved in the audit process.
5. Adverse events & recent mishaps shall be discussed in no blame environment to
improve patient outcome & shall be notified to the administration.
6. Protocols for emergencies shall be displayed by all the Units & regularly updated.
7. Minutes of clinical audit meeting and adverse eateries shall be sent to MS/CE office.









27

SOP 13: Online indenting of Medicine and Disposables
from Pharmacy

The hospital pharmacy will comprise of the Main Store, Satellite Pharmacy A1
(Medical), B1 (ICU), E1 (Casualty Pharmacy), OT Pharmacy, Unit Nursing Counter.
The SOP for the online pharmacy will be:
1. The nurse In charge at nursing counter will place online indent to the concerned
satellite pharmacy to which they are affiliated.
2. The pharmacist In charge of the satellite pharmacy will verify the online indent and
will issue the available medicines/items to the concerned unit after 11:00 am.
3. The medicine will be collected personally by the Nurse of the concerned unit which
has placed the demand or will be delivered by the runner of the satellite pharmacy.
4. The hard copy of the indent will be signed by the pharmacist and the recipient nurse.
One hard copy will be retained at the satellite pharmacy while the other copy will be
taken into custody by the nurse.
5. Besides medicines, medical and surgical disposables will also be issued by satellite
pharmacies.
6. All surgical and allied units will place online demand of surgical/medical disposables
and anesthesia medicines to the OT pharmacy.
7. The Pharmacist In charge of the OT pharmacy will verify the online indent and will
issue the available medicines and medical/surgical disposables items to the concerned
unit.
8. The medicine/disposables items will be collected personally by the nurse of the
concerned unit.
9. The hard copy of the indent will be signed by the pharmacist and the recipient nurse.
One hard copy will be retained at the OT pharmacy while the other copy will be taken
by the nurse.
10. The satellite pharmacies will replenish their consumed stock by placing online indent
to the main pharmacy.

28





11. The Chief Pharmacist will verify the online indent of satellite pharmacies and will
issue the demanded medicines/ disposables to the pharmacist concerned.
12. The hard copy of the indent will be signed by the chief pharmacist,
pharmacist/recipient nurse. One hard copy will be retained at the main pharmacy
while the other copy will be taken into custody by the pharmacist.
13. The Satellite Pharmacy at the Accident and Emergency department will receive direct
demands in the form of prescription from patient/nurse on duty. No online demand
will be placed to the emergency pharmacy till 2:00 pm. Medicine will be issued
directly by the pharmacist to the nurse on duty/patient in Accident and Emergency
department and registered/ computerized by the staff present at the emergency
satellite pharmacy during all the three shifts.
14. After 2:00 pm and on close holidays the satellite pharmacy of A & E department will
entertain online indents from the whole hospital and it will regularize in the same
manner as mentioned above.
15. The satellite pharmacy at Accident and Emergency will replenish their consumed
stock by placing online indent to the main pharmacy.
16. The Chief Pharmacist will verify the online indent of A & E pharmacy and will issue
the demanded medicines/ disposables to the pharmacist of A & E pharmacy.
29

SOP 14: Zakat



1. Zakat forms shall be available with RMO, local Zakat chairman office, district Zakat
Chairman.
2. The patient will get the Zakat form signed by the local/district Zakat chairman.
3. The patient will attach the photo copy of the N.I.C with the Zakat form.
4. OPD chit, indent book and procedure advised by the concerned doctor of the
unit/department will be attached with the request zakat form.
5. The RMO will counter sign/verify the documents.
6. Three copies of the documents are prepared. (original for RMO, one for concerned
unit and one for the patient).
7. One photocopy of the request will be signed by the Local Purchase (LP) shop.
8. The drugs received by the patient will be verified by the RMO for indoor/OPD
patients.
9. The drugs will be given to the patient/attendant and their signatures of receiving shall
be entered in the record book.
10. The bills shall be submitted on monthly basis by the LP contractor.
11. The bills will be verified/corrected by the RMO and after obtaining approval from the
competent authority the cheque shall be given to the LP contractor for payment.
30

SOP 15: Bait-ul-mal


1. The poor patients will apply to the Pakistan Baitul Mal for financial support through
the clinicians and hospital management on the prescribed proforma provided by the
Pakistan Bait-ul-Mal Department which will be available in the RMOs officer.
2. The Proforma along with the application will be submitted by the patient to the
Pakistan Bait-ul-Mal office, Peshawar.
3. The Pakistan Bait-ul-Mal after verification through its own sources, will send a
cheque in the name of the Medical Superintendent for the treatment of the patient
concerned.
4. On receipt of cheque the patient will be asked to report to this hospital for treatment,
and will be referred to the concerned clinician for treatment.
5. All the items needed, advised by the clinician for the treatment of the patient will be
provided by the hospital and payment will be made out of the money sanctioned by
the Pakistan Bait-ul-Mal to the LP contractor or supplier, who so ever supplies the
drugs/items.
6. A utilization certificate by the controlling officer and prescriber will be issued and
copy of it will be attached with the bill.
7. During the treatment if more money is needed for completion of therapy the
application process will be repeated by the applicant through his clinician and
hospital administration and the Pakistan Bait-ul-Mal will provide more funds.
8. On the completion of the therapy with in the sanctioned amount, the utilization report
shall be submitted by the hospital for individual patient/total patients from time to
time to the Bait ul Mal.





31

SOP 16: Indenting of Store items

SOP 16.1: Indenting of Main Store items
1. The nurse In-charge of ward/units will place online indent to the store.
2. The DMS (Store) will verify the online indent of wards/units and will issue the
demanded stores to the registrar/nurse concerned.
3. The hard copy of the indent will be signed by DMS (store) and registrar/recipient
nurse. One hard copy will be retained at the main store while the other copy will be
handed over to the nurse.
SOP 16.2: Indenting of Stationary and P & D store items
These two areas are not yet fully computerized.
1. The nurse In-charge of ward/units will place demand on indent book to the store.
2. The DMS (P & D)/ RMO will verify the indent book of wards/units and will issue the
demanded stores to the registrar/nurse concerned.
3. Half of the indent book page with received signature of registrar/nurse will be
retained by DMS (P & D)/ RMO while the remaining half page will be retained by
the indenter as unit record.
4. Main stock register will be updated in the main store and sub stock/expense register
will be maintained and updated by the consumer units/wards.
32

SOP 17: Record Room


1. The department/unit will submit the charts on monthly basis with the attached list of
patients.
2. Record keeper will collect the charts and sign them.
3. Record keeper will place the charts in order at the specified location for units.
4. The computer operator will enter the chart (with admission number, discharge date
and final diagnosis etc)
5. The IT department shall have a dual system for data storage.
6. The record of more than five years old will be disposed off.
7. The medico-legal chart will be prepared by the registrar of the concerned unit. A
photocopy signed by the record keeper will be kept by the registrar while the original
copy will be kept by the record keeper.
33

SOP 18: Ward Cleanliness and Maintenance

1. The hospital shall have a well designed, comprehensive and coordinated infection
control program aimed at reducing / eliminating risks to patients, visitors and
providers of care.
2. Preferably each ward shall have a designated and qualified infection control nurse(s)
for controlling infection.
3. The head nurse in-charge of the ward shall be the designated individual for
coordinating and implementing the quality improvement program.
4. The quality improvement program is a continuous process and shall be updated at
least once in a year.
5. The head nurse shall make sure that the ward is kept clean at all times. This includes
the floors, windows, beds, toilets, galleries, cupboards, side tables etc. The registrar
shall ensure that all this is done.
6. All equipment or lights etc that needs replacement must be immediately reported to
the Registrar by the head nurse and dispenser.
7. Duty rota on three shift bases will be prepared by the registrar/ head nurse for the
class-IV staff deployed in the ward. The rota will be prepared on three shift basis i.e.
8:00 am to 2:00 pm, 2:00 pm to 8:00 pm and 8:00 pm to 8:00 am next morning.
8. The registrar/ head nurse will be responsible for the discipline of their auxiliary staff
and report their absentia or lack of interest in duty to the administration for
disciplinary action.
9. The head nurse will ensure that ample supply of surf, phenyl and other antiseptics is
timely demanded from the main store and is always available in the units.
10. Garbage bins shall be in sufficient quantity in each ward. The head nurse/ registrar
will ensure procurement of garbage/ dust bins from the main store. The head nurse
will ensure proper disposal of wastes like sharps, dressings, used I/V bottles and drip
sets etc.
11. All the glasses, doors, ceiling fans, air conditioners and other ward appliances/
equipments will be kept clean by the orderlies.
34




12. The registrar/ head nurse will ensure that visiting hours are strictly observed by
patient attendants.
35

SOP 19: ICU

1. Patients will be readmitted in ICU from different units like medical, surgical, neuro
surgery, gynae, ENT and ophthalmology departments who are critically ill.
2. The staff present in ICU will be responsible for all the orders given for medication
and nursing care.
3. Once the patient arrives in ICU, the arrival report will be taken by medical officer on
duty and will consist of mention of time and date of arrival, history of present illness,
past history, family history, and detail of injury, drug history etc, clinical findings,
writing investigations and management plan.
4. The medical officer will discuss the new admission with registrar and senior registrar.
5. The doctor on duty will inform relatives of patients and take proper detailed
consensus with explanation of any possible procedure if needed as part of patient
management.
6. I/C ICU will ensure the provision of necessary facilities/equipment in ICU like.
Continuous oxygen Supply
Suction facility.
Bed side monitor
Arterial blood gases analyzer (ABGs).
ECG machine.
Defibrillator.
Mechanical ventilator.
7. I/C ICU will develop & implement a protocol for keeping ICU infection free and
clean.


36

SOP 20: Accident and Emergency Department


SOP 20.1 : Emergency cover in A & E Department
1. The casualty Department shall have all important emergency drugs and equipment
available in it as mentioned in SOP-1.
2. Beside A & E department shall also have
Anti-Snake Venom serum.
ARV(Imuno globulin vaccine, Human diploid cell Immune serum)
Effective & efficient ambulance service at function round the clock.
3. All patients coming to emergency will be attended by the CMO.
4. Record of medico legal patients will be maintained in MLC register.
5. Elective patients coming to emergency department before 1:00 pm will be politely
directed to the concerned outpatient department (OPD).
6. Chief complaints and provisional diagnosis of the patients shall be clearly mentioned
on the prescription chit and vital signs recorded on the same.
7. Medicines prescribed and administered in the casualty shall be recorded on the chit.
8. After initial treatment and resuscitation, all patients will be shifted to the concerned
unit for definitive care when the vital signs are stabilized. All the referrals shall be
entered in a referral register.
9. In case of serious emergencies when the patient is not stable enough for shifting, the
doctor from concerned unit will be called for opinion.
10. Careful & swift emergency treatment shall be followed by consultation/referral to the
concerned specialty, immediately, without wasting time in experimentation.
11. The relevant documents shall accompany the patient and the doctor in concerned
department shall be given prior information to make necessary arrangements.
12. Carbon copy of the prescription chit will be retained in Casualty for record.
13. In case of serious emergencies when the patients are not stable enough for shifting,
the doctor from concerned unit will be called for opinion.

37





14. In case of any ambiguity or administrative problem I/C casualty or shift DMS will be
immediately informed.
15. All drugs in the casualty will be prescribed by the CMO and will be administered in
the casualty and record shall be maintained.
16. No drugs will be given to the patient for administration/use elsewhere.
17. Doctors on duty in casualty shall refrain from prescribing unregistered drugs, or drugs
on patient preference, not indicated otherwise.
18. All the medical claims and bills will be duly checked and signed by the I/C casualty.
19. Following investigations shall be generously utilized where ever needed:-
20. Radiographs of chest and pelvis and cross table lateral view of cervical spines
21. ECG
22. FAST (Focal assessment sonography in trauma)
23. CT Scan for head injury
24. Pulse oximetry
25. DPL (Diagnostic peritoneal lavage)
SOP 20.2: Emergency Cover in units/wards
1. The surgical, Gynae, medical, paeds, cardiolgy units/wards will provide emergency
OPD cover.
2. Patient coming via emergency will be seen by doctors on call (HOs and TMOs both)
in their respective wards..
3. Those who need admission will be clerked, investigated, managed, resuscitated in the
emergency chamber.
4. Those who need emergency surgery will stay in the chamber pre and post operatively.
Rest of the patients will be shifted to regular beds.
5. Those patients needing operations shall be notified to the SR before shifting to the
theatre.

38





6. Patients will be re-admitted in ICU from different units like medical, surgical, neuro-
surgery, gynae, ENT and ophthalmology departments if they are critically ill.
7. Only stable patients will be shifted out of the ward for important investigations.
8. Important surgical interventions shall be done on the same day if the condition of the
patient permits.
39

SOP 21: Gastro Intestinal Endoscopies

1. The patients who are advised endoscopy by the consultant for procedures like ERCP,
Polypectomy banding, dilatation, colonoscopies etc. will be referred to GI lab for a
date and appointment
2. When patients arrive on the date of procedure, proper check up of the patient will be
done to get information that whether the patient is hemodynamically stable or not for
the procedure which is to be performed. After that consent will be taken and risk,
benefits, and alternatives explained to the patient.
3. When procedure is performed, it shall be clearly written on the treatment chart, and
post procedure orders shall also be mentioned.
4. Every patient on whom procedure has to be performed will be screened for Hepatitis
B & C & HIV.
5. If biopsy is taken it shall be properly labeled and sent to the Histopathology
department.
6. Before the procedure the patient attendant will be given a receipt and sent to the
admission counter to deposit the procedure fee.







40

SOP 22:Cardiological Procedures



1. For outdoor patients consultant/ senior doctors in OPD and for indoor patients
consultant/seniors in unit will advise the procedures like ETT, ECG, Echo, Holter,
TEE etc
2. Before the procedure the patients attendant will be given a receipt and sent to the
admission counter to deposit the procedure fee.
3. When patients arrive on the date of procedure, proper check up of the patient will be
done to get information.
4. When procedure is performed, it shall be clearly written on the treatment chart, and
post procedure order shall also be mentioned.











41

SOP 23: Radiological Procedures

1. Patients coming to the Radiology department will have investigation forms duly filled
in and advised by the treating doctors and will get his examination registered at the
fee counters in the department.
2. The department will run in three shifts.
3. Evening and night shifts will provide cover to casualty and ward emergency cases
only.
4. X-rays and ultrasound will be done round the clock
5. CT-Scan will be done round the clock and reported daily.
6. All the above radiological procedures shall be free for indoor patients in the morning
shift.
7. MRI is a paid service both for indoor, outdoor and emergency cases. MRI will be
done daily upto 8:00 pm and shall be reported on the same day except that a few
cases are kept for teaching purposes.
8. For emergency cases these investigations shall be provided free round the clock.
9. Imaging results shall be available within a defined time frame.
10. The HOD will document policies and procedures for emergency care.
11. Critical results shall be intimated immediately to the concerned personnel.








42

SOP 24: Laboratory Investigation

1. Scope of the laboratory services shall be provided as per the requirement of the
patient.
2. Adequately qualified and trained personnel shall be available to perform and
supervise the investigations.
3. Laboratory tests not available in the hospital shall be outsourced to organization(s)
based on their quality assurance system.
4. All the samples collected in the ward will be properly labeled
5. All the routine/baseline investigations which do not need the orders of the Professors
I/C of the concerned unit (like blood complete, urine exam, blood urea, blood sugar
etc) will be sent in time to the laboratory before 11:00 am.
6. Specialized investigations or any other test advised may be sent to the laboratory up
to 12:00 noon. These investigations will be compiled and reported upto 2:00 pm.
7. Emergency investigations will be entertained any time round the clock.
8. All the pre operative patients shall be screened by Elisa test. The ICT quick method
will be utilized only for dire emergencies.
9. Samples from the wards for Elisa tests shall reach laboratory from 9:00 am-4:00 pm.
10. Blood for PT/APTT will be sent in citrated tube in proper volume in the ratio of 0.2
ml reagent and 1.8 ml blood.
11. Patient for fasting blood sugar must have 12:00 hrs fasting and random glucose
checked after lunch/dinner.
SOP 24.1: Online Laboratory Investigation
1. All the routine indoor free investigation will be booked online at unit nursing
counter.
2. All the paid indoor investigations will be booked at pathology counter.
3. After 2:00 pm all the investigations will be booked at pathology counter
4. All the samples must reach the laboratory before 11:00 am.


43





5. Investigation results will be entered by TMOs/laboratory technicians in pathology
lab computers.
6. The results will be retrievable on units nursing counter round the clock as per online
booking of the investigation time.
44

SOP 25: TMOs/MOs Duty

SOP 25.1: Duty Rotas
1. These shall be made by the SR or Assistant Professor of the ward & shall include duties
in OPD, OT,& ward
2. The doctors on duty have to be physically present in the ward.
3. The HO & TMO shall leave the ward after their duty is over only when the next doctor
on duty has arrived. However doctors on duty in the afternoon & night shift shall all be
present in the evening round.
4. Doctors shall communicate with each other at the time of change of duty i.e. they shall
inform the next doctor on duty about the status of serious patients etc

SOP 25.2: Guidelines for TMOs/MOs Duty
1. All the doctors are required to come to ward at 7:45 am in the morning.
2. TMO's will countersign the DPR of HOs and write down their own comments before
each round.
3. TMO will write brief arrival reports of allotted beds on the day of admission.
4. TMO on duty on operation day will write arrival report of post operative patient.
5. The calls will be written by TMOs not by house officers. In case of bed case the
concerned TMO will call to the concerned unit and verbally discuss.
6. The home treatment and follow up in the discharge slip will be written by TMOs and
counter signed by JR/SR.
7. All doctors will put their names along with signature on every document of the
patient.
8. The TMO who has done night duty will be exempted from routine round next
morning.
9. All the TMOs / HOs shall be present in evening round conducted by
registrar/SMO/SR and shall mark their presence on attendance register otherwise they
will be considered absent.
45




10. TMO will ensure the OT medicine are made available to the patients on OT list. In
case of any deficiency, they will be responsible.
11. A written and informed consent will be taken by TMO from the patient in presence of
an adult relative.
12. Post operative patients coming to the ward will be assessed by the TMOs and HOs
and their vital sign, level of consciousness and status of the drain will be noted in
arrival report.
13. Investigation request forms will be filled by TMOs and the specimens will be sent to
histopathology.
14. Post operative patient with significant bleeding will be managed in emergency
chamber and their vital signs, drain and Hb will be checked regularly
15. Senior will be informed immediately if the patient becomes unstable.
16. TMOs will actively participate in academic activities i.e. ward presentation, journal
club, morbidity / mortality meetings and hospital seminars etc.
17. TMO and HO will stay in the emergency chamber during their duty hours.
18. All blood transfusions will be done by doctors.
19. In surgical units a separate register for operations i.e. elective and emergency will
be kept up to date and will be checked by the JR daily.
20. Call register will be kept up to date and will be checked three times a day after each
ward round.
21. Non emergency routine calls from other units will also be noted in this register.