Académique Documents
Professionnel Documents
Culture Documents
WHY???
Lets improve ourselves!! Not just for NABH accreditation
PART-A
Has to be duly filled by the Nurse in charge and make sure that it is filled by the time the treating surgeon comes!
PART-B
To be duly filled by the attending doctor! Simple MBBS Stuff
Discharge Planning
Need to be completed at admission
PLAN OF CARE
PLAN OF CARE MEDICAL/CONSERVATIVE Tick boxes make the job easy, its going to take only a few SURGICALof your time minutes
A good artist always signs off Consultants need to countersign every admission within 24 hours
Registrars
CASUALTY
CMO-Nurses-Registrars
IP
WITHIN 1 HOUR
IP
WITHIN 24 HOURS
Registrar Dietician-DMOConsultants
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
TIME OUT
All work should cease during a period of time when all members of the operative / procedural team,using active communication, confirms correct patient, correct procedure, correct site and side, sterility of the equipment availability of all items needed for anaesthesia and surgery antibiotic prophylaxis any patient allergies.
Donot start operating before this checklist is done MAKE TIMEOUT A HABIT
CONSENT
Please make sure it is taken by the treating doctor/ team member but not the nurse incharge!!!
SURGEONS NOTES
Admission Note
We need to explain to the pt Disease Inv needed Treatment process Cost ( estimated) Probable outcomes This form takes care of all this Please fill this at admission
Please fill in the orders Inv requested Plan of care Spl instructions Preop orders This form is for the pt to go from OPD / Casualty to the ward
Admission Note
This part need to be filled in by Front Office / Patient counselor
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
CODES
Emergency Codes
CODE BLUE RED BLACK PURPLE PINK MEANING MEDICAL EMERGENCY FIRE BOMB THREAT SECURITY THREAT CHILD ABDUCTION
Grey
HIC
HIC MANUAL Available on every desktop Antibiotic policy Hand Hygiene Surveillance Tool kit Needle stick injury
VULNERABLE PATIENTS
Admission and Discharge criteria for ICU Who all are Vulnerable patients and care of such of patients
Geriatric patients (>65 years of age) Pediatric patients (<16 years of age) Mentally challenged patients Physically challenged patients Comatose patients
10 COMMANDMENTS
Write Medications Order in Capital Letters. Document your visit with Notes Duly Signed with the Date, Time, Signature and Name. Avoid Verbal Orders. Use of Alcohol Hand Rub Before And After Each Patient Examination. Make a Habit of patient and Family education as Part of Care.
10 COMMANDMENTS
Ensure Informed Consent for all Procedures. Assess and Reassess Patient as per Hospital Policy. Prepare/ Counter Sign Discharge Summaries and Talk to Patient Regarding Discharge Instructions Follow-up and Care at Home. Prescribe as per Hospital Formulary and Follow the Antibiotic Policy.
Have Formal Meetings/ Briefings with the other Specialists when more than One Doctor is treating the Patient.