4 sunshiners2

• 1. SUNSHINE RECOMMENDATIONS
  

2. WHY???
Lets improve ourselves!!
Not just for NABH accreditation
3. What am I doing here???
I am here just to enlighten you overSUNSHINE 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
4. INTEGRATED IN-PATIENT INITIAL ASSESSMENT
Please make sure that this is filled as soon as the patient is admitted in the hospital
5. 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!
6. PART-B
To be duly filled by the attending doctor!
Simple MBBS Stuff
7. Discharge Planning
Need to be completed at admission
8. PLAN OF CARE
PLAN OF CARE
MEDICAL/CONSERVATIVE
SURGICAL
Tick boxes make the job easy, its going to take only a few minutes of your time
9. Sign and date your work
A good artist always signs off
Consultants need to countersign every admission within 24 hours
10. Our Time frames
11. DRUG ORDER SHEET
Please please. Write your prescriptions in capitals (I mean CAPITALS)
12. Do check for allergies
You can specify the times
Dont just sign
Date it please
No trade names please
13. DRUG ORDER SHEET
Instruction by telephone from a prescriber to a nurse to administer a medicine previously not prescribed is unacceptable in normal circumstances.
Sunshine hospital medication prescription and administration policy
14. VERBAL orders
A verbal order shall be issued only by anybody who is a Consultant or above 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 the written down order is correct, in case of drugs she shall even spell the drug to recheck with the consultant and then close it.
Doctor who issued the verbal order within 24 hrs should counter sign that verbal order
15. WHAT TO MENTION SEPARATELY
1) Parenteral infusions other than the medications (like IV fluids, TPN)
2) Stat medications
3) SOS medications
16. Dont just sign
Date it please
No trade names please
No abbreviations, all caps please
17. SURGICAL PATIENT RECORD
An exhaustive booklet of 16 pages (BUT IT IS VERY IMPORTANT!)
Make sure that the first 4.5 pages are duly filled before the patient reaches OT!
18. TIME OUT
All work should cease during a period of time when all members of the operative / procedural team,using active 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.
19. Donot start operating before this checklist is doneMAKE TIMEOUT A HABIT
20. CONSENT
Please make sure it is taken by the treating doctor/ team member but not the nurse incharge!!!
21. Another important part of the consent process
Doctors need to Countersign
22. SURGEONS NOTES
23. 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
24. 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
25. Admission Note
This part need to be filled in by Front Office / Patient counselor
26. 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
27. 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
28. OTHER THINGS WE NEED
Credentialing and Privileging
29. CODES
Emergency Codes
30. HIC
HIC MANUAL Available on every desktop
Antibiotic policy
Hand Hygiene
Surveillance Tool kit
Needle stick injury
31. VULNERABLEPATIENTS
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 (