WHY??? Lets improve ourselves!! Not just for NABH accreditation
What am I doing here??? I am here just to enlighten you overSUNSHINE policies regarding documentation of the in patient details 1) Integrated in-patient initial assessment form 2) Drug Order sheet 3) Surgical patient Record 4) Intra Hospital Referral form 5) Admission Note
INTEGRATED IN-PATIENT INITIAL ASSESSMENT Please make sure that this is filled as soon as the patient is admitted in the hospital
PART-A Has to be duly filled by the Nurse in charge and make sure that it is filled by the time the treating surgeon comes!
PART-B To be duly filled by the attending doctor! Simple MBBS Stuff
Discharge Planning Need to be completed at admission
PLAN OF CARE PLAN OF CARE MEDICAL/CONSERVATIVE SURGICAL Tick boxes make the job easy, its going to take only a few minutes of your time
Sign and date your work A good artist always signs off Consultants need to countersign every admission within 24 hours
DRUG ORDER SHEET Please please…. Write your prescriptions in capitals (I mean CAPITALS)
Do check for allergies You can specify the times Don’t just sign Date it please No trade names please
DRUG ORDER SHEET Instruction by telephone from a prescriber to a nurse to administer a medicine previously not prescribed is unacceptable in normal circumstances. Sunshine hospital medication prescription and administration policy
VERBAL orders A verbal order shall be issued only by anybody who is a Consultant or above that and none other than that.. Before closing the conversation (telephone or person) the nurse or duty medical officer shall read back the order to the doctor and confirm if the written down order is correct, in case of drugs she shall even spell the drug to recheck with the consultant and then close it. Doctor who issued the verbal order within 24 hrs should counter sign that verbal order
WHAT TO MENTION SEPARATELY 1) Parenteral infusions other than the medications (like IV fluids, TPN) 2) Stat medications 3) SOS medications
Don’t just sign Date it please No trade names please No abbreviations, all caps please
SURGICAL PATIENT RECORD An exhaustive booklet of 16 pages (BUT IT IS VERY IMPORTANT!) Make sure that the first 4.5 pages are duly filled before the patient reaches OT!
TIME OUT All work should cease during a period of time when all members of the operative / procedural team,using active communication, confirms correct patient, correct procedure, correct site and side, sterility of the equipment availability of all items needed for anaesthesia and surgery antibiotic prophylaxis any patient allergies.
Donot start operating before this checklist is doneMAKE TIMEOUT A HABIT
CONSENT Please make sure it is taken by the treating doctor/ team member but not the nurse incharge!!!
Another important part of the consent process Doctors need to Countersign
Admission Note We need to explain to the pt Disease Inv needed Treatment process Cost ( estimated) Probable outcomes This form takes care of all this Please fill this at admission
Please fill in the orders Inv requested Plan of care Spl instructions Preop orders This form is for the pt to go from OPD / Casualty to the ward
Admission Note This part need to be filled in by Front Office / Patient counselor
Intra Hospital Referral form Once completed this will go into the case sheet The visiting consultant will have a better idea why he is there in the first place
OTHER THINGS WE NEED - Contd Discharge summary to be given to all patients including LAMA, MLC etc Discharge summary to contain reason for admission, findings, diagnosis, patient’s condition at discharge, investigation results, procedure, treatment given, follow up advice, how to obtain urgent care
OTHER THINGS WE NEED Credentialing and Privileging
HIC HIC MANUAL Available on every desktop Antibiotic policy Hand Hygiene Surveillance Tool kit Needle stick injury
VULNERABLE PATIENTS Admission and Discharge criteria for ICU Who all are Vulnerable patients and care of such of patients Geriatric patients (>65 years of age) Pediatric patients (<16 years of age) Mentally challenged patients Physically challenged patients Comatose patients
10 COMMANDMENTS Write Medications Order in Capital Letters. Document your visit with Notes Duly Signed with the Date, Time, Signature and Name. Avoid Verbal Orders. Use of Alcohol Hand Rub Before And After Each Patient Examination. Make a Habit of patient and Family education as Part of Care.
10 COMMANDMENTS Ensure Informed Consent for all Procedures. Assess and Reassess Patient as per Hospital Policy. Prepare/ Counter Sign Discharge Summaries and Talk to Patient Regarding Discharge Instructions Follow-up and Care at Home. Prescribe as per Hospital Formulary and Follow the Antibiotic Policy. Have Formal Meetings/ Briefings with the other Specialists when more than One Doctor is treating the Patient.
Thank you Please send your feed back to me @ Vippin@gmail.com