POLICIES & PROCEDURES ON CARE OF PATIENTS E / …

1 POLICIES & PROCEDURES ON care OF. Document Name : PATIENTS . E / NABH / SGH / COP / 01 - 08. Document No. : No. of Pages : 49. Date Created : 01/04/2017. Date of Imple mentation : 01/04/2017. Designation : Prepared By : Name : Signature : Designation : Approved By : Name : Signature : Designation : Responsibility of Updating : Name : Signature : 1. AMENDMENT SHEET. Section Details of the amendment Reasons Signature of Signature no & the of the page no preparatory approval authority authority 2. CONTROL OF THE MANUAL.

2 The holder of the copy of this manual is responsible for maintaining it in good and safe condition and in a readily identifiable and retrievable. The holder of the copy of this Manual shall maintain it in current status by inserting latest amendments as and when the amended versions are received. RMO is responsible for issuing the amended copies to the copyholders, the copyholder should acknowledge the same and she should return the obsolete copies to the RMO. The amendment sheet, to be updated (as and when amendments received) and referred for details of amendments issued.

3 The manual is reviewed once a year and is updated as relevant to the hospital POLICIES and PROCEDURES . Review and amendment can happen also as corrective actions to the non-conformities raised during the self-assessment or assessment audits by NABH. The authority over control of this manual is as follows: Preparation Approval Issue Accreditation coordinator RMO Managing Director, Sigma Hospital The procedure manual with original signatures of the above on the title page is considered as Master Copy', and the photocopies of the master copy for the distribution are considered as Controlled Copy'.

4 Distribution List of the Manual: Designation 1 Chairman 2 RMO. 3 Nursing Manager 3. CONTENTS. Topics Page Number COP 1 Policy On Uniform care Of PATIENTS 5. COP 2 POLICIES & PROCEDURES On Emergency Services 7. POLICIES & PROCEDURES On Rational Use Of Blood & Blood COP 3 15. Products COP 4 POLICIES & PROCEDURES On care Of PATIENTS In ICU / HDU 19. COP 5 POLICIES & PROCEDURES On care Of Obstetric PATIENTS 25. COP 6 POLICIES & PROCEDURES On care Of Pediatric PATIENTS 29. POLICIES & PROCEDURES On care Of PATIENTS Requiring COP 7 32.

5 Anesthesia COP 8 POLICIES & PROCEDURES On Surgical care Of PATIENTS 42. 4. SIGMA HOSPITAL Doc. No. E / NABH / SGH / COP / 01 - 08. Issue No. 01. Rev. No. 00. POLICIES & PROCEDURES ON. Date 01/04/2017. care OF PATIENTS . Page Page 5 of 49. COP 1 - POLICY ON UNIFORM care OF PATIENTS . PURPOSE. To delineate policy for the planning and providing of uniform patient care , for following clinical practice guidelines in line with the laws and regulations prevailing in India. SCOPE. To ensure uniform care to all PATIENTS using the services of the hospital.

6 The scope includes POLICIES and PROCEDURES for: The care of Emergency PATIENTS ( ). Use of Blood and Blood Products ( ). care of ICU & High Dependency Unit PATIENTS ( ). care of Obstetric PATIENTS ( ). care of Pediatric PATIENTS ( ). care of PATIENTS requiring anesthesia ( ). care of PATIENTS undergoing surgical PROCEDURES ( ). POLICY. Uniform care of PATIENTS The planning and provision of care shall be based on individual patient assessment and shall focus on the patient's response to actual or potential alterations to health.

7 All PATIENTS are treated alike irrespective of their religion, cast, social status, financial ability etc. The safety of all PATIENTS seeking health care at this hospital is the prime responsibility of this uniform patient care system is laid down in all areas so as to provide excellent service Similar care is given in different settings which are guided by applicable laws and regulations; care delivery shall be uniform in emergency and ambulance services, Cardio Pulmonary Resuscitation, while using blood and blood products, during care of PATIENTS in the ICUs, and other high dependency areas, Post-surgical recovery rooms, etc.

8 SGH has the policy for delivering uniform care to all PATIENTS irrespective of the care setting right from the admission to discharge for IPD cases, in OPD services and emergency services. 5. SIGMA HOSPITAL Doc. No. E / NABH / SGH / COP / 01 - 08. Issue No. 01. Rev. No. 00. POLICIES & PROCEDURES ON. Date 01/04/2017. care OF PATIENTS . Page Page 6 of 49. Laboratory facilities, OT facility, Diagnostics, Nursing care are uniformly provided to all PATIENTS irrespective of category of PATIENTS . All protocols are uniformly given in the same manner to all PATIENTS irrespective of the category status.

9 Uniform care is guided by all laws & regulations. It is further ensured that the care and treatment orders are legibly signed, named, timed and dated by the concerned doctors and nurses, the main idea being that the authors of these orders are identifiable by all and the chronology of care process is maintained. Clinical practice guidelines are adopted to guide patient care whenever possible. REFERENCE: NABH: Pre Accreditation Entry Level Standards for Hospitals, 4th Edition December 2015. 6. SIGMA HOSPITAL Doc.

10 No. E / NABH / SGH / COP / 01 - 08. Issue No. 01. Rev. No. 00. POLICIES & PROCEDURES ON. Date 01/04/2017. care OF PATIENTS . Page Page 7 of 49. COP 2 POLICIES & PROCEDURES ON EMERGENCY SERVICES. PURPOSE. POLICIES and PROCEDURES guide the admission of PATIENTS coming to the emergency department of s i g ma H o s p it a l SCOPE. All PATIENTS coming to the emergency department for care PROCEDURE. To aid clinical diagnosis, samples are collected and sent to lab for analysis and reporting. Reports shall be sent back to the Emergency department on a priority basis.