Draft SOPs For Hospital - Management

Draft SOPs – under print: This publication may be reproduced in part or in whole with due
acknowledgement to QI Division, NHSRC

All rights reserved © National health System Resource Centre, National Rural Health
Mission,
Ministry of Health & Family Welfare, Government of India
National Health system Resource centre,
Technical Support Institution with National Rural Health Mission
NIHFW Campus, Baba Ganganath Marg, Munirka, New Delhi-110067.
Note
This book is based on learning from the experience gathered during the process of establishing Quality
Management system in Public Health facilities across the country by National Health system Resource
centre, in partnership with states under National rural Health Mission.
The SOPs described in this book are Templates only and are generic in nature. Modifications and
customization as per needs, requirements and available resources are required at facility level. The
purpose of this Standard Operating Procedure Manual is to provide support and guidance to the Hospital
staff in developing their own Facility-specific SOPs after customization of the templates.
The SOPs can be adopted for developing SOPs for other levels of health-care facilities after due
modification and customization.
The content of the this book are for purpose of General Information and may not be used for taking
patient related decision in particular fact situation.
This publication may be reproduced in part or in whole with due acknowledgement to NHSRC.
This Book is prepared by National Health System resource centre and edited by:
Foreword
Content
Page
Number
I Introduction
II Standard Operating procedures
(a) Clinical Procedures
SOP 1 Outdoor Patient (OPD) Management
SOP 2 In-Patient (IPD) Management

(General/Critical/intensive)
SOP 3 Hospital Emergency and Disaster Management
SOP 4 Maternal and Child Health Management

SOP 5 OT and CSSD/TSSU Management
SOP 6 Blood Bank/Blood Storage Management
SOP 7 Hospital Diagnostics Management
SOP 8 Hospital Infection Control Management
SOP 9 Data, Information and Record Management
SOP 10 Hospital Referral Management
SOP 11 Pharmacy Management
SOP 12 Management of Death.
(b)
Administrative Procedures
SOP 13 Patient Registration, Admission & Discharge
Management
SOP 14 Hospital Stores & Inventory Management
SOP 15 Procurement & Outsourcing Management
SOP 16 Hospital Transport Management
SOP 17 Hospital Security and Safety Management
SOP 18 Hospital Finance and Accounting Management
SOP 19 Hospital Infrastructure and Equipment Maintenance

Management.
SOP 20 Hospital Housekeeping and General Upkeep
Management
SOP 21 Human Resource Development and Training
Management.
SOP 22 Dietary Management
SOP 23 Laundry Management
SOP 24 Hospital Waste Management
A. Introduction
Quality in health care has been a abstract notion. People define quality in their on way
according to their perceptions and priorities. Quality as perceived by different stakeholders.
Although everyone values some extent the attributes of quality just discussed, different groups
to attach different level of importance to individual attributes, leading difference in how
clinician, patient, health system and society define quality.
Healthcare Providers – Clinician such physician and others who provide healthcare services,
tend to perceive quality of care first and foremost in terms of technical performance From the
point of view of health care providers, these desired outcomes are related to successful
treatment of morbid conditions and / or successful prevention of morbid conditions and
averting deaths. This aspect of quality of care can be assessed by technical person,
accreditation bodies, medical boards and academicians only. Two dimensions of our working
definition effective and safe can be attributed to technical quality.
The Patient’s/ Users Definition –Although patients, like clinician, are deeply concerned with
how good the technical aspect of care is, most patients do not possesses the capacity to
evaluate the technical elements of care. Patient therefore tends to form their opinions about
quality of care based on their assessment of those aspects of care they are more readily able to
evaluate: the interpersonal aspect of care and amenities of care. This can be measured in terms
of patients’ / User satisfaction. The major factors like access, waiting time, behaviour of service
provider, cost and environment of health care facility decides the patient’s perception.. Despite
positive results from a medical perspective that do encourage a few users to access services, it
is well known that people often delay seeking health services. Users’ experiences of health care
in a facility, whether personal or as shared by another who has utilised the said services, have a
major impact in their decision to seek services. For example, people do not wish to go to a
facility where they receive rude and inhumane treatment at the hands of the service providers.
This delay or refusal to seek services is more apparent for preventive and promotive care where
the client is not in “active suffering” in the present day and time.
Governments/ Administrators Definitions –Administrator defines in quality in terms of

optimal and rational utilization of resources , timely execution of programs, improvement in
health indices like MMR and IMR, comprehensive coverage of programs and meeting the
targets.
Society’s Definition -At the broader societal level the definition of quality of care reflects
concern of cost effectiveness, equal access and equity in service delivery, transparency and less
out of pocket expendere and their involvement in decision making . Society also perceives
quality in terms of protection of health rights specialty of marginalized and venerable
populations.
Framework of quality of care – The most accepted frame work for assessing the quality of care
is Donabedian classifies QOC in terms of three aspects-
1. Structure – Structural includes material resources like infrastructure, drugs and equipments;
and Human Resources such as the number, variety, and qualification. Evaluation of quality that
rely on such structural elements implicitly assume that well qualified people with well
appointed and well organized settings will provide high quality care . It must remember, that
although good infrastructure makes good quality more likely to ensue, it does not guarantee it.
2. Process – Care can also be evaluated in terms of the process of care, which refers to what
takes place during delivery of care.
3. Outcome – The other aspect of quality of car can be assessed in terms of outcome measures,
which seeks to capture wether goals of care are achieved . Since the goals of care can be
defined quite broadly, outcome measures have to include the cost as well as patient
satisfaction with care.
Stakeholders Structure Process Outcome
Patient’s Barrier Free Access Short Waiting Time & No out of Pocket
Requirement Prompt Referral if Expenditure
Public Amenities like required
waiting area / toilets Availability of
Good behaviour by services as
Availability of service service providers guaranteed
providers
Privacy, Patient Satisfaction
Availability of drugs confidentiality
and consumables Treatment and Cure
Grievance Redressal
Clean & Hygienic Care
Environment Information and
involvement in care
Service Providers Adequate and Adherence to Clinical Mortality, Morbidity

Requirements planned Protocols or referral etc.
infrastructure
Infection Control Effectiveness of care
Equipments & Drugs Practices in term of average
supply lengthens of stay.
Training and Skill
Adequate Human Development Complications,
Resource adverse drug
Safe and effective reactions and
Enabling Work Nursing care Hospital acquired
Environment infection
Employee
Satisfaction
Health Systems Allocation of Efficient logistics Optimal utilization of

Requirements adequate resources management resources
Operational Facilities Monitoring and Coverage of

Supervision programs
Adequate Technical
Support Effective Improvement in
implementation of Health Indicators
programs
Productivity in terms
of volume
Society’s Equitable distribution Involvement in Social security in

Requirements of resources planning and decision terms of affordable
making and assured services
Access to Health care
facilities Prompt response in
disaster conditions
So from above discussion it is clear that quality is all about-
1. Meeting patients requirements

2. Minimizing the variations and Standardizing the processes
3. Measuring and improving all aspects of services Structure, process & outcome.
Health care is one of the most risk prone and process sensitive service sector; hence there
are no chances of mistakes and variations. The most accepted approach for standardization
and quality in health care is Quality Management System. Quality Management System is
set of interrelated activities which try to measure, standardize and improve the quality of
service by implementing enabling documents like standard operating procedures. QMS has
for simple steps
1. Write down the processes as want do to achieve your organizational goals

2. Start working according to these written procedures (SOPs) next time and every time.
3. Check whether you are working according to set procedures or not through periodic
internal assessments
4. Act upon the discrepancies you find out during the assessment process so processes
can be further improved.
Quality
PLAN DO CHECK ACT
Check
Implement Periodically Act upon the
Write down
and work whether you the gaps in
procedures
according to are working compliance to
as you want
written according to set
to do
procedures set procedures
procedures
Quality Management System
Commonest method of learning how to perform procedures in the workplace is by verbal

instructions by seniors, which very often lead to variations. There is a felt need among
healthcare workers for SOPs in their workplace, which are drafted by end users by consensus.
However, SOPs should be customized to suit existing practices in different healthcare
institutions.
SOPs (Standard Operating Procedures) have been found to be of immense use in proper
working, training of personnel and favorable outcomes in every Industry. Thus SOPs are an
essential pre-requisite for any Quality initiative. Studies show that SOPs have significant
potential to enable provider organizations to improve quality without increasing costs. SOP is
therefore an important document in terms of quality measures and evaluation.
Definition of SOP
An SOP is a set of written instructions that document a routine or repetitive activity. It is a set of
detailed written instructions to achieve uniformity of the performance of a specific function. A
standard operating procedure or SOP is a set of instructions that address the who, what, where
and when of an activity.
Sops In Healthcare is defined as a written set of instructions that a healthcare worker

should follow to complete a job safely, with no adverse effect on personal health or environment
and in a manner that maximizes the probability of a beneficial health outcome in an efficient
manner. In simple terms a SOP is…a written process.
WHY WRITE SOPS?
Sops are written with the aim to provide people with all the information necessary to perform a
job properly. They help to ensure that the procedures are performed correctly and consistently,
as variation can be very costly.
SOPs also serve as a checklist for conducting reviews and audits. They serve as an explanation
of steps in a process, so they can be reviewed in failure/adverse outcome investigations. SOPs
are written to ensure safety and maximize operational and outcome requirements. SOPs are the
foundation of training. SOPs help people to focus on specific activities that lead toward goal
achievement. They improve communication and teamwork among workers and management.
They help in perpetuation of “best practices”.
BENEFITS OF SOPs:
1. SOPs can be used as a set of ‘Performance standards’. They are important in

establishing and enforcing work standards. They help to ensure that the same task is
consistently performed by all workers. At the same time the serve to define the
acceptable level of performance for a task.
2. SOPs are set of ‘Instructions’. They instruct the worker on how to accomplish a task
effectively, efficiently and consistently. They are also used as training guidelines for
conducting training.
3. SOPs can be used as „Reference’. SOPs have detailed information of the steps
involved in a particular process, so can be referred in case of any ambiguity. It is difficult
to remember every step in correct order, more so in complicated and long processes.
SOPs can be referred in such situations. SOPs also provide time-saving checklist to
ensure that each step is correctly followed.
4. SOPs can be used for ‘Review’. SOPs provide opportunity for critical review of each
step thereby offers scope for improvement. They tell us what to look for when we audit
our procedures and also serve as personal controls to avoid performing wrong steps.
They serve as the basic record of how the task is performed which is critical for success
5. To provide people with all the safety, health, environment and operational information
necessary to perform a job properly.
6. SOPs and CQA in Healthcare-The key concepts in CQA (Continuous Quality Approval)
i.e. reduction in variation and improvement of processes has need for standards as a
basic.
7. SOPs specify job steps that help standardize services and therefore quality.
WRITING SOPS: GENERAL HINTS
1. SOPs are vital to ensure processes are completed in the same way over time and
should be Clear, Concise, Consistent, and Current.
2. SOPs should be written in plain language. Any highly technical jargon should be avoided
or clearly defined. Define acronyms used in the SOPs
3. Steps should be explained thoroughly, but concisely. Long sentences or paragraphs

explaining tasks should be avoided.
4. Write steps in short, descriptive sentences. Do not use vague wording.
5. While describing activities use active voice. Avoid names and use designations instead.
6. Don‟t include the steps that are done by people outside the organization (only include
what that organization is responsible for)
How much detail?
Less detail leads to easier compliance. Whereas more detail are helpful for new employees to
use. So we need to strike a balance! A higher level of detail is called for when-Task is
performed infrequently; many different people are involved in performing a task, correct
performance is critical to hospital‟s performance, Training on the process has not been
comprehensive and there is little time to practice (or train). Not all the SOPs in a Hospital need
the same level of detail. The minimal amount of detail should include:
• Critical “whats”
• Critical “hows”
• The “who” if more than one person is involved.
ARCHITECUTURE (BUILDING BLOCKS) OF SOPs USED IN THIS

MANUAL:
Although a number of processes are carried out in Hospitals to deliver health care service,
following 24 Processes (Clinical & Administrative), which are most common and critical for
performance for a secondary care hospital have been identified and described in this manual.
*The number and name of SOPs are indicative only. State/facility can change or modify as per their
requirements.
CLINICAL PROCEDURES ADMINISTRATIVE PROCEDURES.

1 Outdoor Patient (OPD) 13 Patient Registration, Admission & Discharge
Management Management
2 In-Patient (IPD) Management 14 Hospital Stores & Inventory Management
3 Hospital Emergency and Disaster 15 Procurement & Outsourcing Management

Management
4 Maternal and Child Health 16 Hospital Transport Management

Management
5 OT and CSSD/TSSU 17 Hospital Security and Safety Management
Management
6 Blood Bank/Blood Storage 18 Hospital Finance and Accounting Management
Management
7 Hospital Diagnostics Management 19 Hospital Infrastructure and Equipment
Maintenance Management.
8 Hospital Infection Control 20 Hospital Housekeeping and General Upkeep
Management Management
9 Data, Information and Record 21 Human Resource Development and Training
Management Management.
10 Hospital Referral Management 22 Dietary Management
11 Pharmacy Management 23 Laundry Management

12 Management of Death. 24 Hospital Waste Management
Each SOP has been documented with following headings:
A. Title
This describes the focus of the SOP so that anyone can tell from the title the content of the SOP
when searching a list of SOPs.
B. Scope:
Scope defines the area/s to which the SOP applies.

C. Purpose:
Purpose describes and explains what is to be accomplished

D. Responsibility
This states who has responsibility of execution of the SOP and training.
E. Procedure:
This describes the activities carried out in execution of the process in sequential and
chronological order. Use words such as-Shall, Must, and Will. When more than one person
carries out an activity do not use words like Should or May. When only one person carries out
an activity, begin each activity with an active verb such as-Analyze, Begin, Check, Delete,
Enter, Start, Store, Submit etc.
F. Forms and Formats:
Any Form, Logs, or other documents those are essential for the execution of the SOP.
G. Records:
Records generated during execution of SOP. These include filled Forms & Formats, Registers,
Electronic records etc.
H. Process Efficiency Criteria:
They are the indicators to measure the efficiency and effectiveness of the process. Because to
improve any process, we have to first measure it. A glimpse at these indicators will give
sufficient idea about the process efficiency. These should be selected carefully and regularly
monitored and evaluated.
A. Reference:
List all the references that serve as the basis of the SOP. These includes-Standards, Guidelines
from State Centre or international bodies like WHO, regulations, articles, Textbooks etc.
HOW TO USE THESE TEMPLATES:
The SOPs described in this manual are „template only‟. They are not designed for your facility.
Hence, customization foe meeting needs of facility becomes imperative.
Following steps are advised to make maximum use of these templates.
1. Understand your processes. Involve all who are associated with the process. Walk
through various processes of your hospital. The possible approaches will include
inspection, discussions and analysis of all hospital processes. Then identify the
bottlenecks of your processes.
2. Based on the knowledge of your processes and bottlenecks, develop your own SOPs on
the lines of these templates. You may like to add, delete or modify the content.
Customize it as per your needs, requirements and available resources. All stakeholders
should be involved in the process of customization.
3. Once the SOPs are finalized, distribute them to the end users. Ensure that persons
involved in a particular process have a copy of the SOP.
4. At the same time arrange for trainings for those associated with on the SOPs.
5. After training, implement these processes. Monitor and evaluate on a regular basis, till
they become a part of the work culture of your hospital.
6. The SOPs are dynamic documents and calls for periodic reviews. SOPs should be
reviewed as and when required (at least annually). You can as many changes and as
frequently you desire.
7. Any change in the SOPs should be communicated to all SOPs holder and develop a
mechanism to ensure that only the latest version of the Document is available with the
end user.
PROCESS MAPPING-A SIMPLE TOOL FOR IMPROVING PROCESS
As explained earlier, SOPs are written procedures. Every procedure is executed via various small
processes. A process is defined as set of interrelated and interacting activities which transforms inputs
into outputs. A process is defined as “a series of steps which convert one or more inputs into one or
more outputs.”
A process has three key components.
1. Inputs.
2. Processes-Activities/steps that transforms inputs into outputs.
3. Outputs-end result of processes.
An output of a process can be input of next process. It is understood that the output or final outcomes
depends on not only the inputs but also the processes we employed to convert them into output.
Whenever going for improving quality of healthcare services, more often than not we tend to
concentrate on INPUTS-Infrastructure, Human Resources and Finances. We need to understand that
‘mere provision of resources is not enough’. Effective and efficient utilization of available resources is
equally important if not more, for improvement of quality of healthcare services. In quality paradigm:
 Best Infrastructure-Building, space, ≠
equipments and amenities.
 Best Human Resources-numerical and Best Quality
competence adequacy.
 Adequate Finances.
For example in a CHC 13 Nurses are required and only 8 are available. This cannot be an excuse for poor
quality of services. How to improve quality within limit resources available is a challenge. We can do this
by improving our process. It is evident that we cannot improve quality of services without improving our
processes. Now the question comes-How to improve our Processes? There are several techniques and
methods available. But here we would be discussing a very simple, easy to implement and highly
effective technique-Process Mapping.
What is a Process Map?

A process map is a graphical representation of series of steps of a process. The map is used to document
the step-by-step activities involved in providing a service. A common saying is “A picture is worth a
thousand d words”. Also all of us have visual memory. Hence it is always helpful if we project facts in
picture and figures. A process map visually represents the entire process from start to finish. It provides
a common understanding of the entire process and specific roles and contributions of the process
participants. Furthermore, process maps helps in identification of problem areas and opportunities for
process improvement. Process maps are great Problem solving tools. They help us to determine what
the problem is/what it is not.
The purpose of process mapping is to use diagramming to understand the process we currently use and
ask what is expected of us; what should we be doing to provide better customer focus and satisfaction.
It will identify what best practices we need to incorporate and find appropriate benchmarks for
measuring how we can arrive at better ways of communicating our services. As Dr. George Washington
Carver put it – "It is simply service that measures success."
When we map hospital processes and look at patients’ perspective, we will find that:
 30 - 70% of work doesn’t add value for patient
 up to 50% of process steps involve a ‘hand-off’, leading to error, duplication or delay
 no one is accountable for the patient’s ‘end to end’ experience
 Job roles tend to be narrow and fragmented.
How to do Process mapping?
Step 1: Determine the Process to be mapped and its Boundaries
a. Where does a process begin?

b. Where does a process end?
Step 2: List the Steps
a. Use a verb to start the task description.

b. The flowchart can either show the sufficient information to understand the general
process flow or detail every finite action and decision point.
Step 3: Sequence the Steps

Locate the steps of the process in their proper sequence. Map what actually happens. Record the
activities including time. Create the journey (remembering that some activities happen in parallel)
Step 4: Draw Appropriate Symbols
There are numerous symbols available for process mapping but we will stick with the basic symbols
required for mapping hospital processes:
oval i. Ovals show input to start the process or output at the end of the process.
ii. Boxes or rectangles show task or activity performed in the process.

iii. Arrows show process direction flow.
iv. Diamonds show points in the process where a yes/no questions are asked or a
decision is required. Usually “yes/no” (binary) decisions. Divides the continuing
process flow into two separate paths in response to the question inside the
diamond Usually there is only one arrow out of an activity box. If there is more
than one arrow, you may need a decision diamond.
v. If there are feedback arrows, make sure feedback loop is closed; i.e. it should
take you back to the input box.
Step 5: Inputs/Outputs: Represent the output of each box or diamond as an appropriately labeled arrow
leading to the next step in the process
Step 6:. Number: Number the boxes for reference
Step 7. Keep a note of issues and opportunities at each step.
Step 8: Check for Completeness
Sample Flowchart
Step 9. Identify the bottlenecks. Now the map is complete. Let us now identify the bottlenecks. There
are two types of bottlenecks; Process bottlenecks and Functional bottlenecks.
Process Bottlenecks: Occurs when a step is the limiting rate of the process The step takes a significant
time, and slows the whole process down.
Functional bottle necks Occurs when one functional resource is required for more than one processes.
For example Lab. Services are required by OT, Labour room, wards, ICU, etc.
Step 10: Identify VALUE / NON-VALUE ADDING STEPS
Value adding activities: The activity that transforms the patient and moves them towards the next
defined outcome. The activity is something that the patient cares about and is willing to pay.
Non-value adding: Do not serve any purpose (aim to remove these)
Necessary non-value adding: Do not directly benefit patient but are necessary e.g. completion of forms,
logging patient details onto systems, numerous checks of details.
Remember: It’s the activities that are non value adding not the person. It is also critical to recognise
that the non value adding activities may have been a core part of someone job for many years
Step 11: Identify the wastes in the processes.

Waste is a sensitive issue. Lean philosophy advocates removing the wastes from the processes. Quality
of any process can be improved without doing anything extra or different, simply by removing the
wastes.
Common wastes in the Hospitals are:
1. Confusion:
 Nurses spend 65% of their time looking for things they could not find, clarifying unclear
instructions and doing redundant paperwork. (Jimmerson et al. 2005). Confusion includes
questions like:
 What do I do with this requisition? Is it Inj. Fortum or Inj. Fortwin.
 What does this order mean?
 Where do I have to store this item?
2. Motion/conveyance:
 Physical movement required to get a simple task done and to move people from place to place.
 Redundant reaching for items.
 Walking to another location only to return to the starting point.
 Conveyance of patients and materials from room to room or department to department.
3. Waiting: Waiting for :a procedure to be done, a medication to arrive, or a doctor’s order to be given.
4. Over processing: Doing more activities than is necessary to complete a work. Eg. Multiple entries of
patient’s demographic details during the hospital visit.
5. Inventory: Stored supply that are: Obsolete, Duplicated, Unnecessary. E.g. missed charges for items
used.
6. Defects: For example: Medication errors. Wrong site surgery. Leaving instruments in patient’s body.
Wrong blood group errors. Bed sores. Incidence of fall from bed.
Step 12: Analyse the processes Map:

 How many steps in your process?
 How many duplications?
 How many hand-offs?
 What is the approximate time of or between each step?
 Where are possible delays?
 Where are major bottlenecks?
 How many steps do not add value for patients?
 How many types of wastes are there between each step?
 Where are the problems for patients and staff?
Step 13: Redesign the Process: After analyzing the Process, “TO BE” process may be developed by:
 Eliminate non-value-added activities
 Eliminate duplicate activities
 Combine related activities
 Identify and remove waste at each step.
 Use decision-based, alternative process flow paths.
Facts &Tips:
 Process mapping is basic and simple — the best way to learn it is to do it!
 Process mapping is a repetitive process; maps should never be thrown away but reviewed and
updated.
 Display the maps so all staff can see them and contribute to ongoing improvements.
 There is no right or wrong way to process map. Adapt to your organization and individuals
availability.
 Only record those steps which you carry out MOST of the time (80/20 rule).
 Keep the steps SMALL.
 Make it fun but productive
LIMITATIONS OF PROCESS MAPPING:
1. Process mapping is not panacea for all healthcare service delivery problems.
2. Process mapping is no substitute for knowledge, skills, attitudes and competence.
3. Process mapping are as good as you want them to be. If you have missed the critical
details/activities of a process, you will not be able to improve the process.
4. Process mapping can help in improving quality even with limited inputs. But is of no use when
inputs are not available at all.
Standard Operating Procedures
Outdoor Patient (OPD) Management/
In-Patient(IPD) Management/Hospital
Emergency and Disaster
Management/ Maternal and Child
Health Outdoor Patient (OPD)
Management/ In-Patient(IPD)
Management/Hospital Emergency and
Clinical
Disaster Management/ Maternal and
Procedures
Child Health Management/ OT and
Outdoor Patient (OPD) Management/
In-Patient(IPD) Management/Hospital
Emergency and Disaster Outdoor
Patient (OPD) Management/ In-
Patient(IPD) Management/Hospital
Emergency and Disaster
Management/ Maternal and Child

SOP1: Outdoor Patient Management
1. Purpose:
 To ensure that all services to outpatients are coordinated so that they get the
required care from service providers in the hospital.
 To respond to the need and expectations of the patients and to enhance patient
satisfaction.
2. Scope:
It covers the persons who visit the OPD facility (new and follow up patients) for
treatment, investigation, consultation, checkup and immunization.
3. Responsibility:
 The registration clerks are responsible for issuing registration slip and providing
consultation appointments.
 The OPD Nursing In-charge is responsible for monitoring the respective OPD
unit functioning, maintaining necessary records and assisting the consultants.
 The Consultants are responsible for examination of the patients and for
determining the line of management of the ailment / case thereof.
4. Procedure:
Ref
Sr.
Activity Responsibility document/
no.
Record
4.1 Scope of Services – Hospital provides Medical Indian Public

OPD services as mandated in minimum Superintendent Health
Standards
assured services by Indian Public Health
Standards.
4.2 Display of Information-Information Hospital
regarding OPD clinics available, doctors and Manger
their timings and room no. and directional
signage‟s for clinics are displayed at the
entrance and other relevant locations.
4.3 OPD CONSULTATION PROCESS
4.3.1 After the patient is registered, registration Receptionist at OPD slip

number is generated at registration counter the Registration
Desk
the patient is directed to the doctor for OPD
consultation.
4.3.2 Patient is directed to different OPD‟s by Help Desk

registration clerk based on his assessment Staff/ Volunteer
of the patient requirement.
If he/she is not sure patient is directed to

general OPD clinic where doctors screens
the patient and refer to specialist if required.
4.3.3 Patient Calling System - Duty staff
Patient waits outside concerned doctor room

for his/her turn. Patient is called by
Doctor/attendant as per his/her turn on the
basis of “first come first examine” basis.
If clinic caters to both male and female

patient a definite turn is fixed for female and
old patient.
Two patients are not allowed at one time in

clinic.
For clinics having heavy patient load manual

/ electronic calling system is implemented.
Attendant/Guard is provided on priority basis
for such clinics to mange crowd.
For any critical patient needing urgent

attention queue can be bypassed for
providing services on priority basis.
4.3.4 Receiving the patient in clinic- Medical Officer/

Specialist
Doctor/Attendant greets the patient and
guides him to sit on patient stool/chair by his
side and not full face across the desk.
No patient is consulted in standing position.
If patient is accompanied by
relatives/attendant as per hospital policy
they are also offered seats.
But if patient wants to be consulted alone

and/or doctor feels it necessary he asks
other to leave the clinic.
4.3.5 History Taking- Medical Officer/ OPD slip

Specialist
Doctor reads the referral documents / other
treatment related documents if any provided
by the patient.
Doctor takes the history including main

presenting problem, past medical history,
history of main presenting problem, family
history, occupational history, habits like
smoking & alcohol, allergies, drugs and
other treatment history and other bodily
systems that are not covered in presenting
complaint as required.
In case of complaint of pain details including

site, radiation, severity, time course,
aggravating factors, relieving factors and
associated symptoms are asked as
required.
Doctor notes down the relevant history on

the OPD slip
4.3.6 Physical Examination- Medical Officer/ OPD Slip

Specialist
Examination table with footsteps and
screens for privacy have been provided in
the clinics.
Daylight is preferred over artificial light for

examination.
A female attendant / nurse /relative is

required to accompany the female patient at
the time of examination in the case doctor
examining is male. While examination of
private parts it is essential.
Doctor takes a verbal consent before

examining the patient.
Physical examination including examination

of temperature, pulse and examination is
done as required.
Doctor note down the relevant findings of

examination on the OPD slip.
4.3.7 Risk Assessment &

Differential Medical Officer/ Procedure for
Diagnosis- Specialist patient
registration,
Based on data gathered for History and admission and
discharge
Physical examination severity of problem is
assessed.
Differential diagnosis is given on the basis of

collected information.
Procedure for
If patient requires some urgent treatment / Referral
procedure same is arranged at OPD or Management
patient is shifted to emergency/ OT/

Dressing Room/ Injection room as required.
If the patient requires admission he/she and

accompanying person is informed and
patient is shifted to ward.
If patient requires such interventions /

consultation which are not available in the
hospital patient is referred to higher center.
4.3.8 Investigations Medical Officer/

Specialist
In case laboratory/ radiology investigations
are required to be performed, investigation
requisition form is filled by the doctor/ OPD
attendant.
Only those investigations which are not

available in hospital and essential for
arriving diagnosis are prescribed for outside.
After the investigation patient come back to

OPD for the consultation.
Final Diagnosis is arrived on the basis of

investigation reports and clinical findings.
4.3.9 Prescription- Medical Officer/ OPD Slip/
Doctor prescribes the drugs/procedures Specialist Prescription
after arriving provisional diagnosis/ final
diagnosis.
If required drugs are part of essential drug

list and available in the hospital pharmacy
they are prescribed in generic name and
patient is directed to collect it from OPD
dispensary. Procedure for
Pharmacy
If required drugs are not part of essential Management
drug list/not available at hospital in house
pharmacy, they are prescribed in generic
name and patient is directed to generic drug
store/ Jan aushadhalaya if available in the
Hospital.
In exceptional conditions only when required

drugs are not available in in-house
Pharmacy it is brought to notice of the
facility In charge who take further action to
locally procure the drugs.
Doctor mentions his /her name, initials, date

& registration no. on the prescription. A
stamp for the same has been prepared for
the same.
4.4 Drug Dispensing Procedure for

Pharmacy
If medicines are prescribed, the patient goes
to the pharmacy to collect it.
4.5 Follow Up Medical Officer/ OPD slip

Specialist
Cases where follow up visit is required the
same is mentioned in the OPD slip and the
patient / relatives are informed by the doctor
about the date and time for the next follow
up visit.
4.6 Nursing Process in OPD
4.6.1 In case Medical officer prescribes for Dresser/ Dressing

dressing, Dresser/ Nurses on duty perform Nurses on duty register
dressing as per Medical officer advice. They

enter the details in dressing room register.
Patients are advised by dressing personal
for next dressing if doctor prescribes the
same.
4.6.2 In case medical officer prescribe for the Nurses Immunization

immunization, Nurses on duty generates a Card
immunization card and immunizes the Immunization

patient and details are entered in the register
Immunization card and immunization

register
4.6.3 Injections as instructed by the treating Nurses Injection
doctor are administered by the Nursing staff. Register
4.6.4 Nurses are also responsible for checking the Nurses

functioning of instruments at OPD clinic and
report for the maintenance and breakage if
any.
4.7 Patient Privacy and Confidentiality- Hospital

Manager/
Patients privacy is maintain during all OPD Medical
procedures including consultation, Superintendent/
Medical Officer/
examination, counseling and procedures like
Specialist
injection and dressing. Screens and curtains
have been provided at all such areas of
OPD.
Information and records pertaining to

diagnosis and treatment of patients are not
shared with anybody except clinical staff
involved in treatment.
4.8 Duty Roster – A duty roster is prepared Medical Duty Roster

weekly for deputation of Doctors and Nurses Superintendent/
Hospital
in OPD.
Manger/
Information for Doctors availability is

updated as per the roster. In case of non
availability of any Doctor alternate
arrangements are made if possible. If Clinic
remains unattended information the same is
displayed on the notice board.
4.9 Punctuality, Dress Code and Identity Medical

Superintendent/
Hospital manger monitors that all the Hospital
doctors are available at their clinic at Manger
scheduled time. Any Discrepancy is
reported to Medical Superintendent who
takes corrective action in this regards.
Same measures are also taken for Nursing

and support staff.
All the staff wear their respective

uniform/Apron with name plate/ I-Card.
4.10 Disable Friendly OPD- Medical

Superintendent/
Ramps with handrails have been provided at Hospital
entrance and for other elevated area. Manger
Wheelchairs / Trolleys have been providing

on entrance/ reception.
Disable friendly toilets with handrail and two

ways swing doors have been provided at
OPD.
4.11 Hand Hygiene- Medical Officer/

Specialist
Doctor/Nurse staff wash hands between
examining two patients with soap following
the steps and duration.
Alternately alcohol based hand rub is used

for the same.
Hand washing facilities with running water

and soap/ Hand rub have been at all point of
use.
4.12 Clinic Management – Hospital

Manger
Hospital Manger ensures that all necessary
instruments/
equipments/furniture/consumables including
patient stool, thermometer. BP apparatus,
examination table, other examination
equipments, hand washing facility, X-ray
View box, examination gloves, screens and
curtains are available in the clinic before
start of day.
Any deficiency is noted and discussed with

medical superintendent for correction and
corrective action.
4.13 Patient Amenities- Hospital

Manger /
Patient amenities like safe drinking water, Medical
adequate chairs in waiting area, clean Superintendent.
toilets, fan and air cooling/heating are made
available as stipulated in IPHS and
monitored for their functionality and
adequacy on regular basis.
A May I Help You Desk has been provided

at OPD with dedicated staff.
4.14 Prohibition of Smoking- Prohibition of

Smoking in
Smoking is prohibited in OPD as well other
Public Places
areas of Hospitals under Prohibition of
rules 2008.
Smoking in Public Places rules 2008. Hospital
Superintendent/
A 60 X 30cm board saying, “No Smoking
Hospital
Area – Smoking Here is an Offence” is Manager
prominently displayed at each entrance,
floors, staircases, entrance of the lifts and at
conspicuous place(s) inside. Name of the
person to whom a complaint may be made
is prominently displayed.
Format for
Any person found smoking is fined Rs 200
receipt/Challan
as per the provision of rules. Medical for fine
superintendent or Hospital manager is
authorized to collect this fine against receipt/
challan.
4.15 Administrative and non clinical work at Hospital

OPD Manager/
Medical Officer/
Administrative work like attestation of Specialists
certificates and issue of medical certificates
are not entertained in the OPD timings
Medical representatives from

pharmaceutical companies are not
entertained in OPD timing.
Notice for the same is displayed at the OPD.
4.16 Patient Satisfaction Survey
4.16.1 Sample Size Hospital Sample Size

Manager calculator.
Sample size for patient satisfaction survey is
calculated on the basis of case load of
previous three months.
4.16.2 Data Collection Hospital OPD

Manager/ Feedback
Patient feedback is taken on OPD Patient format
Enquiry
Satisfaction format printed in local language
Counter
on continuous basis. Personnel
For illiterate patients Enquiry counter

personnel or any other designated staff take
the interview and record the feedback on the
form.
When collecting the feedback it is ensured

that all categories of patients eg. Male,
female, BPL, Old age and revisit patients
get representation
4.16.3 Analysis- Hospital Patient
Manager Satisfaction
Analysis of data collected is done on survey
quarterly basis. analysis sheet
Overall and individual attribute scores are

calculated by taking arithmetic mean.
Lowest scoring attributes (bottom two) are

identifies.
4.16.4 Root Cause Analysis – Hospital Minutes of

Manager/ meeting of
Root cause analysis in done in management Process owner MRM
review meeting.
4.16.5 Action Plan – Hospital Action Plan

Manger/
Corrective and preventive action is decided Medical
and action plan is prepared for the same. superintendent/
Process
Progress on action plan is tracked on owners
monthly basis.
4.17 Monitoring of waiting times- Hospital

Manager
Waiting time for registration, consultation,
investigations, pharmacy and consultation
time are monitored through time motion
study and data is analyzed on monthly
basis.
Processes having long waiting time and

causing patient dissatisfaction are discussed
in management review meeting and
corrective and preventive actions is taken
after arriving on route cause.
5. Records:
Sl. Name of Records Record No. Minimum Retention

No. Period
01 Immunization register
02 Doctor‟s OPD Register
03 Dressing room register
04 Injection Register
6. Process Efficiency Criteria
Sr. Activity Process Efficiency Criteria Benchmark/Standard/Target

No.
1 Service Provision Proportion of OPD Services Available
IPHS
2 Consultation Consultation Time
3 Consultation OPD Patients per Doctor
4 Prescription Proportion of drugs prescribed from
outside.
5 Patient Information Patient Right & Information Score
6 Equity Proportion of BPL OPD Patients
7 Follow Up Proportion of Old patient Visit
8 Patient Satisfaction Patient Satisfaction Score for OPD
7. Reference Documents
1. Code of Medical Ethics Regulation 2002

2. Prohibition of Smoking in Public Places rules 2008
3. Persons with Disability Act 1995
4. Indian Public Health Standards
5. Standard Treatment Guidelines issued by state & Government of India
6. Procedure for Referral (SOP 10)
7. Procedure for Patient Admission (SOP 13)
8. Procedure for Pharmacy (SOP 11)
9. Procedure of Diagnostic Services (SOP 7)
SOP 2: In-Patient (IPD) Management

1. Purpose:
o To establish, implement & maintain a system for patient admission in
order to provide IPD services offered by the hospital.
o To provide guideline instructions for General Nursing care with the aim
that needs and expectations of patients are honored.
o To enhance patient satisfaction on continual basis
2. Scope:
It covers all indoor patients admitted and receiving treatment at Hospital.
3. Responsibility:
Doctor, Matron, Nursing In-charge and Ward In-Charge, Housekeeping

supervisor.
4. Procedure:
Sr. Activity Responsibilit Ref

no y document/R
ecord
4.1 Admission
4.1.1 Admission Advise Treating OPD Slip ,

Doctor Patient
Patient visits the OPD/emergency for doctor‟s Registration
consultation. no.,
Doctor‟s
Depending upon the doctor‟s assessment, he Instruction
advises admission (in writing on the OPD for
Slip) to one of the different inpatients areas of admission
the hospital like Inpatients Ward, ICU, and
Labor Room etc.
4.1.2 Inpatient Registration- Registration SOP for

Inpatient registration and allocation of beds is Clerk Patient
done as per the procedure for Patient Registration,
registration, admission and Discharge Admission &
Management Discharge
Management
, Bed Head
Ticket.
4.2 Shifting of Patient to concerned Ward Attendant
Stable Patient is shifted to the concerned
inpatient facilities accompanied by an
attendant.
Stretcher/wheel chair/Trolley are used for
shifting of patient as required.
Critical patients who reach emergency are
first assessed and primary treatment is given
at emergency observation ward only. Patient
is shifted to the ward when the patient is
stabilized.
In case the patient has to be transferred to
ICU/OT Wards he/she is preferably
accompanied by a doctor /Nurse.
4.3 Patient warding in - On duty Registration

The ward nurse receives the patient. Sister In Slip
Patient/Attendant hand over admission slip or charge IPD register
Bed Head Ticket (BHT) to the Sister in-
charge charge.
Wards nurse confirms the identity of the
patient.
Ward nurse reviews the admission notes
/instructions and acts on any urgent
instructions by admitting doctor.
Ward Nurse records the patient details in the
patient admission/discharge register.
4.4 Bed Allotment Sister In

Bed is allocated based on clinical and charge
personal needs of the patient and availability
of beds.
Bed no of allocated bed is recorded in BHT
and admission register.
Patient is shifted to the bed, made
comfortable and is oriented about the layout
of ward with instructions on how to call her in
case of emergency.
A cupboard/ bed side locker is allotted to the
patient.
In case of non availability of bed the ward
nurse makes alternate arrangement for
additional cots/ ground bed.
4.5 Patient Property – Valuables like jewelry,
mobile and cash is handover to the patient
relatives. Patient is instructed to not keep any
valuables with them.
4.6 Consent Sister In Consent
Consent is signed by all the patients admitted charge Format
in the ward. In case patient/ Next to Kin is
illiterate then the thumb impression of the
patient is taken which is witnessed by a
neutral person.
4.7 Initial Assessment- Once patient is settled Doctor on BHT

in the ward, nurse conducts a nursing need Duty
assessment. Ward Nurse
She calls the duty doctor who conducts the
initial assessment if it is not done at
emergency/OPD of the patient records the
findings/ directions in the BHT.
4.8 Priority to treatment – Doctor on
If an admission is done from the OPD on or Duty
from causality on urgent basis life saving Ward Nurse
treatment/ procedures supersedes any
documentation work.
4.9 Orphan/Lawaris Patients – Orphan patients Doctor on
having not accompanier/ relative are specially Duty
monitored. Ward Nurse
Efforts are made to appoint some from local
NGOs/ volunteers who can take care of non
clinical needs of these patients.
Names of all such patients are reported to
local police.
4.10 People living with HIV AIDS Doctor on
Confidentiality of such patient is be Duty
maintained in all cases. Ward Nurse
Patient is not isolates/segregated.
Beds / BHT of such patients are not labeled
marked which denotes their HIV positive
status.
Status of such patients is not discussed with
anybody who is not involved in direct care of
patient.
4.11 Patient Care
4.11. Nurse starts the treatment as per the Ward Nurse
1 instructions on Bed Head Ticket (BHT).
4.11. Monitoring Temperature- Doctor on TPR Chart,

The timing for measuring the body Duty in take &
2
temperature is checked from the Doctors‟ Ward Nurse output Chart,
order or 6 hourly as per nursing chart. Nurse
A non mercury thermometer should be assessment
preferred to record temperature. sheet,
Temperature is recorded in nursing chart. Treatment
Duty doctor is informed in the case of Register
abnormal values.
Thermometer is disinfected in isopropyl
alcohol, covered with a „barrier warp‟.
4.11. Monitoring Pulse rate- Nursing
The timing for measuring the body Chart
3
temperature is checked from the Doctors‟
order or 6hourly as per nursing chart.
Radial pulse is felt and counted for 60
seconds with elbow and forearm resting
comfortably on the bed/table and the palm of
the hand turned upward.
If Radial Pulse is not palpable, other arteries
are palpated. In case of difficulty doctor on
duty is informed.
Pulse for the concerned patient is recorded in
nursing chart.
Doctor on duty is informed in the case of
abnormal values.
4.11. Monitoring Respiratory Rate- Doctor on Nursing
Respiratory rate is measured and Pattern, Duty Chart
4
effort level and rate of breathing is observed. Ward Nurse
For infants and children less than 6-7 years of
age abdominal movements are counted since
they are abdominal breathers.
Signs for respiratory distress such as nasal
flaring, wheezing, use of accessory muscles
of respiration, chest shape and movement
are also looked. If there is any difficulty in
breathing doctor on duty is informed.
Respiratory rate is recorded in nursing chart.
Doctor on duty is informed if the Respiratory
rate recorded is abnormal.
4.11. Monitoring Blood Pressure- Doctor on Nursing

The timing for measuring the Blood Pressure Duty Chart
5
is checked from the Doctors‟ order or 6 hourly Ward Nurse
as per nursing chart.
The auscultatory method of BP measurement
with a properly calibrated and validated
instrument is used.
Preferably a non mercury BP instrument is
used to record the BP
An appropriate sized cuff (cuff bladder
encircling at least 80 percent of the arm) is
used to ensure the accuracy.
Arm of the patient is positioned at the level of
heart and well supported.
Doctor on duty is informed if recorded if
recorded BP is above / below expected or as
mentioned in doctors‟ order.
BP for concerned patient is recorded in the
nursing chart.
4.11. Handling of Medical Devices and Doctor on Procedure
instrument Duty for Hospital
6
All medical devices and instruments are Ward Nurse Infection
cleaned after each patient use in accordance control
with procedures for „Hospital Infection Procedure
Control‟ for
All the measuring equipments used in patient infrastructure
care are regularly calibrated in accordance , and
with manufacturer‟s instructions and equipment
procedure for „Infrastructure and equipment maintenance
maintenance.‟
All Medical devices and equipments are
appropriately stored with access to
authorized individuals only.
4.12 Administration of Medication
4.12. Essential Checks- Before administering any Doctor on Medication

drug name of the drug, time of administering Duty Chart
1
the medication, dosage, route of Ward Nurse
administration and in case of oral drugs,
whether to give before or after food is
thoroughly checked from the medication chart
of the concerned patient.
In case of any discrepancy in name doctor on
duty /Pharmacist is consulted and generic
name is matched.
It is made sure that medication is not
discontinued in the Medication Chart.
Drug is checked for proper storage procedure
and any sign of damage which may harm the
efficacy. Parenteral drugs are checked for
any turbidity in the container.
Date of expiry and batch no. of the drug is
checked and in case of any discrepancy head
nurse and Pharmacists are informed.
In case Doctor is administering the drug, he
checks for any allergies, contraindication as
well as benefits against the adverse effects of
the drugs on evidence.
4.12. Preparation – Doctor on Medication

For oral drugs after washing the hands pills Duty Chart
2
are dropped in a small cup and handed to Ward Nurse
patient. This is done immediately prior to
giving drugs and not in advance.
If the medication is liquid, the bottle is shaken
and correct dose is poured in a measuring
cup.
In case of pills only break which are not
enteric coated.
For parental drugs instructions of
manufacturer are followed.
4.12. Administration- Doctor on Medication
Name of the patient is confirmed by asking Duty Chart
3
the patient/attendant or wristband if available. Ward Nurse
Oral drugs are administered using sufficient
amount of water/liquid or as per special
instructions from the doctors‟ order.
For oral drugs are given to fully conscious
patients in a sitting/propped up position.
4.12. Monitoring/ Recording- Doctor on Medication
After ensuring the drug has been Duty Chart
4
administered the nurse records the time and Ward Nurse
dose that has been given in medication chart.
If complete dose is not given because of any
reason (like vomiting of oral drugs) it is
recorded in nursing chart and informed to
doctor on duty.
Patient is watched for adverse effects and if
any Doctor on Duty is informed.
Storage and disposal of remaining drugs is
done as per procedure for „Hospital Waste
Management‟
4.13 Medical Documentation – Doctor on BHT
Patient‟s complete medical records are Duty
available at all the times during their stay in Ward Nurse
Hospital.
Every page in the medical record has patient
name, identification number and name of the
ward.
Documentation within the medical record
follows the logical sequence of date, time.
Drug prescription chart, diagnostic results,
nursing care plan are kept as separate
sections for prompt easy access.
Data recorded or communicated on
admission, handover and discharge is
recorded using standard format.
Every entry in the medical record is dated,
timed (preferably in 24-Hour format), legible
and signed by the person making the entry.
Deletion and alterations are countersigned.
Entries to medical records are made as soon
as possible after seeing or intervention (eg.
Change in clinical state, ward round,
diagnostic) and before the relevant staff
members goes off duty.
Every entry made in medical record identifies
the person who is responsible for decision
making.
An entry is made in the medical records
whenever a patient is seen by a doctor.
Consent form and resuscitation status
statements must be clearly recorded in
medical records.
4.14 Nursing Care procedures Nurses
Nursing procedures are performed as per
protocols/ guideline of state
 Sponge Bath
 Oral Medication
 Intramuscular Injection
 Subcutaneous Injection
 Assisting Intravenous
Transfusion
 Steam Inhalation
 Ryles Tube
 Oxygen through Nasal Cannula
 Surgical Dressing
 Cardio-Pulmonary
Resuscitation
4.15 Nurse informs the dietary department/ On Duty Diet request.
Kitchen for patient diets according to the Sister In
doctor/Dietician advice charge
4.16 On Duty Nursing
Inventory
Sister In register,
Nurse maintains record of the patient
charge Medication
progress, treatment offered, stocks of
Chart,
inventory & medicines in the ward.
Nursing note
Ward nurse also change the linen at defined
sheet, stock
frequency preferably in morning hours.
register
4.17 On Duty Nursing
Sister In register,
Handover charge Medication
At the end of each shift nurse on duty hands Chart,
over, the details of treatment provided and Nursing note
patient progress, in writing to the nurse on sheet, stock
duty for the next shift. register, Shift
transfer
records.
4.18 Indenting On Duty Indent
All the drugs and consumables required are Sister In Register
indented by the Sister in-charge on a regular charge
basis. For specific drugs and consumables
sisters raise the indent according to the
requirement.
4.19 Interdepartmental Transfer On Duty IPD Register
If patient is required to be shifted to other Sister In
ward for any reason, the sister In charge of charge
the other ward is informed and patient is
escorted /sent to the ward with all the medical
records and drugs. Nurse In charge of both
the wards enters the same in their register.
4.20 If the condition of patient worsens in ward, On Duty
the treating doctor is immediately informed Sister In
and treatment is given as per the doctor‟s charge
advice or patient is shifted to ICU (If Treating
available) or the higher centre as per the Doctor
doctor‟s advise
4.21 Diagnostics
4.21. If any laboratory test is required to be done On Duty SOP for
then the laboratory technician is informed. Sister In Diagnostic
1
Lab technician comes to ward and collect the charge services.
sample/ Nurse Collects the sample and send
it to the laboratory.
4.21. In case, X-Ray, ECG or USG needs to be On Duty SOP for
done, nurse informs the concerned Sister In Diagnostic
2
technician, and at appointed date & time the charge services.
patient is transferred to the concerned
department for the investigation.
4.22 BHT,
Discharge of patient: Treating Discharge
Assessment of the patient is made on daily Doctor Note /
basis. Discharge
Slip
When the patient‟s condition is up to the level
of discharge, the physician writes discharge
note in the patients BHT/IPD file and
prepares a discharge slip
In case of MLC patient, Police is informed

before the patient is discharged
4.23 Nurse ensures that all items issued to the On Duty

patient are returned back Sister In
charge
4.24 Making Payment (if any) On Duty Bill / Cash

Patient/Attendant is requested to clear all the Sister In Memo,
dues, if any. charge Cash Book
Dues are checked, and bills are prepared for Accountant/
making payment, if any. Clerical Staff
In case of any payment, the attendant of the
patient makes the payment to the accountant
and takes payment slip.
4.25 Provisions under Janani-Shishu Suraksha Hospital JSSK
Karyakram Superintende Guidelines
All indoor services including stay (up to 3 nt/ Hospital
days for normal delivery and 7 days for Manager
caesarean section , drugs & Consumables,
blood transfusion, diagnostics and are free of
cost for free pregnant women. Any kind of
user charges are exempted in all such cases.
Similarly all sick new born till 30 days of birth
is given all IPD services free cost.
4.26 Handing over Discharge Slip to Concerned Discharge
Patient/Attendant Nurse / duty slip
Patient is discharged from the hospital with doctor
discharge slip. Briefing is done to the
patient/attendant about the follow up,
prescribed medicines, precaution to be taken
and diet.
4.27 Updating IPD Register Concerned IPD

After discharge of patient, the relevant nurse register/Diet
register/record such as IPD register/Diet Register,
Register, BHT is updated. BHT
4.28 Removing of used linens Housekeeping Linen
After discharge of patient, the used linen such Staff Management
as bed sheets, pillow cover etc. is taken away
for cleaning.
4.29 Referral of patient Concerned Referral Slip
During course of treatment if the patient is Nurse, SOP for
required to be shifted to other centre then the Consultants Referral
treating doctor prepares a referral note.
4.30 Absconding Concerned IPD Register
If any patient leaves the hospital during the Nurse, / BHT
course of treatment without informing the
concerned staff. Police is informed and
record of the same is maintained.
4.31 LAMA Duty Doctor Lama
If a patient wants to leave the hospital but as Concerned declaration
per the treating doctor she/he is not fit for Nurse, format
discharge, a declaration is signed by the IPD Register
patient/ Next to Kin in the language she/he / BHT, LAMA
understands on BHT. In case patient/ Next to Summary
Kin is illiterate then the thumb impression of
the patient/attendant is taken on the
declaration which is witnessed by 2 neutral
people.
LAMA summary is prepared and the

patient/attendant is handed over the same.
4.32 Management of Death Duty Doctor / SOP for
If any IPD patient dies then the procedure of Sister In Management
Management of Death is followed charge of Death,
Death
Register
MLC
register,
Death
Summary
4.33 Visiting hours- Hospital
Visiting hours for outsiders for meeting the Manager
patients are 9 to 10 AM and 4 to 6 PM.
Any visitors having no patient in the hospital

including Media Person and police are not
allowed in the wards without prior permission
from Medical Superintendent/ Hospital
Manager.
4.34 Patient Satisfaction Survey Hospital IPD
Patient Satisfaction Survey is done on Manager feedback
predefined patient satisfaction format. form
Procedure is same as for OPD
Procedure
for OPD
Management
5. Records:

No. Period
01 IPD Register
02 Patient Registration
03 MLC Register
04 IPD/Discharge Register
05 Diet Register
06 Laundry register
07 Death record register
08 Diet Register
09 Stock Register
10 Indent Register
11 Death Register
6. Process efficiency criteria
Sr. Activity Process Efficiency Criteria Benchmark/Standard/Target

No.
1 Patient Care Average Length of Stay
2 Clinical Care Proportion of Patients Discharged
3 Clinical Care Adjusted Death Rate (Death after 48
hours of admissions)
4 Housekeeping Hygiene Score
5 Nursing Care Nurse to Patient Ratio
6 Equity Proportion of BPL patient admitted
7 Patient Patient Satisfaction Score for IPD
Satisfaction
8 Utilization Bed Occupancy Rate
9 Utilization Bed Turn Over Rate
10 Patient Care LAMA Rate
11 Patient Care Patient Safety Score
12 Patient Care No. of Adverse drug reaction
7 References
1. Procedure for Admission (SOP13)

2. Procedure for Referral (SOP 10)
3. Procedure for Infection Control (SOP 8)
4. Procedure for Diagnostic Service (SOP 7)
5. Standard Treatment Guidelines issued by state & Government of India
6. Procedure for Death Management (SOP 12)
7. Indian Public Health Standards
SOP 3: Hospital Emergency and
Disaster Management
1. Purpose
To provide guideline instructions for the provision of immediate relief to and management of the
patients arriving at the hospital with acute medical and surgical emergencies with any injuries
by accidents, sudden attacks of illness, head trauma, Physical abuse, poisoning, burns and
rape cases etc without any discrimination
2. Scope:
Scope of services of the ED range from providing episodic, primary, acute (comprehensive)
care to referrals.
3. Overall Responsibility:
Emergency: Emergency, Disaster : MS, supported by all hospital staff and doctors.
4. Standard Procedures
Sr. no Activity Responsibility Reference

Document/Re
cord
4.1 Service Provision Medical Indian Public

Superintendent Health
Emergency Department (ED) in the hospital Standards
offers comprehensive emergency care 24 hours
a day. An attending Medical officer along with
paramedical staffs in Emergency Department is
on-duty in the ED 24 hours a day.
If specialist consultant is required then medical

officer refers the patient to Surgery,
Orthopedics, Obstetrics /Gynecology, call them
according to patient condition during OPD
hours. Even medical officer call specialist in
case of critical situation of patient, apart from
OPD hours.
Ambulance services are available 24*7 for

transfer of patients. The charges are collected
after receiving the patient from the site of
incident. (as per govt. rules)
Ramps are provided for patients Stretchers and

wheelchairs are stored in the area immediately
adjacent to the ambulance entrance and do not
obstruct this entry. A waiting area, lavatories
and telephones (on required basis) are provided
for patients, families and individuals
accompanying them. Unauthorized individuals
are prohibited from entering the ED treatment
area. The ED design maintains patient privacy
without compromising patient care.
4.2 Receiving of Patients: Ward in-charge, Emergency

ward boy, Register
Patient is received in emergency, the attending paramedical staff,
doctor/ paramedical staff quickly attend to the Doctor
patient without loss of time to assess the
condition where needed and provide initial life
support treatment. Initial treatment includes
evaluation of patient‟s condition and initiation of
management of case.
4.3 Triage
4.3.1 The most severe patients are treated and
transported first, while those with lesser injuries
are transported later. EMO
4.3.2 The following “Sorting Scheme” is used in the EMO & Nurse on
ED for prioritizing the emergency patient care Duty
according to the acuity of the patient‟s condition:
1. Immediate: Those patients whose injuries

are critical but who will require minimal time
or equipment to manage and who have a
good progress for survival. E.g.:- patient with
a compromised airway or massive external
hemorrhage.
2. Delayed: Those patients whose injuries are

debilitating but who do not need immediate
management to salvage life or limb. E.g.:-
Long Bone fracture
3. Expectant: - Whose injuries are so severe

that they have only a minimal chance of
survival. E.g.:- Patient with 90% full
thickness, burns are thermal pulmonary
injuries.
4. Minimal: - Who have minor injuries that can

wait for treatment are who may even assist
in the intern by comforting other patients.
5. Dead: - Who is unresponsive, pulse less,

Breathless, in a disaster, resources rarely
allow for attempted resuscitation.
4.3.3 The registration process of the patient is also Emergency clerk Emergency
initiated in the ED if the patient condition register
permits. In case of limb and life threatening
situations the registration and consent process
are postponed so as to facilitate the initiation of
appropriate emergency care.
4.4 Consent for Treatment
4.4.1 The Hospital requires consent for all invasive or Nursing Staff Consent Form
therapeutic procedures. The general consent
form is filled and signed either by the patient if
possible or the patient representative if the
patient is not is a state to give his consent. In
case of a patient incapable of giving consent, it
is taken from the patient representative or
guardian.
4.4.2 Life-sustaining measures are not withheld for EMO

lack of formal consent if there is no time to
obtain the consent for urgent procedures. The
consent process is postponed and treatment is
started immediately in such cases.
4.4.3 Consent is required for elective blood EMO/ Nursing staff

transfusions that are not life threatening.
4.5 Patient Initial Screening Exam
1. The initial assessment will be done by the EMO/ Staff Nurse Initial
ED EMO/ nurse for emergency patients. Assessment
2. The time frame for the initial assessment s Sheet
measured, analyzed and corrective action
shall be taken to reduce the time.
3. The Initial assessment will include
ascertaining the level of consciousness,
checking the blood pressure, Pulse,
temperature, (Percentage of Oxygen in
blood) Spo2, GRBS (growth receptor bound
blood sugar) in case of diabetics or as per
state guidelines.
4. The initial assessment will ascertain the
condition of the patient whether stable or
unstable and appropriate measures will be
taken.
5. Initial Assessment will include nutritional
assessment of patient
6. initial assessment by the medical officer will
done
7. The initial assessment will result in
documented plan of care.
4.6 Nursing Process in Emergency department Nursing Staff

The ED nursing staff is the responsible person
to oversee the functioning of the ED.
The nursing staff provides all the medical and

logistic support for patient care. As per the
advice of the attending doctor,
medication/dressing, condition monitoring is
carried out.
As per the need, and availability of the service,

specialist may also be called for to attend to the
patient.
In case the patient is received as dead or dies

during the course of treatment, the dead body is
handed over to the attendant and certificate to
this effect is issued indicating reasons.
4.7 Admission: Procedure for

In case the patient condition stabilizes or the Patient
first aid is provided, patient is discharged Emergency in- Discharge
charge Management
The patients are admitted on the basis of

recommendation of doctor based on the Procedure for
patient‟s condition and need. Patient
Admission
The patient/attendants provide information

regarding name, age, sex, date & time of arrival Informed
and informed consent is taken by the in-charge. Consent
Emergency
Emergency registration no. is allotted to the Slip,
patient in emergency department & entry is Emergency
made in the emergency register. On transfer to Register ()
the ward, the ER no. is entered in the IP
register.
4.8 Transfer to the ward:
a) Patient‟s condition is observed in the Doctor/ ward in-

observation room and life support treatment is charge
provided to them.
b) In case of cardiac patients, patients are

transferred in the resuscitation room to handle
the cardiac emergency. The room is equipped
with the crash cart containing essential and
emergency drugs, defibrillator, pulse oximeter,
cardiac monitor, ECG machine etc.
c) Patients requiring minor surgical procedure

are shifted to the procedure room (minor OT) for
carrying out plaster, X-Ray and pathological
investigation.
After providing the life support treatment and Indoor

stabilizing patient‟s condition, the patient is Register
shifted to the ward and entry is made in the
Indoor Patient register.
d) In case the services essential for the
treatment of the patient are not available in the
hospital, patient is provided with the required
first aid and condition explained to the Procedure for
attendant. Patient is referred to the alternate Referral
hospital and required support through Management
ambulance for transfer of patient, is provided.
4.9 Maintenance of Medical Records (Registers

and Documents maintained)
4.9.1 The following records are maintained in the ED: EMO/ Nurse on
Duty
1. List of Doctors on Duty and on call
2. Case files of patients attended in the ED
3. MLC register for medico legal cases
4. Drug Inventory Register
5. Controlled Drugs and Psychotropic
Drugs Inventory
6. Brought Dead form
7. Death form
4.10 Diagnostic Services at Emergency
4.10.1 The ER of Hospital is equipped for undertaking

all essential lab investigations and radiological
work up for the patient; it collaborates with the Lab In charge/ X-
laboratory and imaging department to provide ray In charge
such services on an emergency basis. After the
necessary investigations are ordered, results
are obtained from the laboratory by phone in
cases urgency. When certain investigations like
Blood Toxicology and Arterial Blood Gases
which are not conducted at our in house
laboratories are required, these tests are
outsourced to outside laboratories.
4.11 Handling Medico-legal cases: EMO/ Medical Police

Superintendent Information
a) For MLC cases, police is informed after Book, MLC
starting the treatment & entry is made in Register,
Police information book. Medico-legal record Death
is maintained for cases under that category. Management
b) In case the patient dies, or is received as

dead, appropriate action is initiated towards
conducting the autopsy.
4.12 Brought in Dead
4.12.1 Take past history – HTN / DM / IHD etc., EMO/ Staff Nurse SOP for
Management
Look for / Ask about any suspicious signs:
of Death
 Poisoning – Smell
 Strangulation – Ligature mark around neck /
abnormal sings
 Any external injuries
 Expose the body completely and look for
any sings
 Palpate the head and look for any
hematoma, etc which may be missed.
5 If a female, ask history of married life and if it
is less than 7 years register it as MLC, - it is
mandatory.
4.12.2 Register all brought dead cases as medico-legal EMO
case if death has occurred unexpectedly or from
an unexplained cause.
On arrival, the Emergency Medical officer

should examine the patient thoroughly. He / She
should go into the history in detail and look for
signs of homicide, suicide, violence, external
injuries to rule out any suspicious cause for the
death. In case of female patient, marital history
should be elicited and if EMO feels suspicious
cause for the death, Medico Legal Case has to
be registered
4.12.3 After complete examination and confirmation by EMO Brought Dead

clinical evaluation death & is confirmed, the Certificate
individual should be declared as Brought in
Dead (BID) and the accompanying
relatives/friends must be explained and
informed about the probable cause of death and
they are given only a Brought Dead Certificate
until the cause of death is confirmed. The local
police station should be informed immediately.
4.13 Death on Arrival
4.13.1 If a patient has sudden Cardio-Respiratory EMO

Arrest on arrival at the Emergency Room, the
patient has to be resuscitated. Once death is
confirmed the case should be treated as death
on arrival, and necessary documentation should
be done.
4.13.2 EMO should go into the detailed history of the EMO
patient and arrive at the probable cause of
death. On the basis of this, death certificate
should be issued and arrangements for release
of the body are taken.
4.14 Handling of Death & Release of Dead Body
4.14.1 Death of a patient is handled carefully with EMO &

concern without complacency. Counseling of
next of kin with empathy is importance. All help Nurses
in shifting the body from the hospital is extended
to the next of kin. The dead body is released as
soon as possible after completion of all
formalities.
4.14.2 Acknowledgement for receipt of the body and EMO

the Death Certificate is obtained from Next of
Kin/Legal representative and Handing-over of
the body to patient‟s relatives‟ .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.
A security staff of the hospital is present till the

departure of the deceased and ensures
orderliness in handing over the body to the next
of kin.
4.15 Storage of Medicines in Emergency

Department
4.15.1 All Emergency medications will be available 24 Emergency

Pharmacist &
hrs in the ER. Emergency Nurses
4.15.2 Medication inventory / Crash cart will be Nurses on duty
checked by the nurse on duty with each shift
change, to detect shortage.
4.15.3 Narcotics drugs will be kept in the narcotics box

and will be under the supervision of the nurse in
Charge.
Narcotic drugs will be released only on the

signed requisition of the Doctor/MO.
4.15.4 Working condition of the ER equipments will be Nurse on duty

checked with each change In shift.
Any Malfunction /nonfunctioning of the

equipment will be brought to the notice of the
nurse in charge and the Chief Emergency
medical officer and Complaint is raised.
4.16 Infection Control In ED
Refer to SOP HIC (08)
4.17 Disaster Management
4.17.1 Several types of hazards pose a threat to EMO

the hospital:
1. Internal disasters: fire, explosions,

and hazardous material spills or
releases.
2. Minor external disasters: incidents
involving a small number of
casualties.
3. Major external disasters: incidents
involving a large number of
casualties.
4. Disaster threats affecting the hospital
or community (large or nearby fires,
impending disasters, flooding,
explosions, etc.).
5. Disasters in other communities.
4.18
General Considerations:
4.18.1 Lines of Authority: The following persons,

in the order listed, will be in charge:
1. Chief Medical Superintendent

2. Medical Superintendents (Male
&Female Wing)
3. Matron.
4. Nursing In charge on duty at time of
disaster.
5. Emergency Room In charge
4.18.2 Communications:
A Command Center will be set up at the

Chief Medical Superintendent‟s office to
handle and coordinate all internal
communications. All department heads or
their designee will report to this office and
call as many of their employees as needed.
4.18.3 The person in charge when the disaster

happens will assign a staff to the
communications system in the E.D. This
clerical staff will answer all telephone calls
from this station.
The telephone shall be manned immediately

at the HM office by an administrative staff
4.18.4 but only for informational purposes.
4.18.5 At least one messenger will be assigned to

the telephone operator to deliver messages,
obtain casualty count from triage, etc.
4.18.6 Person directing personnel pool shall send a

runner (preferably a volunteer) to all
departments to advise them of the type of
disaster and number of victims and extent of
injuries when this information is available.
4.18.7 Nursing will be notified by the Nursing Head
or designated persons.
Department Heads will be notified by the

Supervisor or designated staff.
Department Heads will notify their key

personnel.
4.18.8 A "Visitor Control Center" will be set up in

the front lobby. Families of casualties will be
instructed to wait there until notified of
patient's condition. Normal visiting hours will
be suspended during the disaster situation.
A hospital staff member will update, educate

and counsel the family members.
A list of the visitor's names in association

with the patient they are inquiring about
should be kept. Volunteers may be needed
to escort visitors within the facility.
4.18.9 Telephone lines will be made available for

outgoing and incoming calls. One line will be
designated as the open line to the external
Command Center. The person in charge will
designate assigned staff to monitor the
phones.
4.19 Supplies and Equipment:
1. Extra supplies will be obtained from

store personnel through runners.
2. Outside supplies will be ordered by
the store in charges and brought into
the hospital.
4.20 Valuables and Clothing:
Large paper or plastic bags will be made

available in the treatment Areas and the
storeroom for patient's clothing and
valuables are properly tagged with
identification no. and then reposition.
4.21 Public Communication Center:
A communication center for receiving

outside calls and giving information to the
press and relatives shall be set up in PRO/
HM office.
4.21 Morgue Facilities:
4.21.1 Patients pronounced DOA (Death on arrival)
will be tagged black.
4.21.2 Bodies will be stored in a designated place

by Security. Security Personnel will remain
with bodies until removed by proper
authority.
4.21.3 After bodies have been identified, the

information will be filed on the Disaster Tag
and Medical Records notified as to the
identification of the patient.
4.21.4 The bodies will be handed over to the

relatives after proper identification in
presence of representatives from the police
department. Bodies which remain unclaimed
will be handed over to the police after
following the required procedures
5.0 Records
S Record Name Record No. Retention Period

#
1 Emergency register
2 Consent
3 Bed head tickets
4 Emergency medicine stock register
Death Register
Emergency staff duty register
6.0 Process Efficiency Criteria
Sr. No. Activity Process Efficiency Criteria Benchmark/Standard/Target

1 Referral Emergency Referral Rate
2 Initial Screening Average time taken for initial
Assessment
3 Inventory No of drug stock outs in the month
7.0 Reference
1. IMC Code of Ethics 2000

2. IPC & CrP
3. Procedure for admission & Discharge (SOP13)
4. Guidelines for Hospital Emergency Preparedness Planning (GoI)
SOP 4: Maternal and Child Health
Management
1. Purpose:
To develop a system for ensuring care of pregnant women from antenatal to postnatal
period and also address the needs of the newborns, & Children up to 5year. It includes
a comprehensive approach to reduce maternal, neonatal, and infant and less than 5
mortality and protect them from likely health risks they may face.
2. Scope: It covers pregnant woman during the period, from day of her registration for
first ANC to 42 days post delivery, new born, and child up to 5 years.
3. Responsible person: In charge of hospital, Service Provider in OBG Department,

Pediatrician, Medical officer and staff nurse/ANM.
4. Procedure:
Sr. Activity Responsibility Reference
no.
4.1 Service Provision-
4.1.1 All the maternal and Child Health Hospital In IPHS for District
Services are provided as per IPHS for charge/ Hospital
District Hospitals and Operation Medical
Guidelines for Maternal & Child Health Superintendent
issued by MoHFW, Government of Operational
India. This Includes- Guidelines on
1. Antenatal Care including Maternal & New Born
Management of High Risk Health
Pregnancies referred form level 1 and
2 institutions
2. 24X7 services for Emergency
Obstetric Care & New-born care
3. Emergency Care of Sick Children
4. Family Planning Services
5. Medical Termination of Pregnancy
6. Treatment of RTI/STI
7. Blood Storage Facility
8. Essential Laboratory Services
9. Referral Transport Services
All services available in the Hospital
are communicated through citizen
charter & Enquiry Desk.
4.2 Antenatal Care
4.2.1  Registration and First ANC Visit- Registration OPD registration slip
Any pregnant women requiring Clerk
services during antenatal period
visit hospital is registered at Medical Mother & Child
registration counter and OPD slip Officer/ Staff Protection Card
is issued to her. Nurse/ ANM
 Pregnancy is confirmed by
conducting urine examination
using pregnancy test kit (Nischay)
 Last Menstrual Period (LMP) is
recorded and Expected date of
delivery (EED) is calculated for
pregnant woman.
 Pregnant Women‟s present and
no.
past history taken including any
illness or complication during
present & previous pregnancy.
4.2.2 Mother & Child Protection Card- MO/ Mother & Child
 For each ANC registration a paramedical Protection Card
Mother & Child Health Card is staff like staff
issued to pregnant women. nurse and
 All the details including family ANM
identification, pregnancy records,
institutional identification, next due
date of ANC visit, findings of ANC
examination and investigations,
post natal care, care of baby,
details of immunization, growth
child etc. is recorded on this card
at different stages of ante and post
natal care.
 Pregnant woman is instructed to
bring this card at every
subsequent visit to the hospital
4.2.3 Schedule of Visit- Medical Mother & Child
4 ANC visit of every registered Officer/ Staff Protection Card
pregnant woman is insured as per Nurse/ ANM
following schedule
1st Visit- Within 12 Weeks

2nd Visit – Between 14- 26 Weeks
3rd Visit – Between 28 -34 Weeks
4th Visit – Between 36 Weeks and
term.
If a women comes for registration later

in her pregnancy, is also registered
and care is provided according to
gestational age
4.2.4 Antenatal Checkup MO/

 On each visit Patients history & paramedical
no.
complaints are taken and physical staff like staff SOP for Lab
examination for weight, blood nurse and Investigation
pressure, respiratory rate, pallor, ANM
edema and citrus is done.
 On each visit abdominal palpation Guideline/ WI for
for fetal growth, fetal lie and Antenatal Check up
auscultation for fetal heart sound & Examination
and breast examination is done
according to stage of pregnancy.
 Laboratory test for Hemoglobin,
urine albumin & urine sugar is
done on each visit. Guidelines for
 Tests for blood group and Rh pregnancy care and
factor, Syphilis (VDRL/RPR), HIV, management of
blood sugar, malaria & Hepatitis B common obstetric
are also done for each pregnant complications by
woman. Medical Officer
 Regular dose of folic acid is given
1st trimester onwards and Iron
folic acid on subsequent trimester Guidelines for
for at least 100 days. Antenatal care and
 First dose of tetanus toxoid skilled attendance at
injection (Inj. TT) is given as soon Birth by
as possible after ANC registration. ANMs/LHVs/SNs
A second dose given after one
month from the 1st one.
 At each ANC visit pregnant women
is counseled for nutritional
requirements, recognizing danger
sign of labour, birth preparedness,
breast feeding institutional
delivery, arrangement of referral
transport, family planning etc.
 If during ANC patient is found to
be requiring safe abortion they
are processed for same within
the ambit of MTP act.
no.
4.2.5 Medical Termination of Pregnancy MO/ Comprehensive
 If a pregnant woman during ANC Obstetrician abortion care –
is found to be requiring medical Training and service
termination of Pregnancy they delivery Guidelines
are proceeded for same within
the ambit of MTP Act 1972 as MTP Act 1972
soon as possible.
 A consent is taken from pregnant
women in form C prescribed by
MTP Act.
4.2.6 Radio diagnosis during Radiologist/Per PC&PNDT Act 1994
pregnancy – son conducting
Ultrasonography- ultrasonograph
 Ultrasonography of pregnant y/Treating
women if required is performed Doctor
during ANC visits. The reason for
performing ultrasonography must
be covered any of the 23 Form F
indication prescribed in
PC&PNDT Act 1994.
 A declaration is taken on form F
from doctor as well as from
pregnant women.
X-Ray-
 X-ray of pregnant women is
avoided it is allowed only if
approved by radiologist/physician
who overweighs the benefit Safety Code for
against risk of performing x-ray Medical Diagnostic
procedure. X-Ray Equipments &
 Pregnancy status of woman of Installations – Atomic
child bearing age is confirmed Energy Regulation
before performing the procedure Board
by radiographer. A notice for this
purpose is displayed at X-Ray
room.
 Lead shield is provided if X-ray
procedure is performed on
pregnant woman
no.
4.2.7 Management of High Risk MO/ Service Mix
Pregnancy Obstetrician (Suggested Actions)
 If any of signs of high risk – IPHS for District
pregnancy is identified during ANC Hospital
visits the case is referred to in
house obstetrician/Gynecologist Management of Ante
and treatment is is started as per partum Hemorrhage
Standard Treatment Guidelines as
early as possible.
 All the high risk pregnancy cases
coming from lower refereeing
facilities are directly sent to in-
house obstetrician & gynecologist
for management.
 If the management cannot be done
at the facility patient is referred to
Medical College / Tertiary Care
Hospital.
4.3 Emergency Obstetric Care

4.3.1 Rapid Initial Assessment & MO on duty/ EmOC Guidelines
Management – When a woman of Obstetrician/
child bearing age presents with a Paramedic
problem a rapid assessment of her Staff Protocols for
condition on the basis of danger signs Management of
is done to determine the degree of Eclampsia
illness. This includes assessment of
Airway and breathing, circulation,
vaginal bleeding, dangerous fever,
abdominal pain etc
Initial Management done as per
standard EmOC Protocols.
4.3.2 Communication with pregnant MO/ Guidelines for
woman Paramedic communicating with
While communicating with pregnant Staff pregnant woman/
woman/mother service providers mother
ensure following-
respect the woman‟s dignity and right
no.
to privacy;
• are sensitive and responsive to the
woman‟s needs;
• are non-judgmental about the
decisions that the woman and her
family have made thus far regarding
her care.
4.3.3 Admissions & Shifting Referral – MO/Nursing SOP for patient

 The Pregnant women are admitted Staff/ Ward admission,
to the hospital either when they Attendant
arrive in labor or when they
nearing the delivery.
 Pregnant woman diagnosed for Labour Register,
high risk signs such as
malpresentation, and indicated for
elective C-Section surgery are
admitted 2-3 day prior to expected Bed Head Ticket
date.
 Pregnant Women received in
causality/ emergency are attended
by EMO are directed towards
labour ward if no immediate
resuscitation/intervention is
required or patient is not brought in
dead.
 Pregnant women directly reaching
labour room are received Medical
Officer /nursing staff on duty.
 Medical officer analyzes condition
of the patient along with history
and reviews old records, including
referral slip if available to assess
any complications associated with
pregnancy.
 If pregnant women is first stage of
labour she is shifted to pre partum
observation beds where vitals and
dilation is monitored on periodic
no.
basis and partograph is
established
 If pregnant women are in second
stage of Labour she is shifted to
labour room.
 Pregnant woman with eclampsia
are shifted and treated in
eclampsia room.
 Pregnant women requiring
emergency C-Section are shifted
pre surgical area of OT
immediately
 Pregnant women in false labour
are monitored and subsequently
discharged.
 When the condition of the patient
is such that she cannot be
attended in the Hospital due to the
complications or due to lack of
facilities, timely referral is done for
the next higher facility.
 For every admitted pregnant
woman bed head ticket is
generated and entry is done in IPD
register.
4.3.4 Arrangement for intervention Nurse in Check List for Labor

The Nurse in charge makes charge Room preparedness.
arrangement for the necessary
equipments, drugs and other facilities
required for the delivery.
Immediate intimation is sent to doctor
on duty/ gynecologist, and
anesthetist(if c section is required) for
undertaking the delivery process
4.3.4 Labor Room Management Labor Room Check List for New
New Born Corner is available as per Incharge, Born Corner
no.
Guidelines Maternal and Newborn Hospital
Health Guidelines Manager,
Availability and functionality of Medical
required equipments and superintendent
consumables is ensured and checked
on daily basis.
Any breakdown of equipment or
shortage of supply is immediately
intimated to Hospital Administration.
4.3.5 Blood Transfusion- Blood Treating NACO guidelines for
transfusion may required in condition Doctor/MO on Blood Transfusion
like postpartum hemorrhage leading Duty/ Blood
to shock, blood loss at operative Bank In charge
delivery and severe anemia. / Hospital SOP for Blood Bank
 Transfusion should be prescribed Superintendent Management
only when the benefits to the
woman are likely to outweigh the
risks.
 24X7 blood bank facility is
available in hospital.
 In emergency life saving
conditions blood is issued without
replacement and fee after
recommendation from treating
doctor/ authorized person.
 Cross matching of donor and
recipient blood is mandatory
before transfusion.
 For High Risk & elective surgeries
patient, attendants are told to
arrange blood in advance if
enquired.
4.3.6 Anesthesia MO/ EmOC Guidelines
 24X7 availability of anesthetist or a Anesthetist/Ho
medical officer trained in life spital
saving anesthesia skills (LSAS) is Superintendent
ensured in the hospital. / Hospital
 Analgesia and anesthesia is given Manager
no.
as per standard treatment
guidelines for EmOC.
 If there is shortage, anesthetist is
arranged on call basis. Non
availability of anesthetist at the
time of procedure is immediately
reported to hospital superintendent
and hospital manager so
alternative arrangement can be
done.
4.4 Intra Partum Care
4.4.1 Management of 1st stage of labour: Medical
 The patient is informed about the Officer/
condition, counseling is done and gynecologist.
consent is taken by the nurse in-
charge and medical officer. Nurse in- Simplified Partograph
 A partograph is established by charge
staff nurse.
 Monitoring & charting of uterine
contraction, Fetal heart rate,
emergency signs, cervical dilation,
BP, temperature and Pulse is done
on periodic basis depending upon
low/ high risk pregnancy and
progress is updated in partograph.
 In any condition of unsatisfactory
progress of labour due prolonged
latent phase, non progress of
labour, prolonged active phase,
foetal distress, cephalopelvic
disproportion, obstruction,
malpresentation, malposition,
prolonged expulsive phase, the
obstetrician is called in for further
management.
 Decision about induction or
augmentation of labour, vacuum
extraction, symphysiotomy,
no.
forceps delivery , Craniotomy or C-
Section after care full assessment
of patient and procedure is
performed as per standard EmOC
guidelines
 Pediatrician & Anesthetist is
alerted of anticipated surgery and
newborn complications.
 OT In charge is also alerted for
preparedness of Operation
Theatre in case surgery is
required.
4.4.2 Management of 2nd stage of labour: Nurse in- Guideline for
Uterine contraction, FHR, Perineal charge pregnancy care and
thinning & Bulging, visible decent of management of
foetal head during contraction and obstetrics
presence of any sign of emergency is complications for
monitored periodic basis depending MO.
upon the low or high pregnancy.
Episiotomy is performed if required.
In case of shoulder dystocia
obstetrician is called in for further
management.
Delivery of baby and time of delivery
is noted.
Cord is tied and cut with a sterile
blade after 2-3 minutes of delivery.
Immediate newborn care is given.
If newborn cry in 30 seconds newborn
resuscitation is started.
4.4.3 Management of 3rd stage of labour: Medical Labour Register
Inj. Oxytocin or Misoprostol is Officer/
administered. gynecologist.
Birth register
Controlled cord traction is done for
Nurse in-
assist expulsion of placenta. charge Death Register.
Uterine massage is given to prevent
PPH WI for Active
Management of 3rd
no.
If there is there is retained placenta or Stage of Pregnancy
PPH it is managed as per standard
protocol. WI for PPH
BP, Pulse, Temperature, vaginal
bleeding is monitored periodically for
three hours.
In case the child delivered is dead,
then the body is handed over to
relatives and record is maintained in
death register as still birth.
4.4.4 Immediate Postpartum Care-
 Assessment is done for MO/
contraction of uterus, bleeding and Obstetrician/ Guideline for
for vaginal/ perineal tear. Staff Nurse / pregnancy care and
 Sanitary Pad is placed under the Labor Room management of
buttock to collect the blood. Companion / obstetrics
Assessment of blood loss is done Mamta complications for
by counting the blood soak pads. MO.
 Vitals are monitored at periodic
intervals.
 Mother and newborn is kept Labor Room Register
together. Breast feeding is
encouraged.
 Birth Companion is asked to stay
with the mother. She was
instructed to call for help in case of
any danger sign.
 Weight of new born is measured.
 Information of mother and new
born is recorded in labour register.
Newborn and Mother is given
identification tags.
4.4.5 Essential Care of New Born Staff Nurse WI for Immediate
Essential new born care is given Newborn Care
including maintain body temperature, WI for Preventing
maintaining airway & breathing, breast Hypothermia
feeding of new born, care of cord and
no.
eyes.
4.4.6 Neonatal Resuscitation MO/ APGAR Score
st Pediatrician/ Criteria
The APGAR Score is calculated at 1
and 5th minute after birth. Staff Nurse
WI for Neonatal
Resuscitation may be required in
Resuscitation
following condition-
If APGAR score is < 7 then immediate
resuscitation is started.
Neonatal resuscitation is discontinued
only after 10 mins of resuscitation if
there is no sign of life. Prognosis of
newborn is discussed with parents
before discontinuing resuscitation.
All cases of still birth are also given
resuscitation for at least for 10 mins.
Pediatrician & SNCU in charge is
intimated for the further management.
4.5 C-Section Surgery- Obstetrician/

24X7 availability of obstetrician or Hospital
Medical Officer Trained in EmOC is Superintendent
ensured. Non availability of / Hospital
obstetrician for procedure is Manager
immediately informed to Hospital
Superintendent/ Hospital Manger so
alternative arrangement can be made.
4.5.1 Preoperative Care- OT In charge/ SOP for OT & CSSD
Preparing Operation Theater OT Nurse/ OT Management
 Operation theater is cleaned (after Attendant
every procedure)
 Availability of necessary supplies
and equipments including oxygen
cylinder and drugs is ensured
 Availability and working condition
of emergency equipment is
ensured.
no.
 Adequate supply of theatre dress
for anticipated members of
surgical team is ensured.
 Availability of sterile supply and
that they are not beyond expiry is
ensured.
 Availability of clean linen is
ensured.
4.5.2 Preparing Women for Surgical OT Incharge/ SOP for OT
Procedure- Obstetrician/ Management
 Procedure to be performed and its OT Nurse/
purpose is explained to the Anesthetist
woman. If the woman is
unconscious, it is explained to her
family.
 Informed consent for the
procedure is obtained from the
women.
 Woman‟s medical history is
reviewed and checked for any
possible allergies.
 Blood sample is sent for
haemoglobin or hematocrit and
type and screen. Blood is ordered
for if there is possibility of
transfusion.
 Area around the proposed incision
site is washed with soap and
water, if necessary.
 Woman‟s pubic hair is not shaved
as this increases the risk of wound
infection. The hair may be
trimmed, if necessary.
 Vital signs are monitored and
recorded. (Blood pressure, pulse,
respiratory rate and temperature).
 Premedication appropriate for the
anaesthesia is administered.
no.
 Antacid is given to reduce stomach
acid in case there is aspiration.
 Bladder if cauterized if necessary
and urine output is monitored.
 Relevant information is passed on
to other members of the team
(doctor/midwife, nurse,
anaesthetist, assistant and others)
is ensured.
4.5.3 Intra Operative Care OT Incharge/ SOP for OT
 Position-Woman in placed in a Obstetrician/ Management
position that is appropriate for the OT Nurse/
procedure to allow: optimum Anesthetist
exposure of the operative site,
access for the anaesthetist,
access for the nurse to take vital
signs and monitor IV drugs and
infusions, safety of the woman by
preventing injuries and maintaining
circulation, maintenance of the
woman‟s dignity and modesty.
 Surgical Scrub- Surgical Scrub is
done as per standard practices
described Guidelines for surgical
Scrub.
 Preparing Incision Site- Part
preparation is done as per
guideline for preparing incision
site.
 Pregnant Women is monitored for
vital signs throughout the surgery
and findings are recorded.
 Antibiotic and analgesics are given
as per requirement.
 Incision, handling of tissue,
haemostatis, handling of
instruments and sharps, draining,
suturing and dressing is done as
no.
per standard EmOC Protocols.
4.5.4 Post Operative Care- OT Incharge/ SOP for OT
 Woman is placed in recovery Obstetrician/ Management
position. OT Nurse/
 Vitals signs are monitored every Anesthetist
15 mins first hour and every 30
mins next hour.
 Assessment of consciousness
level is done every 15 min until
women is alert.
 Clear airway and ventilation is
ensured.
 Transfusion is given if necessary
 If vital signs become unstable or
haematocrit continues to fall
despite of transfusion, woman is
returned to OT as bleeding may be
the cause.
 Management of gastro intestinal
functions, dressing & wound care,
pain management, bladder care,
administration of antibiotics, suture
removal, management of fever,
and ambulation done as per
standard EmOC guidelines.
4.6 Inpatient Care
4.6.1 Post Natal Inpatient Care of Staff Nurse SOP for IPD
Mothers Management
After delivery, mother is shifted to the
labour ward for post-natal care
 Maternal health is monitored and
every step shall be taken to
improve well being and good
health of mother & new born.
 Medication is administered when
required and prescribed by the
doctor.
 The patient is encouraged for
no.
taking normal diet, plenty of fluids
and start breast feeding the child.
4.6.2 Post Natal Inpatient care of New F.IMNCI Manual
Born
After delivery; all new born not
needing special care shifted to the Guidelines for
Labour ward with mother for postnatal antenatal care and
care and skilled birth
Postnatal ward is kept warm (25°C). attendance at Birth
New Born is kept with mother on the
same bed right from the birth.
Mother is encouraged to breast fed
baby within 1/2 hrs of delivery.
Postnatal new born care includes
review of labor and birth record,
communication with mother,
examination of baby, assessment of
breastfeeding, cord care, skin & eye
care, administration of Vit K,
counseling of mother, immunization
BCG, OPV-0, Hepatitis B (HB-1) and
follow-up.
4.6.3 Shifting of Newborn to SNCU MO/ Staff F. IMNCI Manual
If the new born is has any of any of Nurse/
following condition it is shifted to new Pediatrician
born care unit
birth weight < 1500 gms,
Major congenital malformation
Severe Birth Injury
Severe Respiratory Distress
PPV≥ 5 Minutes
Needing Chest Compression or drugs
Any other indication decided by
pediatrician.
New born is kept under closed
observation
Birth Weight 1500-1800
New Born needing IPPV < 5
Vigorous babies with fast breathing
no.
4.6.4 Discharge of Patient Medical officer/ Discharge slip

Discharge is done after delivery, gynecologist
depending upon the mother‟s
condition but not less than 48 hours Antenatal Care and
for normal delivery. nurse in- Skilled Birth
Discharge slip is prepared by the M.O. charge Attendance at Birth
and entry is made in the discharge
register by ward in-charge.
Mother is briefed about postpartum
care and hygiene, nutrition for self &
Newborn, Exclusive breastfeeding
follow-up advice, keeping baby warm,
complete immunization of newborn
post partum visits, family planning.
She is also counseled about the
danger signs that should immediately
reported to the hospital relating her
and new born.
4.7 Payment to beneficiaries Hospital JSY Scheme
The payment under JSY is provided to Superintendent
the beneficiaries after 48 hour of stay JSY Register
in the hospital after delivery, The Clerk
schedule of payment is informed to
beneficiary by authorized personnel
4.9 Postnatal care after discharge- MO/
Postnatal Care is provided through Obstetrician
MCH/ Obstetrics & Gynecology clinic
Mothers referred to hospital form
postnatal visits by ASHA/ANM for
postpartum complication like PPH and
puerperal sepsis, severe anemia are
assessed in OPD Clinic/ Emergency
and admitted in the hospital if
required.
4.10 Immunization Immunization Universal

Nurse/ ANM Immunization
no.
 The hospital immunization facility programme
under universal immunization
program for children/new Mother and Child
born/neonates which includes all Protection Card
vaccines e.g. OPV, DPT, TT,
BCG, Measles etc. and register is
maintained in the department by
Sister In-Charge.
 Details of immunization given are
entered on Mother and child
protection card.
 Auto disable syringes are used for
immunization.
 Any serious adverse event
following immunization such as
death, Hospitalization, disability
and other serious events that are
thought to be related with
immunization are immediately
reported to MS by Phone.
 Other Serious AEFIs such as
anaphylaxis, TSS, AFP,
encephalopathy, sepsis, event
occurring in cluster are reported to
district immunization officer within
the prescribed time in prescribed
format.
 All the serious AEFI are
investigated by appropriate
authorities and corrective action is
taken.
 After each immunization parents
are informed about-
 What vaccine is given and it
prevents what.
 What are minor side effects and
how to deal with them?
 When to come for next visit
 To keep mother and child
no.
protection card safe and bring it on
next visit.
4.11 Counseling for the family Planning
 The patient is referred from MO/ PP Center Family planning

Obstetrics & Gynecology clinic / In charge registers.
MCH Clinic and other consultation
rooms to the counseling center (if
any) of hospital or counseled in PP
clinic
 The clerk enters patient‟s details in
the register and asks the patient to
fill consent form
 The MO explains the couple on
importance of family planning and
the various permanent(NSV,
Vasectomy, Female sterilization,
Tubectomy) and temporary
methods of family
planning(Intrauterine Devices,
,Condoms )
4.12 Integrated Management of Neonatal MO IMNCI Guidelines

& Childhood Sickness
Patients under age of 2 months are
classified as sick young infants and
patients under 5year of age are
classified as sick child. Their
management is done as per
Integrated Management Neonatal and
Childhood Illness approach. This
Includes
 This includes
 Urgent Referral Services at facility
(Pink)
 Urgent Referral Facility at Out
Patient Department(Pink)
no.
 Treatment Facility at OPD (yellow)
 Home Management (green)
4.13 Emergency Triage Assessment & MO/ WI- Steps in
Treatment- Any sick young infant or Pediatrician/ Management of Sick
child received in hospital is promptly Nursing Staff young Infants and
attended and standard ETAT Children.
procedure followed for management.
4.13.1 Triage- Triage of all young infants and MO/ WI- Triage
children is done in following Pediatrician/
categories as soon they arrive the Nursing Staff
hospital.
-those Emergency signs (E) requiring
Emergency Treatment
- those Priority Signs (P) requiring
rapid assessment and action
- Non urgent (N) cases those can
wait
Triage is done by assessing Airway,
Breathing, Circulation, Coma,
Convulsion and Dehydration (ABCD).
If no emergency sign is seen than
priority signs are looked for.
4.13.2 Assessment & Management of MO/

Emergency Signs- Pediatrician/
Assessment and management of Nursing Staff
Emergency signs done as per WI Basic life support
standard F.IMNCI Protocols. If any Management of WI
signs of hypothermia or hypoglycemia Shock in a child
are present their management is done without SAM
simultaneously. Management of WI
This includes - Shock in a child
Assessment for breathing, central without SAM
cyanosis and severe respiratory WI for Assessment
distress Management of
Is done and Basic Life Support is Coma & Convulsion
given if required. WI for Assessment
Assessment & treatment of shock in and Management of
no.
young infant & children with or without severe dehydration
severe acute malnutrition. Management of
Assessment and treatment of coma Hypoglycemia
and convulsions. Management of
Assessment and treatment of severe Hypothermia
dehydration
Assessment and treatment of
Hypoglycemia and Hypothermia
4.14 Facility based care Sick Young MO/ Management of sick
Infant Pediatrician/ young infants
This includes fluid management, Nursing Staff Checklist for
Management of Hypoglycemia, Post Monitoring of Young
resuscitation care of Asphyxiated Infants
newborn, management of septicemia, Guidelines for
meningitis, diarrhea, tetanus management of
neonatorum, Jaundice and monitoring Neonatal Jaundice
of sick young infant.
4.14.1 Management of Low birth Weight MO/ WI for modes of
Neonates Pediatrician/ providing fluid and
All low birth weight Vit. K Nursing Staff feeding.
intramuscular at birth. Feeding Volumes
Neonates with birth weight less than and rates of rates of
1800 gms are admitted in the hospital. increments in LBW.
Normal body temperature of neonate
is maintained through Kangaroo Indication of
Mother care or through radiant Discharge of LBW
warmer/ incubator as advised by the neonates.
pediatrician.
Fluids and nutrition is provided as per
birth weight or gestation of the
neonate.
4.14.2 Referral and Transport of MO/
Neonates- Pediatrician/
If management of newborn cannot be Nursing Staff
done at the hospital either due to lack
of facilities (neonatal care unit) or due
to need of tertiary care management,
neonate is referred to higher center or
no.
other hospital.
Receiving facility is communicated
about the patient.
Neonate is stabilized with respect to
temperature, airway, breathing,
circulation and blood sugar.
A doctor/nurse/health worker is
arranged for accompanying the
neonate to receiving hospital if
possible.
Parents/attendants of newborn are
communicated about the condition of
new born synthetically and
instructions are given for care of
newborn during transport.
A referral note is prepared and given
to patient‟s attendants describing
condition of new born, reason for
referral and treatment given.
4.15 Facility Based care of Sick Child
4.15.1 Children Presenting with cough or MO/ Treatment for very
difficult breathing – Pediatrician/ severe and severe
Careful assessment of patient is done Nursing Staff Pneumonia
to arrive at a diagnosis that may be
due to respiratory or non respiratory Management of
causes. Acute Asthma
Once a diagnosis is established
management is done as per standard
treatment guidelines.
4.15.2 Management of Children MO/ Classification and
presenting diarrhea Pediatrician/ management of
Assessment of child is done and case Nursing Staff Dehydration
is classified as acute/persistent
diarrhea or dysentery.
Following cases are admitted in the
hospital-
 Children with severe dehydration
 Children with SAM
no.
 Children with Co- Morbid Condition
An ORT corner is provided in the
hospital for day care stay of mothers
& children during Oral Rehydration
Therapy.
4.15.3 Management of children presenting MO/ WI Management of

with fever Pediatrician/ severe and
Initial assessment of children is done Nursing Staff complicated malaria
and causes of fever are identified
according fever with, without localized
signs or rashes and symptoms.
Diagnostic tests are done to confirm
the cause.
Cases of are managed as per
standards treatment guidelines.
4.15.4 Management of Children with MO/ Management of
severe Acute Malnutrition- Pediatrician/ Severe Malnutrition
Initial assessment of children done Nursing Staff in Hospital.
and admitted in hospital if-
 Weight for Height/length is <-3 Z General Treatment of
Score of median of WHO child Malnutrition
growth standards
 Bipedal Edema
Cases are managed as per standard
treatment guidelines.
4.16 Infection Control – Infection SOP for Hospital
Standard Infection Control Measures Control Nurse/ Infection Control
are taken to ensure prevent hospital Staff SOP for Hospital
acquired infections and safe work Nurse/MO/Obs Waste Management
environment to service providers. tetrician SOP for
These measures broadly includes – Housekeeping
Strict adherence to standard hand Management
washing Practices
 use of personal protective Infection Control
equipment when handling blood, Measures in Normal
body substances, excretions and & C-section
secretions Deliveries
no.
 appropriate handling of patient
care equipment and soiled linen
 prevention of needle stick /sharp
injuries
 environmental cleaning and spills-
management
 appropriate handling of Biomedical
Waste
Regular culture surveillance of
infection prone area like labour room,
OT and SNCU is done to insure safe
patient care environment.
4.17 Environmental Cleaning and Housekeeping Guidelines for

Processing of equipments in Labor Staff/ Hospital Environment
Room- Manager Cleaning &
External foot wears are not allowed in Disinfection in Labor
the labor room. It mandatory to wear Room
dedicated labor room sleepers before
entering the labor room. Guidelines for
After every procedure all working processing of
surfaces are disinfected. equipments, surgical
Only staff that is required for gloves and other
procedures is allowed in labor room. Items in Labor Room
Traffic in labor room is kept minimal.
4.18 Rights & Dignity of pregnant MO/ Staff
women Nurse/ Other
 Simple and clear language is used service
while communicating with Providers
pregnant women.
 Pregnant woman is informed about
the status of her health and
supported to understand options
and make decisions.
 Woman is made to feel as
comfortable as possible when
receiving services.
 Before any examination
no.
permission is taken from pregnant
women and procedure is explained
to her.
 During the examination privacy of
patient of pregnant women is
maintained. Screens and curtains
are provided in examination area
and it is ensured that woman is
protected from view of other
people.
 Pregnant women consent is taken
before discussing with her family
or parents.
 Confidential information about
pregnant women is never
discussed with other staff
members or outside the facility.
 Informed consent is taken before
any invasive procedure.
 Any pregnant woman with HIV is
not denied on basis of HIV status.
Her HIV status kept confidential
except to people who are involved
in care.
4.19 Monitoring & Quality Control
4.19.1 Maternal Death Review Treating MO,
All maternal deaths occurring in the FNO, DNO
hospital including abortion and ectopic FMDR Format
gestation related deaths, in pregnant
women and mothers after within 42 Maternal Death
days of termination of pregnancy are Review Guidebook
informed immediately by treating
doctor to facility nodal officer MDR at
the time of occurrence.
The facility nodal officer of the hospital
inform the district nodal officer (DNO)
and subsequently to state nodal
officer within 24 hours.
no.
Facility nodal officer fill the primary
informant format and sent it to (DNO)
Maternal death is immediately
investigated by medical officer treating
the mother using facility based
maternal death review format and
submit it in triplicate to FNO within 24
hours.
A facility Maternal Death Review
committee is constituted as per MDR
guidelines which reviews all maternal
deaths occurred in monthly review
meeting and suggest corrective action
to improve the quality of care.
Minutes of meeting of review meeting
along with case summary are sent to
district nodal officer.
4.19.2 Quality Assurance of Referral Medical
Services- Superintendent
Each woman who is referred to the
district hospital is given a standard
referral slip. This referral slip is sent
back to the referring facility with the
woman or the person who brought her
after writing outcome of referral on it.
Both the district hospital and the
referring facility keep a record of all
referrals as a quality assurance
mechanism
5. Records:

No. Period
1 Immunization
Register
2 Birth Register
4 Still Birth Register
6. Process Efficiency Criteria:

1 Clinical Care Maternal Mortality Rate
2 Clinical Care Newborn Mortality Rate
3 EOC Services C-Section Rate
4 EOC Services No. of deliveries conducted in the
night
5 Antenatal Care Proportion of mothers provided four
or more ANCs
6 Intrapartum Labour Room Score
Care
7 Antenatal Care Door to drug time for antenatal visit
8 Intrapartum Proportion of deliveries for which
Care partograph established.
9 New born Care No. of new born resuscitated
10 JSY Percentage of mothers leaving
hospitals with in 48 hours.
1. Guideline for pregnancy care and management of obstetrics complications for

MO- MoHFW
2. SBA Guidelines for Antenatal Care and Skilled Attendance at Birth- MoHFW
3. Operational Guidelines on Maternal & Newborn Health - MoHFW
4. Facility Based IMNCI- Participant Manual- MoHFW
5. Infection Control Practices in Emergency Obstetric Care –Engender Health
6. Infection Prevention Guidelines- JHPIEGO
7. Immunization Hand Book for Medical Officers- MoHFW
8. Managing complication in Pregnancy and Child Birth- WHO
9. Maternal Death Review Guidebook – MoHFW
10. Operational Guidelines for JSSK
11. Procedure for admission Discharge Management (SOP 13)
12. Procedure for referral Management (SOP10)
13. Procedure for Diagnostic Management (SOP 19)
14. MTP Act 1972
15. PC&PNDT Act 1994
16. Procedure for Blood Bank (SOP 6)
17. Procedure for Operation Theatre Management (SOP 5)
18. Procedure for indoor management (SOP2)
19. Procedure for Infection Control (8)
20. Procedure for biomedical waste management (SOP 24)
8. Work Instructions.
8.1 Antenatal Check up
8.2 Antenatal Examination
8.3 Vaginal Bleeding Before 20 Weeks
8.4 Vaginal Bleeding after 20 Weeks
8.5 Management of Eclampsia
8.6 Simplified Partograph
8.7 Active Management of Third Stage of Labour
8.8 Management of Post Partum Hemorrhage
8.9 Essential New Born Care
8.10 APGAR score
Sl. Parameters Score 0 Score 1 Score 2 Component
No. of acronym
01 Skin color / blue or pale all blue at no cyanosis Appearance
Complexion over extremities body and
body pink extremities
(acrocyanosis) pink
02 Pulse rate Absent <100

≥100 Pulse
03 Reflex irritability no response grimace/feeble cry or pull Grimace

to stimulation cry when away when
stimulated stimulated
04 Muscle tone none some flexion flexed arms Activity
and legs
that resist
extension
05 Breathing absent weak, irregular, strong, lusty Respiration
gasping cry
8.11 Newborn Resuscitation
8.12 Kangaroo Care
8.13 Postnatal Care
8.14 Emergency Triage, Assessment and Treatment of Sick Young Infants and
Childs
8.15 Triage-
8.16 Basic Life Support
8.17
8.18
8.19
Management of Coma & Convulsions
Assessment of Consciousness-
A child who is not alert, but responds to voice, is lethargic. An unconscious child may or may not respond
to pain. A child with a coma scale of “P” or “U” will receive emergency treatment for coma as
described below.
Treatment of Coma and convulsions -
8.20 Assessment & Management of Severe Dehydration
Assessment -
8.21 Management of Severe dehydration in emergency setting (Plan C- without

SAM)
8.22 Management of Hypothermia
8.23 Management of Hypoglycemia-
8.24 Management of Sick Young Infants -
Table 11 : Checklist for monitoring sick young infant
(Mnemonic for monitoring: T.A.B.C.F.M.F.M.C.F.)
SNO CHECKLIST ASSESSMENT ACTION
1 Temperature Mild hypothermia Rewarm by KMC
Hypothermia
Rapid Rewarming by radiant warmer
(Moderate/Severe)
Fever (temperature > 37.5ºC Removal of excess clothing, change
environment, Sepsis screening
2 Airway Obstructed Open the airway (Position and

suction)
3 Breathing Apnoea/Gasping PPV with Bag and Mask
Respiratory Distress Oxygen

4 Circulation Shock • Give 20ml/Kg Normal
saline/RL in 30 min
• Oxygen
5 Fluids No Shock Maintenance Fluid
6 Medication & Suspected sepsis, Jaundice Antibiotics, phototherapy
Other
Management
7 Feeding As per wt & age guidelines

8 Monitor Temperature, Respiration,
Colour, Heart Rate,
CRT,Danger Signs
9 Communication For Home care: • Exclusive Breast
Feeding• Maintain
Temperature• Cord & Eye
Care• Danger Signs• Maternal
Health For care during referral
10 Follow Up • 2 weekly for initial 2-3
visits, every month thereafter•
Check weight, feeding, problems•
Immunization
8.25 Guidelines for initiating Phototherapy Jaundice
8.26 Guidelines for exchange transfusion in Neonatal Jaundice
8.27 Fluid and nutritional Guidelines for LBW Neonates -
Guidelines for the modes of providing fluids and feeding
Age Categories of neonates

Birth weight (gm) Gestation
<1200 <30 1200-1800 30-34 >1800 >34
(weeks)
Initial -IV fluids -Triage - Gavage feeds - Breast feeds - If
Gavage feeds if not sick unsatisfactory, give
cup-spoon feeds
After 1-3 days Gavage feeds Cup-spoon feeds Breast feeds
Later (1-3 wks) Cup-spoon feeds Breast feeds Breast feeds
After some time (4-6 wks) Breast feeds Breast feeds Breast feeds
Feeding volumes and rate of increments in LBW
Age (days) Feed volume (ml/kg/day)

1 60
2 90
3 120
4 150
5 180
6 180
Indications for Discharge of LBW Neonates

 They are feeding from breast or breast and cup
 Gaining weight for 3 consecutive days
 No signs of illness
 Are able to maintain normal body temperature when roomed-in with mother
 Mother is confident of taking care of the baby
8.28 Guidelines for transport of Neonate
A. Ensure warm transport

Use one of the following approaches to keep the baby warm during transportation:
1. Skin to skin care: This is probably the most effective, safe and convenient method. Baby is wearing a
cap and a napkin · Baby is placed facing the mother in skin to skin contact between breasts. Baby‟s
back is covered by tying the blouse or with a fold of gown/ ‟chunari‟
[The skin to skin contact can also be provided by another woman/man /father].
2. Cover the baby: Cover the baby fully with clothes including the head and the limbs. Nurse the baby
next to the mother or another adult during transport.
3. Improvised containers: Use of thermocol box, basket, padded pouch, polythene covering can be used
for ensuring temperature stability during transport. If available, you may use one of these methods.
The use of rubber hot water bottle is fraught with considerable danger due to accidental burns to the baby
if the bottle is not wrapped properly or remains in contact with baby‟s body. It is therefore best avoided. If
no other means of providing warmth is available, this method may be employed, but with utmost caution.
The accompanying members of the team should be explained care of the bottle.
B. Provide other care during transportation

The accompanying person should be explained to ensure the following:
1. Ensure warm feet
Whatever method of keeping the baby warm is employed, make sure that the baby‟s feet are warm to
touch. Warm feet means that the baby is not in cold stress. If the baby passes urine or stool, dry him
promptly. He should not remain wet, otherwise he will lose heat.
2. Ensure an open airway

-Keep the neck of the baby in slight extension
-Do not cover the baby‟s mouth and nose
-Suction mouth and nose if required.
3. Check breathing:
Watch baby‟s breathing. If the baby stops breathing, provide tactile stimulation to the soles to
Restore breathing. If breathing not established, initiate bag and mask ventilation.
4. Provide feeds: Breast feed if baby is active. If the baby is able to feed but the mother is unable to
accompany and breastfeed the baby, the baby must be fed using an alternative feeding method. Insert a
gastric tube if necessary.
8.29 Treatment of very severe Pneumonia and severe pneumonia -
8.30 Management of Acute Asthma
8.31
8.32 Diarrhea treatment Plan B – Treat Some Dehydration with ORS
8.33 Management of Complicated and Severe Cases of Malaria
8.34 Management of Severe Malnutrition in Hospital-
8.35 A. Infection Control Measures during Normal Delivery-
Steps that can be taken to decrease the risk of maternal infection before and during delivery
include:
STEP 1:
Make sure the following items are available:
 Two pairs of high-level disinfected or sterile surgical gloves
 Pair of high-level disinfected or sterile “fingerless” surgical gloves
 Pair of clean examination gloves for washing the perineum
 Basin of clean warm water, soap, a face cloth and clean dry towel2
 Plastic or rubber apron and face shield (or a mask and goggles)
 Waterless, alcohol-based antiseptic hand rub or antiseptic solution
 (e.g., 2% chlorhexidine gluconate or 10% povidone-iodine)
 High-level disinfected or sterile blunt scissors (Mayo)
 High-level disinfected or sterile cord clamp or cloth to tie off the cord
 Injectable oxytocin (with or without methergine) or oral misoprostol
 High-level disinfected or sterile urinary catheter (straight, rubber or
 metal) and clean basin to collect urine (optional)
 Package of gauze squares
 Clean basin for the placenta
 Clean drape or cloth for wrapping the baby
 Clean perineal pads
 Light source (a flashlight or lamp) if needed
 Puncture-resistant sharps container (within arm‟s reach if possible)
 Plastic bucket with a tight fitting lid, filled with 0.5% chlorine solution
 for decontamination
 Plastic bag or a leakproof, covered waste container for disposal of
 contaminated waste items
If episiotomy is required, the following will be needed as well:
 High-level disinfected or sterile needle holder
 High-level disinfected or sterile tissue forceps
 #O chromic suture on, or with, a curved, minimally blunt (preferred)
 or cutting suture needle
 Local anesthetic (without epinephrine)
Prior to Delivery
STEP 2:
 Once the patient is positioned for delivery, put examination gloves on both hands and
wash the perineal area (vulva, perineum, and anal region) with soap and clean water
 Use a downward and backward motion when washing the perineal area so that fecal
organisms will not be introduced into the vagina.
 Clean the anal area last and place the washcloth or towel in a plastic container.
 Shaving perineal (pubic) hair increases the risk of infection associated with delivery
STEP 3:
 Immerse both gloved hands in a 0.5% chlorine solution, remove gloves by inverting, and
place them in the plastic bag or leak proof, covered waste container.
STEP 4:
 Thoroughly wash hands, especially between the fingers, and forearms up to the elbows
with soap and clean water and dry with a clean, dry towel or air dry.
STEP 5:
 Apply 5 mL (about 1 teaspoonful) of the antiseptic hand rub to hand and forearms and
rub until dry; repeat application and rubbing 2 more times for a total of at least 2 minutes,
using a total of about 15 mL (3 teaspoonfuls) of the hand rub. (If hand rub is not
available, apply an antiseptic solution to hands and forearms, rinse with clean water and
dry hands.)
STEP 6:
 Put high-level disinfected or sterile surgical gloves on both hands.
STEP 7:
 Wear protective equipment including a plastic or rubber apron and face shield (or a
mask and goggles) because splashing of blood and blood-tinged amniotic fluid can be
expected.
During Delivery
 If resuscitation of the infant is required, use mechanical suction if available. (If mouth
suction of the airway cannot be avoided, place a trap in the line.)
 If manual removal of the placenta is required, fingerless surgical gloves should be used
to avoid contaminating the forearm with blood.
To use fingerless gloves:
 First, remove the surgical glove from one or both hands using the
 Next, put on a fingerless high-level disinfected or sterile surgical glove(s) and pull up
onto the forearm(s).
 Finally, put a new high-level disinfected or sterile surgical glove on one or both hands.
After Delivery
STEP 8:
 Before removing gloves, put the placenta in the clean basin and place all waste items
(e.g., blood-stained gauze) in the plastic bag or leakproof, covered waste container.
STEP 9:
If an episiotomy was done or there were vaginal or perineal tears requiring surgical repair:
 Place sharps (suture needles) in the puncture-resistant sharps container.
 If disposing of hypodermic needle and syringe, hold the needle under the surface of a
0.5% chlorine solution, fill the syringe and push out (flush) three times; then put in a
puncture-resistant sharps container.
 Alternatively, if reusing syringe (and needle), fill syringe with needle attached with 0.5%
chlorine solution and soak for 10 minutes for decontamination.
STEP 10:
 Immerse both gloved hands in a 0.5% chlorine solution; remove gloves by inverting, and
place in the plastic bag or leakproof, covered waste container if discarding them. If
reusing them, place them in a 0.5 % chlorine solution for 10 minutes for
decontamination.
STEP 11:
 Wash hands or use an antiseptic hand rub.
B. Additional Infection Control Measures for C-Section Surgeries –
 The surgeon and assistant should wear a face shield (or mask and goggles) and a
plastic or rubber apron over their scrub suits because splashing of blood and blood-
tinged amniotic fluid can be expected.
 Double gloving is recommended, especially if reprocessed sterile or high-level surgical
gloves are used.
 A first or second-generation cephalosporin should be given intravenously after the cord
is clamped if the section is high risk (i.e. prolonged ruptured membranes or labor of any
duration
 The health worker receiving the infant should wash her/his hands and put on clean
examination gloves (or reprocessed high-level disinfected surgical gloves) before
handling the baby.
 The baby should be placed on a clean towel after being passed off to the health worker
caring for the infant.
 Change surgical gloves before manually removing the placenta. (If available, use elbow-
length surgical gloves or a combination of fingerless gloves and a new pair of surgical
gloves.
 With prolonged ruptured membranes or with documented intraamniotic infection
syndrome (chorioamnionitis):
 Avoid spillage of amniotic fluid into the abdominal cavity.
 Place folded, moistened sterile laparotomy pads or towels on either side of the uterus
(paracolic gutters) to catch as much contaminated amniotic fluid as possible.
 If large amounts of meconium or amniotic fluid spill into the abdominal cavity, remove
the laparotomy pads or towels in the gutters and lavage the cavity with sterile isotonic
(0.9%) saline solution.
 Do not explore the peritoneal cavity unless absolutely necessary, and then only after
closure of the uterine incision and surgical gloves have been changed.
If the cervix is closed and membranes were not ruptured prior to the caesarean section:
o Dilate the cervix from below (i.e., through the vagina) sufficiently to permit the
outflow of blood and fluid (lochia) after delivering the baby and placenta.
o Insert the gloved finger into the cervix only once to dilate it.
o Do not go back and forth or remove the hand from the pelvis and then put the
finger back into the cervix.
o When dilation is completed, remove the gloves and put on a new pair of sterile or
high-level disinfected surgical gloves
To minimize postoperative wound infections:
o Patients should not be shaved prior to surgery. (If it is necessary to remove pubic
or abdominal hair, clip the hair with scissors just prior to surgery.)
o Make the skin incision with a scalpel rather than with lectrocautery.
o After the fascia is closed, irrigate the wound with sterile isotonic (0.9%) saline
and then blot it dry.
o Whenever possible, do not place drains in the subcutaneous layer.
o Close the skin edges using a subcuticular technique.
o Apply a sterile dressing and care for the wound
Aseptic technique is broken whenever a nonsterile area is touched, such as when the
gloved hand reaches down into the pelvis to extract the baby’s head or buttocks.
Whenever a sterile or high-level disinfected surgical glove (or gloves) becomes
contaminated, it should be changed as soon as possible
C. Postpartum Care of the Mother

Minimizing the risk of nosocomial infection in mothers during the postpartum period
includes the following:
 Wear examination or utility gloves when handling perineal pads, touching lochia
(vaginal discharge) or touching the episiotomy.
 In the immediate postpartum period, check to be sure she is voidingwithout
difficulty.
 Teach her how to wash the perineal area with boiled water after changing a pad
or having a bowel movement (defecation).
 If the patient is breastfeeding, teach her how to care for her breasts and
 Nipples to avoid infection (mastitis).
 If delivery was by caesarean section, to avoid pulmonary problems during the
immediate postoperative period and for the next few days:
 use pain medication cautiously,
 encourage her to move about in bed and take deep breaths frequently, and
 get her out of bed and walking within the first 12 hours
D. Postnatal Care of the Newborn
Minimizing the risk of nosocomial infection in the newborn involves the following:
 Wear gloves and plastic or rubber apron when handling the infant until blood,
meconium or amniotic fluid has been removed from the infant‟s skin.
 Careful removal of blood and other body fluids using a cotton cloth, not gauze,
soaked in warm water followed by drying the skin may minimize the risk of
infection.
 Wash hands before holding or caring for the infant. Alternatively, a waterless,
alcohol-based antiseptic hand rub can be used.
 Bathing or washing the newborn should be delayed until the baby‟s temperature
has stabilized (usually about 6 hours). The buttocks and perineal areas are the
most important to keep clean. They should be washed after each diaper change
using a cotton cloth soaked in warm soapy water, and then carefully dried.
 Cover gowns or masks are not required when handling infants.
 No single method of cord care has proved to be better in preventing infection.
General suggestions are:
 Wash hands, or use an antiseptic hand rub, before and after cord care.
 Keep the cord stump clean and dry
 Do not cover the cord stump with a dressing or bandage.
 Fold the diaper below the cord stump.
 If the cord stump gets soiled or dirty, gently wash it with boiled
 Soapy water and rinse with boiled water and dry with a clean cloth.
 Explain to the mother that if the cord stump becomes red or is draining
pus or blood she should bring the baby to a clinic or hospital equipped to
care for newborns as soon as possible.
8.36 Guidelines for Environment Cleaning & Disinfection in Labor Room
Cleaning & Decontamination working surfaces after every procedure-
Wipe the following surfaces with a cloth soaked in 0.5% chlorine solution (or a mixture of
detergent and chlorine solution) after every procedure.
- Labor Table (Including Legs of table)
- Procedure Tables (including legs of table)
- Others Tables (e.g., mayo tray, auxiliary tables)
-Kelly‟s pad or plastic sheet/drape (Ideally, theses should be replaces with clean ones
after every delivery and decontaminated for 10 minutes in chlorine solution and
thoroughly cleaned.
- Floor
-Any surface splattered with blood and other body fluids or that has come in contact with
providers or other staff person‟s gloved/soiled hands (e.g., instrument trolleys, lamps,
walls, door handles, gurneys)
- Wipe labor room/ OT sleepers with 0.5 % chlorine solution, then wash with soap and
water at the end of day or when ever visibly soiled.
Walls, windows, ceilings and doors, including door handles:

Spot clean when visibly dirty with a damp cloth, detergent and water. In general, routine
damp dusting is adequate for these areas (disinfection is unnecessary). These surfaces
are rarely heavily contaminated with microorganisms, as long as the surfaces remain dry
and intact.
Chairs, lamps, tables, tabletops, beds, handrails, grab bars, lights,

tops of doors and counters:
Wipe daily and whenever visibly soiled with a damp cloth, containing disinfectant
cleaning solution. A disinfectant should be used when contamination is present, such as
for blood or other body fluid spills as described below.
Non critical equipment

(e.g., stethoscopes and blood pressure cuffs): Wipe daily and whenever visibly soiled
with a damp cloth, detergent and water. If the equipment is visibly soiled with blood or
other body fluids or the patient is under contact precautions, it should be cleaned and
disinfected before it is reused.
Sinks:
Scrub frequently (daily or more often as needed) with a separate mop, cloth or brush
and a disinfectant cleaning solution. Rinse with water.
Toilets and latrines:

Scrub frequently (daily and more often as needed) with a separate mop, cloth or brush
and a disinfectant cleaning solution.
Labour Room:
Clean the entire labor room by flooding or wet mopping by double bucket technique
using detergent disinfectant solution at change of each shift or whenever required.
Brooming or dry mopping is not indicated in labor room.
Examination rooms:
Wipe horizontal surfaces with a disinfectant cleaning solution after each procedure
and whenever visibly soiled. Linen or paper on the examination table should be changed
after each patient.
Curtains:
Change and clean curtains according to the routine schedule and when visibly soiled.
Soiled linen:
Collect soiled linen daily (or more often as needed) in closed, leakproof containers.
Waste containers: Clean contaminated waste containers after emptying each time.
Clean non contaminated waste containers when visibly soiled and at least once a week.
Use a disinfectant cleaning solution and scrub to remove soil and organic material.
8.37 Guidelines for processing of equipments, surgical gloves and other Items in
Labor Room
Instrument Cleaning Decontaminati Sterilization High Level Dis

or Other on Infection
Used Items
Airways Soak in a 0.5% Wash with soap Not necessary. Not necessary.
(plastic) chlorine solution for and water. Rinse
10 minutes prior to with clean water, air
cleaning. or towel dry.
Rinse and wash
immediately.
Ambu bags Wipe exposed Wash with soap Not necessary. Not necessary
and CPR face surfaces with and water. Rinse
masks gauze pad soaked in with clean water, air
60B90% or towel dry.
Alcohol or 0.5%
chlorine; rinse
immediately.
Aprons (heavy Wipe with 0.5% Wash with liquid Not necessary Not necessary
plastic or chlorine solution. soap and water.
rubber) Rinse with clean Rinse with clean
water. water, air or
Between each Towel dry at the
procedure or each end of the day or
time they are taken when visibly soiled.
off.
Bed pans, Not necessary. Using a brush, Not necessary Not necessary
urinals or wash with
emesis disinfectant solution
basins (soap and
0.5% chlorine).
Rinse with clean
water.
Blood If contaminated with If soiled, wash with Not necessary Not necessary
pressure cuff blood or soap and water.
body fluids, wipe with Rinse with clean
gauze pad water, air or towel
Or cloth soaked with dry.
0.5% chlorine
solution.
IUDs and Not appropriate. Not appropriate. Not recommended. Not recommended.
inserters Most IUDs and
(never reuse) inserters come in
sterile packages.
Discard if package
seal is broken.
PPE (caps, Not necessary. Wash with soap Not necessary Not necessary
masks, (Laundry staff and hot water.
cover gowns should wear plastic Rinse with clean
aprons, gloves water, air or
And protective foot machine dry. Wrap
and eyewear when for reuse.
handling soiled
linen.)
Stethoscopes Wipe with gauze pad If soiled, wash with Not necessary Not necessary
soaked in soap and water.
60–90% alcohol. Rinse with clean
water, air or towel
dry.
Storage Soak in 0.5% Wash with soap Dry heat for 1 hour Boil container and lid
containers for chlorine solution for and water. Rinse after reaching for 20 minutes. If
instruments 10 minutes prior to with clean water, air 170°C (340°F), or container is too
(metal or cleaning. or towel dry. Autoclave at 121°C large: Fill container
plastic) Rinse or wash (250°F) and with 0.5% chlorine
immediately. 106 kPa (15 lbs/in2) for solution and soak for
20 minutes (30 20 minutes.
minutes if wrapped). Rinse with water that
has been boiled for
20 minutes and air
dry before use.
Suction bulbs Soak in a 0.5% Wash with soap Not necessary Not necessary
(rubber) chlorine solution for and water. Rinse
10 minutes prior to with clean water, air
cleaning. or towel dry.
Rinse and wash
immediately.
Suction Soak in 0.5% Pass soapy water Not recommended. Steam or boil for 20
cannulae chlorine solution for through cannulae (Heat from autoclaving minutes.
(plastic) for 10 minutes prior to three times, or dry- heat ovens will
manual cleaning. removing all damage cannulae.)
vacuum Rinse or wash particles.
aspiration immediately.
(MVA)
Suction Soak in 0.5% Pass soapy water Not recommended. Steam or boil for 20
catheters chlorine solution for through catheter (Heat from minutes. (Chemical
(rubber or 10 minutes prior to three times. Rinse autoclaving or dry-heat HLD is not
plastic) cleaning. three times ovens will recommended
Rinse or wash with clean water Damage plastic because chemical
immediately. (inside and catheters; rubber residue may remain
outside) catheters can be Even after repeated
autoclaved.) rinsing with boiled
water.)
Surgical Soak in 0.5% Wash with soap If used for surgery: Steam for 20 minutes
gloves chlorine solution for and water. Rinse Autoclave at 121°C and allow drying in
10 minutes prior to With clean water (250°F), and steamer.
cleaning. and check for 106 kPa (15 lbs/in2) for
Rinse or wash holes. If to be 20 minutes.
immediately. sterilized, dry Do not use for 24B48
Inside and out (air hours.
or towel dry) and
package.
Surgical Soak in 0.5% Using a brush, Preferable: Acceptable
instruments chlorine solution for wash with soap and Dry heat for 1 hour Steam or boil for 20
(metal) 10 minutes prior to water. Rinse with after reaching 170°C minutes.
cleaning. clean water. If to be (340°F)e, or Chemically high-level
Rinse or wash sterilized, air or Autoclave at 121°C disinfect by soaking
immediately. towel dry and wrap (250°F) and 106 kPa for 20 minutes. Rinse
in packs or (15 lbs/in2) for 20 well with boiled water
individually. minutes (30 minutes if and air dry before
wrapped). use or storage.
For sharp
instruments: Dry heat
for 2 hours after
reaching 160°C
(320�F).
Thermometers Not necessary. Wipe with Not necessary Not necessary
(glass) disinfectant solution
(soap and 0.5%
chlorine). Rinse
with clean water, air
or towel dry.
Transfer Soak in 0.5% Using a brush, Preferable: Acceptable:

forceps chlorine solution for wash with soap and Dry heat for 1 hour Steam or boil for 20
(chittle) and 10 minutes prior to water. Rinse with after reaching minutes.
container cleaning. clean water. If to be 170°C (340°F)e, or Chemically high-level
(metal) Rinse or wash sterilized, air or Autoclave at 121°C disinfect by soaking
immediately. towels dry. (250°F) and for 20 minutes.
(Reprocess per shift 106 kPa (15 lbs/in2) for Rinse well with
or when 20 minutes (30 boiled water and air
contaminated.) minutes if wrapped). dry before use.
SOP 5: OT and CSSD/TSSU
Management
1. Scope
The scope of this procedure covers the patients selected for surgical procedures
2. Purpose:
The purpose of this procedure is to develop a system for managing Operation Theatre for
quality patient care.
3. Responsibility
Operation Theatre Incharge:
a) He is responsible for administrative aspects of OT including the scheduling of surgeries

as per priorities and seriousness of posted cases.
b) He is responsible for developing and implementing that OT aseptic and environmental
sterility practices mentioned in the Infection Control and Hygiene procedure.
c) He is responsible for formulating the OT protocols and procedures.
d) He is assisted by the Nurse In-charge for OT for routine supervision of above mentioned
issues.
OT Assistant (Senior / Junior):
a) Is responsible for booking & rescheduling of cases to be performed in OT and preparing

the OT list for the next day.
b) Ensure all the instrument / linens are autoclaved / sterilized respectively to be used for
subsequent operation,
c) Performs routine Check & recording of proper functioning of equipments with the help of
checklist, later on signed by Officer In-Charge Theatre before commencement of OT on
daily basis,
d) Ensures that infected cases are taken at the end of the list of surgeries for the OT,
e) Ensures that OT is fumigated; instruments / equipments are disinfected and cleaned
after infected cases are operated,
Staff Nurses:
a) Is responsible for receiving & handing over of patient along with respective patient‟s
case file, diagnostic reports duly filled and signed by concerned doctor / specialist,
b) Is responsible for briefing the patients & next of kin and filling of required consent forms
with full signature, date and time,
c) Is responsible for preparation of patient for operation including ensuring site shaving,
antiseptic application and draping of the site.
d) Is responsible for setting up of OT table for specific operation with required instruments /
linen / equipments,
e) Ensures the availability of cross-matched whole blood units before the commencement
of operation and same is recorded,
f) Is responsible for assisting the entire surgery team during the process of entire
operation,
Sweeper:
a) Responsible for Cleaning / Scrubbing of the OT, recovery room and associated area as
per procedure specifications provided by the infection control program.
b) Responsible for proper segregation of different categories of wastes generated after
every procedure and handing it over to the Biomedical Waste collection personnel.
c) Responsible for assisting OT I/C & Staff Nurse in Fumigation / Sterilization / autoclaving
inside OT,
4.0 Standard Procedures
S# Activity Responsibility Ref.

Document
/Records
4.1 Scheduling of Surgery
4.1.1 The surgeon‟s posting surgeries informs the OT OT Technician/ OT call

technician through an OT Call Register for OT Surgeon register
booking. This slip include the date and type of
surgery to be performed.
4.1.2 The OT Technician records the request in the OT OT technician OT booking

Booking Register In case of any clash in schedule register
or non-availability he informs the concerned
surgeon.
4.1.3 He forwards the details of the OT bookings to the OT Technician

OT Incharge and Anesthetist.
4.1.3 Operating List (for the next day is consolidated at OT Incharge Operating
about 3.00 P.M. in the afternoon of the previous list
day by the OT technician and the same is approved
and issued by the OT In-Charge and prominently
exhibited on the notice Boards of the theatre.
4.1.4 Emergency cases are accorded priority by the OT OT Incharge

In-Charge of Operation Theatre.
This may require rescheduling of planned surgeries
which is intimated to the concerned authorities.
4.2 Pre-operative Procedure
4.2.1 Surgeon gives written pre operative instructions to Staff Nurse

ward nurse e.g. Nil orally, enema etc.)
4.2.2 Physical Preparations (Shaving of site, enema, Staff Nurse

bath, dress, valuables / jewellery) is done
4.2.3 Staff nurses receive the patient sent from the ward Staff Nurse
and transfers him / her to the pre-operative area
with the assistance of the attendee.
4.2.4 Written Consent for Surgery is obtained from the Staff Nurse Consent
patients / patient‟s relatives.
4.2.5 Staff nurse conducts the following pre-operative Staff Nurse Pre-
checks. operative
Checklist
 Medications
 Patient Identifications
 Case Record and Investigation Reports / Films
 I.V. Fluids
 Blood Requirements
 Prophylactic Antibiotics (If prescribed)
4.3 Pre-operative Anesthetic Checks
4.3.1 A pre-operative evaluation of the patient is done by Anesthetist PAC form

the anesthetist for all cases posted and admitted for
surgery a day prior to the surgery. In case the
patient is not deemed fit for surgery, the Surgeon
and Nursing In-Charge for OT is informed through
the ward nurses. In emergency case pre anesthesia
check up is done in emergency/OT.
4.3.2 Post receiving of the patient at the OT the Anesthetist Case Sheet
anesthetist verifies the identity of the patient against
details provided in the case sheet with the patient
and the OT nurse and does a quick evaluation of
the patient‟s vitals and records the same in the
case sheet.
4.4 In Process Checks during Surgery
4.4.1 The Scrub Nurse controls the number of sponges Scrub Nurse
on the table. At the commencement and the closure
of the surgical incision, the scrubbed nurse counts
the sponges used and satisfy herself that these are
correct & inform the surgeon accordingly.
4.4.2 The surgeon verifies himself that all swabs have Surgeon Case Sheet
been counted for, before the closure of the surgical
incision. In the case of any discrepancy in the
number of swabs, the surgeon records this fact on
the case sheet of the patient and informs the Civil
surgeon/ Deputy medical superintendent.
4.4.3 The surgeon keeps the scrubbed nurse informed of Surgeon/ Scrub Nurse
the location of swabs in the operational field to
facilitate her counting. After the first count has been
taken, the scrubbed nurse and the surgeon
carefully check the number of swabs still in use.
Before the closure of the incision a final count is to
be done
4.4.4 The scrub nurse checks all the instruments on the Scrub nurse
operating table and the hemostat clamps
immediately before the operation. Under the
supervision of the surgeon the scrub nurse checks
the instruments and hemostat clamps again before
the closure of the surgical incision
4.4.5 The scrubbed nurse counts all the needles on the Scrub nurse
table before the commencement of the operation.
As a rule, the scrubbed nurse does not part with the
second needle till the first is returned to her by the
surgeon. In the event of more than one needle
being in use at the same time, the scrubbed nurse
takes care to see that all the needles are returned
to her. The scrubbed nurse makes a count of the
needles before the closures of the surgical incision.
In the event of any discrepancy, the surgeon is
informed promptly.
4.5 Post Operative Care of the Patient
4.5.1 Post operation the patient is shifted the Recovery Ward Nurses
Room or Post Operative Ward and thereafter
supervised by concerned specialist.
4.5.2 A provisional Surgery Note containing the details of Surgeon Surgery

the surgery is prepared by the surgeon with his Note
signature before the patient is transferred out of OT
complex.
4.5.3 Detailed post operative care instructions are Surgeon Case Sheet
documented in the case sheet by the surgeon.
4.5.4 The anesthetist orders the transfer of the patient Anesthetist
from recovery room towards (in case the patient
was shifted to recovery room) after verifying his /
her progress.
4.5.5 Anesthetist supervises the Post Operative Patient Anesthetist

in the Post Operative Ward (in case patient was
transferred to Post Operative Ward) for the
progress.
4.6 Operation Theater Asepsis and Environment

Management
4.6.1 The staff nurse conducts daily checks of the Staff nurse
cleanliness of the OT. She ensures that all areas
found soiled are again cleaned under her
supervision.
4.6.2 The staff nurse ensures that OT surfaces, tables Staff Nurse
and instruments are scrubbed with disinfectant
agents on a daily basis.
4.6.3 Staff nurse / OT Incharge ensures that the OT is OT Incharge Fumigation

fumigated on a weekly basis and / or after each Record
biohazard case. The details of the fumigation will be Register
recorded in the Fumigation Register.
4.6.4 All personnel entering the OT will wear OT gowns /

dress including footwear and undergo proper
scrubbing procedure to ensure sterility of the clean
areas.
4.7 OT Documentation
4.7.1 The details of regarding Anesthesia are noted in the Anesthetist Anesthesia
Anesthesia Register. register
4.7.2 Anesthetist notes down all the drugs and Anesthetist Operation
consumables, which are used during the surgery in theatre
the Operation Theater Indent Register. Indent
register
4.7.3 OT Nurse In-charge records the details of each Surgery

surgery performed in the various Surgery Registers register for
as the case may be;
General
surgery,
 Surgery Register – General Surgery
OB&G
 Surgery Register – Obstetrics &
Gynecology Orthopedics
 Surgery Register – Orthopedics
4.7.4 OT Nurse In-Charge prepares a monthly statement OT Nurse In charge

of surgeries performed and submits the same to the
OT in charge, civil surgeon.
4.7.5 Staff Nurses maintains the Psychotropic and Staff Nurse Psychotropic
Narcotics Drugs Register for the control of and
controlled drugs and substances as per statutory Narcotics
register
requirements.
4.7.6 Staff Nurses maintains the inventory of OT Staff Nurse Inventory

consumables and medicines. Register
4.7.7 Pharmacists will maintain the records of the non- Pharmacist Dead
functional / damaged equipments and informs OT Inventory
me /C and the Stores I /C. They update the same in register
the Dead Inventory Register.
4.8 CSSD
4.8.1 Receipt and Issue of Packs: CSSD Assistant Receipt &
Issue
Register
Receipt of items from various point of generation
from 9.00 am to 1.00 pm.
Issue of sterile packs from the CSSD from 3.00 pm

to 6.00 pm.
However in departments like OT, ICU, Emergency

Department etc is exempted from the above
mentioned time dimensions since it is difficult to
restrict their activity within specific time limit due to
the emergency nature of care provided by them.
4.9 General Cleaning of the Department
4.9.1 The general working area of the CSSD is mopped Housekeeping staff
everyday including the following area within the
CSSD environment.
 Packing area
 Sterile packs Storing
 Decontamination area and sluice room
4.10 Generation of Items to Sterilize
4.10.1 The items to be sterilized at the Central Sterile CSSD Assistant

Supply Department are washed with detergent,
sorted and packed at the respective point of
generation (Wards, ICUs, Emergency Department,
OTs, and OPDs etc).
4.10.2 The Housekeeping staff is responsible for Housekeeping Staff

transporting the prepared packs from the point of
generation to the Central Sterile Supply
Department.
4.10.3 OT linen is send directly to the laundry for cleaning. Laundry Staff
The laundry washed linen are received, packed and
forwarded to the CSSD for sterilization.
4.11 Return of Unutilized Packs: Respective

Departments
In case the packs which are sterilized in the CSSD

remains unutilized in the respective user
departments for a period of 72 hours, the same are
returned to the CSSD department for re-
sterilization.
4.12 Maintenance and Calibration of Equipment
4.12.1 Maintenance of the equipments are done as per the AMC Agency
annual maintenance contract (AMC) entered into
with the vendor of the respective CSSD
equipments. All details in these regard are
maintained by the Biomedical Equipments
Engineering and Maintenance Department of the
hospital.
4.12.2 All equipments used in the department are Hospital Manager/

appropriately calibrated at periodic intervals to Calibration Agency
ascertain whether they are performing at the
expected level and a record of the same is
documented in the department as well as with the
concerned clerk in the administrative Department of
the hospital.
4.13 Recall Procedure : CSSD Technician Recall

Register
Whenever a breakdown in the sterilization system
is noted all packs sterilized by the faulty machine is
immediately called back from the respective area
where the sterile packs has been supplied.
The packs called back are sent for re sterilization
using a proper machine.
5.0 Reference Records
S# Record Name Record No. Retention Period
1 OT call register
2 OT booking register
3 Operating list
4 Fumigation Record
Register
5 Anesthesia register
6 Operation theatre Indent

register
7 Surgery register for
General surgery, OB&G
Orthopedics
8 Psychotropic and
Narcotics register
9 Dead Inventory register
Sr No. Activity Process Efficiency Criteria Benchmark/Standard/Target
1 Infection Control Surgical Site Infection Rate
2 Scheduling Surgery Cancellation Rate
3 Utilization OT Utilization Rate
4 Utilization Major Surgeries per Doctor
7.0 Reference Documents
1. WHO Surgical Safety Checklist

2. Procedure for Hospital Infection Control (SOP 8)
3. Surgical Care at District Hospital
SOP 6: Blood Bank/Blood Storage
Management
1. Purpose:
To ensure the availability of safe blood unit with facility for compatibility testing, storage
and issue of blood in an aseptic environment on 24*7 basis trough trained
professionals.
2. Scope :
To store and issue collected blood to patient, organizing blood donation camp,
counseling for blood donation and testing of blood for HBsAg, HIV, VDRL and MP.
3. Overall Responsibility: Blood Bank In-Change/Pathologist.
4. Procedure:
Sr. Activity/ Description Responsibility Ref. Doc. /

No. Record
4.1 Collection of Blood Blood bank I/C Blood donor

record
The blood is collected only by a licensed
blood bank by:
No. Record
 Organizing blood donation camps.

 Through Replacement
Blood donation camps shall be organized

to augment blood stocks.
Donor, organizer / medical social worker of

the blood bank shall contact offices,
institutions, industries, social and religious
organizations, colleges and schools to
collect need based volume of blood from
targeted group of donors located at a
particular venue at regular intervals.
Record shall be maintained for such

camps indicating details of the blood
collected, donor details etc
4.2.1 Donor Selection Physician
Blood shall be accepted only from

voluntary, non remunerated, low risk, safe
and healthy donors.
4.2.2 Collection of Blood from Donors Physician and

blood bank
Blood shall be drawn from the donor by a assistant
qualified physician or under supervision by
trained assistant.
Each bag is duly identified with date,

donor‟s details.
The blood so received from the donor shall

be kept in temporary cold
storage/container or properly labelled in
No. Record
untested blood area.
4.2.3 Testing of Donated Blood Technician
The blood received from the donor shall be

verified for:
 Determination of ABO group.

 Determination of Rh type
 Infectious diseases tests (HIV,
hepatitis, Malaria, Chicken pox etc.)
Record shall be maintained for the name of

the donor along with the results. Blood bank
record
The blood group & Rh are indicated on the
bag along with registration number given in
blood bank register at which the details of
the donor & blood sample are recorded.
4.2.4 Preparation of Blood Components
The sterility of all components shall be

maintained during processing by the use of
aseptic methods and sterile disposable
bags with anticoagulation solutions.
4.2.5 Labelling
A system is in place to ensure that all

storage areas are labelled and blood is
shifted to final container only when all
mandatory testing is completed as per
requirements.
Blood group O – Blue
No. Record
Blood group A - Yellow
Blood group B – Pink
Blood group AB – White
4.2.6 Storage and Expiry of Blood and Its

Components
A designated area shall be used for

storage of untested tested and expired
blood. The area shall be properly labelled
and the access to such areas shall be
controlled.
Adequate alternate storage facility with

written display of instructions to maintain
the blood and components at a particular
temperature conditions.
In the event of failure of power UPS shall

be provided in the area of preservation.
The storage equipment are so placed that

the temperature alarm (beyond the
prescribed limits) is audible to the blood
bank personnel to ensure immediate
corrective action.
No. Record
4.2.7 Disposal of Blood
After blood collection, sample remaining in Bio-Medical

the tubing is collected in test tubes for Waste
infectious disease screening and cross (Management &
match. The needles containing portion of Handling) Rules
the tube cut down and disposed into sharp
disposal containers.
Units deemed unsuitable for transfusion,

those not transfused and those designated
for disposal for any reason, shall be
disposed of by an appropriate method in
accordance with all applicable regulations
and requirements.
All such components/bloods shall be

disposed off as per Bio Medical Waste
(Management &Handling) rule.
4.2.8 Transportation of Blood and Its

Components
Transportation may be needed from the

place of collection to the blood bank.
Whole blood, red cell concentrate, should

be transported in a manner that will
maintain a temperature of 10C ± 2C.
Platelet/ granulocyte concentrate stored

and transported at 22C ± 2C.
Blood Components required to be stored

frozen shall be transported in a manner
No. Record
that their frozen status is maintained.
4.3.1 Blood Requisition: Blood

Requisition form
During critical situation where doctor nurse in-
decides that the patient is at great risk and charge
requires transfusion, blood requisition
forms is completed by the nurse in-charge,
after notification of the doctor and sends it
to the blood bank.
The information is recorded on the blood

bank register. Blood Bank
register
4.3.2 Sample collection:

The blood group & Rh of the patient are
tested through sample collected by the Blood bank
blood bank technician either in blood bank technician
or in inpatient department based on the
patient‟s condition.
Sample collection & cross matching is

done in a hygienic environment.
4.3.3 Identification of sample:
Sample drawn from the patient is identified

by putting a label mentioning name, age &
registration no. of patient on the sample
collection tube.
4.3.4 Previous records
No. Record
Previous record of ABO and Rh type of

patient shall not used for cross matching; a
cross matching report must be generated
and name of person performing test and
generating report must be recorded.
4.3.5 Surgeries:
Cross-match procedure is done before

surgery so that the blood would be quickly
available if needed.
4.4 Other blood components:
If there is an order for a blood component

that Blood Bank does not have on hand
and will have to prepare the same, the
physician is notified as to the status or time
frame in preparing that component.
4.5 Discrepancy of Blood type:

In case of any discrepancy noticed in the
blood group type, the following step must
be followed:
If in testing a patient's blood, it is found
that the type does not match what is on
record in the blood-bank; all the
appropriate people must be notified,
specially the physician concerned, so that
appropriate measures can be taken to
prevent effect on the patient.
No. Record
4.6 Issue of Blood Blood Bank

Register
After successful testing of blood sample
and cross matching, blood is issued to the
indenter.
The details are entered in blood bank

register
4.7 Blood Transfusion Reactions: If after Nurse I/C

transfusion any transfusion reaction is blood bank
noticed in patient it should be immediately physician
reported to blood bank by nurse I/C and
case should be investigated by blood bank
4.7.1 Investigations in a Case of Transfusion Nurse I/C

Reaction
The occurrence of a transfusion reaction

should be immediately reported to the
blood bank.
The reporting authority should send: (1) A

post transfusion blood sample, (2) A post
transfusion urine sample, (3) A pre
transfusion blood sample, if available, (4)
Blood bag along with tubing.
4.7.2 To overcome transfusion reactions the Blood bank I/C

blood bank should have:
• The patient‟s original cross match

specimen, which is normally
preserved for at least 48 hours after
dispatching the blood or its
products.
No. Record
• The donor‟s pilot tubing/bottle, this

should also be preserved for 48
hours.
• The entire laboratory and blood
bank records.
• The blood should take immediate
steps to establish the cause of the
transfusion reaction.
• Proper records must be maintained
and the results should be
communicated to the concerned
department.
4.8 License of Blood Bank Medical Copy of Blood

Officer- Blood Bank License
The copy of license for storage of blood is Bank
available with the Blood bank In-charge
and shall be renewed periodically.
5. Records:

No. Period
01 Blood bank Register
02 Blood collection Record
03 Blood testing record

1 Licensure Availability and timely renewal of
Blood bank license
2 Service Provision No. of Patients referred due non
availability of blood unit
3 Service Provision No. of units issued without
replacement
4 Screening No. of Units discarded during the
screening procedure
5 Collection Proportion of blood collected
through voluntary collection in
camps.
6 Storage No. of Blood units expired
7 Issue Turn Around Time for Blood issue
6 References:
 Standards for Blood Banks & Blood Transfusion Services- NACO

 Voluntary Blood Donation – An operational guidelines- NACO
 Guidelines for setting up the blood storage unit – NACO
 Bio-Medical Waste (Management & Handling) Rules
SOP 7: Hospital Diagnostics
Management
1. Purpose:
To provide all kind of available diagnostic services to patients.
2. Scope:
It covers all patient care areas of hospital.
3. Responsibility:
The Medical Officers / treating physician shall be responsible for prescribing, diagnosis
and further treatment based on reports.
4. Procedures:
No. Record
4.1 Radiology Department
4.1.1 Arrival of Patients in Radiology depts. Radiology

Request
Patients arrive in the dept. with radiology
requisition slip given by the treating doctor
4.1.2 Explaining the Procedure to Patient &

Recording of Patient details
All the details of the patients (like name, Staff Diagnostic
age, procedure requested for etc) are Nurse/Technician Register
entered in diagnostic register.
Staff nurse inform the patient about the

procedure to be performed and duration
of the procedure.
4.1.3 Radiation Protection
Confirm about the pregnancy status of Radiology

technician
female patients of child bearing age and
provide her lead shield as per AERB
norms.
All the technician/workers dealing with

radiation exposure are provided with TLD
badges which are compulsory to be worn
during working hours.
4.1.4 Preparation of the patient Staff Consent from
No. Record
Consent is taken from patient or his nurse/technician

relatives before procedure.
Clean patient gown is provided to patient

to prepare him for procedure
Patient/ attendants are requested to

render the area which is required for
diagnosis is advised to be free from any
jewellary and accessories
4.1.6 Processing & Drying of films

After exposure, film is processed & dried
and once it is ready, it is kept for
reporting.
4.1.7 Turnaround time for reports
The report is sent to the concerned Radiologist X-Ray Report
doctor/dept directly if patient is admitted in

IPD and through patient/relative if patient
is visiting in OPD/ as per turnaround time
for reporting is decided by hospital.
For Emergency reports
In case of an emergency report, the

radiologist will see the film and give a
verbal report to the treating physician.
If the patient is referred or wants to go to

some other hospital (on request or
against medical advice), efforts made to
No. Record
generate the reports on priority bases.
4.1.8 Maintenance of Record: Radiologist List of Records
The record related to the dept. such as

Requisition slips for conducting x-ray,
Radiology Register, File of X-ray,
Maintenance Record of X-ray Machine,
consent form of patient are maintained by
staff nurse.
4.1.9 Inventory Management List of Items in

the department
Inventory of following items is maintained Staff nurse with minimum
at all the time in sufficient no. quantity in
 Linen Stock Register

 Cassettes
 Lead Apron, Gloves
 Chemicals
 X-ray films
As per daily OPD/IPD load stock of the
above items is maintained. It is ensured
that these items are available in adequate
nos. at all time.
Based on lead time of procurement,

minimum stock, avg. consumption, the
indent is sent to store on time.
4..2 USG
No. Record
4..2.1 The treating physician/ medical officers Requisition Slip

shall prescribe for the USG scan
specifying the details of the type of
investigation to be done in USG
requisition slip. Patient arrives at dept with
requisition.
4.2.2 The staff nurse enters details of the
patient in the USG appointment Register.
4.2.3 Staff nurse explain & instruct the patient Staff nurse USG
Appointment
about pre requisite for USG and give
register
them appointment , except in case of
emergency
4.2.4 Patient arrives at the department Staff nurse
complying with all instructions for
preparation as per appointment, and duty
sister forward patient scan details to the
radiologist/sonologist
4.2.5 Staff nurse assist patient and prepare
her/him for USG
4.2.6 The radiologist writes down the findings. Radiologist
4.2.7 The staff nurse shall clean the patient‟s

exposed body part after finishing the scan
and tell the patient to wait in the pt.
waiting area for the report.
4.2.8 The report is prepared by radiologist and Radiologist and

it is handed over to the patient staff nurse
No. Record
4.2.9 In case of any pregnancy or obstetric Radiologist PNDT form

cases, PNDT form filled by the patient
before performing scan.
4.3 Laboratory services
4.3.1 Out Patient Service: Lab

The respective treating physician shall investigation
prescribe the various investigations on the requisition form
Investigation request slip and patient
reaches to sample collection area of the
lab with requisition slip.
The lab technician enters the request
received, in the lab. Collection Register lab technician
and allot a lab / Hospital registration
Lab register
number for the sample to be collected.
The lab technician collects the sample

and it‟s labeled and transported to testing
area of lab lab technician
After the sample collection, the patients

are intimated about the time for collection
of report
The lab technician segregates the

specimens according to the various Hematology
testing areas and start testing samples. register,
biochemistry
The lab Technician at the respective register, special
No. Record
testing area shall record the details of the test register

samples received in the respective
registers.
4.3.2 In patient services Hematology
register,
The lab technicians / nurses shall collect
biochemistry
the sample of in-patient and send it to the
register, special
lab with request form and the patient test register
details are labeled on the sample test
tube / container.
The lab technician record all the details of

the samples received in the respective
registers
4.3.4 Reporting
The Lab. technicians shall type the
reports and get it approved from the lab
in-charge/Pathologist and issue the
reports to patient /treating physician and
also records the results in register before
dispatching reports.
4.3.5 Samples that are sent out side
facility:(if hospital have such facility)
The lab-in charge record the details of the
samples and patient in the reference
patient lab register
For the samples that are sent outside the
hospital, lab technician of outside lab is
informed to collect the sample and
delivers the reports as agreed.
No. Record
4.3.6 Stock Maintaining & Monitoring:

A stock register shall be maintained for
the items and wherever required re-order
level shall be maintained in the stock
register itself.
List of the items required items shall be

well informed to the administrative
department through indent.
5. Records:
S no Record Record No. Minimum Retention Period
1 X-ray Nominal Register
2 X-Ray Film Stock Register
3 Ultrasound Scan Register
4 Ultrasound Film Stock Register
5 Collection Register (IP/OP)
6 Biochemistry Register
7 Hematology Register
8 Special Tests Register

1 Routine Testing Turn Around Time
2 Utilization Lab test done per indoor patient
3 Emergency Turn Around Time
Testing
4 X-Ray Film Percentage of films wasted
Processes
5 X-Ray reporting Turn Around Time
6 Proficiency Z score in external validation
1. PC& PNDT Act 1996

2. Atomic Energy Act 1962 , AERB guidelines
3. The Bio-Medical Waste (Management and Handling) Rules,1998
4. ISO 15189: 2007 - Medical Laboratories Particular Requirements for Quality &
Competence
5. Guidelines for Good Clinical Laboratory Practice –ICMR
6. Guidelines for Quality Assurance for smear microscopy for diagnosing Tuberculosis
-RNTCP
7. Manual on Quality Assurance for Laboratory Diagnosis of Malaria – NVBDCP
8. Guidelines for Standard Operating Procedures for Haematology – WHO
SOP 8: Hospital Infection Control
Management.
1. Purpose:
 To maintain standards in infection control measures and minimize hospital

acquired infections in patients, visitor and staff.
 To define policy and procedure regarding hospital acquired infections in the
hospital.
 To ensure effective hand for prevention of infection. All health care personnel
must comply to make this measure effective.
2. Scope:
 Document and issue infection control procedure.

 Conduct training.
 Surveillance and monitoring.
 Develop action plan and function accordingly.
3. Responsibility: Hospital infection control committee and Medical Superintendent
4. Procedure:
Sr. Activity Responsibility Ref
no document/Record
4.1.1 Development of Infection Control List of Infection
Programme: It includes formation Medical Control Committee
of infection control committee, Superintendent members, Infection
Infection control team and infection control team
control nurse at healthcare facility. members
Infection Control Committee:
a) MS
b) Hospital Manager(if available),
c) Matron,
d)General Surgeon,
e) Orthopedic,
f)Anesthetist,
g)Pathologist,
h)Microbiologist(if available)
i)Administrative Officer,
j)Pharmacist,
k)Medical Officer
Infection Control Team:

Pathologist/Microbiologist, Hospital
Manager, Matron, Infection Control
Nurse, 1 HOD
Infection Control Nurse: A senior/
trained nursing sister is appointed
for this purpose.
4.1.2 Responsibility of ICC: Chairman ICC
 To determine the criteria for
reporting of infections
 To review with the medical
audit committee the use of
antibiotics.
 To ensure the development
of forms or data sheets used
for collecting and reporting of
data for the infection control
programme.
 To prepare and update
procedure manuals of
no document/Record
aseptic techniques used in
the hospital
 To determine the policy on
screening and immunization
of hospital staff
 To determine the content
and methodology of training
programme for hospital staff
in prevention and control of
Hospital infection.
 To develop action plan and
assigning work accordingly.
4.1.3 Responsibility of infection Chairman ICT
control Team:
 Advise management of at
risk patients.
 Carry out targeted
surveillance of hospital
acquired infections and act
upon data obtained.
 Provide a manual of policies
and procedures for aseptic,
isolation and antiseptic
techniques.
 Investigate incidence of
reported infection and take
corrective measures.
 Assist in training of all new
employees as to the
importance of infection
control and the relevant
policies and procedures.
 Surveillance of infection,
data analyses, and
implementation of corrective
steps. This is to be based on
reviews of lab reports,
reports from nursing in
no document/Record
charge etc.
 Waste management.
 Supervision of isolation
procedures.
 Monitors employee health
programme.
4.1.4 Responsibility of IC nurse: Chairperson

 The duties of the ICN are infection control
primarily associated with team
ensuring the practice of
infection control measures
by nursing and
housekeeping staff.
 Identify problems in
implementation of infection
control polices and provide
solutions.
 In addition the ICN conducts
infection control rounds and
monitors the following
practices on daily basis:
a) Bio Medical Waste.
b) Autoclave log book in
OT.
c) Linen segregation is
done or not (dirty and
contaminated).
d) Hand washing.
e) Sharp disposal in wards.
f) Use of needle cutter.
g) Preparation of
Hypochloride solution.
 The ICN is also to be

involved in training of
paramedical staff including
nurses and housekeeping
no document/Record
staff.
4.1.5 Meeting of ICC Minutes of meeting

The infection control team meets
once in a month and otherwise as
necessary.
Incharge of Infection Control Team

keeps the Management Review
Team updated on the states of
Infection in the Hospital.
4.2 SURVEILLANCE AND
REPORTING OF INFECTION :
Surveillance for infection can be
active or passive.
4.2.1 PASSIVE CLINICAL REPORTING
 Clinicians suspecting
occurrence of HAI may
report this to the Head/
member of the Infection
Control Committee. All
details regarding the patient,
procedures, medication etc.
are made available.
 The member secretary of
committee of the Infection
Control Committee/
Pathologist in-charge of the
pathology department shall
be responsible for reporting
any information about
infections suspected to be
hospital acquired.
4.2.2 ACTIVE SURVEILLANCE:

High risk areas of the hospital are
identified as:
OT, ICU, Blood Bank, Labour
no document/Record
Room, dressing room, emergency,
burn ward, Kitchen, Drinking Water
and CSSD.
4.2.3 OT- Culture swabs and air sampling OT I/C

plates are sent from Operation
Theatres after fumigation every
fortnightly.
Monitoring of working OT: Air

sampling of a working OT is done
once a month. Sampling of in use
disinfectants: 1ml of sample of in-
use disinfectants, hand wash
agents are sent to microbiology
laboratory in a sterile container
once a month/ 6month or annually
(at defined frequency).
Records are kept with OT in

charge. In case of unacceptable
results decision on corrective
measures are taken by HICC.
4.2.4 ICU :Surveillance samples: ICU I/C and Lab
 Water samples from attendant
humidifiers
 ET tube secretions
 Urine samples from
catheterized patients
Surveillance samples are sent to
pathology/ laboratory. Data is also
sent to microbiologist/ pathologist
for analysis. Analyses of data are
considered for action by HICC.
Records of the same are
maintained.
Samples of disinfectant in use:

random two samples of 1 ml of
no document/Record
disinfectant in ICU are sent in a
sterile container monthly. Swabs
may be sent after cleaning.
Records are maintained in ICU
dept.
4.2.5 Blood Transfusion Unit Lab attendant.
Cleaning of transfusion unit storage
areas is done and swabs are sent
for culture on monthly basis.
4.2.6 Food Handlers Kitchen I/C and
Screening of food handlers is done Lab attendant
biannually.
Samples include nasal swabs and
stool samples.
Records to be maintained by
Kitchen Incharge.
4.2.7 Drinking Water Sanitary Inspector/
Bacteriological surveillance shall be Maintained
done monthly from govt. recognized supervisor and Lab
water testing laboratory. attendant
Records maintained by Pathology
Department.
4.2.8 CSSD OT I/C or CSSD

Swabs are sent for sterility check I/C and Lab
after cleaning weekly. attendant
Records kept by OT Department.
4.2.9 Isolation and Barrier nursing: Nursing

Isolation of patient is done to superintendent and
reduce the chances of spread of treating doctor, on
infection through air and contact duty doctor
when patient is
a. Suffering from highly
transmissible diseases e.g.
chicken pox. Patient is
placed in a separate room.
b. Viral Hepatitis, Tuberculosis,
no document/Record
Infection Disease etc
Barrier nursing/ Isolation must be

continued until subsequent cultures
give a negative report
4.3.1 Staff health plan: Hospital infection

To control spread of infection from control committee
staff to patient or to protect staff
from occupational hazards annual
medical checkup of staff will be
done for staff of hospital along with
vaccination for Hepatitis B/any
other immunization required is
provided to all staff members.
4.4 Infection Control Measures:

Following infection control
measures shall be followed in the
hospital.
4.4.1 Hand Hygiene: On duty doctor,
Adequate hand washing facility is staff nurse and all
available in all patient care areas. paramedic as well
Elbow operated taps and as housekeeping
washbasin and soap are available staff involved in
in service provider‟s room & inpatient care.
patient care areas.
If water facility is not available

alcohol rub may be provided in
patient care area.
Scrub area is available in OT area

with elbow operated or foot
operated water tap facilities.
4.4.2 Aseptic technique: OT I/C
Aseptic technique is followed strictly
no document/Record
in OT as well as if the procedures
are done outside OT.
4.4.4 Segregation of contaminated Ward I/C
materials and instruments:
Contaminated pieces of linen,
sputum cups, bedpans, instruments
and biomedical waste are kept
separately to avoid mixing with the
clean ones.
4.4.6 Disinfection: Housekeeping staff

Disinfection of equipments and or General duty
furniture‟s are carried out with attendant
bleaching powder solution
At least once a day or based on the
procedure done/ contamination.
4.4.7 Sterilization practices: Ward I/C or CSSD

The efficient CSSD ensures the Incharge
supply of properly sterilized article
to all users of the hospital.
The unsterile items are stored
separately from the sterile items.
4.4.8 Good housekeeping: Housekeeping staff Housekeeping
Cleaning of OT walls, floors, tables Check list
and fixtures are organized as per a
schedule programme at pre- Biomedical waste
determined intervals and use of Management &
appropriate disinfectant is strongly handling rule, 1998.
advocated. (Procedure 20, Hospital
housekeeping & General Upkeep
Management)
Biomedical waste are collected,
segregated, transported, stored and
disposed off as per BMW
management & handling rule, 1998.
(Procedure 24, Hospital Waste
Management)
no document/Record
4.4.9 Antibiotic policy: Infection Control
Antibiotic policy is adopted to Committee.
monitor and control involvement of
organisms showing multi-drug
resistance and to control the use of
antibiotic policy in clinical practices
Medical
officers/microbiologist/pharmacist &
nurses takes part in the preparation
of antibiotic policy.
Method:
1. Identification of relevant
pathogens in exudates and
body fluid collects from
patients.
2. Sensitivity test done to
determine the degree of
sensitivity or resistance of
pathogens isolated from
patients to an appropriate
range of antimicrobial drugs.
3. Sensitivity testing is the in-
vitro testing of bacterial
cultures with antibiotics to
determine susceptibility of
bacteria to antibiotic.
4. Antibiotic with higher
efficacy, low side effect and
less chances of anti
microbial resistant shall be
used in the hospital.
4.4.10 Soiled linens: Ward I/C and

All soiled linen is considered Laundry supervisor
potentially infected and treated
accordingly.
4.4.11 Use of PPEs The entire
Use of personal protective healthcare worker
equipment when handling blood, involved in patient
no document/Record
body substances, excretions and care and relatives
secretions; of patient visiting
isolation wards/
Using personal protective ICU.
equipment provides a physical
barrier between micro-organisms
and the wearer. It offers protection
by helping to prevent micro-
organisms from:
 contaminating hands, eyes,
clothing, hair and shoes;
 being transmitted to other
patients and staff
Personal protective equipment
includes:
· gloves;
· protective eye wear (goggles);
· mask;
· apron;
· gown;
· boots/shoe covers; and
· cap/hair cover
4.4.11 Prevention of injury with sharps
Precautions to be observed:
 Needles should not be

recapped, bent or broken
by hand.
 Disposable needles &
other sharps should be
discarded into puncture
proof containers at the
site of procedure
 Sharps should not be
passed from one HCW
(Health Care Worker) to
another. The person
using the equipment
no document/Record
should discard it. If
necessary a tray can be
used to transport sharps.
 All sharps containers to
be discarded when 3/4ths
full.
4.5 Infection Control Audit Infection Control
The infection control audit shall be Infection Control Audit Check list
carried out on periodical basis. Committee.
Timely actions shall be taken Audit report, CAPA
against the observations raised report
during the audit.
The Infection Control team
members shall conduct inspection
periodically.
Records are maintained by head of

infection control team.
5 Records:

No. Period
01 Infection Control Audit

Record
02 Housekeeping Check List

Record
03 Minutes of Meeting of
Infection Control Committee
04 Swab Register

1 Active No. of culture surveillance found
Surveillance positive
2 Compliance to Infection Control Score
infection control
practices
1. Biomedical waste Management & handling rule, 1998

2. Infection Management & Environment Plan (IMEP) Guidelines – MoHFW
3. Practical Guidelines for Infection Control in Health Care Facilities – WHO
SOP 9: Data, Information and Record
Management
1. Purpose:
To provide guideline instructions & process of Data and Information of Hospital

Statistics and Medical Records with the aims that
 Hospital Statistics and Medical Records are readily retrievable, and

 Feedback loop is established for continuous improvements of
Health Indicators.
2. Scope:
It covers all patient medical records and Statistics in the hospital.
3. Responsibility: Medical Superintendent
4. Procedure:
no Document
/Records
4.1.1 Objective: The Primary objective of the

Medical Record Department is to develop
good Medical Records containing
sufficient data written in sequence of
events to justify the diagnosis, treatment
and end result of all patients treated in a
hospital, keep them under safe custody
and make the readily available as and
when required for
 The Patient.
 The Doctor
 Hospital Administrators.
 Medico Legal Purposes.
 External Reporting.
4.1.2 For Patient, it
 Serves to document the clinical

history and activities of patient
treatment.
 Serves to avoid omission or
repetition of diagnostic and
therapeutic measures.
 Assists in continuity of Care even in
future illness whether it requires
attention in or out of the Hospital.
 Serves as evidence in Medico-legal
Cases.
 Give necessary certification for
employment purposes.
4.1.3 For The Doctor, it
 Assures quality and adequacy of

diagnostic and therapeutic
measures undertaken.
no Document
/Records
 Serves as an assurance of
continuity of medical care.
 Evaluates Medical Practices.
 Protection in litigation.
4.1.4 For Hospital Administrator/ Deputy

Superintendent
 To document the type and quantity

of work undertaken and
accomplished.
 To evaluate proficiency of Medical
Staff for administrative and clinical
purposes.
 To evaluate the services of the
hospital in terms of accepted norms
and standards.
 To serve as an Administrative
record and Performance.
 To assist in futures Programmers
for Planning and developments of
hospital.
4.1.5 For Medico Legal Purposes, it serves
 As a documentary evidence
 To dispose claims of the
Insurances.
 For Patient‟s WILL to indicate if the
patient was of normal mental state
or not.
 Malpractice Suits.
 Authorization for operation etc.
signed document for consent for
operation will prove that the Patient
/ Relative have allowed the
no Document
/Records
performance of such Procedure.

 Criminal cases – as a Potential
Document
4.1.6 Development of Hospital Performance
Statistics
Statistical and epidemiological Data are

needed to implement and manage
medical care planning and to obtain
Health Indicators to monitor and evaluate
their effectiveness for Hospital
Management as follows:
 Bed Occupancy Rate

 Average No. of Out Patients
 Average No. of Admissions
 Sex wise Admissions
 Average Length of Stay of Patients.
 Gross and Net Death Rate.
 Number of Types of Operations
performed (Major & Minor)
 Number of X-ray / C.T.Scan, Ultra
Sound etc.
 Laboratory Tests.
 Information about Institution Deaths
(Deaths occurring over 48 hrs.)
 Total Number of Babies born in a
hospital.
 Daily Census of the Hospital etc.
4.1.7 Reporting to state Authorities
 This is the responsibility of the

department to submit the following
Diagnostic Reports to Health
Agencies like D.H.S, and other
no Document
/Records
departments under the ambit of

Health & Family welfare department
 Daily / Weekly / Monthly Malaria
and Dengue Fever cases to the
Chief Medical Officer.
 All Communicable Diseases to the
D.H.S
 Notifiable diseases are reported
immediately to control room to
Chief Medical Officer
 Monthly Leprosy Cases to the
D.H.S
 Morbidity / Mortality Statistics to the
D.H.S., on yearly basis as and
when required by the Directorate of
Health and Family Welfare.
4.2 Process of Creating Medical Records
4.2.1 Medical Record contains different sections Doctors & Nurses

for recording the information as
 Identification Section
 Medical Section
 Nurses Section.
All entries made in the medical and
nursing section of the patient record are
entered by authorized care provider.
4.2.2 Identification
This section fills up the Bio Data / Socio

economic data / Patient Identification Data
at the time of Registration and Admission.
no Document
/Records
OPD file is generated at OPD registration

counter; on the Admission Request of the
Doctor Indoor patient Admission record is
generated. Personal data for following
particulars are provided at Admission
counter by the Patient / Relatives.
 Name of Patient
 Father‟s / Husband‟s Name
 Age & Sex
 Occupation
 Permanent / Emergency Address.
 Telephone / Mobile Numbers
 Nationality
 Religion
 Medico Legal Case if any.
These details are filled in the admission

register and the patient is given an
identification number.
4.2.3 Medical Section
The Medical Section is filled up by the

Attending Doctor, and pertains to History,
Physical examination, Treatment /
progress of the patient, or if operation is to
be performed, then Operation notes are
also recorded, all the information is
recorded in the IPD booklet/BHT
Basic:-
 Initial diagnosis Record Sheet

 History Record Form
no Document
/Records
 Reasons for Admission

 Physical Examination Record Form
 Progress And Treatment Record
Form
 Consultation Record Forms (
special)
 Different Investigations Report
Forms
In Special cases- Consent Forms,

Operation Record Form.
Discharge summary is given in case of

Discharged – cured, LAMA, Discharge on
request or Death. A copy of the same is
preserved in the patients‟ medical record.
i. In case of death, Medical certification

of cause of death forms is to be filled
up by the attending Doctor or
emergency medical officer under
Registration of Birth and Death Act
1969.
ii. A copy of the death certificate is
preserved in the patient‟s medical
records file.
4.2.4 Nurses Section Nurses Medication
Record Forms
The Nurses Section is responsible for T.P.R. Chart.
filling up the following INTAKE and
OUTPUT
 Medication Record Forms Record Form.
 T.P.R. Chart. Diet sheet
 INTAKE and OUTPUT Record Discharge
Form. summary
no Document
/Records
 Diet sheet
Discharge summary is given in case of
discharge cured, LAMA, DOR or death
4.3 Flow of Medical Record from

Admission to Post Discharge
4.3.1 The Medical Record Department ensures

a smooth flow of Medical Record of the
patient from the day of his admission to
the day of his discharge and onward
maintenance till the retention period.(as
per state government norms)
4.3.2 Admission request form is filled by the

treating doctor of the patient. Formalities
for admission of the patient are carried in
the registration counter (during working
hours) or in the emergency department of
the hospital (during non peak hours) .The
general inpatient case sheet/IPD booklet
for patients is prepared at the time of
admission at admission counters.
All data pertaining to the patients stay in

the hospital and care provided are
preserved in the patient‟s bed head
ticket/IPD booklet. This booklet is
maintained by the nursing staff of the
concerned ward.
4.3.3 After getting the orders of discharge of

the patients from the treating Doctor, the
no Document
/Records
on duty Nursing Staff get the discharge

summary prepared from the Doctor
/Medical officer.
4.3.4 In case the patient is transferred or

referred to another hospital the medical
record contains information regarding
reasons for transfer, name of the
hospital where the patient is being
transferred
4.3.5 After discharge of patient, medical

record is checked for its completeness
and sends it to MR department by on
duty ward nurse.
4.4 Midnight Census:
4.4.1 Ward Census Reports from each ward is Ward Nurse Mid Night
generated by nursing staff at night duty. Census report
The reports are submitted individually to
the Emergency Medical Officer on duty/
Nurse superintendent.
4.4.2 The record clerk collects the data from the

Emergency Department/ nurse
superintendent office the next morning
and compiles the same for preparing the
census report.
The census report is submitted to the I/C

of hospital on a regular basis by the
no Document
/Records
medical record clerk
4.5 Confidentiality and Integrity of Record
4.5.1 The hospital identifies its responsibility as

custodian of medical records and
observes the following procedure to
maintain its confidentiality, security and
integrity
4.5.2 Patient is the owner of his medical record

and no form of it would be made available
to any third party without written
authorization from the patient. The
hospital observes the following guideline
instruction for the purpose:
4.5.3 Retrieval / Accessibility of Medical Medical record

Record: requisition slip
 Maintain records in proper

accessibility manner.
 Hand over the records as & when
required by I/C of hospital for
administrative purposes by getting
slip signed by the person receiving
the record.
 Physician / Surgeon for follow up
purposes by getting permission
from I/C of hospital and get the
records.
 Records required for Medico Legal
Cases in the Court of Law by the
Doctor / M.O.‟s.
no Document
/Records
 For Follow up of In-patients by the

Doctors as well as by the Patients.
 As & when they require Discharge
Summary, Investigation Reports
etc.
 Patient‟s relatives will require a
written authorization from the
patient for obtaining information
from the medical records. However
such information would not be
given in original, a xerox of the
same would be handed over to the
patient and signature taken in
specific format.
4.5.4 Incase loss or tampering of patient‟s Medical record

medical record data is reported, the clerk
medical record clerk would immediately
inform the same to the Deputy I/C of
hospital who would be responsible for
taking appropriate action. He will inform
the external agencies as applicable and
would hold an internal enquiry for
investigating the cause for such event. He
would form an internal committee under
the Deputy I/C of hospital and would hold
the enquiry in reality and would submit the
report to the I/C of hospital as per the
committee‟s finding for further action.
In case the internal committee confirms

any sort of negligence or discrepancy on
part of any hospital employee, I/C of
no Document
/Records
hospital would inform the same to higher

authorities of the Health and Family
Welfare Department for further action.
4.5.5 The Medical Record Department is

responsible for proper storage, retrieval
and maintenance of confidentiality and
security of the record.
4.5.6 At the end of the day medical record clerk

is responsible to lock the department in
the presence of a security staff.
The key is handed over to the MS office.

There after the security department is
made responsible for the protection of the
medical record room.
4.6 Retention Policy :
4.6.1 The Department is responsible for

consolidation of all Forms belonging with
patient is sent for storage in a manner with
the help of Admission Number, which is
assign at the time of Admission.
These records are stored in the Medical

Record Departments for the following
Retention Period norms are followed as
per state guideline.
no Document
/Records
4.7.1 Security of record:
a. Access to Medical Records Department

is limited to only person authorized
department staff.
b. In case any record is issued to any

designate individual as per the retrieval
policy; the same is recorded in the
outgoing patient record entry register
for accountability.
c. No form of record is issued to any
person without proper authorization
from the designated authorities.
d. During non working hours the security
staff in responsible for safety of the
department
4.7.2 At the end of the designated retention
period the medical record clerk will seek
written approval from the top management
for destruction of the medical records who
have crossed the retention period.
Only after obtaining written from the

designated hospital authority, the medical
records will be destructed by the MR
department.
4.8 Hospital statistics like IMR, MMR, birth rate,

death rate etc. to be documented and
reported.
Reporting of all the details to be done as

per hospital and state Govt. norms.
no Document
/Records
5. Records:
S. Record Name Record Number Retention Period

No.
1. Mid Night Census register
2. Death Register
3 LAMA Register
4 Record Issue Register

1 Medical Audit No. of cases audited
2 Death Audit Proportion of deaths occurred in
hospitals audited.
3 Retrieval Retrieval time of for medical records
1. Medical Record Manual –WHO
2. Internal Statistical Classification of Diseases and Related Health Problem (ICD-

10) – WHO
SOP10: Hospital Referral Management
1. Purpose:
To provide referral services to the patients who require treatment that are not within the
scope of services of hospital and the referral shall be made to other Hospital.
2. Scope : Patient in the hospital who could not be managed there.
3. Responsibility: The treating consultant/On-duty medical officer shall decide

referral.
4. Procedure:

no
4.1 Patient coming in for emergency
and treatment required for well
being of the patient does not lie
within the scope of services
provided by hospital are referred to
higher center.
Efforts are made to stabilize the
condition of patient.
4.2 Decision to refer a patient is taken On duty doctor

by the on duty treating doctor and
same is informed to the patient‟s
relatives.
4.3 The treating doctor indicates the On duty doctor Emergency register
same in writing the hospital
prescribed patient‟s case sheet.
4.6 In case of unknown patients police MLC register
is informed.
4.7 Driver is intimated to keep Staff nurse on duty
ambulance ready and patient
details is handed over to him.
4.8 If it is possible in case of unstable
patient a call is made to the
concerned hospital where the
patient is intended to be shifted.
4.9 A referral slip containing details of Referral Slip

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 and
handed over to patients relatives
5. Records:
Name of record Record Number Retention Period

Referral register
MLC register
Consent form
6. Process efficiency criteria:

1 Ambulance Response time for ambulance
Response
2 Ambulance No. of trips per day per ambulance
7. Reference
 Procedure for Emergency Management (SOP 3)
SOP11: Pharmacy Management
Purpose:
To establish a system for:

 Effective and efficient management of pharmacy services in the hospital
including storage and dispensing of drugs.
 Ensuring patients receive medicines appropriate to their clinical needs, in doses
that meet their individual requirements, for an adequate period of time.
 Assuring the selection, purchasing, control, storage, dispensing and distribution
of pharmaceutical items as per WHO guidelines and in compliance with state‟s
drug policy.
2. Scope:
It covers all activities related to medicine inventory management, storage and

dispensing of drugs to the patients (OPD & IPD)
3. Responsibility:
Storage-Chief Pharmacist and Dispensary-Concerned pharmacists
4. Procedure:
Sl. Activity/ Description Responsibilit Ref.

No. y Documents /
Record
4.1 Based on EDL (Essential Drug list) of state, Drug Drug and Drug Formulary.
and Therapeutic Committee develops “Drug Therapeutic
Formulary” appropriate to Hospital needs and scope committee
of services. A copy of the formulary is available at MS/Pharmacist
Pharmacy and all treating Physicians and
departments.
4.2 Receipt of Drugs
No. y Documents /
Record
Drugs are received in the hospital through Chief Challan or

DHS/CMSO based on the requirement Pharmacist / related
generated & sent by the hospital. The drugs are Store In- documents
supplied on as and when available through DHS Charge
based on supplies from supplier.
At times, the drugs are received in the central Stock Register

store and the same are collected by the Chief
Pharmacist / In-charge Store on receipt of
intimation.
The drugs received are identified and their

quantity checked. The drugs are received
Shortage note
through acknowledgement on the counter slip.
The items & quantity received are entered in the

stock register.
The drugs not received are noted and intimated

to Hospital incharge particularly for those
required on urgent basis. List of
damaged &
A list is also prepared for the drugs received as expired
damaged or expired. Such drugs are segregated medicines
and a detailed note put up through hospital in
charge to DHS/CHSO
4.3 Storage of Drugs Chief Stock Register

Pharmacist
 Stock is arranged neatly in alphabetic
order with name facing the front.
 Products of similar name and different
strength are stored separately.
 Heavy items are stored in lower shelves.
No. y Documents /
Record
 Fragile items are not stored at the edges

of the shelves.
 Near expiry drugs are segregated and
stored separately.
 Items requiring refrigeration are stored
appropriately.
 Temperature book is maintained for
monitoring of the temperature of
refrigerator.
 Look alike and sound alike drugs are
stored separately.
 Medications that are considered light-
sensitive, as labeled by their respective
manufacturers, will be stored in closed
drawers.
4.4 Disposal of Drugs Chief Expired Drug

Pharmacist Register
Record of drugs expired during the month is
maintained in the Expired medicine register.
Expired drugs & damaged drugs are disposed List of drugs

off as per the state guidelines of the hospital and disposed off
the record of disposal are maintained in Expired
Medicine Register. (i.e. date, quantity of expired
drug etc)
4.5 Supply of drugs Chief Voucher/ Indent

Pharmacist
Drugs are supplied to the dispensary/ ward/
emergency/ ICU etc. as per the Indent of
demanded drugs from these locations.
The pharmacist supplies the drugs to these
No. y Documents /
Record
locations and keeps the duly signed Indent from

the employee who receive the drug (Staff nurse/
Pharmacist dispensary/ ANM) Signed Indent
The intimation for the replenishment of drugs is

given to the Hospital incharge at the Reorder
level.
4.6 A) At store Chief Indent Form,

Pharmacist
Drugs are issued to the dispensary against duly Daily Expense.
filled Indent form which is collected from the
pharmacist or In-charge. Drug Issue
Register
The record of issued drug is maintained in the
daily expense/drug issue register at the store.
A list of available drugs is prepared & intimated List of available

to the doctors. The list is periodically updated drugs/ Updated
stock of
At Dispensary essential drug
list
List of available and non available drugs are
displayed outside the dispensary.
Pharmacist
Record of drug is maintained at the dispensary Stock Register
stock register along with the name, quantity, at dispensary
date of manufacture and expires etc.
Received drugs are kept in the marked

location/slots for ease of identification.
The strips of drug is cut into the small ones and

kept in marked boxes ready for dispensing.
No. y Documents /
Record
The drugs which are to be kept in controlled

temperature, either kept in dispensary store in
controlled condition or in store in controlled
condition.
Dispensing of Drugs
4.7 The patient visits the pharmacy to receive the Pharmacist Registration
prescribed medicine along with the Registration Slip,
slip.
The pharmacist at the dispensary records

registration number, name of drugs issued to the
patient, quantity of drug issued etc. in the Dispensary
dispensary register. Register
Patient is informed of the method of taking the
medicine.
Drugs not available are informed to store
4.8 Local Purchase: Life saving medicines,/

emergency medicines required for day to day
functioning can be purchased from local venders
selected by open tendering system after
approval from MS and chairperson RKS.
4.9 Hospital has a functional Drug and Therapeutic MS MOM.

Committee comprising of:
MS/Head of Institution, Pharmacist, HODs, and
Matron.
5. Records:
No. Period
01 Stock Register
02 Daily Expense /Drug

Issue Register
03 Expired Drug
Register
04 Dispensary Register
05 Available Drug List

1 Service provision Proportion of drugs available against
EDL
2 Dispensing Waiting time at pharmacy counter
1. State Essential Drug List

2. IPHS drug list.
3. State Guidelines for disposal of expired drugs.
SOP12: Management of Death.
1. Purpose:
 To define the procedure for the management of deceased patients,

transportation of the deceased to the mortuary and release of the body to
authorized person.
 To promote proper and dignified management of deceased body.
 To minimize the distress caused by the sight of dead bodies and the odors
produced by their decomposition, it is important to collect and remove cadaver to
mortuary/ handover to relatives at earliest
2. Scope:
It covers the patient who dies during treatment within the hospital (IPD,
Emergency)/brought dead in the hospital.
3. Responsibility: Medical Superintendent
4. Procedure:

no. document/Records
4.1 Death in Ward Duty Medical Officer Death Form ,
.1 When any of the patient‟s BHT/Case Sheet,
condition deteriorates the duty Death Register
doctor is informed by the staff
nurse. Duty doctor check patient
vitals and takes all possible
measures to stabilize the patient.
If patient could not be revived the
patient is declared dead by duty
doctor and the same is informed
to the patient‟s relative
Death of the patient is mentioned

on a patient‟s case sheet/BHT.
And the same is informed to the
treating doctor. Patient death
registers is updated accordingly.
4.1.2 Death in Emergency: When any Duty Medical Officer Medico-Legal
unconscious or very critical Register
patient is brought in to the Death Register
hospitals/emergency department,
the duty doctor examines the
patient and provide treatment as
per patients requirement and try
to stabilize the patient, If patient
is responding to treatment and
stabilized, the further plan of
treatment is decided and patient
is shifted toward/ ICU (as per
condition).
If patient is not responding to
treatment doctors treat patient
as per clinical SOPs/guideline
and try to revive the patient even
after this if the patient could not
be revived; the patient is
declared dead by the duty doctor.
If doctor suspects it as a medico
legal, then the police are
informed. The details are entered
in the Medico-Legal Register.
.
4.1.3 Patient brought dead: When any Duty Medical Officer

patient is brought in to the
hospital emergency department,
the duty doctor examines the
patient, if patient is found dead
during examination patient is
declared brought dead by the
duty doctor.
The police are informed
accordingly.
4.2 Death Certificate On duty Staff Nurse Death Form

The death form for the deceased Death certificate
patient is filled up and submitted
to the concerned authority by
staff nurse and death certificate is
issued by competent authority.
4.3 Issuing of Dead Body On duty medical
a) After death, the dead body Officer & Paramedical
carrying death form is Staff
issued to the patient‟s
attendant.
b) Medical officer and
paramedical staff in
ward/emergency
department ensures the
proper safety of the body
and hands over to the
attendant with verification
of the death form and
cross checking the identity
of deceased
c) To be respectful and
sympathetic to the
attendant while handling
and issuing body
d) In Medico legal cases, the
body is handed over to the
police and a receiving is
made in MLC Register by
the police /his
representative.
e) If the case is of MLC
handover the body to
authorize claimant record
his/her identity and obtain
signature in the register
4.4 Transportation of Dead body from On duty medical
.1 ward: The nurse on duty informs officer/
the duty medical officer regarding Paramedical Staff
the shifting that is required for
dead body(MLC) from the ward
to the mortuary room in case of
MLC/clearance of bills related
issues/unidentified bodies or
requested by relatives of the
deceased.
Duty Medical officer ensures that
the body is duly labeled and
checks the death form before
shifting the body in to mortuary.
4.4.2 Transportation of Dead body from On duty medical

emergency: (a) The nurse on officer/ Paramedical
duty informs the duty medical Staff
officer regarding the shifting that
is required for dead body from
the emergency to the mortuary
room in case of MLC /unidentified
bodies/ requested by deceased.
(b) Duty Medical officer and

paramedical staff in emergency
ensures the proper safety of the
body and hands over to the
police in MLC case with
verification of the death certificate
and cross checking the identity of
deceased.
(c) In case of unknown bodies the

same is handed over to police
after recording the identification
marks in details.
(d) Police may further request to
shift the body to mortuary.
4.5.1 Following details in the mortuary Medical officer on Mortuary register

register are recorded: Name of duty
deceased, age, Sex, IPD no/OPD
no., ward, Date of admission,
Date and time of death, name of
the attendant, whether a
MLC/non MLC
4.5.2 Mortuary Services Mortuary staff
Patient‟s body is kept in the
mortuary till the time it is handed
over to patient‟s attendant.
In case of unclaimed bodies the

body is kept after the post
mortem, till it is claimed by the
deceased relatives.. if by
stipulated time no one comes to
claim , it is handed over to the
MC to perform the last right/ as
per state guideline
4.5.3 Post mortem Mortuary Staff Post Mortem Report

In medico legal cases, the post , Post Mortem
mortem is requested by the Register
police personal. Dead body is
handed over to post mortem
room staff and Post mortem is
carried by the duty doctor.
On the basis of findings, the Post
Mortem report is prepared &
body is handed over to deceased
relatives in presence of police.
Entry of all the performed post
mortems is done in the post
mortem register.
All the post mortems are carried
out in day time (8:00 AM to 5:00
PM) except in special cases with
written order is given by district
magistrate in written.
4.5.4 Mortuary is cleaned, washed and Housekeeping
inspected by maintained staff Supervisor
daily
4.6 Death audit: Audit In charge Death Forms
Death audit is conducted for
every death in hospital
5. Records:
Sl. Name of Records Record No. Minimum

No. Retention Period
01 Death Requisition Form
02 Death Register
03 MLC Register
04 Death Certificate

1 Death Certificate Turn Around Time
7.0 Reference
 Inpatient Management (SOP 2)
 Hospital Emergency and disaster management (SOP 3).
Patient Registration, Admission &
Discharge Management Hospital
Stores & Inventory Management
Procurement & Outsourcing
Management Hospital Referral and
Transport Management Hospital
Security and Safety Management
Hospital Finance and Accounting
Management Hospital Infrastructure
and Equipment Maintenance
Management. Administrative
Hospital Housekeeping
and General Procedures
Upkeep Management
Human Resource Development and
Training Management Patient
Registration, Admission & Discharge
Management Hospital Stores &

SOP 13: Patient Registration,
Admission & Discharge
Management.
1. Scope: This SOP is applicable for Registration of all Outdoor patient, indoor admission &
discharge of all patients.
2. Purpose:
To provide guideline & instruction for Registration of the Outdoor patient and Admission
of the patients to the inpatient care facility and discharge from the hospital.
3. Responsibility-
a) Overall – Medical Superintendent
b) Specific – Treating Doctor/Ward In-charge
Activity Responsibility Ref.

Documents/
Records
4.1 OPD Registration (New Patient)
4.1.1 Patients‟ seeking to avail the OPD facility of Registration Clerk OPD slip/
the hospital arrives at the Help Desk/ Ticket
Registration counter of the hospital and the

patient is guided towards the registration
counter and the following information about
the patients are collected and entered into the
registration register:
a. Name
b. Age of the patient
c.Sex
d. Residential Address
4.1.2 The Registration clerk generates a Unique Registration clerk Registration

Patient ID number. At the time of registration Register
the patients are required to pay a registration

fee as per the Government rates, however the
following category of people are exempted
from paying the registration fee :
 BPL Card Holders
4.1.3 OPD slip is prepared with the Unique Patient Registration Clerk OPD slip
ID number. The Unique Patient Id is entered
into the OPD slip the same is handed to the
patient.
4.2 IP Admission from OPD
4.2.1 No patient will be refused admission if his Treating

medical condition requires him/her to be Doctor/EMO/Hospital
admitted. Manager
While admitting patients in the inpatient
facilities either from the Out Patient
Department or the Emergency Department
care is taken to ensure that patients are
admitted if the required treatment is available
in the hospital. Patients who cannot be
admitted in the hospital due to non availability
of the required medical care is given first aid
and immediately treated.
4.2.2 Patients visit the OPD of the hospital for Treating Doctor OPD slip
consultation. Patient assessed by the doctor
in the OPD and decision regarding the need
to admit the patient in the IP facility of the
hospital is taken by the treating consultant.
4.2.3 The doctor informs the patient and the relativesTreating Doctor
about the need for IP admission and indicates the
same in the OP case sheet of the patient. The
patient/relatives visit the Admission desk of the
hospital for admission of the patient.
4.2.4 The patient/relative provides the OP case sheet Admission Clerk OPD Slip
of the patient to the admission clerk who checks
the same to ensure that IP admission is advised
in writing by the treating consultant of the patient.
4.2.5 General Consent is taken from all patients (or Admission Clerk/ General
his/her relatives) at the time of admission of Treating Doctor Consent
the patient as required. Form
4.3 Admission to General Ward
4.3.1 If the patient is to be admitted in the general Staff Nurse/ Admission Bed Head
wards of the hospital ,the patients details as Clerk Ticket,
indicated in the case sheet along with the Admission
specific general ward where the patient is to register
be admitted is entered in the IP registration
register , IP number is allotted to the patient
and patients BHT is prepared.
4.3.2 The patient along with the BHT is taken to the Ward Attendant Ward In
specific ward by the admission clerk or patient
attendant who submits the BHT to the Admission
respective ward nurse. Register
4.3.3 Patient is received in the bed by the ward Staff Nurse

nurse and made comfortable. Treatment as
indicated in the BHT is immediately initiated.
4.4 Admission from Emergency department to

the IP facilities
4.4.1 Patient arrives directly in the Emergency EMO

Department of the hospital. The patient is
immediately assessed by the ED staff. The
Emergency Medical Officer attends the patient
and provides immediate resuscitation.
4.4.2 Incase the patient is to be seen by a specific EMO BHT

Specialist doctor for further treatment, the
EMO informs the doctor of the specific
specialty. Patients case sheet is immediately
prepared.
4.4.3 The Specialist doctor attends the patient in EMO
the emergency ward, examines the patient
and decides whether the patient is to be
admitted in the IP facilities of the hospital. If
the patient is to be admitted in the IP facilities
of the hospital, the Specialist doctor indicates
the same in writing in the patient case sheet
4.4.4 The patient/relatives visit the Admission desk Admission Clerk In patient
of the hospital for admission of the patient. Registration
The patient is to be admitted in the general register
wards of the hospital, the patient‟s details as
indicated in the case sheet along with the
specific general ward where the patient is to
be admitted is entered in the IP registration
register, IP number is allotted to the patient
and patients BHT is prepared.
4.4.5 The patients BHT is handed over to the Admission Clerk/ Staff Bed Head
patient/ relatives. The patient along with the nurse Ticket
BHT is taken to the specific ward by the
Admission clerk/ attendant who submit the
BHT to the respective ward nurse. Patient is
received in the bed by the ward nurse and
made comfortable. Treatment as indicated in
the BHT is immediately initiated.
Admission of Patient of Medico Legal

Cases
The conclusion on Medico Legal Case is EMO Bed Head

made based on the patient‟s condition / Ticket
unnatural cause of injury etc. Record of such
cases is entered in the Medico Legal Register
and the patient case file is stamped as MLR
“Medico-legal”. The local police constable on
duty is informed immediately.
In case of an Medico legal Case referred from
some other hospital/health center/nursing
home the MLC number is obtained from the
patient relatives. However if the MLC number
is not known then the name of the police
station at which the MLC is registered is
obtained from the patient relatives/attendants
and the same is informed to the local police
constable on duty. The treatment of the
patients is to be started immediately
PATIENT DISCHARGE MANAGEMENT
Decision regarding discharging the patients Medical Officer

rest with the primary treating Doctor of the
patient who make such decision during his
rounds on the previous day prior to the
discharge of patient and the same is
communicated to the patient, relatives, the
concerned ward nursing staff / on duty
Medical Officer. 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.
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. After conforming the patients fit to
be discharged on that day the same is
communicated to ward nurse and the medical
officer on duty.
Preparation of Discharge Summary
After final decision to discharge the patient is Doctor Discharge

taken, the treating Doctors prepares the summary
discharge summary of the patient which
contains the following information:
a. Reasons for Admission
b. Investigations performed and summarized

information about the results of the
investigations
c. Diagnosis made
d. Record of any procedures (operation, etc)

performed
e. Condition of the patient at the time of

discharge
f. Medication instructions
g. Follow up Advice
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.
As per the instructions of the treating Doctor

in the Discharge Summary, patient relatives
are advised by the Ward nurse to collect the
medicine from the pharmacy.
Patient Counseling:
Prior to final discharge of patient from the Discharge

hospital the ward nurse counsels the patient register
regarding the diet, medications , follow up
procedure etc as mentioned in the discharge
summary. Patient follow up visit dates are
clearly informed. Patients discharge records
are entered in the Ward Admission /Discharge
register.
Leave against Medical Advice (LAMA)
Incase patient/relatives want to get Consent for

discharged against medical advice; the same LAMA
is indicated in the patients case record by the
primary treating medical officer. Records are
entered in the LAMA register of the respective
patient ward and a written consent is taken
from the patient/relatives.
Discharge Summary is prepared and the

above mentioned steps are followed
5.0 Reference Records-

#
1 OPD registration register
2 Inpatient Admission register
3 Ward Inpatient Admission register
4 Emergency Admission register
6.0 Process Efficiency Criteria:

1 Registration Waiting time at registration counter
2 Complaint No. of complaint disposed in the
Management month
7.0 Reference Documents-
 Outpatient Management (SOP 01)

 Inpatient Management (SOP 02)
 Hospital Emergency and Disaster Management (SOP03).
SOP 14: Hospital Stores & Inventory

Management.
1. Scope : It covers all activities under the purview of medicine, equipment and goods
storage within the hospital.
2. Purpose: To provide guideline instructions for effective and efficient management of

Receipt, Storage and Issue of goods and medicines in Hospital.
3. Responsibility:
Over all- Medical Superintendent/ Hospital Manager
4. Procedure:
Sl. Activity/ Description Responsibility Ref.

No. Documents /
Record
5.1 Indent of items/Materials from State supplies:
Request from various departments duly signed by

HOD is received by Store I/C. He then prepares a
consolidated list of items and materials to be
procured after checking the stock availability.
This indent is forwarded to MS/ICMO for approval.
After approval from MS the indent is forwarded to
DHS/CMSO.
5.2 Receipt of Items/Materials
Items are received from state supply /the Storekeeper / Bill / Challan
concerned vendor along with bill/challan. Security Guard
The material received is intimated to MS/MOIC

with concerned users for verification.
5.3 Verification of Items
The materials received are verified with respect to Store keeper / Purchase Order
complete specification such as quantity, quality, User , Bill / Challan
date of manufacture, date of expiry (as
applicable), make etc.
In case of any discrepancy, the necessary action

is taken by CS/DS/MOIC and the vendor/sender is
informed accordingly.
Bill / Challan
5.4 Entry in Stock Register Store keeper Stock Register
The details of Ok materials are entered in Stock

Register.
Pharmacy
Management
5.4 Storage of Items
The ok materials are stored/kept at identified Store keeper /

location may be in store, almirah or at user place User
as required.
The rejected materials are kept separately by Bill / Challan

identifying “Rejected”.
5.4.1 The safe storage facilities for vulnerable items
such as spirit, x-ray films etc. are insured.
5.4.2 Storage of Seasonal Items and other items of

patient care
Items which are used for a particular season such

as blanket, room heaters, coolers etc and patient
care such as bed sheets, pillow, pillow cover, Store Keeper
chair etc. are kept in separately and issued to the
concerned department at the start of particular
season or during need.
5.5 Issue of Items
Items are issued against duly filled Indent form

and approved (by department head) which is
received from the indenter. Store Keeper Indent Form,
The record of issued items is maintained in the Stock Register,

daily expense / stock register at the store. Expenses
Register
For issue of medicines, procedure for Pharmacy

Management is followed.
Pharmacy
Management
5.6 Updating of Stock Register Store Keeper
After the issue of items, the Stock Register is Stock Register

updated accordingly.
5.7 Inventory Management
As applicable, the inventory of critical items are Chief Stock Register

maintained as follow: Pharmacist
a) Calculation of Lead time, Reorder level,

EOQ.
b) Maintenance of Buffer / Safety stock. Store keeper
This is done with the intimation/approval from

MS/MOIC.
5.8 Physical Verification Physical

Verification
The physical verification of items is carried out Deputed Officer Record
periodically with respect to quantity, quality, Expiry
etc.
The result of physical verification is intimated to

the MS/MOIC for taking further necessary action,
as applicable.
5.9 Disposal of Obsolete Materials
The expired / condemned items are kept

separately and record of such items are
maintained which include name, quantity, date of Store Keeper
expired etc. List of Obsolete
Items
These types of items are also received from

various departments From time to time for
disposal.
The list of such items are prepared and sent to

MS/MOIC for intimation and approval from the
competent authority for further action.
5.0 Reference Record
#
1 Indent Form
2 Stock Register
3 Expenditure Register
4 List of Obsolete/ Expired

Items
5 Physical Verification Report
6 Indent Form

Inventory No. of drug stock outs in the month
Management
Storage No. of drugs expired in the month
Physical No. of Physical Verification done in
Verification the year
 Pharmacy Management (SOP 11)
SOP 15: Procurement & Outsourcing
Management
1.0 Scope : This procedure involves all activities including procurement of medicines,
medical equipment and furniture and other consumables to various departments and
patients at Hospital
2.0Purpose: To establish a procedure to ensure optimum level of drugs, surgical and

general consumables and equipments inventory is maintained in stores; and procedure for
issue and control of the same to various units of the hospital.
3. Responsibility:
a) Overall – Medical Superintendent

b) Specific – Procurement of Goods- Medical Superintendant
Procurement of Services- Medical Superintendant at facility level.
4. Procedure:
Activity/ Description Responsibility Ref. Documents

/ Record
Procurement of Drugs & other

consumables
/ Record
Regular procurement Drugs procurement Annual demand,

Committee
An annual estimation of the requirement of
drugs (as per approved drug list) & other
consumables (such as swabs, syringes, Guidelines for
chemicals etc) in the hospital is evaluated by demand
a committee constituted by Hospital forecasting from
Superintendant taking into account the past State
consumption pattern, guidelines from State
and additional requirements, if any based on
the demand received from various wards,
departments etc.
The annual demand is sent to the DHS, who

in turn procures the drugs based on
consolidation of requirements from different
hospitals. The drugs are supplied to the
hospital through DHS and are verified in the
hospital by the pharmacist/nominated officer
for items, quantity, condition of supply, date of
expiry etc. The drugs which are likely to
expire in a short interval are taken up for
issue.
Shortages Pharmacist/Medical Indent / demand

Superintendent note
Items which are not received as per
requirement or are received short in supply
are requested again for supplies through an
indent from the hospital sent by the
Pharmacist/nominated officer after approval
/ Record
of CS/In charge of hospital.
Emergency requirement Medical Proposal for Local

Superintendent purchase
In case the drugs or consumables are not
available in the store and are urgently
required, the same are purchased locally
through RKS funds. A proposal indicating the
items required and justification is put up for
the approval of MS and the
drugs/consumables are purchased locally as
per state government guidelines.
The quantity and quality of the items received

are verified by the nominated officer by MS
and payment processed after satisfactory
report.
Purchase of Equipments
Routine/general use Medical List of approved

Superintendent Suppliers
The requirement for equipments of
routine/general use is put up by the
concerned department and approval obtained
from MS.
The items as approved by the State can be

procured from the approved suppliers directly
at the approved rates.
/ Record
In case the required item is not in the list as

approved by State and the same is required
for carrying out essential activities in the Delegation of
hospital, purchases are made by the hospital Power / Schedule
through RKS/General financial rules of states. of Power (SOP)
Major Equipments Medical Bill / Challan

Superintendent
These are usually not regular purchases for
major equipments required in the hospital
based on the disease burden or patient load.
The requirement along with the justification
shall be sent to the DHS after approval from
MS for purchase and supply.
Quality check Store Incharge
The quality of the equipments

purchased/received by the hospital is
checked by the nominated officer/Store
Incharge before processing the bill for its
payments.
Procurement of Services (Outsourcing)
Requirement Medical List of services to

Superintendent be outsourced
The services to be outsourced are evaluated
based on the need of the hospital. Such
services usually include Security,
Housekeeping, Dietary Management, Linen
/ Record
management, etc. Tender Notice
Each hospital independently evaluates the

extent of service required including no. of
personnel, timing of service, deliverables etc.
and forwards the same to DHS
Provisioning Medical Work Order

Superintendent
The outsourced agency is hired through DHS
based on tendering. The letter for award of
work is issued to the agency and a copy is
sent to the concerned hospital.
Monitoring Medical Quality Check

Superintendent Report
The services provided by the hospital are /Hospital Manager
monitored by the nominated officer of the
hospital. The monthly bills submitted by the
agency, after certification of its service, are
processed for payment by the hospital.
Maintenance
The equipment and infrastructure requiring

maintenance are communicated by the
hospital to converging agencies responsible
for the purpose.
/ Record
AMC
Certain specific equipments may require Medical

annual contract for maintenance. For such Superintendent
items a contract is awarded by the hospital
after approval of MS if the value of AMC does
not exceed Rs 5 lakh. For higher values,
proposals are sent to District Health Society
(DHS).
Petty repairs Medical

Superintendent
Repairs of minor nature including
replacements are arranged by the hospital by
engaging a local electrician/plumber/mason
etc as per the need; Payments are made
through maintenance funds, after verifying the
work done.
Major Repairs Medical

Superintendent
Infrastructure requiring major repairs are dealt
through PWD. The requirements are sent to
PWD and estimate of expenditure obtained.
After approval of the estimates, the repairs
are undertaken through PWD.
Petty purchases
Items of routine nature such as stationary, Nominated Officer Bill

petty office requirements are procured directly
from market and approval obtained from MS
/ Record
Quality Monitoring & Performance

Evaluation
The quality of the goods or services supplied

in the hospital are monitored by the Nominated Officer Record of
nominated officer on either their receipt or Performance
after their delivery. Evaluation of
Contractors.
For poor quality received for the goods /
services procured through DHS, suitable
intimation is sent clearly bringing out the
deficiency. Suitable action for improvement is
taken at DHS level.
For the services delivered in the hospital, the

quality is monitored by the nominated officer
and deficiencies, if any, informed to the
service provider. In case suitable
improvement is not taken up, the actions as
indicated in the agreement are taken up.
5.0. Reference Record

#
1 Indent File
2 List of Approved Suppliers
3 Performance Evaluation of
Service Providers
4 Work Order & Quality Check
Report
Reference Activity Process Efficiency Criteria Benchmark/Standard/Target

No.
Monitoring No. of vendors for which
performance appraisal was done
 State guidelines for procurement of services and goods.
SOP 16. Hospital Transport

Management
1.0 Purpose:
Establish a procedure to ensure optimum utilization of hospital vehicles as well

as Quick and Safe transportation of the patient.
2.0 Scope:
The scope of the procedure is to define the intended use of hospital vehicles
and establish a system for service realization. This is applicable to all the staff
handling the vehicle.
3.0 Responsibilities-
Primary Responsibly- Hospital Manger
Routine Responsibility- Driver.
4.0 Procedures
Activity Responsibility Ref

document/Records.
4.1 Ambulance & Vehicle

Management
4.1.1 The Hospital Ambulance and Hospital

Manger
Vehicles are intended to be
used for –
 Transferring patients
to higher/support
centre.
 Picking Up and Drop
of Hospital Staff.
 Picking Hospital
materials and
supplies.
 Serving the hospital
for VIP and
Emergency
Government duty.
4.1.2 The hospital maintains a list Hospital List of Vehicles and

Manger Ambulances
of all vehicles & EMO/Driver
Ambulances owned by the
Hospital with complete
details of Registration
Number, Vehicle Type, Date
of Registration.
All records pertaining to the

Vehicles are regularly
updated like Drivers‟
License, Pollution Control
Check Sheet, Insurance
papers of the vehicle etc.
Each driver is responsible for
ensuring all documents are
intact, updated & available
for each vehicle. This
information is captured in the
Master List of Vehicles
periodically.
4.1.3 Duty Roster of drivers Hospital Duty Roster
responsible for these Manager
ambulances & vehicles is
prepared by the In-charge
handling vehicles&
scheduling is done on
monthly basis.
4.1.4 Vehicles are maintained Driver
based on the mileage and
are serviced under
Preventive Maintenance
program as detailed in the
work instruction available
with the driver.
4.1.5 Vehicle Log (VL) book with Driver Vehicle Log
details on the distance
traveled and fuel consumed
is maintained by each driver
for that vehicle. This log is
updated on filing fuel in the
vehicle & towards ensuring
effective mileage for that
vehicle.
4.1.6 Patients are charged (if any) Driver
for the transfer as per the
norms laid down by the
government/RKS/Hospital
4.2 Deploying of Ambulances
4.2.1 Deploying ambulance in EMO / Hospital

case of Emergency Calls - Manager
-The Emergency call is
received in the Reception /
Registration which will be
noted by the person at
registration/reception.
-He will then transfer the call
to the Emergency Medical
Officer. The E MO gathers
the condition, collects the
address and telephone
number of the patient on
phone and advices for the
precautions to be taken by
patient.
-All the movements are
controlled by the EMO. He
gives the details and
instructions to the driver for
reaching to the site.
-The Hospital
Superintendent can also
control the movement of
Ambulance with the EMO.
4.2.2 Deploying ambulance for EMO /Hospital
transfer of patient out of Manager
hospital
-Ambulance service is
provided to transfer patients
to higher/support centre
upon a request from the
doctor or the patient to the
MS
-In case of transfer of patient
the driver has to inform and
will obtain instructions from
the EMO.
4.2.3 A Pre Departure check for Driver/Nurse
Oxygen, essential
equipments and emergency
drugs, has to be made by
the driver on each visit.
4.2.4 If ambulance not Hospital Ambulance Patient
immediately available then Manager Entry Register
the above details logged in
„Ambulance Patient Entry
register‟ against „Waiting
List‟. The approximate time
of arrival of ambulance at the
specific place also given to
the caller or an alternate
ambulance service shall be
arranged. (eg. 108/102, as
per arrangements made by
the State)
4.2.5 Ambulance will carry only Driver/ Hospital

Manager
Live patients
4.3 Ambulance & Vehicle
Maintenance
4.3.1 -The driver will maintain the Driver
ambulance in clean condition
-The driver has to ensure
that the Oxygen cylinder is
filled completely (gauge
indicator should be at Green
Level)
-The driver will check the
brake oil, siren, lights, horn,
and equipments in the
ambulance in every
shift/before and after every
trip.
-The driver will maintains
adequate fuel in the
ambulance
-The driver shall maintain the
tool kit in case of any
breakdown
4.3.2 Preventive Maintenance of Driver/EMO/ Vehicle Log Book

each vehicle is carried out
on a regular basis as per Hospital
work instruction available Manager
with the driver for that
vehicle and recorded in its
VLB The cost of the
maintenance with bill
reference is also recorded
with this entry in the same
log.
4.3.3 In case of sudden Driver/EMO/ Vehicle Log book
breakdowns, the vehicle is Hospital
taken/ towed to the Manager.
government approved
garage (preferably) or any
other service centre close to
the site of breakdown for
repair & maintenance. The
record of breakdown
maintenance with date, time,
Km, Spares Used & Cost of
Breakdown is recorded in
VLB
4.3.4 The Hospital Manger Hospital
analyses the maintenance & Manger
fuel cost on a monthly basis
to validate the usage of
vehicle and ensure optimal
utilization.
5.0 Records -
Sr. Record Name Record No. Retention Period

no
1 Master List of Vehicles
2 Driver Duty Roster
3 Vehicle Service Record

Register
4 Fuel Consumption Log

(FCL)
5 User Slip
6 Ambulance Register

No.
1 Maintenance No of incidences of machine
breakdown
 Hospital Emergency and Disaster Management (SOP 03)
 Hospital Referral Management (SOP 11)
SOP17. Hospital Security and Safety

Management
1. Scope : Hospital wide.
This covers all infrastructure & services provided by hospitals which have direct bearing on
security and safety such as
 Infrastructure & hospital property

 Control & flow of visitors
 Safety of Patients, visitors and service providers.
2. Purpose:
 To ensure safety and security of the Hospital building, equipments, patients and
staff.
 To provide safe and assuring environment in the hospital premises for efficient
delivery of healthcare services and review for improvement.
3. Responsibility:
A) Security- Hospital Manager and Security Personnel are responsible for effective
implementation of the process.
B) Safety- Medical Superintendent/Hospital Manger/ Departmental In charge and all

staff.
4. Procedure:

No. Documents /
Record
4.1 Security
4.1.1 Planning the requirements for Infrastructure

Security
Requirements are identified for resources needed

for safety and security of Hospital infrastructure Medical
and environment & sent to District Health Society Superintendent /
/M.S. Hospital Manager
4.1.2 Duty hours of the Security Guards are eight hours Hospital Manager/
and guards are on duty for three shifts. The Security
timings are: Supervisor
 Morning Shift: 6 AM to 2 PM
 Afternoon Shift: 2 PM to 10 PM
No. Documents /
Record
 Night Shift: 10 PM to 6 AM
4.1.3 Allocation / Posting of Security Staff at various

points
Security staff is positioned at different entry gates

or points in the hospital such as at Patient Security Staff
Registration, OPD, Wards, and Labor room, OT,
Emergency, ICU, Nursery, Parking and Mortuary
etc.
Special duties are also assigned for VIPs based

on the information received.
24X7 security guards are available in hospital.
4.1.4 Control of Incoming & Out going Items

All purchased items (infrastructure items. general
stores items, engineering items , pharmacy & Security In
medicine related items , vegetables or food / charge/Indenter/In
kitchen items ) when received in hospital are charge
checked by security at Security Gate. After stores/User
security check, the items are allowed to move in section
hospital stores. Same process is followed before
moving any item out.
A Gate Pass System is used for outgoing and

incoming items. For goods/Articles “going out”
from hospital, a gate pass is raised along with
goods/articles in Triplicate. The distribution is as
under.1. Guard at hospital Gate.2. User (Along
with goods/articles). 3. Hospital/ Office copy.(b)
Any articles/goods “coming in” to HOSPITAL are
raised in triplicate. Distribution is as under.1. One
No. Documents /
Record
copy along with goods/Articles 2.One copy with

Guard at HOSPITAL 3. Office copy. All Passes
are countersigned by
Pharmacist/Accountant/MS/Hospital Manager.
4.1.5 Keys Control Hospital Manager. Keys

Register.
A key records register with details of keys and
department concerned is maintained with details of
Keys Issue, and Keys returned.
4.1.6 Restricted visiting Hours: Security

Guard/Duty Nurse
Visiting Hours for attendants and visitors are fixed
and displayed in the Hospital:
Morning: 9:00 am – 10:00 am.
Evening: 4:00 pm- 6:00 pm
Two Visitors passes-Yellow and Green are issued

for all the patients admitted in the Hospital. Yellow
is for attendants requiring staying along with the
patient in night, and Green pass for visitors visiting
other than visiting hours. Attendants are allowed
Entry only after producing the relevant Pass.
4.1.7 Fire Safety and Its controls Hospital Manager/

Fire Safety Officer
The Hospital obtains NOC of Fire Safety from
the Fire Department and an annual request is
Layout of
sent to the department for appraisal of the
hospital
Building and fire safety measures. indicating
No. Documents /
Record
The hospital has been declared „No Smoking‟ Fire

zone. extinguisher /
Sand bucket ,
Fire extinguishers and sand buckets are placed at
different marked points throughout the hospital. A Fire
Hospital layout indicating fire extinguisher / sand Extinguisher
bucket is also kept/ displayed in the hospital file
premises
Hospital Layout with fire exit plan is also displayed.
Fire exit is marked in the hospital for exit during

fire.
In collaboration with Fire Department, Fire Training

and Fire drills are held at periodic intervals. All
employees are provided adequate training, on Fire
Safety. They are informed about the fire
evacuation procedures including fire exits located
in their work places.
Checking and testing of Fire extinguishers and its

refilling is maintained. A list of all fire devices is
maintained with Hospital Manager for effective
control.
No. Documents /
Record
4.1.8 Training to Security Personnel Training In charge
Training on security related issues such as queue

management, crowd control, etc. and use of fire
extinguisher, sand bucket are conducted as per Training File
the need on approval of Facility In charge
4.2 Safety
4.2.1 Hospital Safety Committee: Medical

Superintendent
The Hospital Safety Committee is a List of

multidisciplinary committee consisting of five Hospital
members. It is constituted by Head of RKS. It Safety
meets at least two times in a year or when Committee
required, to evaluate the various safety aspects of Members
the hospital .The Committee undertakes detail
analysis of the ongoing monitoring activities and
gives its feedback on the same. The Committee
submits its report in the meeting of Rogi Kalyan
Samiti conducted for the hospital.
4.2.2 Evaluation of Hospital Activities with respect Hospital Safety

to Safety Committee
The Hospital Safety Committee evaluates the

ongoing monitoring activities on various aspects of
the following problems:
1. Injuries to patients/ visitors

2. Property damage.
No. Documents /
Record
3. Occupational illnesses and injuries to staff

4. Hazardous materials and waste spills,
exposures, and other related incidents
5. Security incidents involving patients, staff,
and visitors in the hospital
6. Fire-safety management problems,
deficiencies, and failures.
7. Utility systems management problems,
failures, or user errors.
8. Staff mobilization during Weather
Emergencies, and natural disasters.
4.2.3 Hazard recognition: Departmental

heads/Hospital
Departmental Heads and Hospital Manager manager
identifies hazards within their specific area of
control. The same is notified to the appropriate
hospital authorities for immediate corrective
actions.
Audits are undertaken on a periodical basis to

identify the measures taken to prevent/reduce the
impact of the potential hazards
4.2.4 SAFETY INSPECTION AND RECORDS Hospital Safety

Committee
The hospital undertakes periodic inspection of the
safety precautions. These inspections are
Hospital
conducted at least twice a year or when required..
Safety
The reports of the safety inspections are reviewed
Inspection
by the hospital‟s safety committee and the same is
Records
submitted to RKS as and when required. The
safety Inspection records are maintained with
No. Documents /
Record
respective departmental authorities
The Hospital Safety Committee may require

periodic assessment of the following safety
aspects:
1. Infection control for e.g. hand hygiene,

cleaning, disinfection, sterilization.
2. Patient safety
3. Electrical/Fire safety for e.g. open
wiring, fire extinguishers, fire mock drill
etc.
4. Biological and chemical hazards
5. Personal Protective Equipments status.
6. Building safety for e.g. seepage, broken
windows etc.
7. Hospital security
Each inspection report records pertinent safety

management violations, noncompliance items, and
observe deficiencies. Employees directly involved
in the use or operation of the facilities or function
being inspected is to participate in the inspection
process.
Corrective and preventive measures are

undertaken and implemented.
4.2.5 ELECTRICAL SAFETY Maintenance

Staff/ Electricity
The hospital undertakes the following measures to
No. Documents /
Record
ensure Electrical Safety: Department
 Inspection of the power outlets throughout

the hospital at defined frequency & SOS.
 Trip Switches are located in different parts
of the hospital to prevent short circuits.
 Inspection of wires to ensures that they are
in appropriate conditions, at defined
frequency..
 Electrical equipment not required during
the night is switched off.
 Areas around electrical switchboards are
kept clear for a distance of at least 1 meter.
 Suitable fire extinguishers are located
adjacent to electrical switchboards.
4.2.6 BIOLOGICAL HAZARDS Hospital Infection SOP for

Control Hospital
Committee Infection
The Hospital identifies primary causes for Control
biological hazards which are:
 Infectious Sharp Objects

 Blood and Body fluid spill
 Biomedical Waste
 Hospital Acquired Infections
Biological Hazards are prevented and managed as
per standard Procedures for Hospital Infection
Controls.
4.2.7 LABORATORY SAFETY SOP for

Laboratory
Standard precautions like personal protective Services
equipment (PPE), safety devices and proper
Laboratory Staff
decontamination and disposal of biohazard us
No. Documents /
Record
wastes are the Laboratory Safety Policy specifies

in details the safety measures undertaken by the
hospitals
4.2.8 Staff Safety: MS/state Health
department.
All staff including out sourced staff goes through
periodic health check up. All staff is vaccinated
against TT and Hepatitis-B.
Adequate PPE are provided to all categories of

staff. Radiographers are provided with lead aprons
and TLD batches which are evaluated periodically
at BARC or its designated laboratory.
5. Records
S no. Record Name Record No. Retention Period
1 Duty Roster Of Security

Personnel
2 Attendance Register
3 Safety Inspection Report &

Their Action
4 Details of Fire Extinguisher &

maintenance
5 Accident Report file
1 Patient Safety Patient Safety Score

2 Mock Drills No. of fire mock drills conducted in
year
3 Security No. of incidences of pilferage/theft in
the year
7.0 Reference:
 Hospital Emergency and Disaster Management (SOP 03)

 Hospital Infection control management. (SOP 08)
 Pharmacy Management (SOP 11)
 Hospital waste management (SOP 24)
SOP 18: Hospital Finance and
Accounting Management
1.0 SCOPE:
The scope of the department relates to effective management of funds received from
State, Untied funds and Rogi Kalyan Samiti funds and to ensure uniformity and
consistency in the method of accounting for program funds & financial reporting.
2.0 PURPOSE:
To establish a procedure for the book keeping function of Account preparation and
Finance methods followed in the Hospital.
3.0 Responsibility-
Primary Responsibility – Medical Superintendent

Routine Responsibility – District Program Manager & District Accounts Manager
4.0 STANDARD PROCEDURES

/ Record
4.1 CASH MANAGEMENT
4.1.1 Cash for user charges is received & handled Clerk Cash Receipt
by clerk at the cash counter/ Registration
Counter
4.1.2 Accountant is responsible for receipt of user Accountant Day Book

charges slip with cash & issue of receipts
and maintains a copy of receipt. Cash is
then logged in the day book on daily basis
and subsequently deposited in the bank.
4.1.3 Accountant is responsible for preparing Accountant Monthly Report

Monthly Reconciliation of money collected
from patients
4.1.4 Accounts department receives bills from Accountant Cheque Entry

procurement department for payment to all Register
suppliers and contractors. Payments are
processed by the accountant.
4.1.5 All banking activities are carried out by Accountant Pass Book
accountant. Pass Books of all accounts are
maintained by hospital and are updated on
fortnightly basis by accountant.
4.1.6 All vouchers are handed over to the Accountant Expense Voucher
Accountant who enters the same in the
different accounting registers :
 All vouchers are fed manually on the
same day of receipt in respective
ledgers.
 The gross amount indicated in the
voucher against various heads is posted
against the concerned heads.
 Deductions shown in payment vouchers
are compiled under each relevant head
 Monthly bank-wise balances arrive after
feeding of all receipt & payment
vouchers.
4.1.7 A Trial balance showing balances of all Accountant Trial Balance
heads are prepared. Both sides of Trial
balance must tally.
4.2 Payment/ Filing if Income Tax, TDS Accountant Returns &

Returns: Certificates
Every month/ quarter/ year TDS on/before

4.2.1 due date‟s returns are filled with statutory
authorities in the prescribed format by
government.
TDS certificates to employees and

suppliers:-
At the end of the financial year TDS
certificate generated for
employees/consultants/contractor‟s/landlord
etc.
4.2.2 Accountant payroll sheet from treasury Accountant Pay Bill Register
department & if any DA arrear, HR arrear
comes from government, the accountant
prepares arrears according to the salary and
sent for cheque preparation in treasury.
4.2.3 Salary Cheque are directly deposited into Accountant Encashment

the account of the employees. DA, HR Register
arrear cheque are given to the employees
by hand or directly deposit into their account Cheque Issue
and updated in the encashment register. Register
4.3 PREPARATION OF ANNUAL ACCOUNTS:
4.3.1 A final trial balance is drawn on the basis of Accountant Final Trail
balances arrived after effecting above Balance
entries.
4.3.2 Statutory Audit is carried out annually by a Finance Statutory Audit

qualified auditor or auditors for the purpose Manager Report
appointed by state government. The audit
work starts from the first week of May every
year. After auditing by the nominated
Auditors, Annual Accounts for the previous
financial year are submitted to civil surgeon/
CMO for approval. Coordination of Audit is
carried out in the manner described below:
4.3.3 Accounts department is responsible for Accountant Statutory Audit

coordinating the work of audit of A/cs. For Report
this purpose the Accounts Section issues a
circular to all Staff members of the hospital,
departments to keep their records ready for
audit as and when audit is scheduled.
4.3.4 Accounts department collects all information Accountant Statutory Audit

& records required by audit from all Report
concerned and provide these to audit.
4.3.5 Accounts department finally coordinates Accountant Statutory Audit

submission of replies to audit objection after Report
collecting information from concerned
sections.
4.4 BUDGET PREPARATION
4.4.1 Estimates and Budget for next financial year RKS/ DPM/DAO
are called from sections utilizing specific
budget-heads in the first week of December
every year and this proposed budget is
approved by the RKS.
4.5.2 The revised estimates and budget estimates RKS/ DPM/DAO

of each section are reviewed in the light of
necessity and estimated receipts of Hospital
The progress of ongoing work is also taken
into consideration.
4.5.3 The receipt estimates and expenditure RKS/ DPM/DAO

estimates should be balanced. The sources
of fund for meeting the shortfall as well as
appropriations to Building Fund or
Equipment Fund should be suitably
approved.

#
1 Day Book
2 Reconciliation Report
3 Pay bill register
4 GIS Register
5 Internal Arrear Register
6 Encashment Register
7 Cheque Issue Register
8 Cheque Entry Register
9 Expense Voucher
10 GPF Register
11 Contingency register - User
12 Pay Bill Receiving Register
13 Minutes of the CPS

Meetings
6.0 Process Efficiency Criteria -
Annual No adverse comment/ Finding

Accounts Audit
Payments No.of % of Bills paid within prescribed
Bills tim time
 General Financial Rules

 State Govt. Instructions issue from time to time.
SOP 19: Hospital Infrastructure and

Equipment Maintenance
Management.
1. Purpose:
Establish and implement a procedure for of systematic maintenance of equipments &
infrastructure so as to ensure effective provision of services in the hospital.
2. Scope:
It covers all the equipments essential for operation of the services, infrastructure and
capital equipment.
3. Responsibility:
Maintenance of Equipment- Medical Superintendent/ Hospital Manager
Maintenance & development of Infrastructure - Medical Superintendent.
4. Procedure:
Sr. Activity
no. Respon Ref.
sibility Docume
nt/Reco
rd
4.1 INFRASTRUCTURE DEVELOPMENT
4.1 Renovation and up-gradation of the

.1 hospital building and premises including
high cost equipment is undertaken/
procured as per the State Govt. norms with Medical
clearance from the Secretary health. Superint
endent
4.2 INFRASTRUCTURE MAINTENANCE
4.2.1 The civil annual preventive maintenance Report/

includes the following: Proposal
Enginee
 Cleaning of the terraces of the ring
hospital of vegetation, malba, etc Mainten
 Repair of plasters, fixing window ance
glass panes, water proofing Staff
measures to handle leakage,
seepage and drainage.
 Ensuring that all patient care areas
are free from Fungus –if fungal
growth is noticed than anti fungal
paints is applied.
 Fencing of every new construction
and maintenance activities to
reduce pollution of patient care
areas.
 Lubrication of all the hinges of doors
and windows for smooth movement.
 Prevent collection and blockage of
water within the premises of the
hospital to prevent breeding ground
for mosquitoes.
 Annual Pest Control measures are
undertaken to ensure rodent and
pest free environments.
 Maintenance of Hospital
Landscape, including gardens and
other green areas.
 Ensure proper ventilation and
lighting of patient care areas and
other work stations.
4.2.2 Report/
MS/ Proposal
 All major areas to undergo Finance
preventive maintenance (concerned Head
with civil works) are identified at the /Mainten
beginning of the Financial Year.
ance
 Necessary estimates and technical
specifications are drawn with the Head/
help of Hospital
Contractors/PWD/maintenance Manger
department of the hospital. Tender
 The plan is sent for approval and for notice
necessary budgetary sanction to the
Rogi Kalyan Samiti (RKS) or to the
relevant Government Authorities
depending upon the size of
estimated budget for the activity.
While the smaller projects are
handled at the level of RKS bigger
projects wait for approval at the Signed
level of the State and District Health agreement
department.
 Post sanctions, tendering process is
initiated.
 The TOR for the job clearly defines
the deliverables with specifications,
timelines for completion of
scheduled task and defines
penalties clauses for non-
completion/unsatisfactory work
done, so that progress of the project
is monitored suitably.
4.2.3  Cleaning drains, removal of debris
and Plumbing are a continuous MS/
activity and is planned by the Mainten
plumber and civil engineering staff ance
on a daily basis during their regular staff
Rounds of the patient care areas
and hospital campus.
 The electrical maintenance staff
plans their activities during their
regular rounds in the patient care
areas
 The required items are indented by
the civil and electrical maintenance
staff.
 The required items are either
supplied by the stores or procured
from the local market with due
approval from the MR depending
upon the availability of budgetary
provisions for the sanctioned heads.
4.2.4  A preventive and breakdown
maintenance Complaint Book shall Departm Mainten
be maintained by all departments ent ance
and wards. heads / book
 Inc case of any event besides the Mainten
regular maintenance, a complaint ance
shall be sent to the maintenance staff
department in the Complaint book
by the concerned Departmental
Head.
 All repair works that are initiated
defines the estimated timelines for
the completion of the job with due
approval from the Engineering
Department Head or the MR/
supervisor designated by MR and
intimates the same to the
complainer.
 The progress of the job is monitored
based on the timeliness of the
completion of the complaint
received and the level of satisfaction
of the complainer.
 No repair and maintenance job is
considered as completed till such
time that a completion certificate is
received from the complaining
departmental supervisor/in-charge.
4.3 Process of preventive and breakdown
maintenance of installed bio medical
equipment & furniture
4.3.1  Procurement Incharge with the help Equipment

of department heads looks after the Maintenance
overall maintenance of the MS of Register
equipment. hospital
 A master list of equipment with
the approved agencies for
maintenance is maintained
centrally in one file along with the
valid contracts
 At the time of procurement itself
equipment are being procured with
CMC/AMC.
 For equipments not being covered
under AMC /CMC , maintenance
Plan is prepared.
 Maintenance Plan will contain
Annual Maintenance Schedules.
 Incase vendors do not provide
maintenance services, request
would be sent to parties interested
in undertaking such exercises.
 A list of Calibration service will be
made annually.
 Necessary Budgetary estimates will
be made annually for these
maintenance works and due
sanction sought.
 All departments should necessarily
display the various lists described
above along with their Calibration
/maintenance status.
 The procurement Incharge and
Department Heads shall work in
close Coordination to see that
Calibration and Maintenance work
are carried out as per the
scheduled plan.
.
4.4 Process of preventive and breakdown
maintenance of utilities :
4.4.1 All the firefighting equipment whether ABC

powder based or the conventional one is Mainten
inspected for its specified standard pressure ance In-
once in every six months. charge
4.4.2 For Intercom, tele-communications Mainten

including audio-visual systems a separate ance in-
list of Vendors and Service providers are charge.
maintained by the maintenance in-charge.
Incase of a failure or breakdown,
immediate complaint is made and is
monitored against the approved terms and
conditions as available with the
maintenance in-charge.
4.4.3 All the signage‟s along with citizen charter Mainten

are updated from time to time and check ance in-
of maintenance every six monthly. charge
and
hospital
manage
r.
5. Records:

No. Period
01 Case file containing

Breakdown Report,
Proposal, approval letter,
tender/quotation,
agreement, offer letter
NOC etc.
02 Equipment Maintenance
Register
03 Equipment history record
04 AMC record.
05 Calibration record
1 AMC % of equipments covered under AMC

2 Repair Turn around time for repair
3 Maintenance Downtime for critical equipments
 State Govt. Guideline for maintenance of equipment and infrastructure
SOP 20: Hospital Housekeeping and

General Upkeep
Management
1.0 Scope :
The scope of the housekeeping services is to ensure cleaning in all internal and external
areas of the hospitals. It also includes:
o Sanitation and hygiene

o Odor control
o Waste disposal
o Pests, Rodents and Animal control
o Environmental Hygiene
o Infection Control
2.0 Purpose:
To provide process, instructions and methodology for Management of House
Keeping with the aim that
 Cleanliness is maintained,
 Infection is controlled, and
 Customer Satisfaction is enhanced
3. Responsibility:
a) Overall – Hospital Manager
b) Responsibility lies with the Matron along with a team to ensure standards in
housekeeping are met and maintained.
4. Procedure:
Activity/ Description Responsibilit Ref. Documents /

y Record
4.1 Service Provision Contract between

the hospital and the
Housekeeping service in the hospital is Medical Outsourced agency
outsourced to an external agency which has Superintenden
deployed adequate nos. of housekeeping staffs t
(as per contract) in the hospital for the general
upkeep and cleanliness.
4.2 Duty Roaster (in House) Hospital Attendance register,

Manger Duty roaster
The Duty roaster for the in-house housekeeping
staff is maintained by the Hospital Manger and
HK staff is posted in various areas of the hospital
to maintain the cleanliness and hygiene in the
hospital
y Record
4.3 Duty Roaster (out Sourced) Housekeeping Duty Roaster

Supervisor
Housekeeping staff is available in the hospital
24*7 on the rotation basis which is maintained by
the housekeeping supervisor of the hospital.
Housekeeping Procedures- W.I. for

4.4
Housekeeping
The floor is cleaned weekly. Detergent and

copious amounts of water shall be used during
one cleaning. Housekeeping Housekeeping
4.4.1
Mopping of the floor is done with the Phenyl and Staff Check list
water. The mopping is always done in one
direction.
The walls are washed with a brush, using

detergent and water.
High dusting is done with a wet mop. Fans and

lights are cleaned with soap and water.
All work surfaces disinfected by wiping with Housekeeping

4.4.2
Bacilllocid/ Carbolic Acid Staff
Cupboards, shelves, beds, lockers, IV stands,

stools and other fixture cleaned with detergent
and water.
4.4.3 Curtains are changed periodically or whenever Housekeeping

soiled. These curtains are sent for regular Staff
y Record
laundering.
Patient‟s bed is cleaned every week with

detergent and water. 1% hypochlorite is used
when soiled with blood or body fluids.
Housekeeping
4.4.4 Collect the waste category wise from the wards,
Staff
OT, LR all the departments and store them at
identified location.
Miscellaneous items
Kidney basins, basins, bed pans, urinals, etc to

be cleaned with detergent and water and
4.4.5
disinfected with Phenyl specially when used for
infected patients
Housekeeping Process for Operation Theatre:

4.5
Before the start of the 1st case
4.5.1 Wipe all equipment, furniture, room lights, suction Housekeeping

points, OT table, surgical light reflectors, other Staff
light fittings, slabs etc with soap solution.
After each case: Housekeeping

4.5.2
Staff
The operation theatre is cleaned –OT table, and
y Record
floor. In case of a spill, treat it according to the

protocol.
Environment.
Wipe used equipment, furniture, Operating table

etc., with detergent and water. If there is a blood
Housekeeping
4.5.3 spill, disinfect with sodium hypochlorite before
Staff
wiping.
Empty and clean suction bottles and tubing with

disinfectant
After the last case
The same procedures as mentioned above are

followed and in addition the following are carried
out.
 Wipe over head lights, cabinets, waste

receptacles, equipment, and furniture with
0.5% bacillocid. Housekeeping
4.5.4
Staff
 Wash floor and wet mop with liquid soap
and then remove water and wet mop with
Phenyl.

Clean the storage shelves scrub & clean
sluice room.
 Collect all the waste category wise in the

specific color coded bags, and keep them in
the Bio medical waste storage site/location
y Record
from where they will be collected by the

outsourced agency.
Weekly Cleaning Procedure
 Remove all portable equipment.
 Damp wipe lights and other fixtures with

detergent.
 Clean doors, hinges, facings, glass inserts

and rinse with a cloth moistened with
detergent.
 Wipe down walls with clean cloth mop with

detergent.
Housekeeping
4.5.5
 Scrub floor using detergent and water .Use Staff
Phenyl to mop it finally.
 Stainless steel surfaces – clean with

detergent, rinse & clean with warm water.
 Wash (clean) and dry all furniture and

equipment (OT table, suction holders, foot &
sitting stools, IV poles, basin stands, X-ray
view boxes, hamper stands, all tables in the
room, holes to oxygen tank, kick buckets and
holder, and wall cupboards)
 After washing floors, allow disinfectant

solution to remain on the floor for 5 minutes
y Record
to ensure destruction of bacteria.
Housekeeping Procedure for Isolation Room:

4.6
Cleaning procedure for isolation room:
 Linen shall be stripped from the bed with

care taken not to shake the linen during this
action. Linen shall be soaked for 1 hour in
1% sodium hypochlorite and then sent to the
laundry.
 All other articles like IV stands and furniture Housekeeping

4.6.1
shall be cleaned with detergent and Staff
disinfected with phenyl.
 Walls shall be cleaned with detergent and
disinfected with bacillocid solution.
 The bathrooms shall be cleaned with

detergent and disinfected with bacillocid
solution.
At discharge (terminal disinfection):
 The pillows and mattress are to be cleaned

with detergent, disinfected with 1% sodium
hypochlorite and dried in sunlight for 24 Housekeeping
4.6.2
hours. Staff
 Bed sheets, curtains, gowns and dusters must

be removed, soaked in 1% sodium
hypochlorite for one hour and then sent to
y Record
laundry.
 After disinfection, wash the room, wall,

window, doors, bathroom, sink and furniture
with soap solution after doing thorough high
dusting in that cubicle.
 Soak bed pan, urinal, kidney basin in

bacillocid solution for 1 hour, wash with
detergent and dry it under sunlight.
 Bath basins, multi-bin, bucket, jugs, mugs are
washed with soap solution and dried in
sunlight.
 Rubber sheets (mackintosh) are to be

cleaned with bacillocid, dried, powdered and
replaced.
Housekeeping Process for Toilets and
4.7 Bathrooms
 The floor of bathrooms is to be cleaned with

a broom and detergent once a day and then
disinfectant solution.
 Toilets are cleaned with a brush using a Housekeeping

4.7.1 Checklist
detergent Disinfection with Phenyl is done. Staff
Stain removal using Hydrochloric acid may
be used.
 Wash basins are cleaned with detergent

powder every morning.
y Record
 Spill management for blood and mercury Housekeeping

4.7.2 BMW guideline
(Refer SOP Hospital Waste Management Staff
No. 24).
Recordkeeping Housekeeping
Cleaning Checklist
 Check list of the cleaning process shall be
Housekeeping
4.8 maintained.
Staff
 The waste generated shall be entered in the
BMW register. BMW Generation
Record Register
Periodical Check
Housekeeping
4.9 Periodical check by hospital Hospital Cleaning Checklist
manger/Matron/deputed officer shall be done and Manager
housekeeping check list shall be signed.
5. Reference Records

#
1 Attendance register
2 Duty Roaster
3 Cleaning checklist
4 Bio-Medical waste Register
1 Cleaning Hygiene Score
7. Reference Documents:
 IMEP guidelines : Ministry of Health and Family Welfare, Govt. of India

 Hospital waste Management (SOP 24)
 Out Patient Management (SOP 01)
 In patient Management (SOP 02)
 Emergency and disaster Management (SOP 03)
 OT and CSSD Management (SOP 05).
SOP 21: Human Resource
Development and Training
Management.
1.0 Scope-
Establish a procedure to manage the human resource development of the staff

serving in the hospital in a systematic way to ensure effective utilization of
resources.
2.0 Purpose-
Extends to all employees working under the purview of the hospital and includes both
permanent and outsourced staff.
3.0 Responsibility-
Over All – Medical Superintendent
4.0 Procedures
Activity Responsibility Ref
document/Record
4.1
Manpower Planning and recruitment of staff
would be as per state guideline.
4.2 The assessment of manpower requirement Medical

in each department/division is periodically Superintendent
reviewed depending on increase or
decrease of workload, technological
changes or any other relevant factor. In-
case any new staff is required for
maintaining continuity of care either directly
or indirectly, the same is communicated to
the state authorities who are responsible for
the approval and provision of the required
manpower.
4.3 All vacancies arising out of creation of new Medical
positions, consequential vacancies on account Superintendent
of internal lateral / vertical movement, transfer
,retirement , resignations etc are communicated
to the state authorities who after due
consideration undertakes the necessary steps
to fill the gaps either by internal promotions ,
transfers ( internal or external) , deputation or
by fresh recruitment .
4.4 Positions which are outsourced and are to be Medical

filled at the hospital level or through RKS, the Superintendent
creation of vacancy is notified to the
appropriate outsourcing authority who is
responsible for filling the vacant (existing /new)
position.
4.5 In case of outsourcing the hospital invites Medical

tender application from potential third party Superintendent
staffing company engaged in business of
providing outsourced manpower service
solutions. The terms and conditions and
process of tender application are strictly in line
with the guidelines specified by the State
Health and Family Welfare Department.
4.6 The respective outsource agency is responsible

for the appointment of the required outsourced
staff.
4.7 A detailed verification of the outsource State Health

candidate‟s educational qualifications, Department
experience, background etc is carried out by
the outsource agency/ as per contract prior to
their actual job placement.
4.8 The hospital conducts induction programme for Medical

the all newly joined employees including those Superintendent
/ Training In
who are placed on deputation to acquaint them
charge
with the hospital its policies, its organization
structure, management personals, employee
rights and responsibilities etc.
Induction training by the hospital is provided as
and when needed.
4.9 The hospital management prepares

a Medical Confidential
confidential report (CR) on annual basis for Superintendent Report
their permanent/Govt. employees of the

hospital under the purview of State Health and
Family Welfare department.
4.10 The Confidential Report is a detailed report

relating to the performance of the employee
against certain preset criteria decided by state
Govt.
4.11 However the Confidential Report is not the only Medical

objective criteria for such decision, length of Superintendent
service of the concerned employee is also
taken into consideration while such decisions
are taken. While the focus is on reducing
subjectivity and enhancing objectivity so as to
achieve fair appraisal of performance, it is also
used as a tool for assessing the strengths and
weaknesses as well as the potential of the
employees.
4.12 Each employee is governed by the terms and State Health Service Rule
conditions of his service as laid down in the Department Book
service rules book (Ref: Service Rule Book) of

the State Health and Family welfare
department.
4.13 Details relating to his terms of employment State Health

such as employee benefits like provident fund , Department
HRA , medical benefits , leave , transfer and

promotion criteria , procedure for
reimbursement of official tours and allowances
accruing to such tours etc are informed to them
as per state government policy.
4.14 The service rule book clearly states the Medical Service Rule
disciplinary actions that can be observed Superintendent Book
/State Health
against the employee for any misconduct or
Department
negligence in work performance and the
procedure for such action in case any
discrepancy is found in the employee
4.15 The disciplinary actions are based on the Medical

principle of natural justice and are an objective Superintendent/
State Health
process. All efforts are made to ensure that
Department
there is no subjectivity in any disciplinary action
taken against the employee and the employee
is given a fair chance to protect his/her shelf
4.16 The employee has the right to appeal to the Medical

appropriate higher authorities in case they are Superintendent
/State Health
not satisfied with the decision taken by the
Department
lower level authority
4.17 The service rule books also address the issue Medical
of staff grievance redressal procedure which Superintendent
/ State Health
aims to establish an effective mechanism to Department
address it.
4.18 An employee who has a grievances can take Medical

up the matter with his immediate superior who Superintendent/
State Health
shall after due consideration shall dispose of
Department
the same within reasonable time
4.19 If employee is not satisfied with disposal of the

grievance, he /she may take it up to higher
authority.
4.20 Every new selected candidateundergoes Medical Board/ Records of

mandatory pre-employment check. Only Medical Fitness
Superintendent
candidates found medically fit are given the
appointment.
4.21 Selected employee undergoes fire

safety Fire Safety Training Record
training and thereafter attends fire drills Department/
Medical
periodically. Similarly employees who are
Superintendent/
exposed to patients and those required to Training In
handle waste are given proper training in charge
handling the waste as well as standard
precautions.
4.22 Annual Medical Checkup and Vaccination: Medical Vaccination/

superintendent Medical Checkup
Hospital Undertakes an annual health check up Records
of all its employees so as to assess their level
of fitness and a record of the same is
maintained. The hospital also conducts periodic
vaccination programs for its employees such as
vaccination against Hepatitis B, Tetanus etc
and a record of the same is maintained.
4.23 Personal records
The personal file of each employees containing Medical Personal

records relating to his employment , Superintendent Records
educational qualification, health status,

registration with professional bodies, training
record , warning or disciplinary actions taken if
any , appointment letter etc are maintained as
per the policy of State Health Department.
However it is the policy of the Health and
Family Welfare Department to preserve the
confidential reports (CR) separately as it is very
confidential in nature and has very limited
access.
4.24 Training need assessment
The training need of the employee is identified Training In Competence

based on the qualification / skill / experience etc Charge Matrix
and also based on any of the following:
 New employee on fresh appointment.

 Horizontal or vertical movement in job.
 Change of technology.
 Competence Assessment by the
hospital.
 Self perceived need of the employee.
4.25 Training Mode:
Training Vehicles/mode (or action plan) Training in Training plan

includes any one of the following: charge
 Class room training

 Formal apprenticeship & mentoring
programs
 Guided self study.
 External training courses ( government
sponsored)
 Professional conferences / seminars ,

etc
4.26 Training calendar:
The training calendar indicates the different Training In Training Plan/

training programme planned by the charge Schedule
administrative department of the hospital for the
various class of employee working under its
purview.
4.27 Training Record:
A training register (for internal training as well Training In Training Record

as training imparted by external trainers in the charge
hospital ) for each individual class of employee
is mentioned where each and every kind of
training attended by the employee is recorded
along with the signature of each individual
employee and the trainer .
External training i.e. training attended by the Training In Training
employee outside the hospital environments charge Certificate
recorded in separate external training record

register. Employees are required to submit a
copy of the certificate awarded by the external
agency for the purpose of record keeping in the
personal file of the employee.
All personal file contains a summarized form of

the training undertaken by the staff member.
4.27 Training Effectiveness Evaluation:
Measuring the effectiveness of the training Training In Training

attended by the employee is a very important charge/ Effectiveness
Departmental Records
task for ensuring the usefulness of the training
In charge
and the degree of knowledge it provided to the
trainees. Trainee‟s evaluation is done by taking
pre test and post test to measure the
effectiveness of the training imparted and the
resultant improvement in the level of knowledge
4.28 Records Generated:
1. Training Calendar Training In Training Records

charge
2. Training Record Register (internal and
external)
3. Training Evaluation Record
Training Record: The training record form is Training record
attached for each personal who have attended book
the training and records for same is maintained
by training I/C in training record book.
4.29 Employee Satisfaction
Employee satisfaction is done annually as per Medical Employee

prescribed format. superintendent/ satisfaction
Hospital survey form
Manager
Reports of survey are discussed in Medical Employee

Management review meeting and area of Superintendent Satisfaction
concern is taken care of. Survey Report
5. Records:

#
1. Training Attendance
2. Training Feed Back
6. Process Efficiency Criteria –
1 Training Training Feedback score in Likert

Scale
2 Training Targeted Training Effectiveness
Effectiveness Achieved
Evaluation
3 Employee Targeted Employee Satisfaction
Satisfaction Score in Likert Scale
Survey
7. Reference Documents-
 Service Rule Book of State Health Department.
SOP 22: Dietary Management
1. Purpose: To establish a system for providing dietary services meeting the diet
requirements of the patient.
2. Scope : It covers all the patients admitted in IPD or observational beds except
patients advised NBM.
3. Responsibility: a) Overall – Deputy Superintendant

b) Specific – Outsourced Agency/ Kitchen I/C
4. Procedure:

No. Documents /
Record
No. Documents /
Record
4.1 Dietary advice
The doctor/ dietician (where available) Doctor/Dietician Bed Head

advises diet as per the nutritional Ticket/ Diet
requirement of patient. Chart
4.2 Calculation of No. of Diet:
The concerned nurses at the IPD calculate Nursing In- Diet Register
the dietary requirement of the patient in the charge
diet register and sent it to the kitchen in-
charge.
4.3 Procurement of Raw Materials:
Approved Diet Menu is available in the Diet Menu

hospital and with the kitchen in-charge.
On the basis of Diet menu & no. of diet to

be prepared, the concerned person at the
kitchen purchases the raw material under Concerned Diet Register
the supervision of the nursing In-charge. Nurse
The inventory of perishable & non
perishable item in the kitchen is properly
maintained by the cook. Vegetables are
purchased on daily basis.
No. Documents /
Record
4.4 Preparation of Utensils, Stove

Utensils are kept ready neat, clean & dry.
Stove and gas cylinder are always kept in Kitchen In-
clean and working environment. charge / Cook
Stove in running condition is kept ready for

use.
4.5 Washing, Cleaning & Cutting
Vegetables are washed with clean water Cook

and cut on clean and hygienic surface.
4.6 Preparation of Food
The food is prepared by the cook in the

hospital kitchen three times a day in a
hygienic environment wearing gloves, caps Cook
No. Documents /
Record
and kitchen gown.
4.7 Quality Check of Cooked Food
The quality of the food is first checked by Cook

the cook itself.
The nursing In-charge herself checks the

quality of food, and after consulting the Monthly Report
patients, concerned duty doctors (during on Quality of
evening and night hours) and the nurses, food
prepares monthly quality report and
submits it to the Civil Surgeon.
4.8 Distribution of Cooked Food
The concerned person distributes the food Diet Register

to the admitted patients at the definite time
thrice a day with the intimation of Helper
concerned nurse.
4.9 Feedback on Cooked Food Diet register
Feedback is taken from the IPD patient Concerned

and reported to the nurses. Nurse
4.10 Cessation of Dietary Services to patient
No. Documents /
Record
When discharge or referral is advice to the Concerned Discharge Slip

patient the concerned nurse update the doctor
diet register and informs the concerned
person at the kitchen to stop the dietary
services of the patient.
5. Records

No. Period
01 Diet Register
02 Kitchen Report
1 Quality Check  Quality check is done

under supervision of the
Nursing In-charge at every
time the diet is supplied
 Weekly check of
housekeeping of Kitchen
with respect to hygienic by
deputed officer.
2 Kitchen/Diet  The diet report on monthly
Report basis shall be submitted to
MS/Health Manager office
up to 5th of every following
month.
7. Reference
 State guideline for Dietary services.
SOP 23: Laundry Management
1. Scope :
This applies to the management of hospital‟s linen ensuring adequate cleaning of the linen for
better hygienic hospital environment and infection control.
2. Purpose
To provide process, instructions and methodology for Management of Laundry process in the
hospital with the following aim
 Clean and timely supply of linen

 Minimization of inventory loss
 Clean linen to every patient admitted in the hospital.
3. Responsibility:
The smooth functioning of the laundry is the responsibility of the:
 Laundry Supervisor
 Hospital Manager
 Nursing Incharge
 Dhobi/Washer man
4. Type:
 In-house/Outsourced
 Mechanized / Hand wash
 Capacity:
 Linen: Bed, Body, OT, Staff
5. Procedure
Ref. Documents /
Sl. No. Activity/ Description Responsibility Record
5.1 Service Provision
5.1.1 Laundry activities are operated through Laundry Contract

contracted service provider, whose staffs Supervisor, Agreement with
clean the hospital linen. The service provider Matron Outsourced
serves as per the guidelines laid in the Agency
contract. Hospital Management is responsible
to handle & manage contractors and
maintains a copy of their contract for reference
& records.
5.2 Daily Activities
5.2.1 Change of Linen Staff Nurse/ Work Instructions

ANM/ for Bed Making
i) There is different color bed linen for each Trainee/Ward
day of the week. Patient bed linen is changed Attendant
once daily in morning 7-8 AM.
ii) Linen is also changed whenever it gets

soiled with vomiting, faeces, blood spills, urine
etc
iii) Linen is also changed whenever a new

patient comes on the bed.
5.2.2 Sorting and storing of used Linen Ward Attendant/ Work instructions
House Keeping for Sorting &
Soiled and Infected Linen is segregated from Staff Handling of
dirty Used linen and stored in a specified area Infected Linen
(dirty utility area) into different marked or
colour coded bags/bins.
Ref. Documents /
5.2.3 Disinfection of Soiled/ Infected Linen Ward Attendant/

Housekeeping
Soiled linen is disinfected by soaking it into Staff
1% Sodium Hypochlorite solution for one hour
before sending it to laundry.
5.2.4 Collection of Used/ Soiled Linen Outsourced

Laundry Staff
Dirty linen is collected between 8:30-9:30 am
daily from Wards, OPD, ICU, Labour room,
Emergency
OT Linen is collected daily between 8.00-8.30
5.2.5 Sorting of Linen in OT- OT Technician/ IMEP guideline

Attendant
All OT Linen (e.g. surgical drapes, gowns,
wrappers) used in a procedure are considered
infectious even if there is no visible stain is
there.
All used linen is collected in Disposal Zone of

OT.
5.2.5 Counting of Collected Linen- Laundry Staff/ Laundry Register

Nursing In
Counting of collected linen is done by laundry charge
staff in presence of nursing in charge.
Details of collected items are entered in
Ref. Documents /
Laundry register counter signed by nursing

Incharge.
5.2.6 Transporting Dirty Linen Laundry Staff/

Dhobi
All the linen is transported in closed leak proof
bags, containers with lids or covered carts to
washing area. Infectious and non infectious
linen is transported separately.
5.2.7 Washing and Drying of Linen Outsourced

Laundry Staff
Washing , drying, Mending and Ironing of
Linen done designated place as per work
instructions
5.2.8 Receipt of Washed Linen Nursing In- Laundry Register

charge /
After washing of linens, the packed linens are
delivered in the hospital at ------ in evening
The quality and quantity of the linens are Hospital

checked. The laundry register is signed by Manager
nursing in-charge and out sourced agency.
Storage and Issue of washed Linen : Laundry Register
The packed and washed linen is stored at Nursing In-

identified place charge
The linen is to the respective wards and

issued according to their requirement.
Ref. Documents /
5.3 Inventory Management
5.3.1 Sets of linen Hospital Manger/

Medical
Hospital has 5 sets of linen per bed Superintendent
1.One set which will be used
2. One set ready for use kept in the ward
3. One set being processed in the laundry
4. One set in transit to be delivered or to be

received in the ward
5. One set for holidays and weekends
5.3.2 List of Linen Hospital List of Linen

Manager
Hospital Manger maintains a list of Linen that
consist of broadly
a. Bed linen
b. Body linen
c. Operation theatre linen
d. Staff linen
E. Department/service linen.
5.3.3 Condemnation of Linen Hospital Manger/ Condemnation

Medical Policy of the
Condemnation committee meets in every
Ref. Documents /
three month to inspect items sorted for Superintendent Hospital

condemnation and recommend their
replacement.
Condemned bed sheets may be used as

dusters, Mops by housekeeping staff
5.3.4 Purchase of New Linen- Hospital Manger/ SOP for

Medical Procurement and
Purchase of new linen is done as procedures Superintendent Outsourcing
procurement and outsourcing management. Management
5.3.5 Pilferage of Linen- Security Guard/

Nursing Staff/
i. No patient is allowed to take linen with them Ward Attendant
at the time of discharge.
ii. Security Guard and ward attendant keep

vigil on vigil on movement of patient so
pilferage of Linen can be avoided
iii. Linens are stored in lock and key and

handover is given at change of shift.
5.4 Quality Control
5.4.1 Hospital manager check the quality of Hospital Weekly Report

laundered linen once in a week and report to Manager
Medical Superintendent accordingly
5.4.2 Nursing in charge report receipt of less linen, Nursing In

delay in delivery, dirty or torn linen on the charge
same day to hospital Manager
5.4.3 If any discrepancies found in the services of Medical Contract

outsourced agency amount is deducted as per Superintendent/
Ref. Documents /
TOR of Contract. Hospital; Document

Manager
5.4.4 Work instructions for Sorting, Sluicing and Hospital

Washing of Linen are displayed at point of Manager
use.
6. Reference Record
Sl. No. Name of Records Record No. Minimum Retention Period
01 Laundry Register
02 Linen Stock Register
Sr . No. Activity Process Efficiency Criteria Benchmark/Standard/Target
1 Availability Linen Index
 Contract Agreement with Outsourced Agency

 Procurement and Outsourcing Management (SOP 15)
 IMEP Guideline: Ministry of Health and family Welfare, Govt. Of India.
SOP 24: Hospital Waste Management
1.0 Scope: The scope of the procedure is applicable to all concerned staff involved in
the segregation, collection and storage of waste before it is collected by concerned agencies for
suitable disposal.
2.0 Purpose:
The purpose of this waste management policy is to outline safe and efficient practices
for the segregation, store, transport and disposal of biomedical and general waste
generated by the hospital and ensure the compliance to Statutory Requirements
3. Responsibility-
o Overall – Medical Superintendent

o Daily Monitoring – Hospital Manager
o Segregation- Process Owner (Doctors, Nurses, Paramedics.)
o Collection, Transportation & Storage- Housekeeping Staff
o Disposal – Outsourced Agency/ Housekeeping Staff.
Ref
S# Activity Responsibility
document/Document
5.1 Segregation of Hospital Waste
5.1.1 Segregation of Bio-Medical Waste is done Process Owner Work instruction for
at point of generation as per Biomedical segregation of
Waste (Management & Handling) rules biomedical waste.
1998 in different color coded bins with
liners.
While separating the waste it is specially Process Owner Work Instructions for
taken into consideration that infectious Segregation of
waste does not mix with non infectious Biomedical waste
5.1.2 waste.
5.1.3 Adequate number of bins and liners for Hospital Department wise list of
proper segregation and collection of Manager color coded bins
biomedical waste are provided at point of
use
5.1.4 All the departments adhere to their Departmental Work instructions for
respective guidelines for handling Heads/ Process handling biomedical
biomedical waste Owner waste
5.1.5 Needles and other sharps are handled and Nursing Staff/ Work instructions for
disposed as per standard protocols to avoid Housekeeping handling and disposing
accidental sharp injuries Staff sharps
5.1.6 Liquid Waste and blood spillage is handled Housekeeping Work instructions for
as per standard guidelines Staff handling liquid waste
5.1.7 Laboratory waste is handled as per Laboratory Work Instructions for

standards protocols Technician/ Handling Laboratory
Housekeeping Waste
Staff
5.1.8 Contaminated Plastic waste is handled as Process Owner Work Instructions for
per standard protocols Handling Plastic Waste
5.2 Collection of Waste:
5.2.1 Waste is collected by housekeeping at the Housekeeping Work instructions for

respective department in two shifts; morning staff collection of Biomedical
and evening (or as required) preferably waste
when there is minimum traffic, except in OT
where the waste is collected after every
operation.
5.2.2 Waste will be collected in two shifts or when Housekeeping Work instructions for
waste bin is ¾ full. staff collection of Biomedical
waste
Transportation of Waste
5.3
5.3.1 Waste is transported to disposal site in Housekeeping Work instruction for

closed container through a predefined Staff Transporting Waste
route avoiding crowded area
5.3.2 A large plastic bag is used to line the wheel- Housekeeping Work instruction for
able bin to prevent any liquid leaks from the Staff Transporting Waste
waste bags from soiling the bin.
5.3.3 This plastic bag is to be replaced in each Work instruction for

shift. Transporting Waste
5.4 Storage of Waste
5.4.1 Blue, Red Yellow and Black waste are held Housekeeping Work Instructions for
in the bins kept permanently in waste Staff Storing Bio Medical
holding room. Sufficient no. of bins is kept Waste
to store waste for a period of 48 hrs.
5.4.2 Kitchen waste will be placed in designated Housekeeping Work instructions for
bins and will be stored for a maximum of 48 Staff storage of General
hrs. Waste
5.5 Safe Disposal of BM Waste
5.5.1 Anatomical waste (yellow bag) disposed in Housekeeping Work instructions for
deep burial pit/Incineration. Staff disposal of Waste
5.5.2 Deep Burial Pit is constructed as per Hospital Work Instructions for
specifications of BMW (Management & Manager construction of deep
Handling Rules. burial pit
5.5.3 Sharps in puncture proof box disinfected Housekeeping Work instructions for
and disposed in sharp pit. Staff disposal of Waste
5.5.4 Contaminated solid waste (Red bag) Housekeeping Work instructions for
disinfected, mutilated and then disposed Staff disposal of waste
with general waste.
5.5.5 Waste is disposed usually disposed same Housekeeping Work instructions for
day. Maximum time limit is 48 hours Staff disposal of waste
5.5.6 General waste is collected from the facility Municipal Work instructions for
and disposed by Municipal corporation in Corporation disposal of waste
landfill. Staff
5.6 Re-usable waste
5.6.1 Fixer from the Radiology department is Housekeeping

removed once in 3 to 4 weeks. This fixer staff
liquid is transported in a closed container by
housekeeping staff to a designated area of
the hospital under the supervision and
guidance of Radiology Staff.
5.7 Statutory & Regulatory Compliance
5.7.1 Hospital abides to all the clauses of Civil Surgeon/ Bio- Medical Waste
Biomedical Waste (Management & Deputy (Management &
Handling Rules) 1998. Superintendent/ Handling) Rules 1998
Hospital
Manager
5.7.2 Hospital has a valid authorization for Civil Surgeon/ Bio- Medical Waste
Handling & Treating Bio-Medical Waste as Deputy (Management &
per BMW (Management & Handlin Rules Superintendent/ Handling) Rules 1998
1998. Hospital
Manager
Which is renewed at prescribed interval?
5.7.3 A annual report is submitted to Pollution Civil Surgeon/ Form II, Bio- Medical
Control Board, by 31st January of every year Deputy Waste (Management &
Superintendent/ Handling) Rules 1998
Hospital
Manager
5.7.4 Any major accident during handling & Deputy Form III, Bio- Medical
transportation is reported to prescribed Superintendent/ Waste (Management &
authority Hospital Handling) Rules 1998
Manager
5.7.5 All the containers are labeled with bio Hospital Schedule III Bio-
hazard sign as per schedule III of BMW Manager/ Medical Waste
(Management & Handlin Rules 1998. Housekeeping (Management &
Staff Handling) Rules 1998
5.8 Monitoring & Quality Control
5.8.1 Hospital manager takes round of entire Hospital Observation Report

hospital to assess the process flow and Manager
compliance of Bio medical Waste
regulations, once a week. Observations are
recorded and corrective and preventive
action is taken.
5.8.2 On the basis of observations Biomedical Hospital BMW Score Card

waste Score card is filled on monthly basis Manager
and reported in MIS.
6.0 Records –
S# Record Name Record No. Retention Period
1 BMW Waste Register
7.0 Process Efficiency Criteria -

No.
Renewal of The renewal of authorization shall be

authorization done with in specified time i.e.
before expiry of authorization.
Storage of BMW The BMW should not be stored for
more than 48 hrs.
Annual Report Annual report of BMW generated is
submitted to State Pollution Control
Board, Bihar on or before 31st March
every year.
BMW Score Score of 10
8.0 Reference Document-
1. Bio-Medical Waste (Handling & Management) Rules 1998

2. IMEP Guidelines, MoHFW, Government of India
9. *Work Instructions-
9.1 Segregation of Biomedical Waste Management
Colour Container Category
Blue Blue plastic bag in plastic bin Broken Glasses , Needles ,
Sharp Syringes etc
Red Red plastic bag in plastic bin Soiled Cotton , Gauzes ,

Catheters , IV tubing etc
Infectious Non sharp
Yellow Yellow plastic bag in plastic Human tissues, organs, body

bin parts, placenta, pathological
(Organ and tissue waste)
and surgical waste,
microbiology and
biotechnology waste
Black Black bag in plastic bin General paper waste; and

also kitchen waste, that is
(General Waste)
disposed separately.
9.2 Department wise Biomedical Waste Generated
9.3 Department wise list of colour coded Bins
 ER – Red, Blue, Yellow, Black, and sharps.
 Pharmacy – Black.
 Lab – Red, Blue, Yellow, Black and sharps.
 OT – Red, Blue, Yellow, Black and sharps.
 Radiology – Red, Blue, Black and sharps.
 OP waiting areas – Black.
 Labour room – Red, Blue, Yellow, Black, and sharps
 Dressing room – Red, Blue, Yellow, Black, and sharps
 Kitchen – High volume biodegradable wet garbage.
 Wards – Black (only black at bed side)
 Nursing Station – Red , Blue, Yellow and black
9.4 Procedure-Segregation in In-Patient Departments
 The in-patients departments generate all types of waste, which has to be segregated at
the point of generation itself for an effective waste management practice in the hospital.
Therefore bins for both infectious and non-infectious waste are placed in all the wards.
 The bedside of each patient shall have a bin meant for carrying only non-infectious
waste like fruit peels, papers etc., unless the patient is classified as infectious.
 Bins for the infectious wastes shall be kept in a specific location (for example the nursing
station) so that it is easy to carry them to the patient where the dressing is being done or
the soiled dressings generated from the patients be carried to the infectious waste bin in
a tray from the point of generation.
9.5 Procedure- Segregation in Operation Theatres
 The waste management strategy for the O.T. shall be designed in such a way so as not
to impede an operation but to ensure that the waste reaches the main bin after being
decontaminated and disposables properly disinfected and destroyed.
 As in all other areas waste disposal program shall be initiated after meetings with the
staff. Management strategies based on these meetings shall be formulated so that the
O. T staff can work smoothly without feeling any extra burden. Bins for infectious waste
shall be lined with yellow bags and these bins will contain contaminated swabs, soiled
bandages and amputated body parts.
 The bags with waste shall be sealed and stored outside the O.T to prevent liberation of
bacteria during handling.
 Used instruments and sharps shall be
- Counted after surgery
- Washed under running tap water
- Placed in a tray, sealed in bags and sent for autoclaving
 A separate container for IV sets, tubing's catheters gloves and syringes shall be
provided in the O.T. After shredding these disposables shall be treated with a chemical
disinfectant for at least an hour and then sent for their final disposal. As lots of medical
kits are opened prior to the operation there is a lot of general waste generated. Hence a
bin for general waste is kept in the O.T. in which all the packaging material shall be
collected. In the changing room contaminated laundry shall be placed in the laundry bag
which shall be sealed in waterproof bags and sent to the laundry for cleaning.
9.6 Procedure- Segregation in Out Patient Departments
 The OPD may also include a casualty/emergency ward. Each room in the OPD should
have three bins. The bins are for the infectious waste which includes soiled bandages.
The other bin is for general waste arid the third bin for the disposable items and used
gloves which can be mutilated and disinfected at regular intervals by a nursing-aid
attendant
 The used needles and syringes should be placed separately and destroyed by the
needle cutter/destroyer, which is to be provided in each ward and department.
 The casualty should have bins for infectious waste general waste and plastic waste the
number of bins for the infectious waste will depend on the number of beds in the room.
 Preferably each bed should have these bins. Bins for plastic waste and general waste
should also be installed in each emergency. The plastic waste should be mutilated and
chemically disinfected. There should be a tray for needles and other sharps. A needle
cutter should also be installed. While treating a patient in the emergency the hospital
staff should always wear protective clothing and gloves as the patient could be a carrier
of any infectious disease
 The waste disposal scheme in this area is as follows
 Segregation of the waste into different categories
 Provide specific collection and disinfection systems for each type of waste
generated.
 There should be distinct containers for different types of waste

 The design of containers should depend on the type of waste and disinfection
method
 The number of bins should be proportional to the waste generated in the casualty
9.7 Handling of sharps

a. Disposal of Needles and Syringes
 Preferably disposable needles and syringes should be used.
 These should be destroyed immediately after use, using a needle destroyer. If the
needle destroyer is not present, the following procedure is recommended for disinfection
of
o Do not detach the needles from the syringes after use.
o Aspirate disinfectant fluid into the syringe
o Immerse the syringe with attached needles in the disinfectant fluid, such as 1%
sodium hypochlorite solution, horizontally in flat metal/glass tray or puncture proof
plastic container
o Keep them immersed in disinfectant fluid for at least 30 minutes
o The needles and syringes can be removed from the disinfectant fluid and destroyed
mechanically before disposal
o Reusable needles and syringes must be cleaned and washed after taking out of
disinfectant fluid, and autoclaved before use.
b. Precautions While Handling Syringes and Needles
 To prevent needle stick injuries, needles should not be recapped with hand. This
prevents accidental needle stick in the hand holding the needle cap.
 Pass syringes & needles in a tray.
 Never pass syringe & needle on directly to next person.
 Also, needles should not be purposely bent or broken by hand, removed from disposable
syringes, or otherwise manipulated by hand.
 Remove the cap of the needle near the site of use. Never test the fineness of the
needle‟s tip before use with bare or gloved hand
 Pick up open needle from tray/drum with forceps. Never pick up an open needle by
hand.
 Never dispose them off by breaking it with hammer/stone.
c. Safe Use and Disposal of Sharps
Sharps must not be passed directly from hand to hand and handling should be kept to a
minimum. Used sharps must be discarded into a sharps container at the point of use. These
must not be filled above the mark indicating that they are full. Containers in public areas must
not be placed on the floor and should be located in a safe position.
9.8 Collection of waste-
 Waste will be collected by housekeeping at the respective department in two shifts;

morning and evening (or as required) using wheel-able garbage bins except in OT where
the waste would be collected after every operation.
 Wheel-able trolleys will be used for transportation of waste from various areas of the
hospital to the temporary waste storage area of the hospital.
 Housekeeping staff will: wear heavy duty gloves, wear a mask, while collecting waste.
 Waste will be collected in two shifts or when waste bin or sharps bin is ¾ full.
 Before plastic bags are collected, they must be properly tied in a manner that does not
allow for any leaks or spillage.
 Never overfill the bins
Work instructions for Transportation of waste
9.9 Transportation of waste
 When waste is collected, from a particular area, it will be wheeled to designated storage
area where it will be weighed and transferred to the appropriate colour bin in the waste
holding room. This will be done each shift.
 A large plastic bag will be used to line the wheel-able bin to prevent any liquid leaks from
the waste bags from soiling the bin.
 This plastic bag is to be replaced each shift.
 The wheel-able bin will be cleaned and disinfected with Sodium hypochlorite solution
once in 24 hrs. This will keep the bin sterile and odourless.
 While transferring waste to storage bins in the basement, housekeeping staff will wear a
protective mask, heavy duty gloves, and rubber boots.
 Always carry Bio Medical Waste in closed containers.
 Transport waste through predefined route within the facility
 Avoid crowded area and peak times.
9.10 Disposal of Waste
a. COLOUR CODING AND TYPE OF CONTAINER FOR DISPOSAL OF BIO-MEDICAL

WASTES
Colour Type of Container -I Waste Category Treatment options as

Coding per
Schedule I
Yellow Plastic bag Cat. 1, Cat. 2, and Cat. 3, Incineration/deep burial
Cat. 6.
Red Disinfected container/plastic bag Cat. 3, Cat. 6, Autoclaving/Microwaving/

Cat.7.
Chemical Treatment
Blue/White Plastic bag/puncture proof Cat. 4, Cat. 7. Autoclaving/Microwaving/
translucent Container Chemical Treatment and
destruction/shredding
Black Plastic bag Cat. 5 and Cat. 9 and Disposal in secured landfill
Cat. 10. (solid)
Option Waste Category Treatment &

Disposal
Human Anatomical Waste

Category No. I (human tissues, organs, body parts) Incineration @/deep
burial*
Animal Waste Incineration @ / deep
Category
(animal tissues, organs, body parts burial*
No. 2
carcasses, bleeding parts, fluid, blood and
experimental animals used in research,
waste generated
by veterinary hospitals colleges, discharge
from hospitals, animal) house
Microbiology & Biotechnology Waste local autoclaving /
Category
(wastes from laboratory cultures, stocks or micro-waving /
No 3
specimens of micro-organisms live or incineration@
attenuated vaccines, human and animal
cell culture used in research and infectious
agents from research and industrial
laboratories, wastes from production of
biological, toxins, dishes and devices used
for transfer of cultures)
Waste sharps disinfection (chemical
Category
(Needles, syringes, scalpels, blades, glass, treatment @ 01/auto
No 4
etc. that may cause puncture and cuts. claving / microwaving
This includes both used and unused and mutilation/
sharps) shredding"
Discarded Medicines and Cytotoxic Incineration
Category
drugs @/destruct ion and
No 5
(wastes comprising of outdated, drugs disposal in
contaminated and discarded medicines) secured landfills drugs
disposal in secured
Solid Waste Incineration @
Category
(Items contaminated with blood, and body autoclaving / micro-
No 6
fluids including cotton dressings, soiled waving
plaster casts, lines, beddings, other
material
contaminated with blood)
Solid Waste disinfection by
Category
(Wastes generated from disposable items chemical
No. 7
other than the waste sharps such as treatment @ @
tubing‟s, catheters, intravenous sets etc). autoclaving/micro-
waving and mutilation/ shredding#
Liquid Waste Disinfection by

Category
(waste generated from laboratory and chemical
No. 8
washing, cleaning, house- treatment@@ and
keeping and disinfecting activities) discharge into drains.
Incineration Ash disposal in municipal
Category
(ash from incineration of any bio-medical landfill
No. 9
waste)
Chemical Waste chemical treatment
Category
(Chemicals used in production of biological, @@ and discharge
No. 10
chemicals used in disinfection, as into drains for liquids
insecticides, etc.) and secured landfill for
solids
b. Disposal of different Type of Waste
c. Disposal of Anatomical Waste
d. Handling and Disposal of Laboratory Waste
e. Disposal of Discarded Blood Units
f. Disposal of Contaminated Plastics
g. Disposal of Liquid Waste
h. Disposal of Disinfectants
I Disposal of Merqury
j. Specifications for Deep Burial Pit
Conclusion
Standard Operating Procedures (SOPs) is the integral part of implementing quality management system.
Sops are the tools of process management. In heart of any QMS process there are four steps which are
directly linked with the evolution of SOPs.
1. Writing down the you plan to (Plan)
2. Doing what you wrote down (do)
3. Showing visible evidence that you are doing what you have wrote done through process pf periodic
assessment (check)
4. Take Corrective Actinon to rectify gaps and take preventive action to so it could not happen again.
(Act ).
Following illustration shows life cycle of evolution and implementation of SOPs.
Some tips for successful implementation of SOPs
Though SOPs are critical for success of quality intervention, care should be taken that its should be
means and not the ends of the implanting quality management system. Many times it has been seen
that documentation becomes the central activity of the quality improvement program leaving the
ground level quality improvement activities on backstage. SOPs are tools for quality management not
quality itself. Well written SOPs with poor acceptability amongst the process owner, are like idle high
end equipments which can not be use your facility if your staff do not know how to use it. So it is critical
that these SOPs are user friendly and supported by a robust and sustainable implementation plan. .
Following are some suggestion to enhance the
1. Evolve People – SOP is a operational tool. The process owner knows better what and how can be
implemented. So it is critical to involve the departmental in charges and process owners while writing
the SOPs . A base draft can be circulated to process owners so they can review it at point of use and give
their feed back on it. Single handily written sops with no inputs from the front line worker may lead to
poor implementation.
2. Ensure Availability – The basic principle is that each worker should know what he/ore she has to do.
So SOPs and work instruction should be available with them It is also necessary that give only the
relevant SOPs/Part of SOPs. A bully document with lot of irrelevant processes that worker do not deal
with, lead to poor acceptability of document If it is not possible to provide copy of SOPs to every staff
than it should be kept at place from it is easily accessible.
3. Keep it Simple - . Information overload is also bad. People should know precisely what they have to
do. Never club the processes, write one process in one column. Write process in present tense as in
there ‘are’ performed and not in future tense as they ‘will’ be preformed.
4. User Friendly - Wherever possible use illustrations & flow chart for illustrations. Some SOPs may be
used by the staff those are not knowing English, so after customization of these SOPs translate the
relevant SOPs into local language.
5. Visual Management – SOPs and work instructions lying cupboards are of no use. Display relevant
procedures and work instructions at point of use. Again caution, do not over do. Only the relevant one.
Work instructions should as possible pictorial.
6. Use SOPs enablers- Use SOPs as tool for training. Only class room training will not do. Provide hands
on training on SOPs reinforced by continuos monitoring.
7. Keep SOPs up to Date – SOPs are dynamic documents. If a new process is added at you facility, add it
to relevant SOP also. Accordingly their may be suggestions for improving a existing process , start it with
amending the process in your SOP. Similarly any new advancement or technical requirements should be
incorporated in the SOP.
8. Use SOPs as assessment tools- During the periodic assessment process use SOPs as criteria for
assessment. Try to see people are working according to the procedures in the SOPs or not.
9. Clear cut Responsibility – Responsibility for doing a particular job should be clearly written against
the process. For critical processes try to do define the alternate responsible person, if the appointed
person is not available, in case.
10. Create a buy in – Some time introducing SOPs create apprehension, that it will increase their work
and will lead to stricter monitoring. It is necessary that staff should know its importance and benefits
they will get by using the SOPs. So addressing ‘What’s in it for me’ is critical to success for
implementation of SOPs.
11. Recognize and Reward Champions – Creating an internal environment for quality is must for long
term sustenance. Recognize and rewards the departments and staff those are adhering to SOPs.
Motivate others to follow the champions.
Annexure
Abbreviations
AEFI Adverse Event following immunization
AERB Atomic Energy Regulation Board
AFP Acute flaccid Paralysis
AMC Annual Maintenance Contract
ANC Ante natal Checkup
ANM Auxiliary nurse Mid wife
ASHA Accredited Social Health Activist
BCG Bacillus Calmette Guerin
BHT Bed Head Ticket
BMW Bio medical waste
BP Blood Pressure
BPL Below Poverty Line
CAPA Corrective action and Preventive Action
CMC Continuous Maintenance Contract
CMSO Central Medical supply office
CQA Continuous Quality approval
CSSD Central Sterile Supply Department
CT Scan Computed Tomography Scan
DA Dearly Allowance
DAO District Account officer
DHS District health Society
DNO District Nodal officer
DOA Date of Admission
DPM District program Manager
ECG Electro cardio gram
ED Emergency Department
EDD Expected Date of delivery
EDL Essential Drug list
EMO Emergency Medical office
EmOC Emergency Obstetric Care
EOQ Economic order Quantity
ETAT Emergency triage assessment treatment
FHR Fetal Heart rate
FNO facility Nodal officer
HAI Hospital Acquired Infection
HB Hepatitis B
HBsAg Hepatitis B surface Antigen
HCW Healthcare worker
HIV Human Immune Deficiency Virus
HM Hospital Manager
HR Human Resource
I/C Incharge
ICC Infection control committee
ICN Infection control nurse
ICT Infection control team
ICU Intensive care unit
IMEP Infection management and Environment Plan
IMNCI Integrated Management of Neonatal and childhood illness

IMR Infant Mortality Rate
IPD Inpatient Department
IPHS Indian public health standards
IPPV Intermittent Positive pressure ventilation
IV Intravenous
JSY Janni Suraksha Yogna
LAMA Left against medical advice
LBW Low birth weight
LHV lady Health visitor
LMP Last Menstrual period
LR Labour room
LSAS Life Saving Anesthesia Skill
MDR Maternal Death review
MLC Medico Legal case
MLR Medico legal Register
MMR Maternal Mortality rate
MO Medical officer
MOHFW Ministry of Health and family Welfare
MS Medical Superintendent
MTP Medical termination of Pregnancy
NACO National AIDS Control Organization
NGO Non Government Organization
NOC No Objection Certification
NSV No scalpel Vasectomy
OPD Out patient Department
OPV Oral Polio Vaccine
OT Operation theater
PAC Pre Anesthesia Checkup
PC &PNDT Pre conception and pre natal Diagnostic test
PP Post partum Hemorrhage
PPE Personal Protective Equipment
PPH Post partum Hemorrhage
PPV Pulse Pressure variation
PRO Public Relations Officer
PWD Public Work Department
RKS Rogi Kalyan Samiti
RPR Rapid Plasma Reagsin
SN Staff nurse
SNCU Sick new care unit
SOP Standard operating Procedure
TDS Tax Deduction Source
TLD Thermo luminiscent Dosimeter
TOR Term of reference
TPR Temperature, pulse and respiration
TSS Toxic shock syndrome
TSSU Theater Sterile supply Unit
TT Tetanus Toxid
USG Ultra sonography
VDRL Venereal Disease research Laboratory
VL Vehicle Log
VLB Vehicle Log Book
WI Work Instructions

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Draft SOPs – under print: This publication may be reproduced in part or in whole with due

acknowledgement to QI Division, NHSRC

Ministry of Health & Family Welfare, Government of India

National Health system Resource centre,

Technical Support Institution with National Rural Health Mission

NIHFW Campus, Baba Ganganath Marg, Munirka, New Delhi-110067.

II Standard Operating procedures

(a) Clinical Procedures

SOP 1 Outdoor Patient (OPD) Management

SOP 2 In-Patient (IPD) Management

SOP 4 Maternal and Child Health Management

SOP 6 Blood Bank/Blood Storage Management

SOP 7 Hospital Diagnostics Management

SOP 8 Hospital Infection Control Management

SOP 9 Data, Information and Record Management

SOP 10 Hospital Referral Management

SOP 11 Pharmacy Management

SOP 12 Management of Death.

SOP 14 Hospital Stores & Inventory Management

SOP 15 Procurement & Outsourcing Management

SOP 16 Hospital Transport Management

SOP 17 Hospital Security and Safety Management

SOP 18 Hospital Finance and Accounting Management

SOP 19 Hospital Infrastructure and Equipment Maintenance

SOP 23 Laundry Management

SOP 24 Hospital Waste Management

Governments/ Administrators Definitions –Administrator defines in quality in terms of

Stakeholders Structure Process Outcome

Service Providers Adequate and Adherence to Clinical Mortality, Morbidity

Health Systems Allocation of Efficient logistics Optimal utilization of

Operational Facilities Monitoring and Coverage of

Society’s Equitable distribution Involvement in Social security in

So from above discussion it is clear that quality is all about-

1. Meeting patients requirements

1. Write down the processes as want do to achieve your organizational goals

Quality Management System

Commonest method of learning how to perform procedures in the workplace is by verbal

Sops In Healthcare is defined as a written set of instructions that a healthcare worker

WHY WRITE SOPS?

1. SOPs can be used as a set of ‘Performance standards’. They are important in

WRITING SOPS: GENERAL HINTS

3. Steps should be explained thoroughly, but concisely. Long sentences or paragraphs

4. Write steps in short, descriptive sentences. Do not use vague wording.

How much detail?

ARCHITECUTURE (BUILDING BLOCKS) OF SOPs USED IN THIS

CLINICAL PROCEDURES ADMINISTRATIVE PROCEDURES.

3 Hospital Emergency and Disaster 15 Procurement & Outsourcing Management

4 Maternal and Child Health 16 Hospital Transport Management

11 Pharmacy Management 23 Laundry Management

Each SOP has been documented with following headings:

Scope defines the area/s to which the SOP applies.

Purpose describes and explains what is to be accomplished

HOW TO USE THESE TEMPLATES:

Following steps are advised to make maximum use of these templates.

PROCESS MAPPING-A SIMPLE TOOL FOR IMPROVING PROCESS

What is a Process Map?

How to do Process mapping?

Step 1: Determine the Process to be mapped and its Boundaries

a. Where does a process begin?

Step 2: List the Steps

a. Use a verb to start the task description.

Step 3: Sequence the Steps

ii. Boxes or rectangles show task or activity performed in the process.