Access Assessment and Continuity of Care
Access Assessment and Continuity of Care
Access Assessment and Continuity of Care
No. of Pages : 35
Designation : Chairman
Approved By : Name : Dr.D.Suresh Kumar
Signature :
The holder of the copy of this manual is responsible for maintaining it in good and safe condition and in a
readily identifiable and retrievable.
The holder of the copy of this Manual shall maintain it in current status by inserting latest amendments as and
when the amended versions are received.
Management Representative is responsible for issuing the amended copies to the copyholders, the copyholder
should acknowledge the same and he /she should return the obsolete copies to the Management Representative.
The amendment sheet, to be updated (as and when amendments received) and referred for details of
amendments issued.
The manual is reviewed once a year and is updated as relevant to the hospital policies and procedures. Review
and amendment can happen also as corrective actions to the non-conformities raised during the self-assessment
or assessment audits by NABH.
The procedure manual with original signatures of the above on the title page is considered as ‘Master Copy’,
and the photocopies of the master copy for the distribution are considered as ‘Controlled Copy’.
S.No. Designation
1 Chairman
2 Management Representative
3 Accreditation Coordinator
CONTENTS
1.0 PURPOSE
To define the services provided by hospital and ensure that the staff are oriented to these.
2.0 SCOPE
To define the services provided by hospital and ensure that the staff are oriented to these.
3.0 RESPONSIBILITIES
4.0 POLICY
The following are the services provided at Sri Lakshmi Medical Centre & Hospital.
1. Front office Registration, Enquiry, Insurance, Billing and Accounts
3. Laboratory Department
4. Radiology
6. Outpatient
7. Human resource
8. Quality Department
9. Information Technology
10. Maintenance
14. Nursing
18. Surgery
22. Orthopaedics
23. Peadiatrics
24. Physiotherapy
26. Ward
5.1 The services provided by the hospital are displayed prominently in the language of English and
Tamil.
5.2 The details of services provided are displayed in an area visible to patients and family members
while entering respective facilities / areas.
5.3 Managing Representative is responsible to identify the requirement of signage boards, to provide
the same and rectify in case of any damage.
5.4 Tariff of room and other basic services of hospital are made available at front office.
program or by reading this document, as appropriate, the same to be recorded in training record
form.
REFERENCE
Pre Accreditation Entry Level standards for Hospitals-First Edition: April 2014
SRI LAKSHMI MEDICAL Doc. No. E / NABH / SMCH / AAC / 01 - 07
CENTRE & HOSPITAL Issue No. 01
Rev. No. 00
ACCESS ASSESSMENT AND
Date 01/11/2014
CONTINUITY OF CARE
Page Page 8 of 35
1.0 PURPOSE
To define Policy & Procedure for Registration, Admission and transfer of the patients at Sri
Lakshmi Medical Centre & Hospital.
2.0 SCOPE
This Policy & procedure is applicable to patient who undergoes Registration & Admission and transfer in
case of non-availability of beds / referral where the required services are not available in Sri Lakshmi
Medical Centre & Hospital.
3.0 DEFINITION
4.0 RESPONSIBLITIES
Front Office staff, Nursing Superintendent, OP staff are responsible to implement this Policy and
Procedure.
5.0 POLICY
5.1 Patients are admitted at Sri Lakshmi Medical Centre & Hospital only if the Hospital can provide the
required services to the patient.
5.2 All patients, out-patients, in-patients and emergency who are willing to avail services at Sri Lakshmi
Medical Centre & Hospital should undergo Registration / Admission process. In case of Emergency, the
same to be carried out in parallel to treatment.
5.3 Patient shall be registered only if they match the hospital services
5.4 When there is no provision to treat the patient in the hospital, assist to transfer the patient to other
hospitals where provision exists. For this a list of nearby Hospitals shall be maintained at the Front
Office.
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6.0 PROCEDURE
6.2 ADMISSION
6.2.1.1 All patients who are to be admitted should complete registration process.
6.2.1.2 Admissions are referred from OP department, Referrals and Causality.
6.2.1.3 The doctor advices for the admission in the Admission note form for OP patients.
6.2.1.4 Billing staff explain the tariff details and availability of type of bed.
6.2.1.5 Patient is admitted based on their choice and availability of type of beds.
6.2.1.6 Every patient is provided unique Inpatient Number at the time of admission.
6.2.1.7 All possible efforts to be taken by the hospital staff to find the identification of patient; if
patient is unidentified then the patient is to be shifted to Government Hospital through
security department (also Police to be intimated) or if admitted, the patient is to be
identified by the Inpatient number till patient name is identified as appropriate.
6.2.1.8 If the staff handling registration and admission needs any clarification on the services
provided by hospital, they should contact Chairman / Administrative Manager for
necessary information.
1.0 PURPOSE
To guide the staff when beds are not available for patients needing admission.
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2.0 PROCEDURE
6.4.1 In case of patients involved in medico legal cases the procedure enumerated below shall be
followed.
6.4.2 All accidents / assaults / suspicious cases / poisoning and RTA related brought dead cases
shall be enlisted as MLC and recorded in the case sheets and maintained separately.
6.4.3 The recording shall be done in Accident Register.
6.4.4 All such Cases are to be informed to the police in writing by the Residential Medical Officer.
6.4.5 A list of MLC cases are shown below:
1. Poisoning.
2. Injury with sharp object / fire arms.
3. Burns especially in women.
4. Drowning.
5. Death / Injury in a woman.
6. Road accidents / Industrial accidents.
7. Conditions which require notification as per the laws for time being in force.
8. Any other conditions where there is a suspicion of some foul play.
9. Where the cause of death is not certain.
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6.5.1 If there is no possibility of bed availability or if the patient is not agreeable to be admitted in
another class, then the treating doctor is asked to possibly defer the admission of the patient
or refer the patient to another centre.
6.5.2 In case of transfer of patients in a life threatening situation (like those who are on ventilator)
to another organization, a doctor / ACLS Trained Staffs accompanies the patient. The
ambulance driver helper, male nurse (Trained in BCLS and / or ACLS), or doctor
accompany during transfer for unstable Patients to other organizations.
2.0 DEFINITIONS
Stabilized - The term “stabilized” means with respect to a medically unstable condition, which
no material deterioration of the condition is likely, within reasonable medical probability, to
result from or occur during the transfer of the individual from a facility.
3.0 PROCEDURE
3.1 Requests from other health care providers to transfer patients who have an emergency
medical condition and require emergency and tertiary level medical care not available at that
facility should be immediately approved when services, space, facilities, and personnel are
available to provide appropriate care.
3.1.1 When the facility making the transfer request is capable of providing the
necessary care, that facility must stabilize the emergency medical condition
prior to transfer.
3.1.2 When the transferring facility is requesting the transfer of an unstable patient,
the following conditions must be met:
3.1.2.1 Physician certification that the expected benefits of transfer outweigh
the risks of transfer
3.1.2.2 Patient or family consent when possible
3.1.2.3 Attempts made by the transferring hospital, within its capability, to
stabilize the patient in order to minimize any risks of the individual
during transfer
3.1.2.4 Our capacity and capability to treat the transferred patient
3.1.2.5 Delivery of all appropriate medical records
3.1.2.6 Transfer shall be made with qualified personnel and transportation
equipment.
3.2 If an emergency patient requires services not available at Sri Lakshmi Medical Centre &
Hospital, the transfer shall be refused with a recommendation to contact another facility
with the necessary capability.
3.3 Transfer of patients shall be made by the referring physician contacting Senior Consultant /
Consultant / Residential Medical Officer of Sri Lakshmi Medical Centre & Hospital.
3.4 The Sri Lakshmi Medical Centre & Hospital staff member shall obtain the details of the
patients’ emergent medical condition and contact Admitting Desk. Admitting Desk shall
verify that beds are available.
3.5 All departments who receive requests for transfer of patients shall maintain this policy and
procedure statement in a place accessible to medical staff, and other personnel to ensure that
physicians who are involved in transfers adhere to its content. Questions shall be referred to
Director Medical Services.
3.6 Similarly, when resources matching the patient needs are not available at Sri Lakshmi
Medical Centre & Hospital patients shall be transferred KG Hospital that can meet the
patient’s needs. The Consultant / Residential Medical Officer shall contact the faculty of the
receiving hospital to ensure that eligibility guidelines are met. Transportation arrangements
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and a medical escort (if needed) shall be made through the Residential Medical Officer.
3.7 Indications for transfer to another facility:
3.7.1 Psychiatric condition
3.7.2 No beds are available at all
3.7.3 Patient desires to be transferred to another facility
3.7.4 Services are not available at the hospital
3.8 Patients being transferred from Sri Lakshmi Medical Centre & Hospital shall be
accompanied by a transfer summary that shall include details of the patient medical
condition, interventions done and the ongoing needs of the patient.
3.9 Such transfers shall be accompanied by the residential medical officer.
3.10 Stabilization prior to transfer shall include securing the airway (if needed), intravenous
access, appropriate fluid replacement and pain control.
2.0 DEFINITIONS
3.0 PROCEDURE
3.1 It is the policy of Sri Lakshmi Medical Centre & Hospital to accept the transfer of stable,
non-emergent patients when space, facilities, and personnel are available. Every effort
shall be made to accept patients when the sending facility does not have the space,
facilities or personnel to provide safe and appropriate care.
3.2 Transfers of stable, non-emergent patients to higher referral centre may be made by
contacting a Consultant physician of the Hospital.
3.3 Stable, non-emergent transfers shall be directly admitted to hospital units.
3.4 Acceptance of stable, non-emergent patients for transfer to Sri Lakshmi Medical Centre
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7.0 RECORDS
8.0 REFERENCE
Pre Accreditation Entry Level standards for Hospitals-First Edition: April 2014
SRI LAKSHMI MEDICAL Doc. No. E / NABH / SMCH / AAC / 01 - 07
CENTRE & HOSPITAL Issue No. 01
Rev. No. 00
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Date 01/11/2014
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Page Page 15 of 35
AAC 03 & 04 - POLICY AND PROCEDURE ON PATIENT INITIAL ASSESSMENT & REGULAR
RE-ASSESSMENT
1.0 PURPOSE
1.1 To outline a systematic process for gathering pertinent clinical data about a patient.
1.2 To establish a comprehensive information base for decision making about patient
care.
1.3 To provide patient with the right care at the time, it is needed.
1.4 To assure care provided to patient is based on an assessment of Patient’s relevant physical,
psychological and social needs.
2.0 SCOPE
This procedure applies to all Patients treated at Sri Lakshmi Medical Centre & Hospital.
3.0 DEFINITION
ASSESSMENT
All activities including history taking, physical examination, laboratory investigations that contribute
towards determining the prevailing clinical status of the patient.
4.0 RESPONSIBILITY
4.1 Treating Doctor, Casualty Medical Officer, Duty Medical Officer and Nurses are responsible to
implement this Policy and Procedure.
4.2 Patient assessment at Sri Lakshmi Medical Centre & Hospital is an ongoing process that begins
before the Patient is admitted and continues throughout treatment.
5.0 POLICY
5.1 INITIAL ASSESSMENT– Residential Medical Officer/ Treating Doctor, DMO are
responsible to carryout initial assessment within One hour or Admission and to document the
same within the 24 hours of Admission.
5.2 Every Inpatient should be reassessed at least once in a day (Non – Critical Care areas) or, as
and when necessary.
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5.3 Critical care patient should be reassessed minimum of every 6 hours or, as and when necessary
(depending on condition of the patient).
6.0 PROCEDURES
6.2 REASSESSMENT
6.2.1 Patient acuity and needs determine the frequency of reassessment i.e. a
patient at high risk to be assessed continually while a stable patient to be
assessed at least once in a day in non-critical care units & every 2 hours or
as and when necessary in critical care units
6.2.2 Reassessment is to be performed by medical and nursing staff. Ancillary
Services involved in the patients care also perform reassessment as required
by patient’s needs.
6.2.3 Reassessment is to be performed to identify and determine / monitor
patient’s response to care / treatment.
6.2.4 Reassessment of Patient care needs including treatment plan / plan of care
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6.3.2 OUTPATIENT
a) Patient name
b) Personal data (like Sex, Age, Height, Weight),
c) Clinical history,
d) Quick examination (as appropriate)
e) Present illness
f) Investigation (if any) and
g) Medications.
6.4 DOCUMENTATION
7.0 RECORDS
8.0 REFERENCE
Pre Accreditation Entry Level standards for Hospitals-First Edition: April 2014
SRI LAKSHMI MEDICAL Doc. No. E / NABH / SMCH / AAC / 01 - 07
CENTRE & HOSPITAL Issue No. 01
Rev. No. 00
ACCESS ASSESSMENT AND
Date 01/11/2014
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Page Page 20 of 35
1.0 PURPOSE
To provide guidelines for laboratory services as per the requirements of the patients.
2.0 SCOPE
All the patients those who avail laboratory services, the hospital ensures availability of laboratory services
commensurate with the health care service offered
3.0 RESPONSIBILITY
4.0 ABBREVIATION
4.1 NABH : National Accreditation Board For Hospitals And Healthcare Providers
4.2 AAC : Access, Assessment and Continuity of Care
5.0 DEFINITION
6.0 REFERENCE
Pre Accreditation Entry Level standards for Hospitals-First Edition: April 2014
7.0 POLICY
7.1 24 hours laboratory services are provided at Sri Lakshmi Medical Centre & Hospital.
7.2 Laboratory services are in consonance with the hospital scope of the services:
7.2.1 Clinical Biochemistry
7.2.2 Hematology
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7.2.3 Serology
7.3 Sri Lakshmi Medical Centre & Hospital clinical laboratory will engage competent personnel for
technical work which includes technologist and Professionals. SMCH ensures that all staff of
Laboratory Services is appropriately trained.
7.4 The clinical laboratory services sets out the acceptance criteria for samples received to ensure
quality and safe service.
7.5 Without written request from the treating doctor, sample shall not be drawn from the patient and
Criteria for written request are as follows: Name of the patient; Age/Sex; MR. no (IP No.); Test
examinations clearly indicated; Doctor’s Name, Signature, date and time.
7.6 Criteria for labeling the samples.
7.7 All samples must be labeled with Name of the patient, sex, age, IP.No, date and time of sample
taken.
7.8 All samples are discarded as per Biomedical Waste Management Handling Rules, 1998 (2000).
7.9 Turnaround time for each tests are defined. Laboratory results are issued within the defined time
frame- Critical results are defined and displayed. Critical results if any are reported to the concerned
doctor through intercom these are recorded. It is the responsibility of the laboratory staff to
communicate any critical test results to the concerned doctor.
7.10 Laboratory personnel are trained in safe practices and are provided with appropriate safety
equipment / devices.
7.11 Tests not done in the hospital are outsourced to an approved outside lab. A “Outsourced Test
Register” is maintained with the following details:
7.11.1 Lab. No.,
7.11.2 Age & Sex,
7.11.3 MR No. / IP No.,
7.11.4 Name of the patient & Consultant,
7.11.5 Signature of the person sending the sample and receiving the test report.
7.11.6 ID. No. & Name of the external Lab,
7.11.7 Test results.
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2.0 SCOPE
All patients who receive services from imaging department.
3.0 RESPONSIBILITY
3.1 Radiologist,
3.2 Radiation Safety Officer,
3.3 Radiography Technicians
4.0 ABBREVIATIONS
4.1 NABH : National Accreditation Board For Hospitals And Healthcare Providers
4.2 AAC : Access, Assessment and Continuity of Care
5.0 DEFINITION
6.0 REFERENCE
Pre Accreditation Entry Level standards for Hospitals-First Edition: April 2014
7.0 POLICY
7.1 Compliance with legal requirement:
7.1.1 AERB / BARC approval for imaging unit has been obtained after inspection and the licenses
are displayed in their respective areas to prove compliance on these issues
7.1.2 All the workers of the imaging services have been provided with TLD badges for monitoring
of their individual exposures to radiation as part of radiation safety program. Regular
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monitoring of these badges has been out sourced and a record for the same is maintained in
the radiology department, of SMCH.
7.1.3 Proper sign posting has been done in the radiology department.
7.1.4 Training of department staff.
7.2 Diagnostic Imaging includes the following:
7.2.1 Computerized Radiography
7.2.2 Mobile Radiography.
7.2.3 Ultrasound and Colour Doppler.
7.2.4 CT scan.
7.3 Identification of patient:
7.3.1 Sri Lakshmi Medical Centre & Hospital shall ensure that all the patients are identified prior
to carrying out their investigations.
7.3.2 All those patients who require assistance will be transported safely without causing any
injury to them in the process.
7.3.3 Where applicable patient shall be advised for pre-test preparation and appointment shall be
scheduled for the test when pre-test preparation deserves time more than a day.
7.3.4 The cases shall be taken up on first come first serve basis, unless otherwise there is
requirement to give priority for specific patients for clinical or other valuable reasons.
7.3.5 Technician shall orient the patient for taking shots based on to film/equipment
positions/process norms and diagnostic requirements on request of medical practitioner.
7.4 Safe transportation of patients: The hospital shall ensure the safe transportation of patients to the
imaging services. For patient’s transportation the Inter – Hospital transfer procedure shall be
followed. The medical staffs arranging transportation is responsible for this task.
7.5 Time frame for all results: Imaging results shall be available within the defined time frame.
Imaging results shall be made available on a prefixed schedule of timing. In case of critical patients
the results shall be intimated as immediate as possible.
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7.6 Critical result intimation: Critical results shall be intimated immediately to the concerned
personnel. Imaging test not available in the organization shall be outsourced to the organization
based on their quality assurance programme.
7.7 Results reporting: The report shall also include the results of any calculations and analysis of
radioactive material deposited in the body of the employee. The report shall be in writing and shall
contain the statement: "You should preserve this report for future reference."
7.8 Outsourced tests: Imaging test not available in the organization shall be outsourced to the
organization based on their quality assurance programme
7.9 Qualified staff for department:
7.9.1 Adequately qualified and trained person shall only be deployed for imaging services.
7.9.2 Only qualified, credentialed and authorized clinician shall be responsible for conducting or
supervising all radiology procedures and reporting.
8.0 PROCEDURE
8.1 Radiology equipment:
8.1.1 The X-ray units in use in the hospital are fixed X-ray unit, portable X-ray units placed in the
high dependency areas, C-arm X-ray unit used in the OT. They are used for diagnostic
purposes only.
8.1.2 Radiation protective jackets and gloves should be worn by the staff in the department during
procedures. The imaging staff should at all times wear the radiation protection badges issued
to them while inside the department and whenever radiation equipment are operated. These
badges are to be stored safely away from the radiation areas while not in use. Radiation
protection badges are to be sent to the radiation monitoring office periodically, results
analyzed and remedial action, if any, required to be taken to ensure the safety of the staff and
patients.
8.1.3 Protection of bystanders while using X-rays, C-arm, etc., shall be ensured.
8.1.4 Protection of abdomen & vital structures of children / patients and staff shall be ensured.
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ANNEXURE A
02 OBSTETRICS 15 – 20 MINS.
05 SCROTUM 10 – 15 MINS.
06 THYROID 10 – 15 MINS.
07 BREAST 10 – 15 MINS.
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X-RAYS:
All types of plain X-ray, special investigation X-rays like IVP, Barium meal, Enema, Swallow
NO. OF
SL. NO. PROCEDURE TAT
VIEWS
15 MIN
01 SKULL AP/ LATERAL 02
02 MANDIBILE AP 01 10 MIN
04 ORBIT PA 01 10 MIN
10 CLAVICAL AP 01 10MIN
12 RIBS AP 01 10 MIN
26 AUG 04 35 MIN
27 IVP 06 2 HRS
28 BARIUM SOLLOW 06 1 HR
29 BARIUM MEAL 06 1 HR
30 HSG 03 1 HR
31 KUB 01 10 MIN
CT: Plain and contrast CT of Brain, Orbit, PNS, CT of spine [Cervical, Thoracic & Lumbo Sacral] CT of
Abdomen, Thorax (Chest), Pelvis. CT of Extremities.
1 HR 15 MIN
PLAIN
01 BRAIN
CONTRAST STUDY 1 HR 30 MIN
PLAIN 1 HR 15 MIN
04 NECK
CONTRAST STUDY 1 HR 30 MIN
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05
PARANASAL SINUSES 1 HR 15 MIN
PLAIN 1 HR 15 MIN
07 CHEST
CONTRAST STUDY 1 HR 15 MIN
09 SHOULDER 1 HR 15 MIN
PLAIN 1 HR 15 MIN
PLAIN 1 HR 15 MIN
11 UPPER ABDOMEN
CONTRAST STUDY 1 HR 30 MIN
PLAIN 1 HR 15 MIS
12 PELVIS
CONTRAST STUDY 1 HR 30 MIN
14 ELBOW 1 HR 15 MIN
15 KNEE 1 HR 30 MIN
16 ANKLE 1 HR 30 MIN
17 OTHERS 1 HR 30 MIN
18 CT KUB 1 HR 30 MIN
19 C S SPINE 2 HRS
FACE
PELVIS
21 3D 3 HRS
SKULL
OTHERS
22 CT BIOPSY 2 HRS
9.0 REFERENCE
Pre Accreditation Entry Level standards for Hospitals-First Edition: April 2014
SRI LAKSHMI MEDICAL Doc. No. E / NABH / SMCH / AAC / 01 - 07
CENTRE & HOSPITAL Issue No. 01
Rev. No. 00
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2.0 POLICY
2.1 Discharge procedures shall be followed to ensure patients are discharged effectively and efficiently,
allowing for optimal utilization of available resources.
2.2 An authorized hospital discharge shall only be made by an order from the primary consultant.
However, a patient may discharge himself/herself against medical advice.
2.3 The Consultant or his designee shall document discharge instructions in the patient’s medical record
at the time of anticipated discharge.
2.4 A Discharge Summary shall be prepared.
2.5 The Ward Sister shall be the responsible person to ensure compliance with this policy.
2.6 The discharge summary shall contain:
The reason for admission
Significant findings
Any diagnosis
Procedures performed
Significant medications administered
Condition at discharge
Discharge medications and follow-up instructions
2.7 In case of death, the discharge summary includes the cause of death
2.8 The nurse shall be responsible for completing the discharge checklist and explaining the discharge
summary to the patient. Patient/family understanding shall be documented on the discharge
checklist by obtaining the patient/family signature.
2.9 All the patients are provided with a discharge summary at the time of discharge.
2.10 Patients requesting discharge against medical advice shall be explained the risks and
consequences. The consent will be obtained from the patient/ family as per the informed consent
policy.
advice are to be explained on the consequences of LAMA and signature to be obtained in LAMA form in
Inpatient Record. Patient who comes to casualty, take treatment and leave hospital with CMO consent as
OP consultation basis are given prescription. All these contain patient condition and treatment given.
4.0 RECORDS
Inpatient Record
5.0 REFRENCE
Pre Accreditation Entry Level standards for Hospitals-First Edition: April 2014