Doctor - 2019

Date of Issue :
Doctors Manual 10/4/2019

Date of Revision:
Document No :
28/03/2019
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Issue no : 07
DOCTORS POLICY AND

PROCEDURE MANUAL
Prepared by: Quality Department Reviewed by: Quality Department
Approved by: Medical Director Signature:

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Index
Policy No. Policy Page No.
1 List of services provided by star hospital 5-6
2 Criteria for admission of patients into hospital 7
3 Criteria for admission of patients into ICUS 8-13
4 Uniform care of Patients 14
5 Initial assessment of patient by doctors 15-16
6 Reassessment of patients 17-18
7 Care of patient 19
8 Prescription of medication 20-30
9 Verbal Medication Orders 31-32
10 Monitoring of patients after medication administration 33
11 Self-administration of medication and patients own 34
medications
12 Adverse drug reactions 35-36
13 Referral policy 37-38
14 Pain management 39-41
15 Fall risk assessment 42
16 Patient Counseling 43-45
17 Medical record 46-48
18 HIV screening of patients 49
19 Care of patients undergoing surgical procedure 50-51
20 Consent 52-56
21 Care of patients requiring cardio-pulmonary resuscitation 57-66
22 Discharge 67-68
23 Leaving against medical advice (LAMA) 69
24 Patient expiry 70
25 Providing End of life care 71-74

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26 Hospital infection control 75-77

27 Quality assurance for patient care 78
28 Role of doctors in emergency codes 79-80
29 Human resource related requirements 81
30 Policy on standard abbreviations for use in Medical Records 82-96
and medication orders
31 Effective communication 97-103
32 Scope of individual departments 104-111
33 Hospital wide Policies 112-143
34 Service Rules 144-171
35 Employee dress code and grooming policy 172

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1. LIST OF SERVICES PROVIDED BY STAR HOSPITAL

1. Anesthesiology
2. Bariatric surgery
3. Blood Bank
4. Cardiothoracic Surgery- Adult
5. Cardiothoracic Surgery- Pediatric
6. Cardiology - Adult & Pediatric
7. Critical Care Medicine
8. CTICU
9. Cosmetic and Reconstructive Surgery
10. Dermatology
11. Dialysis
12. Dietetics
13. Emergency Medicine and Ambulance services
14. Endocrinology
15. ENT
16. Gastroenterology ( Medical, surgery)
17. General Surgery
18. Gynecology and obstetrics
19. ICU
20. Internal Medicine
21. Laboratory Medicine
22. Minimal Access Surgery
23. Nephrology
24. Neurology
25. Neurophysiology( EEG, ENMG)
26. Neurosurgery

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27. Orthopedics and Trauma

28. Ophthalmology(OP services
29. Arthroscopy and joint replacement
30. Pediatric ICU
31. Pediatrics
32. Pharmacy
33. Physiotherapy
34. Pulmonology
35. Psychiatry(OP services)
36. Radio Diagnostics ( MRI, CT scan and USG, X- ray)
37. Renal Transplant
38. Rheumatology
39. Sports Medicine
40. Spine surgery
41. Urology
42. Vascular Surgery

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2. Criteria for admission of patients into hospital:

2. 1 Diagnosis—what patient have
2. 2 Prognosis—what most likely will happen because of patient conditions and in what
time frame
2. 3 Whether patient require care that cannot be given as an outpatient
2. 4 Whether patient require diagnostic testing that cannot be performed as an outpatient
2. 5 Outpatient care fails to improve patient condition
2. 6 Patient need surgery
2. 7 Whether patient require the immediate service of a consultant
2. 8 Patient past medical history
2. 9 The possibility of patient medical concern could be serious
2. 10 Other medical problems that may complicate or cause the current problem to get
worse
2. 11 Abnormal tests, ECGs, lab work, x-rays
2. 12 Abnormal physical exam
2. 13 Unstable vital signs—temperature, heart rate, blood pressure, oxygen concentration
in patient blood

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3. Criteria for admission of patients into ICUs:

3.1. Policy
3.1.1 Intensive care is appropriate for patients requiring or likely to require
3.1.2 Advanced respiratory support needed,
3.1.3 Patients requiring support of two or more organ systems,
3.1.4 Patients with chronic impairment of one or more organ systems who also require
support for an acute reversible failure of another organ
3.1.5 Criteria should be based on physiological parameters
Procedure
3.2. (Objective Parameters Model)
3.2.1. Early warning system
Score 3 2 1 0 1 2 3
Heart rate <40 41-50 51-100 101-110 111-130 >130
Mean BP <70 71-80 81-100 101-199 >200
Resp. rate <8 9-14 15-20 21-29 >30
35.1-
Temperature <35 36.6-37.4 >37.5
36.5
Respond to Respond to
Conscious level Awake No Response
voice pain
(Scores1-0-1 can be managed in wards. Others refer to ICU.)

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3.2.2. Vital Signs

1. Pulse rate <40 or >140 beats / min
2. Systolic arterial pressure less than 80 mmHg or 20 mmHg below the patient’s usual
pressure.
3. Diastolic arterial pressure more than 120 mmHg
4. Mean arterial pressure less than 60 mmHg
5. Respiratory rate >40 or <8 breaths / min with signs of respiratory distress
6. Oxygen saturation <90% on >50% oxygen
7. Scoring systems based on assessment of physiological dysfunction

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3.2.3. LABORATORY VALUES (newly discovered)

1. Serum sodium < 110 meq / L or > 170 meq / L
2. Serum potassium <2.0 meq /L or > 7.0 meq / L
3. PaO2 < 50 mm Hg on FIO2 >0.5
4. pH <7.1 or > 7.7
5. Serum glucose> 800 mg/dL
6. Serum calcium > 15 mg/dL
7. Toxic level of drugs or other chemical substance in a hemodynamically or
neurologically compromised patient.
3.2.4. Radiography/ Ultrasonography/ Tomography (newly discovered)

1. Cerebral vascular hemorrhage, contusion or subarachnoid hemorrhage with altered
mental status or focal neurological signs
2. Ruptured viscera, bladder, liver, esophageal verices or uterus with hemodynamic
instability
3. Dissecting aortic aneurysm
3.2.5. Physical Findings (acute onset)

1. Unequal pupils in an unconscious patient
2. Anuria in the presence of functioning catheter in the bladder
3. Airway obstruction
4. Coma
5. Continuous seizures

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3.3. Diagnosis model

3.3.1 Pulmonary system
1. Acute respiratory failure requiring ventilatory support
2. Pulmonary emboli with hemodynamic instability
3. Patients in an intermediate care unit who are demonstrating respiratory deterioration
4. Massive hemoptysis
5. Upper airway obstruction
3.3.2 Cardiovascular
1. Shock states
2. Life-threatening dysrhythmias
3. Dissecting aortic aneurysms
4. Hypertensive emergencies
5. Need for continuous invasive monitoring of cardiovascular system (arterial pressure,
central venous pressure, cardiac output)
3.3.3 Neurological Disorders

1. Acute stroke with altered mental status
2. Coma: metabolic, toxic or anoxic
3. Intracranial hemorrhage with potential for herniation
4. Acute subarachnoid hemorrhage (SAH)
5. Meningitis with altered mental status or respiratory compromise
6. Central nervous system or neuromuscular disorders with deteriorating neurological or
pulmonary function
7. Status epilepticus.
8. Vasospasm
9. Severe head injured patients ( GCS< 8)

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10. Brain dead or potentially brain dead patients who are being aggressively managed
while determining organ donation status
3.3.4 Drug Ingestion And Drug Overdose

1. Patient with history of drug overdose or drug ingestion who presented with:
2. Hemodynamic instability or
3. Deterioration of level of consciousness with threatened airway or
4. Seizures or
5. Serious side effect which need close monitoring
3.3.5 Gastrointestinal Disorders

1. Life-threatening gastrointestinal bleeding with hypotension, angina or continued
bleeding
2. Fulminant hepatic failure
3. Severe pancreatitis
4. Perforated viscous with or without mediastinitis
3.3.6 Renal
1. Requirement for acute renal replacement therapies in an unstable patient
2. Acute rhabdomyolysis with renal insufficiency
3.3.7 Endocrine
1. Diabetic ketoacidosis complicated by hemodynamic instability, altered mental status
2. Severe metabolic acidotic states
3. Thyroid storm or myxedema coma with hemodynamic instability
4. Hyperosmolar state with coma and/or hemodynamic instability
5. Adrenal crises with hemodynamic instability
6. Other severe electrolyte abnormalities, such as:

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a) Hypo or hyperkalemia with dysrhythmias or muscular weakness

b) Severe hypo or hypernatremia with seizures, altered mental status
c) Severe hypercalcemia with altered mental status, requiring hemodynamic
monitoring
d) Hypophosphatemia with muscular weakness
e) Hypo- or hypermagnesemia with hemodynamic compromise or dysrhythmias
3.3.8 Hematology
1) Severe coagulopathy and/or bleeding diathesis
2) Severe anemia resulting in hemodynamic and/or respiratory compromise
3) Severe complications of sickle cell crisis
4) Hematological malignancies with multi-organ failure
3.3.9. Surgical
1) High risk patients in the peri-operative period
2) Postoperative patients requiring hemodynamic monitoring/ ventilatory support or
extensive nursing care.
3) Postoperative patients with anesthetic or surgical complications requiring ventilatory
support or close monitoring.
4) Postoperative patients with concomitant medical disease or impending system failure.
3.3.10 Miscellaneous
1) Septic shock with hemodynamic instability.
2) Environmental injuries ( lighting, near drowning, hypo/ hyperthermia)

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4 UNIFORM CARE OF PATIENTS:

4.1 Policy:
4.1.1 Care delivery is uniform for a given health problem when similar care is provided in
more than one setting
4.1.2 Hospital adopts evidence-based medicine and clinical practice guidelines to guide
uniform patient care
4.2. Procedure:
4.2.1 It is the right of the patient for uniform care irrespective of race, color, caste, religion
or country of origin.
4.2.2 All patients approaching the hospital for medical treatment will receive care
appropriate to their healthcare need and scope of services provided by the hospital.
4.2.3 Quality of medical care will be same in all care settings of the hospital and no
discrepancy of any sort will be followed in the provision of medical care.
4.2.4 All protocols are uniformly given in the same manner to all patients irrespective of the
category status
4.2.5 Uniform care is guided by all laws & regulation.

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5. Initial assessment of patient by doctors:

5.1. Policy:
5.1.1 The initial assessment is carried out by the authorized Doctor (Resident, Registrar,
consultant) to determine the initial care needed.
5.1.2 Initial assessment results in a documented care plan
5.1.3 Time with in which initial assessment needs to be completed is defined for OP and IP
patients
5.1.4 Within 24 hours it is to be signed by the treating doctor
5.2. Procedure:
5.2.1 Inpatients
5.2.1.1 In the IP, the assessment is performed by the resident Doctor/Registrar/consultant.
(IP initial assessment form has to be filled by the same doctor who is initially
attending the patient after admission irrespective of the place of admission (whether it
is ICU or Wards)
5.2.1.2 Initial assessment must be done with in defined time from the time of admission in
wards and time of arrival in the ER and ICU as shown below
Wards 2 hrs
ER 3 min
ICU 3 min
OP 30 min
5.2.1.3 Initial assessment is documented in the ER in the ER initial assessment form, in the
ICU and wards in the initial assessment form and in PICU in the PICU initial
assessment form.
5.2.1.4 The initial assessment includes
1. Patient details
2. Presenting complaints and past history along with family and personal history

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3. Drug allergies
4. Physical examination
5. Systemic examination
6. Pain assessment
7. Screening of nutritional needs
8. Provisional diagnosis
9. Plan of care which comprises of provisional/ differential diagnosis, medication
order, investigation plan, diet, preventive health aspects, psycho social aspects,
infection control measures, physiotherapy, other special care needs as applicable
for a given patient
10. Nutritional requirements of all patients are assessed by doctor and dietician.
11. All patients are screened for pain. Pain assessment to be done for all the patients
who complain of pain
5.2.1.5 The treating consultant must countersign the assessment and care plan within 24 hrs
5.2.2. Assessment of OP patients:

5.2.2.1 Outpatient are assessed during the clinical visit by the treating consultant.
5.2.2.2 Initial assessment includes:
1. Physical examination of the patient
2. Recording patient’s previous medical history
3. Nutritional Screening, identify patient at nutritional risk
4. Developing a plan of care
5. Based on the initial assessment of patient and established plan of care, reassessment
are performed and documented throughout the care process and follow up
appointments.

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6. Reassessment of Patients
6.1 Policy:
6.1.1 Reassessment must be done at least once a day (or) more frequently as required.
6.1.2 Patients are reassessed to determine their response to treatment and to plan further
treatment or discharge
6.1.3 Reassessment shall also be done in response to significant changes in patients
condition.
6.1.4 Reassessment shall be done for daycare patients or patients awaiting for admission/
bed.
6.1.5 Outpatients are informed of their next followup visit, where appropriate
6.1.6 For inpatients during reassessment he care plan is monitored and modified, where
found necessary and is documented in the progress notes.
6.1.7 Staff involved in direct clinical care document reassessment. The staff could be the
treating doctor or any member of the team.
6.2.1 Reassessment of IP patients:

6.2.1.1 Resident doctors:
6.2.1.1.1 To assist in the delivery of patient care as per the treatment plan.
6.2.1.1.2 Assessment of clinical condition in terms of signs & symptoms, response to
treatment.
6.2.1.1.3 Make note of any new symptom that has arisen.
6.2.1.1.4 Perform relevant physical examination & assess the condition in terms of
improvement or deterioration.
6.2.1.1.5 Initiate treatment for any new symptom.
6.2.1.1.6 Inform the consultant of any emergency or need for change in plan of care.
6.2.1.1.7 Assess the investigation reports timely & inform the consultant of all abnormal
reports immediately. Initiate treatment accordingly.

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6.2.1.1.8 Accompany the consultants on rounds & share the reassessment findings. Make
note of all the orders on rounds.
6.2.1.1.9 Inform the patient & attendants of any procedure required or change in treatment
plan etc.
6.2.1.1.10 Reassessment details along with the vitals checked to be documented in the
progress notes which should be Clear, legible, dated, timed, named and signed by
the treating doctor.
6.2.1.2 Consultants:
6.2.1.2.1 Assessment of clinical condition in terms of signs &symptoms, formulation of
care plan.
6.2.1.2.2 Reassess plan of care & medication, according to response to treatment.
6.2.1.2.3 Mention change in diagnosis, if any.
6.2.1.2.4 Reassessment will include need of reevaluation with diagnostic & radiological
testing.
6.2.1.2.5 Need for any cross consultation by other specialist.
6.2.1.2.6 Physical needs of the patient as per ailment. (Ambulation, position in bed etc.)
6.2.1.2.7 Make notes of the change required for patient’s diet.
6.2.1.2.8 Update the patient & attendants with all progress in condition, investigation
reports, need of procedure, cross consultation, plan for discharge etc.
6.2.1.2.9 Reassessment details along with the vitals checked to be documented in the
progress notes which should be Clear, legible, dated, timed, named and signed by
the treating doctor.
6.2.2 Reassessment of OP patients:

6.2.2.1 Out patients are informed of their next follow-up visit.
6.2.2.2 This should be documented in the case sheet
6.2.2.3 During reassessment the care plan will be modified based on patient condition.

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7. Care of patient:
7.1. Policy: Care of patients is continuous and multidisciplinary in nature
7.2. Procedure:
7.2.1 The patient primary consultant is being responsible for patient care
7.2.2 Care of the patient is coordinated among the doctors in a given setting- OPD,
Emergency, IP, ICU ETC.
7.2.3 Doctors must ensure that there is effective communication of patient’s requirement
among themselves in all settings
7.2.4 The information about the patients care and response to treatment is shared among the
care providers through discussions or by entries in case sheet
7.2.5 Information regarding the patient is exchanged between the doctors at the time of
transfers between departments through transfer note written in progress notes
7.2.6 The medical record of the patient will be made available to the care providers in the
nursing stations. Nursing staff are responsible to keep the medical record of the
patient
7.2.7 The following in-house aids are provided to assist in the care of the patients
1. Online access to laboratory reports
2. Infection control manual( available in ICU)
3. Formulary (online access on consultants desk top)
4. Antibiotic policy (online access on consultants desk top)
5. Nursing standard operating procedure ( at the nursing station)

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8. Prescription of medication:
8.1 Policy:
8.1.1 Prescription should incorporate good practices/ Guidelines for rational prescription of
medications
8.1.2 Minimum requirements of the prescription must be met every time while writing the
prescription.
8.2. Procedure:
8. 2.1 Prescription is done by the treating doctor in the medication order chart for inpatients
and in the OPD sheet in the bottom right corner for OP patients.
8. 2.2 At a minimum , the prescription shall have the name of the patient, OP/IP Number,
name of the drug, Dose, Route and frequency of administration
8. 2.3 All the Medication orders should be Clear, legible, dated, timed, named and signed
bythe treating doctor.
8. 2.4 All hand written prescriptions shall be written in capital letters
8. 2.5 Prescription orders should be written daily or authorized daily by the treating doctor, a
member in the team.
8. 2.6 Phrases like CST/ Continue same treatment/ Repeat all etc should not be accepted
8. 2.7 Whenever there is a modification in the medication order in the existing order for
particular drug, a fresh order will have to be written for that drug
8. 2.8 Medication orders are recorded separately if the doses differ for each time of
administration.
8. 2.9 When writing prescription, abbreviations listed in the approved list (annexure) only
must be used.
8. 2.10 Prescription errors or illegible prescriptions will be initialed after single strike through
and rewritten

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8. 2.11 In case of a medicine(Tablet/ Capsule/ Injection) having two or more drugs the
name and the dose of all the individual drugs has to be written when ever
medications are ordered.
8. 2.12 It is not necessary for preparations having a combination of vitamins and / or
minerals. Similarly, if the combination of medication comes only in one strength, it
is not necessary.
8. 2.13 For prescribing the antibiotics the antibiotic policy of the hospital need to be
followed.
Guidelines for documenting Medication order and administration chart

General instructions
 All prescriptions shall be in CAPITAL LETTERS
 All orders are to be written legibly in ink
 A medication order is valid only if the Doctor enters all the required items
 Only accepted abbreviations should be used. Dangerous abbreviations must be
avoided
 A separate order is required for each medicine.
 No erasers or “whiteout” can be used. Orders MUST be rewritten if any changes are
made, especially changes to dose and/or frequency.
 The medication orders are authorized daily by the consultant or a member in the team
of doctors
(Supporting document - policy on standard abbreviations for use in medical records and
medication orders)
1. Specimen Signature:
 The person making entries for the first time in the medication order chart must
mention their name and designation and do a specimen signature so that there is no
need to write the name every time he or she signs in the medication order chart

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Name Signature Designation

Dr. XYZ Consultant
2. Numbering of Medication order and administration chart

 The Medication order and administration chart must be numbered immediately before
putting into use for patient
 If more than one Medication order and administration chart in used, then this must be
indicated by entering the appropriate chart numbers Eg: 1 of 2
 If additional sheets are used that should be mentioned in the column with number of
sheets used
MEDICATION ORDERS AND Chart No: ____1___ of _______1_________
ADMINISTRATION CHART Charts in use
Only one chart is in use for the patient

MEDICATION ORDERS AND Chart No: ____1___ of _______1+1________
MEDICATION ORDERS AND Chart No: ____2___ of _______1+1________

If Second chart is kept for use, add +1 to the first chart and mention the chart number as 2 on
the added chart
3. Patient details :
The first prescriber must Document

Name of the patient :Mr. Sreenivas . K Weight:65 Kg Height: 160 cm
Age/ Gender:40 yrs/ Male IP No:6789 Ward: Cubicle Ward Bed no:3
4. Drug Allergies and Adverse drug reaction alerts:

 Complete “Allergies and Adverse Drug Reactions (ADR)” details for all patients.
 Once the information has been documented, the person documenting the information
must sign, date and time the entry.
 If any information is added to this section after the initial assessment the person
adding the information must document their initials.
 If the patient is not aware of any previous ADRs, then the No box should be ticked.
 If a previous ADR exists Yes Box should be ticked , then document the following
information in the space provided

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 Name of drug/substance
 Reaction details (eg rash, diarrhea) and type of reaction (e.g. allergy,
anaphylaxis)
 Date that reactions occurred (or approximate timeframe eg “20 years ago”)
 Note: This is the minimum information that should be documented. It is preferable

also to document how the reaction was managed (eg “withdraw & avoid offending
agent”) and the source of the information (eg patient self-report, previous
Allergies and Adverse drug reactions: Yes No If yes: Medicine( or other), Reaction/ type/ Date
Patient had generalized rash with Inj. Monocef during his last admission in the month of June-2016
11/11/2016 8:00 am
( Sign, Date and Time )

documentation in medical notes etc).Eg:
5. STAT Medication and Pre-Anesthesia premedication’s:

 If DMO initiates any medication / STAT medication to the patient that should be
written in this column
 DMO must sign the in the prescribers column
 Consultant in their rounds must check the drug prescribed and if want to continue the
drug to the patient, consultant must document the same in the respective sections of
medication order chart
DMO initiated medicines and Anesthesia premedication’s

Date and time Medicines Dose Route Prescriber sign Time of Nursing staff sign
( Prescribed) administration Given Check
11/11/2016 INJ. PAN 40 mg IV 8: 20 am
8:00 am
6. Telephone orders:
 This section will be filled by the Nursing staff taking verbal orders
 The telephone order MUST be signed and dated, or otherwise confirmed in writing by
the prescriber, within 24 hours.

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Telephone orders( to be signed within 24 hrs. of order)

Date/ Time Medicine Dose Route Frequency Prescriber Date/Time of Nursing staff Sign of the
name administration sign concerned
Doctor
with Date
11/11/2016 INJ. ZOFER 8 mg IV TID Dr. XYZ 11/11/2016
9:00 pm 10:00 pm
12/11/2016
7. Venous thromboembolism prophylaxis

 If the dose of VTE prophylaxis medicine needs to be changed, a new order should
be prescribed on a subsequent chart.
 Consultant/ one of the team member must counter the medication order chart
daily
 Four dose time sections allow these medicines to be administered up to four times
a day.
 Time of administration to be documented
 Initials of nurse that administers the dose and the checking nurse
Patient Name IP No.
VTE Prophylaxis Date 11/11 12/11
Drug Name: ENOXAPARIN Given 8 8

Time
a a Stop
check m m
Given 12/11/2016, 10 pm
Dose Route Frequenc Start Date 8 8
Time
40 mg Sub y 11/11/2016 check P P

cutaneous BD m m
Instructions if any Given
Time
check
Given
Time
Doctors Signature
check
Sign of the consultant/ team member ( to be signed daily)
8. Anticoagulant treatment record
The Anticoagulant treatment recordsection is shaded grey as an extra alert to indicate that it is
anhigh-risk medicine
The indication and target INR (based on guidelines) should be included when Anticoagulant
is initially ordered.
The name of anticoagulant need to be documented

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Anticoagulant treatment record ( drugs requiring INR monitoring )

INR target range : 2.0- 2.5 Clinical indication : MVR ( Tissue valve)
Drug Name : Tab. ACITROM

Date 11/11/2016, 12 pm
Time
PT INR 27.8
result 2.02
Dose 2 mg
Frequency OD
Time to be given 6 pm
at
Dr. Sign
Time given 6 pm
Nurse sign
Given
checked
9. Regular medicines
Regular medication Patient name: IP No:
Start Date Drug Date 11/11 12/11

11/11/2016 TAB. T Given 8 8
No
i
m a a
NEUGABA e
Check
m m
T Given
Dose Route Freque i
Continue on Discharge Yes

Check
ncy m
e
Doctors sign
75 mg Oral T Given Duration:
i
OD m Check
e
T Given
Instructions if any i
m Check
e
Administration at 8 am T
i
Given
m Check
e
T Given
i
Prescribing Doctors Sign m
e
Check
Sign of the consultant/ team member (

to be signed daily)
Sign of Clinical Pharmacist
Limited duration medicines


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When a medicine is ordered for a limited duration, or only on certain days, this must be
clearly indicated using crosses (X) to block out day/times when the drug is NOT to be given
Start Drug Date 11/11 12/1 13/11

Date TAB. NEUGABA 1
No
Ti Given 8
11/11/2 me
a
016 Check
m
Ti Given 8
Dose Route Frequency me

Check
P
M
Doctors sign
75 mg Oral BD for 3 days
Duration:
Ti Given
post OP me
Check
Ti Given
Instructions if any me
Check
Only for 3 days post OP Ti

me
Given
Check
Ti Given
me
Prescribing Doctors Sign Check
Sign of the consultant/ team member ( to

be signed daily)
Eg:
Intermittent dosing orders Medicines requiring intermittent administration must be clearly
indicated by crossing out the days/times when the drug is NOT to be given.
Start Date Drug Date 11/11 12/11 13/11 14/11 15/11 16/11 17/1
11/11/2016 TAB. NEUGABA 1
No
Time Given 8 8a 8a
Check
a m m
m
Time Given 8 8 8
Dose Route Frequency
Check
P P P Continue on Discharge Yes
M M M
Doctors sign
75 mg Oral BD Time Given
Duration:
Check
Time Given
Instructions if any
Check
On alternate days for 4 Time Given
days Check
Time Given

to be signed daily)

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Ceased medicines
 When stopping a medicine, the original order must not be obliterated.
 The medical officer must draw a clear line through the order in both the prescription
and the administration record sections, taking care that the line does not impinge on
other orders.
 The medical officer must write the reason for changing the order (eg Stopped, written
in error, increased dose etc) at an appropriate place in the administration record
section.
 When a medication order needs to be changed, the medical officer must not over write
the order. The original order must be ceased and a new order written.
 The medication administration record provides space to record up to Eight days of
therapy. At the end of eight days, a new chart should be written.

11/11/201 TAB. NEUGABA Time Given 8 8a Stopped – Not required
No
a m
6 Check
m 13/11/2016, 10 pm
Time Given

Check
Doctors sign
75 mg Oral OD Time Given
Duration:
Check
Time Given
Instructions if any
Check
Administration at 8 am Time Given
Check
Time Given

to be signed daily)
10. As required medicines
As required medicine Patient Name IP NO:
Star date Drug Date 11/11 11/11 11/11

Discharge
Duration:
Continue
11/11/2016 PARACETAMOL
Doctors
Yes
No
on
Dose Route Frequency Time 8 am 12 noon 4 pm

500 mg ORAL 4TH HOURLY

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Indication Dose 500 mg 500 mg 500 mg

Febrile
Route oral oral oral
Given
Prescribing Doctors Sign
Check
Sign of the consultant/ team member ( to be
signed daily)
11. Variable dose medicines ordering

This section has been formatted to facilitate ordering of medicines that require variable
dosing based on laboratory test results or as a reducing protocol
Each table in this section is applicable to one drug
For each day of therapy, the following information should be documented by the
prescriber:
 Date
 Dosage (Pre Breakfast, Pre Lunch, Pre Dinner, Bed Time)
 Doctor’s initials
Variable dose drug chart Patient Name IP No:
Date Test Result Drug Name Dose Sign of Time of Sign of

Doctor administration Nursing
staff
11/11/2016 XXX NOVORAPID 20 units 8 am
12. Intravenous infusion therapy:

Patient Name IP No:
Intravenous Infusion
Therapy
Prescriptio Infusion Volum Infusion Addition to Prescribi Infusio Nurse Sign Sign of
n date and Solution e rate infusion ng n start sign of clinical
time Doctors time Docto Pharmacis
Drug Dose Sign Infusio r t
n End
time
11/11/2016 5% 1L EIGHT KC 20 8 am
8:00 am GLUCOS HOUR L mmol
E S 4 pm

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13. Discharge Medication

 For each drug prescribed while an inpatient, the following information must be
documented in the
 Tick YES if need to continue medicine on discharge
 Tick NO if not needed in the discharge medications
 Mention the duration of medication usage required for the patient
 Sign of the doctor
 If the concerned doctor want to add other medicines which were not prescribed
while an inpatient or those medicines with change in dose, route, frequency must
be documented in the discharge medicines section of medication order chart with
sign of the prescriber

No
11/11/2016 TAB. NEUGABA Time Given 8 8
Check
a a
m m
Continue on Discharge Yes 

Time Given
Duration: 5 days
Check
Oral OD
Doctors sign
75 mg Time Given
Check
Time Given
Instructions if any
Check
Administration at 8 am Time Given
Check
Time Given

to be signed daily)
Discharge medication : ( write a new prescription if there is a need to write additional discharge medication or to
change the dose , route and frequency of the medication prescribe during the hospital stay)
( Name of the drug, Dose, Route, Frequency, Duration)
Sign of the prescriber

Date and time

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14. Reasons for not administering

When it is not possible to administer the prescribed medicine, the reason for not
administering must be recorded by entering the appropriate code with red ink pen and
circle it
Reason Code Reason Code
Fasting/ NBM Not available-

F N
supply
Refused Withheld (on

R W
hold)
Vomiting
V

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9.Verbal orders of Medication:

9.1 Verbal orders must be recorded by the resident doctor/ nursing staff in the medical
record.
9.2 Verbal medication orders will include the following information:
1. Date and time order is received
2. Patient name
3. Drug name (brand or generic)
4. Dosage form (e.g., tablets, capsules, inhalants, etc.)
5. Strength or concentration
6. Dose
7. Frequency
8. Route
9. Quantity and/or duration
10. Name of prescriber
11. Signature of order recipient
9.3 The prescriber and the receiver must follow the below mentioned rules for verbal
orders
1. Spell the name of the medication
2. Inform the purpose of the drug to ensure that the order makes sense in the context of
the patient’s condition
3. Inform the mg/kg dose along with the patient’s specific dose for all verbal
neonatal/pediatric medication orders
4. Express doses of medications by unit of weight (e.g., mg, g, mEq, mMol)
5. Pronounce numerical digits separately—saying, for example, “one six” instead of
“sixteen.”
6. Verbal orders, when spoken and when transcribed, will use only approved
abbreviations

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7. When the nursing staff or the doctors call to take or give the verbal orders, the caller
must identify themselves by name and designation.
8. The caller must identify the patient by Name, IP Number and the ward/ bed number.
9. The nursing staff receiving the verbal orders should immediately write down in the
medication order chart/ nondrug order chart respectively.
10. After writing down the orders the nursing staff must read back the prescription.
11. The nursing staff must follow the above rules while reading back the prescription.
12. The doctor giving the verbal orders must confirm that the prescription read by the
nursing staff is correct. Than only the verbal order is deemed complete.
13. The nursing staff receiving the verbal orders should mention the name of the doctor as
“verbal order advised by------------“.
14. The nursing staff who received the verbal order must also mention his/ her ID number
and sign the order.
9.4 The prescriber must counter sign the verbal orders within 24 hours. This is not
applicable if a doctor of the team consulted the treating doctor and writes down the
orders.
9.5 Drugs that will not be considered under verbal order for medication are:
Sedatives
Anaesthetic drugs
Narcotics

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10. Monitoring of patients after medication administration:

10.1 After 15-20 min of administering the medication, all the patients are monitored again
by the assigned Nursing person and the same is documented in the nurse’s notes.
10.2 Close monitoring of patient is required in case of administering
 High risk medications
 Concentrated electrolytes
 Chemotherapeutic drugs
10.3 Monitoring of patent medication administration is done collaboratively by the nurse,
doctor and clinical pharmacist
10.4 Medications are changed based on the monitoring results based on the clinical
response and adverse drug reactions

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11. Self-administration of medication and patients own medications :

11.1 Self-administration of medicines is not allowed as long as the patient stays in the
hospital.
11.2 The nursing staff only administers the medicines after cross checking the prescription.
11.3 Home medications as well as medicines brought from outside of the hospital are not
allowed for administration to the patient.
11.4 Medicines needed for patients are only indented by hospital staff to hospital pharmacy

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12. Adverse drug reactions:

12.1 Policy:
12.1.1 Adverse drug events are defined and recorded.
12.1.2 All Adverse drug reactions are analyzed and CAPA are taken as required.
12.2. Definitions:
12.2.1 Adverse Drug Event: Any untoward medical occurrence that may present during
treatment with the pharmaceutical product but which do not necessarily have a casual
relationship with this treatment
Adverse drug event comprises of both:
Adverse drug reaction
Medication error
12.2.2 Adverse Drug Reaction: a response to a drug which is noxious and unintended and
which occurs at doses normally used in man for prophylaxis, diagnosis or therapy of
disease or for the modification of physiological function
12.2.3 Medication error:Medication error is any preventable event that may cause or lead to
inappropriate medication use or patient harm while the medication is in control of the
health care professional., patient or consumer. Such events may be related to
professional practice, health care products, procedures and systems, including
prescribing, order communication, product labelling, packing and nomenclature,
compounding, dispensing, distribution, administration, education, and use.
12.2.4 Near Miss: a near miss is an unplanned event that did not result in injury, illness, or
damage but had the potential to do so.
12.3. Procedure
12.3.1 Nurse at the time of admission and in between also instruct both the patient and
relatives to ring the bell provided in the room in case of any emergency or if they
want to call the staff nurse on duty for any other purpose.

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12.3.2 In Intensive care units, direct observation of patients is done by the nurses because
they are available near the patient always.
12.3.3 Adverse drug events are reported immediately to the primary care consultant / his
team after the event is observed
12.3.4 The incident is informed to pharmacy chief also immediately so that the bottle /
injections with same batch numbers can be withdrawn from all departments.
12.3.5 Adverse drug events reports are sent to the Drug and Therapeutic committee for
analysis and corrective action.
12.3.6 The Adverse Drug Reaction has to be recorded in the case file and nurses records by
doctor / nurse.
12.3.7 If patients develop any kind of adverse drug reactions the information will be given to
the primary consultant immediately
12.3.8 The consultant to attend the patient immediately and advice the treatment s indicated.
12.3.9 The adverse drug reaction incident form will be filled by the nursing staff and to be
signed by the consultant

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13. Referral policy:

13.1 Policy:
13.1.1 All referrals shall be based on clinical significance and for better outcome
13.1.2 All referrals shall be seen with in the defined time frame
13.2. External referrals:
13.2.1 Decision to refer a patient for consultation to other clinical specialty will be taken by
the primary treating consultant of the patient.
13.2.2 In case the required medical specialty is not available in the hospital the treating
consultant will refer the patient to the concerned specialty in other Hospital.
13.2.3 The primary treating consultant of the patient will indicate the same in writing in the
patient’s medical records.
13.2.4 A transfer form containing details of the patient’s diagnosis, treatment given, reason
for referral etc is filled by the referring consultant and the same is attached in the
patient’s medical records.
13.3 Internal referrals (cross referrals)
13.3.1 If patient require cross reference for his ailments the primary consultant need to
mention in the case sheet of the patient the consultant name/ department to whom he
want to refer.
13.3.2 The referred consultant will be informed about the cross referral by the nursing staff
through HIS
13.3.3 The referred consultant to assess the patient cross referred within half an hour for
emergency referrals and within 24 hours for others from the time of raising the
request for regular referrals and at the earliest depending on the urgency mentioned by
referring consultant.
13.4. Care transfer of patient to another consultant:
13.4.1 If patient needs to be transferred from one consultant/ department to another
consultant/ department based on the ailments/ prognosis of the patients the patient

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name will be transfer in the HIS by the request raised by the nursing staff as per the
written orders of the first consultant.

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14. Pain management:

14.1 Policy:
14.1.1 All patients must be screened for pain
14.1.2 Patients with pain undergo detailed assessment and periodic reassessment
14.1.3 Plans, supports, and coordinates activities and resources to ensure that the pain of all
individuals is recognized and addressed appropriately.
14.2. Assessment:
14.2.1 All patients admitted in the hospital need to be assessed for pain as the fifth vital sign
14.2.2 Pain assessment will be done to the patient while doing the initial assessment and
reassessed based on the intensity of the patient’s pain and the effectiveness of pain
relief strategies
14.2.3 This does not include chest pain due to angina or where the etiology of pain is
physiological like labour pain.
14.2.4 Pain assessment should include- Intensity of pain, pain character, frequency, location,
duration and referral and/or radiation.
14.2.5 The physician is notified of the patient’s pain when treatment fails to reduce the pain
to a level acceptable to the patient, as ordered by the physician, or pain score > 5
using the approved Pain Scales.
14.2.6 If no pain is present, the healthcare provider will reassess for pain as warranted by
patient condition, when the patient complains of pain and post invasive procedure.
14.3. Pain Scales:
14.3.1 The Numeric Pain Intensity Scale (NPIS) will be used universally to assess pain for
patients 13 years or older. Patients will be asked to rate their pain on a scale of 0-10.
Zero represents no pain; a rating of 5 would indicate that the patient is experiencing
moderate pain, and a rating of 10 would indicate the worst imaginable pain.
14.3.2 The Wong-Baker Faces Pain Scale, consisting of graduated facial expressions of
pain, will be used for patients, ages < 13 and those unable to comprehend the

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numerical scale. Zero will represent no hurt and a rating of 10 would indicate the
patient is experiencing the worst possible hurt.
14.3.3 FLACC scale:
14.4. Treatment
14.4.1 Provides education on pain management as part of the patient’s treatment considering
the patient’s personal, cultural, spiritual, and/or ethnic beliefs. (Post-operative
counseling)
14.4.2 Pain is managed by pharmacological treatment, non pharmacological treatment, and
interventional procedures.
14.4.3 Pharmacological treatment may include non-opioids, opioids, and adjuvants. Pain
medication shall be given as a specific dose with a regular schedule. Narcotics can
only be prescribed by a consultant.
14.4.4 Non-pharmacological treatment may include physical interventions and cognitive
behavioral strategies.
1) Physical interventions may include:
a). Heat c). Electrical stimulation (e.g. TENS)
b). Cold d). Exercise

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e). Physical/Occupational therapy g). Manipulation

f). Immobilization h). Massage
In case patient needs further pain management, such patients are referred to centers
specialized in pain management.

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15. Fall risk assessment:

15.1 Every patient will be assessed for fall risk.
15.2 Morse Fall Scale is followed for fall risk assessment of the patient:
Sl Variables Numerical Score
No values
1 No 0
History of falling
Yes 25
2 No 0
Secondary diagnosis
Yes 15
3 None/bed rest/ Nurse 0
assist
Ambulatory aid Crutches/Cane/Walker 15
Furniture 30
4 No 0
IV or IV Access
Yes 20
5 Normal/bed 0
Gait rest/wheelchair
Weak 10
Impaired 20
6 Oriented to own ability 0
Mental status Overestimates or 15
forgets limitation
TOTAL SCORE
The nursing staff should do the fall risk assessment in every shift and should take decisions
based upon the total score as follows:

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16. Patient counseling:

16.1 Policy
16.1.1 The following details are informed/ discussed with the patient/ attender by the doctor
preferably the treating consultant.
1. Plan of care
2. Proposed care including risks, alternatives and benefits
3. Expected results
4. Possible complications of treatment
5. Results of diagnostic tests and disgnosis
6. Safe and effective use of medications and the potential side effects of
the medication
7. Food and drug interactions
8. Diet and nutrition
9. Immunization
16.1.2 Doctors council the patients about the medication usage and are aided by the nurses/
pharmacy staff.
16.1.3 Worsening of patients condition
16.1.4 Discharge plan and advice at the appropriate time and enlist the patient in the
“probable discharge list”.
16.1.5 Doctors council the family members on end of life including organ donation
16.1.6 Video recording of counseling is done as and when required in high risk situation or
when required by the law Eg: Renal Transplant.
16.2. Procedure:
16.2.1 The doctors while initial assessment and reassessment of patient will educate the
patient and family regarding the above mentioned parameters
16.2.2 If there is any deterioration of patient condition, the concerned consultant and ICU
doctors in case of ICU patient will call for a counseling session.

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16.2.3 PRE of the concerned ward will arrange the counseling session.
16.2.4 The prognosis of the patient consdition will be explained to the patient attendant and a
strategy to procedure with the options of treatment available will be formulated.
16.2.5 The counseling points will be documented in the case sheet and the signature of the
patient/ attendant counseled will be taken
16.2.6 The education of patient regarding diet, nutrition, food drug interactions will be done
by the Dietitian, both for OP and IP patients.
16.2.7 Guidelines To Be Followed For Patient Counseling In The ICU
16.2.7.1 There will be a patient / attendant / counseling tracker sheet that will be monitored
by the PRE to ensure that daily counseling and periodic video counseling has been
signed and acknowledged by the patient attender.
16.2.7.2 Daily counseling of the patient attender should be preferably done during the ICU
visiting hours in the ICU. Alternatively, patient attender may be called to the OPD
of the Primary Consultant and counseling is done in OPD at a mutually convenient
time. In such a case, avoid keeping the attendant waiting in the OPD for longer
time.
16.2.7.3 It is the hospitals policy that long stay patients are video counseled every five days.
If the family does not want this, they can refuse by signing out in the patient
counseling tracker sheet.
16.2.7.4 At the time of admission into the ICU, the PRE or the nurse in-charge (at night
time) will identify the patient’s personal attender and the alternate attender who is
responsible for the patient. Their relationships and phone numbers will also be
entered into the tracker sheet.
16.2.7.5 If the ICU consultant faces the situation wherein the patient’s family members are
unsatisfied with the counseling or have too many doubts, the ICU consultant will
inform the primary consultant and together have a repeat counseling done.

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16.2.7.6 Likewise, the ICU consultant may identify other situations for which additional
counseling sessions will have to be done. Primary consultant and other related
specialty consultant to co-operate for these additional counseling’s.
16.2.7.7 Any video recorded counseling should start with a statement stating that “the
Counseling is being video recorded”. This should be followed by an introduction of
all the consultants who are present as also the introduction of the family members
and their relationship to the patient.
16.2.7.8 The video counseling session should conclude with a confirmation that there are no
further doubts or clarifications sought by the families / attendees.
16.2.8. Guidelines To Be Followed For Patient Counseling In End of Life Care
16.2.8.1 The following guidelines should be followed for the situation wherein patient
clinical condition is critical with very poor prognosis for survival.
16.2.8.2 There will be a video recorded counseling of the patients family members when the
opinion is clear for further medical management is futile and the chances of survival
is very poor to nil.
16.2.8.3 Legally it is only permissible not to escalate further medical treatment in a situation
that is medically futile.
16.2.8.4 Legally DNR and other intentional actions (extubation, switching off the ventilator)
to end life are not tenable.
16.2.8.5 Counseling of the family members is to be very clear regarding these legal
constraints.
16.2.8.6 Patients family may need extra support and time for counseling or bed side visits
during this patients end stage.
16.2.8.7 Family members may express an option to take the patient home or to a nearby
Centre for their own convenience. Patient’s family members may need help in
arranging external transport in a suitable manner. Such an option may be offered
and supported.

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17. Medical Records

17.1. Entries in medical records:
17.1.1 All documentation in the medical records must be written in ink and must be legible.
Alert notifications will be documented in red ink.
17.1.2 All entries will be dated and signed. No alterations will be permitted. If an Interpreter
is used for patient interaction the interpreter must sign the entry along with the
provider of the service.
17.1.3 Each page in the chart is to include patient name and IP number.
17.1.4 Entries are to be made within the margins and to the end of the line. If unable to fill
the line, draw a line to the end. There is to be no crowding or writing in the margins,
and no unfilled lines between entries. All unused lines will be crossed out between
documentation.
17.1.5 Clinical records will be reviewed periodically by an audit review committee to
determine compliance with policies and procedures.
17.1.6 The person writing an entry in the medical record shall be clearly identified by a
legible signature and his/her professional designation and service/ employee code
number.
17.1.7 No hospital employee shall authenticate an entry for another person. The parts of
medical record that are the responsibility of the medical practitioner are to be
authenticated by him/her.
17.1.8 Entries shall be signed when they are entered or, if the entry is a verbal order, for
medication other than over-the-counter drugs, it must be countersigned within forty
eight (48) hours.
17.1.9 All entries in the medical record shall clearly identify the date and time of the entry.
The date and time shall identify when the entry is made, regardless of whether it
relates to prior events.

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17.2. Correction of documentation
17.2.1 Documentation error will be corrected by drawing a single line through the incorrect
documentation, initialing and dating the mistake and continuing with the note. The
error will remain legible.
17.2.2 The reader must be able to discern what the incorrect entry states.
17.2.3 The person who documents the original information corrects the documentation. At
no time should another discipline correct documentation or strike through
documentation made by the original author.
17.2.4 Correction fluid or erasers will not be used to correct documentation in the patient’s
record.
17.3. Documents in medical records

17.3.1 All entries in the medical record must be clear, legible, dated, timed, signed and
named. The treating consultant must counter sign the assessment and care plan, verbal
orders, and medication chart with in 24 hrs.
17.3.2 Initial assessment : respective area initial assessment forms
17.3.3 Reassessment: in wards- progress notes, In the ICU- in the respective ICU charts
17.3.4 Medication orders- all drug orders will be written in the medication chart and not in
the progress notes.
17.3.5 All non-drug orders will be written in the non drug order chart
17.3.6 The abbreviations which can be used in the medical record are defined. ( list attached
to the manual)
17.4. Patient care special documentation:
17.4.1 Patient leaving against medical advice (LAMA) –informed consent in writing in the
progress notes must be obtained.
17.4.2 Absconded record the circumstances in which the patients absconded status was noted
also mention if the authorities have been informed.

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17.4.3 Sudden worsening of patient condition- counsel the patients relative or attenders and
document the same in the progress notes and get it signed by them.
17.4.4 Extra ordinary situations when patients approach is one of noncompliance (refusal of
treatment, etc) - informed consent in writing in the progress notes must be obtained
for refusal of treatment.
17.4.5 In the interest of safety if the situation demands a patient may be restrained and the
concerned consultant authorizes the manner and duration of continuation of
restraint
17.4.6 Restraint orders to be documented in the progress notes of patient case sheet.
17.4.7 Such patients are monitored for every 15 minutes for compliance of restraint usage
17.4.8 Continuation of restraints for more than 24 hrs needs informed consent from the
patient’s attenders/relatives.
17.4.9 CPR record format- Uniform across the hospital. Forms are available in the crash
cart. All events during CPR are to be recorded
17.4.10 Photocopies of filled in forms to be sent to CPR committee by the nursing
supervisor within 24 hours
17.4.11 Surgical safety checklist to be completed
17.4.12 All implantable prosthesis details ( stickers depicting batch, serial number ) must
be available in medical record, OT log book and billing sheet and discharge
summary.

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18. HIV screening of patients

18.1 Policy:
1. HIV screening requires patients informed consent
2. Consent for HIV screening must be voluntary
3. Specified exemptions for informed consent for HIV testing include HIV testing that is
not linked to identity, Blood banks and organ procurement.( as per NACO guidelines)
4. Screening should always be accompanied with counselling.
Patient advised HIV screening by the consultant
Pre test counselling will be done by the staff trained on counselling the patients
according the NACO guidelines. Patients will be given
Pre test counselling includes:
Full Disclosure of the nature of HIV disease
Nature of proposed test
Implications of positive and negative test results
Consequences of treatment
Patient
willing to
undergo HIV
screening
All single use devices and consumables

Patient will be screened for HIV
will be used for such patients
Patient tested Negative Patient tested Positive
The case will be scheduled for OT Post test counselling of the patients will be done
following the normal protocols preferably by the infection control
officer/Microbiologist/Counsellor.

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19. Care of patients undergoing surgical procedures:

19.1 Policy:
19.1.1 Surgical patients have a preoperative assessment and a provisional diagnosis
documented prior to surgery
19.1.2 Informed consent is obtained by a surgeon prior to the procedure
19.1.3 Persons qualified by law are permitted to perform the procedures that they are entitled
to perform
19.1.4 A brief operative note is documented prior to transfer out of patient from recovery
19.1.5 Operating surgeon documents the postoperative care plan
19.2. Procedures:
19.2.1 Procedures are performed by doctors who are given the privileges based on their
qualification, training and experience
19.2.2 All patients undergoing surgery are assessed preoperatively and a provisional
diagnosis is made and need to be documented in the medical record of the patient.
This shall be applicable for both routine and emergency cases. This shall be done by
the operating surgeon
19.2.3 Informed consent shall be obtained as per the consent policy mentioned below
19.2.4 Surgical safety checklist to be completed in order to prevent adverse events like
wrong patient, wrong site, wrong surgery
19.2.5 A brief operative note is documented prior to transfer out of patient from recovery.
This note provides information about the procedure performed, post-operative
diagnosis, name of the surgeon, name of anesthesiologist, salient steps of the
procedure, key intraop findings and the status of the patient before shifting from
recovery area. This can be written by the surgeon/ member of surgical team.

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19.2.6 Operating surgeon documents the postoperative care plan. The plan shall include
advice on IV fluids, medication, care of wound, nursing care, observing for any
complications. This plan could be written in collaboration with anesthesiologist

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20. Consent:
20.1 Policy:
20.1.1 Consent may be taken by the doctor who is a member of the team but counter signed
by the primary consultant (physician, surgeon and anesthetist).
20.1.2 There is a list of situations for which informed consent must be taken.
20.1.3 Consent is taken by the concerned consultant.
20.2. Procedure:
20.2.1 The followings things shall be kept in mind before taking consent from patient or
his relative
20.2.2 The patient must be an adult in order to give consent – 18 years and over: When
informed consent for operation is given by an adult patient, his / her signature or right
thumb print should be recorded in the consent form
20.2.3 If the patient is a Minor – below 18 years of age: his parents or next of kin should
give informed consent. Age of next of kin and relationship of those giving the
consent must be known and recorded in the form
20.2.4 Mentally ill Adults: Only patients certified by psychiatrist on being incapable of
giving consent – can get consent from relative
20.2.5 Informed Consent is required for every Surgery/Invasive Procedure
20.2.6 In Emergency cases :
20.2.7 All ages: When relatives or next of kin are not at hand to give consent, the concerned
department consultant authorizes the surgery and there is concurrence for this from
another consultant. The same is documented in the progress notes and signed by the
two consultants.
20.2.8 “Informed High risk Consent” is to be taken from relatives of very ill / high risks
patients undergoing surgery along with video counselling.
20.2.9 Depending on the language which the patient can understand or read, the
corresponding English/ Telugu language form for consent should be used while taking

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the signatureduring informed consent. For other languages use the English form with
a written note about the language in which the patient was informed while taking
consent.
20.2.10 List of situations requiring informed consent are

All surgical interventions
In all high risk cases both medical and surgical management
Blood transfusions
Dialysis.
Interventional procedures
HIV testing
For administration of anesthesia
20.2.11 when and who can take different types of consents
Type of consent When to take consent Who can sign the

consent
Surgery consent /Procedure consent
Non high risk cases Counseling can be done during OP visit. Consultant/ Any of the
If there are no changes in the clinical condition, team member ( may
no need to again council include Registrars)
After patients get admitted
in the hospital
High risk consent While giving video counseling to the patients/ Consultant/ Any of the
attendants team member doing
counseling
If the procedure has Before changing the procedure Consultant/ Any of the
to be changed mid- team member doing
way counseling

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Anesthesia consent/ During PAC Anesthetist

High risk anesthesia If there are changes in the type of anesthesia
consent proposed earlier, New consent is required
Consent for During PAC / Pre procedure By the Doctor performing

moderate sedation If there are changes in the type of anesthesia the procedure/
proposed earlier, New consent is required administering sedation or
a member of the team
doing the procedure
Blood transfusion When requesting to reserve blood for patient Consultant/ DMO after
consent Or counseling the patient
Blood transfusion need is assessed and
recommended by the consultant
Consent for blood transfusion has to be taken
for each transfusion. One transfusion includes
single/multiple unites of same type/multiple
types as mentioned in the consent form and
transfused at a stretch continuously. Fresh
consent has to be taken when there is a gap in
the transfusion or there is a change in the plan
for transfusion.
For patients who are transfusion dependent the
consent can be taken at the first instance and
once in six months. The patient /competent
relative or guardian endorses the consent at each
repeat transfusion.
Dialysis consent Consent need to be taken every time, however Nephrologist/ Dialysis
this consent could be verbal. Once in 6 months ( technician
at a minimum) or whenever there is fresh
information to be provided to the patient a fresh
written informed consent shall be taken
HIV consent OP- before sample collection Microbiologist

IP- Before sample collection Consultant/
DMO/ Sample collection
staff

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after counseling (use

handouts)
Consent for radio Before exposing patient to radiation Radiologist / Radiology

diagnostic technician
interventions
20.2.12 Informed consent includes information regarding the procedure, risks, benefits,
alternatives and who will perform the requisite procedure in the language the patient
or family members understands
20.2.13All the columns in the consent form must be completely filled by the person taking
the consent
20.2.14. High risk consent:
1. For patient who is at a high risk of surgery video consent will be taken from the
attenders explaining about the reasons for high risk and the consequences expected
after the surgery.
2. The video consent will be taken by the anesthetist
3. The consent to be signed by the attenders/ relatives
4. Policy and procedure for audiovisual recording of patient/ attendants counseling
5. Audiovisual recording of patient/ attendants counseling will be done in the counseling
room having 24hrs audiovisual recording facility.
6. List of situations requiring audiovisual counseling of patients/ attendants:
a. Pre-operative patients with high risk for surgery
b. Post-operative counseling - must include intra operative details and post-
operative status of the patient.
c. Organ transplantation
d. Organ donation
e. Worsening of patient condition
f. Patient with more than 5 days of stay in the ICU(family counseling)
g. Any other situations as decided by the primary consultant

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Procedure:
7. Counseling to be done in the room where 24 hours audio visual recording facilities are
available
8. The details of the patient must be entered in the register provided in the room
(all columns must be filled)
9. Video counseling should start with a statement of introduction as mentioned below
a. Self-introduction of lead counselor (Primary consultant)
b. Introduction of other doctors and staff by lead counselor
c. Introduction of patient/ patient attendants by name and relationship with the
patient
d. The counseling should end with a confirmation from the patient / patient
attendants that they have no more doubts to be clarified.
e. Entries made in the register alone will be saved for future reference.

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21. Care of patients requiring cardio pulmonary resuscitation

21.1 Policy:
21.1.1 Basic life support should be initiated as soon as a condition requiring CPR is
identified
21.1.2 Events during cardiopulmonary resuscitation are recorded
21.1.3 Post event analysis of all cardiopulmonary resuscitations is done by a
multidisciplinary committee.
21.2. Procedure:
The following are a list of general guidelines for running a Code Blue in all departments in
our hospital. The CPR run sheet should be filled for each patient who faces life-threatening
emergencies during their hospital stay.
Objectives: Adult
1. Immediate recognition of cardiac and respiratory arrests and activation of the
emergency response system
2. Early cardiopulmonary resuscitation (CPR) with emphasis on chest compressions.
3. Rapid defibrillation
4. Effective advanced life support
5. Integrated post-cardiac arrest care
Objectives: Paediatric
1. Prevention of arrest
2. Early high quality bystander CPR
3. Rapid activation of emergency response system
4. Effective advance life support (including rapid stabilization & transport to definitive
care & rehabilitation
5. Integrated post-cardiac arrest care

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Sequence: CPR basics for Adults (As per AHA guidelines)

1. Chest compressions 3. Breathing
2. Airway 4. Defibrillation

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Steps: Single rescuer

1. Scene safety: Make sure the scene is safe for you & the victim
2. Check response: Assess responsiveness by gently shaking & shouting “Are You
Alright?”
3. Activate emergency response system (Code Blue) : No response check to see if the
victim is breathing. If the patient is not breathing or is gasping, shout for help, if no
one available, activate the emergency response system, get an AED (or defibrillator)
and return to the victim. If another rescuer is available, instruct to activate the
emergency response system and to get the AED (defibrillator) and come
4. Pulse and breathing assessment: Locate trachea using 2 or 3 fingers. Slide these
fingers into the groove between the trachea and the muscles at the side of the neck,
where you can feel the carotid pulse. Feel for atleast 5 seconds but not more than 10
seconds. Simultaneously, look for no breathing or only gasping.
5. CPR: If no pulse is felt, start CPR with chest compressions with the C-A-B sequence.
The compression ventilation ratio should be at 30:2 ratio with chest compressions rate
at 100-120 per minute.
6. Compressions: Put the heel of the hand on the centre of the victim’s chest on lower
half of breast bone. Put heel of the other hand on top of the first hand. Straighten arms
and position shoulders directly on top of the hands. Press down at least 5 cm (2inches)
with each compression, upto maximum depth of 6 cm. Allow the chest to recoil
completely after each compression. Chest compression time and recoil time should be
equal. Minimize interruptions in compressions.
7. Rescue Breathing: If patient is not breathing normally and has a pulse, provide
rescue breaths, 1 breath every 5-6 seconds. Reassess after 2 minutes. If no pulse, start
CPR.
8. Ventilation -Opening airway: 2 methods: a). Head tilt-chin lift b). Jaw thrust

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a) Place the hand on the victim’s forehead and push with your palm to tilt the head back.
Place the fingers of the other hand under the bony part of the lower jaw near the chin
and lift the chin.
b) Jaw thrust is used when suspecting a head and neck injury to minimize neck movements.
Place one hand on each side of victim’s head, resting your elbows on the surface on
which the victim is lying. Place your fingers under the angles of the victim’s lower
jaw and lift with both hands, displacing the jaw forward. If the lips are closed, push
lower lip with your thumb to open the lips. If jaw thrust does not open airway, use
head tilt-chin lift.
 Do not press deeply into the soft tissues under the chin because this may block the
airway.
 Do not use thumbs to lift the chin.
 Do not close the victim’s mouth completely.
9. Breathing: a) Mouth- to- barrier device breathing b) Bag-to-barrier breathing.
a) Mouth to face mask device breathing is performed by positioning yourself at the
victim’s side. Place the mask on the victim’s face, using the bridge of the nose as a
guide for position. Seal the mask against the face using the hand that is closer to the
top of the victim’s head, place your index finger and thumb along the upper edge of
the mask and the thumb of the second finger along the lower edge of the mask. Place
remaining fingers of the second hand along the bony margin of the jaw and lift the
jaw. Press firmly over the mask to give an adequate seal. Deliver air over 1 second to
make the chest rise.
b) Bag-to- barrier breathing is performed by positioning yourself directly above the
victim’s head. Here a reservoir bag is attached to the face mask. Place the mask on the
victim’s face using the bridge of the nose as a guide. Perform a head tilt. Using the C-
E technique open airway. The thumb and index finger of one hand make a “C” on the
side of the mask, pressing the edges of the mask to the face, while the remaining

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fingers go around the angle of the jaw to lift it, open the airway and press the face to
the mask. Squeeze the bag for 1 second to watch the chest rise.
Steps: Two rescuer team

1. First rescuer should remain with the victim to start CPR immediately, beginning with
chest compressions.
2. Second rescuer should activate the emergency response system and get the AED.
3. After connecting the AED and rhythm analysis the both rescuers should occupy
positions at the victim’s side for compressions and at the victim’s head for ventilation.
4. They should switch roles after every cycles (2 minutes) of CPR to reduce rescuer
fatigue.
AED/Defibrillator: They are computerized devices that can identify cardiac rhythms that
need a shock, and they can deliver shock. Once the AED arrives , place
it on the victim’s side without interfering with the rescuer giving compressions.
1. Power On : Before attaching the AED.
2. Attach: Attach the pads of the AED or the chest leads of the defibrillator. Place adult
leads/pads , one on the victim’s right upper chest(directly below the collar bone) and
the other to the side of the left nipple below it. Attach cables. Do not interrupt
compressions while attaching the AED.
3. Analyse: Clear free from the patient while analysing the rhythm, not even the rescuer
giving compressions. Once the AED analyses the rhythm and says it is a rhythm that
needs to be shocked, prepare to shock the patient
4. Clear and shock: Be sure no one is touching the patient before delivering the
shock.This is done by loudly stating “everybody clear” . Check to make sure no one
is in contact with the victim. Press the shock button which will produce a sudden

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contraction of the victim’s muscles. After delivering shock, resume CPR immediately.
If no shock is needed, resume CPR immediately, starting with chest compressions.
5. Reassess: After 5 cycles of CPR or 2 minutes, re analyse the rhythm, to either deliver
a shock or to continue CPR.
 Never push analyse when transporting the victim.
 Minimize interval between compressions and shock delivery
 While 1 rescuer is giving chest compressions the other rescuer attaches pads thereby
minimising interruptions. Chest compressions are stopped only while analysing the
rhythm.
Precautions:
1. Victim has a hairy chest: Press down firmly on the hairy area. If there is difficulty
picking up the rhythm peel off the pads or leads. This will pull off the hair along with
it. If still hair is obstructing then shave off the area with a razor and stick another set
of pads to the area cleaned.
2. Victim immersed in water: Water is a good conductor of electricity so never use the
defibrillator in water. The shock electricity travels along the skin of the victim’s chest
and prevents the delivery of an adequate shock dose to the heart. Pull the victim out of
the water, quickly wipe the chest before attaching the pads or leads.
3. Victim with an implanted defibrillator or pacemaker: If Victims with high risk of
cardiac arrests may have implanted devices, easily detected by a hard lump palpable
under the skin over the upper left chest or abdomen with a scar over it. This device
may block delivery of shock to the heart if the pads or paddles are placed directly over
the device. Avoid placing the pads directly over the device. If the implanted
defibrillator id delivering shocks to the victim, the muscles will contract in a manner
like that observed after an AED shock. Allow 30 to 60 seconds for the Implanted
defibrillator to complete the treatment cycle before delivering a shock from the
external defibrillator. Minimise interruptions in chest compressions during the
defibrillation.

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4. Victims with trans-dermal medication patches or objects on top of the skin where
AED is attached: Remove the patch, wipe the skin and attach the pads or leads.

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22. Discharge:
22.1. Policy:
22.1.1 The patients discharge decision is planned in consultation with the patient and/or
family
22.1.2 A discharge summary is given to all the patients leaving the organization, including
patients leaving against medical advice and on request
22.2. Discharge Decision:
22.2.1 Decision regarding discharging the patients rest with the primary treating consultant
22.2.2 Effort is taken to identify those patients who are nearing the completion of the care
plan as potential discharges for the next day.
22.2.3 The same is communicated to the patient, relatives, and the concerned ward nursing
staff / on duty Medical Officer & PRE as this will help in all-round discharge
planning (draft of discharge summary, financial settlement counseling, patient and
family preparedness for moving home etc.)
22.2.4 However the final decision regarding discharge is made on the basis of the condition
of the patient during the morning round of the primary consultant on the scheduled
day of discharge.
22.2.5 On the scheduled day of discharge the primary treating consultant during his morning
rounds examines the condition of the patient to ascertain whether the patient can be
discharged.
22.2.6 After confirming that the patient is fit to be discharged on that day the same is
communicated to patient and family, the ward nurse and the medical officer on duty
& PRE
22.3 Preparation of Discharge Summary:

22.3.1 After final decision to discharge the patient is taken, the treating consultant reviews
the draft of the discharge summary of the patient which contains the following
information

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Reasons for Admission

Significant findings and diagnosis
Patient condition at the time of discharge
Information on investigation results
Procedure performed
Medication administered and treatment give during patient stay
Discharge medication
Follow-up advice
Instructions about when and how to obtain urgent care
Emergency contact number of the hospital
In case of death discharge summary includes the cause of death.
22.3.2 One copy of the Discharge Summary is handed over to the patient/relatives and the
other copy is attached to the patient’s case file with and acknowledgement from the
patient/ attender.
22.4. Patient Counseling:
22.4.1 Prior to final discharge of patient from the hospital the ward nurse counsels the patient
regarding the diet (by the dietician), medications, follow up procedure etc as
mentioned in the discharge summary.
22.4.2 Patient follow up visit dates are clearly informed.
22.4.3 Patient along with the relatives leave the hospital. Preferably all patients and
especially elderly patients are taken to the hospital entrance in wheel chairs by the
ward attendants and seen off.

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23. Leaving Against Medical Advice (LAMA):

23.1 Incase patient/relatives want to get discharged against medical advice; the same is
indicated in the patients case record by the primary treating consultant/medical
officer.
23.2 The treating consultant will explain all the possible consequences to the patient and
patient’s attendants.
23.3 Records are entered in the LAMA register of the respective patient ward and a written
consent is taken from the patient/relatives.
23.4 LAMA patients are advised that if any complication arises they can contact on the
emergency number of the hospital and Discharge Summary is prepared mentioning
LAMA and the above mentioned steps are followed.

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24. Patient Expiry:

24.1 In case of expiry of the patient the primary treating consultant/medical
officers/nursing staff informs the patient relatives.
24.2 Patients relatives are allowed time with the body.
24.3 Ward nurse makes necessary preparation for cleaning the body.
24.4 Body is cleaned by designated staff and wrapped in dead body wrapper.
24.5 The on duty medical officer prepares two copies of the Death Report and the Death
Summary .
24.6 The Death Report and Death Summary is stamped.
24.7 Body is handed over to the patient relatives or kept in the mortuary within an hour of
death Body handed over to the relatives along with one copy of Death Summary and
Death Report and the other copy is attached to the patient case records.
24.8 In case of medico legal cases the local police station is informed and body is handed
over to the police for due legal process.

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25. Providing end of life care:

25.1 Policy:
25.1.1 Policy and procedure for end of life acre must be based on good practices and in
accordance to the law of the land.
25.1.2 Decisions like “ do not resuscitate/ Do not intubate/ allow natural death etc shall be
only as per the statutory laws and within the guidelines framed by the legal system
25.1.3 The religious and socio cultural beliefs of patients and families shall be addressed and
respected.
25.2. Procedure
25.2.1 Assessment:
a Disease history:
1. Know whether previous treatments correspond to the treatments available and desired
by the patient for his or her underlying illness.
b. Physical assessment:
1. Assess symptoms, function, safety, hydration and nutritional status.
2. Pain assessment (refer pain assessment policy).
3. Assess emotion, cognition, mood, coping responses, fear.
25.2.2. Care plan:
1. The emphasis shall be on providing symptomatic treatment of such patients and to
prevent complications to the possible extent.
2. The patients and family will be involved in taking all such decisions
3. To the extent possible the patient and family choice shall be respected.
4. Terminal care may be offered in the ICU, or in other areas of hospital in keeping with
the wishes of the family.
5. Treatment approach to change from cure to care.
6. Prime aim is prompt control of all symptoms (current and potential)
7. If patient is conscious, he/ she to be explained with sensitivity.

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8. Discontinue all non essential medication/ injections.

9. Optimal dose of medications is determined by increasing the dose until the patient
comfort is achieved.
10. Revie all medications every 24 hrs or more frequently if needed.
11. Physician should be available to the family for guidance and discussion.
12. If a patient is discharged pre terminally from the hospital an appropriate discharge
criteria in accordance with hospital policy to be followed. Suitable arrangements for
transport and home care should be made.
13. Family to be allowed free access the patient during the last days of patient’s life.
Family should be encouraged to participate in the general care and nursing of the
patient. Performance of nonobtrusive bedside religious services or rites may be
allowed.
14. Coordination of care between the physicians, intensives, and nursing staff is required
and is of utmost importance.
25.2.3. Considerations at the Time of Death:

1. In case of the event of impending death of a patient, the medical team regularly
updates the patient’s representatives about the patient’s condition.
2. The patient’s representatives are allowed to interact with the patient.
3. Utmost sensitivity is maintained by the medical team in educating and counseling the
patient’s representatives.
25.2.4. Declaration and Certification of death:

1. Doctor on duty should confirm and declare death.
2. Treating consultant to be informed about death.
3. The necessary details regarding condition of the patient and details of Cardio
Pulmonary Resuscitations is to be written in patient’s file to ensure proper medical
record for Medical Records Department.

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4. Pronouncing death is a solemn ritual and an important competency for end-of-life

care. The communication should avoid euphemisms and use plain language gently
and with empathy.
5. Most families need reassurance that everything appropriate was done to help their
family member. News of a patient's death should be given in person, whenever
possible. When families must be contacted by telephone, special care should be taken
in how the information is disclosed.
25.2.5. Determination of Brain Death: International criteria to be followed for

determination of brain death in appropriate cases.
25.2.6. Organ Donation

1. Requests should focus on allowing families the opportunity to determine whether
organ donation is consistent with either the patient's known wishes or what the patient
would likely have wanted.
2. In suitable patients, the patient and his family will be counseled for organ donation
and if they agree Mohan Foundation is informed about the same.
25.2.7. Care after death:

1. Death of a patient is handled carefully with concern and without complacency.
Counseling of next of kin with sympathy is given utmost importance.
2. How to help someone suffering from bereavement
3. Show : Genuine concern and caring
4. Availability : Be on hand to listen and help with whatever they need
5. Empathize : Say you are sorry for the death and for their pain
6. Expression : Allow the bereaved to express and share feelings
7. Talk : Encourage talking about their loss.
8. Reassurance : Reassure that they did all they could do.

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9. All help in shifting the body from the hospital is extended to the family members.
10. The dead body is released as soon as possible after completion of all formalities.
11. Acknowledgement for receipt of the body and the Death Certificate is obtained from
next of Kin/legal representative. Handing-over of the body is a solemn occasion and it
is ensured that hospital staff takes due care and concern in this respect. Due
arrangements are made if preserving the body in the mortuary is found necessary.
12. A representative of the hospital is present till the departure of the deceased. Security
personnel on duty should ensure orderliness in handing over the body to the next of
kin.
13. In case of MLC cases, the local police station is informed. The body is handed over to
the police and entry made in the MLC register.
14. Religious sentiments are given due consideration. Patients relatives are allowed time
with the body.
15. Autopsy is not carried out in STAR Hospitals but if patient’s attendant insist for the
autopsy police/magistrate is informed and the body is transferred to the government
hospital.

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26. Hospital infection control:

1. List of high risk areas of HIC: OT, dialysis, ICUs, CSSD, Cath Lab, Blood Bank.
2. The hospital antibiotic policy is formulated by the HIC committee in the concerned
clinical departments. This is reviewed once in three months and made available for
the doctors for implementation.
3. HIC committee chairman and microbiologist are the nodal officers for the pre and
post exposure prophylaxis for HIC
4. Any needle stick injury is informed immediately to the infection control nurse who
will initiate the due procedure.
26.1 Hand hygiene: Hand washing for hand hygiene is the act of cleaning the hands
with or without the use of water or another liquid, or with the use of soap, for the
purpose of removing soil, dirt, and/or microorganisms.
5 moments of hand hygiene:
1. Before touching the patient 4. After touching a patient
2. Before clean/ aseptic procedure 5. After touching patient
3. After body fluid exposure risk surroundings
Steps of hand wash:

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26.2. Waste management:

Segregation of Waste:
26.2.1. Policy:
Segregation should happen at source with proper containment, by using different color coded
bins for different categories of waste.
26.2.2. Procedure:
1. Segregation is carried out at the point of generation, to keep general wastes from
becoming infectious thereby reducing the health risks as well as cost of handling and
disposal
2. The in-patients departments/ ER and ICUs generate all types of waste, which have to
be segregated at the point of generation itself for an effective waste management
practice in the hospital.
3. Different categories of wastes are sorted and placed in different color coded
containers / Bins.
4. The bins should be lined with plastic bags (non-chlorinated) with colors matching that

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of the bins as per recommendations given below.

5. The bedside of each patient has a green color coded bin meant for carrying only
General waste like fruit peels, papers etc., unless the patient is classified as infectious.
6. Bins for the biomedical wastes (red, yellow and sharps container) are kept in a
specific location near the nursing station.
s.no Category of Waste Recommended color

Code
All categories of general waste (General office waste
1 Green color bags
comprising of wrapping paper, office paper, cartons
packaging materials including plastic sheets, newspapers&
bouquets etc. Kitchen waste includes leftover food, peels
Etc. )
Anatomical, Pathological and soiled waste
2 Yellow color bags.
(Soiled, Cotton dressing, Bandage, Plastic Caste,
Amputated part, Pathology Specimens,
Cytotoxic drugs and expired medicines.)
All plastic waste, syringes and tubing’s Red color bag.
3
(Plastic, Disposable Syringes, Blood Bags, Catheters,
Tubing’s & bags, Microbiological waste, plastic bins )
Sharps (Sharps-Needle, Lancets, Broken Glass, Puncture
4 puncture proof White
plastic bin proof)
color container

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27. Quality assurance for patient care:

27.1 Doctors by rotation are members of different committees so as to evaluate and
improve the quality of patient care services.
27.2 Doctors take part in hospital wide internal assessment activities.
27.3 Clinical / medical audit: a periodic audit of patient care by the respective clinical
departments. Audit topics are chosen based on the areas of concern in relation to
management of specific diseases. Others are in relation to patient safety, duration of
stay and morbidity.
27.4 There is an incident reporting form available at all nursing stations and with
secretaries of concerned doctors. Any undesirable event without an adverse outcome
(near miss), or with an adverse outcome (adverse event) or with a disastrous outcome
(sentinel event) is recorded in the incident report form.

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28. Role of doctors in emergency codes:

28.1 Code blue:
On announcement of the code team members arrives the area and takes over the resuscitation
process.
1. Consultant Emergency Medical officer (E.R) or Anesthetist or Intensivist
2. Respiratory Therapist
3. Consultant in charge of the patient
4. 2 Nurses from the patient’s unit.
28.2. Red Alert:

1. Provide clinical support to patients who are being shifted from the location of fire
2. ICU Medical Officer to assist evacuation of ventilated patients
3. In case of evacuation ensure that all evacuated patients are attended to at the triage
area (front parking lot)
28.3. Pink Event

1. Search operations of the entire hospital premises will be done by the security staff to
locate the missing child.
2. All other Staff in the hospital will search their respective units and all adjacent
common areas for the missing person.
28.4. Yellow Call:

28.4.1 ER physician / Causality medical officer:
1. Informing about the disaster situation to manager operations if he first comes to know
about the disaster.
2. Helping the nursing staff in setting up the triage area.
3. Triaging the victims.

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4. Treating the patients where ever he was allotted

5. Documenting the medico legal certificate and death certificate.
6. Discharging of relatively no serious patients with stat discharge summary carrying
medication and advice on discharge.
28.4.2. Consultants:
1. The consultants in the team will be called by mobile phone by the communication
staff
the on duty consultants to immediately report in the command center.
2. The areas where medical care to be delivered to be given by the command center.

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29. Human resource related requirements:

29.1 Pre-employment medical examination and annual health checkups
29.2 Update in the personal file in the HR all CMEs, conferences, papers presented, talks
given, publications.
29.3 APMC registration is a must for all doctors
29.4 Credentialing is done for all doctors by the managing director/ medical director and
this is made aware of the concerned doctor and HOD.

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30. Policy on standard abbreviations for use in medical records and medication
orders
30.1 Use plain English - avoid jargon
30.2 Write in full - avoid using abbreviations wherever possible, including Latin
abbreviations
30.3 Use generic drug names
Exception may be made for combination products, but only if the trade name
adequately identifies the medication being prescribed. For example, if trade names are
used, combination products containing penicillin (eg Augmentin®, Timentin®) may
not be identified as penicillin’s. Exception may also be made where significant
bioavailability issues exist, for example cyclosporin, amphotericin
30.4 Write drug names in full.
• NEVER abbreviate any drug name Some examples of unacceptable drug name
abbreviations are: G-CSF (use filgrastim or lenograstim or pegfilgrastim),
AZT (use zidovudine), 5-FU (use fluorouracil), DTIC (use dacarbazine), EPO
(use epoetin), TAC (use triamcinolone) Exception may be made for modified
release products For slow release, controlled release, continuous release or
other modified release products, the description used in the trade name to
denote the release characteristics should be included with the generic drug
name, for example tramadol SR, carbamazepine CR For multi-drug protocols,
prescribe each drug in full and do not use acronyms, for example do not
prescribe chemotherapy as ‘CHOP’. Prescribe each drug separately
30.5 Do not use chemical names/symbols, for example HCl (hydrochloric acid or
hydrochloride) may be mistaken for KCl (potassium chloride) Do not include the salt
of the chemical unless it is clinically significant, for example mycophenolate mofetil
or mycophenolate sodium. Where a salt is part of the name it should follow the drug
name and not precede it

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30.6 Dose
• Use words or Hindu-Arabic numbers, i.e. 1, 2, 3 etc Do not use Roman
numerals, i.e. do not use ii for two, iii for three, v for five etc.
• Use metric units, such as gram or mL, do not use apothecary units, such as
minims or drams
• Use a leading zero in front of a decimal point for a dose less than 1, for
example use 0.5 not .5 Do not use trailing zeros, for example use 5 not 5.0
• For oral liquid preparations, express dose in weight as well as volume, for
example in the case of morphine oral solution (5mg/mL) prescribe the dose in
mg and confirm the volume in brackets: eg 10mg (2mL)
• Express dosage frequency unambiguously, for example use ‘three times a
week’ not ‘three times weekly’ as the latter could be confused as ‘every three
weeks’
30.7 Avoid fractions, for example - 1/7 could be interpreted as ‘for one day’, ‘once daily’,
‘for one week’ or ‘once weekly’ - 1/2 could be interpreted as ‘half’ or as ‘one to two’
30.8 Do not use symbols
30.9 Avoid acronyms or abbreviations for medical terms and procedure names on orders or
prescriptions, for example avoid EBM meaning ‘expressed breast milk
Acceptable Terms or Abbreviation Intended meaning

Dose frequency or timing
BD /bd Twice a day
OD Once daily
Tds Three times a day
Qid four times a day
every 4 hrs, 4 hourly, 4 hrly every 4 hours

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once a week once a week and specify the day in full, eg,
once a week on Tuesdays
three times a week three times a week and specify the exact days
in full, eg three times a week on Mondays,
Wednesdays and Saturdays
SOS when required
Stat Immediately
bol, bolus Bolus, in a large single dose
before food before food
after food after food
with food with food
Discontinue Discontinue
dil. dilute
Route of administration
Epidural Epidural
inhale, inhalation inhale, inhalation
Intraarticular Intraarticular
IM Intramuscular
Intrathecal Intra-thecal
Intranasal intranasal
IV intravenous
Irrigation irrigation
Left left
NEB nebulised
NG naso-gastric
PO oral

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PEG percutaneous enteral gastrostomy

PV per vagina
PR per rectum
PICC peripherally inserted central catheter
Right right
Subcut subcutaneous
Subling sublingual
Topica Topical
Sol solution
Syr syrup
lot. Lotion
Units of Measure and Concentration

G gram(s)
International unit(s) International unit(s)
unit(s) unit(s)
L litre(s)
Mg milligram(s)
mL millilitre(s)
microgram, microg microgram(s)
% percentage
Mmol Millimole
Dose Forms
Cap Capsule
Cream Cream
ear drops ear drops
ear ointment ear ointment

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eye drops eye drops

eye ointment eye ointment
Inj Injection
metered dose inhaler, inhaler, MDI metered dose inhaler
Mixture Mixture
ointment, oint Ointment
Pess Pessary
Powder Powder
Supp Suppository
tablet, tab Tablet
Approved medical abbreviations

A-FIB atrial fibrillation
ABD abdomen (abdominal)

ABG arterial blood gas
ACLS advanced cardiac life support
ACE Inhibitor Angio-tension – converting Enzyme
Inhibitors
AKA above the knee amputation
AKI Acute Kidney Injury
ALS advanced life support
AFB acid fast bacilli
AIDS acquired immune deficiency syndrome
AMI Acute myocardial infraction
ANA antinuclear antibody
ARDS adult respiratory distress syndrome

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ARF Acute renal failure

ASAP As soon as possible
AV atrio-ventricular
AV fistula Arteriovenous Fistula
AVR aortic valve replacement
BILAT Bilateral
BIH bilateral inguinal herniorraphy
BiPAP Bilevel Positive Airway Pressure
BKA below the knee amputation
BLS basic life support
BM bowel movement
BMI body mass index
BP blood pressure
BPH benign prostatic hypertrophy
BS breath sounds
BVM bag-valve-mask
Brady bradycardia
BUN blood urea nitrogen
BMR basal metabolic rate
C1, C2, C3, etc cervical vertebra #1, #2, #3 etc
C-SECTION caesarean section
C-SPINE cervical spine
C/O complaint of (complains of)
Ca Calcium
CA Cancer
CABG coronary artery bypass graft
CAD coronary artery disease

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CATH Catheter
CT scan computerized tomography
CBG capillary blood gas
CC chief complaint
CEPH Cephalic
CHD congenital heart disease
CHF congestive heart failure
CKD Chronic Kidney Disease
CNS central nervous system
CO2 Carbon dioxide
COPD chronic obstructive pulmonary disease
CP chest pain
CPR cardiopulmonary resuscitation
CSF cerebrospinal fluid
CT scan computerized axial tomography
CVA cerebrovascular accident (stroke)
CPAP Continuous Positive Airway Pressure
CRF Chronic renal failure
CRP C-Reactive Protein
C&S culture and sensitivity
CVA cerebrovascular accident
CVC central venous catheter
CVP central venous pressure
CXR chest x-ray
DNR do not resuscitate
DOA dead on arrival/ admission
Dx Diagnosis

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DVT deep vein thrombosis

D&C dilatation and curettage
DIC disseminated intravascular coagulation
DM Diabetes Mellitus
DUB dysfunctional uterine bleeding
DVT deep venous thrombosis
D5W dextrose (5%) IN WATER
ECG Electrocardiogram
EEG electroencephalogram
ET Endotracheal
ETT endotracheal tube
EXT external (extension)
ECHO echocardiogram
E. Coli escherichia coli
ECMO extracorporeal membrane oxygenation
EF ejection fraction
ENDO Endoscopy
ERCP endoscopic retrograde
choledochopancreatography
ESR erythrocyte sedimentation rate
ENT ears, nose, throat (otorhinolaryngology)
FB foreign body
FLEX Flexion
Fx Fracture
FA Folic Acid
F Fahrenheit
FBS fasting blood sugar

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FNA fine needle aspiration

G gram(s)
GI Gastrointestinal
GYN gynecology (gynecological)
GCS Glasgow Coma Scale
GB gallbladder
GDM gestational diabetes mellitus
GE gastroesophageal
GERD Gastroesophageal reflux disease
GFR glomerular filtration rate
GTT glucose tolerance test
HR heart rate (hour)
HTN Hypertension
Hx History
HIV human immune deficiency virus
Hb, Hgb hemoglogin
HBAg hepatitis B antigen
HCG human chorionic gonadotrophin
HCl hydrochloridic acid
HCO3 Bicarbonate
HD hemodialysis
HDL High Density Lipoprotein
HF heart failure
HgbA1c or A1c Glycosylated Hemoglobin
Hx/O history of
HPV Human Papillomavirus
ICP intracranial pressure

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ICU intensive care unit

IABP intraaortic balloon pressure
IBS Irritable bowel syndrome
ICD Internal Cardiac Defibrillator
ICH Intracerebral hemmorhage
IMA internal mammary artery-left/right
INR International Normalized Ratio
I&O intake and output
IPD intermittent peritoneal dialysis
IUD intrauterine device
IV intravenous
IVH intraventricular hemorrhage
JVD jugular vein distension
K+ potassium
KA ketoacidosis
Kcal kilocalories
KUB kidney, ureters, bladder
L-SPINE lumbar spine
L/S-SPINE lumbar sacral spine
L&D labor and delivery
LAT Lateral
LMP last menstrual period
LOC level of consciousness (loss of consciousness)
LBBB left bundle branch block
LDL Low density Lipoprotein
LVF left ventricular function
LFT liver function test

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LIMA left internal mammary artery

LMCA left main coronary artery
L.M.P last menstrual period
LOC level of consciousness
LP lumbar puncture
LSC left subclavian
LV left ventricle/ventricular
LVEF left ventricular ejection fraction
LVH left ventricular hypertrophy
lytes electrolytes
MI myocardial infarction (heart attack)
MRI. magnetic resonance imaging
MCH mean corpuscular hemoglobin
MCHC mean corpuscular hemoglobin concentration
MCV mean corpuscular volume
MR mitral regurgitation
MVR mitral valve replacement
Na+ sodium
N/A not applicable
NAD no acute distress
NPO nothing by mouth
NSAID nonsteroidal antiinflammatory drug
NS normal saline
NSTEMI Non-ST Elevation Myocardial Infarction
NTG Nitroglycerine
NR non reactive
OB/GYN obstetrics/gynecology
O2 oxygen

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O2 sat oxygen saturation

ORIF open reduction, internal fixation
OSA Obstructive Sleep Apnea
P pulse
PALP Palpation
PALS pediatric advanced life support
PAC premature atrial contraction
PVC premature ventricular contraction
PCO2 partial pressure of CO2
PCOS Polycystic Ovary Syndrome
PD peritoneal dialysis
PDA postural drainage and percussion
peg Percutaneous Endoscopy Gastrostomy
PFT pulmonary function test
pH logarithm of reciprocal of hydrogen ion
POCT Point of Care Testing
PPH primary pulmonary hypertension
PPT Partial Prothombin Time
PRBC packed red blood cells
PSA Prostrate Specific Antigen
pt Prothombin Time
PTCA percutaneous transluminal coronary
angioplasty
PVR pulmonary vascular resistance
Rx Medicine
RR Respiratory rate
RA. rheumatoid arthritis

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RA right atrium
RBBB right bundle branch block
R.B.C. red blood cells
RCA right coronary artery
Rh Rhesus
RV right ventricle/venticular
S/P status post
SOB shortness of breath
ST sinus tachycardia
SVT supraventricular tachycardia
SpO2 oxygen saturation by pulse oximeter
S-A sino-atrial
S1, 2, 3,4 Heart sound 1,2,3,4
SAH subarachnoid hemorrhage
SDH Subdural Hematoma
SEMI subendocardial myocardial infarction
SGOT serum glutamic oxaloaetic transaminase
SGPT serum glutamic pyruvate transaminase
T4 thyroxine
TB tuberculosis
TEE transesophageal echocardiogram
THR total hip replacement
TKR total knee replacement
TMT treadmill test
TPN total parenteral nutrition
TPR temperature, pulse, respirations
TRALI Transfusion Related Acute Lung Injury

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TSH thyroid stimulating hormone

TTP thrombotic thrombocytopenic purpura
TUR transurethral resection
TURP Trans urethral resection of prostate
TVH total vaginal hysterectomy
T-SPINE thoracic spine
TIA transient ischemic attack
URI upper respiratory infection
UTI urinary tract infection
VLDL Very Low Density Lipoprotein
VP Shunt ventricular peritoneal shunt
VF ventricular fibrillation
VT ventricular tachycardia
VSD ventricular septal defect
WBC white blood count
Zn Zinc
+ positive
- negative
? questionable
~ approximately
> greater than
< less than
= equal
↑ upper (increased)
L left
R right
↓ lower (decreased)

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1° primary
2° Secondary

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31. Effective Communication

31.1 Definition of communication
It is process of exchange of facts, ideas, opinions and a means that individuals or
organizations share the meaning and understanding with one another
31.2. Components of communication:

Effective communication is a two-way process that includes transmitting and receiving
accurate messages
1. Sender/Encoder
2. Message
3. Medium
4. Receiver/Decoder
5. Feedback
Message
Message Message Message
Source Encoding Channel Decoding Receiver
Feedback
31.2.1 Source /Encoder

1. Source/Encoder is the person who sends message.
2. In oral communication the encoder is speaker, and in written communication writer is
the encoder.
3. An encoder uses combination of symbols, words, graphs and pictures understandable
by the receiver, to best convey his message in order to achieve his desired response.

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31.2.2. Message
1. Message is the information that is exchanged between sender and receiver.
2. The central idea of the message must be clear.
3. While writing the message, encoder should keep in mind all aspects of context and the
receiver (How he will interpret the message).
31.2.3. Channel:
1. Channel is the medium through which encoder will communicate his message.
2. The medium to send a message, may be print, electronic, or sound.
3. The choice of medium totally depends on the nature of you message and contextual
factors discussed above.
4. The oral medium, to convey message, is effective when message is urgent, personal or
when immediate feedback is desired.
5. While, when message is ling, technical and needs to be documented, then written
medium should be preferred that is formal in nature.
6. These guidelines may change while communicating internationally where complex
situations are dealt orally and communicated in writing later on.
31.2.4. Receiver/Decoder
1. The person to whom the message is being sent is called ‘receiver’/’decoder’.
2. Receiver may be a listener or a reader depending on the choice of medium by sender
to transmit the message.
31.2.5. Feedback
1. Response or reaction of the receiver, to a message, is called ‘feedback’.
2. Feedback may be written or oral message, an action or simply, silence may also be a
feedback to a message.
3. Communication is said to be effective only when it receives some feedback.
Feedback, actually, completes the loop of communication.

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31.2.6. Communication Barriers:

There exist barriers for effective communication at different levels in the organization as
follows
1. Physical Barriers
2. Semantic and Language barriers
3. Socio- Psychological Barriers
4. Organizational Barriers
5. Cross- Cultural Barriers
31.2.7. Following is an indicative list which needs to be addressed to make

communication effective
1. Simple organization structure
2. Reduction and elimination of noise levels
3. Greeting, establishing the rapport
4. Proper media selection
5. Eliminating differences in perception
6. Use of simple language
7. Having a favorable body language which includes the way we dress up, sitting
posture, eye contact etc.
8. Avoid information overload, Not using unnecessary medical jargon
9. Showing empathy ( putting ourselves in patient/ Family’s position)
10. Active listening
11. Not being judgmental
12. Give constructive feedback, Clearing the doubts and confirming whether they have
any questions
13. Greeting thanking

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31.2.8. Standardize communication using ISBAR:

The ISBAR model is a simple method to help standardize communication
ISBAR allows all parties to have common expectations:
– What is going to be communicated
– How the communication is structured
– Required elements
1. Identify
• Identify Yourself- Name, Position, Location
• Identify the person you are talking to if not already done
• Identify the patient and unique identification number
2. Situation
• Explanation of WHY you are Calling
• Stating the purpose of the call at the start of the conversation helps the receiver focus
their attention appropriately when listening to you
3. Background –information to contextualise the problem

• Provide RELEVENT information only
• The volume of information will depend on the situation
• Less- If the receiver will see the patient themselves shortly. No background may be
quite appropriate in this situation if the receiver already knows the patient.
• More- If you are wanting management advice over the phone with out the receiver
seeing the patient . The receiver can always fill any important gaps in your story by
asking questions
4. Assessment – your clinical assessment and prediction

• State what you thing is going on. Give your interpretation of the situation
• Don’t leave the receiver to guess what you are thinking

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5. Recommendation – what you think should happen

• State what you would like to see done
• State what you want from the receiver
31.2.9. Communication in special situations:

1. Following are the special situations where enhanced communication is required
 Breaking bad news
 Disclosing death
 Disclosing of an adverse event
 Communication in case of emergency / disaster
 Managing an angry employee
 Handling patient-staff argument
31.2.10. SPIKES protocol for communication in special situations

1. Objectives of SPIKES protocol
Gathering information from the patient/ attendents
Transmitting medical information
Providing support to the patient
Eliciting patients collaboration in developing a strategy or treatment for the future
Six steps of SPIKES

1. s- setting up interview
1. Create an environment/ arrange for some privacy conducive to effective
communication
2. Ensure that the right people are present
3. Make connection and establish rapport with the patient
4. Manage time constraints and interruptions

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2. P- perception of condition / seriousness

1. Assessing the patient's / Attendant’s Perception: determine what the patient knows
about the medical condition or what he suspects
2. Listen to the patients/ attendant’s level of comprehension
3. Accept denial but do not confront at this stage
3. I- Invitation from the patient to give information

1. Finding out how much the patient wants to know- ask the patient/ attendents wishes to
know the details of the medical condition and/ or treatment
2. Accept patient right not to know
3. Offer to answer questions late
4. K- Knowledge: Giving medical facts

1. Giving Knowledge and information to the patient
2. Use language understandable to the patient
3. Consider educational levels, socio-cultural background, current emotional state
4. Give information in small chunks
5. Check whether the patient understood what you said
6. Respond to the patient’s reactions as they occur
7. Give any positive aspects first
8. Give facts accurately about treatment options, prognosis, costs etc
5. E- explore emotions and sympathize

1. Identify emotions expressed by the patient/ attendents
2. Give patient/ attendents time to express their feelings
3. Address the patient's/ attendents Emotions with Empathetic response

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6. S- strategy and summary:

1. Close the interview
2. Ask whether they want to clarify something else
3. Establish a plan for next steps
31.2.11. Unacceptable communication

Policy:
1. Organization defines what constitutes unacceptable communication
2. The staff needs to be sensitized regarding the unacceptable communication
Procedure:
1. Unacceptable communication Includes
2. Shaming, humiliation or spreading malicious rumors
3. Insulting or slighting an individual due to race, religion or appearance
4. Reluctance or refusal to answer questions or return calls
5. Impatience with questions or hanging up the phone
6. The staff will be monitored through the feedbacks from patients and other stake
holders.
7. In case of staff found guilty with respect to unacceptable communication, actipns will
be taken on such staff based on the service standards of the organization.

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32. Scope of individual departments:

32.1. Anesthesiology:
The department of anesthesiology provides complete services, including consultation for the
patients, general anesthesia, spinal and regional anesthesia, sedation, and management of
intensive care patients and acute and chronic pain management
1) General or regional anesthesia or sedation with monitoring
2) Emergency airway management
3) Pain management
4) Acute perioperative pain management
5) Insertion of invasive lines
6) Consultation for respiratory care
7) Supervision of post anesthesia patients
32.2. Bariatric surgery :

1) Lap.sleeveGastrectomy
2) Lap. Gastric Banding
3) Lap. Fundoplication
32.3. Cardiothoracic surgery (adult and pediatric)

1) Isolated CABG (off pump and on pump)
2) CABG with associated procedures (ASD, VSD, Valve procrines, SVR)
3) Double Valve replacement
4) Valve repairs
5) Cardiac Tumors
6) Lobessctomy, segmentectomy
7) Pneumonectomy
8) Tracheal reconstruction
9) Thoracic and Mediastenal tumors

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10) Decortication
11) Bulbectomy
12) Thoracoscopy procedures
13) Thoracotomy and procedures
14) Thymectomy
15) Endovascular repair
16) Emergency surgery
17) Pericardiectomy
18) Open mitral Valvotomy
19) Ventricular septal defect closure
20) Ben tall’s procedure
21) RSOP repair/Window repair
22) BDG shunt
23) BT shunt
24) PDA interruption
25) Closed mitral Valvotomy
26) Aortic Aneurysm surgeries
27) Aortic Dissection
28) Permanent pacing
29) Peripheral vascular Aneurysms
30) Embolectomy
31) Carotid Endarterectomy
32) ASD
33) VSD
34) AV Septal defects
35) TAPVC,PAPVC
36) Coarctation of Aorta
37) IAAA

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38) TOF
39) Re-do surgery
40) IABP (CTS)
41) Intra cardiac repair
42) Single ventricle corrections
43) Arterial switch operation
32.4. Cardiology (adult / pediatric)

The scope of services include
1) ECG
2) TMT
3) 2D Echo
4) Coronary, Carotid, Renal and peripheral Angiogram
5) PTCA +stent
6) Rotablation
7) Device closure of ASD / PD and VSD
8) Cath study
9) EPS+RFA
10) Endovascular repair of Aneurysm (EVAR)
11) All cardiac emergencies are attended round the clock
Common Emergency procedures are:
1) Acute coronary syndrome which includes unstable angina , NSTEMI and STEMI
2) Acute LVF
3) Aortic Dissection
4) Arrythmias
5) Cardiogenic shock
Pediatric
1) Ventricular septal defect

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2) Atrial Septal defect

3) Tetrology of Fallot
4) Pulmonary Stenosis
5) Patent DuctusArteriosus
6) Aortic Stenosis
7) Pulmonary Atresia
8) Coarctation of Aorta
9) AV Canal defect
10) TAPVC, PAPVC
11) d- Transportation of coronary arteries L-TGA
12) Double outlet right ventricle
13) Tricuspid atresia
14) Epstein’s Anomaly
15) Valvular Regurgitant lesions
16) Referrals to the department from consultants
17) Emergencies: All Paediatric Emergencies.
32.5. Critical care:

Admit and care for critically ill patients based on the defined admission and discharge criteria
( Refer ICU manual)
32.6. Gastroenterology:
 Endoscopy
 Colonoscopy
32.7. General surgery:

1) Excision biopsy of mass
2) Hernia surgery

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3) Debridement
4) Thyroid surgery
5) Distal injuries
6) Appendicetomy
7) Acute abdomen
8) Abdominal surgery
32.8. Internal medicine:

Care for the people with both acute and chronic illnesses such as hypertension,
hyperlipidemia, diabetes and other metabolic problems which are risk factors for coronary
artery diseases, renal diseases and several other diseases.
The department focuses on early detection and treatment and also prevention of diseases.
The procedure covers:
1) Outpatient care: Evaluation by consultants in the outpatient and management.
2) Inpatient care: Admission in the wards and special rooms.
3) Referrals to other Departments
4) Referrals from other Departments
5) Emergencies - All Internal Medicine Emergencies.
32.9. Minimal access surgery:

1) MICS ( minimal access invasive cardiac surgeries)
2) Lap. Appendectomy
3) Lap. Cholecystectomy
4) Lap. Hernia repair (inguinal/incision)
5) Lap. Hysterectomy
6) Lap. Myomectomy
7) Lap. Adhesianolysis
8) Diagnostic Laparoscopy and procedure for infertility.

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9) Lap. Hiatus Hernia

10) Lap. Gastric/ Duodenal/ Intestinal perforation closure
11) Lap. Spleenectomy
12) Lap. Adrenalectomy/Nephrectomy
13) Thoracoscopy and procedure
32.10. Nephrology:
Care for the people with
1) Acute and chronic kidney disease,
2) Fluid and electrolyte disorders,
3) Hypertension,
4) Infection related kidney disease and kidney stone disease
5) Dialysis (peritoneal dialysis, CRRT, Hemodialysis)
6) Renal transplant surgery
32.11. Neurology:
Neurologists treat disorders of the brain, spinal cord, nerves and muscles.
1) Includes EEG and ENMG investigations

2) Sleep study
Some common symptoms of neurologic disorders are:
1) strokes
2) seizures
3) Head ache
4) Memory disturbances
5) walking or balancing difficulty
6) Dizziness
7) Visual disturbances
8) Altered sensorium including Loss of conciousness
9) Tingling or numbness
10) bladder control

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11) Sleep disturbances

32.12. Neurosurgery:
Scope includes:
1) Resection of Intra cranial tumors
2) Head injury Cat2
3) Cervical laminectomy
4) Thoracic laminectomy
5) Lumbar Disc
6) Scalp repair
7) Laser Disectomy
8) Supra tentorial deep
9) Infra tentorial deep
10) Atlanto axial fixation
11) Lumbar laminaectomy
12) Spinal tumors
13) VP Shunt
14) De compressive Craniotomy
15) Intra cranial bleed
16) BronchiolatoryEmbolisation
17) Pleurodesis
18) ERCP
32.13. Orthopedics and trauma:

1. Outpatient care: Evaluation by consultants in the outpatient and management.
2) Inpatient care: Admission in the wards and special rooms.
3. Joint replacements
4. Fixation of fractures

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32.14. Pulmonology:
The Pulmonology division caters to both acute and chronic pulmonary diseases like:
1) Pneumonia
2) Bronchial Asthma
3) Tuberculosis
4) Obstructive diseases of airways
5) Lung cancer
6) Pleural diseases,
7) Interstitial lung diseases etc,
8) Pre operative pulmonary evaluation and post operative pulmonary care.
9) Pleural Aspiration
10) Pleural biopsy.
We are equipped to conduct various pulmonary function tests like:
11) Spirometry,
12) Arterial blood gas analysis
32.15. Urology:
1. Uroflometry
2. All surgeries of the urogenital tract
3. Renal Transplant surgery.
32.16. Gynecology and Obstetrics
All cases except high risk Obstetrics cases

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Hospital wide policies

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1. MISSION & VISION
Mission
Our Mission Is To Create A World Class Health Care Facility Which Is Committed To
Deliver Highest Quality Tertiary Medical Care, Through Superior Medical And
Operational Services. We Are Also Committed To Provide Leadership To Enhance The
General Health Status Of The Population In The Region.
Vision:
Our Unified Vision is to offer a Broad Range of high quality, cost effective tertiary care health
services accessible to unique needs of individuals in the region and beyond
Values:
Expertise
Excellence
Empathy

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2. BOARD OF DIRECTORS
3.
Dr. Nagarjuna Reddy Ponugoti Dr. Gopichand Mannam

Chairman Managing Director
Dr. Ramesh Gudapati Mr. P.Jairaj Kumar Sanjay Vijay Sigh Jesrani
Director Director Director

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4. SCOPE OF SERVICES:
A &C Block
 Anesthesiology
 Bariatric surgery
 Blood Bank
 Cardiothoracic Surgery- Adult & Pediatric
 Cardiology – Adult & Pediatric
 Critical Care Medicine
 Dermatology
 Dietetics
 Emergency Medicine and Ambulance
 ICU (Medical, Renal, Pediatric, Cardiothoracic)
 Internal Medicine
 Minimal Access Surgery
 Ophthalmology (OP services)
 Pediatrics
 Physiotherapy
 Pulmonology
 Radio Diagnostics (CT scan and USG, X- ray)
 Vascular Surgery
 Endocrinology
 General Surgery
 Gynecology and Obstetrics
 Nephrology and Dialysis
 Urology & Renal Transplant

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B Block
 Anesthesiology
 ICU ( Critical Care
 Emergency Medicine and Ambulance
 ENT
 Gastroenterology (Medical)
 Gastroenterology (Surgical)
 NICU
 Internal Medicine
 Laboratory Medicine
 Neurology
 Neurophysiology( EEG, ENMG)
 Neurosurgery
 Orthopedics and Trauma
 Arthroscopy and joint replacement
 Pharmacy
 Physiotherapy
 Psychiatry(OP services)
 Radio Diagnostics ( MRI, CT scan and USG, X- ray)
 Rheumatology
 SICU
 Spine Surgery
 Sports Medicine

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5. PATIENT RIGHTS AND RESPONSIBILITIES
PATIENT RIGHTS:
 Right for uniform care irrespective of race, color, caste, religion or country of origin etc.
 Right to receive medical advice and treatment which fully meets the currently accepted
standards of care and quality
 Right to have clear description of medical condition and plan of care.
 Right to receive care with privacy and dignity at all times and under all circumstances
 Right to consideration to spiritual and cultural needs.
 Right to Confidentiality of information relating to your medical condition.
 Right to expect safety in so far as the hospital practices and environment are concerned.
 Right to know the identity and professional status of care provider.
 Right to information on expected cost and tariff rates.
 Right to be informed in a format and language the patient/ family can understand.
 Right to consent and refuse treatment.
 Right to consult a physician of choice from the panel of consultants in the hospital.
 Right to access clinical and medical records.
 Right to know about the hospital rules and regulations.
 Right to make complaints and suggestions.
PATIENT RESPONSIBILITIES:
 Provide accurate information about present and past health condition.
 Read and understand all medical forms including consent forms thoroughly prior to signing.
 Co-operate with the agreed plan of care.
 Observe hospital policies, procedures and rules for safety.
 Make the payment of the bills on time as directed by the hospital.
 Respect the visiting timings and not to bring children below 10 years as visitors.
 Show consideration for the rights of other patients in the hospital by following the hospital rules
concerning patient conduct.
 Not to ask the hospital to provide incorrect information or certificates.
 Not to litter the hospital and Support the hospital in keeping the environment clean.
 Maintain Silence.
 To protect the hospitals property from damage and misuse.

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1. Guide for patient satisfactions:
 Patients are at all times to be treated with dignity and compassion, even if the patient appears
distraught or difficult to manage.
 Make eye contact, wish the patient, introduce yourself, call patient by name using the
corresponding title and with respect, and extend a few words of concern.
 Stop and lend a hand when a patient or visitor looks confused/ worried.
 Communicate- Keep people informed - Explain & let people know what to expect
 Listen attentively to the patient/ attendants and check for understanding
 Maintain privacy and confidentiality of patient
 Demonstrate empathy by showing sensitivity to patients and family needs including those of an
emotional and spiritual nature
 Watch what you say and where you say it.
 Protect personal information.
 Put yourself in the patients place when rendering service.
 Maintain dignity

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HOSPITAL WIDE SAFETY
EMERGENCY CODES:
Star hospital is having emergency codes for the quick response to handle the emergencies listed
below in an effective manner.
All the staff are trained to deal with the below mentioned emergencies
CODE NAME PURPOSE
1 CODE BLUE CPR ALERT
2 RED ALERT FIRE ALERT
3 YELLOW DISASTER
4 CALL
PINK EVENT ALERT
CHILD
5 CODE ABDUCTION
MAJOR
ORANGE ALERT
SPILLS
ALERT
What to do in a code:
If you witness a situation where there is a Fire / Child Abduction /Cardiac arrest / Major
spill anywhere in the premises
• Call internal Emergency Number of STAR Hospital (999 #)
• Inform the Operator of the code Type, Location (Include Block No, Floor No, Ward) Other
information
• DO NOT SHOUT in common language
• Carry out your responsibilities required in handling the code.
• DO NOT FORGET to call OFF the code, after the activities are conducted.

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1. CODE BLUE:
Covers the cases where cardio pulmonary resuscitation may be required.
Responder Concerned personnel Responsibility
1st Staff who first notices the To attend to the patient and
unresponsive patient call for help
Clinical staff to check the patient
and start resuscitation as per the
protocol.
2nd Nearest Physician / Nursing staff / Announce CODE BLUE,
Nursing supervisor Get the Crash cart
Get Emergency kit
CPR record form
3rd Code blue team: Anaesthetist/ Perform medical intervention
Intensivist/ Emergency (BLS & ACLS )
Physician, Cardiologist.
Paediatric intensivist in
case of paediatric code blue
4th ICCU nursing staff Brings back up emergency kit
Call of f code blue after the patient is revived/ declared death/ shifted to higher care unit
after the orders of the code blue team leader.

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2. RED ALERT:
RED ALERT should be initiated when there is fire anywhere in the premises
Classification of Fire:
Fire i s classified based on the material from which fire is produced into four groups
CLASS OF FIRE MATERIALS PRODUCING FIRE
Class-A Fires Wood, Paper, Rags, Some rubber and plastic materials
Class-B Fires Gasoline, Oil, Grease, Paint, Flammable Gases, Some rubber and
plastic materials
Class-C Fires Electrical Fires, Office Equipment, Motors, Switchgear, Heaters
Class-D Fires Metals
Precautions against Fire

 The hospital is a 'No Smoking' zone.
 Do not accumulate combustible material like cotton waste, polythene & jute bags, packing
material, discarded newspapers, etc.
 No work involving fire or spark like welding, soldering etc. must be done near any combustible
materials such as fuel, oils, gas etc.
 Do not leave any electrical wiring open/ naked. Ensure its proper insulation.
 Extension cords and flexible cords cannot be a substitute for permanent wiring.
Fire Safety Team:

 Medical Director
 OP & IP operations manager
 ER Physician
 Maintenance manager
 Nursing superintendent
 Security officer

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FIRE SAFETY EQUIPMENTS:

The Hospital is equipped with fire detection and suppression equipment’s
Smoke Detectors: Raise alarm whenever smoke is detected due to fire. The
location of fire is identified on the panel board using a
code reading mechanism
Sprinklers: Automatically starts pouring water whenever temp rises to

60 degrees Centigrade
Fire- hose-reel: Helps extinguish fire using water under pressure
Fire- Extinguishers: Different types of fire extinguishers helps to remove one or

more of the components of fire
Hydrant pipes To combat fire in the hospital building or around its

surrounding using water under pressure
Miniature Circuit Helps to switch off power supply in the

Breaker (M.C.B.): connected circuit and in detecting and isolating short-
circuits
Sand Buckets Used to absorb spills of oils, smother most of small

fires.

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Fire Doors: These doors are special types of doors, which can
resist fire for 120 minutes
Air curtains: Used for separating smoke free zone in case of fire.
Reduces and eliminates transfer of heat.
Manual Call Point it's an alarming device: The siren automatically starts
(MCP): when switch is pressed
Water Jet system To fight bigger fires, which give out large amount of
radiation, and require to project sufficient quantity of
water from a safe distance
Water curtains It is connected to a water hose and sprays water

vertically. prevents fires from spreading from one
building to the next

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Type of fire extinguishers

Type of Fire extinguisher Content Used in
Type A Water A type of fires
Type BC CO2 / Dry Powder B & C type of Fires
Type ABC Dry Powder All Types of Fires
Process to be followed in case of Red Alert:

1. Fire det ect ed by t he staff/ Sensors across hospital detect fire
2. If staff detected the fire: inform operator (999#) and Announce RED ALERT
3. Security/ maintenance personnel identify the fire zone if fire is detected by smoke
detectors
4. Rescue any person in immediate danger of fire
5. Raise alarm to alert fellow employees
6. Try to contain fire
7. Assess the fire
8. Commence fire fighting
9. Maintenance and Security personnel along with the Operations and Nursing
Superintendent goes to access the threat
10. If Fire is extinguished Code Red concluded and Detail of incident is reported
11. If evacuation required Medical Director / Managing Director to authorize evacuation
12. Patients and staff are evacuated and brought to the assembly area which is the open space
in the front of hospital and parking area

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EVACUATION TIPS
 Proceed t o n e a r e s t exit i n a n orderly fashion
 Do not stop to collect belongings.
 Follow the fire escape route and exit signage.
 Do not use lifts
 Assemble at designated assembly area
 STOP, DROP and Roll to smother burning clothes
 To avoid smoke or fumes during exit stoop low or crawl.
 Before opening feel the door for heat to know whether there is fire on the other side. View
through peep hole if available
 Close the doors before leaving the room
 Fight a fire only if it is safe to do so, or else evacuate.
 Use moist/wet handkerchief or gauze or cloth to protect f r o m inhalation of smoke.
 Never re-enter building until instructed by the police department, fire department or security staff.

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Exit routes:
A Block
 Main entrance
 Staff entrance
 Canteen entrance
 Ramp from cellar
 Ramp through fire door
 Stairs
B Block
 Main entrance
 Staff entrance
 Ramp from cellar
 Back Steps
 Exit through ER exit door
 Stairs
C Block
 Through A block
 Main Entrance
 Backside Gate
 Stairs

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3. PINK EVENT
Should be initiated when an infant or child is missing or abducted.

Notification Procedure
When a staff member suspects an infant is missing from the hospital premises or gets informed
about the missing child from the attenders, the staff will dial 999# and activate the code.
Communication department will collect the following information.
• Description of the missing child such as clothes last worn, identification marks height etc.
• Description of the abductor shall be given if known.
• Inform of the last known location of the infant and how long the infant has been missing.
• Notify the patient's attending physician for inpatient.
Search operation:
• Security staff will be dispersed to the entrances and exits and access/egress to the area will be
restricted.
 Search operations of the entire hospital premises will be done by the security staff.
 All other Staff in the hospital will search their respective units and all adjacent common areas for
the missing person.
 If missing person is found by the staff other than security, security officer to be informed.
 To be handed over to the ward in-charge/ attendant for identification of the found child.
 If the search is unsuccessful the Operations manager and security in charge will inform the local
police station immediately.

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4. YELLOW CALL:
This is announced to handle external disasters such as building collapse, fire, terrorist attack etc.
Hospital is prepared to treat and handle a maximum of 25-30 casualties before diverting victims
to other hospitals involved in city disaster plan
Announcement of code:
Initial Response: Notification and alarm
 Medical Officer/ staff in ER will inform Operations manager.
 The Operations manager will inform the Medical Director/ Managing Director, Nursing
Superintendent.
 Medical Director/ Managing Director will check with local authorities to verify the disaster and
obtain additional information. Authorize announcement of Yellow Call to Operations
manager who will inform communications center to announce the code.
The following centers will be setup.
Name of Place of set up Functions
the place
Command A-block B-block Will organize materials, manpower,
Center and receive constant updates from
Ground floor Reception Area in each department regarding status.
Behind ER front of OP Obtain Help from local police and
Pharmacy volunteer organizations as deemed
necessary Coordinate with partner
hospitals.
Receivi A- Block B- Block The victims will be received at this

Receiving area Ambulance access area who are being shifted to the
ng area
I:Beside OP area In front of hospital
pharmacy Main
Receiving Entrance
area II :
In front of
main entrance
Triage Triage area I E.R. Corridor Quick initial assessment to
Corridor segregate the patients based on the
area connecting to C type of care required using triage
Block tag:
Black (Deceased) which entails
Triage area II no care needed

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In front of ER Red (Immediate) which entails

life threatening injuries
Yellow (Delayed) which entails
non- life threatening injuries
Green (Minor) which entails
minor injuries
Treatm Red area: ER/I.C.U. Treating the patient based on the
ER/ ICU criticality and condition of patient-
ent area
immediate care/ critical care,
Yellow area : Cubical ward delayed care/ observation, minor
Cubicle ward care/ first aid care
Green area : Ground floor
Ground Cafeteria
floor corridor
Informat Main Reception at ER Information to be updated from
ion reception command center and other areas
Center about the victims. Deal with family
and friends of victims

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5. CODE ORANGE:-
Hazmat Team Members:-
 Operations head of the block
 MOD on duty
 Chief Operations officer
 Maintenance manager
 Nursing Superintendent
 Nursing supervisor (Member Secretary)
 Housekeeping manager
 Manager IP services / Manager OP services
 Security officer
Process:
 If the hazardous materials spill is categorized as major spill based on the defined criteria, the
department incharge/ HOD in control of the that hazmat material will activate the “Code
Orange” by calling the emergency code number of star hospitals- 999#
 The communication department staff announces the Code in the PA system
 The hazmat team members come immediately to the area to coordinate the spill management
activities.
 If the area where a major spill has occurred needs to be evacuated the CODE ORANGE team
leader (Operations in charge of that area) should take a decision regarding the same and inform
to Medical Director/ Managing Director.
 Evacuation protocol as defined in Red Alert protocol will be followed.

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6. HAZMAT POLICY
 Provides guidelines for the handling or disposal of hazardous waste
 Characteristics of hazmat materials:
Ignitability • Reactivity
Corrosivity • Toxicity
Labeling of hazardous material containers
 All hazardous material containers shall be properly labeled to indicate the type of material
contained in the container.
 Hazardous waste containers not labeled shall be removed from the area until such label is
affixed to the container.
 If the contents of the container are unknown, that must be indicated on the label.
 All containers of hazardous waste should contain the opening date
Hazardous material containers
 Use a leak-proof container that will safely contain the contents. Containers must be re-
sealable
 The container shall not be overfilled. Empty space of at least five percent of the container
volume shall be left to allow for thermal expansion.
 Be suspicious of any pressure build-up inside the container, when closing the container, do
not secure the cap tightly and if appropriate, place the container in well-ventilated area until
the chemical is removed by the waste collector.
Transportation of hazardous material containers
 During transportation of chemicals, appropriate personal protective equipment (PPE) shall be

worn
 During transport, if a spill occurs do not leave spill unattended at any time.
 All spills shall be cleaned up in accordance with MSDS sheets.

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7. Storage of HAZMAT Materials
 Typical storage considerations may include temperature, ignition control, ventilation,

segregation and identification.
 Proper segregation is necessary to prevent incompatible materials from inadvertently coming
into contact.
 The rooms where potentially infectious waste is stored are identified by signage with the
biohazard symbol.
 Do not overfill containers
 Keep storage areas clean and well-lit
 Stack containers in racks close to the floor, in a way which minimizes the potential for
tipping and spillage.
 Check for damaged labels, outdated chemicals, and damaged containers
 Material safety data sheets (contains the content of the material, handling
guidelines, exposure and spillage management) to be kept near the storage area specific
for each type of hazardous material.
Hazmat kit:
 One hazmat kit will be provided in each floor of the hospital

 Items in hazmat Kit:
 PPE: Rubber glove, Mask, Gum boots, plastic disposable apron
 Absorbable material: Cotton, Tissue papers
 Red/ Yellow color waste collection bags
 One beaker with stirrer for preparation of sodium hypochlorite solution
 Mercury spill kit: 2 x-ray films, one syringe, air tight sealable plastic container, label and
marker
Minor spills
 Spill is small in volume

 Spill can be cleaned up with water or disinfectant
 Can be handled by department/unit staff
 Poses no threat of irritation

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 Minor spills shall be remediated by trained departmental staff in control of the chemical.
Regardless of spill size a spill kit should be initially used to contain the spill and the hazmat
team member secretary to be notified about the incident
 Victims need to be decontaminated before being touched/ treated.
Major spills
 Spill is generally larger in volume

 Spill is hazardous (a health, fire, and/or environmental hazard) or unidentifiable
 Spill requires special clean up procedures
 Cannot be handled by department/unit staff
 Requires evacuation beyond the immediate spill area
 In case of major spills, the department Incharge/ HOD must activate the Emergency CODE –
“CODE ORANGE”
General Spill management activities:
 Notify fellow workers in vicinity of spill. Secure area, by restricting access and posting signs
 Identify The Material(s)
• Use the container label or interview the victim
• If the label is absent or illegible, consider the material to be an unknown and evacuate the
work area.
 Identify the victims and send for decontamination
 Remove any potential ignition sources and unplug nearby electrical equipment.
 Review chemical’s MSDS for a hazard assessment and other pertinent information.
 Locate an appropriate spill kit
 Don appropriate PPE.
 Confine and contain spill. Cover spill with appropriate absorbent material. Neutralize acid
and base spills prior to cleanup.
 Clean up spill using suitable item and place material in appropriate disposal container as per
the MSDS information

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 Carefully remove PPE, place non-reusable items in disposal container and thoroughly wash
hands.
 Document an incident report
 Replenish spill kit.
Type of spill Spill management
Spillage Of Wear proper personal protective equipment

Formalin Dilute the spill immediately with one bucket (10 liters) of water
Close the room immediately. Keep it closed for 24 hrs. Use
forced air circulation to clear the air.
Clean the area by wiping off the liquid
Bio-Medical waste Do not allow anyone to that site and to step on the spill. Collect
Spillage/ Spillage of the waste into an empty container and send to Bio-Medical
Specimens waste management department.
clean the area as well as surrounding areas thoroughly using
Spillage of Blood/ 1% not

Do Sodium
allowhypochlorite solution
anyone to that andtowater
site and (contact
step on time
the spill of
Disinfect
Infectious body fluid minimum
by pouring10 minutes)
freshly prepared 1%Sodium hypochlorite solution over
the spilled area and leaving it for minimum 10 minutes. Clean the
area as well as surrounding areas thoroughly and for major spills
the whole room should be cleaned with soap and water.
Spillage of mercury Collect all mercury
At the end and
of the day, all mercury
thorough contaminated
cleaning items
of the floor withinto a leak
soap and
tight
waterplastic bag or wide mouthed sealable plastic container. Label
is necessary.
the container and hand over to housekeeping supervisor. Inform
about the spill to hazmat team in charge. Never use a vacuum
cleaner to clean up the mercury. Never pour or allow mercury to go
down a drain.

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8. INFECTION CONTROL PRACTICES

Infection control is everyone's job
STAR Hospitals follows the standard precautions and has made policies and procedures
regarding precautionary measures to minimize the risk of transmission of blood borne
pathogens. These policies are to protect employees and patients and these are expected to be
followed by all.
Essential Elements in Hospital Infection Control:

1. Hand Hygiene/Hand wash / Hand rub
2. Personnel Protective Equipments
3. Safe Handling and Disposal of Sharps
4. Safe Handling and Disposal of Wastes
5. Managing Blood and Body Fluid spills
6. Disinfections of the Equipments
7. Environment Disinfections
8. Immunization
9. Isolation
10. Management of Sharp (needle stick) Injury
There is an Infection Control Committee (ICC) functioning in the hospital. An infection

control manual has also been complied and is available with members of infection control
committee.
1. Hand Hygiene
5 Moments of hand hygiene
1. Before touching the patient
2. Before clean/ aseptic procedure
3. After body fluid exposure risk
4. After touching a patient
5. After touching patient surroundings

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Minimum contact time required:

• Hand wash: 40-60 sec
• Hand rub: 20-30 sec
Steps of hand rub and hand wash

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1. Personal Protective Equipment

Personal protective equipment should be used by:
• Health care workers who provide direct care to patients and who work in situations
where they may have contact with blood, body fluids, excretions or secretions.
• Support s t a f f i n c l u d i n g m e d i c a l a i d e s , cleaners, a n d laundry s t a f f i n
situations where they may have contact with blood, body fluids, secretions and excretions &
laboratory staff, who handles patient specimens.
Personal protective equipment includes:
• Gloves • Gown
• Mask • Cap/hair cover
• Apron
1. Biomedical waste management: Segregation of Waste

• The segregation of waste must be done on site i.e.at the waste generation points. Use the
color coded bins/ bags which have been provided while segregating waste.
• PPE must be worn while handling biomedical waste.
S.No Category of Waste Type of Bag or Container

to be used
All categories of general waste (General office waste

1 Green color bags
comprising of wrapping paper, office paper, cartons packaging
materials including plastic sheets, news papers & bouquets
etc.Kitchen waste includes leftover food, peels Etc. )
Yellow:
2 Yellow color Non-
Anatomical, Pathological and soiled waste
chlorinated bags.
Human Anatomical Waste: Human tissues, organs, body
parts and fetus below the viability period
Soiled Waste: Items contaminated with blood, body fluids like
dressings, plaster casts, cotton swabs and bags containing
residual or discarded blood and blood components.

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Expired or Discarded Medicines: Pharmaceutical waste like

antibiotics, cytotoxic drugs including all items contaminated
with cytotoxic drugs along with glass or plastic ampoules, vials
etc.
Chemical Waste: Chemicals used in production of biological
and used or discarded disinfectants.
Discarded linen, mattresses, beddings contaminated with blood
or body fluid.
Microbiology, Biotechnology and other clinical laboratory
waste: Blood bags, Laboratory cultures, stocks or specimens of
microorganisms, live or attenuated vaccines, human and animal
cell cultures used in research, industrial laboratories,
production of biological, residual toxins, dishes and devices (Autoclave safe plastic
used for cultures. bags or containers)
Chemical liquid waste: Liquid waste generated due to use of

chemicals in production of biological and used or discarded
disinfectants, Silver X-ray film developing liquid, discarded
Formalin, infected secretions, aspirated body fluids, liquid Separate collection system
from laboratories and floor washings, cleaning, house-keeping leading to effluent
and disinfecting activities etc. treatment system
Red: Red coloured non-

3
Contaminated Waste (Recyclable): (a) Wastes generated from chlorinated plastic bags or
disposable items such as tubing, bottles, intravenous tubes containers
and sets, catheters, urine bags, syringes (without needles and
fixed needle syringes) and vaccutainers with their needles
cut) and gloves.
White (Translucent):
4 Puncture proof, Leak
Waste sharps including Metals: Needles, syringes with fixed
proof, tamper proof White
needles, needles from needle tip cutter or burner, scalpels,
color container
blades, or any other contaminated sharp object that may

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cause puncture and cuts. This includes both used, discarded

and contaminated metal sharps
Blue:
5 Blue Color bag
Glassware: Broken or discarded and contaminated glass including
medicine vials and ampoules except those contaminated with
cytotoxic wastes.
Metallic Body Implants
1. Handling of soiled linen:

Any linen soiled with body fluids of a patient is to be treated as contaminated linen. Soiled linen
is separated from the rest of the linen on the floors itself. Soiled linen is double bagged before sending
for washing.
1. Safe handling of sharps:

To reduce the risk of potential exposure to a blood borne disease, or injury, sharps must be handled
in the following manner:
• Sharps must never be passed by hand to another colleague. Always place sharps on a tray and
have it picked up by the other staff.
• Never re-cap a needle
• Needles and syringes must be disposed of as one unit
• A sharps disposal container is available at every patient care area. If required carry the
waste sharp in a tray to the disposal container.
• When finished using a sharp, staff are individually responsible for its safe disposal. The task
cannot be delegated.

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9. RISK MANAGEMENT
Definitions:
Near miss: Is an unplanned event that did not result in injury, illness or damage but had the
potential to do so. Errors that did not result in patient harm, but could have, can be categorized as
near misses.
Adverse event: an injury related to medical management, in contrast to complications of disease.
Medical management includes all aspects of care, including diagnosis and treatment, failure to
diagnose or treat, and the symptoms and equipment used to deliver care. Adverse events may be
preventable or non- preventable.
A Sentinel event: A relatively infrequent, unexpected incident, related to system or process
deficiencies, which lead to death or major and enduring loss of function for a recipient of health
services.
Major and enduring loss of function refers to sensory, motor, physiological, or psychological
impairment not present at the time of services were sought or begun. The impairment last for a
minimum period of two weeks and is not related to any underlying condition.
Identification of Potential Risks & Hazards is done in:
• Safety rounds
• Infection control rounds
• Specific Audits
1. RISK REPORTING and analysis PROCESS

3.1 Ensure Patient/ Person affected by the incident is safe.
3.2 Take relevant immediate corrective measures required for the safety of the Patient/ Person
affected or for the safety of the people or staff with the possibility of harm from exposure to
that incident.
3.3 Notify about the incident to the concerned staff/ HOD/ quality department and take the
instructions from them if any for immediate actions.
3.4 Notify:
3.5 Within business hours (9am – 5pm):
3.6 Member secretaries of different committees/HOD/ Quality department

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3.7 Outside business hours (5pm – 9am):

3.8 Patient related: Nursing Supervisor on duty. Ext: 200
3.9 Issues not related to patient : MOD
3.10 Incident form to be filled by the person/ staff who witnessed the incident or person/ staff
involved in the incident after the immediate corrective actions required are done
3.11 The Incident form should be used to record all incidents/ Accidents (including near misses) to
patients, staff and other persons.
3.12 Only the facts must be recorded but not opinions
3.13 Completing incident form does not constitute an admission of liability of any kind by any
person.
3.14 All the columns in the page 1 of incident form should be filled by the person reporting the
incident except the serial number.
3.15 The serial number will be issued by the quality department for each incident form for filing
purpose
3.16 Tick the concerned boxes to specify the category of incident, individual affected and type of
incident.
3.17 The description of incident should include Location of occurrence, people involved, sequence
of events, consequences etc.
3.18 Immediate actions taken by the person or staff involved in the incident/ person or staff
reporting the incident or any other person or staff concerned with the incident must be
mentioned in the defined column
3.19 Document the name and department of the person to whom the incident is notified
immediately.
3.20 The completely filled in incident form to be handed over to the Member secretory of the
committee/ directly to quality department
3.21 The incident form to be given to Quality department within 24 hrs. of occurrence of the
incident. But where death or serious injury has occurred report immediately.
3.22 The department responsible for the actions it should have taken to prevent the incident / the
department responsible to take corrective and preventive measures for the incident reported
will be identified by the quality department and the incident form will be forwarded to the
concerned department HOD for their recommendations.

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3.23 HOD can attach statement of staff/ patients/ Family associated with the incident if required.
3.24 The risk assessment will be done by the quality department using the risk assessment matrix.
3.25 The assessment of risk will be done to know the
3.26 Consequence, on a scale of 1 -> 5, should the risk become a reality
3.27 Likelihood of the risk occurring, on a scale of 1 -> 5
3.28 The incident will be analyzed taking inputs form the wards/ department; evidences with
respect to the incident will be collected by the quality department.
3.29 The incident form along with the collected data will be presented in the concerned committee/
concerned chairperson of the committee (in case immediate actions are required and where
calling for the committee meeting takes time) for the analysis of the incident and
recommending the corrective and preventive measures.
3.30 Recommended corrective and preventive measures will be communicated to the concerned
department HOD through proper channel( IOC/ Mail/ minutes of meeting) for
implementation and evaluation

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Table 1:
Type of incident Whom to report Tool for reporting Committee

discussed in
Medication errors D&T committee member Secretary/ General Incident D&T committee
including adverse drug clinical pharmacist reporting form
reactions Adverse drug
reaction form in case
of ADRs
Needle stick injuries Infection control nurse Needle stick Infection control
reporting form committee
Facility safety issues Safety and disaster management General Incident Safety and disaster
committee member Secretary reporting form management
(Sr. Mgr Operations ) committee
Clinical events( falls, Clinical risk management committee General Incident Clinical risk
bedsores etc) member secretary ( Nursing reporting form management
academics in charge) Nursing committee
superintendent

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ABSTRACT OF SERVICE RULES

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These rules apply to all employees of Star Hospitals
The Management shall be the sole judge on the interpretation of all or any of these rules
and its decision thereon shall be final and binding on all person concerned.
CLASSIFICATION OF PERSONS WORKING IN THE HOSPITAL
 PERMANENT EMPLOYEE means a probationer who, after having completed the

period of probation of 6 month or its extended period of any to the satisfaction of the
management is declared to be a permanent employee.
 PROBATIONER means an employee provisionally employed to fill a permanent

vacancy and has to complete the period of 6 months’ probation initially fixed or
extended will continue to be a probationer.
 INTERNSHIP: A student or a recent graduate undergoing supervised practical

training.
 CONTRACT EMPLOYEE: Person rendering service and not on rolls of the hospital
RECRUITMENT AND EMPLOYMENT:
 Every employee at the time of his appointment, promotion or reclassification shall

be given a written order specifying his appointment, promotion or reclassification
as the case may be signed by the Head of Human Resources Department or any
other person authorized by the Management on his behalf.
 The Management has the sole and exclusive authority for and discretions in the
matter of the appointment and on control of the employees including their
promotions, transfer and in the classification and determination of the number of
employees required for the hospital.

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 The Management may for the above purpose hold at its own discretion oral or
written tests or verify records, assess the skills, the seniority, state of health of the
employee and suitability of the employee.
 Every employee is liable, at the sole discretions of the Management to be

transferred at any time from one type of work to another type of work, from one
department to another department, from one section to another section, to another
branch hospital , controlled or operated or managed anywhere by Star Hospitals.
Upon such transfer, an employee shall be governed by the terms and conditions of
service rules and regulations etc., as may be applicable to the employees of the
same category at the place to where they are transferred.
 The refusal to accept the transfer shall be counted as an act of indiscipline subject
of suitable disciplinary action or punishment including removal from the service,
demotion etc. Without prejudice to the above, the employee on transfer shall not be
entitled to wages for the period of delay in reporting for duty at the new place of
work.
 At the discretion of Management an employee may be sponsored either in full or in

part for training programs in or outside the organization.
MEDICAL EXAMINATION:
 The Management reserves the right to test any employee for his fitness to hold post at
any time with or without notice or to discharge, transfer, demote or otherwise based
upon the fitness
 For this purpose, the employee shall readily submit himself to medical examination
by the Medical Officer.

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 Non submission for medical examination by any employee will be major misconduct
meriting dismissal from service.
 If an employee is found by the Medical Officer to be physically in-capable of

performing his work function or suffering from communicable disease or declared
not fit for work, in such event the employee will not be entitled to any extra leave
but will have to take his own leave. In the interest of hospital functioning and
patient care the Management may take a decision to terminate service.
 Employees suffering from any infections disease or illness shall report the fact to the
employer and shall not be allowed to work in the establishment till he is completely
cured of such diseases.
DUTY HOURS / SHIFT WORKING:
 The rules regarding hours of work, shifts, and weekly holiday shall be in accordance
with the industry norms.
 The period of duty and hours of work of each category of employees and each shift
will be fixed by the HOD/ Management and liable to be changed for the purpose of
rotation to suit the work requirements of the establishment and or to balance the
pressure of work as the case may be. The employee shall not object to break duty or
split duty hours as per the department’s requirement.
 Shifts could be of eight hours or 12 hours by rotation depending upon the area of
service
 The management will have the right to introduce additional shifts or discontinue
existing shifts or alter the timings of existing shifts. If more than one shift is worked,
an employee is liable to be rotated from one shift to another. Employee shall not
change their shifts without orders and permission from the Department Head who

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gives prior information to the Human Resources Department. Such change can be
made either temporarily or permanently. If, as a result of such change employees are
likely to be discharged, such discharge will be affected as per the provisions of
industry norms.
ATTENDANCE & LATE COMING:
 Every employee shall on reporting for duty each day mark his attendance in the
manner as may be prescribed by the Management and be at their work station at or
before the starting time
 After the attendance is marked every employee shall present himself in uniform where
provided, to work in his respective departments at the appointed time and shall leave
duty at the end of the shift unless he hands over charges properly to the employee
detailed for the new shifts.
Late Coming:
 If any employee does not report for duty within 15 minutes of the starting time
schedule, it will be considered as late .
 Late coming beyond 15 minutes on the third occasion will attract loss of pay or half
day leave.
 If an employee is habitually late it will be treated as misconduct.
 If an employee after registering his attendance in the manner prescribed is found

absent from his place of work during working hours without permission or if
although present in such place refuses to carry out his/her work, it will be
considered as misconduct and his/her wages will be subject to disciplinary action
including salary deduction .

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 If an employee is required to leave early or arrive late for work, a written permission
will have to be obtained from the concerned department head and to be submitted in
HR for approval.
 The employees may be allowed to avail permission to come late or leave early up to a
maximum of 2 hours in a month but not exceeding one hour on each occasion of
such permission.
OVERTIME /WEEKLY OFF / HOLIDAY WORKING:
 The Management will have the right to require all or any employee to work on the
weekly off days and on declared holidays if the department so require. This will be
in accordance with the notice or order which may be issued in writing or orally
from time to time to the employees concerned and their being compensated as per
the industrial norms.
 One hour before or after the working hours will not be counted as overtime
 The employee not able to finish his given task in the working hours and staying
back to finish the work will not be counted in overtime
 Employee can avail the compensatory off within 30 days from the date of doing
compensatory duty.
ENTRY, EXIT AND SEARCH:
 No employee shall enter or leave the premises of the establishment except through the
allotted gate or gates provided for the purpose and as specified by the Management.
 All male employees entering, leaving or while inside the hospital premises are liable
to be searched by the Security Officer or any other person authorized by the
Management. All female employees are liable to be detained by the Security or any
other person authorized to do so by the Management for search at the gates or inside

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the establishment by a female Security Officer/Guard or such other female persons

appointed for that purpose by the Management.
 No property or any other material or equipments etc, belonging to the establishment

shall be taken out of the premises without obtaining a gate pass from one of the
officers authorized to issue the same.
 No employee is permitted to bring their personal jewelry, valuables etc., into the
hospital and if they do so and thefts or losses occur of the same, then it will be
entirely their own risk and the hospital will not at all be responsible for the same.
 An employee of the hospital immediately after cessation of the employment with the
establishment will not be allowed into the premises without prior permission of the
management.
 Employees will be required to make available all articles carried by them for
inspection at gate.
 The Management will have the rights to prevent any entry or exit of any employee for
any reasonable cause.
 Employee coming on Bicycle, Scooter, Motor Bike, Car or any other vehicle will be
required to park the same in the area marked for the purposed of such parking.
IDENTITY CARD:
 Every employee (Any Classification of employee) shall be provided with an

Identity Card
 There shall be no tampering with the Identity Card.
 The Identity Card shall be the property of the Star Hospitals- and its loss must
immediately be reported to the establishment. Failure to report the loss shall render
the employee liable to disciplinary action. A new Identity Card will be issued on
payment, in the event of the Identity Card being improperly kept and needing

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premature replacement. It may however be made available free of cost in case of

wear and tear which would normally not be more frequent that one or two years
from the date of last issue.
 Every employee shall wear the Identity Card on all times, while on duty. Every
employee shall on being required to do so, show his Identity Card to any person
superior to him or any other person authorized by the Management to inspect the
same on demand. However, if any employee is found to be habitually or
intentionally not wearing the ID card despite repeated counseling it will be
considered as misconduct and actions will be taken on the discretion of the
management.
 Every employee will return the Identity Card to Star Hospitals – prior leaving his
services.
LOCKER FACILITIES:
 The Management reserves the right of inspection of the lockers, by any authorized
person appointed for this purpose, at any time without prior information to the
employee concerned. If the employee is not reporting to duty the locker will be
opened in front of the Departmental Head concerned and Security personnel.
 On termination of service, the locker shall be deemed to have been surrendered

automatically to the Management.
 No foodstuffs, intoxicants, perishables or inflammable material or any other

objectionable material or articles shall be kept in the lockers and in the locker room
and the locker shall not be used for any purpose other than for which it is allotted

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RESIDENTIAL ADDRESS/CHANGE OF ADDRESS:
 Every employee shall give his correct local as well as permanent postal Addresses
with proof to the Human Resources Dept. at the time of his appointment and shall
thereafter intimate in written if there will be any change, immediately.
 In the absence of such information the last known address on record will be
considered as the address of the employee for all communications.
EXPENSES REIMBURSEMENT POLICY:
 Reasonable travelling expenses, where incurred in the performance of an employee’s

duties, will be reimbursed, provided that all claims are made on the appropriate
form, signed by the appropriate Manager and supported with the necessary
substantiating documentation.
Telephone/ Cell phone usage
 Usage of personal phone by the employee during working hours must be kept to
a minimum.
 Phones provided at the work stations are to be used to conduct official work
communications.
 No personal outgoing calls or usage of social media sites are allowed from
company phone for any purpose.
 Communication shall be in a pleasing manner with the use of ILSBAR principles.

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Computer/ Software and Internet usage policy:
 Software, Email and internet usage assigned at an employee computer are solely for
the purpose of conducting official business of the Hospital in compliance with
Hospital and department policy.
 Under no circumstances hospital computers or other electronic equipment be used to

obtain, view or reach social media sites or reach any pornographic or otherwise
immoral, unethical, or nonbusiness related internet sites.
 The hospital has the right to monitor all of its information technology system and to
access, monitor, and intercept any communications, information, and data created,
received, stored, viewed, accessed or transmitted via those systems. Employees
should have no expectation of privacy in any communications and/or data created,
stored, received, or transmitted on, to, or from the hospital’s information technology
systems.
GIFTS AND FAVOURS:
 An employee will not give or accept gifts or favors to value their business
relationships with other organization or individuals doing or seeking to do business
with the Star Hospitals
 Employee involved in giving or accepting gifts and/or favors in violation of the above
will be liable to immediate disciplinary action.
DATE OF PAYMENT OF WAGES:
 Payment of wages will be regulated by the provision of the law in this regard.
 Overtime wages for overtime will be governed by the provisions of the law in this
regard.

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 No employee shall draw overtime wages unless such overtime has been
authorized in advance by the Head of Department and Management.
 All employees are paid wages on a monthly basis and payment is offered not later
than 5th day of each month.
 All wages are paid after deducting any amounts that may legitimately be deducted
under any Act or Government notification or agreement between the Star
Hospitals and employee.
DEDUCATION FROM WAGES/SALARIES:
 Dedication from salaries / wages of an employee will be made in accordance with

the provision of Payment of Wages Act. 1936 and rules framed there under.
UNCLAIMED SALARIES WAGES:
 In the event of death of employee, claim for unpaid salaries / wages will be made by
his nominee or legal heirs, within one year from the date of death, such claim will be
settled after thorough scrutiny and satisfying the validity and legality of the claim.
 GENERAL:
Interdepartmental visiting is strictly prohibited and employee of one Department / Section
will not be allowed to enter another Department / Section unless he/ she has work
connected with his official duties or an employee of the hospital
 Smoking Policy: As per law, hospital is a no smoking zone and shall attract penalty in
case of violation.
 Taking or using alcohol or drugs or selling drugs are strictly prohibited in star hospitals.
No employee will be allowed to come to work in the premises of the establishment, if he
is under the influence of alcohol or his breath smells of alcohol and in such contingencies
he shall be liable for disciplinary action.

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 Carrying any kind of weapon in the hospital premises is strictly prohibited in Star
Hospitals
 Thieving is major offense and any employee caught thieving will be liable for severe
disciplinary action including termination of service.
 No employee shall disclose to another person or to any other outsider any information
pertaining to the presence, arrival or departure of any patient and guest unless authorized
to do so.
 Employees shall at all times maintain good discipline and conduct themselves soberly and
temperately and show all proper respect / civility to all persons having any dealings with
the Star Hospitals- and shall at all times use his best endeavors to promote the interest of
the Star Hospital.
 Every employee shall carry out the work for which he has been employed and in
accordance with the specific or general instruction given to him/her by superiors.
 Employees shall not engage in work other than that assigned by the Management during
his working hours.
 Each employee shall be responsible for and must take proper care of Star Hospitals –
property specifically entrusted to him. Deduction from employee’s salary / wages may be
made for damage to or loss of such property if it is directly attributable to his carelessness
or negligence.
 Tools, equipment and supplies provided by Star Hospital must be used for business work
only. Any kind of personal use of these items will not be allowed at any circumstances.
 Employees shall keep their machine/medical equipment’s/instruments/work place clean,

neat and tidy.
 During the employment, the employee at all time must observe secrecy in respect of any
technical trade or business data, patients/ customers details or data or any other
information that come to employee knowledge or possession, which according to the

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hospital are necessarily confidential and form valuable property of the hospital. Employee
shall not disclose or cause the disclosure of any such data in any manner what so ever.
Any breach in the policy will attract disciplinary actions
ACCIDENTS:
 If any employee sustains injury by accident during his working hours the Employee or
any other employee on his behalf present on the spot shall report the accident to his
superior who shall arrange for immediate medical attention as appropriate. First aid
would be given immediately and further course of treatment shall be planned according to
the employees eligibility for E.S.I. / Insurance.
 In the event of an accident occurring due to the negligence of Employee or due to non-
adherence of work rules, safety rules, instructions and/or not usage of safety equipment’s
/ appliances the Star Hospitals –will not have any responsibility/liability with respect to
such accident. In addition, the Employee will be liable to suitable disciplinary action as
mentioned above.
HOLIDAYS:
 A notice specifying the days to be observed as paid holidays as per law shall be displayed
on the notice board. Those of the employees who are required to work in any of these
holidays shall be entitled to a compensation holiday or to wages as per provision of the
Acts applicable.
LEAVE POLICY:
 Being an essential service, regular attendance for work is a vital factor in ensuring smooth
and uninterrupted operations. This requires that employees plan their leave. In other to
guide employees on the subject of leave, the following leave rules are laid down:
 Leave of any kind cannot be claimed as a matter of right. When the exigencies of the
services so require, discretion to refuse/defer or revoke leave of any kind is reserved by

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the authority empowered to grant it.

An employee shall before proceeding on leave intimate to the sanctioning authority his
address, while on leave and shall keep the said authority informed of any change in the
address previously furnished whenever a change takes place.
 Leave will not be granted to an employee under suspension or when disciplinary
proceedings are pending.
 When an employee remains absent for duty for a continuous period of more than 7 days
without prior intimation or sanction suitable action will be initiated against him.
TYPES OF LEAVE:
1. Casual Leave
2. Sick Leave
3. Earned Leave
4. Maternity Leave
5. Special Leave
6. Radiation Leave
7. Compensatory Off
8. Leave on Loss of Pay
LEAVE PROCEDURE:
 HOD will apply for the leave on behalf of the employee through online portal.Casual
leave would require a notice of 48hrs/2days and sick leave at least 2hrs before shift
timings. It is mandatory to keep the concerned departments informed by direct verbal
communication and not in the form of text messages which can be missed. failing which,
one day of unauthorized absence will be treated with two days of loss of pay.

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CASUAL LEAVE:
 An employee shall be eligible for Casual Leave on pro rata basis i.e., one day every
completed month of service up to a maximum of twelve days for every year of service.
Employees who have joined before 15th of that month will be entitled to a leave in the
month of joining. Thereafter an employee shall be eligible for Casual Leave up to a
maximum of Twelve days in each Calendar year i.e., January to December.
 Casual Leave shall be not cumulative and will lapse automatically at the close of every
Calendar year.
 Casual Leave can be applied for ½ a day not more than 4 times in a Calendar year.
SICK LEAVE:
 An employee shall be eligible for sick leave on appropriate basis up to a maximum of

twelve days during the first year of service. He shall be entitled to twelve days of sick
leave per year during the following year of service.
Sick leave can be accumulated up to 60 days. Sick leave for five days or more shall be
granted only on production of a medical certificate from Causality Medical Officer of
Star Hospitals, In case medical certificate is obtained from a Registered Medical
Practitioner for sickness lasting for more than 5 days same has to be endorsed by the
casualty Medical Officer with a declaration that he is fit to resume duties, failing which
sick leave will not be granted, the management will have right to curb sick leave obtained
on false grounds.
EARNED LEAVE:
Every employee who has worked for a period of one year shall be eligible for 15 days
earned leaves which is calculated at 1.25 days every month. Earned leaves earned during

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the year will be encashed in the month of August yearly, leaving behind a deposit of 15
days leave and encashment will be made for leave days exceeding 15.
MATERNITY LEAVE:
Women employees will be eligible for maternity leave as per the Maternity Benefit Act.
Women employees shall be critical to 24 weeks of Maternity Leave as per the Act as amended
from time to time.
 In the case of a woman, who is pregnant, she shall submit an application to the
departmental head starting the date from which she will be absent from work, not being a
date later than one month from the date of her expected delivery. On receipt of
application through Departmental Head, the Head of HR shall sanction Maternity Leave.
Women employees entitled to Maternity Leave shall authorize or nominate a person to

receive maternity benefit on her behalf. No woman employee shall be allowed to work in
the establishment during the period for which she receives maternity benefit.
SPECIAL LEAVE:
An employee donating blood at the Blood Bank will be granted a day’s Special Leave
only on production of a certificate from the Blood Bank Offices of the hospital to that
effect on the day of donation. Special Leave will not be granted to employees who donate
blood to their relatives in a private capacity.
Special leave shall also be granted to employees in the event of any ailments or accidents
arising out of or in the course of employment. The limit for sanctioning such special leave
will be at the discretion of the management.
RADIATION LEAVE:
Radiographers will be entitled to one month radiation leave once a year based on the
exposed radiation level. It is under the discretion of the management. Radiation leave

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cannot be accumulated or carried forward to next year.
COMPENSTORY OFF:
Compensatory off is a rest day given to employees wherever whenever they are called
upon to work on a holiday or during any time of a period of eight hours other than the
scheduled hours of work. Compensatory off shall be availed within 30 days from the date
of which it becomes due to employee.
LEAVE ON LOSS OF PAY
 Leave on loss of pay, purely at the discretion of the management, is granted to an

employee when no other leave is due to him. Except unexceptional circumstances the
duration of leave on loss of pay shall not exceed one month on any occasion for which
special sanction has to be obtained from the Head of Human Resources Department.
 The Head of Human Resources Department may grant such leave in combination with
or in continuation of leave of any other kind addressable to the employee except
casual leave.
 No pay and allowance are admissible during the period of such leave.
ENCASHMENT:
 However, when an employee dies while in service his legally nominated person will
be paid sum which would have been payable to the employee, if he had not availed
the earned leave that he had accumulated as on the date of retirement.
 If an employee is discharged from service or quits his employment during the course
of the calendar year, he or his heir or nominee, as the case may be, shall be entitled to

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wages in lieu of the quantum of leave to which he was entitled to immediately before
his discharge, dismissal, quitting of employment.
 For the purpose of the above payment, the emoluments payable at the time of death or
retirement or resignation from service will be taken into account.
RECALL FOR DUTY: An employee on leave may be recalled from duty by the department
head whenever the hospital deems fit to do so.
LEAVE DURING NOTICE PERIOD: In the event of the employee resigning the services,
he should not avail any type of leave during the notice period, an active service during such
period is mandatory. In case of default it is considered as LOP
PERFORMANCE APPRAISAL:
 The management will appraise and maintain performance record of employees

periodically and or as and when required. The Hospital follows open appraisal system
for different categories.
 The performance appraisal of all the employees of the hospital will be done as per the
following table.
CATEGORY PERIOD
Probationer First six months
Confirmed Once in a year in two batches

employees (April and Oct)
 The management will appraise the performance of employee in the format and
manner solely decided by the Management and the conclusion of such appraisal will
be final and will be binding upon all concerned.

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 All promotions, demotions, up gradations, transfers, annual increments, will also be

effected on the basis of performance appraisal ratings and other factors of suitability
relevant for a particular position or job as decided by the Management.
 Performance of an employee will be assessed based on the Parameters defined in the

performance appraisal form.
 Promotion of staff will purely depend upon existence of a vacancy and suitability of
an employee for the higher grade / position and the responsibilities thereof.
MISCONDUCT:
 Misconduct shall mean any act or omission whether specified herein or otherwise,
whether amounting to substantive act, abetment or connivance, committed which in
any manner or guise is detrimental to the interest of the business or discipline or
reputation or prestige of the Star Hospitals –and the establishment whether committed
with the premises or precincts thereof.
Serious workplace misconduct includes, but is not limited to:
 Theft;
 Fighting;
 Behavior/language of a threatening, abusive or inappropriate nature;
 Any kind of discriminatory behavior, harassment or victimization
 Misuse, damage to or loss of Hospital property;
 Falsification, alteration or improper handling of Hospital -related records;
 Unsatisfactory customer service;
 Disclosure or misuse of confidential information;
 Unauthorized possession or concealment of weapons;
 Insubordination (e.g., refusal to carry out a direct assignment);

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 Misuse of the Hospital electronic information systems;
 Possession, use, sale, manufacture, purchase or working under the influence of non-
prescribed or illegal drugs, alcohol, or other intoxicants;
Any action that violates national, state or local law
 Without prejudice to the powers of the Star Hospitals /Management to terminate the
services of any employee in accordance with the Star Hospitals /Management policy
may, as its own discretion, in lieu of such termination, impose punishments for any
acts of misconduct in accordance with the provisions of the rules hereinafter
contained. Where, however, the imposition of any such punishment on any employee
or class of employees is governed by any special law, the punishment shall be
imposed in accordance with such law.
PUNISHMENT:
PROCEDURE FOR DEALING WITH MISCONDUCTS:
Any act of misconduct/discipline shall be reported to the HR Manager in writing, who shall
act as “Enquiry Officer” for the alleged misconduct.
The report can be from the HOD/ other employee or HR themselves can start proceedings
voluntarily.
The enquiry officer will try to collect some outlining facts before a decision is made to
proceed further. This may involve enquiring about the incident, collecting statements from
the employee or any potential witness.
An employee who is alleged to have committed an act of misconduct shall be given a MEMO
in writing by the HR manager or such other officer who are so authorized by the

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Management, calling for a written explanation within 48 hours form the receipt of the
MEMO.
Contemplating an enquiry/pending enquiry including the period allowed to him for giving his
explanation he may also be suspended or deployed in another area or department for the
duration of the investigation, restricting the scope of duties, increasing the level of
supervision.
The employee will submit his explanation in writing pleading guilty for refuting the
allegations made out in the MEMO within the stipulated time. The management will consider
the explanation submitted by the employee and if the explanation is found to be not
satisfactory a domestic enquiry will be conducted.
 No domestic enquiry will however be necessary:
If any employee has been convicted by Court of Law
Where the charges are admitted by the employee and at the discretion of Management
QUANTUM OF DISCIPLINARY ACTION:
 An employee guilty of misconduct may be punished with warning, fine or censure.
 With stoppage of increment with or without cumulative effect.
 Withholding of promotion, recovery from pay or such other amount as may be due to
him of the whole or part of any pecuniary loss caused to hospital by negligence or
breach of orders.
 Demoted to a lower grade or post.
 Suspended for a period not exceeding, thirty days.
 Discharged with notice.
 Dismissal from service without notice.


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DOMESTIC ENQUIRY:
 The HR manager who is the enquiry officer will take charge of enquiry proceedings
about the misconduct.
 The employee will be communicated the date, time and place where the enquiry is to
be conducted. It may be done orally or in writing.
 He shall be given full opportunity to respond to the charges and permitted to be

defended by a co-employee working in the same department in which he is detailed to
work excepting the employee who is cause of misconduct or against whom an enquiry
is pending. No other employee or outsider shall be permitted to assist, defend or
represent the employee in the domestic enquiry.
 The HR manager shall submit his report to the Management.
 In awarding punishment under the Service Rules, the Management will take into
account the gravity of the misconduct, previous record of the employee and any other
extenuating or aggravating circumstances that may exit.
 The decision of the management will be communicated in writing to the person

proved guilty and the same will be filed in the personal file.
 The range of punishment varies as follows.

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APPEALS:
 The Managing Director shall be the appellate Authority for all categories of
employees
 An employee aggrieved of the order of the disciplinary action may appeal against to
the appellate authority in writing
 The appellate Authority shall consider whether the findings are justified or whether
the penalty is excessive or inadequate and pass appropriate orders within 30 days of
receipt of the appeal from the staff who is proved guilty.
 The order of the Appellate Authority shall be final and binding on the
employee/appellant.
REDRESSAL OF GRIEVANCE OF EMPLOYEES AGAINST UNFAIR

TREATMENT:
 If an employee has a grievance relating to his/her employment, the matter should be

raised initially with the employee's immediate supervisor. The supervisor will
attempt to resolve the complaint informally. He/she shall enquire into the grievance

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and will discuss it with the complainant and will normally communicate the decision
to the complainant orally.
 If the grievance has not been resolved at this stage, the complainant may refer the
grievance in writing to the Head of Department. Again if the HOD is unable to solve
the grievance, it is then forwarded to the Human Resource Manager/.
 The Human Resource Manager will try to resolve the issue, if not then arrange a
meeting with the grievance Redressal committee where all parties to the grievance
will attend.
 The final appealing authority is the Managing Director.
TERMINATION OF EMPLOYMENT:
 Unless otherwise provided by any law for the time being in force, the employment
can be terminated by either side with one month’s notice to the other or in lieu of such
notice, by paying the other side an amount equivalent to one month’s salary.
 Provided that the employee desirous of resigning from the employment shall submit a
written application stating the reasons for his resignation, along with the application
for resignation to the management all correspondence, specification, books,
documents, marked data, cost data, designs, blue prints, drawings, literature, effects or
records belongings to the Star Hospitals / Management related to its business and
shall not make or retain any copies of the same.
 Not withdraw the resignation except at the discretion of the Management and the
resignation once accepted shall be final.
 On the submission of the resignation, be liable to be relieved forthwith by the

Management.
 Submit a clearance certificate to the Human Resources Department for full and final
settlement of dues.

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 Return any property belonging to the Star Hospitals / Management, failing which, be
liable for the deduction of the cost of the same from his wage or salary or any other
dues without prejudice to any other manner of recovery.
SUPERANNUATION:
Every employee shall compulsorily retire on a date he / she
 Attains the age of 58 years.

 Is declared medically unfit.
Provided that the Management may in its discretion re-employ an employee, who has retired
as mentioned above is found medically fit on such terms and conditions as may be agreed.
Provided further that an employee who under special circumstances has been employed in the
establishment although he has already attained the age of 58 years at the start of his
employment, shall always be treated as a temporary employee and he will not be entitled to
any benefits except those expressly mentioned in the letter of appointment.
Employees to give the star hospitals –account of star hospitals –property on the
termination of his service:
Before leaving the services of the Star Hospital the employee shall return to the Star Hospital
all papers, books, tools, uniforms, identity card and any other property of Star Hospitals in his
possession / custody or charge and obtain a clearance certificate from Star Hospitals, in case
of his failure to do so, Star Hospital shall recover reasonable and appropriate value of the
articles by deduction before effecting the full and final settlement of his account.

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CERTIFICATE OF SERVICE:
Every permanent employee shall be entitled to a service certificate at the time of leaving
service, his dismissal, discharge or retirement from service.
SPECIFIC AGREEMENT TO PREVAIL: If an employee is employed by the Hospital

under a specific agreement signed by the both the parties, the terms of the agreement so far as
that differs from the provisions of these Service Rules govern his employment and for the rest
of the matters, these Service Rules shall apply to him.
1. Employee rights and responsibilities:

Every Employee, during the course of his tenure with the organization, shall be privileged to the
right-
 To be aware of the hospital wide policies
 To avail the benefits being extended by the organization
 If any one believes that he/she has been the victim of harassment, or know of another
employee who has, the right to report it immediately to the HR department
 To be treated considerately and respectfully, and not discriminated on the basis of caste,
religion, sex or socio-economic background.
 To be aware of and to be entitled to the terms and conditions of his/her employment
 Competitive merit-based selection processes for recruitment or promotion
 Training and development that enables you to be productive in your work and to pursue
your chosen career path
 Equal access to benefits and conditions
 Fair processes to deal with work-related complaints and grievances.
Responsibilities of the employees are:
 Following hospital service rules and regulations
 Fulfilling the job responsibilities allocated.
 Respecting other employees rights
 Observe hospital policies, procedures and rules for safety
 To protect the hospitals property from damage and misuse

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 Employees shall at all times maintain good discipline and conduct themselves.
 Employees shall maintain confidentiality about the patient's condition and plan of care
and not to be communicated in any form outside the work area
 Be punctual and repeated tardiness will be major rule violation.
 Every individual is responsible for their personal belongings.
2. Employee benefits:
1. PF: According to the PF rules.
2. Gratuity: The employee will be entitled for the gratuity after completion of 5 years
continuous services.
3. Health benefits: staff with less than Rs.21000/- gross salary per month is eligible for ESI
and others are covered under free Insurance scheme for 1lakh coverage
4. Discounts on medical services: staff is eligible for 50 % discount on OPD Investigation
and package. 25% off on investigation and packages for family ( If Unmarried-family is
parents. If married, family is spouse and unmarried children)
5. Eligible for 10% off on O.P Pharmacy bill
6. In-House consultation is free for staff through E.R.
7. Marriage gifts: Employees who got married after one year of their service are eligible
for marriage gift. An amount will be issued on the basis of current designation after
submission of the application form and marriage photo.
8. Birthday Celebrations
Every employee will be given a birthday card on their birthday
9. Best employee awards
This will be given quarterly
The categories in best employee award are
a). Administration b).Technical c).Nursing d).House Keeping e).Special Category f) Security
g) F &B
10. Merit Scholarships for staff children:
Scholarships are usually given based on the academic performance to the children of the
staff with more than one year of service at Star Hospitals.
paid as funeral expenses

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11. Employee welfare fund:

A sum of 50,000 rupees is paid as employee welfare fund to the employee family members
(Spouse/ Children/ parents) if employee death occurs while he/she is in active service with the
hospital
Eligible employees for this benefit are: all current full time and who have completed one year
of service under the on rolls of hospital
Funeral expenses:
Employee who completes one year of services, if the dependents expires a sum of 10,000/- will be
paid as funeral expanses

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35. EMPLOYEE DRESS CODE AND GROOMING POLICY

Our dress code policy outlines how we expect our employees to dress at work. Employees should
note that their appearance matters when representing our Organisation in front of clients, patients,
visitors or other parties.
Managers must ensure that the uniform and Appearance/Dress Code Policy is implemented within
their area of responsibility and to ensure that employees are aware of the policy.
Employees wearing uniform and non uniform are expected to follow professional grooming
standards and dressing style.
Dress code for staff without uniform –
Male: Formal shirt and trouser. T-shirts and jeans will not be permitted.
Female: saree or salwar kameez. No western outfit / long skirts will be allowed while at work.
Men are expected to attend work in formal shoes.
Hair must be neat and clean and should not be an obstruction to eye contact.
Extreme colors and styles of hair are not acceptable.
In clinical areas, female employees are expected to braid and tuck their hair under the apron or else
use a high knot.
Staff working in clinical areas should keep the nails clipped short and not use nail colors. Staff
working in other areas should keep the nails clean and short and should not extend past the finger
tips.
Facial hair must be trimmed to give a professional appearance with the exception of those staff who
have religious compulsions.
Staffs working in clinical areas are encouraged to use perfumes/cologne/body deodorants that are
pleasant and not too strong and offensive.
Usage of bright shades of lipstick will not be appreciated.
Tattoos must be covered.
Repeated breach of the Code will be viewed as misconduct and will be addressed in accordance with
the Disciplinary policy or the Organisation.
This policy applies to all our employees.
********************** End of Document *********************

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Doctors Manual 10/4/2019

DOCTORS POLICY AND

Prepared by: Quality Department Reviewed by: Quality Department

Approved by: Medical Director Signature:

Prepared by: Quality Department Reviewed by: Quality Department

Approved by: Medical Director Signature:

Prepared by: Quality Department Reviewed by: Quality Department

Approved by: Medical Director Signature:

26 Hospital infection control 75-77

Prepared by: Quality Department Reviewed by: Quality Department

Approved by: Medical Director Signature:

1. LIST OF SERVICES PROVIDED BY STAR HOSPITAL

Prepared by: Quality Department Reviewed by: Quality Department

Approved by: Medical Director Signature:

27. Orthopedics and Trauma

Prepared by: Quality Department Reviewed by: Quality Department

Approved by: Medical Director Signature:

2. Criteria for admission of patients into hospital:

Prepared by: Quality Department Reviewed by: Quality Department

Approved by: Medical Director Signature:

3. Criteria for admission of patients into ICUs:

Heart rate <40 41-50 51-100 101-110 111-130 >130

Mean BP <70 71-80 81-100 101-199 >200

Resp. rate <8 9-14 15-20 21-29 >30

(Scores1-0-1 can be managed in wards. Others refer to ICU.)

Prepared by: Quality Department Reviewed by: Quality Department

Approved by: Medical Director Signature:

3.2.2. Vital Signs

Prepared by: Quality Department Reviewed by: Quality Department

Approved by: Medical Director Signature:

3.2.3. LABORATORY VALUES (newly discovered)

3.2.4. Radiography/ Ultrasonography/ Tomography (newly discovered)

3.2.5. Physical Findings (acute onset)

Prepared by: Quality Department Reviewed by: Quality Department

Approved by: Medical Director Signature:

3.3. Diagnosis model

3.3.3 Neurological Disorders

Prepared by: Quality Department Reviewed by: Quality Department

Approved by: Medical Director Signature:

3.3.4 Drug Ingestion And Drug Overdose

3.3.5 Gastrointestinal Disorders

Prepared by: Quality Department Reviewed by: Quality Department

Approved by: Medical Director Signature:

a) Hypo or hyperkalemia with dysrhythmias or muscular weakness

Prepared by: Quality Department Reviewed by: Quality Department

Approved by: Medical Director Signature:

4 UNIFORM CARE OF PATIENTS:

Prepared by: Quality Department Reviewed by: Quality Department

Approved by: Medical Director Signature:

5. Initial assessment of patient by doctors:

Prepared by: Quality Department Reviewed by: Quality Department

Approved by: Medical Director Signature:

5.2.2. Assessment of OP patients:

Prepared by: Quality Department Reviewed by: Quality Department

Approved by: Medical Director Signature:

6.2.1 Reassessment of IP patients:

Prepared by: Quality Department Reviewed by: Quality Department

Approved by: Medical Director Signature:

6.2.2 Reassessment of OP patients:

Prepared by: Quality Department Reviewed by: Quality Department

Approved by: Medical Director Signature:

Prepared by: Quality Department Reviewed by: Quality Department

Approved by: Medical Director Signature:

MEDICATION ORDERS AND Chart No: __2_ of _1+1__