SUNSHINE

RECOMMENDATIONS

WHY???
Lets improve ourselves!! Not just for NABH accreditaEon

What am I doing here???

I am here just to enlighten you over SUNSHINE policies regarding documentaEon of the in paEent details 1) Integrated in-paEent iniEal assessment form 2) Drug Order sheet 3) Surgical paEent Record 4) Intra Hospital Referral form 5) Admission Note

INTEGRATED IN-PATIENT INITIAL ASSESSMENT

Please make sure that this is lled as soon as the paEent is admiUed in the hospital

PART-A
Has to be duly lled by the Nurse in charge and make sure that it is lled by the Eme the treaEng surgeon comes!

PART-B
To be duly lled by the aUending doctor! Simple MBBS Stu

Discharge Planning
Need to be completed at admission

PLAN OF CARE
PLAN OF CARE MEDICAL/CONSERVATIVE Tick boxes make the job easy, its going to take only a few SURGICAL f your Eme minutes o

Sign and date your work

A good arEst always signs o Consultants need to countersign every admission within 24 hours

Our Time frames

Field of ac+vity OP Time frame 2 HOURS
Responsible Person

Registrars

CASUALTY

30 min, as per triage level

CMO-Nurses-Registrars

IP

WITHIN 1 HOUR

Nurses iniEal assessment

IP

WITHIN 24 HOURS

Registrar DieEcian-DMO- Consultants

DRUG ORDER SHEET

Please please. Write your prescripEons in capitals (I mean CAPITALS)

Do check for allergies You can specify the Emes

Dont just sign Date it please No trade names please

DRUG ORDER SHEET

InstrucEon by telephone from a prescriber to a nurse to administer a medicine previously not prescribed is unacceptable in normal circumstances.
Sunshine hospital medica1on prescrip1on and administra1on policy

VERBAL orders
A verbal order shall be issued only by anybody who is a Consultant or above that and none other than that.. Before closing the conversaEon (telephone or person) the nurse or duty medical ocer shall read back the order to the doctor and conrm if the wriUen down order is correct, in case of drugs she shall even spell the drug to recheck with the consultant and then close it. Doctor who issued the verbal order within 24 hrs should counter sign that verbal order

WHAT TO MENTION SEPARATELY

1) Parenteral infusions other than the medicaEons (like IV uids, TPN) 2) Stat medicaEons 3) SOS medicaEons

No trade names please

Dont just sign Date it please

No abbreviaEons, all caps please

SURGICAL PATIENT RECORD

An exhausEve booklet of 16 pages (BUT IT IS VERY IMPORTANT!) Make sure that the rst 4.5 pages are duly lled before the paEent reaches OT!

TIME OUT
All work should cease during a period of Eme when all members of the operaEve / procedural team,using ac+ve communica+on, conrms correct paEent, correct procedure, correct site and side, sterility of the equipment availability of all items needed for anaesthesia and surgery anEbioEc prophylaxis any paEent allergies.

Donot start operaEng before this checklist is done MAKE TIMEOUT A HABIT

CONSENT
Please make sure it is taken by the treaEng doctor/ team member but not the nurse incharge!!!

Another important part of the consent process

Doctors need to Countersign

SURGEONS NOTES

Admission Note
We need to explain to the pt Disease Inv needed Treatment process Cost ( esEmated) Probable outcomes This form takes care of all this Please ll this at admission

Please ll in the orders Inv requested Plan of care Spl instrucEons Preop orders This form is for the pt to go from OPD / Casualty to the ward

Admission Note
This part need to be lled in by Front Oce / PaEent counselor

Intra Hospital Referral form

Once completed this will go into the case sheet The visiEng consultant will have a beUer idea why he is there in the rst place

OTHER THINGS WE NEED - Contd

Discharge summary to be given to all paEents including LAMA, MLC etc Discharge summary to contain reason for admission, ndings, diagnosis, paEents condiEon at discharge, invesEgaEon results, procedure, treatment given, follow up advice, how to obtain urgent care

OTHER THINGS WE NEED

CredenEaling and Privileging

CODES
Emergency Codes
CODE BLUE RED BLACK PURPLE PINK Grey MEANING MEDICAL EMERGENCY FIRE BOMB THREAT SECURITY THREAT CHILD ABDUCTION External Disaster/ Mass Emergency

HIC
HIC MANUAL Available on every desktop AnEbioEc policy Hand Hygiene Surveillance Tool kit Needle sEck injury

VULNERABLE PATIENTS
Admission and Discharge criteria for ICU Who all are Vulnerable paEents and care of such of paEents
Geriatric paEents (>65 years of age) Pediatric paEents (<16 years of age) Mentally challenged paEents Physically challenged paEents Comatose paEents

IS IT THAT DIFFICULT ???

10 COMMANDMENTS
Write Medica+ons Order in Capital LeSers. Document your visit with Notes Duly Signed with the Date, Time, Signature and Name. Avoid Verbal Orders. Use of Alcohol Hand Rub Before And AWer Each Pa+ent Examina+on. Make a Habit of pa+ent and Family educa+on as Part of Care.

10 COMMANDMENTS
Ensure Informed Consent for all Procedures. Assess and Reassess Pa+ent as per Hospital Policy. Prepare/ Counter Sign Discharge Summaries and Talk to Pa+ent Regarding Discharge Instruc+ons Follow-up and Care at Home. Prescribe as per Hospital Formulary and Follow the An+bio+c Policy. Have Formal Mee+ngs/ Briengs with the other Specialists when more than One Doctor is trea+ng the Pa+ent.

 Thank you Please send your feed back to me @ Vippin@gmail.com