POLICIES / PROTOCOLS FOR HOSPITAL

IDENTIFY PATIENTS CORRECTLY

1. Every patient is given a unique medical record number and this number is Permanent.
2. Registration personnel must ensure that the patient data is correctly entered during
registration.
3. If a patients is brought in unconscious to the Emergency Department, the patients is
registered and identified as ‘UNKNOWN’ and a MEDICAL RECORD NUMBER is
given until full details are available.
4. All patients admitted to the hospital are given the wristband. Wristbands are removed
at discharge. If wristband is removed for various reasons, (e.g. surgical procedures) a
new band is attached at alternate site or immediately after completion at the procedure.
5. The admitting nurse must verify the patient’s particulars before sticking the name label
on the patient’s wrist. The nursing staff must verify the information on the wrist band
with the patient and ensure patient wears the wristband.
6. Before giving any medications, blood, and blood products, taking blood and other
specimens for clinical testing, or providing any other treatment or procedure, every
patient shall be identified by the two identifiers, i.e. name of patient and MEDICAL
RECORD NUMBER. The doctors, nurses and allied health staff must read the
wristband, if available, and whenever possible, ask the patient to state his/her full name
and birthdate.
7. In a conscious patients, identification is done by checking against the name and
MEDICAL RECORD NUMBER on the patient’s wristband.
8. In an unconscious patient, identification is done by checking against the name and
MEDICAL RECORD NUMBER on the patient’s wristband.
9. In patients who are unable to identify themselves (especially the young, elderly and
mentally challenged) the care provider has to ask the parents or guardians for the name
and double check with the MEDICAL RECORD NUMBER on the wristband.
10. For outpatients, identification is done by checking against the name and MEDICAL
RECORD NUMBER on the patient’s appointment card or name and identity card
number as stated on the patient’s identity card.

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IMPROVE EFFECTIVE COMMUNICATION

1. All verbal and telephone orders / test results shall be immediately recorded, dated and
signed by the registered Nurse or allied health staff receiving the order.
2. The receiver should read back the order to the ordering physician or the test results to
the person who gave the verbal report.
3. The person who gave the order or test results should confirm after the read-back.
4. All order / test results shall be documented in the PATIENT MEDICAL RECORD by
the receiver and the person who instructed it.
 The doctor, nursing and allied health staff must verify the verbal and telephone
orders per policy (write, read back, confirm and witnessed by), and document it
in PATIENT MEDICAL RECORD (Doctor Clinical Notes).
 The doctors must document the verbal or telephone order and counter sign, as
per hospital requirement within 24 hours.
5. In an emergency situation, the receiver will repeat the order verbally or by telephone
and must be witnessed by another staff. The instruction must be carried out stat and
documentations should be done as soon as possible.

IMPROVE THE SAFETY OF HIGH ALERT MEDICATION

1. Concentrated electrolyte solutions are only stored in the Pharmacy Department and the
locked cabinet / trolley.
2. Name and strength of medication must be verified before administering to the patient.
3. An independent verification of the medication name, strength, and amount to be
administered is conducted by a second trained and qualified individual. Calculations
used in determining the amount to be administered are also performed by this
individual.
4. The dose of medications to be administered is prepared just prior to administration as
per doctor’s order.
5. The medication, strength and dose to be administered are compared and confirmed with
the patient’s record as per doctor’s order.
6. The pharmacist / physician is contacted if the dose to be administered exceeds the
maximum permitted.
7. The double checks are documented in the patient’s record.

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ENSURE CORRECT SITE, CORECT PROCEDURE AND CORRECT PATIENT
SURGERY

1. All the patients shall be informed of the location of their Surgical or procedure site in
the ward especially when there is more than one possible site.
2. The doctor in charge of the patient shall ensure that the exact site of procedure is
mentioned in the consent form.
3. The exact site of procedure shall be recorded in the operating schedule list.
4. Pre-operative verification shall be done in the ward and in OT using the standard OT
checklist. The checklist shall be completed by the ward nurse who sends the patient to
OT and the receiving nurse In OT.
5. All relevant documents, x-ray films, equipment, instruments and / or implants are
available and functional. Team members involved in the procedure are responsible to
check the required equipments, instruments/implants.

REDUCE THE RISK OF HEALTHCARE ASSOCIATED INFECTIONS

1. The department and ward in-charge / manager, or designee shall instruct each employee
in his or her role in the prevention of health care associated infection. The in-
charge/manager will incorporate infection control and prevention practices into
departmental policies and procedures.
2. Educational programs reviewing principles of infection control and prevention will be
given to current and newly hired employees involved directly or indirectly in patient
care. These programs will include the practical application of infection prevention
techniques specific to the nature of service of that department.
3. Each department in-charge/manager or designee will supervise employees in infection
prevention practices, evaluate the need for further training and provide as needed in
consultation.
4. Proper hand hygiene is the most important measurement for the prevention of spreading
infection.
5. Indication for Hand hygiene-
 Before patient contact
 Before aseptic tasks
 After body fluid exposure risk
 After contact with patient

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  After contact with patient’s surrounding

REDUCE THE RISK OF PATIENT HARM RESULTING FROM FALLS

1. All patients shall be assessed by the nurses for the risk of falls on admission using the
Modified Morse Scale.
2. All patient categorized with high risk of falls, shall be Identified with a graphic label
which is attached to the bed side, room door or PATIENT MEDICAL RECORD.
3. The patient and family shall be educated about falls prevention.
4. The patient and family shall be accompanied by a hospital staff / family member
whenever they are out of the bed / ward.
5. Patient with high risk of falls shall be provided with Fall 16 Preventive condition or
medications.
6. Reassessment of patient is required when indicated by a change in condition or
medications.
7. All falls shall be reported in accordance to the hospital requirements such as incident
reporting.

ADMISSION TO THE ORGANIZATION

 All elective referrals shall be screened for elective outpatient appointment.

 All patients presenting to the Emergency Department shall be screened.
 Elective Referrals-

A) Letter by referring physician:

i) Patient with the relevant information (patient’s medical history, clinical examination,
investigation results, medication and past treatment) shall be given an outpatient appointment.

ii) When patient’s referring letter indicates the need for early appointment, the letter
shall be given to the respective on-call consultants or base on patient request

B) Phone call by referring physician:

i) The appointment counter staff (Front Office registration assistant) shall request
clinical information and schedule an outpatient appointment. When there is a request from
referring physician, the phone call shall be transferred to the consultant on call.

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  Outpatient registration:

a) There is a standardized procedure for outpatient registration.

 Outpatient Consultation:
 ECG, Chest X-Ray and necessary blood tests will be done if the patient does not
have recent reports.
 Clinical evaluation requires medical history, medication history, previous
treatment and physical examination.
 All the results of diagnostic tests will be reviewed by the attending physician for
determining if the patient is to be admitted, transferred, or referred.
 After the outpatient consultation, the patient will be referred for:
 Outpatient follow-up appointment.
 Referral for elective surgery.
 Non Elective Admission for a) Patient from outstation who prefers one visit for
consultation and treatment.
 The patient shall be discharged to the referring physician if he or she does not have
follow up in PMC.
 Patient shall be informed when there will be a wait or delay in care and treatment. The
patient shall be informed the reasons for the delay or wait. This information will be
documented.

DISCHARGE

1. Discharge planning is done early in the process of patient care depending on subsequent
physician and nursing assessment.
2. The discharge process is initiated after the daily physician’s ward round and upon
agreement from the patient’s response to treatment, clinical status and investigation
results (e.g. CXR, ECG, and echocardiography following cardiac surgery) allows for
patient to be managed at home by the family.
3. Family members shall be included in the discharge planning. They shall be informed
once the discharge decision/process is finalized.
4. The discharge process involves the following:
 Medications
 Follow up appointment

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  Understandable follow up instructions are given to patient and family.
 The instruction include any return for follow up care and when to obtain
urgent care
 MC when applicable
 Letter of discharge summary when required by the patient or PAP.
 Subsequent management plan
 Diet Counseling
 Discharge summary / reply to referring institution should be prepared by
the attending or designated physician. The discharge summary includes
the following information
 Reason for admission
 Diagnosis (principal and secondary)
 Relevant physical findings
 Procedures done and copies of operative notes
 Hospital course and complications
 Important investigation results
 Condition upon discharge
 Medications
 Follow up instructions
5. Where possible, the discharge process must be completed by 11am.
6. The discharge summary / reply shall be prepared in 2 copies.
 A copy will be given to the patient at point of discharge. If not completed at the
time of discharge, it will be the responsibility of patient to collect it within 2
weeks.
 A copy to be retained in the Patient Medical Record.
7. PMC will help to arrange for transportation, or to collect patient’s family or friends for
transporting, depending on the patient’s condition and status.

POLICY & PROCEDURE FOR INCIDENT REPORT

1. Inform to the doctor or primary consultant to review patient immediately upon incident
occur.
2. Inform to the head of department (H.O.D) immediately or nursing supervisor on duty
during absence of the H.O.D.

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 3. Obtained and documented the immediate observation of patient involve as a baseline
parameter in PMC 140.
4. Continue monitor the patient accordingly to the need of Observation Issue incident
occurred according to PMC 140 (Appendix Event Categories is attach as reference).
5. Make sure the attending Doctor complete the report after attended the patient.
6. Make sure treatment been ordered is carry out accordingly Alert the incident to the
investigation team as soon as possible.
7. Send the PMC 140 to Quality Assurance department within 24 hours.

POLICIES AND PROCEDURES NEEDLE STICK INCIDENT

1. Staff pricked by sharp. Perform first aid → squeeze the blood from puncture site
immediately. → run under tap water.
2. Staff involved to inform sister in charge / senior staff during sister’s absent Inform the
infection control nurse.
3. Staff involved to see medical officer immediately.
4. Fill up the incident reporting form together with staff involved and submit to QA.
5. Inform the infection control doctor regarding the incident.
6. Refer the case back to the infection control Doctor for further investigation and follow
up.
7. The incident will take over by infection control Doctor for follow up.
8. Refer Putra Medical Centre Guidelines on the control of hospital acquired infection
flow chart for needle stick incident.

POLICIES AND PROCEDURES STOCK REQUISTION

1. Check the stock in hand and balance.

2. Fill in the request form- Icare system.
3. Send the request form to storekeeper as schedule.
4. Receive the stock and check as ordered.
5. Keep stock in respective storage areas.

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POLICIES AND PROCEDURES OF COMMUNICABLE DISEASE NOTIFICATION

1. Diagnosed by the consultant in-charge with supporting investigation results (X-Ray,

blood result) if available Patient’s particulars in notification form to be filled up.
2. Notification form must be completely filled up regarding the final diagnosis.
3. Notification form must be stamped with the PMC chop and signed by the consultant on
the lower left side corner of the form.
4. Notify the Public Health Inspector (PHI) on call through the nearby state health office
by phone or fax stat, when indicated.
5. Dispatch the original copy to the nearby State Health Office.
6. To notify online first. Carbon copy must be kept in patient file / ticket.
7. Notification chop must be stamped in the admission card inside the patient’s file &
PMC.

POLICIES AND PROCEDURES MANAGEMENT OF CLINICAL WASTE

Types of Clinical Waste

1. Segregate clinical waste in appropriate groups:-
a) Sharps and objects
b) Clinical waste Disposal of Sharps and Objects

2. Discard sharp instrument and objects e.g. syringes, needles cartridges and scalper
blades into sharps container.
3. Do not re sheath or re-cap before discarding into sharp bins.
4. Do not leave used sharps lying around Never fill sharp container more than two-third
full.
5. Ensure that sharp containers are securely closed before disposal.
6. Replace with new sharp container as soon as possible.
7. Place 2/3 full sharp container into clinical waste carriage.
8. Disposal of Clinical Waste Discard the bellow item listed clinical waste into yellow bag
e.g. soiled surgical dressing, cotton wool, gloves, swabs material used to clean spillage.
9. Never fill yellow bag more than ¾ full tie the bag with plastic seal.
10. Tag with label and send to clinical waste carriage at holding area.
11. Replace with new clinical waste bag into bin.