4 Sun Shiners

8/4/2019 4 Sun Shiners

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SUNSHINE RECOMMENDATIONS


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WHY???

Lets improve ourselves!!

Not just for NABH accreditation


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What am I doing here???

I am here just to enlighten you over SUNSHINE

policies regarding documentation of the in

patient details

1) Integrated in-patient initial assessment form

2) Drug Order sheet

3) Surgical patient Record

4) Intra Hospital Referral form

5) Admission Note


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INTEGRATED IN-PATIENT INITIAL

ASSESSMENT

Please make sure that this is filled as soon

as the patient is admitted in the hospital


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PART-A

Has to be duly filled by the Nurse in charge

and make sure that it is filled by the time the

treating surgeon comes!


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PART-B

To be duly filled by the attending doctor!

Simple MBBS Stuff


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Discharge Planning

Need to be completed at admission


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PLAN OF CARE

PLAN OF CARE

MEDICAL/CONSERVATIVE

SURGICALTick boxes make the job easy, its going to take only a few

minutes of your time


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Sign and date your work

A good artist always signs off

Consultants need to countersign every

admission within 24 hours


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Our Time frames

Field of activity Time frameResponsible Person

OP 2 HOURS Registrars

CASUALTY 30 min, as per triage level CMO-Nurses-Registrars

IP WITHIN 1 HOUR Nurses initial assessment

IP WITHIN 24 HOURS RegistrarDietician-DMO-

Consultants


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DRUG ORDER SHEET

Please please. Write your prescriptions in

capitals (I mean CAPITALS)


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No trade names please

Do check for allergies

Dont just sign

Date it please

You can

specify thetimes


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DRUG ORDER SHEET

Instruction by telephone from a prescriber to anurse to administer a medicine previously notprescribed is unacceptable in normal

circumstances.Sunshine hospital medication prescription and administration policy


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VERBAL orders

A verbal order shall be issued only by anybody who is a Consultant orabove that and none other than that..

Before closing the conversation (telephone or person) the nurse or duty

medical officer shall read back the order to the doctor and confirm if thewritten down order is correct, in case of drugs she shall even spell thedrug to recheck with the consultant and then close it.

Doctor who issued the verbal order within 24 hrs should counter sign

that verbal order


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WHAT TO MENTION SEPARATELY

1) Parenteral infusions other than the medications(like IV fluids, TPN)

2) Stat medications

3) SOS medications


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No trade names please Dont just

sign

Date it

please

No abbreviations, all caps

please


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SURGICAL PATIENT RECORD

An exhaustivebooklet of 16 pages(BUT IT IS VERY

IMPORTANT!) Make sure that the

first 4.5 pages areduly filled beforethe patient reachesOT!


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TIME OUT

All work should cease during a period of time when allmembers of the operative / procedural team,usingactive communication, confirms

correct patient,

correct procedure, correct site and side,

sterility of the equipment

availability of all items needed for anaesthesia and

surgery antibiotic prophylaxis

any patient allergies.

D t t t ti b f thi


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Donot start operating before this

checklist is done

MAKE TIMEOUT A HABIT


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CONSENT

Please make sure it is taken by the treating

doctor/ team member but not the nurse

incharge!!!


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Another important part of the consent

process

Doctors need to Countersign


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SURGEONS NOTES


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Admission Note

We need to explain to the pt

Disease

Inv needed

Treatment process

Cost ( estimated)

Probable outcomes

This form takes care of all this

Please fill this at admission


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Please fill in the orders

Inv requested

Plan of care Spl instructions

Preop orders

This form is for the pt to go from OPD /Casualty to the ward


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Admission Note

This part need to be filled in by Front Office /

Patient counselor


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Intra Hospital Referral form

Once completed this will go into the case sheet The visiting consultant will have a better idea why

he is there in the first place


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OTHER THINGS WE NEED - Contd

Discharge summary to be given to all patients

including LAMA, MLC etc

Discharge summary to contain reason for

admission, findings, diagnosis, patients

condition at discharge, investigation results,

procedure, treatment given, follow up advice,

how to obtain urgent care


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OTHER THINGS WE NEED

Credentialing and Privileging


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CODES

Emergency Codes

CODE MEANING

BLUE MEDICAL EMERGENCY

RED FIRE

BLACK BOMB THREAT

PURPLE SECURITY THREAT

PINK CHILD ABDUCTION

Grey External Disaster/ Mass

Emergency


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HIC

HIC MANUAL Available on every desktop

Antibiotic policy Hand Hygiene

Surveillance Tool kit

Needle stick injury


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VULNERABLE PATIENTS

Admission and Discharge criteria for ICU

Who all are Vulnerable patients and care of

such of patients

Geriatric patients (>65 years of age)

Pediatric patients (


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IS IT THAT DIFFICULT ???


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10 COMMANDMENTS

Write Medications Order in CapitalLetters.

Document your visit with Notes DulySigned with the Date, Time, Signature

and Name.

Avoid Verbal Orders.

Use of Alcohol Hand Rub Before And

After Each Patient Examination.

Make a Habit of patient and Familyeducation as Part of Care.


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10 COMMANDMENTS

Ensure Informed Consent for all Procedures.

Assess and Reassess Patient as per Hospital Policy.

Prepare/ Counter Sign Discharge Summaries and Talk to PatientRegarding Discharge Instructions Follow-up and Care at Home.

Prescribe as per Hospital Formulary and Follow the AntibioticPolicy.

Have Formal Meetings/ Briefings with the other Specialists whenmore than One Doctor is treating the Patient.


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Thank you

Please send your feed back to me @

[email protected]
mailto:[email protected]:[email protected]

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4 Sun Shiners