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Hope Requirements

This document lists various policies, procedures, and documentation requirements for a hospital. It includes requirements such as having documented procedures for handling patient specimens, discharging patients, handling emergency patients and using blood products. It also requires documented procedures for administering anesthesia, preventing errors, dispensing medications, and using medical equipment. Other documented policies address infection control, equipment maintenance, emergency planning, record security, and staff disciplinary processes. The document also lists various forms that must be documented for patient assessment, treatment, and discharge in areas such as outpatient, inpatient, emergency, labor and delivery, pediatrics, ICU, and post-operative care. Documentation of training programs, waste handling, safety practices, and quality improvement activities are also

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818 views7 pages

Hope Requirements

This document lists various policies, procedures, and documentation requirements for a hospital. It includes requirements such as having documented procedures for handling patient specimens, discharging patients, handling emergency patients and using blood products. It also requires documented procedures for administering anesthesia, preventing errors, dispensing medications, and using medical equipment. Other documented policies address infection control, equipment maintenance, emergency planning, record security, and staff disciplinary processes. The document also lists various forms that must be documented for patient assessment, treatment, and discharge in areas such as outpatient, inpatient, emergency, labor and delivery, pediatrics, ICU, and post-operative care. Documentation of training programs, waste handling, safety practices, and quality improvement activities are also

Uploaded by

corona virus
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as XLSX, PDF, TXT or read online on Scribd
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Desktop

Hospital registration
Shop & Establishment Act
Partnership/ Ownership proof
Staff Details
BU permission
Lift License
INDEX copy
Hospital organogram
Procedure(s) guide collection, identification,
handling, safe transportation, processing and
disposal of specimens.*
Process addresses discharge of all patients
including Medico-legal cases and patients
leaving against medical advice.*
Documented procedure (s) address care of
patients arriving in the emergency including
handling of medico-legal cases.*
Documented policies and procedures are
used to guide the rational use of blood and
blood products.*
Documented procedure for the administration
of anaesthesia.*

Documented procedure addresses the


prevention of adverse events like wrong site,
wrong patient and wrong surgery.*
Documented procedure incorporating
purchase, storage, prescription and
dispensation of medications.*
Documented procedures address
procurement and usage of implantable
prostheses.*
Infection control manual, which is periodically
updated and conducts surveillance
activities.*
Documented operational and maintenance
(preventive and breakdown) plan for clinical
and support service equipment.*
The organization has a documented safe exit
plan in case of fire and non-fire
emergencies.*
Documented disciplinary and grievance
handling procedure.*
Documented policies and procedures for
maintaining confidentiality, integrity and
security of records, data and information.*
Documented procedures exist for retention
time of medical records, data and
information.*
Define process to whom the patient record
can be released*
Procedure on destruction of medical records*
Mobile
Shop & Establishment Act
GPCB
MOU for out sourced Agency of BMW
PC- PNDT
AERB
MTP
Generator/ UPS & back up sign
Safety Belt in Wheel chair & Strecher

Radiation Hazard Symbol

PC- PNDT Act Display


Photo of first change for quality improve
Photo of second change for quality improve
5 QI

BT Consent, Anesthesia Consent, Surgery Consent of


3 indoor pt

OPD Assessment form

IPD Assessment form

Emergency assessment form

MLC form

Obs. Scope of services

Pedia Scope of services

Obs. Pt. Ante natal check up, Maternal nutrition, Post


natal care

Pedia assessment :nutritional growth & immunization


schedule

Reassessment of ICU & Ward pt


Pre - Intra - Post Anesthesia

Pre operative assessment of surgeon

post op care of surgeon

Discharge card

LAMA Discharge
Medication Administration of nursing
TPR- I/O Chart
Nursing note
LASA storage area
Medication prescriptions
Medication order from each dept
medication labelling with date and time of preparation,
name of the drugs and its dilution 
Display handwashing poster
hospital maintain cleanliness
Housekeeping check list
Autoclave register
Autoclave drum
Laundry area
OT, LR, ICU culture report
Washbasin with elbow operated tap
PPE used by staff
Waste handling staff with PPE & rubber gloves
BMW buckets
Biohazard symbol on BMW area
BMW poster
BMW transportation in labelled close container
Staff handling needle cutter
BMW storage area
Annual fee receipt of BMW
Endotoxin report
Photo of water tank with last cleaning date
Bacterial report of water
Handling of pt. complaint record
ADR form
critical result register
TAT display
Scope of lab
critical result register
TAT display
Scope of radiology
BT reaction form
CAPA of BT reaction
Facility round check list
Storage of O2 cylinder area
MRD check list
filled case sheet of pt. dr. name, sign, date , time
Training On :
Scope of services
Safe practice in LAB
Safe practice in Radiology
Child abduction
Infection control practice
Video of fire mock drill
spill management
Safe education programme
needle stick injury
Medication error
Grievance Handling
Discipllinary procedure

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