COPNABH PREACR –ENTRY LEVEL

COP-1

CARE OF PATIENT IS GUIDED BY ACCEPTED NORMS AND PRACTICE

CLIINCAL PRACTICE GUIDELINES ARE ADOPTED TO GUIDE PATIENT CARE WHENEVER POSSIBLE

CLINICIANS ARE ENCOURAGED TO CONSIDER THE USING EVIDENCE BASED MEDICINE FOR THE PROVISION OF OPTIMUM CARE TO THE PATIENTS :

INTERNATIONALLY ACCEPTED PROTOCOLS OF CARE ARE DOCUMENTED AND ACCEPTED AS THE PLAN OF CARE

SOPS AND WI ARE AVAILABLE FOR GUIDANCE AT WORKPLACE

DEPARTMENT MANUALS ARE PERUSED AND ACCEPTED AS RECOMMMENDATION BY HEADS OF DEPARTMENTS

CARE AND TREATMENT ORDERS ARE SIGNED AND DATED BY CONCERNED DOCTOR

ALL ORDERS GIVEN BY THE DOCTOR DURING INTIAL ASSESSMENT OR CONSEQUENT REASSESSMENTS ARE TO BE SIGNED WITH DATE AND TIME BY DOCTOR

WITHIN 24 HOURS THE CONSULTANT HAS TO COUNTERSIGN THE ORDERS AND PLAN OF CARE

COP 2 EMERGENCY SERVICES INCLUDING

AMBULANCE SERVICES ARE GUIDED BY DOCUMENTED PROCEDURES

DOCUMENTED PROCEDURES ADDRESS CARE OF PATIENTS ARRIVING IN EMERGENCY INCLUDING HANDLING OF MLC CASES

TO TRIAGE ALL INCOMING PATIENTS. TO HAVE PATIENTS ASSESSED BY QUALIFIED

INDIVIDUALS. TO DIAGNOSE, TREAT, ADMIT AND PROVIDE

APPROPRIATE REFERRAL AND FOLLOW UP. TO ENSURE CRITICALLY ILL PATIENTS RECEIVE THE

TOP PRIORITY CARE AS DETERMINED BY TRIAGE GUIDELINES.

TO INITIATE LIFESAVING TREATMENT. TO PROVIDE END OF LIFE CARE.

STAFF SHOULD BE WELL VERSED IN THE CARE OF EMERGENCY PATIENTS IN CONSONANCE WITH SCOPE OF SERVICES OF HOSPITAL

STAFF ARE TRAINED IN EMERGENCY CARE TO DEAL EFFECTIVELY WITH THE PATIENTS

ALS/BLS TRG AND DISASTER MANAGEMENT TRG HOSPITAL CODES TRG

COMPETENCY EVELUATION DONE STAFF ARE TRAINED IN EMERGENCY CARE TO DEAL EFFECTIVELY WITH THE PATIENTS

ALS/BLS TRG AND DISASTER MANAGEMENT TRG HOSPITAL CODES TRG

COMPETENCY EVELUATION DONE

ADMISSION OR DISCHARGE TO HOME OR TRANSFER TO ANOTHER ORGANISATION IS ALSO DOCUMENTED

DEPENDING ON CLINICAL FINDINGS PATIENT IS ADMITTED TO WARD OR SENT TO HOME

IF PATIENT DESIRES OR TREATMENT IS OUT OF THE SCOPE OF HOSPITAL SERVICES THEN PATIENT IS TRANSFERRED IN SUITABLE FASHION WITH A TRANSFER NOTE AND MEDICAL ATTENDENT AS REQUIRED

AMBULANCE IS PROPERLY EQUIPPED

AMBULANCE MAYBE ALS/BLS HAS TO BE EQUIPPED WITH BASIC OR ADVANCED

LIFESAVING EQUIPMENT AND OXYGEN EQUIPMENT HAS TO CHECKED REGULARLY AND ALL

LICENSES SHOULD BE IN ORDER DAILY FUNCTIONING CHECK EMERGENCY MEDICATION STOCK HAS TO BE

AVAILABLE ALWAYS

AMBULANCE IS MANNED BY TRAINED PERSONNEL

DRIVER AND STAFF HAS TO BE TRAINED IN BLS/ALS DEPENDING ON TYPE OF AMBULANCE

TRAINING AND COMPETENCY HAS TO BE CHECKED

COP3-DOCUMENTED PROCEDURES DEFINE RATIONAL USE OF BLOOD AND BLOOD PRODUCTS

DOCUMENTED POLICIES AND PROCEDURES ARE USED TO GUIDE THE RATIONAL USE OF BLOOD AND BLOOD PRODUCTS

BLOOD / BLOOD COMPONENTS SHOULD NOT BE PRESCRIBED UNLESS THERE IS A REAL INDICATION.

REQUEST SHOULD BE MADE BY A CONSULTANT/DOCTOR WORKING IN THE HOSPITAL.

BLOOD TRANSFUSION REQUEST FORM SHOULD BE FILLED BY A DOCTOR

CONSENT FOR TRANSFUSION SHOULD BE TAKEN FROM PATIENT / GUARDIAN AFTER EXPLAINING THE TRANSFUSION REQUIREMENT OR DOCTOR CAN GIVE CONSENT IN CASE OF UNACCOMPANIED PATIENTS WHO ARE INCAPABLE OF GIVING CONSENT.

DOCUMENTED PROCEDURES GOVERN THE TRANSFUSION OF BLOOD AND BLOOD

PRODUCTS

REQUISITON FORM SIGNED BY DOCTOR CONSENT TAKEN FROM PATIENT /ATTENDENT CROSSMATCHED BLOOD TRANSFUSED UNDER

CLOSE MONITORING TRANSFUSION RECORD MAINTAINED AND ALSO

ENDORSED IN FILE DISPOSAL OF BLOOD BAG ACC BMW RULES

TRANSFUSION SERVICES ARE GOVERNED BY APPLICABLE LAWS AND REGULATIONS

PROTOCOLS TO BE FOLLOWED ACCORDING TO INSTRUCTIONS OF GOVT

ONLY AUTHORISED BLOOD BANK WILL PROVIDE SAFE BLOOD WHICH HAS TO BE TRANSFUSED FOLLOWING THE NATIONAL GUIDELINES

ALL BLOOD TRANSFUSION REACTIONS ARE REQUIRED TO BE REPORTED AND NECESSARY CA TAKEN

INFORMED CONSENT IS TAKEN FOR DONATION AND TRANSFUSION OF BLOOD

AND BLOOD PRODUCTS

PATIENT/ATTENDENT HAS TO BE INFORMED ABOUT ALL ASPECTS OF THE BLOOD TRANSFUSION AND CONSENT TAKEN BEFORE TRANSFUSION

EACH DAY OF TRANSFUSION REQUIRES FRESH CONSENT

PROCEDURE ADDRESSES DOCUMENTING AND REPORTING OF TRANSFUSION REACTIONS

I. STEP 1 - STOP TRANSFUSION II. STEP 2 - KEEP IV LINE OPEN WITH 0.9 % NACL III. STEP 3 - NOTIFY PHYSICIAN AND TREAT SYMPTOMATICALLY IV. IF TRANSFUSION IS TERMINATED  SEND FRESHLY COLLECTED POST – TRANSFUSION SAMPLE

OF BLOOD (PREFERABLY FROM OPPOSITE ARM) AND SAMPLE OF URINE TO BLOOD BANK.

 SEND THE RESIDUAL BLOOD COMPONENT UNIT ALONG WITH ADMINISTRATION SET TO BLOOD BANK.

 FILL IN THE ADVERSE BLOOD TRANSFUSION FORM AND FORWARD THE SAME TO THE HEAD OF CLINICAL AUDIT COMMITTEE.

 

COP-4 DOCUMENTED PROCEDURES GUIDE THE CARE OF PATIENTS AS PER THE SCOPE OF SERVICES PROVIDED BY HOSPITAL IN ICU AND HDU

CARE OF PATIENTS IS IN CONSONANCE WITH DOCUMENTED PROCEDURES

ICU MANUAL HAS THE STANDARDISED PROTOCOLS TO BE FOLLOWED IN ICU

TRAINING AND FAMILIARISATION OF ICU STAFF REGARDING THE HOSPITAL PROTOCOLS IS DONE

ICU ADMISSION AND DISCHARGE CRITERIA DEPENDING ON SCOPE OF THE HOSPITAL SERVICES IS DOCUMENTED AND STAFF IS ORIENTED

INFECTION CONTROL PRACTICES ARE FOLLOWED AND STAFF IS TRAINED AND ORIENTED

ADEQUATE STAFF AND EQUIPMENT ARE AVAILABLE

ICU IS EQUIPPED WITH CRITICAL LIFE SAVING EQUIPMENT MAINTAINED/CALIBRATED REGULARLY FOR OPTIMUM FUNCTIONING ACCORDING TO NO OF BEDS

STAFF IS ADEQUATE WITH RATIO 1;1ALS/BLS TRAINED AND TRAINED ON HANDLING PATIENTS REQUIRING CRITICAL CARE

EMERGENCY AND VITAL MEDICATION IS MADE AVAILABLE 24 HOURS

THERE IS BACK UP CRITICAL CARE EQUIPMENTS./SUPPLIES/ELECTRICITY/SUCTION/OXYGEN /STAFF FOR EMERGENT REQUIREMENTS

STAFF IS TRAINED IN EQUIPMENT MANGMENT AND EMERGENCY CASES MANGEMENT

COP-5 DOCUMENTED PROCEDURES GUIDE THE CARE OF OBSTRETICAL PATIENTS AS PER THE SCOPE OF SERVICES PROVIDED BY THE HOSPITAL

THE ORGANISATION DEFINES THE SCOPE OF OBSTETRIC SERVICES

THE ORGANISATION DEFINES AND DISPLAYS THE LEVEL OF OBSTETRIC CARE AVAILABLE IN THE HOSPITAL

IT DISPLAYS IF HIGH RISK CASES ARE ACCEPTED FOR CARE

EQUIPMENT,INFRASTRUCURE ,MEDICINES,STAFF FOR OPTIMUM CARE ARE AVAILABLE

QUALIFIED AND TRAINED STAFF ARE AVAILABLE 24 HOURS

QUALIFIED GYNECOLOGIST AND OBSTRETRICIAN ARE AVAILABLE

OBSTETRIC PATIENTS CARE INCLUDES REGULAR ANTENATAL CHECK UP, MATERNAL NUTRITION AND

POST NATAL CARE

THE ORGANISATION DEFINES AND DISPLAYS OBSTETRIC CARE AS INCLUDING ANC CHECK UP,NUTRITIONAL CARE,INTRAPARTUM ,POST PARTUM AND POST NATAL CARE AVAILABILITY

IMMUNISATION FACILITY,FAMILY PLANNING COUNSELLING

‘REGISTRATION WITH GOVT FOR MTP AND TUBECTOMY IS DONE FOR ENSURING COMPLETE MATERNAL CARE

BIRTH INFORMATION IS FWD TO STATE CELL FOR REGISTRATION

ALL MTP AND TUBECTOMY AND CONTRACEPTIVE USE CARE INFO IS FORWARED ACC TO GOVT REGULATIONS TO GOVT DEPT RESPONSIBLE FOR FAM WELFARE

THE ORGANISATION HAS THE FACILITIES TO TAKE CARE OF NEONATES

THE ORGANISATION ENSURES AVAILABILITY OF CARE OF NEONATES ALONG WITH OBSTETRIC CARE IN ITS SCOPE

NEONATAL CARE INCLUDE IMMED RESUSCITAION CARE ,NICU CARE AND EMERGENCY CARE

QUALIFIED AND SKILLED STAFF TRAINED FOR PEDIATRIC CARE UNDER PEDIATRIC COVER IS AVAILABLE

EQUIPMENT INFRASTRUCURE ,MEDICINES FACILTIES FOR MANAGEMENT ARE AVAILABLE

COP-6 DOCU PROCEDURES GUIDE THE CARE OF PAEDITRIC PATIENTS AS PER THE SCOPE OF SERVICES PROVIDED BY HOSPITAL

THE ORGANISATION DEFINES THE SCOPE OF ITS PEDIATRIC SERVICES

DEPENDING ON STAFFING/INFRASTRUCTURE/EQUIPMENT AVAILABILITY THE ORGANISATION DECIDES ITS SCOPE OF SERVICES

SERVICES MAY INCLUDE SPL OR SUPERSPL NEONATOLOGY/PEDIATRIC CARDIOLOGY/PAED SURGERY ETC

THE SCOPE OF SERVICES IS DISPLAYED STAFF IS ORIENTED

PROVISION IS MADE FOR SPECIAL CARE OF CHILDREN BY COMPETENT STAFF

PEDIATRIC PATIENTS HAVE SPECIAL NEEDS AND THEY ARE VULNERABLE PATEINTS

SPECIALISED TRAINED STAFF ALONG WITH PEDIATRICIANS CARE FOR THEM

PROTOCOLS OF CARE ARE DOCUMENTED AND FOLLOWED

SEPARATE WARD /ATTENDENT SPACE/FEEDING ROOM/PLAY AREA /SEPARATE TOILETS /EXTRA SECURITY

SEPARATE EQUIPMENT FOR PEDIATRIC PATIENTS IS MADE AVAILABLE FOR THEIR NEEDS

DIETARY SERVICES ARE ALSO AVAILABLE FOR SPECIAL NEEDS

PATIENT ASSESSMENT INCLUDES DETAILED NUTRITIONAL ,GROWTH AND IMMUNISATION ASSESSMENT

ALL PAED PATIENTS ARE ASSESSED FOR NUTRITIONAL STATUS AND IMMUNISATION STATUS

ALSO ASSESSED FOR MILESTONES,PSYCHOSOCIAL NEEDS

COUNSELLING OF PARENTS DONE FOR THE SAME

PROCEDURE ADRESSES IDENTIFICATION AND SECURITY MEASURES TO PREVENT CHILD/NEONATE ABDUCTIO AND ABUSE

CODE PINK VULNERABLE PATIENTS REQUIRE SPECIAL SECCURITY AND ATTENTION STAFF ENGAGED IN CARE IS TRAINED IN SPECIAL

CARE OF THE NEONATES AND CHILDREN WRIST BANDS FOR VULNERABLE PATIENTS

THE CHILDS FAMILY MEMBERS ARE EDUCATE D ABOUT NUTRITION AND IMMUNIZATION

ASSESSMENT OF PEDIATRIC PATIETNS IN OPD OR IPD INCLUDES NUTRITIONAL STATUS EVALUATION/MILESTONES EVALUATION/BIRTH HISTORY AND IMMUNISATION STSTUS AS ROUTINE

IMMUNIZATION CARDS INCLUDE MILESTONES AND NUTRITIONSL STATUS REVIEW

STAFF IS TRAINED FOR BIRTH WEIGHT AND NUTRITIONAL STATUS ASSESSMENTS

COP 7 DOCU PROCEDURES GUIDE THE ADMINISTRATION OF ANESTHESIA

THERE IS A DOCUMENTED POLICY AND PROCEDURE FOR ADMINISTRATION OF ANESTHESIA

ANESTHESIA ADMINISTRAION POLICIES AND PROCEDURES ARE DOCUMENTED IN THE HOSPITAL PROCEDURE MANUAL FOR OT

INTERNATIONALLY ACCEPTED PROTOCOLS GUIDE ALL ASPECTS OF ANESTHESIA IN HOSPITAL

ALL PATIENTS FOR ANESTHESIA HAVE A PAC

BY QUALIFIED TRAINED ANESTHETIST

NO PATIENT CAN BE TAKEN UP FOR ANY SURGICAL PROCEDURE WITHOUT A PAC BY QUALIFIED TRAINED ANESTHETIST

PAC FORM IS FILLED WITH ALL DETAILS AND SIGNED BY ANESTHETIST

CONSENT FOR ANESTHESIA IS ALSO TAKEN BY ANESTHETIST

THE PAC RESULTS IN FORMULATION OF AN ANESTHESIA PLAN WHICH IS DOCUMENTED

DEPENDING ON THE PAC A PLAN FOR ANESTHESIA IS DOCUMENTED ON PAC FORM

THE PREPARATION FOR PATIENT BY OT STAFF IS BASED ON THE PLAN OF ANESTHESIA SIGNED BY ANESTHETIST

IT IS ALSO DOCUMENTD IN THE OT LIST ALL SPECIAL REQUIRMENTS ARE ALSO

DOCUMENTED

AN IMMED PRE OP REEVALUATION IS DOCUMENTED

IMMED PREOP RE EVALUATION OF THE PATIENT IS MANDATORY

IT IS DOCUMENTED IN THE PREOP REEVAULATION FORM AND THE CHANGES IF ANY ARE DOCUMENTED ACCORDING TO LATEST STATUS OF THE PATIENT

SURGICAL SAFETY CHECKLIST IS USED

INFORMED CONSENT FOR THE ADMINISTRATION OF ANESTHESIA IS OBTAINED BY ANESTHETIST

THE PATIENT IS COUNSELLED AND INFORMED ABOUT HIS ANESTHESIA STATUS AND PLAN OF ANESTHESIA AND ALL SIDE EFFECTS

CONSENT IS TAKEN AND ALSO SIGNED BY ANESTHETISAND PATIENT

ANESTH MONITORING INCLUDES REGULAR AND PERIODIC RECORDING OF HEART RATE,CARDIAC RHYTMN,RESPIRATORY RATE,BLOOD PRESSURE.O2 SATURATION,AIRWAY SECURITY AND PATENCY, AND END TIDAL CARBON DIOXIDE

THE MONITORING IS DOCUMENTED IN THE ANESTHESIA NOTES AND CHART

ALL PARAMETERS ARE MONITORED AND INTRAOPERATIVE MONITORING NOTES ARE DOCUMENTED

EACH PATIENTS POST ANESTHESIA STATUS IS MONITORED AND DOCUMENTED

ALL PARAMETERS ARE MONITORED AND DOCUMENTED IN PATIENT FILE BY AN ANESTHETIST AND DULY SIGNED

CRITERIA FOR SHIFTING FROM RECOVERY AREA ARE DOCUMENTED AND STAFF ORIENTED TO IT

DEFINED CRITERIA ARE USED TO TRANSFER PATIENTS FROM THE RECOVERY AREA

DOCUMENTED AND ACCEPTED GUIDELINES FOR TRANFER OF PATIENT FROM RECOVERY AREA ARE FOLLOWED

THE ANESTHETIST DOCUMENTS

ADVERSE ANESTHESIA EVENTS ARE RECORDED AND MONITORED

ALL ADVERSE ANESTHESIA EVENTS ARE TO BE RECORDED IN ADR FORM

ROOT CAUSE ANALYSIS TO BE DONE CA AND PA TO BE DONE ALL SUCH OCCURRENCES ARE THEN DISCUSSED

FOR PREVENTION EQUIPMENT/PROCEDURE/STAFF/MATERIAL ERROR TO

BE RECTIFIED

COP 8-DEFINED CRITERIA GUIDE THE CARE OF PATIENTS UNDERGOING SURGICAL PROCEDURES

SURGICAL PATIENTS HAVE PREOP ASSESSMENT AND A PROV DIAGNOSIS DOCUMENTED PRIOR TO SURGERY

SURGEON SHOULD DOCUMENT PRE OP ASSESSMENT AND PROV DIAGNOSIS ALONG WITH PLAN OF CARE BEFOR TAKING FOR SURGERY

WARD AND OT STAFF TO BE INFORMED ABOUT THE REQUIRMENTS ACCORDINGLY

AN INFORMED CONSENT IS OBTAINED BY SURGEON PRIOR TO PROCEDURE

THE PROCEDURE AND ITS IMPLCATIONS ARE EXPLAINED TO THE PATIENT BY THE SURGEO AND CONSENT FOR THE SURGERY PLANNED IS TO BE TAKEN BY SURGEON AND SIGNED BY PATIENT AND SURGEON

TIME AND DATE TO BE MENTIONED ANY POSSIBLE COMPLIACTIONS AND DIAGNOSIS TO

BE DOCCUMENTED IN CONSENT FORM IN LANGUAGE UNDERSTOOD BYBPATIENT

DOCUMENTED PROCEDURE GUIDE PREVENTION OD ADVERSE EVENTS LIKE WRONG SITE,WRONG PATIENT,WRONG SURGERY

USE OF WHO SURGICAL SAFETY CHECKLIST TO AVOID SENTINAL EVENT LIKE WRONG PATIENT WRONG SITE WRONG SURGERY INTERNATIONALLY ACCEPTED AND USED CHECKLIST

QUALIFIED PERSONS ARE PERMITTED TO PERFORM THE PROCEDURES THEY ARE ENTITLIED TO PERFORM

CREDENTIALLING IS DONE TO ENSURE ONLY QUALIFIED PERSONS PERFORM THE PROCEDURES THEY ARE COMPETENT TO PERFORM

CREDENTIALLING COMMITTEE ENSURES THIS STAFF IS ALSO TRAINED AND ASSESSED FOR

COMPETENCY PERIODICALLY

THE OPERATING SURGEON DOCUMENTS THE OPERATING NOTES AND THE POST OP PLAN OF CARE

THE OPERATING SURGEON DOCUMENTS THE OPERATIVE FFINDINGS ,OPERATING NOTES

HE DOCUMENTS POST OPERATIVE PLAN OF CARE FOLLOW UP IS DONE BY SURGEON HE ALSO DOCUMENTS IF BIOPSY OR OTHER

PROCEDURE WERE DONE

THE OT IS ADEQUATELY EQUIPPED AND MONITORED FOR INFECTION CONTROL PRACTICES

INFECTION CONTROL PRACTICES ACCORDING TO THE INFEECTION CONTROL MANUAL ARE FOLOWED IN OP TH

PPE ARE USED ,ZONING IN OT IS MAINTAINED UNIVERSAL PREACUTIONS ARE FOLLOWED REGULAR MICROBIOLOGICAL MONITORING IS DONE

TO ENSURE INFECTION FREE ATMOSPHERE INFECTION CONTROL OFFICER AND NURSE MONITOR

THE INFECTION CONTROL PRACTICES TRAINING IN ALL INFECTION CONTROL PRACTISE IS

ENSURED ALL PROTOCOLS ARE FOLLOWED AS ADVISED

PATIENT,PERSONNEL,MATERIAL FLOW CONFORM TO INFECTION CONTROL PRACTICES

ZONING AND UNIDIRECTIONAL FLOW IN OT STERILE AND UNSTERILE MATERIAL AND EQUIPMENT

DO NOT MIX UNSTERILE EQUIPMENT CLEANED -MOVE TO CSSD LAUNDRY BAGGED MOVED TO UNSTERILE AREA BIOMED WASTE BAGGED ,SHIFTED IN COVERED

CONTEINER FOR DISPOSAL

DOCUMENTS AND FORMS CASE SHEET CONSENT FORMS-ANESTH/SURGERY/PROCEDURE PAC FORM/ PREOP EVALUATION FORM BLOOD TRANSFUSION FORM ADR FORM TRANSFUSION REACTION FORM PAC FORM INTRAOP MONITORING FORM/POST OP

MONITORING FORM/OT NOTES/NURSING OT NOTES/ANESTHESIA NOTES/

SURGICAL SAFETY CHECKLIST INFECTION CONTROL RECORDS TRANSFER SHEET

ICU MANUAL OT MANUAL INFECTION CONTROL MANUAL