Registration / Help Desk and Billing Services

• You must ensure that all patients visiting the hospital are registered, unless the required services are unavailable, in which case the patient should be directed to the appropriate nearest facility. (Please also refer to Emergency Services)
• After registration, depending on the clinical need, the patient should be guided to the appropriate service area, such as OPD or ER.
• You are responsible for informing the patient about their rights and responsibilities, providing cost estimates, and offering guidance on third-party services such as insurance.
• Billing should be done according to the hospital tariff list, which should be made available to the patients in a suitable format.
  
  

Assessment and Plan of Care

• Every patient should undergo an initial assessment by qualified and/or trained personnel.
• Further management of the patient, including OPD treatment, admission, transfer/referral, and investigations, should be based on the findings of the initial assessment and conducted by a registered medical practitioner.
• Upon admission, a general consent for admission must be obtained.
• If there is no availability of beds or if clinical needs require, patients should be referred to another facility along with the necessary clinical information or notes. Safe transport arrangements must be ensured.
• You should ensure that reassessments of admitted patients are done at least once a day or as per clinical requirements, and these reassessments must be documented.
• Any examination, treatment, or management of a female patient should be done in the presence of a female attendant or nursing staff if performed by male personnel inside the hospital, and vice versa.
  
  

Informed Consent Procedure: Informed consent must be obtained from the patient, their next of kin, or legal guardian when required, according to prevailing guidelines and regulations. This consent should be in a language that the patient can understand, especially before procedures like invasive treatments, anaesthesia, blood transfusions, HIV testing, research, etc.

Care of Patient

• You must ensure that patient care is provided according to the best clinical practices, referencing Standard Treatment Guidelines as notified by relevant government bodies or national/international professional organizations.
• Patients and/or their families should be educated on preventive, curative, promotive, and rehabilitative aspects of care, either verbally or through printed materials.
• All relevant documents related to invasive procedures should be maintained in the patient’s record, including the procedure safety checklist.
• Patients must be monitored during and after all procedures, such as anaesthesia, surgeries, blood transfusions, etc., and this monitoring should be documented.
• All staff involved in direct patient care must receive basic training in CPR.
  
  

Emergency Services

• Emergency patients should be attended to on priority. The Emergency Department must be equipped with trained staff.
• If emergency services are unavailable in the hospital, first aid should be provided, and arrangements for appropriate transfer/referral should be made.
  
  

Medication Prescription, Administration, and Monitoring

• Prescriptions should include the patient’s name, date, name of the medication, dosage, route, frequency, duration, and the name, signature, and registration number of the prescribing medical practitioner, all in legible writing.
• Drug allergies should be ascertained before prescribing or administering medication. If any allergies are discovered, they should be communicated to the patient and recorded in the case sheet.
• Patient identity, medication, dose, route, timing, and expiry date must be verified prior to the administration of medication.
• Safe injection practices should be followed according to WHO guidelines.
• High-risk medicines must be identified and verified by two trained healthcare personnel before administration.
• Patients must be monitored after medication administration, and any adverse drug reactions or events should be recorded and reported.
  
  

Infection Control

• The hospital must follow standard precautions, including hand hygiene and the use of personal protective equipment, to reduce the risk of healthcare-associated infections.
• Adequate and proper spacing in patient care areas should be ensured to prevent the transmission of infections.
• Regular cleaning of all areas with disinfectants should be done as per prescribed and documented procedures.
• Infection control practices should be followed in high-risk areas such as the operation theatre, ICU, HDU, etc., as per good clinical practice guidelines.
• Housekeeping and sanitary services must maintain appropriate hygiene and sanitation in the facility.
  
  

Safety of Patients, Staff, Visitors, and Relatives

• Security and safety measures must be in place to ensure the safety of patients, staff, visitors, and relatives. For example, proper identification of mothers and babies in obstetric facilities.
• You must ensure the safety of patients, attendants, staff, and visitors by preparing for both fire and non-fire emergencies. This includes conducting periodic training, mock drills, and ensuring compliance with local fire safety laws.
• During an epidemic, natural calamity, or disaster, the hospital must cooperate with the designated authority and provide reasonable assistance and medical aid as necessary.
  
  

Patient Information and Education

• You must explain the disease condition, proposed care, including risks, alternatives, and benefits to the patient and/or their family. You must also inform them of the expected cost of treatment and any progress or changes in the patient’s condition.
• Patient and/or family members should be educated on the safe and effective use of medication, food-drug interactions, diet, and disease prevention strategies.
  
  

Discharge

A discharge summary should be provided to all patients discharged from the hospital. It should contain relevant information in an understandable format, including the points specified below:

• • Name and registration number of the treating doctor.
  • Patient’s name, demographic details, and contact number (if available).
  • Date of admission and discharge.
  • Relevant clinical history, assessment findings, and diagnosis.
  • Investigation results.
  • Details of medical treatment, invasive procedures, surgeries, and other care provided.
  • Discharge advice, including medications and other instructions.
  • Instructions on how to obtain urgent care.
    
    

Informed Consent / Consent Guidelines

The informed consent should include, at a minimum:

• • Name of the patient or guardian (in case of a minor or mentally disabled).
  • Registration number of the patient.
  • Date of admission.
  • Name and registration number of the treating doctor.
  • Name of the procedure, operation, investigation, blood transfusion, anaesthesia, or potential complications.
  • Signature of the patient/guardian with the date and time.
    
    

Discharge Summary

The discharge summary should include, at a minimum:

• • Name and registration number of the treating doctor.
  • Name, demographic details, and contact number of the patient (if available).
  • Date of admission and discharge.
  • Relevant clinical history, assessment findings, and diagnosis.
  • Investigation results.
  • Details of medical treatment, invasive procedures, surgeries, and other care provided.
  • Discharge advice, including medications and other instructions.
  • Instructions on when and how to obtain urgent care.