Dr Lim Meng Lang Manual Template Updated

8/14/2019 Dr Lim Meng Lang Manual Template Updated

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Operating Manual and SOPs for Siburan Union Clinic

1. Company Profile2. Policy Statement3. Organization Chart

4. Plan of Organization5. Consultation Hours6. Emergency call information7. Written Policy

a. Registered Medical Practitionerb. Procedure for Patient Registration, Attendance and Referralc. Use of antibioticsd. General Maintenance of Clinice. Transport of Laboratory Specimensf. Consentg. Incident Reportingh. Infection Control

8. Staff identification9. Order for Diagnostic Procedure, Medication and Treatment Orders10. Patients Medical Record Register11. Billing Procedure12. Fee schedule13. Referral Form14. Basic Emergency Care15. Procedure for BLS1 and BLS216. Flow chart for BLS117. Patients Rights18. Grievance Procedure

19. Feedback Form20. Incident Reporting Form21. Disaster Preparedness22. Use of volunteers23. Volunteer Application Form24. Volunteer Health Questionaire25. Pharmaceutical services26. Registers and Records of Patients (Radiological or Diagnostic Imaging Services)27. Clinic Procedures28. Housekeeping29. Social & Welfare Contribution30. Staff Assessment31. Acknowledgement by staff

COMPANY PROFILE


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Siburan Union Clinic was established on 1 November 1990.The clinic is a sole-proprietorship and it is managed by Dr. Lim Meng

Lang, a graduate from the University of Nottingham Medical School.He is assisted by a dedicated and competent team of 5 clinic assistantssome of whom have more than 10 years experience on the job.

We provide comprehensive medical care for all age groups at the primary level. We have in-house facilities for ultrasonography,electrocardiography, nebulization, random blood glucose analysis androutine urinalysis.

POLICY STATEMENTOUR MISSION IS TO PROVIDE COST-EFFECTIVE HEALTH CARE WITH THE SUPPORT ANDCOOPERATION OF OUR PATIENTS.

OUR PATIENTS CAN EXPECT THE HIGHEST LEVEL

OF INTEGRITY, RESPECT, EMPATHY ANDEFFICIENCY FROM OUR STAFF.

1. Our staff shall wear a badge for identification.2. We will, upon request, provide estimated charges

prior to treatment. We will inform the patient of anyunanticipated charges. We will, upon request,provide itemized billing at no extra cost. Our professional fees shall conform to the Fee Scheduleas in the Private Healthcare Facilities and Services(private Hospitals and Other Private HealthcareFacilities) Regulations 2006.


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3. All patients shall be informed of their medicaltreatment and care.

4. All patients shall be entitled to a reply as set out inour grievance procedure.

5. All patients shall be provided with a medical reportwith the payment of the appropriate fee and only withwritten consent from the patient concerned.

Organization Chart


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SIBURAN UNION CLINIC

Plan of Organization

1. The Doctor s hall be in overall charge of all activities in the clinic.2. The chief clinic assistant shall assist the doctor in all matters pertaining to the smooth

running of the clinic. She will prepare the invoices and bills at the end of each month.She will assist the doctor in maintaining the duty roster and record of the annual leave

and sick leave of all staff.3. The senior clinic assistants will assist the chief clinic assistant and the doctor in all theabove tasks.

4. The clinic assistants will assist fellow staff and the doctor in the smooth running of theclinic.

5. All clinic assistants of whatever grade shall be involved in all tasks pertaining to thesmooth and efficient running of the clinic. Such tasks including registration of patients,keeping necessary records, assisting the doctor in the consultation room, dispensingmedications under the direct supervision of the doctor, general housekeeping work,making bill payments and the like, accompanying the doctor on home visits and anyother activity that the doctor may direct.

6. The Person-in-charge may appoint any staff on a contract basis to advise him onstrategies for the organization and to assist him in the preparation of accounts and thelike. Such a person shall not have any direct contact with patients or be involved inclinical patient care.


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SIBURAN UNION CLINIC

The official clinic hours in this clinic are:

Monday 8am 2pmTuesday to Friday 8am 12noon 1.30pm 7.30pmSaturday 8am 12noon 1.30pm -4pmSunday/Public Holiday 8am 12noon


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EMERGENCY CALL INFORMATION

POLICE/FIRE/AMBULANCE 999RESCUE 991

HOSPITAL UMUM SARAWAK 276666TIMBERLAND MEDICAL CENTRE 234466NORMAH MEDICAL SPECIALIST CENTRE 440055KUCHING SPECIALIST HOSPITAL 365777

_____________________________________________ Dr and staff ADDRESSES AND TEL/hp NUMBERS

RED CRESCENT SOCIETY 428228ST JOHNS AMBULANCE 240907


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WRITTEN POLICY OF CLINIC

1. Registered Medical Practitioner

Only a registered medical practitioner registered under the Medical Act 1971 andholding a valid practicing certificate shall be allowed to practice in this clinic.

Only registered practitioners who have a valid written contract between himself/herself and the clinic shall be allowed to practice in this clinic.

All registered medical practitioners practicing in this clinic shall be responsible for thequality and compassionate care and treatment of all patients seen by him/her and shallat all times act in compliance with all relevant laws and regulations of Malaysia.

2. Procedure for Patient Registration, Attendance and Referral

All new patients shall be registered in the Patient Register.

Patients information shall be entered as per regulation in the front sheet. Anyinformation that the patient has refused to divulge/or unable to provide shall be enteredas Not Available or N/A.

Follow-up patients shall be registered in the follow-up continuation sheet upon arrival.

All patients who are referred shall have their available information recorded in theReferral register.

No staff shall divulge any patient in formation to any third party.

All patient information shall be treated with the strictest confidentiality.

3. Use of Antibiotics


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In the event of a notifiable infectious disease infection, the Person-in-charge may order appropriate cultures to determine the sensitivity of the appropriate organism.

Appropriate antibiotics prescribed for treatment of the reportable infectious diseaseshall be recorded.

4. General Maintenance of the Clinic

This clinic shall be kept in good repair and shall provide a safe and comfortableenvironment for all its staff,

All equipment will be regularly checked and maintained on a schedule determined bythe Person-in-charge.

5. Transportation of Laboratory Specimens

Laboratory specimens shall be transported to an authorized laboratory as determined bythe Person-in-charge.

All specimens shall be collected and kept in the appropriate container supplied by thelaboratory.

All specimens shall be duly labeled with the patients name, registration number anddate of collection.

Specimens shall be sent to the laboratory within 24 hours of collection in sealed plastic bags provided by the laboratory and accompanied by the completed test request form.

All staff handling laboratory specimens must wear protective gloves and take allnecessary precautions to prevent direct contact with the specimen and to avoid needle-stick injuries.

No food shall be kept in the refrigerator where laboratory specimens are kept.

6. Use of Volunteers

This clinic will allow volunteers to work at its premises provided the volunteer has the

relevant qualification, training and experience in the relevant healthcare profession.

All volunteers will have to apply in writing and appear for an interview with thePerson-in-charge.

Upon approval, the volunteers shall be registered in the Volunteer Register.


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Volunteers shall undergo a period of orientation and supervision as determined by thePerson-in- charge.

Volunteers shall only be allowed to assist or perform professional care as determined bythe Person-in-charge.

7. Consent

For any special procedure, minor operation or anaesthesia, the patient shall be requiredto give written consent in the form and manner as set out in the Consent Form.

The Person-in-charge performing the special procedure, minor operation or anaesthesiashall ensure the Consent Form is duly signed before undertaking the above.

8. Incidental Reporting

Any unforeseeable or unanticipated incidents such as death of patient, fires in clinic,assault or battery of patient, malfunction, intentional or accidental misuse of patientcare equipment shall be reported to the Person-in-charge.

Clinic staff shall immediately inform the Person-in-charge of the incident uponoccurrence.

The Person-in-charge will document the details of the incident and obtain a writtenstatement from witness(es) if a witness(es) is present.

Original and copies of report, relevant patient notes, relevant documents shall be kept inseparate files for safe-keeping and future reference.

A copy shall be sent the Director-General of Health by registered post (within 10working days) following the incident.

A receipt of the report shall be requested.

9. Infection Control

All staff must be diligent and take the necessary measures to prevent, identify andcontrol infection acquired in or brought into the clinic. Such measures include wearingface masks, using rubber gloves and cleaning the various surfaces and equipment withan appropriate disinfectant.

All infections amongst staff must be reported to the person-in-charge so thatappropriate evaluation, analysis and recording can be carried out.


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Any reportable infectious disease among patient or staff shall be reported to theMinistry of Health in the infectious disease notification form or any other form supplied

by the State Health Department.

All infections amongst patients will be closely monitored by the person-in-chargeduring the course of his clinical work and if there is unusual increase in the rate of infections, the Health Department will be informed.

All staff with any infectious or communicable disease will be taken off duty until he or she is no longer contagious to other people.

Any equipment that has become contaminated during the treatment of an infectious patient shall be withheld from use and appropriately disinfected under the supervisionof the person-in-charge.

All staff must regularly wash their hands properly and practice good hygiene.

Disposable rubber gloves must be used by all staff when dealing with biologicalhazards.

The clinic shall comply with any directives or guidelines issued by the Director Generalor any appropriate government authority.

STAFF IDENTIFICATION

All clinic staff shall wear staff identification nametags during clinic hours

ORDER FOR DIAGNOSTIC PROCEDURE, MEDICATION OR TREATMENT ORDERS

All diagnostic procedures, medication or treatment will be given upon receipt of a written or verbal order of a registered medical practitioner.

The generic or trade name and dosage of all medications prescribed and dispensed in this clinicwill be labeled upon the instructions of the Person-in-charge. The person-in-charge shall

inform the patient about its administration.

PATIENTS MEDICAL RECORD REGISTER

All patients medical records shall be kept in a safe and orderly fashion in the clinic.


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No records shall be transferred out of the clinic without expressed approval of the Person-in-charge.

Any movement of patients medical record shall be entered into the Patients Medical RecordMovement Register.

BILLING PROCEDURE

If requested by the patient, it is the policy of the clinic to inform the patient details of their medical bills prior to treatment. It is also the policy of this clinic to issue itemised bills uponrequest by the patient.

A copy of the Seventh Schedule (Professional Fees) shall be made available for the patientsreference.

PRIVATE HEALTHCARE FACILITIES AND SERVICES AC T.

FEE SCHEDULE (PROFESSIONAL FEES) (Seventh Schedule)

Consultation RM10 RM35Consultation after clinic hours Up to 50% above usual rate

ECG RM35PAP SMEAR RM45

URINE PREGNANCY TEST RM15STRIP URINE TEST RM10BLOOD GLUCOMETER TEST RM10CATHERISATION RM85ULTRASOUND(Antenatal Level 1) RM55

MEDICAL EXAMINATION(excluding X Ray, ECG, lab tests) RM40 RM200

MEDICAL REPORT RM50 RM200

The full fee schedule (Seventh Schedule) is available for viewing upon request


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REFERRAL FORMDate:Time:

SIBURAN UNION CLINIC62 Siburan Bazaar

17 th Mile Kuching-Serian Road94200 Kuching

Sarawak Tel: 082-863395 Fax: 082-863758

To: _____________________

_____________________

_____________________

Dear Dr

Provisional Medical Diagnosis : ____________________________ Current Medications:

Known Allergies:Patients Condition on Transfer:

Yours sincerely ,


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DR. LIM MENG LANGBMedSci (Hons), BM, BS(Nottingham, UK)

BASIC EMERGENCY CARE SERVICE

1. Any emergency patient when brought to this clinic will be accorded emergency careimmediately. Such care shall commensurate with the capability of this clinic and theexpertise of the staff involved.

2. The nature and scope of such emergency care services provided by this clinic are:i. Basic life support (as per UK standard)

ii. Any other measures in accordance with the clinics capabilities asdetermined by the Person-in-charge

3. Prior to the transfer of the patient to another healthcare facility, the receivinghealthcare facility shall be notified of the impending transfer.

4. Upon transfer of the patient to another healthcare facility, appropriate record of the patient shall be kept in the Referral Register.

THE PROCEDURE FOR BLS1 IN THIS CLINIC IS AS FOLLOWS:

1. Lie patient flat in an open space, and feel for the pulse and observe the respiration.If there is a pulse, take the BP. If there is no pulse, begin BLS.

2. Take brief history from any accompanying persons. Exclude anaphylaxis.3. Instruct available staff to get more help immediately. Telephone ambulance service.4. Loosen all the patients clothes, and thump patients chest as hard as possible

(thumpversion).5. Commence oxygen via a mask if patient is breathing spontaneously, using an

oropharyngeal airway + mask.6. If no spontaneous breathing, breathe hard into the mouth. Maintain airway at all

times.7. Arrange transfer of patient to nearest hospital as soon as possible.8. Telephone Emergency Department of the nearest hospital and inform receiving

person. Record name of receiving person, time of call, time of transfer and patientscondition.

THE PROCEDURE FOR PATIENTS REQUIRING BLS (2) (FOR PATIENTS REQUIRINGINTRAVENOUS SUPPORT)

1. Lie patient flat in an open space, and feel for the pulse and observe the respiration.If there is a pulse, take the BP.

2. If peripheral vein is accessible, insert IV needle/cannula immediately.3. Take brief history from any accompanying persons. Quickly assess blood loss andinjuries.

4. Apply pressure bandages/tourniquet (if possible) to decrease major bleeding.5. Instruct available staff to call for help immediately. Telephone ambulance service.6. Administer oxygen by mask. If patient is in respiratory distress, use an

oropharyngeal airway + mask.


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7. If no spontaneous breathing, breathe hard into the mouth. Maintain airway at alltimes.

8. If no pulse or spontaneous respiration, commence BLS1 immediately.9. Arrange transfer of patient to the nearest hospital as soon as possible.10. Telephone Emergency Department of the nearest hospital and inform receiving

person. Record name of receiving person, time of call, time of transfer and patientscondition

FLOW CHART FOR BASIC LIFESUPPORT (BLS1)

COLLAPSED PATIENT

SUMMON HELP

CHECK RESPIRATION VE

CLEAR AIRWAY +VE REFER

CALL AMBULANCE

30 CHEST COMPRESSIONSMOUTH TO MOUTH

2 BREATHS, 30 COMPRESSIONS

TELEPHONE:

AMBULANCE SERVICE (SGH) 230689SARAWAK GENERAL HOSPITAL 276666

PATIENTS RIGHTS


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It is the policy of this clinic to inform the patient concerned about the nature of his/her medicalcondition(s) and any proposed treatment, investigation or procedure and the likely costs of thetreatment, investigation or procedure as part and parcel of his consultation.

It is the duty of the patient to ensure that he/she has understood all relevant information withrespect to the above at the end of the consultation.

All patients in this clinic will be treated with strict regard to decency and professionalism.

A medical report shall be forwarded within two weeks upon written request and upon paymentof the fee as per the Seventh Schedule (Professional Fees Medical Report Fee)

GRIEVANCE PROCEDURE

It is the policy of this clinic to have a grievance mechanism for patients. The mechanism shall be as follows:-

Any patient with a grievance shall be asked to first discuss his/her with the Person-in-charge.

If this fails to resolve the problem, he/she shall then be requested to lodge his/her grievance inwriting by filling in the FEEDBACK FORM which will be provided by this clinic for theconvenience of the patient concerned.

Upon completion of the Feedback Form, he/she shall then inform the senior staff of this clinicwho shall then receive and acknowledge receipt of the completed form.

The same staff shall inform the patient that investigation shall be completed within two weeks.

The staff shall then forward the FEEDBACK FORM to the Person-in-charge as soon as possible.

The Person-in-charge shall conduct an investigation within two weeks upon receipt of the formand shall record his findings in the Grievance Investigation Report.

Upon completion of his investigations, the Person-in-charge shall inform the patient of thefindings.

If this does not resolve the matter, the Person-in-charge shall then inform the patient that theclinic will arrange for the services of a mediator from the local Private PractitionersAssociation or any other mediator that is agreeable to both parties to resolve the matter.

If this fails, the Person-in-charge will then refer the matter to the Director-General for adjudication.

FEEDBACK FORM


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Name of Patient: _____________________

I.C. No.: ____________________________

Address: ____________________________

___________________________________

___________________________________

Tel. No.: ___________________________

Date and Time of Incident: ____________________________

PATIENTS COMMENTS :

______________________

Signature

INCIDENT REPORTING FORM

Name of Doctor-in-charge: ___________________________


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Designation:_______________________________________

I/C No:___________________________________________

Clinic Address: _________________________________________________________________

Date/ Time: ______________________________________

Nature of Incident:

Action Taken:

Witness Statement:

Name of Witness:IC No.:Address:Tel. No.:

DISASTER PREPAREDNESS

In the event of a disaster in the vicinity of this clinic, the Person-in-charge or an appointedmember of the clinic shall immediately inform the relevant authorities.

All staff who are contactable shall be called back to the clinic. All leave for shall be cancelled.

The clinic shall be cleared of all non-emergency patients.


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A suitable area of the clinic will be prepared to receive and provide basic life support for emergency patients.

Ambulance and the nearest hospital will be informed of the transport and arrival of patients.

All staff and resources from this clinic shall be made available to the relevant authorites in theevent of any disaster

USE OF VOLUNTEERS

This clinic will allow volunteers to work in its premises provided the volunteer is a person withsuch qualification, training and experience in the relevant healthcare profession.

All volunteers will have to apply in writing and appear for an interview with the person-in-charge.

Upon approval, the volunteers shall be registered in the Volunteer Register.

Volunteers shall undergo a period of orientation and supervision as determined by the person-in-charge.

Volunteers shall only be allowed to assist or perform professional care as determined by the person-in-charge

VOLUNTEER APPLICATION FORM

NAME:I.C. NO.:ADDRESS:

SEX:MARITAL STATUS:


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QUALIFICATIONS:

RELEVANT JOB EXPERIENCE:

REASON FOR VOLUNTEERING:

PERIOD OF AVAILABILITY:

VOLUNTEER HEALTH QUESTIONAIRE

NAME

IC NO

ADDRESS

SEX


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MARITAL STATUS

OCCUPATION

DATE OF BIRTH

Date of last consultation

Reason

Name of Dr consultedAre you on any form of medication at present?If yes, please state typeof medications

Have you at any timeconsulted apsychiatrist?

If Yes, please elaborate

Have you EVER been told or been treated for the following conditions?Epilepsy or seizures or mental conditions?

Heart problems?Chest or Lungproblems?Diseases of liver andgallbladder?

Urological problems?

Venereal diseases?Cancer, cysts or growth?

Disease of the Eye?Diseases of the Ear,Nose and Throat?

Any infectiousdiseases?Diabetes Mellitus or anyendocrine problems?Any illness notmentioned above?

Do you smoke?


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If so, how many?

Do you drink?

If so, how much?

Have you ever usedhabit forming drugs or narcotics?Are your familymembers in goodhealth?

If not, please elaborateHave your weightchanged more than 5 kgin the past year?

Females only.

Are you pregnant now?

Have you ever had anybreast or gynaecologicalproblems?

I, the undersigned, hereby confirm that the above answers are full, complete and true.

_______________________ ________________________(date)

PHARMACEUTICAL SERVICES

The Person-in-charge shall be the Head of Pharmaceutical Services in this Clinic.

He is responsible for the coordination and supervision of all activities relating to pharmaceutical services which includes the compounding of drugs and he shall ensure the provision of a comprehensive pharmaceutical service within the private medical clinic.

All medications shall be purchases from authorized pharmaceutical companies and shall beduly recorded in the Stock Register by the Person-in-charge.


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The prescription and dispensing of all scheduled poisons/medications under the Poisons Actshall be recorded in the Poison Book as prescribed.

No medications shall be dispensed to any patient without authorization of the Person-in-charge.

All medications shall be stored in clean and sanitary area and shall not be subjected todetrimental changes in temperature and humidity. The manufacturers recommendation withrespect to storage shall be strictly adhered to.

All expired, discontinued or contaminated medicine shall be disposed of in accordance with therelevant laws and regulations

The cold chain for vaccines shall be properly maintained at all times and the storage of vaccines shall strictly comply with the manufacturers recommendations and that of the WHO.

REGISTERS AND RECORDS OF PATIENTS(RADIOLOGICAL OR DIAGNOSTIC IMAGING SERVICES)

This clinic shall maintain a record in relation to the radiological or diagnostic-imaging studies performed on any patient as follows:

Name of Clinic /Dr requesting Test: Name of Patient:Patient Clinic Number:Date of Request:Date of Receipt:

Name of radiologist/radiographer Test results:Other particulars:


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CLINIC PROCEDURES

1. All clinic assistants shall be involved in the registration, attendance and referral of patients. The appropriate data must be accurately entered into the registers, computer and medical card.

2. All staff must report any untoward incident or accident to the Doctor.3. All staff must wear an identification badge at all times while at work 4. All staff must be punctual for work 5. All staff must practice good hygiene and wash their hands properly6. All staff must wear the uniform provided or dressed appropriately7. All staff must be pleasant and be professional in their dealings with patients8. All staff must use disposable gloves and other protective clothing while dealing with

hazardous material9. All staff must be proactive in keeping the clinic premises clean and tidy


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10. All staff must take the necessary precautions to keep themselves and patients awayfrom infections

11. All staff must produce a medical certificate from a registered medical practitioner if they are unable to work

12. All antibiotics used can only be prescribed by the doctor and this will be done with duecare and according to the best clinical practice guidelines.

HOUSEKEEPING

1. Senior clinical assistant (RR) has been appointed to supervise the housekeepingservices. This appointment will remain in effect until further directive by the person

in-charge.2. The clinic shall be cleaned every week on Tuesday. If this is not feasible for any

other reason, the cleaning shall be carried out the following day(s).3. All staff shall assist the supervisor in the housekeeping services.4. All surfaces and floors shall be properly cleaned with special emphasis to infection

control.5. All equipment including the computer should be cleaned in accordance to the

manufacturers recommendations.6. All staff must wear the appropriate attire to protect themselves while cleaning.7. Additional cleaning or disinfection may be carried out if and when the need arises.8. The toilet shall be inspected and cleaned if necessary every half-hourly by a clinical

assistant who should ordinarily be the clinic assistant performing chaperoningduties on that particular day. The toilet should at all times be adequately stocked

with toilet paper.

SOCIAL & WELFARE CONTRIBUTION

The person-in-charge shall decide on the quantum any of any contribution in the form of money or any services rendered to any charitable organization or to any individual on a case-to-case basis. The Person-in-charge may request for supporting evidence to justify the requestfor discounts or exemption of fees. Any request on behalf of a patient by a highly respectablemember of the medical profession or society will be given special consideration.

Persons considered eligible for discount or exemption from charges or fees include thehomeless, inmates of old folks homes and orphanages. Discount or exemption may be appliedto professional fees, medical report fees and in the provisional of emergency care.

This clinic when specially requested and with sufficient notice will provide public education,talks and participate in activities organized by NGOs and government-linked organizations.Public education talks involve talks to school children, pregnant mothers and patient supportgroups.


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This clinic will provide donations and assistance to associations and organizations engaged inhealthcare activities, non-government or charitable organizations in their healthcare activitiesand the quantum of such donation or assistance shall be decided by the Person-in-charge

There shall be no publicity in any form when such contribution is made.

Staff Assessment Form

Confidential

Staff Assessment for the Year _______________________

Name of Staff: ______________________________

GRADE

PUNTUALITY

PRESENTATION

KNOWLEDGE


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WORK ATTITUDE

COMMENTS

Documents

Dr Lim Meng Lang Manual Template Updated