NABH Policy: Hospital Apex Manual
NABH Standard Reference: CQI Procedure / Issue No / Revision No . Date: Hospital Apex Manual / 01 / 05 / 10– 01 – 2022 Page No. 2 of 84
Sl. No TITLE Page no 1 Amendment sheet 03 2 Control of Manual 04 3 Manual Preparation 04 4 Manual Revision 05 5 Introduction 06 6 Mission vision Statement & Koshys Values & Relationship Values of Koshys 06 7 Koshys Hospital -- Strategic Plan 07 8 Staff Retention Tools And Strategy 08 9 Scope Of Services 09 10 List of Non Available Services 10 11 Quality Management Program 12 12 Committees functioning at Koshys Hospital Committees formed at various levels to look after the quality and safety: 13 13 Organogram 30 14 List Of Statutory Requirements 31 15 Introduction To NABH 32 16 List of Policies 33 17 Quality Indicators 39 18 Code Committees 49 18 Annexure 1 – List of abbreviations be used 52 19 Annexure 2 – List of abbreviations do not be used 65 20 Annexure 3 – Asset Coding Format 67 21 Annexure 3 – Covid Protocol 81
Approved by Issue NABH coordinator, Koshys Hospital Medical Director, Koshys Hospital NABH coordinator, Koshys Hospital
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Sl.No Sec., Page No and Date of Revision
1 Page 25 10.01.2019 Rev.01
2 Page 31 10.01.2019 Rev.01
3 Page 51 10.01.2019 Rev.01
4 Page 68 10.01.2019 Rev.01
5 Page 25 10.01.2019 Rev.01
NABH Policy:
Hospital Apex Manual
NABH Standard Reference: CQI Procedure / Issue No / Revision No . Date: Hospital Apex Manual / 01 / 05 / 10– 01 – 2022 Page No. 3 of 84
Nature of Amendement
QA defined for ER, Surgical Services, OT
Restructuring of Organogram
List of abbreviations be used
List of abbreviations not be used
Reason for Amendment
Point raised during pre assessment
MD has taken over the role of CEO
Point raised during final assessment
Point raised during final assessment
Signature of the MD
Signature of the Accreditation coordinator
6 Page 25 05.01.2020 Rev.02
7 Page 14, 16 05.01.2020 Rev.02
Ethics Committee removed
Strengthening of Document control
Points raised during final assessment
Point raised during final assessment Page 69 10.01.2019 Rev.01
Addition Code White
Addition Minimum Quarom for Committee Meetings
8 Page No.81, Addition of Covid Protocol
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NABH coordinator, Koshys Hospital Medical Director, Koshys Hospital NABH coordinator, Koshys Hospital
NABH Standard Reference: CQI
Procedure / Issue No / Revision No .
Date: Hospital Apex Manual / 01 / 05 / 10– 01 – 2022 Page No. 4 of 84
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 form.
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.
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 authority over control of this manual is as follows:
The Hospital Apex Manual defines the established policies of Koshys Hospital and is prepared in accordance with the requirements of NABH standards 5th edition. The NABH co-ordinator is responsible for preparation, correct interpretation of the policies contained in this Manual and their compliance to the requirement of NABH.
The Medical Director of the hospital is the approval authority for the Hospital apex Manual. NABH coordinator is the issuing authority for this Manual.
The present issue of this Hospital apex Manual is issue ‘05’ and Revision ‘01’, with all subsequent revisions to the sections incremented consequently.
The NABH co-ordinator shall maintain the latest version of this Manual as “MASTER COPY” (The original print with signature used for photocopying). It shall bear the stamp “MASTER COPY” on the back side of all pages.
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Hospital Apex Manual
NABH Standard Reference: CQI
Procedure / Issue No / Revision No .
Date: Hospital Apex Manual / 01 / 05 / 10– 01 – 2022 Page No. 5 of 84
The NABH coordinator is the issuing authority; He / She shall arrange to get requisite number of copies for distribution (as per manual distribution list). Each page of such copy shall bear the stamp. “CONTROLLED COPY” on the front side.
Copies which are not required any control shall bear the stamp “UNCONTROLLED COPY” on the front side of each page.
On revising any document, the NABH co-ordinator shall retain the master copy of the same as historical documentation after stamping “OBSOLETE COPY” on the front side.
The controlled copy of the Hospital apex Manual shall have the following distributions.
SI. No MANUAL HOLDER COPY No. 1. Medical Director 01
2. Accreditation Coordinator 02
Whenever an amendment is requested by any Functional Head, the NABH co-ordinator shall ensure that the relevant Functional Heads are consulted; the amendment is reviewed and approved by the Medical Director before releasing the amendment. Revisions to this manual are identified by a revision number and the effective date. They are included in the header.
The present issue of the Hospital Apex Manual is issue ‘01’ and Revision ‘02’
On revision, the document shall be given the subsequent revision number (Revision No. 02, 03, 04, 05 etc.); but the issue status will remain as ‘01’ up to nine revisions.
When the number of revisions exceeds “Revisions No. 09”, the entire document shall re-issued with the subsequent number “Issue No. 02, 03, 04, etc.” respectively for every 9 revisions.
When the issue number exceeds “Issue No. 9” in any of the included portions or when the situation so warrants, the whole document shall be re-issued as a fresh document.
Koshys Hospital was established in 2002 as a tertiary centre of excellence. The basis of the centre service was based on the healthcare needs of the region.
Koshys Hospital provides high end tertiary care in Orthopedics, Pediatrics, Obstetrics and Gynecology
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NABH Policy: Hospital Apex Manual
NABH Standard Reference: CQI
Procedure / Issue No / Revision No .
Date: Hospital Apex Manual / 01 / 05 / 10– 01 – 2022 Page No. 6 of 84
and Nephrology. Also covered under the scope are the departments of Gastroenterology and Pulmonology. The Institute provides complete services for treatment of emergency, acute and follow up care for patients of all age groups.
The services have state of the art technology and equipment, highest level of environmental controls and fully trained and experienced staff who are dedicated to the care of patients.
Koshys Hospital strives to provide an unparalleled blend of affordable and quality health care through: Nurturing reliable, highly trained and compassionate professionals. Creating a warm environment of trust and integrity. Building strong and healthy communities.
To provide each patient access to world class health care services and exemplify the highest ethical practices.
Quality: - We put quality at the heart of everything that we do. a. We take responsibility for the standard and the outcome of our work. b. We endeavor to provide services which are safe, effective and can deliver a good experience. c. We will use best practice and feedback to innovate and constantly improve our service quality.
a. Work collaboratively in partnership (Network) with all our stakeholders. b. To be known as caring, compassionate and kind team of professionals.
c. To support development of skills, talents and abilities.
OUR SERVICE:
To improve year on year, the confidence, trust and safety in our hospital for all our patients, their relatives, visitors and staff To provide cost effective and affordable services to patients who choose our services.
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OUR PATIENT:
Hospital Apex Manual
NABH Standard Reference: CQI
Procedure / Issue No / Revision No .
Date: Hospital Apex Manual / 01 / 05 / 10– 01 – 2022 Page No. 7 of 84
To improve year on year the good experience of patients and their outcomes. HOPE FOR ALL” We will treat every, patient with this positive spirit.
OUR STAFF:
To develop further a highly dedicated, skilled and motivated workforce, that strives to improve patientcare and service performance
OUR BUSINESS:
To ensure Koshys hospital is financially stable by providing value to our stake holders and thus, make our vision a reality.
Koshys Hospital management believes in nurturing cultures that ensure focus on providing high quality, compassionate care. Hence, the leadership is committed in developing, selecting, promoting and empowering our line managers and other staff to nurture such cultures as one of the key progressive elements for our future.
We are also moving away from the command –and –control cultures to systems that are robust in achieving a “Zero defect policy” through team work.
Staff will also be recognized for their contribution and talents and will be suitably rewarded.
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NABH Policy:
Hospital Apex Manual
NABH Standard Reference: CQI Procedure / Issue No / Revision No . Date: Hospital Apex Manual / 01 / 05 / 10– 01 – 2022 Page No. 8 of 84
This will be done through objective analysis and in a professional and methodical manner.
Exit interviews are being introduced to flag up issue for suitable corrections to be done when ever needed.
Staffs with high productivity are our human asset capitals hence; staff retention is one of our high priorities.
Thus, our attrition levels must be minimized. Regular departmental meetings are conducted to check satisfaction levels by the MD.
A “free walk in” culture policy has been introduced to flag-up serious issues for employees, which can be informed directly to the MD/.
NABH Policy: Hospital Apex Manual NABH Standard Reference: CQI Procedure / Issue No / Revision No . Date: Hospital Apex Manual / 01 / 05 / 10– 01 – 2022 Page No. 9 of 84
Clinical Biochemistry
Clinical Microbiology and Serology
Clinical Pathology
Allergy Test (Blood)
Diagnostic Services
CT Scanning
Electrophysiological Studies Pharmacy
Dispensary Professions Allied to Medicine - Dietetics - Ambulance - Physiotherapy - Body Holding Area - Support Services LIST OF NON AVAILABLE SERVICES:
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NABH Policy:
Hospital Apex Manual
NABH Standard Reference: CQI
Procedure / Issue No / Revision No .
Date: Hospital Apex Manual / 01 / 05 / 10– 01 – 2022 Page No. 10 of 84
8. ESWL 9. Organ Transplant 10. Bone Marrow Transplantation 11. Radiotherapy 12. Intensity Modulated Radiation Therapy (IMRI) 13. Radio frequency Ablation 14. CRRT Continuous Renal replacement Therapy 15. MARS: Membrane Absorption Resin done in liver failure 16. Diffusion studies 17. Laser therapy 18. Pediatric Cardiac Surgery and PICU. 19. Cosmetic procedures
1. Providing Medical care in form of Consultation for out patients & inpatient areas for diagnosis, treatment & follow up of condition like:
A. Chronic diseases - CED, CLD, CHF, COPD, Asthma, Hypo/hyperthyroidism
B. Lifestyle disease : Diabetes Mellitus, Hypertension, dyslipidemia , OSA
C. Common Rheumatological condition like RA, SLE
D. Infectious disease Pneunmonia, meningitis, UTI/Pyelonephritis, Tuberculosis, Dengue, Typhoid, HIV, Covid, GI-Infection
E. Handling some of acute medical conditions like:DKA/ HHS, HTN emergency, Acute asthma/ Exacerbation of COPD, Acute pulmonary edema, snake Bite/ poisonings.
2. Health Education & Health promotion.
3. Providing fitness for surgery-pre-operatively., Optimizing of vital parameters prior to surgery
Outpatient and inpatient care of all general surgical cases except major trauma cases requiring vascular intervention.
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NABH Policy: Hospital Apex Manual
NABH Standard Reference: CQI
Procedure / Issue No / Revision No .
Date: Hospital Apex Manual / 01 / 05 / 10– 01 – 2022 Page No. 11 of 84
ANTENATAL CARE
POSTNATAL CARE
HIGH RISK PREGNANCIES (GDM,GHTN) INFERTILITY TREATMENT.
URO-GYNAECOLOGICAL PROBLEMS
ENDO-GYNAECOLOGICAL PROBLEMS
GYNAE-ONCOLOGY PROBLEMS
PAP SMEAR, HSG, IUCD INSERTION
OPD and IPD services to 0- 16 yrs age group
Normal newborn care and follow up.
Lactation support
Infectious and noninfectious cases
Growth and development monitoring
Early intervention programme
Adolescent problems
Level 1- 3 NICU cases
Pediatric surgery
All pediatric and neonatal surgeries except cardiac surgeries.
The department of anesthesiology provides complete anesthesia services including consultation for patients. All patients including pediatric, Neonates, OBG, geriatric will be served by services provided round the clock.
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NABH Policy: Hospital Apex Manual NABH Standard Reference: CQI Procedure / Issue No / Revision No . Date: Hospital Apex Manual / 01 / 05 / 10– 01 – 2022 Page No. 12 of 84
NABH Policy: Hospital Apex Manual
NABH Standard Reference: CQI Procedure / Issue No / Revision No . Date: Hospital Apex Manual / 01 / 05 / 10– 01 – 2022 Page No. 13 of 84
Op and IP care of all urological cases including, adult urology, andrology, pediatric urology and uro oncology. Endourology procedures- Diagnostic a& therapeutic Uretroscopy, uretroscopic DJ stenting,Rirs,Cystoscopy, TURP,LaserTURP,Pcnl, mini perc, Turbt, Cystolithotrepsy,Lap Pyeloplasty Laproscopic procedures like Lap nephrectomy,Lap uretrolithotomy,Lap pyeloplasty Reconstructive urology like Urethroplasty, Pyeloplasty, Ureteric reimplantation, Bladder reconstructive procedures.
NABH Policy: Hospital Apex Manual
NABH Standard Reference: CQI
Procedure / Issue No / Revision No . Date: Hospital Apex Manual / 01 / 05 / 10– 01 – 2022 Page No. 14 of 84
- Turbinectomy
- Tonsillectomy
- Adenoidectomy
- Uvulopalatophary
- Nasoplasty
Neck space Infections
Treatment of EAR, NOSE, THROAT Infection
Allergic Rhinits
Vertigo
Surgical Gastroenterology
Outpatient & inpatient care of all surgical gastroenterological cases except transplant.
ERCP
Upper GI Endoscopy
Lower GI Endoscopy
Endoscopic interventions
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Quality: Mission Critical Medical Excellence
AND LEADERSHIP
NABH Policy: Hospital Apex Manual
NABH Standard Reference: CQI Procedure / Issue No / Revision No . Date: Hospital Apex Manual / 01 / 05 / 10– 01 – 2022 Page No. 16 of 84
The quality management programme is the guiding force for continuous Quality improvement and knowledge enhancement of our Doctors, nurses and the support staff.
The quality policies and procedures are coordinated by the Quality Assurance Committee.
The management ensures that adequate resources including staff and funds for meeting its quality objectives.
Quality Manual is reviewed at least once in a year for evaluating its suitability and effectiveness and any additions or deletions.
The indicators will also be reviewed for their trends, effectiveness and relevance.
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Committees functioning at Koshys Hospital Committees formed at various levels to look after the quality and safety: 1. Quality Assurance Committee
NABH Policy: Hospital Apex Manual NABH Standard Reference: CQI Procedure / Issue No / Revision No . Date: Hospital Apex Manual / 01 / 05 / 10– 01 – 2022 Page No. 18 of 84
General:
The committee shall meet quarterly or earlier in case the requirement is there.
A yearly calendar is prepared for the meetings.
The meetings will be coordinated and minutes maintained by Manager Quality and audits.
Objective:
To review:
The quality initiatives taken by the various departments in last three months.
The appropriateness of these initiatives.
The trend of various indicators developed by the departments in last three months.
The analysis of falling and stagnant trends.
Approval or consideration of various resources needed for the improvement in the unfavorable trends.
Any other safety issue.
Any other open discussion related to quality and safety.
Minimum Quorum a. Medical Director b. NABH Coordinator c. Medical Superintendent d. Infection Control Nurse e. Nursing Superintendent
General:
NABH Policy:
Hospital Apex Manual
NABH Standard Reference: CQI
Date: Hospital Apex Manual / 01 / 05 / 10– 01 – 2022 Page No. 19 of 84
Procedure / Issue No / Revision No .
• The committee shall meet monthly to review every surveillance activity and earlier in case the need may be felt by chairperson or any issue brought by any member.
• The decision of the chairperson is final.
• The areas to be monitored by the committee are defined in the infection control manual and the committee is guided by the manual again.
Purpose:
The principal goal of infection control program is the prevention of nosocomial infection in patients, personnel, and visitors. In order to provide a safe environment for patients & personnel, we shall endeavor to involve every member of the hospital in the surveillance, prevention and control of nosocomial infection.
To objectively & systematically monitor & evaluate the quality & appropriateness of all hospital activities as they relate to infection control for patients, staff & visitors.
To assure that infection control policies & procedures are consistently being followed throughout the hospital
To assess nosocomial infection rates through regular surveillance, with identification of thresholds of infection rates, beyond which departmental action, investigation and intervention is indicated
To review & update infection control policies at least every year
To ensure compliance to NABH accreditation standards.
The committee shall meet once in a month.
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NABH Policy:
Hospital Apex Manual
NABH Standard Reference: CQI Procedure / Issue No / Revision No . Date: Hospital Apex Manual / 01 / 05 / 10– 01 – 2022 Page No. 20 of 84
Chairperson : Medical Director Convener: Chief Pharmacist
Members :
1. Medical Superintendent 2. Consultant in Internal Medicine 3. General Surgeon 4. Orthopedic Surgeon 5. Consultant (OBG)
6 Consultant Pediatrician/NABH coordinator 6. Intensivist 7. Consultant Anesthetist 8. Nursing Superintendent 9. Manager Pharmacy 10. Pharmacist 11. Administrator Minimum Quorum
a. Medical Director b. NABH Coordinator c. Medical Superintendent d. Pharmacist
e. Nursing Superintendent f. Administrator
Scope: Covers all the areas of the hospital for Pharmacy.
The purpose of the Pharmacy and Therapeutics Council is to formulate and review policies regarding the selection, regulation, compliance, distribution, storage, safe use, and administration of drugs within hospital. The committee shall meet once in three months
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NABH Policy:
Hospital Apex Manual
NABH Standard Reference: CQI Procedure / Issue No / Revision No . Date: Hospital Apex Manual / 01 / 05 / 10– 01 – 2022 Page No. 21 of 84
In addition to the items described in Section on “General Responsibilities”, the duties of the Pharmacy and Therapeutics Council shall include, but are not limited to:
a. Managing the Drug Formulary system, which involves evaluating clinical data on medications, requested for addition and regularly evaluating current medications for possible deletion?
b. Providing Medical Staff oversight for the entire medication use process (prescribing preparation and dispensing, administering, and therapeutic monitoring) across the continuum of care (inpatient, outpatient, and home care).
c. Providing review and approval for all medication use process procedures regularly.
d. Providing input and approval for any new, revised, or updated medication use procedures.
e. Monitoring the stability of the Medication Use system and ensuring an on-going performance improvement effort.
f. Approve/disapprove drugs and drug combinations.
g. Move the Institution towards a generic drug regime rather than the branded drug system.
h. Ensure sound business practices and promote “good drug culture’ in the organization- i.e. use drugs and pharmaceuticals manufactured by reputed pharmacy companies.
i. Monitor, review and provide protocols for: (See Appendix A for all the indicators)
j. Medication errors.
k. Drug availability according to the need of the patients.
NABH Policy: Hospital Apex Manual
NABH Standard Reference: CQI Procedure / Issue No / Revision No . Date: Hospital Apex Manual / 01 / 05 / 10– 01 – 2022 Page No. 22 of 84
a. Medical Director
b. NABH Coordinator
c. Medical Record Manager d. Medical Superintendent e. Administrator
f. Manager IT
Scope: Covers all the medical records of the hospital.
Purpose:
To develop implement and continually improve the safe, confidential, systematic & effective method of receiving, filing storing retrieving & discarding the medical record of the patients admitted for the treatment in accordance to the legal requirements. Also to monitor the contents of the medical records and their availability.
The committee shall meet once in three months to discuss a. Standardization of medical records forms and formats. b. Maintain the copy of all the forms and formats used in medical records. c. Get the forms and formats controlled by the Medical director. d. Receive any request for change in the change in forms and formats from the end user. e. Review the need for the change and do the needful. f. The findings of the audit conducted for the completion of the medical records against a standardized checklist, g. Their trends, h. Ways of improving i. And further actions.
Both the live and completed documents will be audited. The audit for the quick availability of the records will be made twice a month by any one designated member to be decided by the committee in the meeting for the next month. Quarterly report will be presented to the Quality Assurance Committee.
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COMPOSITION:
NABH Policy: Hospital Apex Manual
NABH Standard Reference: CQI Procedure / Issue No / Revision No . Date: Hospital Apex Manual / 01 / 05 / 10– 01 – 2022 Page No. 23 of 84
Chair person : Medical Director/CEO
Convener : Non Clinical safety officer
Members :
1. Medical Superintendent 2. NABH coordinator /Clinical safety officer 3. Administrator 4. Coordinator – Laboratory 5. Radiologist 6. Nursing Superintendent 7. Security Manager 8. Manager- Engineering 9. Manager-Biomedical 10. Infection Control Nurse 11. Pharmacist 12. Manager IT 13. Safety champions: 14. Department in -charges ( MICU, NICU,SICU,LR,ER, OT, Wards ,Co-ordinator in charge)
Medical Director
Non clinical safety manager
NABH Coordinator/ Clinical safety officer Medical Superintendent HIC Officer / Microbiologist Engineering manager
Infection Control Nurse Nursing superintendent
Purpose
To define the processes through which the hospital provides a safe and healthy environment in which hazards are eliminated or minimized for employees, staff, patients and visitors. This will be achieved by engineering controls, personnel protective equipments, education and work related on site surveillance.
Objective:
Continually evaluate the effectiveness of these processes to ensure performance improvement.
Identify the individuals to oversee developments and implement these processes and intervene whenever necessary.
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Hospital Apex Manual
NABH Standard Reference: CQI
Procedure / Issue No / Revision No .
Date: Hospital Apex Manual / 01 / 05 / 10– 01 – 2022 Page No. 24 of 84
Communicate the issues and gaps to the appropriate departments/units or governance.
Distribute, practice, enforce and review the safety policies and procedures every three years or earlier if necessary.
The committee shall meet monthly.
Standards of performance:
Risk assessment and hazardous surveillance rounds will be conducted semiannually in patient care areas and annually in other areas. Employees working will be interviewed semiannually for their knowledge about the safety processes and policies with a target of a 90% against a checklist prepared centrally All employee injuries/illness will be reviewed monitored and evaluated Trends will be identified Department wise safety training to be completed at least 90%.
The specific to the Hospital Safety Committee is:
Initiate and coordinate hospital wide safety programme.
Review summaries of incident reports and recommend and ensure completion of corrective actions. Review quarterly the compliance to the life safety which can be the reports generated out of the fire drills etc. The review includes the employee and staff performance, recommendations and ensures the corrective actions.
Review quarterly the reports regarding the scheduling of required safety checks and preventive maintenance of electrical and non-electrical equipments patient care areas as well as non patient care areas.
Review quarterly the reports regarding proper operation and malfunctioning of utility systems; Recommend and ensure completion of corrective actions.
Review quarterly the reports regarding the hazardous material. Review quarterly the security reports.
Review quarterly the emergency preparedness reports. Facilitate employee orientation and training programme.
The responsibilities of Non clinical safety officer are:
Coordinate quarterly fire drills which include employee and staff performance evaluation as well as fire protection system evaluation; recommend and ensure completion of corrective actions as needed; submit quarterly report to the Hospital Safety Committee
Coordinate ILSM fire drills; inspect area to ensure compliance with ILSM (No smoking allowed in the building; keep pathways and fire exit clear, limit amount of combustible materials, store flammable materials properly, Be on the lookout for possible fire hazards.) Report these immediately to the safety officer. Recommend and ensure completion of corrective actions as needed.
Manage the hazardous materials management program; provide personnel and area exposure monitoring as needed; ensure compliance with applicable local, state, and Federal regulations.
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NABH Policy: Hospital Apex Manual
NABH Standard Reference: CQI Procedure / Issue No / Revision No . Date: Hospital Apex Manual / 01 / 05 / 10– 01 – 2022 Page No. 25 of 84
Coordinate disaster drills biannually; facilitate the critique following the drill, recommend corrective actions as needed; participate on the Disaster Committee; work with the Disaster Committee to ensure completion of corrective actions.
Tabulate data obtained during fire drills and safety rounds and submit quarterly report to and work with the Hospital Safety Committee to recommend and ensure completion of corrective actions as needed.
To conduct bi-monthly facility inspection rounds & to present corrective and preventive action to safety committee.
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NABH Policy:
Hospital Apex Manual
NABH Standard Reference: CQI
Procedure / Issue No / Revision No .
Date: Hospital Apex Manual / 01 / 05 / 10– 01 – 2022 Page No. 26 of 84
Frequency of meeting: Meeting shall be held once in 3 months.
SCOPE:
Channel information and advice to hospitals and blood services on best practice and performance monitoring with the aims of:
a. Improving the safety to blood transfusion practice. b. Improving the appropriateness of clinical blood transfusion. c. Promote the highest quality and consistency in transfusion practice.
Responsibilities:
Audit use of blood whole blood, blood components, occurrence of post transfusion reactions.
To discuss and formalize various guidelines for appropriate use of blood and blood products.
To monitor and discuss issues related to :
a. Safety of blood from transmissible diseases.
b. Minimal amount of blood / blood products used. Monitor transfusion practices compared to institutional, national or international benchmarks –promotion of safe and effective blood transfusion practice.
To review all transfusions closely and reporting and follow-up of any adverse reactions to transfusion.
To provide appropriate patient information and educate them on blood transfusion.
Provide information, appropriate education and training of blood transfusion to the staff members.
Disseminate and implement national policies and guidelines as per DCI/NACO.
Development and review of institutional transfusion policies and systems e.g. patient and sample identification.
Blood transfusion services, practice and performance monitoring aimsa. Collection and Blood orderly practices, use & wastage statistics, errors and incidents b. Reporting and follow-up of adverse reaction to transfusion. c. Promoting Quality and consistency in transfusion practice.
Development of educational and training materials as required.
Identification of staff training requirements in clinical and laboratory transfusion practice.
NABH Policy:
Hospital Apex Manual
NABH Standard Reference: CQI Procedure / Issue No / Revision No . Date: Hospital Apex Manual / 01 / 05 / 10– 01 – 2022 Page No. 27 of 84
7. Casualty Medical Officer 8. ER staff nurse in charge & ICU staff nurse in charge 9. Nursing Superintendent
Minimum Quorum a. Medical Director b. NABH Coordinator c. Medical Superintendent d. Consultant Anesthesiologist e. Intensivist f. Nursing Superintendent
Purpose: The committee is responsible for the post- event analysis and takes corrective actions. Frequency of meeting: Meeting shall be held monthly
Responsibilities:
To monitor and track response to all CPR events and Code Blue cases in the hospital.
Aid improves response time and easy access to emergency medical equipment including crash carts.
Decide upon the composition and responsibilities of each member of the Code Blue team.
Recommend special training initiatives of the Code Blue Team members. CORE COMMITTEE
NABH Policy: Hospital Apex Manual
NABH Standard Reference: CQI Procedure / Issue No / Revision No . Date: Hospital Apex Manual / 01 / 05 / 10– 01 – 2022 Page No. 29 of 84
Engineering (Minimum Quorum – All).
Purpose: The committee is responsible for overseeing the Fire and Non-fire emergencies. Frequency of meeting: Meeting shall be held on once in 6 months. Responsibilities:
To prepare polices on prevention, management and control of emergency situation within the Hospital.
To supervise training, mock drills and implementation of policy / plan.
To issue Disaster Management plans.
To manage Disaster events.
To supervise training and mock drills.
To assess variation in the mock drills
test plan at least twice in a year.
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NABH Policy:
Hospital Apex Manual
NABH Standard Reference: CQI
Procedure / Issue No / Revision No . Date: Hospital Apex Manual / 01 / 05 / 10– 01 – 2022 Page No. 30 of 84
a. Medical Director b. NABH Coordinator c. MS d. Intensivist e. Nursing Superintendent
The Consultant Doctors and/or the Junior Residents representing the patients discussed are invited to present the case and explain their course of treatment to the Committee.
Purpose:
The Medical Audit Committee is set up with the objective to improve patient care and serves as a stimulus for eliminating sub standard practices and prevents repetition of mistakes. The committee has been set up to review and advice upon appropriate medical care and related administrative functions towards each patient that contributes to ‘Quality Assurance’ of the services through a system based on ‘peer review’. In addition, deficiencies in record keeping, administrative procedures and various errors are brought to light for early correction.
Frequency of meeting:
Meeting shall be held every month.
Responsibilities:
To review the overall management plan and the process followed in each case of death.
To ensure completeness and accuracy of records. To ensure correctness and substantiation of final diagnosis.
To ensure that the final result in consonance with the nature of the case and expected prognosis. To analyze errors in diagnosis, treatment or judgment.
To evaluate causes of complications and poor results.
To ensure if the case requires additional referral consultation and was it done at the correct time and properly recorded.
To ensure reduction of avoidable deaths.
COMPOSITION
Chair Person : Principal, Koshys College of Nursing Convener : Administrator, Koshys Hospital
Minimum Quarom a. NABH Coordinator
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NABH Standard Reference: CQI
Procedure / Issue No / Revision No . Date: Hospital Apex Manual / 01 / 05 / 10– 01 – 2022 Page No. 31 of 84
b. Admin c. NS d. HR Manager
Purpose:
To address any complaints which fall within the framework laid done through the Sexual Harassment of Women At Work Place (Prevention, Prohibition and Redressal) Act 2013
Frequency of meeting:
Meeting shall be held once in 6 months.
Responsiblities:
The committee shall have powers equivalent to function under code of civil procedure 1908.
The committee will increase awareness and instill confidence and a sense of security among the female employees.
A charter for complaints given below will be circulated for the information of all female employees.
a. Physical contact and advances
b. A demand or request for sexual favors
c. Sexually colored remarks
d. Showing pornography
e. Any other unwelcome physical, verbal or non-verbal conduct of sexual nature.
f. Abusing verbally and passing snide remarks on their appearance.
g. Gender biases derogatory remarks.
Mobile numbers of all committee members shall be made available for all employees to contact at any given point of time.
Total confidentiality shall be maintained for all complaints received by the KOSHYS INTERNAL COMPLAINTS COMMITTEE
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Chair Person : MD/CEO
Convener : NABH Coordinator
Members : 1. Administrator
2. Nursing Superintendent
3. Manager HRD
Minimum Quorum – All.
Purpose:
The Human Resources Committee has been set up to make policy decisions related to Human Resources Department
Frequency of meeting: Meeting shall be held once in 6 months.
Responsibilities:
To monitor, analyze and advice on the staffing plan at the unit.
To renew contracts when applicable.
To review and make amendments in HR policy.
To advice on retention plan for deserving candidates
To decide on various health issues of employees and formulating and implementing policies accordingly.
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1. NA 2. No Objection Certificate for Fire License
NO: 454:ADV: CFO: BWZ:2017 05.06.2017 NA Director Karnataka Fire Services 3. No Objection Certificate from Pollution Board
AW-303361 PCB ID/143-13997 11.08.2017 30.09.2022 Sr.Environmental l Officer 5. Income Tax PAN AAACL5263B 20.03.1998 NA Income Tax General Manager 6. Lift License 1/2/4590 10.10.2002 NA Chief Electrical Inspector 7. Narcotic & Psychotropic License EX16MKOSHYSHOS PITALSES202107261 2
07.08.2021 30.06.2022 Deputy Commissioner 8. Retails Drug License 20/142760 & 21/142761 15.04.2021 14.04.2026 Drug Controller 9. Fixed X-Ray 16-LOEE-111354 16.06.2021 16.06.2026 Atomic Energy Regulatory Board, Govt of India 10 Mobile X- Ray 16-LOEE-111355 16.06.2021 16.06.2026 Atomic Energy Regulatory Board, Govt of India 11 CT 16-LOEE-146991 22.01.2018 22.01.2023 Atomic Energy Regulatory Board, Govt of India 12 Mamography 21-LOP677392 05.10.2021 05.10.2026 Atomic Energy Regulatory Board, Govt of India 13 C-ARM 16-LOEE-114457 16.06.2021 16.06.2026 Atomic Energy Regulatory Board, Govt of India 14 Radiation Safety Officer 21-RSO-2693259 15.11.2021 15.11.2024 Atomic Energy Regulatory Board, Govt of India
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15 16 Employees Provident Fund NA Regional PF Commissioner 17 Employee State Insurance KRP/LE/1623/2006 5300029419000 13.06.2011 NA Employee State Insurance Corporation 18 Medical Termination of Pregnancy Act - MTP 1401/65.04-05 13.12.2004 NA Govt. of Karnataka 19 PCNDT Act Reg No:1839 24.07.2017 23.07.2022 Govt. of India 20 Consumer Protection Act & Medical Profession
-- Complied NA Govt. of India 21 Certificate of Registration BAU-09120-AS-NH 01.07.2010 Kar. Pvt Med Est Authority Bangalore Urban District 22 Microsoft Open License 45476069 19.05.2009 NA Microsoft
All other statutory requirements, licenses and Acts are complied with and evidenced by booklets and certificates.
The NABH standards have been laid down keeping the Indian ethos and working environment in mind. The main focus of the standards is on patient, employee, visitor and environment safety. These standards are at par with the standards laid down for accreditation of hospitals elsewhere in the developed and developing countries. These standards are applicable to multidisciplinary hospitals and single specialty hospitals providing secondary, tertiary and quaternary levels of health/medical care. They are not applicable to primary health care institutions and rural hospitals. All the standards are core standards and no optional standards have been laid down. Those hospitals that are not providing certain services like Obstetrics and Gynaecology, Paediatrics, etc, the corresponding standards would not be applicable to them while carrying out the assessment surveys. The compliance with these standards will indicate that the hospital is patient, staff and environment friendly. The standards are deceptively simple. Ongoing through the details during the phase of implementation of the standards one would realize that extra efforts and resources are indeed required for ensuring compliance with the standards. It may also be observed, at the time of implementation, that there may be some duplication at a
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few places. Duplication is a necessity since it will ensure compliance with the said standards and also emphasize the importance of the standards and the objective elements.
NABH is aware that apart from extra resources needed for implementation, a few guidelines are equally necessary for easy comprehension and correct implementation. The ensuing guidelines, chapter-wise in tabulated form, have been laid down for e easy comprehension, better understanding of the standards and the objective elements, removing and clarifying ambiguities uniform application of standards across the organization, and smoother and more efficient implementation. The best way to implement the standards is to have an in-house quality committee/team that will be responsible for making the quality manual based on the NABH standards, the initial implementation of the standards and the subsequent monitoring of the same. While there might be initial expenses for ensuring implementation and monitoring of the standards, in the long term these costs will be recovered by the organization owing to the better and more efficient and effective quality of patient care. Finally it must also be understood that accreditation is an ongoing process. Each time one has to raise the bar and hence the importance of continual quality improvement. Accreditation is thus a journey and not a destination
Sl. No Policies and procedure related to the hospital Policy References Associated Documents
POL/KH/AAC/1 Brochures 2. Registration and Admission POL/KH/AAC/2 MRD Manual 3. Transfer of stable and unstable of patients POL/KH/AAC/3 ICU Manual 4. Initial Assessment POL/KH/AAC/4 All Clinical Manuals 5. Re-Assessment POL/KH/AAC/5 All Clinical Manuals 6. Laboratory Services POL/KH/AAC/6 Lab Quality Manual 7. Laboratory Quality Assurance Programme POL/KH/AAC/7 Lab Quality Manual 8. Laboratory Safety programme POL/KH/AAC/8 Lab Quality Manual 9. Imaging Services POL/KH/AAC/9 Radiology Manual 10. Imaging services Quality Assurance Programme POL/KH/AAC/10 Radiology Manual 11. Radiation Safety programme POL/KH/AAC/11 Radiology Manual 12. Continuity of and Multidisciplinary patient care POL/KH/AAC/12 All Clinical Manuals 13. Discharge process
1. Definition and display of services
POL/KH/AAC/13 -14. Content of Discharge Summary
POL/KH/AAC/14 Patient Discharge summary
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Sl. No Policies and procedure related to the hospital Policy References Associated Documents
POL/KH/COP/1 All Clinical Manuals 2 Emergency services POL/KH/COP/2 Emergency Manual 3 Checklist for emergency medicines and equipments in the ambulance POL/KH/COP/3.1 Emergency Manual 4 Community Emergencies and Disasters POL/KH/COP/4 DM Manual 5 Cardio Pulmonary Resuscitation (CPR) POL/KH/COP/5 ICU Manuals 6 Procedure Guide Nursing Care POL/KH/COP/6 Nursing Manual 7 Performance of various Clinical Procedures POL/KH/COP/7 Policy Manual AAC1a 8 Rational Use of Blood and Blood Products (Transfusion) POL/KH/COP/8 9 Provision of Intensive Care and High Dependency unit POL/KH/COP/9 ICU Manual 10 High risk Obstetrical Patients POL/KH/COP/10 OBG Manual 11 Care of Paediatrics Patients POL/KH/COP/11 12 Patient undergoing moderate sedation POL/KH/COP/12 Endoscopy Manual 13 Administration of Anesthesia POL/KH/COP/13 -14 Care of surgical patients POL/KH/COP/14 OT Manual 15 Organ Transplant NA 16 Patient with high risk of morbidity and mortality POL/KH/COP/16 Nursing Manual 17 Pain management POL/KH/COP/17 Nursing Manual 18 Rehabilitative services POL/KH/COP/18 Physiotherapy Manual
Provision of uniform care to patients
Nutritional therapy POL/KH/COP/19 Diet Manual 20 End of life care POL/KH/COP/20 All Clinical Manuals 23 Research Activities NA NA
MANAGEMENT
MEDICATION
1 Pharmacy services POL/KH/MOM/1 Pharmacy Manual
Hospital Formulary POL/KH/MOM/2 Drug Formulary
Storage of Medication POL/KH/MOM/3 Pharmacy Manual & Nursing Manual
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Involvement of patient and family member in making decision POL/KH/PRE /2 All Manuals
Involvement of patient and family in the careplanning and delivery process POL/KH/PRE /3 Clinical Manuals
Informed consent POL/KH/PRE /4 All Clinical Manuals
Right to information and education about their care needs POL/KH/PRE/5 All Manuals
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RESPONSIBILITY OF MANAGEMENT (ROM)
POL/KH/FMS/7 Hospital Safety
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Sl. No Policies and procedure related to the hospital Policy References Associated Documents Manual
POL/KH/HRM/1 HRD Manual 2 Define process for staff requirement POL/KH/HRM/2 HRD Manual 3 Induction training 4 Professional training and development of the staff POL/KH/HRM/3 HRD Manual 5 Training is based on specific job desciption POL/KH/HRM/4 Training Record 6 Training is done in safety and quality related aspects 7 Appraisal system for evaluating the performance of an employee
1 Human resource planning
POL/KH/HRM/5 HRD Manual 8 Disciplinary procedure and Grievance handling mechanism POL/KH/HRM/6 HRD Manual 9 Organization health needs of the employees
POL/KH/HRM/7 Annual Health Check up 10 Employee record for each staff member POL/KH/HRM/8 Personal Record of an Employee 11 Process for collecting, verifying and evaluating the credentials of medical professionals permitted to provide patient care POL/KH/HRM/9
HRD Manual 12 Process for collecting, verifying and evaluating the credentials of nursing staff POL/KH/HRM/10 HRD Manual 13 Process for collecting, verifying and evaluating the credentials of Para-Clinical professionals. POL/KH/HRM/10 HRD Manual
POL/KH/IMS/1 EDP & MRD Manual 2 Management & of data & Information. POL/KH/IMS/2 MRD Manual 3 Complete and accurate medical record 4 Reflects the continuity of care POL/KH/IMS/3 MRD Manual 5 Confidentiality, integrity and security of information
1 Information Needs
POL/KH/IMS/4 MRD Manual 6 Ensures availability and current and relevant documents, records, data and information and provides for retention of the same. POL/KH/IMS/5 EDP & MRD Manual 7 Carries out review of medical records
POL/KH/IMS/6 MRD Manual
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1
PSQ3a
2 PSQ3a
Time for initial assessment of indoor patients
Number of reporting errors 1000 investigations. CT & Histopath
Sum of time taken for the assessment Total number of patients in indoor
Number of reporting errors Number of test performed 1000
3 PSQ3a
Percentage of adherence to safety precautions by employees working in diagnostics.
Number of employees adhering to safety precautions
4
PSQ3a
Incidence of medication errors (Medication
Total number of Opportunies of Medication errors
Number of employees sampled 100
No of patient days. 1000
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PSQ3a
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errors per patient’s days).
Percentage of medication charts with error prone abbreviations
6
PSQ3a
Number of medication charts with error prone abbreviations
Percentage of admission with adverse drug reaction (s).
Number of adverse drug reactions
7
PSQ3a
Percentage of unplanned return to OT.
Number of unplanned return to OT
Number of Inpatient 100
8
PSQ3a
Percentage of case where the organization procedure to prevent adverse events like wrong site, wrong patient and wrong surgery have been adhered to.
9
PSQ3a
Percentage of transfusion reaction recipient. The causes include red blood cell
Number of cases where the procedure was followed.
Number of discharges and deaths 100
Number of patient operated 100
Number of transfusion reactions
Number of surgeries performed 100
Number of units transferred 100
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incompatibility allergic sensitivity to the leukocytes, platelets, plasma, protein components of the transfused blood; or potassium or citrate preservatives in the banked blood.
10 PSQ3a Standarized Mortality ratio for ICU
Actual deaths in ICU Predited deaths in ICU 100
11 PSQ3a
Return to the emergency department within 72 hours with similar presenting complaints.
Number of returns emergency within 72 hours with similar presenting complaints
Number of patient who have to come to the emergency 100
12 PSQ3a
Incidence of hospital associated pressure ulcers after admission (Bed sore per 1000 patient days).
Number of patients who developed new worsening of pressure ulcer
Number of patient days 1000
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time for issue of blood and blood components.
21 PSQ3c Nurse Patient Ratio
22
Number of Nursing Staffs
PSQ4c Waiting time for out patient consultation. Sum (Patient total in time for consultant)
23 PSQ4c Waiting time for diagnostics Sum total patient reporting time
24 PSQ4c Time taken for discharge
Sum of time taken for discharge
components issue
Number of beds
Number of patients reported in Out patients
25
PSQ4c
Percentage of medical record having incomplete and / or improper consent
26
PSQ4c
Percentage of stock outs including emergency drugs.
Number of medical records having incomplete and / or improper consent
Number of patients reported for Diagnostics
Number of stock outs
Number of patients discharged
Number of discharge and deaths. 100
Number of drugs listed in hospital formulary / consumables is temporarily unavailable 100
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27
PSQ4d Number of variations observed in mock drills
Total Number of variations observed in mock drills 28 PSQ4d Patient Fall Rate
Number of patient falls
Number of patient days 1000 29 PSQ4d Percentage of near misses
Number of near misses reported
Number of incidents reported 100 30 PSQ3d Incidence of needle stick Injuries
Number of parenteral Exposures No of occupied beds 1000 31
PSQ3d
Appropriate handovers during shift change (to be done separately for doctors and nurse) (per patient per shift).
Total number of handovers done appropriately
Total number of handovers opportunities 100 32
PSQ3d
Compliance rate to medication prescription in capitals
Total number of prescriptions in capital letter
Total no of prescriptions 100
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Sl No Indicator
1
Percentage of cases (inpatient) wherein care plan with desired outcomes in documented and counter signed by the clinician.
2
Percentage of cases in-patient wherein screening for nutritional needs has been done.
3
Percentage of cases (inpatient) wherein the nursing care plan is documented.
4
Percentage of reports correlating with clinical diagnosis. (Histopathology and CT
5
Percentage of patients receiving high risk medications developing adverse drug event.
6
Percentage of modification of anesthesia plan.
Numerator
Number of inpatient case records wherein the care plan with desired outcomes has been documented
Denominator Multipli ed by
Total number of patients 100
Number of IP records where in nutritional assessment has been documented
Number of inpatient case records wherein the nursing care plan has been documented
Number of reports corelating with clinical diagnosis
Number of patients receiving high risk medications who have an adverse drug event
Number of patients in whom the anesthesia plan modified.
Total number of patients 100
Total number of patients 100
7
Percentage of unplanned ventilation following anesthesia.
Number of patients requiring unplanned ventilation following anaesthesia.
Number of tests performed 100
Number of patients receiving high risk medications 100
Number of patients who underwent anesthesia 100
Number of patients who underwent anaesthesia 100
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8
Percentage of adverse anaesthesia events.
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Hospital Apex Manual
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Number of patients who developed adverse anaesthesia.
Number of patients who underwent anaesthesia
100
9
Anaesthesia related mortality rate.
Number of patients who died due to anesthesia
Percentage of cases in which the planned surgery is changed intraoperatively .
Number of cases in which the planned surgery is changed intraoperatively
Number of patients who underwent anesthesia
100 10
Total number of surgeries performed 100 11 Re- explorations rate.
Number of re-explorations done during same admission
Total Number of surgeries performed 100 12
Percentage of wastage of blood and blood components.
Number of blood and blood components units wasted among those issued.
Number of blood components units issued from the blood bank. 100 13
Percentage of blood component usage
Number of components used
Number of blood and bllod components used 100 14
Re-intubation rate.
Percentage of serious adverse events
Number of serious adverse events reported within the defined timeframe
Number of serious adverse events reported within and outside the defined timeframe
100
Number of re-intubation within 48 hours of extubation Number intubations 100 15
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Percentage of drugs and consumables procured by local purchase
17
Within Hospital drug formulary
18
Outside Hospital drug formulary
Number of drug/items purchased by local purchase within formulary.
Number of drug/items purchased by local purchase outside formulary.
Number of drugs/items in hospital formulary list.
Number of drugs/items in hospital within as well as outside formulary list.
100
100
Percentage of drugs and consumables rejected before preparation of goods receipt note (GRN)
19
Percentage of variations from the defined procurement process
Total quantity rejected
Total quantity received before (GNR) 100 20
Total number of variations from the defined procurement process
Total number of items procured 100 21
Percentage of staff provided pre-exposure prophylaxis
Number of employees who were provided preexposure prophylaxis
Number of employees who were due to be provided pre exposure prophylaxis
100 22
Bed occupancy rate.
Number of in patient days in a given month
23
Average length of stay.
Number of in patient days in a given month
Number of available bed days in that month 100
Number of available dischages and deaths in that month
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Utilization Rate 25 OT OT utilization time in hours Resource Hours 100 26 ICU Equipment Utilization
Number of Equipment utilised days.
Equipment days available 100 27 Bed Utilisation
Number of bed utilised
Number of bed days available 100 28 Critical equipment Down time
Sum of down time for all critical equipment in hours in a month 29 Out patient satisfaction index Averge score achieved
Maximum possibe score 100 30 In patient satisfaction index Averge score achieved
Maximum possibe score 100 31 Employee satisfaction index. Averge score achieved
Maximum possibe score 100 32
Employee attrition rate.
Number of employee who have left during the month
Number of employee at the beginning of month + newly joined staff 100
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NABH Policy: Hospital Apex Manual
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Employee absenteeism rate. Number of employee who are on unauthorized absence
Number of employees 100
34
Percentage of employee who are aware of employee rights, responsibilities and welfare schemes.
Number of sentinel events reported, collected and analyzed within the defined timeframe
36
Number of employees who are aware of employee rights responsibilities and welfare schemes
Number of employees interviewed 100 35
Number of sentinel events analyzed within the defined timeframe
Number of sentinel events reported / collected 100
Incidence of blood body fluid exposure
IPD Areas
In IPD areas: number of blood body fluid exposures
Number of inpatient days 1000
OPD Areas
OPD areas: Number blood body fluid exposure
Number of OPD patient visits 1000 37
Percentage of medical records not having discharge summary.
Number of medical records not having discharge summary
Number of discharge and deaths. 100 38
Percentage of medical records not having codification of Diseases (ICD)
Number of medical records not having codification as per international classification of disease.
Number of discharge and deaths. 100
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39 Percentage of missing records. Number of missing records Number of records 100
Number of patients 100
40
Incident of patient identification errors
Number of patient identification errors
CODE PINK
Members : Consultant Pediatrician in campus Nursing Superintendent Security Officer
Nurse in charge of each department Administrator MD/CEO
CODE BLUE Members : Intensivist in campus
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Physician in campus
ER doctor
ER nurse
Designated Code Blue nurse
Members : MD/CEO Administrator Medical Director Security Officer
Chairman Emergency (MD/CEO)
Chief Engineer
Head of security
ERT
Support team of engineering staff
Security staff
Duty Manager
Shift Engineer
Security Officer
Duty Manager
Security officer
Shift engineer
ERT
Support team of engineering staff
Security staff
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Code committee procedures: Associated Documents
Hospital safety Manual DM Plan
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Sl.No ABBREVIATIONS
attack)
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Acute respiratory distress syndrome. 31
ARF
Acute renal failure 32
ASAP
guerene
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Complete blood count. 63 cc
Cubic centimeters. 64 CCA Customer care assistant 65 CCB Calcium channel blocker 66 CCF Congestive cardiac failure 67 CD Compact disc 68 CDC Centers for disease control & prevention 69 CHD Coronary heart disease 70 CHO Carbohydrate 71 CK MB Creatinine kinase- myocardial 72 CKD Chronic kidney disease 73 CKD Chronic kidney disease 74 CLABSI Central line associated blood streem infection 75 cm Centimeter 76 CME Continuing medical education 77 CMO Chief of medical officer 78 CMV Cyto megalo virus 79 CNS Central nervous system 80 CO2 Carbon dioxide 81 COPD Chronic obstructive pulmonary disease. 82 CP Cereberal palsy 83 CPAP Continuous positive airway pressure 84 CPK: Creatinine phosphokinase 85 CPR Cardio pulmonary resuscitation 86 C-RP C-reactive protein test
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Cerebrovascular accident 95
94 CVA
CVC
Central venous catheter 96 CVP
Central venous pressure 97 CVS Cardio vascular system 98 Cx Cervix 99 CXR Chest x-ray 100 D & C Dilatation & curettage 101 D/S Discharge 102 DBP Diastolic blood pressure 103 DC Differential count 104 DDT Diploma in dialysis technology 105 DHS Dynamic hip screw 106 DIC Disseminated intravascular coagulation 107 DKA: Diabetic ketoacidosis 108 DM Diabetes mellitus. 109 DNR Do not resuscitate. 110 DOA Date of admission 111 DSA Dialyses surface area 112 DTR Deep tendon reflexes 113 DVT Deep vein thrombosis 114 EA Epidural anaesthesia 115 ECG Electrocardiogram 116 EEG Electroencephalogram 117 EF Ejection fraction 118 EMR Electronic medical record 119 ENT Ear nose throat 120 EOLC End of life care 121 ER Emergency room 122 ERCP Endoscopy re tograde colangio pylogram 123 ESR Enthrocyte sedimentation
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124 ESWL Extracorporeal shock wave 125 F French 126
F. Fahrenheit 127 FBS Fasting blood sugar 128 FCTG Fetal cardiotocography 129 Fe Female 130 FHR Fetal heart rate 131 FSH: Follicle stimulating hormone 132 FTND Full term normal delivery 133 FUO Fever of unknown origin 134 g Gram 135 GA General anaesthesia 136 GCS Glasgow coma scale 137 GDM Gestational diabetic mellitus 138 GE Gastro enterology 139 GI Gastro intestinal 140 GI or GIT Gastro intestinal /tract 141 gm Grams 142 GN Glomerulonephritis 143 GORD Gastro-oesophageol reflux disease 144 GRBS Glucose random blood sugar 145 GTT Glucose tolerance test 146 GYN Gynecology department 147 H/o History (of complaint) 148 HAV: Hepatitis a virus 149 Hb Hemoglobin 150 HBAg: Hepatitis b antigen 151 HBIG Hepatitis b immunoglobulin 152 HBSAG Hepatitis b virus antigen 153 HBV Hepatitis b virus 154 HCG Human chorionic gonadotropin 155 HCO3 Bicarbonate
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156 HCP Health care provider 157
Hct Hematocrit 158
HCV: Hepatitis c virus 159 HCW Health care worker 160 Hg Mercury 161 HIC Hospital infection control 162 HIV Human immuno deficiency virus 163 hpf High-power field 164 HPI History of present illness 165 HR Heart rate 166 HRT Hormone replacement therapy. 167 HSG Hystero salphingo graphy 168 Ht Height 169 HTN Hypertension. 170 HVS High vaginal swab 171 I&D Incision and drainage. 172 I&O: Intake and output 173 IBD Inflammatory bowel disease 174 IBS Irritable bowel syndrome (a medical disease that involves the gastrointestinal tract.) 175 ICD Intercostal drainage 176 ICN Infection control nurse 177 ICU Intensive care unit 178 IDDM Insulin-dependent diabetes mellitus. Type 1 diabetes. 179 Ig: Immunoglobulin 180 IGT Impaired glucose tolerance 181 IHD Ischemic heart disease 182 IM Intramuscular. 183 IMP Impression 184 INH Isonicotinic acid hydrazide 185 INJ Injection 186 INR International normalized ratio
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Hospital Apex Manual
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187 INV Investigations 188
Intra-ocular pressure 189
IOP
Intra-uterine contraceptive device 191 IUD Intra uterine death 192 IUGR Intra uterine growth retardation 193 IV Intravenous 194 IVP Intravenous pyelogram 195 JVP Jugular venous pressure 196 K/C/o Known case of 197 K+ Potassium 198 KFT Kidney function test 199 KUB Kidney, ureters, bladder 200 L.B.B.B. Left bundle-branch block 201 L.E. Lupus erythematosis 202 L.U.Q Left upper quadrant 203 LA Local anaesthesia 204 LBW Low birth weight 205 LFT Liver function test 206 LGA Large for gestational age 207 LLQ Left lower quadrant 208 LMP Last menstrual period 209 LN Lymph node 210 LOC Level of consciousness 211 LP Lumbar puncture
190 IUCD
212 LSCS
213 LVDD
Lower segment caesarian section
Left ventricular diastolic dysfunction
214 LVF Left ventricular failure 215 LVSD Left ventricular systolic dysfunction
216 M Male
217 M/H Medical history
218 MAC Monitored anaesthesia care
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219 MAP Mean arterial pressure 220 mcg Micro gram 221
MCV Mean corpuscular volume 222 MDI Metered dose inhaler 223 meq: Milliequivalent 224 MET/S Metastases 225 mg Milligram 226 MI Myocardial infractin 227 MICU Medical intensive care unit 228 ml Milliliters. 229 MLC Medical legal case 230 mm Millimeter 231 mmHg Millimeter of mercury 232 MO Medical officer 233 MRCP Magnetic reasonace colangio pancreatgraphy 234 MRD Medical record department 235 MRI Magnetic resonance imaging 236 MRSA Methallin resistant staphylococcus avreus 237 MSU Mid-stream urine sample (for culture and sensitivity) 238 MTX Methotrexate 239 MVP Mitral valve prolapse. 240 Na+ Sodium 241 NABH National accreditation board for hospital and health care providers 242 NAD Nothing abnormal discovered 243 NBI No bone injury 244 NCP Nursing care plan 245 neg Negative 246 NICU Neonatal intensive care unit 247 NNJ Neonatal jaundice 248 NPH Neutral protein hagedorn(type of insul 249 NPO Nil per orally
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NABH Policy:
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NABH Standard Reference: CQI Procedure / Issue No / Revision No . Date: Hospital Apex Manual / 01 / 05 / 10– 01 – 2022 Page No. 67 of 84
250 NS Normal saline 251
NSAIDS: Nonsteroidal anti-inflammatory drugs 252
NST Non stress test
253 NVBS Normal vesicular breathsounds 254 NWB No weight-bearing 255 O/E On examination 256 OA Osteoarthritis
257 OB Obstetrical department 258 OED Order entry done 259 OGD Oesophago-gastro-duodenoscopy 260 OGTT Oral glucose tolerance test 261 OM/ASOM/CSSOM
Otitis media/acute suppurative otitis media/chronic suppurative otitis media
262 OP Out patients 263 OPD Out-patient department 264 OR Operating room 265 ORIF Open reduction and internal fixation 266 OT Operation theater 267 otc Over the counter (bought medication) 268 P.A Postero-anterior 269 p.o. By mouth. From the latin terminology per os. 270 P.P.D Purified protein derivative (of tuberculin) d 271 P.R. Pulse rate 272 p.r.n. As needed 273 P/R Per rectum 274 PA Posterior -anterior
275 PACS Picture archiving communication system
276 PAD Peripheral arterial disease 277 Path Pathology
278 PC Pre conception
279 PE Pulmonary embolisnm
280 PEARL
Pupils equal and reacting to light and accommodation
281 PEFR Peak expiratory flow rate
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Hospital Apex Manual
NABH Standard Reference: CQI
Procedure / Issue No / Revision No . Date: Hospital Apex Manual / 01 / 05 / 10– 01 – 2022 Page No. 68 of 84
Pulmonary function test. A test to evaluate the how well the lungs are functioning. 283 PID Pelvic inflammatory disease 284 plt Platelets 285 PM Post mortem examination 286 PMS Premenstrual syndrome 287 PND Paroxysmal nocturnal dyspnea 288 PNDT Prenatal diagnostic test act 289 PNR As required 290 POP Plaster of paris 291 post-op. Post-operative 292 PPE Personal protective equipment 293 PPL Puncture proof contained 294 PT Prothrombin time 295 Pt. Patient 296 PTA Plasma thromboplastin antecedent 297 PTC Plasma thromboplastin component 298 PTCA Percutaneous transluminal coronary angioplasty 299 PTH Parathyroid hormone 300 PTSD Post-traumatic stress disorder 301 PTT Partial thromboplastin time 302 PUD Peptic ulcer disease. A type of ulcer of the stomach. 303 PV Per vagina 304 PVD Peripheral vascular disease 305 q2h Every 2 hours. As in taking a medicine every 2 hours. 306 q3h Every 3 hours. As in taking a medicine every 3 hours. 307 QA Quality assurance
282 PFT
308 qAM Each morning. As in taking a medicine each morning. 309 qhs At each bedtime. As in taking a medicine each bedtime. 310 QI
Quality indicators
311 qod Every other day. As in taking a medicine every other day. 312 qPM Each evening. As in taking a medicine each evening. 313 R/LIF Right/left iliac fossa 314 R/O Rule out
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Hospital Apex Manual
NABH Standard Reference: CQI
Procedure / Issue No / Revision No . Date: Hospital Apex Manual / 01 / 05 / 10– 01 – 2022 Page No. 69 of 84
315 RA Right atrium 316
RBBB Right bundle branch block 317
RBC Red blood cell mi 318 RCU Renal care unit 319 RDS Respiratory distress syndrome 320 RDT Radio diagnostic technology 321 RFT Renal function test 322 RHD Rheumatic heart diseaseay 323 RMLE Right medio lateral episiotomy 324 RO Reverse osmosis 325 ROM Range of movement 326 RR Resperotory rate 327 RS Respiratory system 328 RSI Repetitive strain injury 329 RTA Road traffic accident 330 RX Prescription or treatment 331 S/B Seen by 332 S/C Subcutaneous 333 SA Spinal anaesthesia 334 SA node Sinus auricular node 335 SAB Sub arachnoid block 336 SBP Systolic blood pressure 337 SGA Small for gestational age 338 SICU Surgical intensive care unit 339 SIDS Sudden infant death syndrome 340 SLRT Straight leg raising test 341 sp.gr Specific gravity 342 SSI Surgical site infection 343 Stat Immediately 344 STD Sexually transmitted disease 345 STI Sexually transmitted infection 346 tab Tablet
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NABH Standard Reference: CQI
Procedure / Issue No / Revision No . Date: Hospital Apex Manual / 01 / 05 / 10– 01 – 2022 Page No. 70 of 84
347 TAH Total abdominal hysterectomy 348 TB Tuberculosis 349 TC
Total count 350 temp Temperature 351 TFTs Thyroid function test 352 THR Total hip replacement 353 TIA Transient ischaemic attack 354 TIVA Total intravenous anaesthesia 355 TKR Total knee replacement 356 TLD Thermo luminescent dosimeters 357 TM Tympanic membrane 358 TMJ Tempomandibular joint 359 TPN Therapeutic parenteral nutrition 360 TRAD Teleradiology 361 TSH Thyroid stimulating hormone. 362 TURP Transurethral resection of prostate 363 TURP/B
Transurethral resection of the prostate/bladder 364 UID No Unique identification number 365 UPS Uninterrupted power supply 366 URI Upper respiratory infection 367 USG Ultrasonography 368 USS Ultra sound scan 369 UTI Urinary tract infection 370 VAP
Ventilator associated pneumonia 371 VD
Venereal disease 372 VDRL
Venereal disease research laboratory 373 VF Ventricular fibrillation 374 VT
Verticular tachycardia 375 WB Weight-bearing 376 WBC White blood cell
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377 В.М.R.
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NABH Standard Reference: CQI
Procedure / Issue No / Revision No .
Date: Hospital Apex Manual / 01 / 05 / 10– 01 – 2022 Page No. 71 of 84
Basal metabolic rate mise
Write the complete chemical name (eg, magnesium sulphate, hydrochloric acidm potassium chloride). (eg. MgSO4, HCL, KCL) HCL = Hydrochloric Acid
Abbreviated chemical names MgSO4 = Magnesium Sulphate
Drop down selection lists should contain the full chemical name.
Abbreviated chemical names
KCL = Potassium Chloride
Write the complete medicine name. (eg. MTX, HCT, AZT)
Prescribe generically unless you need to give a patient a specific brand medicine.
Sometimes brand names do not adequately identify the medicine being prescribed (eg. Augmentin® or Timentin® may not be identified as containing a penicillin). The funded brand often changes in New Zealand and prescribing generically enables suitable products to be dispensed or administered, saving delay and sometimes expense to the patient.
Policy: Hospital Apex Manual
NABH Standard Reference: CQI
Zero: lack of a leading zero (eg. 5mg)
Zero: adding a trailing zero (eg. 5mg)
Procedure / Issue No / Revision No .
Date: Hospital Apex Manual / 01 / 05 / 10– 01 – 2022 Page No. 72 of 84
5mg = 0.5mg
Avoiding leading zeroes by rewriting the dose as smaller units (eg. 0.5mg = 500 micrograms). If not possible, include a leading zero (eg. 0.125mg).
Never write a zero after a decimal point. 100.0g = 100g Write 1.0mg as 1mg. Write 100.0mg as 100g.
1.0mg = 1mg
Roman numerals (eg. ii, iv, x) Numbers 1, 2, 3, 4, etc. Use words or Hindu – Arabic numbers (ie. 1, 2, 3, etc.)
U, u (unit)
Mistaken for “0” (zero), the number “4” (four) or “cc” Write “unit”.
IU (International Unit) Mistaken for IV (intravenous) or the number 10 (ten). Write “International Unit”.
Q.D., QD, q.d., qd (daily) Mistaken for each other Write “daily”.
Q.O.D., QOD, q.o.d., qod (every other day)
Period after the Q mistaken for “I” and the “O” mistaken for “I” Write “Every other day”.
Trailing zero (X.o mg)*
Decimal point is missed
Write X mg Lack of leading zero (.X mg) Write o.X mg
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NABH Policy: Hospital Apex Manual
NABH Standard Reference: CQI Procedure / Issue No / Revision No . Date: Hospital Apex Manual / 01 / 05 / 10– 01 – 2022 Page No. 73 of 84
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Purpose:
NABH Policy: Hospital Apex Manual
NABH Standard Reference: CQI Procedure / Issue No / Revision No . Date: Hospital Apex Manual / 01 / 05 / 10– 01 – 2022 Page No. 74 of 84
To approve documents for adequacy prior to issue.
To ensure that documents remain legible and readily available. To review and update as necessary.
To re-approve the documents.
To ensure that changes and the current revision status of documents are identified.
To ensure that relevant version of applicable documents are available at point of use.
To prevent the use of obsolete documents ad to apply suitable identification to them if they are retained for any purpose.
To ensure that documents of external origin are identified and their distribution is controlled.
Process:
Request for introducing documents is submitted by concerned head of the departments to quality team who reviews the same and approves/rejects the proposal in quality assurance committee. Once approved, the document number is issued by the quality team. Document distribution list is maintained in the quality room. Yearly once, all documents have to be reapproved by the QA committee. Committee also approved/disapproves the changes required in the current document and issues the new version. Obsolete versions are removed and destroyed from all areas. One copy of obsolete forms are persevered in the quality room for future reference.
1. KH-R-MED-0 D/17 – Initial Assessment for Day care procedure 2. KH-R-MED-01/17 – Initial Assessment For Medical Specialties 3. KH-R-MED-01 A/17 – Initial Assessment Form in patient Obstetrics 4. KH-R-MED-01 B/17 – Initial Assessment Form for inpatient (Gynecology)
KH-R-MED-01 C/17 – Initial Assessment for Surgery / Orthopedic
KH-R-MED-01E/17-Initial Assessment Form For Emergency Room
KH-R-MED-01 E/17 – ER Assessment
KH-R-MED-01 F/17 – Initial Assessment for Pediatric
KH-R-MED-02/17
Neonatal Case Record
Doctor orders & progress record 11. KH-R-MED-04/17 – Consultation Request 12. KH-R-MED-05/18 – Prescription of Medication
KH-R-MED-03/17
KH-R-MED-06/17 – A.N.C Card 14. KH-R-MED-07/17 – Medical Certificate 15. KH-R-MED-08/17 – Immunization Record 16. KH-R-MED-09/17 – Informed consent for Surgery 17. KH-R-MED-11/17 – Informed consent for procedure KH-R-MED-11/17/VER-01/19 - Informed consent for procedure (Ammendented on
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NABH Policy: Hospital Apex Manual NABH Standard Reference: CQI Procedure / Issue No / Revision No . Date: Hospital Apex Manual / 01 / 05 / 10– 01 – 2022 Page No. 75 of 84
20.07.2019)
18. KH-R-MED-12/17 – informed consent for Moderate Sedation 19. KH-R-MED-13/17 – Informed consent for Blood products 20. KH-R-MED-14/17 – Informed consent for high risk Surgical procedure 21. KH-R-MED-15/17 – Informed consent for Restraint 22. KH-R-MED-16/17 – Informed Consent for Anesthesia 23. KH-R-MED-17/17 – Informed consent for HIV antibody testing 24. KH-R-MED-18/17 – Informed consent for Day care procedure 25. KH-R-MED-19/17 – High risk consent ICU 26. KH-R-MED-20/17 – NICU consent form 27. KH-R-MED-21/17 – Check list to make Surgery safe 28. KH-R-MED-22/17 – Operation record 29. KH-R-MED-22A/17 – LSCS Operation Record 30. KH-R-MED-23/17 – Post pop plan of care D/O 31. KH-R-MED-24/17 – Post OP plan of care D/I 32. KH-R-MED-25/17 – Pre-op Anesthetic evaluation form 33. KH-R-MED-26/17 – Informed consent for Medical photography 34. KH-R-MED-27/1 7 – Discharge Summary (Medical Pediatric) 35. KH-R-MED-28/17 – Discharge Summary Surgery & Ortho 36. KH-R-MED-29/17 – Obstetric Discharge Summary 37. KH-R-MED-30/17 – Gynecology Discharge Summary 38. KH-R-MED-30/17 – Initial Assessment Surgical/Orthopedic Cases 39. KH-R-MED-31/17 – Well baby Discharge Summary 40. KH-R-MED-31A/17 – NICU Discharge Summary 41. KH-R-MED-33/17 – Discharge Summary for Day care procedure 42. KH-R-MED-34/17 – DAMA Discharge Summary 43. KH-R-MED-35/17 – Wound Certificate 44. KH-R-MED-36/17 – Medical Certificate for death 45. KH-R-MED-37/17 – CPR Event form 46. KH-R-MED-41/17 – Delivery Note 47. KH-R-MED-43/17 – Consent for Thrombolysis 48. KH-R-MED-45/17 – Restraint monitoring form 49. KH-R-MED-46/17 –Doctors Hand over Sheet 50. KH-R-MED-48/18 –Prescription For Narcotic 51. KH-R-MED-55/17 – Medication Error –Reporting Form 52. KH-R-MED-56/18 – MTP Consent Form 53. KH-R-MED-01/21- Daily Counselling form - Intensive care unit
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1. KH-R-NUR-01/17 – Nursing Initial Assessment Form
2. KH-R-NUR-02/17 – Nurse Daily Record 3. KH-R-NUR-03/17 – Clinical chart 4. KH-R-NUR-04/17 – Intake output chart
5. KH-R-NUR-06/17 – Diabetic follow up chart
6. KH-R-NUR-08/17 – Pre operative check list 7. KH-R-NUR-10/17 - Medication order and administration sheet
8. KH-R-NUR-11/17 – Critical care flow chart
9. KH-R-NUR-12/17 – NICU Monitoring chart
10. KH-R-NUR-13/17 – NICU Ventilator chart
11. KH-R-NUR-14/17 – Exchange transfusion Flow Sheet NICU
12. KH-R-NUR-15/17 – Check list for NICU shift out Baby
13. KH-R-NUR-16/17 – Check list the discharge of normal Baby
14. KH-R-NUR-17/17 – Check list for transfer between ward/ unit 15. KH-R-NUR-18/17 – Patient transfer Form (Intra Hospital)
16. KH-R-NUR-27/17 – Transfusion Monitoring Chart
17. KH-R-NUR-29/17 – Adverse Reaction for drug 18. KH-R-NUR-30/17 – Transfusion Reaction Form 19. KH-R-NUR-47/17 – Convulsion chart
20. KH-R-NUR-51/17 – Tubing Chart 21. KH-R-NUR-52/17 – Atropine Chart 22. KH-R-NUR-53/17 – Positioning and bed sore chart 23. KH-R-NUR-62 /17- Nurse Hand over Chart
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18.
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19.KH-R-NUR-36 E/17 – Narcotic drug inventory book 20.KH-R-NUR-38/17 – Minor OT changes book 21.KH-R-NUR-39/17 – ECG Register 22.KH-R-NUR-40/17 – BBMP Register 23.KH-R-NUR-41/17 – Job book 24.KH-R-NUR-42/17 – Nursing allocation book 25.KH-R-NUR-43/17 – Fumigation Register 26.KH-R-NUR-44/17 – Laundry Book 27.KH-R-NUR-45/17 – NST Register 28.KH-R-NUR-46/17 – D & C Register 29.KH-R-NUR-48/17 – OT Register 30.KH-R-NUR-49/17 – Labor Room Register 31.KH-R-NUR-49/17 – Patient drug Replacement book 32.KH-R-NUR-54/17 – MLC Book 33.KH-R-NUR-56/17 – Oral anticoagulation Chart 34.KH-R-NUR-57/17 – Body part disposal register
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NABH Policy: Hospital Apex Manual
NABH Standard Reference: CQI Procedure / Issue No / Revision No . Date: Hospital Apex Manual / 01 / 05 / 10– 01 – 2022 Page No. 79 of 84
35. 36.KH-R-NUR-61 A/17 – HIC Monitoring Form 37.KH-R-NUR-61 A/17-Complaint Register 38.KH-R-NUR-61 A/17-Needle stick
Radiology
1. KH-R-RAD-01/17 – Consent for CT
2. KH-R-RAD-02/17 – X-Ray form (Request For X-Ray Examination 3. KH-R-RAD-03/17 – 4D Ultrasound Request Form
4. KH-R-RAD-04/17 – CT Request 5. KH-R-RAD-05/17 – X-ray report 6. KH-R-RAD-06/17 – CT report 7. KH-R-RAD-07/17 – Bed side Ultra sonogram 8. KH-R-RAD-08/17 – High risk consent for radiology 9. KH-R-RAD-09/17 – Antenatal USS report 10. KH-R-RAD-10/17 – USS report 11. KH-R-RAD-10 A/17 – ECHO report 12. KH-R-RAD-10 B/17 – Radiology Critical Report Register 13. KH-R-RAD-10 E/17 – Incident Register 14. KH-R-RAD-10 F/17 – Break Down Register 15. KH-R-RAD-11/17- X-Ray Reporting Register
16. KH-R-RAD-11A/17- Recall Register for CT, X-Ray, USS. 17. KH-R-RAD-12/17 – X-Ray Register
18. KH-R-RAD-12 A/17 – ECHO Register
19. KH-R-RAD-12 B/17 – USS Register 20. KH-R-RAD-12C/17 – CT Register 21. KH-R-RAD-13/17 – Stock Register
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22. 23. KH-R-RAD-13B/17 – CAPA Register
24. KH-R-RAD-14/17 – Contrast Register
KH-R-MRD(UPDATED)
KH-R-MRD-01/18 GENERAL CONSENT
KH-R-MRD-02/17-VER -01/19 ASSEMBLING FORM
KH-R-MRD-03/17 MEDICAL AUDITING KH-R-MRD-4A/17 MIDNIGHT CENSUS KH-R-MRD-05/17 DAILY ADMISSION LIST
KH-R-MRD-06/17 PATIENT DIAGNOSIS REPORT
KH-R-MRD-07-C/17 OUT GOING REGISTER KH-R-MRD-09/17 BIRTH REGISTER
KH-R-MRD-10/17 TRACER CARD KH-R-MRD-11/17 INTERNAL RECORDS REQUEST FORM KH-R-MRD-12/17 RECORDS REQUEST FORM (Tick the appropriate) KH-R-MRD-13/17
NEW PATIENTS REGISTRATION FORM
NEW BORN REGISTRATION FORM KH-R-MRD-15/18 BIRTH REPORT KH-R-MRD-15A/18
KH-R-MRD-13A/18
MEDICAL AUDIT FORM ADMISSION RECORD DAILY ADMISSION LIST
KH-R-BIL
KH-R-BIL-01/17 Activity record for billing KH-R-BIL-01/17/VER 01 Activity record for billing KH-R-BIL-02/17 ICU & NICU Billing sheet
KH-R-PHY(UPDATED)
KH-R-PHY-01/17
Orthopaedic Assessment Form
KH-R-PHY-02/17 Neuro Rehabilitation
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NABH Policy: Hospital Apex Manual
NABH Standard Reference: CQI Procedure / Issue No / Revision No . Date: Hospital Apex Manual / 01 / 05 / 10– 01 – 2022 Page No. 81 of 84
KH-R-PHY-03/17 KH-R-PHY-04/17 Paediatric Assessment Form
KH-R-PHY-05/17
Physiotherapy Progress Note
KH-R-PHY-05/17-VER01/19
Physiotherapy Progress Note
KH-R-PHY-06/17 Physiotherapy Referral Form KH-R-PHY-07/17 Consent Form for Physiotherapy KH-R-PHY-15A/17 In Patient Register Op Register
KH-R-RAD (updated)
KH-R-RAD-01/17 Consent form KH-R-RAD-02/17 Requisition for X-Ray Examination KH-R-RAD-03/17 Requisition Form-4D Ultrasound
KH-R-RAD-04/17 Requisition Form
KH-R-RAD-05/17 X-Ray Report Issue KH-R-RAD-06/17 CT Report Issue KH-R-RAD-07/17 Bed side Ultra Sonogram KH-R-RAD-08/17 High Risk Consent For Radiology KH-R-RAD-09/17 Antenatal USS Report KH-R-RAD-10/17 USS Report KH-R-RAD-10A/17 KH-R-RAD-10B/17 Radiology Critical Report Register-X-Ray & USS
KH-R-RAD-10C/17 C-ARM Register KH-R-RAD-10D/17
KH-R-RAD-12B/17 USS Register
KH-R-RAD-13A/17 Inventory Register -USS
KH-R-MED-2/20 Informed consent for Transfer for diagnostic test / procedure KH-R-MED-1-20
New document - 2021
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KH-R-MED-01/21
KH-R-MED-02/21
NABH Policy: Hospital Apex Manual
NABH Standard Reference: CQI Procedure / Issue No / Revision No . Date: Hospital Apex Manual / 01 / 05 / 10– 01 – 2022 Page No. 82 of 84
Informed consent for Transfer for diagnostic test / procedure
KH-R-MED-03/21 Informed consent for Laparoscopic Cholecystectomy
KH-R-MED-04/21 Informed consent for Laser Pilonidal sinus
KH-R-MED-05/21
Informed consent for Laparoscopic Appendicectomy KH-R-MED-06/21 Informed consent for Laser Fistulectomy KH-R-MED-07/21 Informed consent for Laser Hemorrhoidectomy + Lase Lateral Sphincterectomy
KH-R-MED-08/21 Informed consent for Hemorrhoidectomy KH-R-MED-09/21 Informed consent for Hernia Repair KH-R-MED-10/21 Informed consent for Medical Gastroenterology Procedure KH-R-MED-11/21 KH-R-MED-12/21 Informed consent for fitness travel by flight
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NABH Policy: Hospital Apex Manual
NABH Standard Reference: CQI Procedure / Issue No / Revision No . Date: Hospital Apex Manual / 01 / 05 / 10– 01 – 2022 Page No. 84 of 84
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