Internal Audit NCs raised by Mr.

Mohan
Radiology:
1. Reporting of xray is major NC.
OP:
1. OUT PATIENT Reporting Card should have a column for FOLLOW UP DATE.
ECG :
1. MOU with Narayana Hrudayalaya
IT:
1. Data Backup policy for It Non Insta material
IP:
1. Patient Admission Document: Patients responsibilities not evidenced.
2. Corrective action to be documented about patient complaint.
3. Patient satisfaction index to be prepared.
Nursing:
1. General Consent Form: Relationship to patient is not evidenced. MR No.
44652
2. High Risk Patient: definition
3. High Risk Consent Form should be bilingual.
4. All Care Plan and Treatment plan must have name, signature with date
and time.
5. MLC Case referred from other hospital Clarification needed.
6. No Whitener to be used in case sheet.
7. Care Plan for all patients to be mentioned in case sheet with outcome,
which is mandatory, is not evidenced in case file. MR No.44652
8. Restraint consent form is not evidenced.
9. Restraint Consent Form not evidenced in case sheet. MR No. 44652
10.Restraint Consent Form to be changed.
11.Soft Skill and Communication training required for staff directly coming in
contact with patient. These include Nursing Staff, Admin, Doctors, Security
Personnel, Housekeeping, Therapists.
12.Diet Follow up sheet not evidenced in case sheet. MR No. 44602
13.Lab reports are not signed. MR No. 44602
14.Competency of Nurses to be assessed.
15.HR to Define policy for age specific competency to handle paediatric
therapies.
16.Skill matrix pf nursing staff to be prepared.
17.IP Patients previous allopathy medication to be written in case sheet by
Duty Doctor/Medical Officer and counter signed by Dr.Bhat.
18.Yoga and Physiotherapy assessment and re assessment should be
recorded in case sheet.
19.Look Alike and Sound Alike medication training to nursing staff.
20.Credentialing and Privileging of nurse.

21.Age specific competence for nurses.

22.Bi phasic defibrillator training to be given to nurses.
HIC:
1.
2.
3.
4.
5.

Epidemic disease data collection and analysis

Change in Catheter Policy.
Code Blue team to be formed and Code Blue Mock drill to be conducted.
Calibration for Autoclave machine Documented.
Recall mock drill for sterilization.

HR:
1.
2.
3.
4.
5.
6.

How to measure mission of organisation- read balance score card.

Expectations from HR Employee, Management, Outsourced.
Skill gap analysis assessment.
Assessment of Probationer Staff Policy.
Policy to Ensure work life balance.
Movement of a person from one place to another - requires training and
documentation
7. Therapists assessment and evaluation to perform High Risk Therapies.
Credentialing and Privileging.
8. HR to Define policy for age specific competency to handle paediatric
therapies.
9. Training plan for therapists who completed 1 year.
10.Service Rules to be updated.
11.Service Rules Training to all staff.
12.Make list of improvements in hr dept. in the last 3 years
13.Statutory requirements to be documented
14.Core values- all activities should be around the core values
15.Training to all employees about patients rights and responsibilities &
Employees rights and responsibilities
16.Training to all on service standards wrt patients
17.Training plan for outsourced staff
18.Standardise training session goals, protocols, pre post questionnaire
19.Documented protocol which explains internal and external communication
mechanism and training of the same
20.Grievance - definition
To send checklists:
1. Nursing care plan
2. Doctor care plan
3. Fire mock drill deviation report
4. Imaging critical report format
5. Nursing Audit Checklist