Outpatient Department

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 Outpatient Department
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1. About the Department:

Scope of services

Timings

Types of patients served:-

2. Organogram

3. Quality Policy

4. Quality Objectives
 Outpatient Department
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5. Functioning of the Helpdesk Counter

S. Activity Responsibility Record
No
1. The help desk counter shall be functional 24X7, manned by two Helpdesk Help desk reference
executive register
help desk executives working in shifts.
2. The help desk counter shall be provided with Telecom & Public Helpdesk Help desk reference
executive register
addresal system for convey of information and any public
announcements to be made.
3. The help desk counter executive shall maintain a list of all referral Helpdesk Help desk reference
executive register
linkages and ambulance contact number and shall coordinate with
OPD/IPD nursing staff for effective dissemination of information as
required during the process.
4. The help desk executive shall even take-up external calls and Helpdesk Help desk reference
executive register
provide required information or channelize the call towards
responsible person
5. The help desk executives shall always maintain up-to date Helpdesk Help desk reference
executive register
information regarding the following
 About the hospital and its organizational structure
 List of services available and their location
 Service timings
 List of doctors
 Services available under various National Health programme

Reference standard - ME G4.2

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6. Patient Registration
S. Activity Responsibility Record
No

Registration of new patient

1. Registration is done for all patients requiring OPD and / or Registration clerk OP Registration slip
Registration register
Emergency services. OPD In-charge shall be contacted for any
clarification or in matter of conflict.
2. Registration timings:
3. Patient/patient relative provides general information such as Registration clerk OP Registration slip
Name, Age, Sex, Address etc to the Registration Clerk at the
registration counter and this information is entered in the OPD
registration slip and is provided to the patient, this slip shall even
have the unique registration number that has been allotted to the
patient.
4. A registration register shall be maintained with the clerk to record Registration clerk Registration register
the details of total registrations done for the day.
5. In case of automated registration counter, all information shall be Registration clerk OP Registration slip
filled in the system to generate a printed registration slip that is
handed over to the patient.
6. All patient pays fee Rs /- towards out-patient registration and a Registration clerk OP Registration slip
payment slip is given for that
7. The Registration Clerk guides the patient towards OPD clinics. Registration clerk Nil

Registration of follow-up patient

Reference standard - ME G4.2

 Outpatient Department
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7. Patient calling inside OPD

S. Activity Responsibility Record

No

1. The patient once reaches at the respective OPD OPD Nil

clinic Aaya/Staff nurse
2. The OPD aaya/nurse shall check the registration slip, and ask the OPD OPD slip
patient to wait for their turn clinic Aaya/Staff nurse

3. In case the patient has arrived at the wrong clinic, they shall be OPD Nil
guided towards their respective clinic. clinic Aaya/Staff nurse

4. The staff nurse/aaya shall ensure that the patient is seated OPD Nil
comfortably and is waiting for his/her turn and there is no clinic Aaya/Staff nurse
overcrowding in or around the clinic
5. Patients shall be allowed entrance to the clinic only as per their OPD Nil
clinic Aaya/Staff nurse
turn i.e. “first come first examine” basis.

Reference standard - ME G4.2

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8. Receiving of Patient inside clinic, taking consent and OPD Consultation

S. Activity Responsibility Record

No
1. Patients shall be allowed entrance to the clinic only as per Staff Nurse/Doctor OPD Register
their turn i.e. “first come first examine” basis.
2. The doctor shall receive the patient in OPD and ensure he is Doctor Nil
comfortably seated and then take his details and complaints
and ensure examination of the patient is carried out in
privacy.
Taking Consent
3. The staff nurse inside OPD shall enter Patient’s serial Staff nurse OPD Register
number, registration number, complaint, etc in the
Out Patient register.
4. Before Assessing the patient, Patient/Attendant signature Staff OPD case paper
shall be taken on the general consent form attached on the nurse/Consultant
backside of the OPD case paper.
Clinical Assessment and Reassessment
5. The consultant shall first take Patient’s case history and Doctor OPD case paper
undertake an initial assessment to examine the symptoms of
illness.
6. In case of medication advice, prescription for medication shall Doctor Medication slip
be written on the medication prescription slip and patient (OPD case paper)
shall be guided towards the pharmacy to avail the drugs.
Patient may be instructed for a follow up check up if required
after undertaking the course of medication.
7. Investigations (Pathology, Radiology, Ultra Sonography etc) if Doctor Investigation requisition slip
required for physical evidence to confirm the disease or
illness shall be ordered in the investigation requisition slip by
the consultant.
8. Patients shall be advised to return back with investigation Doctor OPD case paper
reports for further consultation.
Reference standard – ME G4.2,
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9. Patient Referral

S. Activity Responsibility Record

No
Inter dept referral
1. Through investigation findings or re- asessment if the need is Doctor, Referral form
Staff nurse Refer In- Out register
felt for a second opinion from another clinical area or the
patient seem to be requiring care from other clinical speciality
then the patient shall be opted for a inter dept
referral.
2. The consultant shall fill the referral form indicating patient Doctor Referral form
details, reason for referral and course of treatment provided.
3. The patient shall be guided towards the referral clinic along Doctor, OPD case paper
Staff nurse
with the case sheet.
Outer referral
4. In case of any certain service/ super speciality care required for Doctor Referral form
the patient that is not available in the hospital then patient shall
be referred to a higher facility.
5. The consultant shall fill the referral form indicating patient Doctor Referral form
details, reason for referral and course of treatment provided.
6. The staff nurse shall document the referral details in the Refer Staff nurse Refer In- Out register
In- Out register and coordinate for the referral process.
7. An advance telephonic communication with the referral centre Staff nurse Refer In- Out register
shall be done to ensure the required service is available and
intimate the staff of the higher centre about the referral to be
done.
8. Ambulance service for the patient shall be arranged which shall Staff nurse Refer In- Out register
be free of cost for maternal referrals only for others an amount
of Rs shall be charged
9. Patient along with the referral form and case sheet shall be Staff nurse Referral form
referred to the higher centre.
10. The nursing staff shall also follow up about the condition of the Staff nurse Refer In- Out register
patient post referral.
Reference standard – ME G4.2
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10. Protecting Patient Rights

S. Activity Responsibility Record
No
Addressing gender needs
1. Separate queue for females at registration counter shall be Facility – Incharge, Nil
maintained. Registration desk
2. The OPD area shall have separate visitor toilets for male and Facility – Incharge Nil
female.
3. There shall be available a Breast feeding corner with Facility – Incharge Nil
comfortable seating arrangement and ventilation provision at
the OPD area.
Disable friendly facilities
4. The OPD entrance shall have ramps with railing. Facility – Incharge Nil
5. The OPD entrance shall ensure availability of Wheel chair or Facility – Incharge Nil
stretcher easy Access to the OPD for non ambulatory &
disabled patients.
6. There shall be provision of a disable friendly toilet in the OPD Facility – Incharge Nil
area.
Maintaining Patient Privacy & Confidentiality
7. All the OPD clinics shall have privacy screen at Examination Doctors, OPD staff Nil
Area. nurse, ICTC
counsellor
8. All OPD clinics shall ensure the presence of a female staff Doctors Nil
nurse at the examination area whenever a male doctor has to
examine a female patient.
9. Only one Patient at a time shall be seen at the clinic. Doctor Nil
10. Confidentiality of HIV reports at ICTC shall be maintained. The ICTC counsellor Nil
identity of HIV+ve & leprosy patients shall not be revealed to
anyone except the patient, his family and the counsellor/
treating doctor
Patient Counselling
11. The doctor shall inform the patient about his /her clinical Doctors Health education
condition and the treatment plan, any potential risks/side handouts if available
effects if any concerning the treatment and the options of
treatment.
12. Counselling of the patient on Diet & Nutrition and preventive Doctors Health education
measures to be adopted if any is to be carried out. handouts if available
Informed Consent
13. The Patient and his/her family members shall be counselled ICTC testing centre Informed consent form
and Informed consent shall be taken from the patient before
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conducting HIV testing.

14. A printed bilingual informed consent form shall be used for ICTC testing centre Informed consent form
taking the informed consent

Reference standard – ME G4.2

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11. Conducting Patient satisfaction survey

S. Activity Responsibility Record

No
1. Listening to patients' views is essential for providing Facility-Incharge Nil
patient-centred healthcare service. Hence carrying out a
satisfaction survey is an essential tool for continuous quality
improvement, since the feedback received directly from the
users helps in mapping the lacunae in service and provides
scope for further improvement.
2. Monthly satisfaction surveys shall be carried to get patient Facility-Incharge Nil
feedback on the services provided.
3. Feedback shall be received from the patient on printed Facility-Incharge OPD Satisfaction Survey
satisfaction survey questionnaires. Questionnaire
4. The patients shall be given print out forms of satisfaction Facility- Incharge Satisfaction Survey
survey forms (In Hindi) and asked to rate their satisfaction Questionnaire
for each attribute in terms of Poor, Fair, Good, Very good
and Excellent.
5. Monthly analysis of average patient satisfaction survey shall Facility- Incharge Satisfaction survey report
then be carried out and action shall be taken on the lowest
scoring parameters to improve the scoring pattern and
patient satisfaction survey

Reference standard - ME G4.2

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12. Equipment management

S. Activity Responsibility Record

No
Calibration of Equipments
1. All the measuring equipments/ instrument shall be OPD -Incharge Nil
calibrated.
2. An ISO certified calibration agency shall be identified to OPD - Incharge Nil
calibrate the equipments/instruments.
3. Calibration labels/stickers shall be placed on the equipment OPD - Incharge Equipment register
denoting the date of calibration and indicating the status of
calibration/ verification when recalibration is due.
4. All calibration certificates shall be maintained by the OPD - Incharge Calibration certificate
Incharge or centrally stored by the Store-Incharge of the
hospital.
5. The OPD shall maintain an equipment register to document OPD - Incharge Equipment register
details of equipment and calibration status.
6. It shall be the duty of the Incharge to ensure updation of OPD - Incharge Equipment register
calibration for all equipments as per their schedule.
General Maintenance
7. Up to date manufacturer’s instructions for operation and OPD - Incharge Manufacturer’s instruction
maintenance of equipments shall be kept in the department
so that the same can be readily available to staff when
required.
8. Defective/Out of order equipments shall be labelled and OPD - Incharge Equipment register
stored appropriately away from traffic area, until it has been
repaired
9. Daily dusting/ dry wiping of equipments shall be done by OPD - Incharge Nil
housekeeping staff. The laboratory technician shall do a
daily check on the functioning of equipments every morning
before commencement of testing procedure.
10. An equipment register shall be maintained to document OPD - Incharge Equipment register
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details of equipment - name, hospital code, and date of

installation, name of manufacturer, maintained in A
house/maintained by external agency or manufacturer,
Warranty Period, under AMC/CMC.
Preventive and Breakdown Maintenance
Preventive Maintenance
11. All equipments shall be covered under AMC/CMC including OPD- Incharge Equipment register
Preventive maintenance.
12. The lab-Incharge shall maintain an updated record on AMC OPD- Incharge Equipment register
& Preventive maintenance in equipment register this should
include details like :
o Frequency of Preventive Maintenance/Calibration
- As per manufacturer guidelines
- Presently being followed
o Preventive Maintenance/Calibration Done On
o Preventive Maintenance/Calibration Due On
o Expenditure with cost and details
o Remarks with Functional Status
13. Preventive maintenance shall be carried out as per OPD- Incharge Equipment register
Maintenance Schedule for each individual equipment based
on manufacturer’s recommendations.
14. The following shall be checked during a preventive OPD -Incharge Equipment Service Report
maintenance-
 Physical condition of the equipment/ facility
 lubrication, calibration, cleaning or replacing parts that
are expected to wear or which have a finite life
 Maintenance report verification
Maintenance / Service report shall be obtained from service
agency and after verification marked as O.K. /Not O.K.
Breakdown Maintenance
15. Faulty or defective equipment shall not be used regardless OPD -Incharge Equipment register
of how minor is the problem and must be reported in the first
instance to the in-house maintenance engineer /outside
agency hired for maintenance as soon as possible and seen
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that the problem is attended to as soon as possible.

16. A label of “out of order” shall be attached to the equipment OPD -Incharge Nil
and information regarding breakdown shall be passed to all
staff including any shift changes.
17. On restoration of the equipment, the Equipment Breakdown OPD -Incharge Nil
Record should be updated. This indicates that the
breakdown/maintenance is performed of the equipment.
The “out of order” sticker shall be removed after the
restoration of the equipment.
18. All the breakdowns occurring in the department should be OPD -Incharge Equipment register
maintained in the equipment register and include the
following
o Breakdown Date and Time
o Breakdown Details (Technical fault or other reasons)
o Date and Time of Rectification
o Total Time Taken (Rectification Time – Breakdown
Time)
o Rectification Details with expenditure including cost (if
any)
o Remarks with functional status
o Reasons for delay if any

Reference standard - ME G4.2

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13. Referral of Patients

S. Activity Responsibility Record

No
1. In case of any certain service/ speciality care required for OPD Medical Officer Nil
the patient that is not available in the hospital then patient
shall be referred to a higher facility.
2. However Basic first aid or stabilization of the patient shall be OPD Medical Officer, Nil
Staff Nurse
done prior referral.
3. The CMO (OPD Medical Officer) shall fill the referral form, OPD Medical Officer, Referral form
Staff Nurse
indicating patient details, reason for referral and course of
treatment provided.
4. The staff nurse shall document the referral details in the OPD Medical Officer, Refer In-Out register
Staff Nurse
Refer In- Out register and coordinate for the referral
process.
5. An advance telephonic communication with the referral OPD Medical Officer, Refer In-Out register
Staff Nurse
centre shall be done to ensure the required service is
available and intimate the staff of the higher centre about
the referral.
6. Ambulance service for the patients is charged for the OPD Medical Officer, Refer In-Out register
transfer as per norms of the RKS except BPL Patient. Staff Nurse

7. JSSK patients and 108 patients are not charged. OPD Medical Officer, Nil
Staff Nurse
8. Patient along with the referral form and case sheet shall be OPD Medical Officer, Referral form
Staff Nurse
referred to the higher centre.
9. The nursing staff shall also contact the referral centre and OPD Medical Officer, Refer In-Out register
follow up about the condition of the patient post referral. Staff Nurse

Reference Standard: ME G4.2

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14. Equipment Management

S. Activity Responsibility Record

No
Calibration of Equipments
1. All the measuring equipments/ instrument shall be calibrated. OPD -Incharge Nil

2. An ISO certified calibration agency shall be identified to OPD - Incharge Nil

calibrate the equipments/instruments.
3. Calibration labels/stickers shall be placed on the equipment OPD - Incharge Equipment register
denoting the date of calibration and indicating the status of
calibration/ verification when recalibration is due.
4. All calibration certificates shall be maintained by the Incharge OPD - Incharge Calibration certificate
or centrally stored by the Store-Incharge of the hospital.
5. The OPD shall maintain an equipment register to document OPD - Incharge Equipment register
details of equipment and calibration status.
6. It shall be the duty of the Incharge to ensure updation of OPD - Incharge Equipment register
calibration for all equipments as per their schedule.
General Maintenance
7. Up to date manufacturer’s instructions for operation and OPD - Incharge Manufacturer’s instruction
maintenance of equipments shall be kept in the department
so that the same can be readily available to staff when
required.
8. Defective/Out of order equipments shall be labelled and OPD - Incharge Equipment register
stored appropriately away from traffic area, until it has been
repaired
9. Daily dusting/ dry wiping of equipments shall be done by OPD - Incharge Nil
housekeeping staff. The laboratory technician shall do a daily
check on the functioning of equipments every morning before
commencement of testing procedure.
10. An equipment register shall be maintained to document OPD - Incharge Equipment register
details of equipment - name, hospital code, and date of
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installation, name of manufacturer, maintained in A

house/maintained by external agency or manufacturer,
Warranty Period, under AMC/CMC.
Preventive and Breakdown Maintenance
Preventive Maintenance
11. All equipments shall be covered under AMC/CMC including OPD- Incharge Equipment register
Preventive maintenance.
12. The lab-Incharge shall maintain an updated record on AMC & OPD- Incharge Equipment register
Preventive maintenance in equipment register this should
include details like :
o Frequency of Preventive Maintenance/Calibration
- As per manufacturer guidelines
- Presently being followed
o Preventive Maintenance/Calibration Done On
o Preventive Maintenance/Calibration Due On
o Expenditure with cost and details
o Remarks with Functional Status
13. Preventive maintenance shall be carried out as per OPD- Incharge Equipment register
Maintenance Schedule for each individual equipment based
on manufacturer’s recommendations.
14. The following shall be checked during a preventive OPD -Incharge Equipment Service Report
maintenance-
 Physical condition of the equipment/ facility
 lubrication, calibration, cleaning or replacing parts that
are expected to wear or which have a finite life
 Maintenance report verification
Maintenance / Service report shall be obtained from service
agency and after verification marked as O.K. /Not O.K.
Breakdown Maintenance
15. Faulty or defective equipment shall not be used regardless of OPD -Incharge Equipment register
how minor is the problem and must be reported in the first
instance to the in-house maintenance engineer /outside
agency hired for maintenance as soon as possible and seen
that the problem is attended to as soon as possible.
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16. A label of “out of order” shall be attached to the equipment OPD -Incharge Nil
and information regarding breakdown shall be passed to all
staff including any shift changes.
17. On restoration of the equipment, the Equipment Breakdown OPD -Incharge Nil
Record should be updated. This indicates that the
breakdown/maintenance is performed of the equipment.
The “out of order” sticker shall be removed after the
restoration of the equipment.
18. All the breakdowns occurring in the department should be OPD -Incharge Equipment register
maintained in the equipment register and include the
following
o Breakdown Date and Time
o Breakdown Details (Technical fault or other reasons)
o Date and Time of Rectification
o Total Time Taken (Rectification Time – Breakdown Time)
o Rectification Details with expenditure including cost (if
any)
o Remarks with functional status
o Reasons for delay if any

Reference Standard: ME G4.2

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15. Other Outpatient Services

S. Activity Responsibility Record

No
OUTPATIENT PHARMACY
1. Patient presents the OPD medicine slip at the pharmacy counter. Pharmacist Medicine prescription slip
2. Pharmacist at the counter shall dispense the available drugs / Pharmacist Medicine prescription slip
medicines and also brief the dosage and frequency of medicine at
the time of dispensing to the patient.
3. If any prescribed medicine is not available in the dispensary it shall Pharmacist Medicine prescription slip,
be made available by local purchase. Drug Dispensing Register
4. The quantity of issued medicines shall be entered in the dispensing Pharmacist Drug Dispensing Register
register/pharmacy software if available.
IMMUNIZATION CLINIC
5. Patient is directed towards injection room by OPD attendant. Staff Nurse Immunization register
6. Patient shows the OPD case paper to nursing staff at injection Staff Nurse Immunization register
register.
7. Nursing staff at injection room shall administer the injection as Staff Nurse Immunization register
advised and enter the detail in Immunization Register (i.e. name of
pt, pt ID, case, requisition given by, and injection administered).
8. In case of ARV, separate register (ARV Register) shall be Staff Nurse ARV register
maintained.
9. Needles, syringes and swabs shall be disposed as per Biomedical Staff Nurse Nil
Waste (Management and Handling) Rules, 1998.
DRESSING ROOM
10. Patient is directed towards dressing room by OPD attendant Dresser/ Dressing room register
Staff Nurse
11. Patient comes to dressing room and shows OP case paper. Dresser/ Dressing room register
Staff Nurse
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12. Patient’s details are entered into the dressing register. Dresser/ Dressing room register
Staff Nurse
13. The dresser carries the process of wound dressing Dresser/ Dressing room register
Staff Nurse
14. Swabs, bandage etc are disposed as per Biomedical Waste Dresser/ Nil
(Management and Handling) Rules, 1998. Staff Nurse
SERVICES PROVIDED UNDER NATIONAL HEALTH PROGRAMME
15.  National Immunization Programme Nodal officer Reporting Formats
 Revised National Tuberculosis (TB) Control Programme
 National AIDS Control Programme
 Maternal & Child Health Programme
 Family Planning Programme
 National Blindness control program
 National Leprosy elimination Programme.
 National Vector Borne Disease Control Programme
 National Tobacco Control Programme
 National Flurosis Disease Control Programme
 National Iodine deficiency Diseases Control Programme
 National Communicable Disease Control Programme
 National Non Communicable Disease Control Programme
 National Diabetic Control Programme
 National Diarrhoea Control Programme

Reference Standard: ME G4.2

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16. Updation and storage of records

S. Activity Responsibility Record

No
1. All the details of assessments, re-assessment and investigations Doctor, All forms & formats and
Staff Nurse registers maintained in
shall be recorded and updated in the OPD case sheet by the
& In - charges OPD
consultant/ doctor.
2. Any minor Procedures if any like immunization/dressing etc shall Doctor,
Staff Nurse
be recorded in the patient case sheet.
& In - charges
3. The facility shall ensure safe and adequate storage and retrieval of MRD In -charge
medical records if OPD records are stored in MRD.
4. All registers maintained for OPD shall be identified and numbered. In - charge

Reference Standard: ME G4.2

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17. Cleaning of OPD Area

S. Activity Responsibility Record

No
1. OPD lobby area shall be mopped with disinfectant added water Housekeeping Housekeeping checklist
solution. staff

2. All patient care area shall be first mopped with disinfectant and Housekeeping Housekeeping checklist
then with detergent water. staff

3. Use of brooms shall be avoided, only dry & wet mopping shall be Housekeeping Housekeeping checklist
followed. staff

4. Dusting of tables, racks, cupboards and windows shall be done Housekeeping Housekeeping checklist
either before or after OPD timings to avoid dispersion of dust staff
particles in air and thereby inside nostrils of patient which may
cause them discomfort.
5. Infection Control Nurse shall ensure housekeeping staff is trained Infection control Housekeeping checklist &
for spill management. Nurse Infection control round
checklist
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18. No Smoking Policy in OPD

S. Activity Responsibility Record

No
1. The hospital has a “No Smoking Policy” according to which Hospital staff, Signages on No Smoking
smoking is prohibited inside hospital premises. patient, visitors policy

2. As per the organisation policy, any hospital staff found guilty of Hospital staff No smoking Policy
non-adhering to the above policy shall be liable to a fine of Rs
200/-
3. If the staff at the hospital come across any patient/patient Hospital staff No smoking Policy
attendant with a regular smoking habit shall educate them on the
harmful impact of smoking and motivate them to quit smoking.
4. Any patient/attendant if found smoking inside hospital premises Hospital staff No Smoking Policy
shall be alerted about the No smoking policy and asked to refrain
from the same immediately
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