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4 sunshiners2

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Sunshine Hospitals Recommendations for Doctors.

Sunshine Hospitals Recommendations for Doctors.

Published in: Health & Medicine, Business

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  • 1. SUNSHINE RECOMMENDATIONS
  • 2. WHY???
    Lets improve ourselves!!
    Not just for NABH accreditation
  • 3. 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
  • 4. INTEGRATED IN-PATIENT INITIAL ASSESSMENT
    Please make sure that this is filled as soon as the patient is admitted in the hospital
  • 5. 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!
  • 6. PART-B
    To be duly filled by the attending doctor!
    Simple MBBS Stuff
  • 7. Discharge Planning
    Need to be completed at admission
  • 8. 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
  • 9. Sign and date your work
    A good artist always signs off
    Consultants need to countersign every admission within 24 hours
  • 10. Our Time frames
  • 11. DRUG ORDER SHEET
    Please please…. Write your prescriptions in capitals (I mean CAPITALS)
  • 12. Do check for allergies
    You can specify the times
    Don’t just sign
    Date it please
    No trade names please
  • 13. 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
  • 14. 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
  • 15. WHAT TO MENTION SEPARATELY
    1) Parenteral infusions other than the medications (like IV fluids, TPN)
    2) Stat medications
    3) SOS medications
  • 16. Don’t just sign
    Date it please
    No trade names please
    No abbreviations, all caps please
  • 17. 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!
  • 18. 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.
  • 19. Donot start operating before this checklist is doneMAKE TIMEOUT A HABIT
  • 20. CONSENT
    Please make sure it is taken by the treating doctor/ team member but not the nurse incharge!!!
  • 21. Another important part of the consent process
    Doctors need to Countersign
  • 22. SURGEONS NOTES
  • 23. 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
  • 24. 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
  • 25. Admission Note
    This part need to be filled in by Front Office / Patient counselor
  • 26. 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
  • 27. 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
  • 28. OTHER THINGS WE NEED
    Credentialing and Privileging
  • 29. CODES
    Emergency Codes
  • 30. HIC
    HIC MANUAL Available on every desktop
    Antibiotic policy
    Hand Hygiene
    Surveillance Tool kit
    Needle stick injury
  • 31. 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
  • 32. IS IT THAT DIFFICULT ???
  • 33. 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.
  • 34. 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.
  • 35. Thank you
    Please send your feed back to me @ Vippin@gmail.com