STANDARD OPERATING SYSTEM
Registration – OPD (FRONT DESK OFFICE)
Patient with attender or without attender approaches reception to avail
consultation.
Reception staffs to check with patient or attender about their query, according to
their query allotment of consultants been said and asked whether it is first visit or
subsequent visit.
If it is first visit gets patient information to register in software to generate the new
UHID.
Following information must be obtained during registration process:
1. Name
2. Age
3. Gender
4. Address
5. Contact phone number
6. Date & time of arrival
7. Login to specialist
If it is not first visit, reception staff enquires to patient for the registration
number / OPD file for direct login.
Once registration done handover to the concerned OPD nursing in-charge.
For referred patients, along with registration process following information has to
be filled in the referral slip and filed separately viz. name of referring Dr/facility
and reason for referral with signature and date.
For emergency patients, or critical patients are transported directly to critical care
unit and their registration will be completed when treatment in progress with the
help of accompanying member.
MEDICO – LEGAL Cases:
In case of patients involved in medico – legal cases the
procedure enumerated below shall be followed:
1.
All accidents (Road /Industrial)
2.
Assaults
3.
Suspicious cases
4.
Poisoning
5.
RTA shall be enlisted as MLC and recorded
in the case sheets.
The recording shall be done in Accident Register by Medical Officer and to be
informed to the Police according to the locations where been happened.
Admission process - IPD (OPD PROCEDURE TO IPD:
ADMISSION ADVICE: Patient visits the OPD depending upon the doctor’s assessment he / she
advises admission, reason for admission should be explained to the patient, attender by Medical
officer / OPD Nurse.
IN - PATIENT REGISTRATION: Admission formalities should be filled and filed by OPD Nurse
(as per Surgical / Medical Management case sheet) one who admitting the patient in proper manner
with following documents:
IPD File with Name, Age, Gender, UHID, Phone number
Medical Management
1. Ip Admission Slip – Signed by Chief Consultant
2. Admission and advance Slip - Signed by Patient / attender / Medical Officer
3. Admission Consent Form - Signed by Patient / attender / Medical Officer
4. Graphic (T.P.R) Chart
5. IN-PATIENT Case sheet
6. IN-PATIENT Drug chart
7. Vital's Chart
8. Intake - Output Chart
9. Initial Nursing Assessment Form
10. Doctor's Notes
11. Physiotherapist Notes
12. Nursing Progress Notes
13. Diabetic Chart
14. Billing Chart
Surgical Management
1. Ip Admission Slip – Signed by Chief Consultant
2. Admission and advance Slip - Signed by Patient / attender / Medical Officer
3. Admission Consent Form - Signed by Patient / attender / Medical Officer (with date / time)
4. Graphic (T.P.R) Chart
5. IN-PATIENT Case sheet
6. IN-PATIENT Drug chart
7. Vital's Chart
8. Intake - Output Chart
9. Initial Nursing Assessment Form
10. Doctor's Notes
11. Physiotherapist Notes
12. Nursing Progress Notes
13. Diabetic Chart
14. Billing Chart
15. Pre-operative Checklist
16. Operative Notes
17. Pre - Operative Anaesthetic
18. Surgical Consent Form
19. Anesthesia Consent Form
20. PACU Sheet
21. Surgical Safety Checklist
Shifting of patient to the ward and handover complete OPD notes & documents to
IPD ward in–charge nurse.
PROCESS MAP:
REGISTRATION OF Handover to OPD
ENTRY OF THE PATIENT
THE PATIENT / OPD Nursing in-charge
FILE
LAB
Monitoring the OPD
Investigation
Units
Radiological
investigation Vitals, maintaining
CONCERNED OPD
Medicine necessary records and
CONSULTANT
IPD referrals routing of the patient
to available OPD
IF ADMISSION
ADVISED IPD ADMISSION
WARD
ICU
BILLING
EXIT OF THE PATIENT
