Clinical Procedure Manual-Ref

UNITED CIIGMA Hospital
TABLE OF CONTENTS

TABLE OF CONTENTS
32
33
34
35
36
37
38
C-1.1
C-2.1
C-3.1
C-5.1
C-7.1
C-10.1
D-1.1
39
40
41
42
D-1.2
D-1.3
D-2.1
D-2.1
43
44
45
46
47
48
49
50
51
E-3.1
E-4.1
F-2.1
F-2.2
F-2.3
F-2.4
H-1.1
I-4.1
J-2.1
Acquisition of medicines
Inventory control
List of high risk medication
Medication administration
Management of adverse drug event
Handling of medical gases
Patients and familys rights and
responsibilities
Citizens charter
Patients complaints and grievance handling
Obtaining consent
List of situations where informed consent is
required
Sterilization
Handling of biomedical waste
Patients satisfaction survey
Employee satisfaction survey
Medical Audit
Handling of Sentinel events
List of acts and laws applicable to the hospital
Employee grievance handling
Maintenance of medical records

Policy No. A-2
Type of document - Procedure
Issue Date:
Revision No:00
Document No. A-2.1
Registration
Revision Date: -
Purpose: To carry out the registration of patients smoothly

Scope: OPD and Emergency registration
S. NO.
1.
STEPS
RESPONSIBILITY
Registration is done for all patient requiring OPD and / or

Emergency services. OPD and emergency in-charges shall
be contacted for any clarification or in matter of conflict
OPD and Emergency

In-charges
For OPD
2.
OPD registration shall be done on the basis of first come

first served
Registration staff
Ask following details from the patient / relative
Registration staff
1. Name
2. Age
3. Sex
4. Income
5. Address
Check the referral slips if any for identifying the specialty. If

referral slip is not available, patient shall be registered under
General OPD
Registration staff
3.
Enter the details in HMIS
Registration staff
4.
Take the print and handover to patient
Registration staff
5.
Direct the patient towards concerned OPD consultation area
Registration staff
For emergency
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Policy No. A-2
Issue Date:
Revision No:00
Document No. A-2.1
Registration
Revision Date: -
6.
Emergency registration is done 24 hrs a day at AE Ward
If patient is serious, he/she is directly sent to casualty bed or

to doctor and one of the relative is asked to get the
registration done. Registration should not delay emergency
care
Case writer, Medical

Officer on duty, Staff
nurse on duty
For unidentified patients registration shall be done as

unknown.
Medical Officer, Staff

nurse
If on later date identity is confirmed the same shall be

entered in registration detail through back entry.
Staff Nurse on duty,

Case writer
UNITED CIIGMA
Hospital worker
Policy No. A-2
Issue Date:
Revision No:00
Document No. A-2.2
Admission
Revision Date: -
Purpose: To admit the patient requiring in-patient care
S. NO.
STEPS
RESPONSIBILITY
1.
Admission can be through OPD or through Emergency. In

case of conflict or further clarification, RESIDENT
DOCTOR / Matron shall be contacted
RESIDENT
DOCTOR, Matron
2.
Decision for admitting a patient is made by treating

consultant. The reason for the admission is explained to the
patient.
Consultant
3.
The admission along with the ward is recorded in OPD case

paper / emergency case paper
Consultant
4.
All admissions are done from OPD case counter and from
emergency registration counter
Case writer
5.
Enter all patient related details in admission module of

HMIS
Case writer
6.
Following details of patients attendant are entered in HMIS
Case writer
Name
Address
In case of unidentified patients this step is not followed

7.
2 visitor passes are given to the patient / relative for free. If

the patient / relative needs extra pass he / she is directed to
the RESIDENT DOCTOR Office to collect the same
8.
Patient is directed to the concerned ward. Need for

stretcher / wheelchair / ward boy shall be identified and
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Case writer
Case writer, OPD

incharge
Policy No. A-2
Issue Date:
Revision No:00
Document No. A-2.2
Admission
Revision Date: -
provided to the patient

9.
Staff nurse of the concerned ward shall check admission

paper and case paper having doctors order for admission.
10.
A bed shall be arranged for the patient. If bed is not

available Concerned doctor / Matron shall be contacted.
11.
Treatment as advised in inpatient case paper is started
12.
If patient is serious, he / she is assessed by Medical Officer

before initiation of treatment
13.
Admission is recorded in admission book
14.
Diet form is filled and sent to kitchen
15.
Specialist is sent information about the admission of patient
Staff nurse on duty
Staff nurse on duty
Staff nurse
Staff nurse, Medical
officer
Staff nurse
Staff nurse
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Staff nurse

Issue Date:
Policy No. A-3
Document No. A-3.1
Revision No:00
Transfer of stable and non-stable
patients
Revision Date: -
Purpose: To safely transfer the patient outside the facility

S. NO.
STEPS
RESPONSIBILITY
1.
Patient shall be referred to GMKM College & Hospital,

Salem if the treatment needs of patient doesnt match the
scope of services provided by hospital
Consultant
2.
Decision for transfer to other facility shall be taken by

consultant and same shall be noted on OPD / IPD /
Emergency case-paper
Duty Doctor / Ward

Medical Officer
3.
In case of emergency, the concerned consultant is informed

by the Medical Officer on duty
Medical officer on
duty
4.
Consultants advice is taken before transferring the patient
Medical officer on
duty
5.
Oral and written consent of the patient is taken on the case

paper. If the patient is not willing for transfer consent of
patient relative is taken and continue the treatment.
Medical officer on
duty
6.
In case of unidentified patients police is informed.
Medical officer on
duty
7.
Treatment given and diagnosis is written on the case paper
Medical officer on
duty
8.
Driver is informed to keep the ambulance ready
Staff nurse on duty
9.
Referral slip is given to the patient / relative
Staff nurse on duty
10.
In case of unstable patient, a call is made in the concerned

department at reference Hospital or any other hospital of
patients choice handover the treatment slip to the ambulance
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Staff nurse

Issue Date:
Policy No. A-3
Document No. A-3.1
Revision No:00
Transfer of stable and non-stable
patients
Revision Date: -
driver / patient attender to be handed over to GMKMCH,

Salem.
11.
Emergency assistant accompanies the unstable patient
12.
This shall be cross-signed by RESIDENT DOCTOR for

ambulance. If the patient is BPL same shall be recorded
RESIDENT DOCTOR
13.
If the patient is stable, he / she is transferred in a general

ambulance with driver and cleaner
Medical Officer /
Consultant
14.
If the patients condition is unstable, he should be stabilized

in emergency before transferring
Medical officer
15.
If the patient is serious (as decided by doctor), an ambulance

with critical care facility shall be arranged.
Medical officer
16.
Patient shall deposit the ambulance charge to the driver at

the destination and collect the receipt for the same.
Office
17.
Duty medical officer shall arrange ambulance and driver to

transfer the patient
Staff Nurses
18.
In case of conflict RESIDENT DOCTOR shall be contacted
RESIDENT DOCTOR
UNITED CIIGMA
Emergency assistant

Policy No. A-5
Document No. A-5.1
Type of document - Guidelines

Clinical assessment and its
documentation
Issue Date:
Revision No:00
Revision Date: -
A. Purpose: To follow a uniform protocol for clinical assessment and reassessment of patients
requiring same type of healthcare in OPD, IPD and emergency
Read and follow the policy
The goal of the patient assessment function is to determine what kind of care is required to
meet a patients initial needs as well as his or her needs as they change in response to
care.
B. Initial assessment at General OPD:
Medical Officers or duty staff nurse initially screens each patient on following parameters.
o
History of illness
Height and weight if necessary
Temperature, Blood Pressure and Respiration
Allergies or any associated disease
Medical officer shall write the progress notes, investigation, prescribe treatment or refer to
required specialty as per initial assessment. All these shall be documented and signed,
named, dated and timed by medical officer
C. Assessment at specialty OPD
Each patient shall be assessed as per their disease process
Patients physical, psychological, social status and nutritional needs shall be assessed.
The assessment process for an infant, child, or adolescent patient shall be individualized.
Special needs of the patients who are receiving treatment for emotional or behavioral
disorders have shall be addressed.
Special needs of patients who are possible victims of alleged or suspected abuse or neglect
shall be addressed
Based on assessments, treating physician shall document plan of care for the patient.
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Policy No. A-5
Document No. A-5.1

documentation
Issue Date:
Revision No:00
Revision Date: -
These records shall be signed, named, timed and dated by person who is entering in the
record.
D. Assessment at Emergency
Medical officer on duty staff nurse authorized paramedical personnel shall assess all
patients attending emergency.
Same parameters as mentioned in General OPD should be assessed.
In case of mass casualties triage shall be followed instead of assessment
Specialist shall be called and required assessment made on discretion of casualty medical
officer.
E. Initial assessment of admitted patient
Initial assessment is done and documented in medical record of the patient for all admitted patient
The assessment shall be done by Medical Officer / duty staff nurse
The assessment shall include generic and individualized elements specific to patient age,
diagnosis and condition.
Following elements shall be considered for assessment as per requirement. These are generic in
nature
Reason for admission;
Physical status;
Cognitive status;
Psychosocial status;
Communication status;
Allergies;
Special precautions;
Pain;
Medication uses;
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Policy No. A-5
Document No. A-5.1

documentation
Issue Date:
Revision No:00
Revision Date: -
Substance abuse;
Domestic violence/neglect/abuse screening*
Communicable disease exposure;
Personal routines and self-care needs;
Nutritional screening;
Spiritual / cultural practices;
Advance Directives (adults 18 years);
Educational status;
Financial concerns;
Need for discharge planning;
Belongings inventory and disposition.
F. Additional assessment requirements for the infant, child, or adolescent patient
Emotional, cognitive, communication, educational, social, and daily activity needs;
Developmental age, length or height, and weight;
Head circumference (age: day 1 up to and including 24 months)
Effect of family or guardian on the patients condition;
Effect of the patients condition on the family or guardian;
Immunization status;
Weight (in kg);
Family or guardians expectations for involvement in the patients assessment, initial treatment,
and continuing care;
Availability of appropriate child restraint device
G. Assessment of Obstetric and high-risk obstetric patients
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Policy No. A-5
Document No. A-5.1

documentation
Issue Date:
Revision No:00
Revision Date: -
(This includes pregnancies with Diabetes, HTN, Asthma, eclampsia, convulsions, multiple
pregnancies, elder mother (>35 years), bad obstetric history (abortions etc)
The assessment shall include
o Weight
o Height
o Routine lab investigations
o BP
o Hb
o Blood group / RH Typing
o Urine (routine & microbiological)
o Months of pregnancy (regularly noted on each visit)
o Tetanus injections
o 2-3 ultrasounds in whole period
H. Time frames for initial assessments
Initial clinical assessment shall be completed at the earliest as warranted by the situation, and
documentation as per given time frame as follows
o
Emergency within 1 hour of registration
IPD within 24 hrs of admission.
I. Reassessments
Re-assessment shall be done throughout patients hospitalization by Medical Officers
twice a day for emergencies and once a day for other IP cases. The frequency can be
augmented based on the clinical condition.
All clinical re-assessments shall be recorded and signed with name, date and time duly
endorsed in the medical record by the assessor.
The re-assessment shall faithfully reflect the patients clinical condition, response to
treatment and inputs to plan further line of treatment or discharge.
In addition to clinical assessment patients shall also be reassessed daily for safety risks,
e.g. potential for falls and skin breakdown.
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Policy No. A-5
Document No. A-5.1

documentation
Issue Date:
Revision No:00
Revision Date: -
Reassessments to determine patient response to care and progress in meeting identified

outcome goals are documented at least every 24-hours on general care units, and at least
every 12-hours in critical care units.
Reassessment is always done following a significant change in patient condition, a change
in diagnosis, and at the time of unit transfer.
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Policy No. A-7

Document No. A-7.1

Type of document Work
Instruction
Issue Date:
Revision No:00
Work instructions for Laboratory
Revision Date: -
Purpose: To effectively provide all clinical pathology services as required by the scope of
clinical services of the hospital.
S.No.
1.
Instructions
To receive the samples along with the requisition
Responsibility
Technician
forms and verify the particulars. Give Laboratory

number and record in the departments register and in
2.
computer.
Urine freshly voided specimen is preferred, When
Technician
there is delay in testing/transporting, the sample

should be refrigerated to prevent bacterial
contamination
Routine examination includes both physical, chemical
and microscopic examination
-
Physical examination volume, colour, specific

gravity.
Chemical examination screening for presence of

albumin, sugar, ketone bodies, bile pigments, bile
salts and urobilinogen
Microscopic examination to look for epithelial

cells RBC, pus cells, casts, crystals bacteria and
foreign bodies.
To use multistix strips for all samples. Any

abnormality detected is to be confirmed by
conventional methods i.e. a. Proteins- heat acid test
3.
Stool - fresh specimen is preferable
Technician
Routine analysis includes physical, chemical and
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microscopic examination i.e. colour, consistency,

blood or mucous if present, pH, occult blood and
microscopic examination for ova and cysts
In specific cases microscopic examination for ova and
4.
cysts is to be done by concentration techniques

Semen analysis
Technician,
Give following instructions for semen collection

-
3 day period of abstinence is recommended
To receive the sample as per instructions given in

point one
To do the physical examination for colour, pH,

liquefaction time, viscosity, volume,
To do the sperm count for motility and

morphology
To Estimate fructose in case of infertility
5.
6.
To enter all results in the register

To verify the typed report with the register and initial
Technician
Technician
7.
8.
the report in the lower right hand corner.

To check the results and sign before dispatch.
To dispatch OPD, IPD and outside reports to the
Sr.Lab Technician
Lab technician
9.
specific departments.
To ensure minimum wastage in the department and all
wastes are handled properly.
Technician
UNITED CIIGMA
Policy No. A-7
Document No. A-7.2

Instruction
COLLECTION,
IDENTIFICATION, HANDLING,
SAFE DISPOSAL OF
SPECIMENS
Issue Date:
Revision No:00
Revision Date: -
Purpose:
Sample shall be handled in a safe and secured manner in following ways:
Sample Collection.
Sample collection shall be carried out on 24 hours basis either in the sample collection room or in
the laboratory
Sample Identification
Access No is generated in the software against every sample request from ward in the
software
All samples will be labeled with the name, age, sex, OPD/IPD No and Access No of the
patient
All samples will be accompanied by a written requisition for lab investigation
The lab reception receiving the samples will enter the details in register
Sample Handling
All samples will be handled as per the infection control guidelines
Universal precautions are to be observed while handling samples
Safe Transportation of Samples
All samples requiring transportation will be transported in vacutainer
All measures shall be taken for samples are not to be allowed to deteriorated
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Necessary precautions are to be taken depending on prevailing environmental factors
Processing of Samples
Processing of samples is to be carried out as per the requirements of individual tests
Procedure for testing is to be standardized and necessary instructions issued to all

concerned personnel
Samples will be processed without delay, and on priority for emergency cases.
Disposal of Specimens
Disposal is to be carried out in accordance with bio-medical waste handling rules.
Precautions in accordance with the hospital infection control manual are to be observed
UNITED CIIGMA

Policy No. A-7
Document No. A-7.3
Type of document - Guideline

Reporting of Critical and Noncritical test results
Issue Date:
Revision No:00
Revision Date: -
A. Purpose:
To provide a protocol for notification of critical patient test results. Each department is
responsible for ongoing assessments and to identify and implement a process, as needed, for the
reporting of critical values.
B. Definitions:
Normal: A test result that is within the normal variation and does not require follow-up.
Non-Critical: A test result that is beyond the normal variation and that:
A. Is not what is expected due to the patients current medication and/or disease state
B. May require follow-up to ensure stability, resolution, or further evaluation and/or
C. May change the medical management of that patient.
Critical: Tests result beyond the normal variation with a high probability of a significant increase
in morbidity and/or mortality in the foreseeable future and requires rapid communication of
results for determination of intervention.
Read Back: The individual accepting the critical test result must record and then read back the
critical test result, in its entirety, to the reporter at the time the result is given.
C. Communication Tools:
Electronic: Hospital Management Information System
Manual: Hand delivery or pick up to/by the testing area, patient care area or physician / nurse /
ward staff.
Verbal: including verbal report in person or by telephone / intercom / pager
D. Order of Notification:
Ordering / Treating Physician / Staff nurse on duty / Casualty Medical Officer
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Each department reporting critical values must have in place a defined process, which
documents the reporting of pre-approved critical values.
E. Normal / Non Critical Test Results Reporting and Documentation
Laboratory
Results are reported in HMIS and also entered in patients records
Radiology
Results are reported in HMIS and also entered in patients records
Both the image(s) and report are archived, when applicable.
F. Critical Test Results Reporting and Documentation
Laboratory
1. When a critical result is identified, the Laboratory Technologist contacts the ordering
physician or their assistant within 15 minutes of test readiness via a phone / intercom
2. For the patient who is no longer in the hospital or clinic, the Laboratory Technologist
contacts the ordering physician or their assistant immediately after identification of
critical result
3. If the ordering physician or their assistant is not reached within 15 minutes of test
readiness, the Laboratory Technologist will follow the order of notification.
Radiology
1. When the radiologist identifies a critical test result, a verbal report is given to the
ordering physician immediately in person or by phone.
2. If the ordering physician is not available, the radiologist immediately contacts their
assistant and a verbal report is given in person / phone / intercom
3. If their assistant could not be reached, the radiologist will immediately follow the order
of notification.
4. The result is reported in the HMIS
5. . The image(s) and the report are archived, when applicable.
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G. System Failures
Clinical Laboratory
With any applicable communication system failure a hard copy of the critical result will be
delivered to the ordering physician or their assistant. The
Laboratory Technologist will document the name and credentials of the person receiving the
report with the time of delivery in HMIS.
Radiology
With any applicable communication system failure, the radiologist will give an in person verbal
report to the ordering physician or their assistant.
UNITED CIIGMA

Policy No. A-7
Type of document - Guideline
Issue Date:
Revision No:00
Document No. A-7.4
Lab Safety Programme
Revision Date: -
Purpose: Laboratory staff to carry out safe practices while working in laboratory. Laboratory shall
conduct regular training on the safe practices in their departmental training programme. Nonadherence to these safe practices shall be recorded as non-conformity and appropriate corrective
and preventive measures shall be taken
Following safe practices are documented for practicing in daily routine work of lab. Laboratory
shall continuously identify other potential hazards and develop safe practices to prevent the same.
Procedure:
1. Standard practices for lab safety
a. Only disposable blood collection devices will be used for collection of blood
specimens.
b. Appropriate PPE shall be used for protection of patients, phlebotomists, laboratory
technicians and other laboratory workers.
c. No recapping of used needles is allowed.
d. No mouth pipetting is allowed
e. Exterior of blood container shall be wiped for any trace of blood with appropriate
disinfectant.
f. All specimens shall be labeled carefully.
g. MSDS shall be available for hazardous chemicals,
h. All fluids shall be discarded only after treatment with 1% sodium hypochlorite or
freshly prepared solution of NaDCC (sodium dichloroisocynuarate, 140 ppm
solution).
i. All laboratory workers will perform hand wash as per the appropriate indications.
j. All laboratory workers will be immunized with Hepatitis B vaccination.
2.
Safety with blood borne pathogen
Potential hazard: All the laboratory employees are exposed to the risk from acquiring infections
from blood borne pathogens while handling contaminated lab samples such as blood or other body
fluids (i.e., cerebrospinal fluid, and semen).
Safe practices:
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STANDARD PRECAUTIONS WILL BE STRICTLY ADHERED TO AS A SAFETY

MEASURE.
a. Wear appropriate PPE when exposure to blood or other potentially infectious body
substance is anticipated.
b. Gloves must be worn when hand contact with blood, mucous membranes, or nonintact skin is anticipated, or when handling contaminated items or surfaces
c. Hepatitis B vaccination for all laboratory employees
d. Access to the work area shall be strictly limited to authorized persons.
e. All activities involving other potentially infectious materials shall be conducted in
biological safety cabinets or other physical-containment devices within the
containment module. No work with these other potentially infectious materials
shall be conducted on the open bench
3. Safety with tuberculosis:
Potential hazard: Exposure of laboratory employees to TB from working with specimens (e.g.,
acid fast bacilli smears) that may contain acid-fast bacilli (Mycobacterium tuberculosis). Specimens
that may be potential sources of acid-fast bacilli (Mycobacterium spp.) are respiratory secretions
(sputum, Bronchoalveolar lavage or endotracheal aspirates), aspirated pus, tissue, cerebrospinal
fluid and other serous fluids, and urine.
Safe practices:
a. All culture or specimens suspected of containing TB bacilli must be manipulated in
settings where specific engineering controls, administrative procedures, and appropriate
personal work practices ensure containment of the organism and protection of the
workers
b. The laboratory procedures involving chances of aerzole generation shall be performed
in biological safety cabinet (class II). Such procedures include:
i.
Pouring liquid cultures
ii.
Using fixed-volume automatic pipettes
iii.
Mixing liquid cultures with a pipette
iv.
Preparing specimens and culture smears
v.
suspensions of acid-fast bacilli.
vi.
Dropping and spilling tubes containing
Centrifugation and vortexing cell suspension.
4.Safety with chemicals
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Potential hazard: Staff exposure to hazardous laboratory chemicals leading to burns or other
adverse effects
Safe practices:
a. MSDS shall be available on workplace for all hazardous chemicals
b. Chemicals shall be used as per manufacturers instructions for safety
c. Eating, drinking, and smoking are prohibited in areas where laboratory chemicals
are present. Hands shall be thoroughly washed after working with chemicals.
Storage, handling and consumption of food or beverages shall not occur in
chemical storage areas, nor refrigerators, nor with glassware or utensils also used
for laboratory operations
d. Each employee shall keep the work area clean and uncluttered. All chemicals and
equipment shall be labeled with appropriate hazard warnings. At the completion of
each work day or operation, the work area shall be cleaned
e. Mouth suction or pipetting or starting a siphon is prohibited.
f. Skin contact with all chemicals shall be avoided. Appropriate PPE will be used
while handling hazardous chemicals. Employees shall wash exposed skin prior to
leaving the laboratory
g. Additional specific precautions based on the toxicological characteristics of
individual chemicals shall be implemented as deemed necessary by the lab
supervisor
h. All glassware will be handled and stored to minimize breakage; all broken
glassware will be immediately disposed of in the broken glass containers
5.Safety with chemical spills, releases and accidents
a. In Case of Fire: The first reaction shall be to evacuate the occupants of the
building. Fire extinguishers are available in labs and are inspected annually. They
may be used by trained personnel to fight small fires.
b. In case of spills: Person not wearing personal protective devices shall remain away
from spillage area. Spillage surface shall be cleaned with 1% sodium hypochlorite
or sodium dichloroisocynuarate as per the spillage management guidelines of
United Ciigma Hospital.
6.Safety with formaldehyde exposure.

Potential hazard: Employee exposure to Formaldehyde. Formaldehyde can cause acute effects
like Eye and respiratory irritation, severe abdominal pains, nausea, vomiting and possible loss of
Consciousness. Chronic effects of formaldehyde include laryngitis, bronchitis or bronchial
pneumonia.
Safe practices
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a. Use of appropriate PPE including goggles

b. If there is any possibility that an employee's eyes may be splashed with solutions
containing 0.1 percent or greater formaldehyde, acceptable eyewash shall be done.
7.Safety with Xylene, concentrated acids or alkalies Exposure
Potential hazard: Employee exposure to hazardous chemicals such as Xylene concentrated acids
or alkalies. This can cause acute effects like Eye and respiratory irritation, severe abdominal pains,
nausea, vomiting and possible loss of consciousness. Chronic effects includes, skin burns, irritation
laryngitis, bronchitis or bronchial pneumonia
Safe practices
a. Protective clothing should be worn to prevent any possibility of skin contact
b. In the event of a spill or leak, persons not wearing protective equipment and
clothing should be restricted from contaminated areas until cleanup has been
completed
8.Safety with needle stick and sharp injuries
Potential hazard: Employee exposure to blood borne pathogens from needle stick injuries or cuts
from sharp objects when working with specimens, centrifuge tubes or overfilled sharps containers.
Safe practices:
a. Use safer needle devices and needle less devices to decrease needle stick or other
sharps exposures
b. Properly handle and dispose of needles and other sharps
c. Do not bend, recap, or remove contaminated needles and other sharps unless such
an act is required by a specific procedure or has no feasible alternative
d. Do not shear or break contaminated sharps.
e. Have needle containers available near areas where needles may be found
f. Discard contaminated sharps immediately
g. Do not pick up broken glassware, such as capillary tubes directly with the hands
h. Dispose of regulated wastes including capillary tubes properly
i. Wear gloves when among other things, handling or touching contaminated items or
surfaces, such as capillary tubes
j. In case of needle stick or sharp injury, wound shall be washed with soap and water
and blood shall be allowed to flow freely. Complete needle stick injury-reporting
form and follow Hospital Needle Stick Injury protocol
UNITED CIIGMA

Policy No. A-10
Issue Date:
Revision No:00
Document No. A-10.1
Identification of patients
Revision Date: -
Purpose:
To provide an identification system to insure that all hospital patients are properly identified prior
to any care, treatment or services provided.
Exception: Patients unable to provide identifying information, who experience conditions
requiring emergency care, will receive treatment prior to identification if such care and treatment
is necessary to stabilize the patients condition.
Procedure:
1. An identification slip shall be prepared by the case writer and given to the patient / attender at
the time admission. Identification slips are carried with admission paperwork to the respective
ward and affixed at the point by the receiving personnel.
2. The identification slip shall show the IPD / OPD number, patients name, age and sex.
3. Initially, the identification slip shall be checked by the ward staff Nurse to ensure that it is
legible and contains the correct information when the patient is admitted.
4. Prior to the administration of tests, treatments, medications, procedures or transfer, the
healthcare professional providing the care is responsible for verifying the patients identity by
utilizing two identifiers: patient name and patient medical record number. Staff shall verbally
assess the patient to assure proper identification, the patients name and date of birth, and match
the verbal confirmation to the written information on the identification.
5. If the identification slip is illegible, missing, or contains incorrect information, the test,
treatment, medication, or procedures will not be done until the patient is properly identified.
6. Nursing is responsible for obtaining a new slip in the event that an identification band is
illegible, missing, or contains incorrect information, obtaining a new band is from Patient
Registration and Admissions.
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Policy No. A-10
Issue Date:
Revision No:00
Document No. A-10.1
Identification of patients
Revision Date: -
7. The patient can return the identification slip before discharge. In the event of death, the
identification slip shall remain on the patients body.
UNITED CIIGMA

Instructions
Policy No.
Document No.
Work Instructions for Radiology
Issue Date:
Revision No:00
Revision Date: -
Purpose:
To provide appropriate means for the transporting of patients who must be sent to other
designated areas for special tests, procedures or advanced care.
Procedure:
A. The treating physician shall take care of:
1. Writing an order for transportation
2. Designating what portion of patients medical record / clinical information is to be sent with
the patient.
3. Scheduling the test or procedure to be performed
4. Ordering IV to be changed to IV lock prior to transfer
5. Paramedical / Attendant to accompany the patient
B. Nursing staff will be responsible for:
1. Making the necessary arrangements for transportation as follows
a. Identification information and ordering physician, location (unit, room and bed
number)
b. Name of facility and department to which patient is to be
transported
c. Test or procedure to be performed
d. Date and time for scheduled test or procedure and
e. Mode of transport wheelchair / stretcher / ambulance / special requirements if
any.
2. Notifying the concerned personnel where necessary
3. Patient shall be identified as per procedure for patient identification prior to transfer
4. Nursing staffs are responsible to change IV to IV lock prior to transfer.
C. Emergency department will be responsible for making the arrangements for external
transportation from casualty.
Purpose: To effectively provide all radiology services as required by the scope of clinical
services of the hospital.
UNITED CIIGMA

Policy No.
Document No.
S. No.
1.

Instructions
Issue Date:
Revision No:00
Instruction
To give clear-cut instructions for pre-requisite for
Revision Date: -
Responsibility
Radiographer
carrying out the procedure (e.g. empty stomach/full

stomach, empty bladder/full bladder, purgative/no
purgative) and the cost of the procedure if
2.
applicable.
To give clear instructions to patients who require
Radiographer
contrast (oral/rectal/I/V) so that they are physically

3.
4.
5.
6.
7.
8.
9.
and mentally prepared.

To receive the investigation form for x-ray.
To enter all the required details in register
To position the patient as per the requirement.
To load the film in the cassette.
To adjust control panel as per the requirement.
To expose the film.
Standing behind the lead screen for radiation safety.
Technician / Radiographer
Radiographer
Radiographer
Radiographer
Radiographer
If a relative has to be present, make sure that they

10.
use a lead apron for radiation safety.

To process exposed film in the dark room /
11.
automatic film processor.

Ensuring that the exhaust fan is on for minimum
Technician
12.
exposure to fumes.
To store the used fixer in a separate container and
Incharge /Technicians
13.
marked Hazardous Waste.

Collecting all waste films for disposal to waste
Incharge / Technicians
14.
contractor.
To inform the Housekeeping personnel. Whenever a
Incharge
used fixer container becomes full or sufficient waste

films have accumulated so that it can be disposed off
15.
to an authorized waste contractor.

To write and sign the report after analyzing the
Radiologist / M.O i/c
radiographs (where applicable).
UNITED CIIGMA

Policy No.
Document No.

Instructions
Issue Date:
Revision No:00
Revision Date: -
16.
To enter the particulars in the dispatch register and
Technician/ Radiographer
17.
obtain signature of the person receiving the reports.

To perform emergency radiography after working
Technician
hours and portable x-rays in wards / operation

18.
19.
theatre.
To ensure minimum wastage in the department and
ensure all wastes are handled properly
To ensure that every one gives maximum
productivity / customer satisfaction and implements
hospital service rules, policies, dress code, systems,
office orders, circulars, minutes of various meetings
or any joint decisions.
Radiologist
The radiology department staff
/ incharge / radiologist
UNITED CIIGMA

Policy No.
Document No.

Interdepartmental /
interspeciality referral
Issue Date:
Revision No:00
Revision Date: -
Purpose: To refer the patient to another department requiring interdepartmental / inter-speciality

services for continuity of services.
S. NO.
STEPS
RESPONSIBILITY
If the patient required another departmental services, he /

she is referred to the department
Referring Consultant
The reason for referring is written down on the case paper
Referring Consultant
If the patient is serious or requires emergency care, the

referring doctor shall stabilized first and refer to the concern
department / consultant
Referring consultant
If the patient is serious or requires emergency care, the

referred department / consultant is informed by phone or
other means
Referring consultant
Proper transportation facilities is provided to the patient
Staff nurse and Ward

Attendant
The patient should be accompanied or guided to the referred

department
Staff nurse and Ward

Attendant
Patient transportation, if required shall be done as per

document no. A 10.2 (Transportation of patient (internal
and external))
UNITED CIIGMA

Policy No.
Issue Date:
Revision No:00
Document No.
Discharge of patient
Revision Date: -
Purpose: To stream line the process of discharging patients from hospital

Process owner: Treating physician
Scope: All patient discharges of inpatient, observation patients, daycare patients, patients
undergoing transfer to another external facility, DAMA and absconded patients. Patients death in
hospital will also be reflected in the discharges.
S. NO.
1
STEPS
RESPONSIBILITY
The treating physician will decide on patients readiness for
Treating physician
discharge / transfer for advance treatment. Patients who

request
discharge
against
medical
advice
are
also
considered.
If the patient leaves without intimation or informing the
ward staff, it shall be recorded on patients medical record as
patient absconded and considered to be discharged.
Patient death in hospital is to be reflected in discharge
2
procedure
If the patient is not fully recovered, patient shall be advice to
Treating Physician
stay in the hospital till recovered. If still unwilling to remain,

request to be obtain in writing from patient / family
member / attendant / guardian
3
Absconded MLC patients are to be intimated to RESIDENT

DOCTOR and COO and a report to be made to the local
Treating physician /
RESIDENT DOCTOR
police
4
After the decision to discharge a patient is made, the
Treating physician
discharge summary (as per guideline) should be given at the

time of discharge
5
Discharge shall be recorded in a register, which shall include
UNITED CIIGMA
Staff nurse

Policy No.
Issue Date:
Revision No:00
Document No.
Discharge of patient
Revision Date: -
patients identity, discharge diagnosis, date and time of

discharge, ward / unit, special remarks if any.
7
Discharge advice, medication, follow up and other necessary
Staff nurse
instructions shall be given to the patient at the time of

handing over the discharge card
8
Patient feedback / satisfaction survey proforma to be
Staff nurse
completed and collected at the time of discharge

9
Special transportation arrangements if necessary shall be

made
10
Staff nurse / Family

member
Endorse Death / DAMA / Absconded / Medico-legal case on
Staff nurse
patients medical record where necessary

11
Patients Indoor case paper is to be sent to Medical Records

Department as scheduled and record maintained
UNITED CIIGMA
Staff nurse / MRD in

charge

Policy No.
Issue Date:
Revision No:00
Document No.
Contents of Discharge Summary
Revision Date: -
Discharge summary shall be made for all discharged / DAMA patients. In case of patients death,
death summary shall be prepared.
The instructions in discharge summary shall be in a manner that the patient / family member can
easily understand.
Use of medical terms and jargons shall be avoided to the extent possible
Discharge summary shall comprise the following components.
1. Reason for admission, significant findings, diagnosis, condition at the time of discharge
2. Information regarding investigation results, any procedure performed, medication and
other treatment given
3. Follow up advice, medications, any other instructions in an understandable manner
4. Instructions about when and how to obtain urgent care are to be incorporated
5. In death cases the summary is to include cause of death
6. The discharge diagnosis is made available in the discharge summary.
UNITED CIIGMA

Policy No.
Document No.
Type of document - Policy

Patients and Familys rights
and responsibilities
Issue Date:
Revision No:00
Revision Date: -
All the patients and their families visiting the hospital have the following rights, which are
respected by every staff member of the hospital. Patients and families may bring to the notice of
the RESIDENT DOCTOR any instance of violation or perceived violation of these rights.
Respect for dignity and privacy of patients
All patients and their family are entitled to due respect for personal dignity, and suitable privacy
for patients undergoing examination, certain procedures, and treatment.
Protection from physical abuse or neglect
Utmost care is to be taken that patients are not harmed because of neglect or physical abuse. This
is to address areas like physical security, assault, and use of criminal force, harassment, adequacy
of equipment safety, unnecessary use of restraint, manhandling, and such illustrative situations.
Special care shall be taken while dealing with the vulnerable group of patients such as the elderly,
paediatric, neonate, women, mentally challenged, deaf, dumb, blind, and the physically
handicapped. (Refer Document No. B - 9.1, regarding care of vulnerable patients).
Confidentiality of information regarding patients
All information in respect of patients is ideally kept confidential except in instances where
disclosure is required by law. Families also may be denied disclosure of some kinds of
information unless consented to by the patient. This will not apply to minors, and individuals who
are incapable of exercising rational decision-making. Only those personnel have the right to
access patient information, who are involved in the care of the patient or specifically authorised
by the hospital.
Patients right for refusal of treatment
The patient has the right to refuse treatment. Exceptions to this are made in case of minors or
those cases where the patient is incapable of exercising judgment and appreciation of the
consequences of their actions. Other exceptions are in cases where the law restricts this right.
(See gazette notification for patient rights also)
Informed consent
Patients and family rights includes right to be informed and provide consent before anaesthesia,
blood and blood products transfusion, any invasive high risk procedure or treatment (Refer policy
no. D- 2 also).
This includes information and consent before any research protocol is initiated.
Voicing a complaint
UNITED CIIGMA

Policy No.
Document No.

Issue Date:
Revision No:00
Revision Date: -
Patient, family or guardian has the right to voice their complaints. Complaints are to be
communicated through their treating physician or RESIDENT DOCTOR in the prescribed
manner preferably in writing. Complaints can be placed in the complaint and suggestion box, or
endorsed in the complaint and suggestion register. A suggestion and complaint book has been
kept in the reception and with the office of the RESIDENT DOCTOR. A Complaint and
Suggestion box has been placed in the same locations. Those desirous of sending such
communications by post may address their complaints and suggestions to the Office of the COO,
whose address is as follows:
To The COO
UNITED CIIGMAX Hospital,.
abcdefgh
Information on expected cost of treatment
The patient and their family / guardian have the right to receive reliable information on the
expected cost of treatment, will be available in the RESIDENT DOCTORs office.
Right to know their treatment details:
Patients, and families where minors and incapacitated patients are concerned, have the right to
know their treatment details.
Access to Emergency Services
If patients have severe pain, injury, illness, that convinces them that they are faced with an
emergency medical situation, they have the right to receive screening and stabilization at the
available emergency service in the hospital, regardless of capacity to pay.
Participation in Treatment Decisions
Patients have the right to know the various options for treatment available and to participate in
making decisions about their care. Parents, guardians, family members, or other individuals that
they designate, can represent them, if they so desire.
Patients right to information and education about their healthcare needs
Patients have a right to be educated about the following in a language and format that they can
understand
o Safe and effective use of medicines, and their potential side effects.
o Diet and nutrition requirements
o Immunization
o Their specific disease process, complications, and prevention strategies.
o Prevention of infections, where applicable
USERS RESPONSIBILITIES
UNITED CIIGMA

Policy No.
Document No.

Issue Date:
Revision No:00
Revision Date: -
Users of the hospital are entitled to demand adherence of all concerned to the charter principle as
indicated above and bring any shortcomings or deficiencies to the notice of appropriate
authorities
Users should appreciate the various constraints under which the hospital is functioning and ensure
its smooth functioning without inconveniencing other patients and visitors
They should help the hospital authorities in keeping the hospital and surroundings clean and in
proper sanitary condition.
Provide useful feedback and constructive suggestions regarding the quality and extent of service
available at the hospital.
Refrain from misusing the facilities available or demanding an undue favour from staff or
officials.
UNITED CIIGMA

Policy No.
Document No.
Type of document Procedure

Patients Complaints and
Grievance Handling
Issue Date:
Revision No:00
Revision Date: -
Name of the Hospital: UNITED CIIGMAXX Hospital, yyyyyyy Dist.

Address:
Telephone No.:
1. Preamble
This charter is an expression of commitment and resolve of this hospital to provide to its patients
information about the services that are available, the quality and standards of service that they
may expect, as also the machinery and procedure available for redressal of their grievances and
complaint.
2. Hours of work
Out Patient Department
Registration 8.30am 12.00am
OPD consultation 8.30am 12.00
Administrative office
Weekdays: 9.45 am 5.45pm
Lunch break: 12.45pm 1.45pm
Closed on Sundays and gazetted holidays
Casuality / Emergency department : Open throughout 24 hours on all days
Medical officer
: Available throughout 24 hours on all days
Duty doctor
: Casualty / emergency will have a minimum of one duty
doctor available for 24 hrs.
Specialist services
Weekdays: 8.30am 12.00pm
Emergency : 24Hrs (On call)
Closed on Sundays and hospital holidays (As per government holidays)
UNITED CIIGMA

Policy No.

Grievance Handling
Document No.
Issue Date:
Revision No:00
Revision Date: -
3. Scope of services
The Hospital shall provide following services: General Specialty
Related
Additional
Time
Remarks
OPD- Morning and

Evening as per
Schedule
Emergency
Examination and
admission round
the clock all 365
days through
Casualty
Department
ICCU facility
available. Cases
for interventional
cardiology
referred to higher
centre. 2 D Echo
facility available
on fixed day.
Services
General Examination
General Medicine
Basic Cardiology
OPD- Daily
Morning
IPD- Daily
Diabetes Care
Obstetrics &
High-risk Pregnancy
Gynecology
Family Welfare services
General Surgery
Burns Cases
Pediatrics
Well baby clinic

Neonatology
OPD- On
designated days
IPD- Daily
OPD- On
designated days
IPD- Daily
OPD- On
designated days
IPD- Daily
Immunization Services
Orthopedics
ENT Surgery
Physiotherapy
OPD- On
designated days
IPD- Daily
OPD- On
UNITED CIIGMA
Laparoscopy
surgery facility
Complicated
neonatal and
pediatric surgery
cases referred to
higher level
Joint Replacement
surgery facility

Policy No.

Grievance Handling
Document No.
Ophthalmology
Facility for Intra Ocular

Lens Implant with Phaco
Dermatology
Emulsification
Sexually Transmitted
Cryodermabrasion
Basic Dental services
available
Anesthesia services
Pain Clinic on fixed day
Pathology Laboratory
Hematology
Pathology
Bio Chemistry
Radiology
X- Rays
Sonography Examination
CT Scan
Integrated
Prevention of parent to
Counseling and
child services also
Testing Centre (for
available
Revision No:00
Revision Date: -
designated days
IPD- Daily
OPD- On
designated days
IPD- Daily
OPD- Daily
Morning and
Evening
Diseases Clinic
Dental services
Issue Date:
OPD- Daily
Morning and
Evening
As per OT
Schedule
Investigations as
per schedule
during OPD hours
Investigations not
available in OPD
are referred to
Government
Hospital, or
Private Lab as per
patients choice
Routine
investigations done
during OPD hours
Emergency
Investigations
done round the
clock 365 days
HIV and STD
testing facility
available during
routine OPD hours
HIV/AIDS)
UNITED CIIGMA
Indoor as and
when necessary
Critical
investigations
available round
the clock 365 days
Investigational
procedures like
IVP, Barium Meal
and follow up
done only after
consultation of
Radiologist
depending on
workload.
Positive people
network given
support

Policy No.
Document No.

Grievance Handling
Issue Date:
Revision No:00
Revision Date: -
Others
o
o
Certificate (Medical fitness, Disability certificate, Health Certificates, Age certificate)

Emergency Medical Response
4 Other facilities
a. The list of doctors on duty, names of Medical Officer, RESIDENT DOCTOR/COO, along
with their location is displayed / available at reception
b. Wheelchairs and stretchers are available on request at the gate / reception for facility of
patients who are not in a position to walk
c. A location map is on display at the main waiting area for easy access to various departments
by patients
d. Every staff in this hospital can be identified by their uniform.
e. Information regarding the fees and other payments if any to be made for use of various
facilities / diagnostic and other machines and equipment and / or for specialists fees /
medicines etc.are also displayed / available at the reception
f. Adequate safe drinking water and toilet facilities are available for the convenience of the
public.
g. Adequate display boards are available at different locations for guidance of visitors and
outpatients
h. Ambulance / Mortuary vans are available for use on payment as per rules throughout 24 hrs.
i. Laboratory is available in the hospital premises at ground floor, for various tests.
j. Public telephone booth is available at Ground floor.
k. Tea Stall is available at ground floor for catering to visitors and outpatients during normal
working hours
l. There is a standby generator to cater to emergency and critical areas in case of general
breakdown of electricity.
m. A pharmacy is located at OPD and Emergency which is open 24 hours a day
5. Service standard
This hospital has
Doctors : 31
Nurses : 41
Beds : 265
UNITED CIIGMA

Policy No.
Document No.

Grievance Handling
Issue Date:
Revision No:00
Revision Date: -
5.1 Standards of service and adequate degree of patient care can be provided to the extent proper
and workable ratio between doctor to patient, nurse to patient and beds to patients are maintained,
as per available manpower. Consistent with this every possible effort will be made by this
hospital:
a. To provide access to hospital and professional medical care to all patients who visit the
hospital
b. To prescribe a workable maximum waiting time for outpatients, before they are attended to
by a qualified doctor and / or specialists and continuously strive to improve upon it
c. To ensure that all equipment in the hospital are maintained efficiently in proper working
order
d. To ensure availability of beds and operation theatres facilities as freely as possible
e. To ensure treatment of emergency cases with utmost promptitude and attention
5.2 Every outpatient seeking treatment at the hospital will be registered and issued a case paper
for recording various details of the symptoms, diagnosis and treatment being provided.
5.3 The patients and families rights are in consonance to accreditation standards and are
documented separately in this charter
5.4 All patients and visitors to the hospital will receive courteous and prompt attention from the
staff and officials of the hospital in the use of its various services
5.5 Reliability and promptness of diagnostic investigation results is ensured and whenever
possible such reports will be made available.
5.5 Operation theatre is maintained on a regular basis to ensure that they are serviceable all the
time and every effort will be made to keep the hospital and its surroundings, clean, infection-free
and hygienic.
5.6 A regular system of obtaining feedback from the users is in place through exit interviews and
periodic surveys. The inputs from these are continuously used for improving the service standards
5.7 The hospital has necessary equipments required for provision of service mentioned in scope
of services and system to ensure proper maintenance and working of various equipments.
5.8 If any equipment is out of order, information regarding the same shall be displayed suitable
indicating the alternate arrangements, if any, as also the likely date of recommissioning the
equipment after repairs and replacement.
5.9 When things go wrong or fail, appropriate action is taken on those responsible for such
UNITED CIIGMA

Policy No.
Document No.

Grievance Handling
Issue Date:
Revision No:00
Revision Date: -
failures and action taken to rectify the deficiencies. Complainants will also be informed of the
action taken, if requested
5.10 In case of likely persistence of the deficiency, the reasons for the delay in rectifying the
deficiency and the time taken for rectifying the same will be displayed prominently for the
information of the public.
5.11 Special directions are given to the non-medical staff to deal with the patients and public
courteously. Any breach in this regard when brought to the notice of the hospital authorities shall
be dealt with appropriately.
5.12 Hospital encourages the patients and the public to inform the authorities when things go
wrong. Suggestion / complaint boxes and registers are provided at the reception, RESIDENT
DOCTOR office, Matron office and administrator
5.13 Hospital follows all policies, processes, programmes, committee meetings, regulatory
guidelines which has been prepared to meet the standards of accreditation as set by NABH
6. Grievance / Complaint / Redressal
As given in patient rights.
7. Patient and Familys Rights
All the patients and their families visiting the hospital have the following rights, which are
respected by every staff member of the hospital. Patients and families may bring to the notice of
the RESIDENT DOCTOR any instance of violation or perceived violation of these rights.
7.1 Respect for dignity and privacy of patients
All patients and their family are entitled to due respect for personal dignity, and suitable privacy
for patients undergoing examination, certain procedures, and treatment.
7.2 Protection from physical abuse or neglect

Utmost care is to be taken that patients are not harmed because of neglect or physical abuse. This
is to address areas like physical security, assault, and use of criminal force, harassment, adequacy
of equipment safety, unnecessary use of restraint, manhandling, and such illustrative situations.
Special care shall be taken while dealing with the vulnerable group of patients such as the elderly,
paediatric, neonate, women, mentally challenged, deaf, dumb, blind, and the physically
handicapped.
7.3 Confidentiality of information regarding patients
UNITED CIIGMA

Policy No.
Document No.

Grievance Handling
Issue Date:
Revision No:00
Revision Date: -
All information in respect of patients is ideally kept confidential except in instances where
disclosure is required by law. Families also may be denied disclosure of some kinds of
information unless consent obtained from the patient. This will not apply to minors, and
individuals who are incapable of exercising rational decision-making. Only those personnel have
the right to access patient information, who are involved in the care of the patient or specifically
authorised by the hospital.
7.4 Right for refusal of treatment
The patient has the right to refuse treatment. Exceptions to this are made in case of minors or
those cases where the patient is incapable of exercising judgment and appreciation of the
consequences of their actions. Other exceptions are in cases where the law restricts this right.
7.5 Informed consent
Patients and family rights includes right to be informed and provide consent before anaesthesia,
blood and blood products transfusion, any invasive high risk procedure or treatment
This includes information and consent before any research protocol is initiated.
7.6 Voicing a complaint
Patient, family or guardian has the right to voice their complaints. Complaints are to be
communicated through their treating physician or RESIDENT DOCTOR in the prescribed
manner preferably in writing. Complaints can be placed in the complaint and suggestion box, or
endorsed in the complaint and suggestion register. A suggestion and complaint book has been kept
in the reception and with the office of the RESIDENT DOCTOR. A Complaint and Suggestion
box has been placed in the same locations. Those desirous of sending such communications by
post may address their complaints and suggestions to the Office of the COO, whose address is as
follows
To The COO
XXXX Hospital, YYYY Dist.l.
Address:
7.7 Information on expected cost of treatment
The patient and their family / guardian have the right to receive reliable information on the
expected cost of treatment will be made available in the RESIDENT DOCTORs office.
7.8 Right to know their treatment details:
Patients, and families where minors and incapacitated patients are concerned, have the right to
know their treatment details.
7.9 Access to Emergency Services
UNITED CIIGMA

Policy No.
Document No.

Grievance Handling
Issue Date:
Revision No:00
Revision Date: -
If patients have severe pain, injury, illness, that convinces them that they are faced with an
emergency medical situation, they have the right to receive screening and stabilization at the
available emergency service in the hospital, regardless of capacity to pay.
7.10 Participation in Treatment Decisions
Patients have the right to know the various options for treatment available and to participate in
making decisions about their care. Parents, guardians, family members, or other individuals that
they designate, can represent them, if they so desire.
7.11 Patients right to information and education about their healthcare needs
Patients have a right to be educated about the following in a language and format that they can
understand
o Safe and effective use of medicines, and their potential side effects.
o Diet and nutrition requirements
o Immunization
o Their specific disease process, complications, and prevention strategies.
o Prevention of infections, where applicable
8. Responsibilities of users
8.1 Users of the hospital are entitled to demand adherence of all concerned to the charter principle
as indicated above and bring any shortcomings or deficiencies to the notice of appropriate
authorities
8.2 Users should appreciate the various constraints under which the hospital is functioning and
ensure its smooth functioning without inconveniencing other patients and visitors
8.3 They should help the hospital authorities in keeping the hospital and surroundings clean and
in proper sanitary condition.
8.4 Provide useful feedback and constructive suggestions regarding the quality and extent of
service available at the hospital.
8.5 Refrain from misusing the facilities available or demanding an undue favour from staff or
officials
9. Suggestion for improvement
Any suggestion for improvement of this charter document will be most welcome and may be
addressed to COO /RESIDENT DOCTOR
UNITED CIIGMA

Policy No.
Document No.

Grievance Handling
Issue Date:
Revision No:00
Revision Date: -
Purpose: To have a system of receiving, reviewing and taking appropriate action on patient
complaint and grievances
Patients and families have a right to voice a complaint and seek redressal of the same.
A complaint and suggestion box shall be provided in the general area and should be labeled
appropriately.
Patient and family can also voice complaint directly to RESIDENT DOCTOR office.
In this case the complaint / grievance shall be documented.
Along with the complaint and suggestion box 6 registers shall be maintained and kept at
following places
1. General OPD
2. Main reception counter
3. Accident & Emergency ward
4. Matron
5. RESIDENT DOCTOR
RESIDENT DOCTOR of the hospital shall be in charge of receiving patient grievances,
complaints, and suggestions for redressal.
On receipt of complaint person in charge shall;
Provide the aggrieved person with a written response for his / her complaint, along with
the action taken, and an application number which may be used as reference by the
applicant.
Contact the concerned health service provider and remedy the situation, when possible;
and
Provide to the aggrieved person, printed information in Tamil on all the remedies
available to him / her, including the right to file an application for a grievance at the
district court
The person in-charge shall submit the register of complaints along with action taken to the state
monitoring committee at the end of each month through the RESIDENT DOCTOR and COO.
UNITED CIIGMA

Policy No.
Issue Date:
Revision No:00
Document No.
Obtaining consent
Revision Date: -
Policy No. D - 2 - Consent

Consent shall be obtained from patients and family for informed decision making about their
care. Consent is of two types, viz. general, and informed.
Consent is to be given by
o By the patient, unless he or she is a minor.
o If patient is incapable of informed decision making, consent shall be obtained from next
of kin / parent / guardian, as per law of the land.
o In case of unidentified patient in unconscious condition, treating doctor shall take a
decision in life saving circumstances. Permission will be sought from COO / RESIDENT
DOCTOR for surgery
o In case the patient incapable of independent decision-making is a prisoner, the consent
shall be taken from the Jail Superintendent.
General consent is to be taken when the patient enters the hospital to avail of the services as an
inpatient, daycare, observation and detention, specified investigations and procedures as
mentioned in the document.
Scope of general consent is communicated to the patients and / or the family members.
Informed consent is obtained as above in situations, which are listed in the document. This shall
include information on risks, benefits, alternatives, which will perform the requisite procedure.
The consent shall be taken as per the documented procedure and communicated in a language that
the patient / family can understand.
Purpose: To have a uniform and appropriate methodology for obtaining consent for medical
treatment from patient or family
Scope: General and special consent
S. NO.
STEPS
RESPONSIBILITY
1.
General consent for treatment shall be taken at the time of

admission on admission paper and should be attached in
medical record
2.
Informed and special consent shall be taken by treating
UNITED CIIGMA
Staff nurse
Treating physician

Policy No.
Issue Date:
Revision No:00
Document No.
Obtaining consent
Revision Date: -
physician for the situations listed in document D-2.2

3.
Take into account, patients psychological features, culture,

and educational level while obtaining consent.
Treating physician
4.
Provide following information to take informed consent
Treating physician
Procedure to be performed with reason
During the course of operation/procedure, unforeseen

conditions may be revealed or encountered which
necessitate surgical or other emergency procedures in
addition to or different from those contemplated at the
time of initial diagnosis
Use of anaesthesia and of which type
Nature and purpose of the operation and / or procedures,

the necessity, thereof, the possible alternative methods,
treatment, prognosis, risk involved and possibility of
complication
5.
Take consent that patient is not suffering from

Hypertension/Diabetes/Bleeding disorders/heart diseases,
allergies, drug reaction or similar other conditions
Treating physician
6.
If photographing or televising of the operation / procedure

has to be done, for the purpose of medical, scientific or
educational purpose, consent has to be taken for that account
Treating physician
7.
The consent shall be taken on consent form which shall

contain
Treating physician
Signature/thumb impression of patient,
UNITED CIIGMA

Policy No.
Issue Date:
Revision No:00
Document No.
8.
Obtaining consent
Revision Date: -
Signature, names and address of the witness
(In case patient incapable of independent decision

making) Signature / thumb impression of guardian (as
per policy) with name and relationship with patient
Signature of doctor incharge with name and designation
Date and time of signing the consent
In case if the consent is taken on plain paper (in medical

record), it should contain items mentioned in S.No. 4 (in
written) in addition to those mentioned in S. No. 7
UNITED CIIGMA
Treating physician

Policy No.
Type of document List
Document No.
List of situations where

informed consent is required
Issue Date:
Revision No:00
Revision Date: -
Informed consent from the patient / family is required whenever patient is undergoing any of the
following procedures
1.
Transfusion of blood or any other blood product
2.
Ascites tapping / Abdominal paracentesis
3.
Thoracentesis
4.
Direct Laryngoscopy / Bronchoscopy / Cystoscopy / Colonoscopy / Sigmoidoscopy
5.
Bone marrow biopsy / aspiration
6.
Fine needle aspiration cytological studies (FNAC)
7.
CT guided or US guided FNAC
8.
CT scan with contrast
9.
Lumbar puncture
10. Any surgical procedure

11. Foleys catheterization
12. Nasogastric tube insertion
13. Intubation
14. Immuno therapy, intravenous or sub-cutaneous
15. Abdominal, pleural or pericardial drainage and drainage tube insertion
16. Central line placement
17. For restraining the patient
If patient is not aware of the diagnosis or is incapacitated, the lead caregiver signs the consent.
In emergency situation doctor on duty can sign the consent or give verbal affirmation for any
procedure.
UNITED CIIGMA

Policy No.
Issue Date:
Revision No:00
Document No.
Attending patients at Emergency
Revision Date: -
Purpose: To streamline the system of attending the patients in emergency

Primary responsibility: Medical Officer on duty in casualty
Sl no
1.
Procedural steps
Receive Patient on stretcher
Responsibility
Ward boy and
Brother
Nurses
2.
Call the doctor
3.
Immediately check
L. I. S. A : Life Threatening
Impression
Stabilize Cervical Spine
Doctor /Staff Nurse
4.
Air Way : Suction

Head Tilt Chin Lift /
Jaw Thrust Maneuver
Oral Airway
Assess for Advance Air Way Management
Definitive Air Way.
Breathing : IPASS-O2
I : Inspection
P: Palpate
A: Auscultation
O: Oxygen
(1) Do you see any sign of inadequate respiration?
(2) Is the rate and quality of breathing adequate to sustain
life?
(3) Is the patient complaining of difficulty breathing?
(4) Quickly palpate the chest for unstable segments,
repetition (trauma), and equal expansion of the chest
(5) If the patient is responsive and breathing < 8 or >24,
administer oxygen using a None Rebreather Mask
(NRM) at 15 lts/minute
(6) If the patient is unresponsive and breathing is adequate,
administer oxygen using a NRB at 15 lts/minute
(7) If the patient is unresponsive and breathing is
inadequate, administer oxygen using a Bag Valve Mask
(BVM).
Circulation: VCRS
Check: Natural Voids
Doctor /Staff Nurse
5.
6.
UNITED CIIGMA
Doctor /Staff Nurse
Doctor /Staff Nurse

Policy No.
Issue Date:
Revision No:00
Document No.
Revision Date: -
Carotid Artery
Radial artery
Skin: Color Temperature, Condition
Manage For Shock
Take Two Large bore IV Lines when needed
7
Admit the patient

Decision Making:
If expert opinion is delayed for more than 20 Minutes for any
reason then critical decision is taken by Medical officer to
transport patient immediately by Rapid Transport to Advance
Trauma Centre.
Call Ambulance
Doctor
CHECK FOR CUPS:

Critical
Unstable
Potentially Unstable
Stable
Exam:
Rapid Physical Examination
DCAP BTLS:
D: Deformities
C: Contusions
A: Abrasions
P: Penetration / Puncture
B: Burns
T: Tenderness
L: Lacerations
S: Swelling
HeadNeckChestAbdomenGroinExtremities
Doctor /Staff Nurse
Take Full Set of Vital Signs

Blood pressure
Pulse
Respiration
Skin: Temperature,
Pupil
Doctor /Staff Nurse
10
UNITED CIIGMA
Doctor /Staff Nurse

Policy No.
Issue Date:
Revision No:00
Document No.
11
Revision Date: -
FIVE:
F: Focused Exam
I: Initial Assessment
V: Vital Signs:
Every 1 hour for Unstable patient
Twice a day for Stable Patient
As & when situation required it will be done
Every 15 Minutes in Stable Patient
E: Evaluate Intervention /Treatment
Doctor /Staff Nurse
12. If time permit do detailed physical examination
Doctor /Staff Nurse
UNITED CIIGMA

Issue Date:
Policy No.
Document No.
Revision No:00
Handling of road traffic accident
cases
Revision Date: -
Purpose: To follow a uniform guideline to handle cases of road traffic accident or trauma
Sl No.
1.
ACTIVITY
Receive Patient on stretcher
RESPONSIBILITY
Servant / Brother
2.
Call doctor over telephone
Nurses
3.
Immediately check
L. I. S. A : Life Threatening
Stabilize C Spine
Impression
AVPU
Doctor/Staff Nurse
4.
Air Way:
Suction
Head Tilt Chin Lift /
Jaw Thrust Maneuver
Oral Airway
Assess for Advance Air Way Management Definitive Air
Way.
Breathing: IPASS-O2
I : Inspection
P: Palpate
A: Auscultation
S: Seal Holes
S: Stabilize (Flail Chest)
O: Oxygen Check Devices
and Adequacy
Circulation: VCRS
Check: Natural Voids
Carotid Artery
Radial artery
Skin: Color Temperature, Condition
Manage For Shock
Take One Large bore IV Lines, another if necessary
Doctor /Staff Nurse
Admit the patient

Decision Making:
If expert opinion is delayed for more than 10 Minutes for any
reason then critical decision is taken by Medical officer to
Doctor
5.
6.
7.
UNITED CIIGMA
Doctor /Staff Nurse
Doctor /Staff Nurse

Issue Date:
Policy No.
Document No.
Revision No:00
cases
Revision Date: -
transport patient immediately by Rapid Transport to Advance

Trauma Centre.
Call Ambulance
8.
CHECK FOR CUPS:

Critical
Unstable
Potentially Unstable
Stable
Examination:
Rapid Physical Examination
DCAP BTLS:
D: Deformities
C: Contusions
A: Abrasions
P: Penetration / Puncture
B: Burns
T: Tenderness
L: Lacerations
S: Swelling
HeadNeckChestAbdomenGroinExtremities
Doctor /Staff Nurse
10.
Take Full Set of Vital Signs

Blood pressure
Pulse
Respiration
Skin : Temperature
Pupil
Doctor /Staff Nurse
11.
FIVE:
F: Focused Exam
I: Initial Assessment
V: Vital Signs:
Every 1 hour for Unstable patient
Twice a day for Stable Patient
As & when situation required it will be done
E: Evaluate Intervention /Treatment
Doctor / Staff Nurse
9.
UNITED CIIGMA
Doctors/Staff Nurses

Issue Date:
Policy No.
Document No.
Revision No:00
cases
Revision Date: -
12.
If time permit do detailed physical examination
Doctor /Staff Nurse
13.
Get SAMPLE history from attendant

S: Signs & Symptoms
A: Allergies
M: Medication
P: Pertinent to past history
L: Last Oral Intake
E: Events Leading To Injury / Event
Doctor /Staff Nurse
UNITED CIIGMA

Policy No.
Issue Date:
Revision No:00
Document No.
Handling of cases of poisoning
Revision Date: -
Purpose: To properly handle poisonous cases

S. NO.
STEPS
RESPONSIBILITY
All cases of poisoning including snakes bite are registered

under MLC
Duty Doctor
Keep the patient in stretcher and scrap properly with soap

and water in case of cutaneous exposure
Staff nurse
Patient is dressed with hospital uniform
Staff nurse
Proper history of the patient has to be taken to find out

whether it is inhalation type or ingestion type of poisoning
If possible the patient / relatives should bring the culprit

toxic substance or similar compound
Patient relatives
According to signs and syndromes treatment is started to

stabilize the patient
Doctor
Accordingly treatment can be done by regular monitoring of

the patient
Doctor
UNITED CIIGMA
Doctor

Policy No.
Issue Date:
Revision No:00
Document No.
Handling of burns cases
Revision Date: -
Purpose: To provide emergency medical care to cases of burn injury

S. NO.
STEPS
RESPONSIBILITY
All major burns cases shall be registered under MLC
Duty Doctor/ COO
Emergency aids are given and admitted in burns ward
Duty Doctor
Clean water bath of the patient
Applied normal saline
Clean the body with sterilized gauze piece
Apply vaseline with silver sulphadiazine cream to the

sterilized gauze and dressing is done
Put the patient on the sterilized bed (used cradle if the

patient is old or not able to walk or move)
Hospital worker
Antibiotic injections, pain injections, etc are given
Staff nurse
5%DNS / IV fluids are given to the patient
Staff nurse
10
Patient who is not able to take food is given continuous IV

fluids as per doctors advice
Staff nurse
11
4 important aspects of burnt cases are cleanliness, dressing,

proper nutrition and sterilization
Staff nurse / Nursing

Assistants
12
Further treatment by doctors

Assistants
Assistants
Assistants
Assistants
Consultant
UNITED CIIGMA

Policy No.
Issue Date:
Revision No:00
Document No.
Triaging of patients
Revision Date: -
Purpose: To properly identify patients and provide the care as per needs in mass casualty or
disaster
Triage: Triage is the process of sorting patients based on their need for immediate medical
treatment as compared to their chance of benefiting from such care. Triage is done in the
emergency service department, when faced with mass casualties and limited medical resources,
which must be allocated to maximize the number of survivors.
S. NO.
STEPS
RESPONSIBILITY
All paramedical staff, emergency medical staff are involved

in triaging of patients
Controlling officer of
mass casualty
Colour tags are used for triaging of patients

-
Red > Alive, Required Emergency Care
Yellow > Alive, Does Not Required Emergency

Care
Green > Injured but can wait longer with first aid
Black > Death
Paramedical / all
involved
Patients with red tag are shifted to the emergency

department / hospitals and given emergency medical care
and further treatments
Paramedical / all
involved
Patients with yellow and green tag are given first aid on the
spot and if required shifted to hospital
Paramedical / all
involved
Patients with black tag are shifted to mortuary for post

mortem
Paramedical / all
involved
All the cases are registered under MLC and police are
informed
Paramedical / all
involved
UNITED CIIGMA
Policy No.
Issue Date:
Revision No:00
Document No.
Medico Legal Cases
Revision Date: -
Purpose: To handle MLC properly for legal aspects

S. NO.
STEPS
RESPONSIBILITY
1.
All cases of medico-legal importance are registered as MLC

and marked as MLC. This shall be decided by COO
Duty Doctor
2.
All MLC shall be treated free of cost for first 24 hours
3.
Police is informed which is available round the clock the

hospital
4.
Medical records for MLCs are maintained separately
MRD Incharge
5.
MLC records are kept in different shelves
MRD Incharge
6.
MLC records are submitted to concerned records keeper

after patient is discharged
UNITED CIIGMA
RESIDENT DOCTOR
COO
Staff Nurse

Policy No.
Issue Date:
Revision No:00
Document No.
Code blue response
Revision Date: -
Purpose: To take immediate action in case of medical emergency situation for patient / staff /
visitor, to ensure that required urgent medical care / resuscitation activities is provided on time.
Procedure:
S. No.
1.
Procedural steps
The team is identified for the day and consists of the
Responsibility
RESIDENT DOCTOR
following:
1.
MO on duty
2.
1 staff nurse on duty
3.
1 Hospital worker on duty from emergency /

casualty
4.
An anesthetist is on call to assist in difficult

intubation
and
for
post
intubation
management
2.
The name of the team members and shifts shall be

published
3.
in
advance
for
information
RESIDENT DOCTOR
and
preparedness of all concerned.

A code blue medical emergency shall be anticipated
First responder
if patient is unresponsive, meaning he is not

breathing or his heart has stopped beating, or both,
in which case near by medical / nursing personnel
4.
shall be summoned immediately

First responder / medical / nursing /paramedical
First responder
personnel shall check the responsiveness by

speaking loudly to the casualty, and trying to rouse
them by shaking his shoulder.
If there is no response send / call for help as the
UNITED CIIGMA

Policy No.
Issue Date:
Revision No:00
Document No.
5.
Code blue response
Revision Date: -
patient is being treated.

Institute CPR / BLS (Refer guidelines document No.
paramedical
B 6.2)
medical professional on the
Code blue team members, whosoever on duty shall
spot
Code blue team
Nursing
immediately reach the specified location (within 1

minute) and manage the emergency situation as per
7
necessary (Refer Document No. B-6.2)

All resuscitation efforts are recorded in patients Code blue team in charge
medical records with summary of procedure/s,
pharmacologic interventions, length of intervention,
and outcome clearly recorded.

The medical audit committee will review all such
Medical audit committee
resuscitation records and provide analysis of each

event, for corrective and preventive measures, if any
UNITED CIIGMA

Policy No.
Document No.
Type of document Guidelines

Management of Medical
Emergency / cardiopulmonary
arrest
Issue Date:
Revision No:00
Revision Date: -
Basic Life Support

Resource reference: American Heart Association guidelines on CPR, BLS and ALS
Basic Life Support (BLS) establishes a clear airway followed by assisted ventilation and support
of the circulation, all without the aid of specialised equipment.
When approaching a patient who appears to have suffered a cardiac arrest the rescuer should
check that there are no hazards to him before proceeding to treat the patient. Although this rarely
arises in hospital, patients may suffer a cardiac arrest due to electric shocks or toxic substances. In
these situations the rescuer may be in considerable danger, and must ensure that any hazard is
taken account of and eliminated as a risk.
Checking responsiveness is best done by speaking loudly to the casualty, and trying to rouse them
by shaking a shoulder. If there is no response send for help as the patient is being treated.
Opening the airway - this is normally done by simply extending the head and performing a chin
lift. In some patients a jaw thrust will be required along with the insertion of an oropharyngeal
airway. False teeth that are loose or other debris within the airway should be removed.
Assisted ventilation should be provided if the patient is not breathing. It may be provided using
expired air ventilation (mouth to mouth, mouth to nose, using a Laerdel pocket mask) or by using
a self inflating bags, usually with supplemental oxygen. Oxygen should be added to self-inflating
bag, using a reservoir on the inlet side of the bag. Adequacy of ventilation is judged by each
breath producing adequate movement of the chest on inspiration. In general tidal volumes of 400
- 500mls are optimal.
Chest compressions (previously known as cardiac massage) are used whenever a central pulse
(carotid) is absent. The technique creates positive pressure within the chest and forces blood out
of the chest during the compression phase. Due to the valves within the venous system and the
heart, most of the blood flows forward through the arteries. When the chest recoils to its normal
position blood returns to the chest from the venous side of the circulation. A small amount of flow
is produced by direct compression of the heart between the sternum and the spine. During chest
compressions approximately 25% of the normal cardiac output is produced.
Current guidelines advise that 15 chest compressions are carried out for each ventilation when
two rescuers are available. In the event of only one rescuer, 1 ventilation should follow 30
compressions. The overall rate of chest compressions should be 100/minute.
When starting chest compressions:
UNITED CIIGMA

Policy No.
Document No.

arrest
Issue Date:
Revision No:00
Revision Date: -
Get the patient on a firm surface

Feel the xiphisternum, and measure 2 fingerbreadths up on the sternum without moving
your fingers, place the heel of the second hand on the sternum. Put both hands together
and depress the sternum 4-5cm in an adult.
Keep your elbows straight, and ensure that all the pressure is directed through the sternum
and not through the ribs. To perform chest compressions adequately, it is necessary to be
above the patient. Stand on a platform if necessary.
During a cardiac arrest change the person performing chest compressions regularly, as it is
tiring when performed properly.
The rescuer performing chest compressions should count out loud "1,2,3,4,5", and the
rescuer ventilating the patient should count the number of cycles completed.
Early BLS has been shown to improve outcome, particularly when access to advanced airway
management and defibrillation is likely to be delayed. Although the barely adequate level of
oxygen delivery achieved during BLS may be regarded as a holding measure, it is of great
importance and will occasionally reverse the primary cause of the cardiac arrest and restore some
circulation preventing the rhythm degenerating into a systole.
Advanced Life Support
Advanced Life Support refers to the use of specialised techniques, in an attempt to rapidly restore
an effective rhythm to the heart. The most important components of the advanced life support
techniques are direct current defibrillation and efficient BLS.
General Management Principles for Cardiac Arrest
1.
2.
3.
4.
5.
6.
7.
Establish the safety of the victim and potential rescuer.

Confirm the diagnosis of an arrest
Send for help
Establish Basic Life Support
Aim for early and frequent defibrillation if indicated, with regular doses of adrenaline
and CPR.
If there is doubt about the rhythm, no ECG monitor is available, treat adults as being in
VF.
Except for defibrillation, chest compressions should not be interrupted for more than 10
seconds to allow invasive procedures or advanced airway management.
UNITED CIIGMA

Policy No.
Document No.
8.
9.
10.

arrest
Issue Date:
Revision No:00
Revision Date: -
Administer drugs intravenously whenever possible. Use a 20-50ml 0.9% saline flush with
the peripheral route.
Consider and treat any underlying causes
Consider anti arrhythmic drugs and sodium bicarbonate
UNITED CIIGMA
Policy No.
Type of document Criteria
Document No.
Admission and Discharge

criteria for Intensive Care Areas
Issue Date:
Revision No:00
Revision Date: -
ADMISSION AND DISCHARGE CRITERIA

Criteria for admission to ICU
. Mechanical support of organ function
Respiratory ventilation / CPAP
Renal haemofiltration / haemodialysis
Cardiac blood transfusion
Hepatic blood transfusion
Neurological intracranial pressure monitoring

. Patient requiring support of 2 or more organ system even when this does not include
the respiratory system
. Potentially reversible patient condition
.
.
Circumstances in which emergency treatment already carried out (e.g. intubation and
ventilation) even when there is no realistic prospect of survival
Patient requiring 1:1 nursing care
Criteria for discharge from ICU

. Patient no longer requiring organ system support
.
.
Reversal of initial condition for which patient admitted to ICU

In case of bed shortage relatively stable patient shifted to HDU / wards
UNITED CIIGMA

Policy No.
Document No.

Infection Control Practices in
Intensive Care Settings
Issue Date:
Revision No:00
Revision Date: -
Purpose: To identify sound infection control practices used in the intensive care setting to reduce
or control nosocomial transmission of infectious organisms.
I. General Practices:
A. A conscious-careful attitude must be incorporated into each patient care practice in these
high-risk areas to reduce the risk of nosocomial colonization or infection.
B. While entering the ICU either
1. The general footwear shall be removed and only the approved footwear shall be used
inside or
2. the footwear shall be covered by shoe-cover
C. Handwashing is the single most important practice to reduce the nosocomial infection
risk. All individuals in the intensive care setting should practice hand hygiene appropriate
to the task as given below. Alcohol based hand rubs shall be used before gloving for
performing any invasive procedure on the patient. DO NOT use alcohol when the
presence of spores (c. difficile, anthrax etc.) is known or suspected. In such cases wash
hands vigorously with soap and water.
Guidelines for hand wash: Soap and Water
Before beginning work and before going home.
Before direct patient contact.
Before and after eating.
After washroom (toilet).
Before caring for neutropenic or severely immune suppressed patients.
After contact with a patients intact skin (eg taking BP, lifting a patient).
After contact with inanimate objects, including medical equipment in the
immediate vicinity of the patient.
After removing gloves.
Whenever hands are visibly soiled.
Whenever hands are contaminated.
When contact with Bacillus anthracis, c. difficile, or other spores is known or
suspected.
After hand decontamination with any product, always allow the skin to dry before donning
gloves.
UNITED CIIGMA

Policy No.
Document No.

Issue Date:
Revision No:00
Revision Date: -
D. Fumigation: Complete fumigation shall be done in the whole Intensive care setting per
month.
II. Isolation / barrier nursing practices
A. The barrier nursing practice shall be followed for the patient care. Patients shall be
assessed individually to determine any infection that would require additional isolation
precautions.
B. Personal Protective Equipment is available to all the staff in the Intensive care for the
appropriate use. Standard precaution shall be followed for same
III. Intravascular Device Related Infections
A. Surveillance
i.
Palpate the catheter insertion site for tenderness daily through the intact dressing.
ii.
Visually inspect the catheter insertion site if the patient develops tenderness at the
insertion site, fever without obvious source, or symptoms of local of bloodstream
infection.
iii.
In patients who have large bulky dressings that prevent palpation or direct
visualization of the catheter insertion site, remove the dressing (wearing gloves)
and visually inspect the catheter site at least daily. If loose, damp or soiled, the
dressing may need changing more frequently.
iv.
The time and date of catheter insertion shall be noted down.
B. Barrier Precautions During Catheter Insertion and Care
i. Wear clean gloves when inserting a peripheral venous or arterial catheter
ii. Wear maximum barrier protection, including sterile gowns, gloves, mask, and
cap and use a large sterile drape when inserting a central line (arterial or venous).
C. Selection of Catheter Insertion Site
i. In adults patients, use an upper extremity site in preference to one on a lower
extremity for catheter insertion. Transfer a catheter inserted in a lower extremity
site to an upper extremity site as soon as the latter is available.
ii. In paediatric patients, insert catheters into a scalp, hand or foot site in preference
to a leg, arm or antecubital fossa site.
iii. Use a subclavian site (rather than a jugular or a femoral site) in adult patients to
minimize infection risk for nontunneled central line placements.
iv. Place catheters used for Hemodialysis and pheresis in a jugular or femoral vein
rather than a subclavian vein to avoid stenosis if catheter access is needed.
UNITED CIIGMA

Policy No.
Document No.

Issue Date:
Revision No:00
Revision Date: -
v. Weigh the risk and benefits of placing a device at a recommended site to reduce
infectious complications against the risk of mechanical complications (e.g.
pneumothorax, subclavian artery puncture, air embolism, catheter misplacement).
vi. Do not routinely use cut-down procedures as a method to insert catheters.
D. Catheter Site Care

D.1 Cutaneous Antisepsis
i.
Although the surface area for prepping is dependent on the size of the extremity,
in adult patients, an area 2 to 4 inches in diameter is generally accepted for
central lines.
ii.
Cleanse the skin with chlorhexidene or chloraprep as first choice because of its
residual effects; second choice, povidone iodine swab.70% alcohol may be used
to prep for peripheral catheters.
iii.
Chlorhexidine cannot be used on children less than two months of age.
iv.
Do not palpate the insertion site after the skin has been cleansed with the
antiseptic.
v.
Do not routinely apply topical antimicrobial ointment to the insertion site.
D.2 Cathter site dressing
i.
Use either sterile gauze or a semipermable transparent dressing to cover the
catheter site.
ii.
Tegaderm is the only transparent dressing approved for use with intravascular
devices.
iii.
The use of the biopatch at the insertion under a transparent dressing will reduce
bacterial colonization rate.
iv.
The first change of the dressing shall take place after 24hr. The second change
shall take place after 48 hrs after the first change. Afterwards, change catheter
site dressings every 72 hours routinely or before or when they become damp,
soiled or loose.
v.
Replace catheter site dressing when the device is removed or replaced Change
dressings more frequently in diaphoretic patients.
vi.
Avoid touch contamination of the catheter insertion when replacing the dressings.
E. Replacement of Catheter
i.
In adults replace short peripheral venous catheters and rotate peripheral venous
sites every 48-96 hours to minimize the risk of phlebitis. Remove and replace
when signs and symptoms of infections are present, i.e. warmth, tenderness,
erythema or tenderness at the insertion site.
ii.
Leave peripheral venous catheters in place in children until IV therapy is
completed unless complications (e.g. phlebitis, infiltration) occur.
UNITED CIIGMA

Policy No.
Document No.
iii.
iv.

Issue Date:
Revision No:00
Revision Date: -
Replace peripheral intravenous locks every 96 hours.

The frequency of replacement of peripherally inserted central venous catheters
and totally implantable devices are a physician decision.
F. Parenteral Fluids
i.
Intravenous fluids other than parenteral nutrition should be changed at a
maximum of 24 hours.
ii.
Complete infusions of lipid parenteral nutrition fluids (e.g. 3 in-1 solutions)
within 24 hours of handing the fluid.
iii.
Do not use parental nutrition catheters for purposes other than hyperalimentation
(e.g. administration of fluids, blood/blood products).
iv.
If a multi-lumen catheter is used to administer parenteral nutrition, designate one
port for hyperalimentation. Do not use the designated hyperalimentation port for
other purposes (e.g. administration of fluids, blood or blood products).
UNITED CIIGMA

Policy No.
Issue Date:
Revision No:00
Document No.
Care of Vulnerable Patients
Revision Date: -
The hospital ensures that vulnerable patients (elderly, physically and / or mentally challenged and
children) are protected from abuse, which we define as a violation of an individuals human or
civil rights by any other person or persons. A coordinated approach is used to manage any
reported instance or suspicion of abuse against vulnerable patients admitted to the hospital.
Hospital has a sensitive, multi professional approach in dealing with disclosures of abuse or
possible abuse. This is aimed to
Protect the vulnerable patients from abuse
Respond quickly and sensitively to any incident or suspected case of abuse `to enable joint
working of hospital personnel with external services when necessary.
Safe and Secure environment for vulnerable patient
To ensure a safe environment for all vulnerable patients the hospital trains all staff members
to be sensitive to such matters.
Providing anti slip mats in the bathrooms and other surfaces that may need them physically
ensures a safe and secure environment and providing beds with guard rails are available and
used when the need arises.
Documented procedures are available for restraining patient safely if the need is felt.
Provision of facilities and on-site inspections to the vulnerable group of patients such that
they are safe from abuse, are ensured by the management.
Informed consent
UNITED CIIGMA

Policy No.
Issue Date:
Revision No:00
Document No.
Revision Date: -
In cases where the vulnerable patient is not mentally competent, informed consent is obtained
from the lead caregiver and the procedure for this is documented.
In case the vulnerable patient is mentally competent informed consent is obtained from the
patient or patient designee for all actions to be taken. It is ensured that while doing so the
patient understands that he / she have a right to reject offers of assistance and to refuse
intervention.
Training of the staff

Staff should be trained for care of vulnerable patients with respect to
Understanding and recognizing vulnerable patients
Principles of staged, step down care
Moving and handling of vulnerable patients.
Training in prevention and management of falls, unconscious patients, supervised feeding,

decubitus ulceration (its prevention and care), interacting with caretakers for continued care.
Procedure to follow in case of abuse of vulnerable patient
When a case of abuse of a vulnerable patient is suspected or disclosed, the main consideration
is the protection of the vulnerable patient.
When such an event occur the senior member of the nursing team on duty is immediately
informed. She / He will then inform the Consultant / COO. The concerns are documented in
the medical records by the first person to report the abuse.
The Matron, COO and Clinical consultant form the investigating team. The COO decides
whether social services or the police need to be informed.
A detailed investigation is carried out.
If the vulnerable adult is judged to be mentally competent, he can reject offers of assistance
and refuse intervention.
UNITED CIIGMA

Policy No.
Issue Date:
Revision No:00
Document No.
Revision Date: -
If the investigating team cannot resolve the situation, appropriate social services are informed
and a multi agency meeting is convened to resolve the issue.
All these proceedings to be recorded and maintained by COO office.
UNITED CIIGMA

Policy No.
Document No.
Protocols for Operation theatre

and Intensive Care Settings
Issue Date:
Revision No:00
Revision Date: -
1 Visitors protocol for OT and Intensive Care Setting
Visitors entry for patients in Intensive care area and Post operative area is restricted
to one attendant only at a time during the visiting time (10.30 AM to 11.00 AM and
4.00 PM to 4.30 PM)
Children below 12 years are not allowed inside the OT / ICU complex.
Visitors suffering from contagious disease (cough and cold etc) are not allowed to
enter.
Shoes or chappals are to be removed when going in to the ICU
Visitors are not allowed to bring materials such as food, flowers and other materials,
which can be a potential source of infections.
Protocol for personnel

a All personnels including housekeeping staff will wear clean OT attire while entering OT.
b No personnel are allowed to move outside the complex with clean OT attire and come
back except in emergency situation.
c Surgeons for surgeries of 4 hours or more will use double gloves.
d Doctors, nurses and technical staff use proper hand wash techniques before handling any
patient to prevent cross infection. A bottle of hand wash disinfectant solution is
attached to each bed in ICU.
Other Protocols
o
All cleaning and disinfection procedures are completed at least 1 hour before the
schedule of surgery in OT.
In ICU, fumigation is done when there are no patients. In case of any reports of
alarming infection rate / alarming pathogen isolation from any of the patient
admitted to ICU, attempt is made to isolate such patient. The other patients are
shifted to temporary ICU in wards (if possible) and the ICU is fumigated and
culture sent to microbiology department.
Note: These practices are reviewed periodically by Coordinator as well as Hospital Infection
Control Committee
UNITED CIIGMA

Policy No.
Document No.
Criteria for discharge from

recovery area
Issue Date:
Revision No:00
Revision Date: -
Following criteria shall be used to determine appropriateness of discharge from the recovery area.
The patient should be well oriented to time and space.
The patient should be fully conscious, able to recognize the next of kin, doctors and
hospital staff.
The patient should comprehend verbal and written directions in an appropriate manner
and respond accordingly.
Vitals recorded by the Doctor should be stable and within acceptable limits.
The Medical Officer applies the following criteria to transfer the patient from the recovery area
and / or intensive care unit in concurrence with the doctor in charge of the case.
Conformation of the stable vital signs.
Stable oxygen saturation level.
Return to pre procedure mental status.
Adequate pain control.
Minimum bleeding, nausea, vomiting.
Resolving and acceptable level of neural blockade, resolution of the neuraxial blockade
UNITED CIIGMA

Policy No.
Issue Date:
Revision No:00
Document No.
Restraint of Patient
Revision Date: -
Purpose
To provide guidelines regarding appropriate restraint use for the medical well-being of nonviolent
medical-surgical patients and unanticipated severely aggressive or destructive behaviour that
places the patient(s) or others in imminent danger.
Scope
o
The use of restraint are primarily to protect the patient and others against injury because
of - (a) patients emotional or behavioural disorder Or (b) any other reason that threatens
the patients safety. The restrain may be physical or chemical- the policy applies to both.
Restraint use within the hospital is limited to situations with adequate, appropriate
clinical justifications. Restraint may be considered appropriate in the following
conditions: a. When the patients condition or behaviour indicates an immediate & ongoing
high risk of self harm (either deliberate or unintentional).
b. When patients behaviour poses immediate & ongoing serious risk to others.
c. When he/she seriously compromises the therapeutic environment e.g. by
damaging the property.
d. When it is necessary to give essential clinical treatment to the individual who is
refusing the treatment.
e. When there is legal support to carry out the prescribed treatment against
the
persons will.
2. Orders for restraint intervention are appropriate only after alternative measures have
failed and safety issues demand an immediate physical response. Such alternative
measures may include but not limited to: behavioural intervention, distraction, verbal de-
UNITED CIIGMA

Policy No.
Issue Date:
Revision No:00
Document No.
Revision Date: -
escalation, communication using non-threatening body language/tone of voice, more

frequent observation, environmental change (quiet surroundings), room change, comfort
measures, obtaining family/relative/attendant support, orientation to his/her surroundings,
treatment change, verbal calming techniques, obtaining a psychiatric consult.
3. This policy does NOT apply to the regular clinical procedures such as plaster cast,
surgical positioning, radiotherapy, protection of surgical and treatment sites in paediatric
patients.
4. The use of restraint shall not be not based on an individuals restraint history or solely on
a history of dangerous behaviour. Restraints will only be used for as long as necessary to
help a patient regain control of his behaviour.
Each episode of restraining shall be recorded with
a. The reason of restraining
b. Alternative measures tried (may be other than mentioned above)
Authority
The authority to restrain is reserved with the treating physician.
However, in an emergency situation when there is an imminent risk of a patient harming
himself/herself or others, including staff, nonphysical interventions are not viable, safety issues
require an immediate physical response and a physician is not readily available to conduct an
assessment and write restraint orders the nurse (based upon an appropriate assessment of the
patient) may initiate use of physical restrain. In such case, the nurse shall intimate the treating
doctor after the restrain episode and shall get the record/patient file signed by him for the event
afterwards.
UNITED CIIGMA

Policy No.
Issue Date:
Revision No:00
Document No.
Revision Date: -
The nurse shall never use the chemical restrain (sedation) by own. In case of emergency, the
verbal orders from the doctor shall be deemed acceptable. (Refer policy no. C 3, Prescription
and dispensing of medication, in policy manual).
Consent
Consent of the family shall be taken for restraining the patient except the situations where the
delay in restrain due to any reason can prove to be a threat to the patients and /or others safety,
the restrain shall be used on patient without any written consent. In such cases, the condition
itself may be considered as general consent of the family.
Monitoring
1. The patients diagnosis, treatment, and health status dictates whether continual
assessment, monitoring, and revaluation are required or if the patient can be monitored
and reassessed at regular intervals.
2. Monitoring is accomplished by via observation, interaction with the patient, or by direct

patient examination.
3. The nurse shall periodically assess the patient. The physician on his clinical judgement
shall decide the frequency for this. The assessment shall include: a. Evaluation of the continued need for restraints/ changes in patients
behaviour/clinical condition regarding readiness for restraint discontinuation
b. Alternatives/less restrictive restraint interventions attempted
c. Whether the restraint has been appropriately applied.
d. Skin and circulatory assessment of the affected extremity
e. Needs of patient regarding food/ toilet.
f.
Repositioning for comfort as possible
g. Physical well-being, hygiene, dignity/rights maintained.

h. Level of distress/agitation
UNITED CIIGMA

Policy No.
Issue Date:
Revision No:00
Document No.
Revision Date: -
Restraint Termination
Restriction of patient movement or activity by restraints shall be terminated at the earliest
possible time.
The decision to terminate the restraint shall be based on observation and assessment that
determines that
(i) The patient no longer needs the restraint to protect self or others or
(ii) Behavioral guidelines ordered by the physician have been met and documented.
The physician, after assessing the patient himself, makes the decision to terminate
restraint use.
Once a restrain has been terminated, a fresh order must be obtained prior to reapplying
the restraints.
UNITED CIIGMA

Policy No.
Issue Date:
Revision No:00
Document No.
Pain Management
Revision Date: -
GUIDELINES FOR PAIN MANAGEMENT

Assessment
A. Initial assessment of patients experiencing pain or likely to experience post-operative
other pain during the course of treatment is made by reviewing
a. Pain history and characteristics including previous and/or ongoing instances of
pain.
b. Previously used methods for pain control
c. Typical coping responses to stress pain
d. Ways patient describes or shows pain
e. Patients knowledge/expectations/preferences for pain management methods
B. Interdisciplinary patient assessment form / referral forms be used to trigger further
assessment and treatment for all hospitalized patients
Reassessment
Reassessment should occur with each new report of pain, at a suitable interval following
any pain control intervention (particularly if a new medication or dosage is involved), and
at regular intervals appropriate to individual person status.
Pharmacologic management
1.
Analgesic management should generally be via the least invasive route possible
2.
The use of NSAIDs should be considered in all patients requiring opioid agents for the
control of pain because of their significant opioid dose sparing effect
3.
Efforts must be made not to delay administration of any analgesic dose
4.
Placebo use is not appropriate in pain management. Its use is acceptable in the context of
specific protocols (e.g. diagnostic nerve block)
Non-Pharmacological management
a. Physical agents Heat, cold, massage, exercise, immobilization, TENS
b. Psychological approaches education, psychotherapy
UNITED CIIGMA

Policy No.
Issue Date:
Revision No:00
Document No.
Pain Management
Revision Date: -
Patient education
1.
A nurse, physician or other clinical staff will initiate teaching on all patients
experiencing (or likely to experience) pain. All appropriate members of the healthcare
team must complete documentation of teaching.
2.
Physicians and staff should instruct patients in appropriate use of analgesics, before the
pain becomes severe.
3.
Specific instructions after procedures or at discharge regarding pain and its management
will be provided by a nurse, physician, or involved staff member and will be documented
UNITED CIIGMA

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UNITED CIIGMA Hospital

UNITED CIIGMA Hospital

UNITED CIIGMA Hospital

Type of document - Procedure

Document No. A-2.1

Purpose: To carry out the registration of patients smoothly

Registration is done for all patient requiring OPD and / or

OPD and Emergency

OPD registration shall be done on the basis of first come

Ask following details from the patient / relative

Check the referral slips if any for identifying the specialty. If

Enter the details in HMIS

Take the print and handover to patient

Direct the patient towards concerned OPD consultation area

UNITED CIIGMA Hospital

Type of document - Procedure

Document No. A-2.1

Emergency registration is done 24 hrs a day at AE Ward

If patient is serious, he/she is directly sent to casualty bed or

Case writer, Medical

For unidentified patients registration shall be done as

Medical Officer, Staff

If on later date identity is confirmed the same shall be

Staff Nurse on duty,

Policy No. A-2

Type of document - Procedure

Document No. A-2.2

Purpose: To admit the patient requiring in-patient care

Admission can be through OPD or through Emergency. In

Decision for admitting a patient is made by treating

The admission along with the ward is recorded in OPD case

Enter all patient related details in admission module of

Following details of patients attendant are entered in HMIS

In case of unidentified patients this step is not followed

2 visitor passes are given to the patient / relative for free. If

Patient is directed to the concerned ward. Need for

Case writer, OPD

Policy No. A-2

Type of document - Procedure

Document No. A-2.2

provided to the patient

Staff nurse of the concerned ward shall check admission

A bed shall be arranged for the patient. If bed is not

Treatment as advised in inpatient case paper is started

If patient is serious, he / she is assessed by Medical Officer

Admission is recorded in admission book

Diet form is filled and sent to kitchen

Specialist is sent information about the admission of patient

Staff nurse on duty

Staff nurse on duty

UNITED CIIGMA Hospital

Policy No. A-3

Type of document - Procedure

Document No. A-3.1

Purpose: To safely transfer the patient outside the facility

Patient shall be referred to GMKM College & Hospital,

Decision for transfer to other facility shall be taken by

Duty Doctor / Ward

In case of emergency, the concerned consultant is informed

Consultants advice is taken before transferring the patient

Oral and written consent of the patient is taken on the case

In case of unidentified patients police is informed.

Treatment given and diagnosis is written on the case paper