SOP FOR ORTHOPEDIC DEPARTMENT

1) RMO must reported on duty morning at 8 am.

2) RMO Will be working for 24/7. They must present in in hospital, with prior permission they can go
to home on post call day.

3) OPD /OT must start by 8:15am

4) Ward rounds must be completed before 9.am every day.

5) No outside drug or investigation routinely allowed, if and only if it is necessary it has to be

documented on printed form duly sign by RMO & with their MMC Reg. no this has to counter sign by
on duty Mo, ward S/N has to keep record of this.

6) While writing drug name on paper only generic name has to be written, no trade name is allowed
name of the drug must be complete in an on aspect i.e. name of patient full, with OPD or IPD no.
DOA Unit Name of drug Strength, no of days with frequency to take drug

7) After admitting pt in word pt daily BP must be taken & documented on his case paper irrespective
of whether he is Hypertensive or not

8) After admission pt. who require surgery with requirement of implant, approximate cost with
detail description of implant must be written on case paper

9) If pt. is poor he must be guided by S/N. Arogya Mitra for MJPJAY or PMJAY.

a) MJPJAY after registration preauthorization form must be filled in all aspects timely.

b) Only after getting preauthorization pt. posted for operation after completion of fitness.

c) preauthorization must be taken in one day advance. Pt. must not be posted for operation in
anticipation of preauthorization in coming morning.

d) Once preauthorization is received, then usually no change will be allowed for procedure in
operation.

If at all deviation from redecided procedure is essential then it has to be justified by Reg & counter
sing by unit HON, this has to be approved by Department .MO or Sr.MO well in advance. and should
be informed to patient and his close relative.

10) Pt examination findings, advice Investigation must be written in this paper clearly.

11) All lab & X ray, CT Scan, USG requisition from must be completely filled in all aspect.

12) There investigation report must be documented in brief on pt case paper.

13) If conservative management is decided it must be documented.

14) Hon advice must be written on paper under heading advice by HON.
15) Blood transfusion is serious procedure, consent for every transfusion is must. RMO. Must be
present during BT & up till 4 hrs. after BT.

BT note must be completed in all aspect like date, time, name of RMO , check blood bag no, exp.
date etc. .

No Bt is allowed after 9.pm.

In very exceptional situation with proper justification & permission from Hon, dept. MO or Sr OM or
duty MO night BT is allowed.

16) For treatment of tuberculosis RNTCP diagnostic algorithms must be followed.

Sputum for AFB or CBNAAT.

Body Fluid for CBNAAT

For body tissue sample has to send to LTMG before 2 pm from Mon to Sat with complete requisite
form. Radiological evidence could be consider for confirmation of tuberculosis, For culture, patient’s
sample must be sent in normal saline in sterile container to LTMG,JJ,GTB etc.

17) Pt investigation record with film, ECG, USG, etc. and their report must be kept in pts file till his
discharge.

RMO is not allowed to keep this record with them without prior permission of MS.

Since this is major referral hospital for eastern suburb & Thane districts. We are gating more no. of
pt. & we have limited resources.

To function smoothly & for better pt. service. Pt. selection for admission & procedure is given top
most importance.

For operation

1) Anesthetist fitness in all aspect must be completed, in word itself, fitness couldn’t ask over
operation table.
2) For HTN & Diabetic pt. BP & HGT must be recorded / check daily in night & 1 hr before operation
in ward itself.
3) If any operating surgeon or expert is coming from outside (Raja wadi Hospital) then permission
must be taken in advance with remark of unit Hon.
4) Consent for operation is to be taken very seriously.
a) Consent must be procedure specific well in advance.
b) Well in advance preferably on evening before operation so that pt & his relative get sufficient
time for their mental preparation.
c) Name & sign by pt. himself if major & if miner then sign of guardian or parent.
d) Sign. & name of operating RMO & Name of unit head with Reg. no. Of RMO (operating).
e) Date & time place must be mentioned on consent form.
5) Two OT table will be routinely given in present circumstances, so OT list of4 pt. (2 major & 2
minor) is allowed. If time permits & anesthetist allowed then add on can be put on list only after 2
pm after completion of routine list.
6) Priority of operation must be kept in mind. i.e. Patient with co morbid condition (i.e DM / HTN)
age, not as per convenience of operating staff.
7) If you cannot complete your list then pt must be destrave before 12 pm & reason must be
documented in his paper & ot register counter sign by Reg. & hon .immediately.
8) OT notes must be completely in written over OT register & pt’s case paper immediately. If not
done then OT sister I/C & ward sister I/C must bring this matter to administration coming morning so
that responsible RMO will not permitted to enter for next OT.
9) Evening round must be completed by 8 pm
10) For unknown pt. or pt without relative operation consent form must be sign by post MS, RMO &
HON of that unit & one post MS RMO or HON from another unit well in advance. Consent must be
sign by pt & RMO well in advance.
11) For poor pt if he or she can’t offer cost of implant & not eligible for MJPJAY or PMJAY help of
CDO must be taken for this RMO must give complete estimation of implant to CDO.
12) Discharge must be complete in all aspect i.e. MJPJAY or PMJAY procedure must be complete for
homeless or unknown pt discharge help of CDO his asked.