ORGANIZATION CHART OF NURSING SERVICE

The usual way of illustrating a formal organization is by means of an organization

chart. The basic organization of all services, their relationship to one another, lines of
authority, responsibility and communication among various departments which are
located at different levels of hierarchy are illustrated by an organization chart. There is no
stereotyped organization chart suitable for every hospital. Such a chart should come as a
result of the consideration made on the objectives, responsibilities and feasible
programme of a specific hospital.
The organization char illustrates the formal structures in two dimensions — horizontal
and vertical. The horizontal dimension depicts differentiation of the total organizational
job into different departments. The vertical dimension refers to the hierarchy of authority
relationship with a number of levels from top to bottom authority flows downwards along
these lines.
The organization chart illustrates the various levels of authority from the higher to the
lower levels. The different levels are:
I) At the top level is the policy making body (e.g. governing body)
2) At the next level is operating authority (e.g. administrator or superintendent of the
organization)
3) At the next level are broad areas of services with their departmental heads (e.g.
medical service, nursing service, dietary service etc.)
4) At the next level are the supervisory manager (from line managers) who supervises the
front line workers (e.g. ward sister/head nurse).
5) At the lowest level are the personnel delegated with responsibility for the performance
of specific functions (front line workers)..
These charts also illustrate various types of relationships existing between positions:
I) Line relationship: This exists between a superior and the subordinates immediately
and directly responsible for certain functions through which the formal communications
flow. e.g. the relationship of nursing superintendent to the head nurse. This is represented
by continuous lines.
2) Later relationship: These types of relationship exist between positions in various
parts of organization, where no direct authority is involved. E.g. relationship of the
nursing superintendent (nursing service with the principal (nursing education).
3) Functional relationship: Functional relationship exists whenever an individual has
the right to control certain activities in other departments outside his formal chain of
command. e.g. the in-charge of the laundry department controls the supply of linen in a
medical ward. Therefore, a functional relationship exists between the in-charge of the
laundry department and the in-charge of the medical ward.
4) Staff relationship: Literally, the word ‘staff’ means the stick carried in the hands for
support. The nature of the staff authority is merely advisory. The staff cannot take
decisions on behalf of and issue commands to the line managers. Staff authority consists
of experts. and specialists in various fields who give support to the executives who hold
the line authority.

PRESENTATION OF ORGANIZATION CHART

There are three ways in which organization chart can be prepared. They are:
1) Vertical or top-down chart:
This shows the organization structure in the form of a pyramid. The highest position is
shown at the top level followed by other positions in the hierarchy or management levels.
Positions shown in the same horizontal level in the chart usually be considered to have
the same relative importance in the organization.
2) Horizontal or left to right chart:
In the horizontal chart, the organizational levels are represented by vertical columns. The
flow of authority from higher to lower levels are represented by movement from left to
right
3) Circular chart:
In this chart, the organizational levels are represented by the arrangement of circles
within circles. The sizes of sphere may indicate the comparative areas or responsibility of
the managers.
 Formulation of philosophy, aims and objectives: Nursing

The outstanding faculty of the CSUB Department of Nursing has designed the
departmental philosophy and curriculum around the Nursing metaparadigm concepts of
client, environment, health and the nurse.
We assume nursing is a scientific discipline and as a discipline makes a distinctive
contribution to the maintenance and promotion of health. This contribution is achieved
through facilitating maximum functional health status by collaborating with individuals,
families, groups and the community. Activities to accomplish nursing goals are viewed as
congruent with society’s expectations and needs.
Professional nursing draws upon the related disciplines of natural and social
sciences, humanities and nursing science for its theory as a foundation for practice. In
addition, nursing continues to develop and refine its knowledge base through ”scientific
inquiry” into its theory and practice. Critical thinking, progressive inquiry, and decision-
making skills are emphasized through the use of the nursing process, which is directed
toward achievement of maximum functional status for the client. The use of this process
results in complex independent judgments based on accurate data and knowledge. We
believe that the ability to engage in this process necessitates a baccalaureate level of
nursing education. Such education is the essential preparation for beginning professional
nursing practice.

Client
The client of nursing is the recipient of nursing care and may include the person
across the lifespan, family, group or community. The faculty believes in the integrity,
dignity, and worth of the person as an open, goal-directed, humanistic being. We assume
each person as an open system includes distinct, but integrated physiological,
psychological and socio-cultural systems. The person as an open system actively engages
in interchange of energy with the environment and tends to achieve a balance among the
various forces operating within and upon it. As an open system, the individual attempts to
achieve balance with respect to these forces by utilizing, conserving, and replenishing
energy in order to function effectively and efficiently. The motivating energy underlying
this interchange with the environment is assumed to be present from conception through
the lifespan. Developing through the process of adaptation, each person is engaged in
modification through interaction with the environment. Effective adaptation during
development can be defined as momentary periods of balance and maximum functional
status. Genetic endowment, spiritual orientation, education, occupation, and
cultural/ethnic group membership influence individualized development. Although
individuals strive to achieve balance and maximum functional status, they also actively
seek new experiences that may disturb their balance at least temporarily. These new
experiences may require variable behavioral modifications to re-establish balance.
Further, we believe that individuals are rational, ever-changing, and capable of making
critical choices.
Within our philosophical framework, the person across the lifespan, as an open
system, interacts with, is part of, and influences other systems. The family is a dynamic
social system which responds to the needs and desires of its members and the community
in which it is located. As the primary reference group for the individual, the family serves
to protect, educate, and nurture. Individuals or sub-populations sharing a common
purpose or problem are the group/aggregate clients of nursing. A community, also a client
of nursing, interacts with individuals, groups and institutions for their mutual protection
and common good. Because we believe in the value of relationships, linking people to
each of the above social systems, we view the individual not in isolation, but as an
integral part of the larger whole. These relationships are significant because they
influence the individual’s development, systems stability, functional status and health.

Environment
The environment may be defined as a composite of all the conditions and
elements that make up the internal and external surroundings and influence the
development of individuals. Additionally, the environment may be conceptualized as
human, social, political, economic, geographic and physical factors influencing each
other. We view society as the network of dynamic relationships that links individuals to
other systems such as family, other individuals, group/aggregates, community, nation and
the universe. The individual and society are linked to and part of the environment.
Further, individuals, society, and the environment mutually influence each other through
exchange of energy. One aspect of the interaction of these multiple factors is their
influence on health.

Health
Health can be defined as a state of maximum wellness/functional health status at a
given point in time. The concept of maximum wellness has been classically defined as an
“integrated method of functioning which is oriented toward maximizing the potential of
which the individual is capable within the environment where he is functioning” (Dunn,
1959, p. 18). Hence our belief that health consists of the ability to function optimally
within an ever-changing environment and that health influences one’s growth and
development. Health is composed of multiple factors, some of which include the presence
or absence of a disease state and the ability to adapt to internal and external stressors. The
definitive parameter of health is defined by specific societies. Personal responsibility for
an individual’s health is defined by specific societies. Personal responsibility for an
individual’s health is assumed by virtue of the individual’s ability to make free choices.

Nurse
We believe the professional nurse works autonomously and collaboratively with
others to promote the health of individuals, families, and communities. Nurses are
individually accountable to the public they serve. As a patient advocate and change-agent,
the nurse works with others to facilitate growth and needed changes in the healthcare
delivery system by evaluating and utilizing research findings. The professional nurse not
only interacts with patients/clients during the provision of care but, also supervises and
coordinates the care given by others. Advanced communication, education, leadership,
research and clinical skills are used to carry out these nursing functions.
Professional nurses provide nursing services to individuals of all ages and to
families in a wide variety of healthcare settings where they function with various degrees
of independence and complexity. Increasingly, evolving nursing roles in the healthcare
delivery system will require even greater independent decision-making, accountability,
and autonomy of practice. Scientific and technological advances necessitate commitment
to life-long learning and may include higher education. While ensuring the welfare of the
public, the nurse also has the added responsibility to enhance the welfare of the
profession of nursing. This is accomplished by being actively involved with political and
social forces impacting upon the profession.
 Formulation of philosophy, aims and objectives: Nursing
School/College

PURPOSE
The purpose of the Master of Nursing (MN) program is to prepare nurses at an
advanced level and to provide leadership in nursing.

PHILOSOPHY
The MN program is based on the belief that advanced practice in nursing requires
graduate level preparation that provides students with the opportunity to both broaden
and deepen their knowledge and competencies in nursing. The advanced practitioner uses
critical, has a well developed knowledge base, and demonstrates advanced skills in an
area of nursing. Advanced nursing practice skills are developed through the testing of
selected nursing interventions, implementation of research findings, and the analysis and
Critique of theoretical work.

PROGRAM OBJECTIVES
Graduates of the program will be able to:
1. Critically appraise existing knowledge in nursing (philosophical, theoretical, research-
Based, and other).
2. Appropriately apply knowledge to improve nursing practice.
3. Promote evidence-based practice.
4. Conduct a research project or participate in a consolidated practicum experience in a
Specialty area of nursing.
5. Examine and critically analyze issues in nursing and health care.
6. Demonstrate advanced knowledge and competency in an area of nursing practice.
7. Demonstrate leadership in nursing.
CURRICULUM DESIGN

The curriculum is designed to enable students to meet the objectives of the

program. The curriculum fosters the interrelatedness of knowledge and practice.

The curriculum includes:

1. A theoretical component that enables students to critically examine the development
and basis for professional nursing practice.
2. A research component that enables students to critically evaluate research in nursing
and other health-related fields asa basis for evidence-based practice and provides
students with beginning research skills.
3. A practice component that enables students to develop advanced nursing competencies
and provide clinical leadership in nursing. An important part of the practice component
is the consolidated practicum experience.
 BUDGET FOR NURSING SERVICES

INTRODUCTION
The word “budget” is derived from the old English word “budget tee” means sack
or pouch which the chancellors of the exchequer used to take out of his papers for laying
before the parliament, for the financial scheme.

Definition
Budget-heart of administrative management.
 estimation of future needs(T N Chhabra)
 predicts the activity of an organization over a set period of time.(MarrinerTomeey
1996)
 a balance estimated expenditure and receipts for a given period of time(Dimoc)

Objectives of budget
Provision of
 Definite target for income and expenditure
 Useful tool for the control of costs
 Tool for communication and coordination within the organization.
 Coordination of activities of different function
 Cash flow statement month by month
 Future policy decision
 Financial planning and decision making
 Identification of controllable and uncontrollable cost area
Features of budget
It should be
 Flexible
 Simple in design
 Synthesis of past, present and future
 Product of joint venture
 Teams of statistical standards
 Composed of two segments, income and expenditure
 Time period, usually annual
 Forward planning and gives direction

Principles of budget
 Planned one
 on cash basis
 Revenue and capital portion should be distinct
 Gross and not net
 Close estimation
 Estimates correspond to accounts
 Rule of lapse

Budget in Health Care Systems

Budgets are basic for finance, more than a forecast of income and expenditure (sources of
funds of health services in India).

Budget for Nursing in Hospital

 Request for the needs of various departments
 Review the budget appropriation and actual expenditure for the current year
 Contemplated changes
 Salary fixation
 Requirement estimation
 Summary of new needs
URLs (1) and (2) can be referred for the details.
Budget Proposal for Nursing Educational Institutions
Items which are budgeted for the average government schools of nursing in India
 Salaries for the staff
 Stipends for the students
 new equipments and supplies
 Hires and other household supplies
 Office supplies
 Maintenance of transport
 Maintenance of library
 Contingency fund
URLs (3) and (4) can be referred for the details.
Preparation of budget statement in Nursing Education Program
 Nurse administrator or head of a budgetary unit is responsible for the annual budget
in the school of nursing.
 President and other budgetary unit heads
 Proposal for next financial year
 Financial practices of institutions

Steps in budgeting for college of nursing

Request for the needs of various departments
Review the budget appropriation and actual expenditure for the current year
Contemplated changes
Salary fixation
Requirement estimation
Summary of new needs
Roles and Responsibilities of the Nurse Administrator/Principal In Budgeting
Co-operative activity of the nursing superintendent and her/his associates
including the supervisor. The budget request may be broken down to the different units,
example salaries, supplies, equipments , other purchase requirements. The administration
of nursing unit has certain specific functions in the preparation of budget request for
programmed planning, estimating the cost , justification of requests and for
administration of budget in nursing unit.
The steps of planning budget for nursing unit is as follows
Assistance of his/her subordinates
Review of budget
Ascertain changes
Preparing requirements
Summary of new needs
Submitting to institutional administrator

Responsibilities of nursing administration in Budget

Participation in planning budget
Consult an take assistance of his/her subordinates
Request sufficient finds
Submit budget request
Support the budget when it is allotted.
Cover the routine budget control
To sum up roles and functions of administrator/manger are as given below:
Roles
He/she
 Visionary
 Knowledgeable
 Flexible
 Creative
 Influences and inspires group members
 Recognition
 Client safety
Functions
 Identify the importance of the unit needs
 Articulate and document needs
 Assessment of internal and external environment
 Demonstrate knowledge
 Provide opportunities for subordinates(budget planning)
 Co-ordination
 Assessment of personnel needs
 Monitoring aspects
 Documentation of clients need for services

Budget Proposal in Nursing

The Budget for any grant proposal should be completed in consultation with the
Faculty of Nursing (FON) Research Finance Office and Research Office. The reason for
this consultation is two-fold: to ensure that the budget line items and & costs are
accurately reflected for the proposed project including indirect costs, and to identify early
on any potential impacts on the FON resources such as space,,,9quiPment and other
items.
The budget section consists of two parts — the itemized tabular budget with costs and
totals, and the budget justification or explanation section. The justification section is
essential if the budget is complicated and the details in the proposal and itemized budget
are not clear in showing the need for the budget item.
Typical divisions of the tabular budget are Personnel (including Salaries, Wages and
Benefits (at about 15% of total salary, and participants payment), Equipment, Project
costs (including lab costs, photocopying, printing materials, supplies, workshop costs),
Travel, and Indirect Costs (which for a research grant is anywhere from about nil to 40%
of the project costs, depending on the type of project). A checklist for proposal budget
items would contain the following:
A) Personnel Salaries and Wages
1. Academic personnel if appropriate
2. Research Assistants
3 Stipends (Training grants only)
4. Consultants.
5. Project subjects or participants — for interviews or other activities
6. Computer programmer
7. Statistician
8. Tabulators. Data entry personnel
9. Secretaries
10. Editorial assistants
11. Technicians
12. Wage help
13. Staff benefits (depending on the type of the appointment from 10% to18%)
14. Salary increases if appropriate and approved
B) Equipment
1. Fixed equipment
2. Movable equipment
3. Office equipment including computers
4. Equipment installation
5. Equipment maintenance
C) Materials and Supplies
1. Research project supplies
2. Test materials, questionnaire forms
3. Animals & animal care
4. Laboratory supplies (including glassware and chemicals)
5. Electronic supplies
6. Report materials
7. Communication for advertising positions in papers
8. Equipment less than $1000
D) Travel
1. Administrative
2. Field Work
3. Professional meetings
4. Travel for consultations
5. Conferences
6. Other ground or airline travel
7. Catering and hosting expenses (please check the granting agencies
guidelines for eligibility)
E) Services
1. Computer licenses
2. Duplication services/photocopying
3. service contracts
4. survey/data analysis
F) Other
I. Space rental
2. Alterations and renovations
3. purchase of books and periodicals
4. patient reimbursement
5. training costs
6. Phone/pager charges
7. Sub-contracts
8. Dissemination expenditures
9. Indirect Costs (15% - 40% of total project costs, depending on the type of the project)
 MEDICAL RECORDS

A medical record, health record, or medical chart is a systematic documentation of

a patient’s medical history and care. The term ‘Medical record’ is used both for the
physical folder for each individual patient and for the body of information which
comprises the total of each patient’s health history. Medical records are intensely personal
documents and there are many ethical and legal issues surrounding them such as the
degree of third-party access and appropriate storage and disposal. Although medical
records are traditionally compiled and stored by health care providers, personal health
records maintained by individual patients have become more popular in recent year
Purpose
The information contained in the medical record allows health care providers to
provide continuity of care to individual patients. The medical record also serves as a basis
for planning patient care, documenting communication between the health care provider
and any other health professional contributing to the patient’s care, assisting in protecting
the legal interest of the patient and the health care providers responsible for the patient’s
care, and documenting the care and services provided to the patient. In addition, the
medical record may serve as a document to educate medical students/resident physicians,
to provide data for internal hospital auditing and quality assurance, and to provide data
for medical research. Personal health records combine many of the above features with
portability, thus allowing a patient to share medical records across providers and health
care systems.
Format
Traditionally, medical records have been written on paper and kept in folders. These
folders are typically divided into useful sections, with new information ‘added to each
section chronologically as the patient expri6nces new medical issues. Active records are
usually housed at the clinical site but older records (e.g., those ‘of the deceased) are often
kept in separate facilities.
The advent of electronic medical records has not only changed the format of medical
records but has increased accessibility of files.
Contents

Although the specific content of the medical record may vary depending upon
specialty and location, it usually contains the patient’s identification information, the
patient’s health history (what the patient tells the health-care providers about his or her
past and present health status); and the patient’s medical examination findings (what the
health-care providers observe when the patient is examined). Other information may
include lab test results; medications prescribed; referrals ordered to health-care providers;
educational materials provided; and what plans there are for further care, including
patient instruction for self-care and return visits. In some places, billing information is
considered to be part of the medical record.

Demographics

Demographics include patient information that is not medical in nature. It is often

information to locate the patient, including identifying numbers, addresses, and contact
numbers, it may contain information about race and religion as well as workplace and
type of occupational information. It may also contain information regarding the patient’s
health insurance. It is common to also find emergency contacts located in this section of
the medical chart.

Medical history

The medical history is a longitudinal record of what has happened to the patient since
birth. It chronicles diseases, major and minor illnesses, as well as growth landmarks. It
gives the clinician a feel for what has happened before to the patient. As a result, it may
often give clues to current disease states. It includes several subsets detailed below.
Surgical history
The surgical history is a chronicle of surgery performed for the patient. It may have dates
of operations, operative reports, and/or the detailed narrative of what the surgeon did.
Obstetric history

The obstetric history lists prior pregnancies and their outcomes. It also includes any
complications of these pregnancies.
Medications and medical allergies

The medical record may contain a summary of the current and previous medications as
well as any medical allergies.

Family history

The family history lists the health status of immediate family members as well as their
causes of death (if known). It may also list/diseases common in the family or found only
in one sex or the other. It may 1so include a pedigree chart. It is a valuable asset in
predicting some out comes for the patient.

Social history

The social history is a chronicle of human interactions. It tells of the relationships of the
patient, his/her careers and trainings, schooling and religious training. It is helpful for the
physician to know what sorts of community support the patient might expect during a
major illness: It may explain the behavior of the patient in relation to illness or loss. It
may also give clues as to the cause of an illness (i.e., occupational exposure to asbestos).

Habits
Various habits which impact health, such as tobacco use, alcohol intake, recreational drug
use, exercise, and diet are chronicled, often as part of the social history. This section may
also include more intimate details such as sexual habits and sexual preferences.
Immunization history

The history of vaccination is included. Any blood tests proving immunity will also be
included in this section.
Growth chart and developmental history

For children and teenagers, charts documenting growth as it compares to other

children of the same age is included, so that health-care providers can follow the chil&s
growth over time. Many diseases and social stresses can affect growth and longitudinal
charting and can thus provide a clue to underlying illness. Additionally, a child’s behavior
(such as timing of talking, walking, etc.) as it compares to other children of the same age
is documented within the medical record for much the same reasons as growth.

Medical encounters

Within the medical record, individual medical encounters are marked by discrete
summations of a patient’s medical history by a physician, nurse practitioner, or physician
assistant and can take several forms. Hospital admission documentation (i.e., when a
patient requires hospitalization) or consultation by a specialist often take an exhaustive
form, detailing the entirety of prior health and health care. Routine visits by a provider
familiar to the patient, however, may take a shorter form such as the problem-oriented
medical record (POMR), which includes a problem list of diagnoses or a “SOAP’ method
of documentation for each visit. Each encounter will generally contain the aspects below:
Chief complaint
This is the problem that has brought the patient to see the doctor. Information on the
nature and duration of the problem will be explored.
History of the present illness
A detailed exploration of the symptoms the patient is experiencing that have caused the
patient to seek medical attention.
Physical examination
The physical examination is the recording of observations of the patient. This includes
the vital signs and examination of the different organ systems, especially ones that might
directly be responsible for the symptoms the patient is experiencing.
Assessment and plan
The assessment is a written summation of what are the most likely causes of the patient’s
current set of symptoms. The plan documents the expected course of action to address the
symptoms (diagnosis, treatment, etc.).
Orders
Written orders by medical providers are included in the medical record. These detail the
instructions given to other members of the health care team by the primary providers.
Progress notes
When a patient is hospitalized, daily updates are entered into the medical record
documenting clinical changes, new information, etc. These often take the form of a SOAP
note and are entered by all members of the health-care team (doctors, nurses, dietitians,
clinical pharmacists, respiratory therapists, etc). They are kept in chronological order and
document the sequence of events leading to the current state of health.
Test results
The results of testing, such as blood tests (e.g., complete blood count) radiology
examinations (e.g., X-rays), pathology (e.g., biopsy results); or specialized testing (e.g.,
pulmonary function testing) are included. Often, as in the case of X-rays, a written report
of the findings is included in lieu of the actual film.
Other information
Many other items are variably kept within the medical record. Digital images of the
patient, flow sheets from operations/intensive care units, informed consent forms, EKG
tracings, outputs from medical devices (such as pacemakers), chemotherapy protocols,
and numerous other important pieces of information form part of the record depending on
the patient and his or her set of illnesses/treatments
Administrative issues
Medical records are legal documents and are subject to the laws of the country/state in
which they are produced. As such, there is great variability in rule
governing production, ownership, accessibility, and destruction. Production
Written records must be marked with the date and time and scribed with indelible pens
without use of corrective paper. Errors in the record should be struck out with a single
line and initialed by the author. Orders and notes must be signed by the author. Electronic
versions require an electronic signature.
Ownership
The data contained within the medical record belongs to the patient, whereas the physical
form the data takes belongs to the entity responsible for maintaining the record.
Therefore, patients have the right to ensure that the information contained in their record
is accurate. Patients can petition their health care provider to remedy factually incorrect
information in their records.
Accessibility
The most basic rules governing access to a medical record dictate that only the patient
and the health-care providers directly involved in delivering care have the right to view
the record. The patient, however, may grant consent for any person or entity to evaluate
the record. The full rules regarding access and security for medical records are set forth
under the guidelines of the Health Insurance Portability and Accountability Act
(FJIPAA). The rules become more complicated in special situations.
Capacity
When a patient does not have capacity (is not legally able) to make decisions regarding
his or her own care, a legal guardian is designated (either through next of kin or by action
of a court of law if no kin exists). Legal guardians have the ability to access the medical
record in order to make medical decisions on the patient’s behalf Those without capacity
include the comatose, minors (unless emancipated),. and patients with incapacitating
psychiatric illness or intoxication.
Medical emergency -
In the event of a medical emergency involving a non-communicative patient, consent to
access medical records is assumed unless written documentation has been previously
drafted (such as an advance directive)

Research, Auditing, And Evaluation

Individuals involved in medical research, financial or management audits, or program
evaluation have access to the medical record. They are not allowed access to any
identifying information, however.
Risk of death or harm
Information within the record can be shared with authorities without permission when
failure to do so would result in death or harm, either to the patient or to others.
Information cannot be used, however, to initiate or substantiate a charge unless the
previous criteria are met (i.e., information from illicit drug testing cannot be used to bring
charges of possession against a patient).
The Data Protection Acts and later the Freedom of information Act 2000 gave patients or
their representatives the right to a copy of their record, except where information
breaches confidentiality (e.g., information from another family member or where a
patients has asked for information not to be disclosed to third parties) or would be
harmful to the patients wellbeing (e.g., some psychiatric assessments). Also, the
legislation gives

patients the right to check for any errors in their record and insist that amendments be
made if required.

Destruction
In general, entities in possession of medical records are required to maintain those
records for a given period. The medical records are required for the lifetime of a patient
and legally for as long as that complaint action can be brought. Any recorded information
should be kept legally for 7 years, but for medical records additional time must be
allowed for any child to reach the age of responsibility (20 years). Medical records are
required many years after a patient’s death to investigate illnesses within a community
(e.g., industrial or environmental disease or even deaths at the hands of doctors
committing murders, as in the Harold Shipman case).

Abuses
The outsourcing. of medical record transcription and storage has the potential to violate
patient-physician confidentiality by possibly allowing unaccountable persons access to
patient data.
Falsification of a medical record by a medical professional is a felony.
Governments have often refused to disclose medical records of military personnel who
have been used as experimental subjects.
 HOSPITAL LABORATORY
Hospital laboratory services unit provides excellent diagnostic facilities in the areas of:
• Histopathology
• Cytology
• Haemato pathology And Clinical Pathology
• Biochemistry
• Microbiology, serology & VHRL
• Medical Genetics
With its highly qualified, well trained, and experienced staff of more than 40 Junior and
Senior technicians, the Lab Services provides all aspects of clinical laboratory scjenc
practice - analysis, quality control education and management - as per the globally
accepted standards. The Lab Services staff also participates from time to time in health
camps organized by various departments like orthopedics, general medicine, renal camps
etc.
Histopathology
It is the systematic study of tissues and organs for determination of the disease and to
provide useful information for diagnosis and prognosis. The range of tissue samples
varies from whole organs like uterus, spleen, and segments of intestine to a 3-mm.
diameter gastric mucosal biopsy.
The tissues received are processed and reports generated within 24 -48 hours.
Highlights:
• Neuropathology
• Gyneco logic pathology
• Oncopathology
. Dermatopathology
• Routine surgical specimens
• Cytochemical stains done as and whe required Cytology
It is the art and science of evaluatio cells aspirated with the use of needle or those shed
from various surfaces into the body cavities.
FNAC - Fine Needle Aspiration Cytology is performed an all types of masses in the
body- especially breast, thyroid, lymph nodes. Ultrasound and CT guided aspirates are
also performed.
A meaningful report is available at the earliest to help plan the treatment protocol. The
various cytological specimens handled are:
• Vaginal Cytology (PAP Smears)
• pleural fluid
Ascitic Fluid
• Synovial Fluid
• Dialysate Fluid
•CSF
• Urine
These are assessed for presence or absence of malignant cells.
Histopathology & Cytology Tests
Haemato pathology And Clinical Pathology
Accurate blood counts are important for proper evaluation and treatment- We employ
sophisticated Automated Haematology Cell Counter to provide a reliable Complete Blood
Count (CBC). Peripheral blood smears are done on all suspicious CBC. Bone marrow
aspirates help in diagnosing leukaemia, lymphomas, metastatic turmours and various
anemia’s etc.
Apart from Blood parameter analysis, clinical pathology provides testing facilities for
testing of various body fluids, stool samples, Special tests like Hams test/Osmotic
fragility etc.
Clinical Pathology Tests
Biochemistry
Chemical changes take place within the human body whenever there is a disease process
present. Biochemistry analyzes and quantifies these chemical changes to help in prompt
diagnosis, treatment and follow up.
The specimens analysed by biochemistry department include - blood, and body fluids like
pleural fluids, ascitic fluid, urine, CSF etc.
Apart from routine tests like Liver Function tests, Lipid Profile, Renal ftinction tests,
Diabetic Profile, Electrolytes, many special tests are also carried out.
• Thyroid Hormones
• Fertility Hormones
• Tumour Markers
• Drug Assays
• Cardiac markers

Bio - Chemistry Tests

Microbiology, Serology & VHRL
This division of laboratory services deals with the detection of various types of
microorganisms causing infection in the human body. For this purpose blood, CSF, urine,
pleural fluid, ascitic fluid or crush preparation is cultured and growth or absence of
growth of organisms is looked into. Sensitivity pattern of the cultured organisms to
various antibiotics is also assessed. This helps to initiate the proper medication to the
patient. The department uses the automated system BACTEC 9050 rapid culture system
for the same.
Hepatitis virus antibodies are detected in VHRL laboratory by ELISA method. Micro
Biology Tests
Medical Genetics
All our genetic information - one which dictates who we are is present in structures called
chromosomes. There are 23 pairs of chromosomes found in the nucleus of all the cells of
human body. Chromosomes are made up of DNA. These are responsible for normal
growth of an individual. Any alteration or defect in these produces various genetic
disorders. The genetic lab deals with detection of such diseases - like Downs syndrome,
Turner’s syndrome, even cause for recurrent abortion, mental retardation etc.
The tests done are karyotyping (chromosomal analysis DNA Comet (drug toxicity) etc in
peripheral blood cells. The interpretation is done by expert cytogeneticist.
 HOSPITAL LAUNDRY

The importance of a clean environment and linen for optimal patient care has
been stressed upon since the very inception of hospitals. It goes without saying that
“supportive” services are indispensable for a hospital to perform in the true perspective
and deliver good patient care; besides going a long way in developing good public
relation of the hospital. A sick person coming to the alien environment of the hospital gets
tremendously influenced and soothed by the aesthetics or cleanliness of the surroundings
and the linen. On the contrary, dirty linen tends to result in psychological dissatisfaction
like a chain reaction, which creates a negative image of the entire hospital. Studies have
proved beyond doubt, that hospital acquired infections show an increase whenever
laundry and linen services are inadequate.

Conventional Technology

Conventionally, the following equipment are used and the linen is sequenced through
washing machines, (cylinder, vaccum-cup or agitator types) hydro-. Extractors, (motor
driven, top loading type) drying tumblers (motor driven, heat injected, front loading type)
calendaring machines (single or multiple roller with variable speed control) flat bed
steam press, (pneumatic push button types). Most of the hospital mechanized laundries in
our country are presently using various combinations of these machines of varying
capacity depending upon the quantity and type of linen used in the hospitals.
State of the Art Technology
The advent of computer and microprocessor controls in the various laundry equipment
revolutionized their performance and dramatically reduced the number of employees as
well as working hours per employee. The first logical step was a modular, microprocessor
controlled washing machine which was operated by a punching card, depending upon the
requirement of the user regarding control of pH, temperature, amount o detergents,
booster, bleach and souring agents, the number of rinses of water, depending upon the
degree of soiling of the linen.
1 — Washer extractors: The next step was the fusion of the washing machines to the
hydro-extractor which eliminated the need for separate extractors, thus bringing about
medical decrease in space requirements. These equipments are also computer
programmed and can cater to a wide array of soiled linen. The programmable logical
controllers (PLC’s) are the “Keys” used to control operation and stoppages of
equipments; these collect and transmit information to a central computer regarding the
actual processing, quality and any disturbances which occur. The linen after being
processed by these machines was sent directly to the finishing systems or the drying
tumblers, for onward transmission.

2 — Tunnel Washing Systems: The eighties witnessed the advent of the continuous
batch processing systems which are also known as the tunnel washing systems. The
modem generation of tunnel washers, if set up and used correctly are designed to give
vastly improved productive economics in situations where the loads to be processed are
substantially high i.e. in the range of about 400kgs/hr. these new wonder machines have
overcome the two big disadvantages of the washer extractors, which due to their high
speed (revolutions per minute) cause more wear and tear in the linen. In addition, these
are batch processing systems which in fact set the working pace for the functioning of the
laundry, which results in easier handling of the laundry, which results in easier handling
of the work and less strain for the staff deployed there.
 ACCOUNTS, BILLING AND COMPUTER SECTION
Computerized Billing Service For Medical Consultants
Services in this sector include;
Efficient billing of accounts to patients, insurance companies, or to the patient accounts
departments of direct paying hospitals, whichever is relevant.
• Account formulation and coding to insurance company requirements.
• Billing and collection of uninsured or self-paying patient bills.
• Billing and collection of out-patient and consultation fees.
• Assisting with the setting up of efficient and stream lined data collation systems ma
hospital environment.
This comprehensive service encompasses a full administrative role which includes the
reconciliation of all accounts against and other relevant insurance payments and the
follow up of unpaid, underpaid, pended and rejected accounts. Hospital Accounting
Services liase directly with insurers, patients and hospital staff to ensure that your private
practice income is maximized.
Hospital Accounting Services undertake to provide a professional and hassle free billing
service, thereby reducing stress associated with efficient account management and
creating more quality free time for clients.
Medical Legal Account Services
The latest addition to wide range of services is medical legal account service,
which is being utilized by consultants nation-wide. Medical legal-service provides a
professional and efficient method of medical legal billing.
This service is designed once again to perform the task not to have the time or
resources to do. Legal cases are usually long winded ad certainly time consuming. It has
designed a computer program specifically/to deal with Medical Legal Accounts. By
utilizing this service you can bill for Medical Legal accounts in the certain knowledge
that these accounts will be/dealt with and monitored on an ongoing basis to ensure that all
possible accounts are paid. What follows is a brief outline of how this unique service
operates.
 When a Medical Legal case arises you simply supply us with the name and
address of the Patient and the relevant treatment details. (A special form will be supplied
for this purpose). If any details regarding the patient’s Solicitors you would supply as a
standard part of service hospital prepare a detailed annual report of all financial affairs
handled by Hospital Accounting Services on your behalf in the preceding tax year. This
can be used when preparing your end of year accounts and is widely accepted by the
Revenue Commissioners as a bone-fide statement of financial affairs in relation to your
private billing. This report is usually passed by you to your accountant and may be used
for tax return purposes.

Overdue Account Collection For Hospitals

Hospital offers an efficient, professional yet discreet account collection service for
overdue accounts. This service is tailor made to your requirements and designed to
maximize payment of unsafe accounts, and reduce considerably the administrative
headache caused by passing unpaid accounts to a third party. Some of the unique features
of this dedicated service, outlined below, will give you an overview of how this service
can be of benefit to you.
An initial letter is sent to the patient on specially designed Hospital Accounting Services
letterhead. This letter is designed to seek immediate payment and advise of hospital’s
involvement in the collection process. In cases where medical card information may be
relevant, a provision is made on the reverse of our stationary to allow the patient to
supply medical card details. The hospital also has the provision for patients to pay
accounts by credit card, either by post or phone.
Where payment is not forthcoming within 10 days , automatically transfer to associate
organization “Credit Consultancy Systems” and a series of 3 letters are then instigated
automatically over a 30 day period at 10 day intervals.
As hospital direct all payments and queries to office it eliminate the constant and time
consuming need for payment confirmation from your accounts department. However, all
cheque. Postal order payments are made payable to your hospital I health board and
forwarded weekly to you with a comprehensive payment analysis. Credit Card payments
are forwarded weekly to you by one cheque with a comprehensive payment analysis.
Detailed action reports provide a comprehensive breakdown of payments, medical card
details and any other reasons that may occur to explain why an account need not be paid.
(i.e. where a patient has paid the health act charge to another hospital.)The existing
clients find this information very useful in the management of their resources. Hospital
Accounting Services deal exclusively in the medical sector. The hospital has extensive
knowledge of account collection for hospitals and health boards and the hospital with
these details also. If this information is not available hospital will search it .Hospital
Accounting Services will ensure the account is included in the Patients claim for
compensation by contacting both the patient and their solicitor where necessary .Hospital
request written confirmation from one or both parties that your account will be included
in any compensation award.
Once hospital has received confirmation that your account is included in a claim,
your account is then “pended” for further monitoring. i.e. your account is automatically
held in our computer until the case is resolved and your account paid.
To ensure efficiency we continue to monitor the situation on your behalf. At pre
determined intervals we contact the Patient/Solicitor to obtain updates on the status
of all accounts in writing. This ensures that your account is monitored on an on-
going basis until successfully concluded.
As you may be aware many consultants find the medical legal process difficult to
monitor and control due to the long time span between the provision of a service and the
completion of court proceedings. The service saves you time and frustration and
guarantees you a maximum return on your medical legal accounts.

Account Analysis Reports

This unparalleled and vital service leaves you in complete control of your
accounts. At all time you will know what your present position is, what bills are
outstanding and when they are due for collection. Access to your accounts is at the push
of a button and you can receive interim reports by fax on demand.
A broad outline of information and benefits of detailed analysis reports is as follows.

The analysis contains all pertinent details relating to private practice income, including
total monthly and annual bill out, payment analysis including a breakdown of insured
payments and even the amount of retention tax paid. Hospital can advise you at any time
as to the status of accounts paid, outstanding, pended or rejected. You can access details
of individual volumes and values of individual procedures you may carry out over any
specific period. In fact, hospital can provide virtually any information either you or your
accountants may ever require.
 BLOOD BANK

Mission:
“No blood shall ever be collected from professional blood sellers. The blood bank shall
make every effort to collect blood only from voluntary donors, through blood donation
camps/drives. Even in case of relative (replacement ) donors the blood bank shall ensure
that the patients are not forced to find donors. It will be our endeavour to educate the
patients and avoid blood transfusion between first degree relatives to prevent the life
threatening complication of Post transfusion Graft Versus Host Disease.”
Services
• Hepatitis C screening
• To develop a computerized blood banking information system (CABINET).
• To meet the transfusion needs of thalassemic children
• To install a fully automated ELISA system to screen for infections in blood.
• To install an automated blood component extractor. -
• To begin Nucleic Acid Testing of blood.
• Transfusion Centre and licensed to hold blood donation camps.
The Blood Bank laboratory has stringent quality assurance measures in place to ensure
that the blood transfused is nearly 100% safe. In addition to being ISO 9001-2000
certified.

Facility
The Hospital Blood Bank is socially committed and for those needy patients, blood is
provided free of cost, and the patient shall only pay the processing fee for tests and
storage.
The hospital also has an ongoing Thallesmia Program for Thallasemic patients. The
Blood Bank has an attached Transfusion Center where such Thallassemic children receive
transfusions either free or at subsidizes rates. The blood bank has also helped
hemophiliacs as well with factor concentrates.
The Blood bank has been constantly raising funds and material for transfusion for the
poor with the help of philanthropic individuals and organizations.
Staffs are in a position to deal directly with the vast majority of queries that surface with
regard to your accounts. This enables us to proceed with the business of collecting your
accounts with the minimum of input from your staff, thus freeing up their valuable time.
The hospital’s clients include public and private hospitals and several health boards avail
of services exclusively. References are of course.
The blood bank has to its credit blood donation drives conducted on various .occasions
like -marriages and birthdays.

Technology: Nucleic Acid Testing of Blood Bags.

Automation in Blood collection, processing and ELISA testing. The most noteworthy is
the testing of all blood bags for nucleic acid. (RNA/DNA) of HJV, Hepatitis B and
Hepatitis C by Polyrnerase Chain Reaction.
Blood Components ,Aphaeresis and Stem Cell applications:
Majority of the blood that is collected is broken down into blood components primarily
red cells, plasma and platelets.
Fresh whole blood is a vestige of past transfusion practices when appropriate components
were not available. The time taken to test for transfusion transmitted diseases is about 24-
48 hours by ELISA and NAT . By this time the platelets decay and the coagulation factors
in plasma lose potency if stored in the refrigerator. The whole blood collected from the
donor is split into blood components within 6-8 hours of collection and stored under
appropriate conditions-Red cells in the refrigerator(28C) Plasma at (-30 C or below) and
platelets at 20-24 C with constant agitation.
Apheresis: Aphaeresis is selective removal of a particular component of blood from the
donor with returning of the remaining components back into him.
Also equipped with the latest in aphaeresis and stem cell technology.
The blood bank has hemonetics MCS+ and Cobe Spectra LRS for platelet pheresis and
stem cell collection The Blood Bank also has a liquid nitrogen cryo- preservation unit.
Timings
Monday to Saturday: 7 am to 8 pm
Sunday & Holidays: 9am to 1 pm

DIETARY

Dietary Department provides nutritionally adequate meals to patients. The Dietary

Department strives to meet the therapeutic nutritional needs of the patients by complying
with physicians’ orders. The Dietary Department has a Licensed Registered Dietitian on
staff. The hospital also provides dietary consultation and also diabetic education.

Services
A patient’s nourishment is a top priority in hospital providing a nourishing, well-
balanced, properly controlled diet is one that takes great skill and planning. The dietary
department must provide meals three its patients and employees three times a day.
Several separate meals must he prepared each day to accommodate various required
diets, Along with meal planning, [lie dietary department must supply nutritional care for
its patients by providing diet counseling.
 CENTRAL STERILE SUPPLY DEPARTMENT (CSSD)
The objective of establishing a Central Sterile Supply Department is to make
reliably sterilized articles available at the required time and place for any agreed purpose
in the Hospital as economically as possible, having regard to the need to conserve the
time of users [especially Doctors And Nurses].
The Sterile Supply Department within a hospital receives stores, sterilizes and
distributes to all departments including the wards, outpatient department [OPDJ and other
special units such as operating theatre [OTJ. Major responsibilities of CSSD include
processing and sterilization of syringes, rubber goods [catheters, tubing], surgical
instruments, treatment trays and sets, dressings etc. it is also responsible for eonornic and
effective utilization of equipment resources of the Hospital under controlled supervision.
The main objectives of the Central Sterile Supply Department are:
 To provide sterilized material from a central department where sterilizing practice is
conducted under conditions, which are controlled, thereby contributing to a reduction
in the incidence of hospital infection.
 To take some of the work of the Nursing staff so that they can devote more time to
their patients.
 To avoid duplication of costly equipment’s, which may be infrequently used.
 To maintain record of effectiveness of cleaning, disinfection and sterilization process.
 To monitor and enforce controls necessary to prevent cross infection according to
infection control policy.
 To maintain an inventory of supplies and equipment.
 To stay updated regarding developments in the field in the interest of efficiency,
economy, accuracy and provision of better patient care.
 To provide a safe environment for the patients and staff.
The CSSD also aims at assuming total responsibility for processing hospital
items thereby assuring that all of them receive the same degree of cleaning and
sterilization. It also contributes to the educational program within the hospital relating
to infection control and develops a cost-effective program by cost analysis of
personnel , supplies and equipment.
ASSESSMENT TOOL FOR EVALUATING NURSING STANDARD,
NURSING SERVICE, AND NURSING EDUCATION

Introduction
Evaluation of the student clinical practice is critical element in professional educational
programme. Evaluations of the learner’s practice still occurs in an environment with built
in threats and pressure. Since the nursing process is the methodology of practice the
major point in evaluating clinical practice is the learner’s competency in using a process.

Definition of Evaluating: Evaluating is the process of determining to what intent the

educational objectives are being realized.

Principles of clinical evaluation:

Need to be
Objective
Reliable
Valid
Acceptable
Feasible
Assessment Instrument
1. Rating scale: Surgical Nursing practicing
2. Competency to be assessed.
 a. Data-gathering
b. Communication
c. Patient management planning
d. Reporting
3. Specific abilities to be assessed
a. Ability to meet basic and special nursing needs of adult patients.
b. Ability to communicate successfully with patients and health team members.
c. Ability to infer implications for nursing from current research and events.
d. Ability to develop rapport with patients.
4. Purpose of assessment : formative.
Used to assess clinical competence for each of two one week but highly relied
on for assigning a clinical guide in the last part of the course in adult medical
surgical nursing.
5. Comments no evaluation data are available
Clinical Evaluation Tool:
Key:
A: Excellent constantly outstanding achievement.
B: Very good consistently above minimum expectations.
C: Average consistently meets minimum expectations.
D: Poor minimum expectations not meet consistently
E: Fail unsatisfactory, unsafe performance
N/A: Not applicable
N/O: Not observed
Course behavior I.
Employs the nursing process in meeting with the basic and unique reach of adult
clients.
Criteria it will follow.
1. Obtain basic data on the client. 0 1 2 3 4 N/A
2. Identifies health problem and potential health problem
3. Validates Client problems in the clinical area
4. Formulates a plan care for assigned clients
5. Formulates goals related to potential health problem
6. Implements the plan of nursing care for assigned clients
7. Evaluating the plan of nursing care daily for assigned clients
Total points criteria (1-7) = 4+(3)+3( )2+ ( )1+( )O =_______

Course Behavior II
Employs communication stick in the collaborative process with members of the health
team using of adult clients.
Criteria:
8. Discuss with other team members their goals and plans
0 1 2 3 4 N/A
for clients so as to support or chance those plans through
nursing care.
9. Attends to clients need through use of referrals, both to
department with in the hospital and to other community
agencies
10. Informs other team members of progress towards
meeting goals for clients in order to ensure continuity.
11. Uses therapeutic interviewing techniques to obtain
subjective data from clients
Total points criteria (8-11) = 1( )4+( )3+( )2+ Q1+( )0 =________

Course Behavior III

0 1 2 3 4 N/A
Utilizes selected current research findings in approach to
nursing intervention for adult clients
Criteria:
12. Demonstrates the use of research findings in planning and for examining the rationale
for nursing intervention.
Course Behavior IV
Explores current health related events and their implications for professional growth and
action in adult nursing. 0 1 2 3 4 N/A
Criteria:
13. Submits in writing a critique of a specified activities. 0 1 2 3 4/A
Total points criteria (12-13) 4+Q3+Q2+ Q1+QO _____
Course Behavior V
Combines responsibility and accountability in providing health care for adult clients
Criteria:
14. Supports routines and regulations of health care 0 1 2 3 4 N/A
system and facilities compromise when goals of the
client and health care system are in conflict.
15. Report to the clinical unit prepared to care for
assigned
Clients.
16. Records all pertinent information concisely and legibly
on chart, kardex and medical records..
17. Verbally reports significant observations of charge
nurse or nursing staff members caring for client.
Total points criteria (14-17) = (14 )4+( )3+( )2+ Q1+( )O = _____
Course Behavior VI
18. Recognizes individual learning needs and avails self or opportunities of learning
19. Is self directing in providing care to clients?
20. Creates an atmosphere of mutual trust acceptance and 0 1 2 3 4 N/A
respect.Incorporate knowledge of self and self direction
in interpersonal relationship and learning situation.
Criteria:
Total points criteria (18-20) = Q4+( )3+( )2+ 1+( )O =
Course behavior VII.
Applies knowledge of principles and theories from the sciences and humanities in
accessing client.
Criteria
0 1 2 3 4 N/A
21. Discuss in clinical conference theoretical knowledge
related to the clients problems.
22. Utilities knowledge of medication in administering care to clients.

23. Integrates into nursing care knowledge of the major 0 1 2 3 4 N/A

health problems and stressor affecting the adult

population.
24. Utilizes knowledge of the teaching process in the
care
of clients.
2.5 Integrates knowledge of caution and prevention and
treatment procedure in the care of clients with injuries of
illness requiring immediate attention
Total points criteria (21-25) = 4+(3)+3( )2+ Q1+( )0 =________
Average_____
A sample budget table follows:

Twelve-Month Budget

Budget Categories Sponsor Other

Funds
Personnel
 Project Coordinator
 Research Assistant (full-time or ½ time)
 Subjects/participants
 Editor
 Technician
 Transcriptionist
Benefits (10 to 18 per cent of the salaries depending On
the type of appointments)
Equipment
 Computer
 Software (unique for project work)
 Other for lab
Project costs- materials and supplies
Laboratory supplies- project related
 Questionnaire forms
 photocopying
 a Telephone and pager
 Test materials
 Food/beverages for workshops (formerly hosting costs)
 Equipment less than $1000
Travel
 Travel to specific conference to report on results
 Travel for project data collection
Cotract for Services
 Service contracts for laboratory equipment
 Computer — data analysis advice
 Professional printer services
 Transcriptions
Other — Miscellaneous
 • Space rental (eg: inteirview room)
Sub total costs
Indirect Costs
15% - 40% of total costs for project (depending on the
type of the project)
Total Cost
Duty chart:
Sl. Name of the 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
No employee
1 Soumya jose N N N N N N N N/O E M M M M M D/O
2 Tharazacharia L M M M M M D/O N N N N N N N N/O
3 Sujatha shibu M E E E E D/O CL E E E E E M D/O N
4 Bincymol E M M D/O E E E M M M M D/O E E E
5 Anjanamma D/O E E M M E M D/O N N N N N N N
6 Kumar N/O E E E E E M D/O M M M M M M M
7 Robin M M E M M D/O E E E M M E D/O E E
8 Jaimon M M D/O E E M D/O N N N N N N N N
9 Anu Jacob N N N N N N N N N/O E E M D/O E M
10 Vijaya D/O N N N N N N N N/O M/O D/O L E M E
11 Shiby peter N N/O E E M M M E D/O E E M M E E
 Patients Classification System in Medical Intensive Care Unit

Month of January 2009

Steps: I
To predict patients days by level of patients activity
- Census report
- Classification data
Number of patients/ month
Census Report- 40
Steps: II
Category Level of care No. of patients
I Self care 4
II Minimal care 5
III Moderate care 5
IV Intermediate 6
V Intensive care 20

Step: III
Level Pats/day Std/hrs/day Hrs of care/ 24hrs
I 1 1.0 1
II 2 2.0 4.0
III - - -
IV - - -
V 2 14 28/33hrs

Steps: IV
Determine the working days / employee daily working hrs/ employees
Regular off 52
½ day 26
Annual leave 10
Casual leave 08
Sick leave 12
Public leave 10
Non working days 118
Total working days = 365-118 = 247
Steps V:
1 nurse= 247 days
Total no of Staff= 8
Therefore 12 nurse= 247 x 8= 1976 working days per year
To complete the number of nurses available per day, divide 1964 by the number of days in the
year
= 1976
365
= 5.41 Round of 6hrs
If the 6 nurses, each work an eight hours per day, they may be assigned as
follow
Day shift- 3
Evening shift- 2
Night shift- 1
Using ratio of 55% professional and 45% non professional
=18.7 x 55 = 10.2
100

=18.7 x 45 = 8.4
100