Table of Contents

INRODUCTION.............................................................................................................................................4
SCOPE OF THE DOCUMENT.....................................................................................................................5
THE PURPOSE OF THE DOCUMENT..........................................................................................................5
DEFINING SCOPE OF PRACTICE................................................................................................................6
ASSUMPTIONS RELATED TO SCOPE OF PRACTICE...................................................................................6
INTERNAL MEDICINE...................................................................................................................................6
Introduction.............................................................................................................................................6

RESPONSIBILITIES OF INTERNS................................................................................................................8
RESPONSIBILITIES OF GENERAL PRACTITONER........................................................................................9
RESPONSIBILITIES OF RESIDENTS.............................................................................................................9
RESPONSIBILITIES OF INTERNIST...........................................................................................................11
Scope of Practice -Department of Obstetrics and Gynecology................................................................13
Introduction...........................................................................................................................................14
SPMC- Department of Obstetrics and Gynecology................................................................................14
Major areas of Clinical Services and Activities of OBGYN Department..................................................14
Rationale of This scope of practice........................................................................................................17
Scope of this documents.......................................................................................................................17
Roles and Responsibilities in OBGYN Department by Professions.........................................................17
Super and Sub-specialist in OBGYN fields..........................................................................................17
Obstetrician and Gynecologists........................................................................................................17
General Duties and Responsibilities of OBGYN Residents...............................................................19
Year one OBGYN Resident/R-1/.........................................................................................................22
Year II OBGYN Residents/R-2/...........................................................................................................23
Year III OBGYN Residents/R-3/..........................................................................................................24
R-4(Year IV Senior OBGYN Residents)................................................................................................24
Duties and responsibilities of the chief resident....................................................................................26
A. General Practitioners........................................................................................................................26
Integrated Emergency Surgical Officers /IESO/.....................................................................................27
Interns...................................................................................................................................................28

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Medical students...............................................................................................................................28
OBGYN Department Area specific placement and Scope of practices...................................................30
Out-Patient Clinics............................................................................................................................30
A. Intern’s Roles & Responsibilities..............................................................................................30
B. General Practitioner’s responsibility........................................................................................30
C. Year-I OBGYN resident’s responsibility....................................................................................31
D. Year II resident’s responsibility.................................................................................................31
E. Year III resident’s responsibility................................................................................................32
G. Obstetrician and Gynecologist’s (consultant) and Sub-Specialists’ responsibility...............33
A. Intern’s responsibility...............................................................................................................34
C. Year I resident’s responsibility..................................................................................................34
F. Year IV Residents......................................................................................................................36
G. Consultant’s responsibility....................................................................................................36
Operative Procedures and Operation theatre.........................................................................................37
1. Interns, General practitioners and Junior (R-1 &R-2) residents Roles.....................................37
2. Role of R-III, R-IV and Duty Senior/Ob&Gyn/...........................................................................37
1. Interns, General practitioners and Junior (R-1 &R-2) residents Roles.....................................38
B. Year III, Senior resident’s and Consultants responsibility........................................................40
Summary of Service Area specific and Procedural Scope in OBGYN Department...........................41
Out-patient Clinical Services by areas in the Out-patient department............................................42
Minimum level of HP/Scope of Practice/.........................................................................................42
ANC (Antenatal care clinic)...............................................................................................................42
Regular Gynecologic OPD, referral and sub-specialty clinics...........................................................43
Obstetric Triage.................................................................................................................................43
High Risk ANC Clinics.........................................................................................................................43
Scope in Clinical Teaching-learning Activities..........................................................................................49
Rounds..............................................................................................................................................49
Teaching rounds................................................................................................................................49
Business rounds................................................................................................................................49
Medical students...................................................................................................................................51
Interns:..............................................................................................................................................52
Residents...........................................................................................................................................54

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Pediatrics department..............................................................................................................................68
Introduction...........................................................................................................................................68
Duties and responsibilities of the pediatrician (consultant)............................................................69
Duties and responsibilities of the chief resident..............................................................................69
Duties and responsibilities of the teaching resident........................................................................70
Duties and responsibilities of Year I resident...................................................................................70
Duties and responsibilities of Year II resident..................................................................................70
Duties and responsibilities of Year III resident.................................................................................71
Duties and responsibilities of the INTERN.............................................................................................71
Duties and responsibilities of the GENERAL PRACTITIONER(GP).....................................................72
Area specific placement and scope.......................................................................................................73
1. Emergency room (ER)................................................................................................................73
Intern’s responsibility.......................................................................................................................73
Year I resident’s responsibility.........................................................................................................73
Year II resident’s responsibility........................................................................................................73
Year III resident’s responsibility.......................................................................................................73
Pediatrician’s (consultant) responsibility.........................................................................................74
Intern’s responsibility.......................................................................................................................74
Year I resident’s responsibility.........................................................................................................74
Year II resident’s responsibility........................................................................................................74
Year III resident’s responsibility.......................................................................................................75
3. Outpatient department (OPD)..................................................................................................75
Intern’s responsibility.......................................................................................................................75
General practitioner’s (GP) responsibility........................................................................................75
Year I resident’s responsibility.........................................................................................................75
4. Follow up clinics........................................................................................................................75
Rounds..............................................................................................................................................76
Teaching rounds................................................................................................................................76
Business rounds................................................................................................................................76
Interns:..............................................................................................................................................81
GENERAL PRACTIONER.....................................................................................................................83
R-I–Junior Resident ER......................................................................................................................85
R-1-Junior Critical Care......................................................................................................................87

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 R-II – Senior Year...............................................................................................................................88
R-II – Senior Year CRITICAL CARE......................................................................................................90
R-III- SENIOR RESIDENT ER................................................................................................................90
R-III- SENIOR RESIDENT CRITICAL CARE............................................................................................93
Orthopedic Emergencies...................................................................................................................94
Dermatologic Emergency..................................................................................................................95
psychosocial emergencies................................................................................................................96
area specific allocation in er..................................................................................................................96

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INRODUCTION
St Peter specialized hospital started its services in 1955 E, C as a research center for TB and a
sanatorium for the patients, and evolved to be a specialized hospital delivering many specialty
services and trainings. In accordance with the demand and need of expanding health service in
the country now St Peter is thriving to establish a training center in major clinical fields and
working to be solely engage in academia.
The hospital currently giving many specialty and sub specialty services aligned with the basic
hospital services. To accomplish this task the hospital currently structured with four major
departments (obstetrics and gynecology, pediatrics, surgery and internal medicine) and other 8
specialty units. During practicing in this departments and units there were different
professional overlaps, irrational use of drugs and redundant lab investigations and also
difficulties to transcribe and implementation of medical orders in the wards. To overcome this
problems the hospital studied the root cause and prepared this scope of practice document .As
part of the process for the development the hospital tries to develop its own professional scope
of practice
Legal scopes of practice for the health care professions establish which professionals may
provide which health care services, in which settings, and under which guidelines or
parameters. With few exceptions, determining scopes of practice is a region -based activity.
State legislatures consider and pass the practice acts, which become state statute or code.
Nation regulatory agencies, implement the laws by writing and enforcing rules and regulations
detailing the acts.
Every day health professionals are entrusted with people’s health care and, consequently, their
lives. Society does not bequeath this responsibility lightly; it comes with the reasonable
condition that health care providers, who are the subjects of this trust, abide by stringent
professional, ethical, and legal standards. Attending to human health is a complex and difficult
task. It is no surprise, therefore, that the regulations imposed on health professionals also are
highly complex and difficult to understand. This document attempts to clarify the extent of and
differences between those regulations as they apply to people who work in various licensed
health care fields in the St. Peter hospital.
In the section, “Scope of Practice and Limitations,” which follows “Defining Health
Professionals,” the document presents a detailed discussion of the various health professions,
explaining the different providers’ scopes of practice. The subsequent section, “Delegation and
Supervision,” describes the different providers’ authority to delegate and supervise, and the
final section, “Education, Training, and Examination,” discusses the education, training, and
licensure requirements for the different health professionals. We hope this helps the reader to
compare more easily the similarities and differences between health professions. In all cases,
we strive to make objective comparisons.

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SCOPE OF THE DOCUMENT
The scope of this document is in all area of practice in the hospital , including students fro
another institutions and all the hospital’s medical practitioner staffs

THE PURPOSE OF THE DOCUMENT

Purpose The purpose of this document is to provide information and guidance for the hospital
SMT decision making regarding in the scope of practice of healthcare professions.
Specifically, the purpose is to:
1. Promote better consumer care across professions and competent providers
2. Improve access to care n Recognize the inevitability of overlapping scopes of practice.
3. Offer some assurance to the public that the regulated individual is competent to provide
certain services in a safe and effective manner
We envision this document as an additional resource to be used by SMT, healthcare professions
and regulatory boards in preparing proposed changes to practice acts and briefing managers
regarding those changes, just as various professions’ model practice acts are used.

DEFINING SCOPE OF PRACTICE

A 2005 Federation of State Medical Boards report defined scope of practice as the “Definition of the
rules, the regulations, and the boundaries within which a fully qualified practitioner with substantial and
appropriate training, knowledge, and experience may practice in a field of medicine or surgery, or other
specifically defined field. Such practice is also governed by requirements for continuing education and
professional accountability.

ASSUMPTIONS RELATED TO SCOPE OF PRACTICE

In attempting to provide a framework for scope of practice decisions, basic assumptions can be made:

1. The purpose of regulation — public protection — should have top priority in scope of practice
decisions, rather than professional self-interest. This encompasses the belief that the public should
have access to providers who practice safely and competently.

2. Changes in scope of practice are inherent in our current healthcare system. Healthcare and its
delivery are necessarily evolving. These changes relate to demographic changes (such as the aging of the
“baby boomers”); advances in technology; decreasing healthcare dollars; advances in evidence-based
healthcare procedures, practices and techniques; and many other societal and environmental factors.
Healthcare practice acts also need to evolve as healthcare demands and capabilities change.

3. Collaboration between healthcare providers should be the professional norm. Inherent in this
statement is the concept that competent providers will refer to other providers when faced with issues
or situations beyond the original provider’s own practice competence, or where greater competence or
specialty care is determined as necessary or even helpful to the consumer’s condition.

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4. Overlap among professions is necessary. No one profession actually owns a skill or activity in and of
itself. One activity does not define a profession, but it is the entire scope of activities within the practice
that makes any particular profession unique. Simply because a skill or activity is within one profession’s
skill set does not mean another profession cannot and should not include it in its own scope of practice.

5. Practice acts should require licensees to demonstrate that they have the requisite training and
competence to provide a service. No professional has enough skills or knowledge to perform all aspects
of the profession’s scope of practice. For instance, physicians’ scope of practice is “medicine,” but no
physician has the skill and knowledge to perform every aspect of medical care. In addition, all healthcare
providers’ scopes of practice include advanced skills that are not learned in entry-level education
programs, and would not be appropriate for an entry-level practitioner to perform. As professions
evolve, new techniques are developed; not all practitioners are competent to perform these new
techniques.

INTERNAL MEDICINE
Introduction
Internal medicine is the medical specialty dealing with the prevention, diagnosis,
and treatment of internal diseases Physicians specializing in internal medicine are
called internists.
internists are physicians specializing in internal medicine, a discipline focused on
the care of adults emphasizing use of the best medical science available in caring
for patients in the context of thoughtful, meaningful doctor-patient relationships
as exemplified by the life and work of Sir William Osler, the "father" of internal
medicine.
The department of internal medicine one of the of the oldest department in the
history of St. Peter’s specialized hospital and continues to be dominant service
provided by the hospital. In recent years’ hospital become one of the preferred
sites for the clinical rotation of medical students both for the government and
private institutions
The purpose of this document is to provide a general overview of the health
professionals roles, responsibilities and functions while on rotation in the SPSH
Internal Medicine department. it’s the responsibility of the department to provide
clear scope of practice for all the professional who are working in the department
failure to do so was demonstrated in one retrospective study that conducted at
SPSH medical ward shows 75% of ceftriaxone use was inappropriate for the
justification of use in the same study 78.6% of the orders were written by interns

7
alone different clinical and death audit findings are also suggestive of most of
patient progress and investigations are ordered by interns alone the importance
of this document is to give best quality service by responsible professional for the
patients

Terminologies and Definitions

Scope of practice: Scope of practice describes the procedures, actions, and
processes that a healthcare practitioner is permitted to undertake in keeping
with the terms of their professional license. The scope of practice is limited to
that which the law allows for specific education and experience, and specific
demonstrated competency.
Nurse: a person who cares for the sick or infirm specifically licensed health-care
professional who practices independently or is supervised by a physician, who is
skilled in promoting and maintaining health.
Intern: A medical intern is a physician in training who has completed medical
school and is engaged in a year of additional training at a hospital has a medical
degree but does not yet have a license to practice medicine unsupervised.
General practitioner: a general practitioner (GP) is a medical doctor who treats
acute and chronic illnesses and provides preventive care and health education to
patients.
Resident: Residents are doctors in training. They have graduated from medical
school, been awarded an M.D. degree, and now are training to be a particular
type of doctor
Internist: Internal medicine physicians, are specialists who apply scientific
knowledge and clinical expertise to the diagnosis, treatment, and compassionate
care of adults across the spectrum from health to complex illness.
Sub specialist: A narrow field of study or work within a specialty
Super specialist: a specialist concentrating or practicing in a narrow range of a
specialty within sub specialty.

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RESPONSIBILITIES OF INTERNS

Interns are primarily responsible for the care of patients under the guidance and
supervision of the attending physicians and residents. Interns may provide care
for inpatients, outpatients, or patients in the emergency department.
Under the guidance of senior residents, chief medical residents, attending
physicians, and an assigned preceptor, he/she will develop numerous critical skills
that include the following:

 obtaining complete, pertinent, and accurate patient histories

 performing thorough, targeted physical examinations
 planning diagnostic workups
 instituting therapeutic plans, including writing appropriate orders and
prescriptions
 Ensuring that laboratory and other investigations are ordered and carried
out and the results are collected and appropriately documented
 maintaining medical records in multiple electronic health records systems
 communicating with other health professionals to ensure top-quality
patient care using print and electronic research resource
 communicate effectively with patients and attendants
 participate in morning meetings and ward rounds followed by
documentation of decisions for each patient
 order that is written by an intern must be cosigned with immediate senior
 expected to perform procedures under close supervision like abdominal
Paracentesis thoracentesis and lumbar Puncture

RESPONSIBILITIES OF GENERAL PRACTITONER

General practitioners (GPs) have knowledge of a broad range of illnesses, and

diagnose and treat patients of all ages.
 obtaining complete, pertinent, and accurate patient histories
 performing thorough, targeted physical examinations
9
  planning and performing diagnostic workups
 instituting therapeutic plans, including writing appropriate orders and
prescriptions
 maintaining medical records in multiple electronic health records systems
 perform procedures like abdominal Paracentesis thoracentesis and lumbar
Puncture
 attend morning sessions grand round and different academic sessions
 expected to make interdepartmental as well as intradepartmental
consultation when needed

RESPONSIBILITIES OF RESIDENTS

1) R-1

During the crucial first year, the resident will receive close, direct supervision
throughout his/her clinical training. Under the guidance of senior residents, chief
medical residents, attending physicians, and an assigned preceptor, he/she will
develop numerous critical skills that include the following:

 obtaining complete, pertinent, and accurate patient histories

 performing thorough, targeted physical examinations
 planning diagnostic workups
 instituting therapeutic plans, including writing appropriate orders and
prescriptions
 maintaining medical records in multiple electronic health records systems
 communicating with other health professionals to ensure top-quality
patient care using print and electronic research resources
 deliver appropriate care for patients

The resident will also begin to earn credentialing in key procedures and will take
on supervisory roles with other residents and medical students.

10
2) R-2

 During this year, the resident will build on skills developed during the R-1
year and develop the ability to supervise and guide R-1 residents and
medical students.
 During the second year, the resident will work toward increased
competence and authority, learning to efficiently manage an inpatient team
of medical students and R-1 residents. The resident will develop a variety of
patient care skills, including the ability to develop and implement discharge
plans for hospitalized patients and future courses of care for ambulatory
patients.
 Through these experiences, the resident will increasingly assume
responsibilities for teaching and communicating with other health care
professionals. The resident will be expected to deliver concise
presentations at morning report, as well as a number of conferences on
vital, practical topics relevant to internal medicine.
 Core rotations will help to broaden the resident’s skill set, as well as
procedural abilities and efficiency. The resident will continue to cultivate
the facility at using research to support diagnoses and treatment plans.
 The resident will have time to expand his/her knowledge base in specialty
areas, enrich his/her expertise in certain high-demand areas, and design
and carry out research.

R-3

 Third year resident assume leadership responsibilities while providing

highly efficient, attentive care to a variety of patients.
 This year puts the resident in clinical situations similar to those he/she will
experience in the second year, but much more will be expected of him/her.
 The resident will be assigned to a supervisory position in a critical care unit,
on night duty or on internal medicine inpatient unit and emergency room.
In this role, the resident will be responsible for teaching, management, and
oversight of medical students and first- and second-year residents, and the

11
 resident will carry a full slate of his/her own patients. Consulting with
patients to understand their symptoms and health concerns.

RESPONSIBILITIES OF INTERNIST

 Diagnosing and treating acute illness and chronic diseases in adults

 Prescribing or administering medication, therapy, and other specialized
medical care to treat or prevent illness, disease, or injury.
 Attend and lead morning session, grand round, ward /ICU rounds and
seminars
 Monitoring patients' conditions and progress, and re-evaluating
treatments, as necessary.
 Maintaining detailed notes of appointments with patients, including
comments, tests and/or treatments prescribed, and test results.
 Referring patients to other medical specialists, when necessary.
 Preparing official health documents or records, when necessary.
 Conducting research into the testing and development of new medications,
methods of treatment, or procedures to prevent or control illness, disease,
or injury.
 Supervise residents general practitioners and interns
 Perform procedures abdominal Paracentesis, thoracentesis, lumbar
Puncture, BMA, BM biopsy and pleural biopsy

Rounds and morning session

Morning sessions is expected to be conducted three times per week and led by
chief resident and attendings is a quick clinical presentation of overnight
admission critical patents and death to be conducted from 8:00 am to 8:30 am

12
The evaluation of patients as a team is critical to multidisciplinary care. These
rounds occur throughout the day; however, they are mandated during certain
times.
o Pre-rounds (7:30 am to 7:45 am): R-1 evaluation of patients to assess
critical overnight concerns
o Sign out rounds (7:45 am to 8 am): Acceptance and discussion of
overnight admissions
o Work rounds (8:30 am to 9:30 am): Team evaluation and assessment of
patients
o Attending work rounds (9:30 am to 10:30 am): Work rounds with the
assigned attending involving patients predetermined by the resident
o Attending rounds (11:30 am to 12:30 noon): Didactic discussion of
patient management issues, with case presentations of admitted
patients

Documentation
Admission notes
 Should be properly documented by both the Intern and 1st year resident
 Admission note to the ICU should be documented by GP/resident
Round note
 should be documented by the intern and cosigned by the immediate senior
Progress note
 daily progress note should be documented by the interns and residents
procedure note
 procedure not should be documented clearly by the individual who did the
procedure
Discharge notes
 Should be documented by the intern and GP/resident; intern alone can
write discharge note but it should be cosigned with GP/resident
 In the ICU, transfer note should be written by GP/resident
13
Referral notes
 Should be documented by the GP/ resident.
 The intern can write referral notes but should cosign with the resident/GP.
Death summary
 Should be strictly written by the GP/resident
Outpatients clinics

1. Medical OPD: the clinic is expected to be covered by GPs first year

resident can be assigned as needed
2. Medical referral clinic led by internist and patients can be seen by
Residents
3. Subspeciality clinic led by particular subspeciality patent can be seen by
fellow, R3 and R2

Monitoring and Evaluation

 Monitoring and evaluation should be conducted on regular bases by the
department
 Methods of Monitoring and evaluation
- Daily morning session
- Ward rounds
- Chart rounds
- Monthly death and clinical audit

Scope of Practice -Department of Obstetrics

and Gynecology

14
Introduction

SPMC- Department of Obstetrics and Gynecology

Obstetrics and Gynecology is a medical specialty dedicated to the broad,

integrated medical and surgical care of women’s health throughout their lifespan.
The combined discipline of Obstetrics and Gynecology requires extensive study
and understanding of reproductive physiology, including the physiologic, social,
cultural, environmental and genetic factors that influence disease in women.

Obstetrics and gynecology encompass preventive health, reproductive health,

Gynecological surgery, maternal and fetal care and for women of all age groups.

Preventive counseling and health education are essential and integral parts of the
practice of OBGYN as they advance the individual and community-based health of
women of all ages.

SPSH-Department of OBGYN has been evolved dramatically in the past five years
both in providing comprehensive women’s care and academic activities. Before
six years, the hospital MCH service was limited to providing labour and delivery
care with an average of not more than 30 deliveries per month and operative
delivery was started in 2006EC with only one senior and two IESOs. Now we are
finalizing preparations and, on the verge, to start a residency program.

Major areas of Clinical Services and Activities of OBGYN Department

Out-pati ent services

• Pre-conceptional and Antenatal care services

• Regular Gynecologic clinic

• Gynecologic Referral clinic with dedicated Gynecologist

• High risk/ Referral ANC clinic- working five days in a week with Obstetrician
and midwives who are respectful and compassionate.

15
 • Family planning and other RH services - Open five days in a week and
provides full range of family planning services as integral part of basic
health services with particular emphasis on long term methods.

• Comprehensive Abortion and Post Abortion care services.

• EPI Clinic-working five days in a week

• Delivery /maternity triage for non-laboring mothers

• Ultrasound services
In-pati ent Service includes but not limited to:

• Labour and delivery services including operative vaginal delivery, assisted

breech delivery, cesarean section etc… 24 hrs and 7 days in a week. So far,
we have reached more than 250 monthly deliveries.

• Major and minor gynecologic surgeries (both on Emergency and Elective

basis).

• Inpatient Medical management of women with gynecologic problems,

obstetrics complication, medical disease of pregnancy and post-partum
complication, etc.
OBGYN Department Human Resource profi le

Currently the department is staffed by seven Obstetrician and Gynecologist and

one Sub-specialists in Urogynecology and reconstructive surgery, four IESOs,
adequate numbers of GP and other health workforces including MSc in RH &
clinical midwiferies, BSc midwives and nurses

16
Terminologies and Definitions
Scope of practice: Scope of practice describes the procedures, actions, and
processes that a healthcare practitioner is permitted to undertake in keeping
with the terms of their professional license. The scope of practice is limited to
that which the law allows for specific education and experience, and specific
demonstrated competency.

Nurse: a person who cares for the sick or infirm specifically licensed health-care
professional who practices independently or is supervised by a physician, who is
skilled in promoting and maintaining health.

Midwife: a person who cares for the sick or infirm specifically licensed health-care
professional who practices independently or is supervised by a physician, who is
skilled in promoting and maintaining health.

MSc in RH, Clinical midwifery and other related fields

Integrated Emergency Surgical Officers:

Intern: A medical intern is a physician in training who has completed medical

school and is engaged in a year of additional training at a hospital has a medical
degree but does not yet have a license to practice medicine unsupervised.

General practitioner: a general practitioner (GP) is a medical doctor who treats

acute and chronic illnesses and provides preventive care and health education to
patients.

Resident: Residents are doctors in training. They have graduated from medical
school, been awarded an M.D. degree, and now are training to be a particular
type of doctor

Gynecologist and Obstetricians: are specialists who apply scientific knowledge

and clinical expertise to the diagnosis, treatment, and compassionate care for
women

Sub specialist: A narrow field of study or work within a specialty

17
Super specialist: a specialist concentrating or practicing in a narrow range of a
specialty within sub specialty.

Rationale of This scope of practice

• Health care quality- Providing individualized and timely women care for
better outcome

• Delay of care especially in health facilities (Tertiary Delay)

• No clear scope of practice in the department that dictate

• Growing legal and ethical issues in-terms of clinical teaching (teaching with
patient)

Scope of this documents

• This scope of practice will be applied to all health professionals, residents

and interns practicing in the Department.

Roles and Responsibilities in OBGYN Department by Professions

Super and Sub-specialist in OBGYN fields

The resident will be assigned to a supervisory position in a critical care unit, on

night duty or on internal medicine inpatient unit and emergency room. In this
role, the resident will be responsible for teaching, management, and oversight of
medical students and first- and second-year residents, and the resident will carry
a full slate of his/her own patients. Consulting with patients to understand their
symptoms and health concerns

Obstetrician and Gynecologists

Obstetricians and Gynecologists are qualified and competent physicians who

completed a four-year specialty program in OBGYN and provide comprehensive
care for the prevention and promotion of the reproductive & sexual health and
for the reduction of maternal and perinatal mortality and morbidity

18
Gynecologist and Obstetricians are the leaders of the department in both clinical
care and academic activities with full responsibility in quality care and patient
safety along with training a competent and compassionate next generation
specialist in the field of OBGYN. Therefore, they should be a role model and a
good mentor for residents and medical students in the department. Some of the
general roles and responsibilities of seniors in OBGYN department are as follows
(but not limited):

 Leads the team and assumes overall responsibility for clinical care and
academic activities

 Oversees and coordinates the delivery of care, and when appropriate,

delegates patient care responsibilities to other practitioners within their
legislated scopes.

 Determines the type of cases that needs referral to specialty, subspecialty

clinics and inpatient services.

 Supervises high risk ANC clinics, Gyn referral and subspecialty clinics.

 Attends consultations from senior residents from out-patient, wards and

OR.

 Decide on elective admission for major gynecologic surgeries and high-risk

obstetrics cases

 Moderates seminars, journal club, ward rounds and morning sessions.

 Lead the timely evaluation of residents and other students in the

department

 Lead maternal death and perinatal death audits (MPDSR)

 Responsible for monitoring and evaluation of both clinical and academic

activities in the department

 Follow and Monitor documentations, data quality and utilization

 Lead QIP and Researches undergoing in the department

19
  Responsible for development and revision of guidelines, protocols and
important documents in the department

General Duties and Responsibilities of OBGYN Residents

A residency program in obstetrics-gynecology must be a structured educational

experience, planned in continuity with undergraduate and continuing medical
education, in the health care area encompassed by this specialty. The program
should provide an opportunity for resident physicians to achieve the knowledge,
skills, and attitudes essential to the practice of obstetrics and gynecology and
must also be geared toward the context and priorities of the health care delivery
system. But at same time Quality of care and Patient safety should be maintained
in teaching hospitals with the principle the right patient should timely be
evaluated and treated. Residents are expected to provide patient care to
Obstetric and Gynecologic conditions that is compassionate, appropriate and
effective for the promotion of health, prevention of illness, treatment of disease
and end of life care. They have to:

 Gather accurate & essential information from all sources, including medical
interviews, physical examinations, medical records and
diagnostic/therapeutic procedures.

 Make informed recommendations about preventive, diagnostic and

therapeutic options and interventions that are based on clinical judgment,
scientific evidence, and patient preference.

 Develop, negotiate and implement effective patient management plans and

integration of patient care.

 Perform competently the diagnostic and therapeutic procedures

considered essential to the practice of Obstetrics and Gynecology

 Communicate patient and family of end of life concerns, issues, and rights.
Work with ancillary services to help with these issues.

Medical Knowledge

20
Residents are expected to demonstrate knowledge of established and evolving
biomedical, clinical and social sciences, and the application of their knowledge to
patient care and the education of others. They have to:

 Apply an analytical approach to acquiring new knowledge.

 Access and critically evaluate current medical information and scientific

evidence.

 Develop clinically applicable knowledge of the basic and clinical sciences

that underlie the practice of Obstetrics and Gynecology

 Apply the acquired knowledge to clinical problem solving, clinical decision-

making, and critical thinking in patient care.

Practice Based Learning and Improvement

Residents are expected to be able to use scientific evidence and methods to

investigate, evaluate, and improve patient care practices. They have to:

 Identify areas for improvement and implement strategies to enhance

knowledge, skills, attitudes and processes of care.

 Analyze and evaluate practice experiences and implement strategies to

continually improve the quality of patient care.

 Develop and maintain a willingness to learn from professional mistakes and

use these challenges to improve the system or processes of care.

 Use information technology or other available methodologies to access and

manage information, support patient care decisions and enhance both
patient and physician education.

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Communication and Interpersonal Skills

Residents are expected to demonstrate interpersonal communication skills that

enable them to establish and maintain professional relationships with patients,
families, and other members of health care teams. They have to:

 Provide effective and professional consultation to other physicians and

health care professionals and sustain therapeutic and ethically sound
professional relationships with patients, their families, and colleagues.

 Use effective listening, nonverbal, questioning, and narrative skills to

communicate with patients and families.

 Interact with health care team in a respectful, appropriate manner.

 Respect seniors’ decisions for betterment of patient care.

 Maintain comprehensive, timely, and legible medical records.

 Work effectively as a member of the ward team and the clinic form.

Professionalism and ethics

Residents are expected to demonstrate behaviors that reflect a commitment to

continuous professional development, ethical practice, an understanding and
sensitivity to diversity and a responsible attitude toward their patients, their
profession, and society. They have to:

 Demonstrate respect, compassion, integrity, and altruism in relationships

with patients, families, and colleagues.

 Demonstrate sensitivity and responsiveness to the gender, age, culture,

religion, sexual preference, socioeconomic status, beliefs, behaviors and
disabilities of patients and professional colleagues.

 Adhere to principles of confidentiality, scientific/academic integrity, and

informed consent.

22
  Recognize and identify deficiencies in peer performance

 Remain professional in appearance and behavior in the performance of all

duties.

Systems Based Practice

Residents are expected to demonstrate both understanding of the contexts and

systems in which health care is provided, and the ability to apply this knowledge
to improve and optimize health care. They have to:

 Recognize, access, and utilize the resources, providers and systems

necessary to provide optimal care.

 Evaluate the limitations and opportunities inherent in various practice

types and delivery systems, and develop strategies to optimize care for the
individual patient.

 Apply evidence-based, cost-effective strategies to prevention, diagnosis,

and disease management.

 Collaborate with other members of the health care team to assist patients
in dealing effectively with complex systems and to improve systematic
processes of care.

 Collaborate with the national champions’ in reproductive health

Clinical Teaching & methodology – Residents as teachers

The OBGYN residency program also designed to enable the resident learn how to
effectively transfer knowledge and coach juniors or medical students. Residents
are expected to know effective methods and play a role in OBGYN teaching.

23
Year one OBGYN Resident/R-1/

During the first year, OBGYN resident will receive close, direct supervision
throughout his/her clinical training. Under the guidance of senior residents, chief
medical residents, attending physicians, and an assigned preceptor, he/she will
develop numerous critical skills that include the following:

 Lear how to take complete, pertinent, and accurate patient histories for
obstetrics and gynecologic cases
 Develop basic skills to perform thorough, targeted physical examinations
including pelvic examination and Leopold’s maneuvers
 Differentiate normal and abnormal labour and consult his immediate senior
whenever there is abnormal finding and complications
 Plan basic and diagnostic workups (including basic ultrasound lab tests)
 Instituting therapeutic plans, including writing appropriate orders and
prescriptions
 Document and maintaining medical records in hard copies and electronic
medical records systems
 Follow normal labour, follow postnatal woman and postoperative stable
cases
 Communicating with other health professionals to ensure top-quality
patient care using print and electronic research resources

The resident will also begin to earn credentialing in key procedures and will take
on supervisory roles with other residents and medical students.

Year II OBGYN Residents/R-2/

 During this year, the resident will build on skills developed during the R-1
year and develop the ability to supervise and guide R-1 residents and
medical students.

24
  During the second year, the resident will work toward increased
competence and authority, learning to efficiently manage an inpatient
team of medical students and R-1 residents. The resident will develop a
variety of patient care skills, including the ability to develop and
implement discharge plans for hospitalized patients and future courses of
care for ambulatory patients.
 Through these experiences, the resident will increasingly assume
responsibilities for teaching and communicating with other health care
professionals. The resident will be expected to deliver concise
presentations at morning report, as well as a number of conferences on
vital, practical topics relevant to internal medicine.
 Core rotations will help to broaden the resident’s skill set, as well as
procedural abilities and efficiency. The resident will continue to cultivate
the facility at using research to support diagnoses and treatment plans.
 The resident will have time to expand his/her knowledge base in specialty
areas, enrich his/her expertise in certain high-demand areas, and design
and carry out research.

Year III OBGYN Residents/R-3/

 The overall role & responsibility of R-III is to deal with more advanced and
challenging obstetric cases, gynecologic conditions and procedures.
 Evaluate, diagnose and propose appropriate management for women with
obstetrics complications and gynecologic conditions.
 Recognize and treat possible maternal complications
 Perform both abdominal and transvaginal ultrasounds with senior resident
or consultants
 Order laboratory investigations and imaging with co-signing
 Perform and interpret antepartum diagnostic tests accurately and integrate
the interpretation of such tests into clinical management algorithms
 Third year resident also assume leadership responsibilities while providing
highly efficient, attentive care to a variety of patients.

25
  This year puts the resident in clinical situations similar to those he/she will
experience in the second year, but much more will be expected of
him/her.
 The resident will be assigned to a supervisory position in different
obstetrics and gynecologic service areas.
 They will be responsible for teaching, management, and oversight of
medical students and junior residents, and the resident will carry a full
slate of his/her own patients.
 Provide Counseling for patients to understand their conditions, health
concerns, work up, options of management and possible outcomes.

R-4(Year IV Senior OBGYN Residents)

 Establish and coordinate diagnosis and treatment plans for all patients
 Lead daily ward rounds with or without seniors
 Participate in teaching activities of medical students, interns and junior
residents
 Supervise students, interns and junior residents on their daily practice in
OBGYN departmental clinical & academic activities.
 Perform specific operations under the supervision of the attending surgical
staff as deemed appropriate by the attending surgical staff.
 Participate in daily outpatient high risk and referral/sub-specialty clinics
with responsible senior physician.
 Assist and perform major gynecologic and advanced/complicated obstetric
surgeries with responsible senior.
 Establish daily treatment plans for patients on the inpatient service
including: Labour-delivery, maternity and Gynecologic wards.
 Perform daily evaluation on inpatients with physical examination, review of
laboratory tests and nursing records and write progress note as necessary
(clinical audit or chart audit).
 Perform specific bed side procedures including U/S, Amniocenthesis, ECV,

26
  Monitor completion of admission note, discharge summaries, progress
note, post-operative acceptance note, procedure note, operative notes,
post op order, Death certificate and medical certificate.
 Participate on daily morning session and Present duty activities according
to the duty schedule.
 Present seminar session, death round, journal club and the likes as assigned
by the attending surgeon
 Participate in research and QIP activities with attending staff
 Lead the team in communication with the responsible senior

 Fourth year resident assume leadership responsibilities while providing

highly efficient, attentive care to a variety of patients.
 This year puts the resident in clinical situations similar to those he/she will
experience in the third year, but much more will be expected of him/her.
 The resident will be assigned to a supervisory position in different service
areas of the department especially in duty hrs and involved in the care of
high-risk mothers, complicated cases and major operative procedures
 Responsible for teaching, management, and oversight of medical students
and junior residents and the resident will carry a full slate of his/her own
patients.
 Consulting with patients to understand their symptoms and health
concerns
 Handle high risk mothers and primarily responsible for the continuity of
care

Duties and responsibilities of the chief resident

The chief resident and teaching resident will be appointed based on the
performance of the resident during the period of training and approved by the
departmental meetings. The chief resident is accountable to the department
head.

 Manage resident and intern rotations

 Organize seminars and examinations of interns, residents and workshops
27
  Lead morning sessions
 Make regular meeting with residents
 Bring areas of quality improvement in the day-to-day activity of the
department by closely discussing with residents
 Manage problems with residents and strictly control overall duty and other
activities
 Fill gaps of OBGYN seniors in teaching-learning programs, consultations,
and clinical practice whenever there is an emergency program overlapping.
 Will have a full authority to communicate, consult and report any
departmental academic or patient issues to the responsible senior or
department administrative and head of the department

A. General Practitioners

General practitioners (GPs) have knowledge of a broad range of illnesses, and

diagnose and treat patients of all ages.

 Obtaining complete, pertinent, and accurate patient histories

 Performing thorough, targeted physical examinations

 Planning and performing diagnostic workups

 Instituting therapeutic plans, including writing appropriate orders and

prescriptions

 Maintaining medical records in multiple electronic health records systems

 Perform procedures like abdominal Paracentesis thoracentesis and lumbar

Puncture

 Attend morning sessions grand round and different academic sessions

28
  Expected to make interdepartmental as well as intradepartmental
consultation when needed

Integrated Emergency Surgical Officers /IESO/

Though the role of IESO’s is crucial in primary and district hospitals, where there
are no obstetrician and general surgeon, their role is not well defined in tertiary
and teaching institutions. So far, they play a significant role in reducing maternal
mortality and morbidity, and they also shared major burden of the tertiary
institutions by handling these emergency operative conditions.

In our hospital, they contribute a lot in when obstetrics emergency services

concerned and still providing service for pregnant women who is in need
including service expansions to health centers. Some of the role and
responsibilities of IESO’s in current practice are:
 Evaluate and admit labouring mothers
 Perform basic bedside ultrasound
 Institute treatment and management plans
 Attend deliveries including vacuum delivery
 Perform uncomplicated emergency c-sections

Interns

Interns are primarily responsible for the care of patients under the guidance and
supervision of the attending physicians and residents. Interns may provide care
for inpatients, outpatients, or patients in the emergency department.

Under the guidance of senior residents, chief medical residents, attending

physicians, and an assigned preceptor, he/she will develop numerous critical skills
that include the following:

 Obtaining complete, pertinent, and accurate patient histories

29
  Performing thorough, targeted physical examinations
 Planning diagnostic workups
 Instituting therapeutic plans, including writing appropriate orders and
prescriptions
 Ensuring that laboratory and other investigations are ordered and carried
out and the results are collected and appropriately documented
 Maintaining medical records in multiple electronic health records systems
 Communicating with other health professionals to ensure top-quality
patient care using print and electronic research resource
 Communicate effectively with patients and attendants
 participate in morning meetings and ward rounds followed by
documentation of decisions for each patient
 order that is written by an intern must be cosigned with immediate senior
 expected to perform procedures under close supervision like abdominal
Paracentesis thoracentesis and lumbar Puncture

Medical students
Subject to relevant laws and regulations, students have the right to:
 Learn, enquire, understand and know
 Protection of their constitutional human rights and freedoms, personal
safety and security of their personal property
 Be evaluated solely on academic basis based on the Federal Hospitals
standards
 Participate in a free exchange of ideas in an open academic environment
 Have access to patients under the strict supervision of the clinical
instructors.

Duties of Medical students in OBGYN Department

30
Students are duty bound to observe and respect the country’s laws and the rules
and regulations of the Federal Hospital and the department protocols. Some of
the duties of medical students include:
 Attend classes, seminars, bedside teaching, clinical conferences, etc., and
respect the individual authority of any academic staff in the leadership and
management of the teaching learning process.
 Interact with members of the department staffs in a respectful and
courteous manner.
 Respect the privacy and dignity of all patients they are interacting with.
 Always introduce themselves and take consent before taking history and
perform physical examinations
 Have identity badge that contains at least full name, photo and level/year
of training in respective fields.
 Make proper use and care of hospital property and resources
 Refrain from unlawful and unethical practices.

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OBGYN Department Area specific placement and Scope of practices
Out-Patient Clinics

Out-Patient clinics in the context of OBGYN department include: Obstetrics

triage, Gynecologic emergency Opd, ANC clinics including referral and sub-
specialty clinics, Regular and subspecialty Gynecologic Opds.

A. Intern’s Roles & Responsibilities

 Main role of intern’s will be observation & assisting the GP or Residents

in their first four weeks of attachment to the department
 Clerks and evaluate stable patients/mothers under direct supervision
of 1st year resident or GP
 Practice physical examinations and acquire clinical skills including
Leopold’s maneuver, digital pelvic & speculum examinations,
auscultation of FHB, etc.
 Can take and follow vital signs for patients/clients until admission
 Can order basic and initial investigations (e.g.: U/A, urine HCG, CBC,
BG&Rh, CXR, U/S) for emergency patients with communications and
co-signing.
 Can observe &/or assist emergency and minor gynecologic procedures
(emergency delivery, MVA, MRP, etc)
 After adequate exposure and supervisions or their midterm evaluation,
they can be involved some procedures and clinical practice with direct
and indirect supervision.
 Complete medical records and documentations
 Hand-over to the duty team at the end of working hours

B. General Practitioner’s responsibility

 Lead the team in the absence of residents
 Do quick Evaluation and identify high risk conditions and timely
communicate to responsible IESO or Senior in charge

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  Order basic lab investigations and can sign emergency ward admission
for labouring and other women’s that need inpatient management after
informing the responsible/duty senior.
 Initiate emergency management and stabilization
 Can perform simple emergency procedure like MVA, Bedside U/S with
communications and direct/indirect supervision

C. Year-I OBGYN resident’s responsibility

 Main responsibilities of R-1 are acquiring basic knowledge and skills in

providing out-patient care for obstetrics and gynecologic through
observations and practice under direct supervisions
 Can provide basic ANC services and minor gynecologic compliant
 Evaluates new patients
 Makes proper documentation of medical records and registrations
 Can write orders for initial management in OBT and emergency gyn-opd
 Can make order baseline investigations
 Can do minor and emergency procedures under indirect supervisions of
R-2
 Communicates with the ward team for admissions and should write
relevant evaluation and admission note with co-signing of R-2.

D. Year II resident’s responsibility

 Evaluates new and repeat uncomplicated obstetrics and gynecologic

cases
 Can evaluate women with common obstetrical, medical and surgical
complications, order initial investigations and initiate management and
consult
 Practice basic obstetrics ultrasound under direct supervisions
 Can admit obstetrics patient to labour ward with communications
 Attends any consultation from the 1st year resident and GP

33
  Helps in the decision making to admit patients to maternity ward after
consulting and co-signing the immediate senior resident.

E. Year III resident’s responsibility

The overall responsibility of R-3 resident is to diagnose, plan management
of common gynecologic emergency and cold cases as well as obstetric
cases including:
 Coordinate and involved in different outpatient care of obstetrics and
gynecologic patients
 Perform a pertinent history, focused physical examination, selection
and interpretation of diagnostic tests and initial treatment plan for the
common presenting complaints in ob/gyn
 Evaluate patients and develop initial treatment plans for common post-
operative signs/symptoms and complications in referral clinics under
indirect or direct supervision of senior resident or consultants

 Describe pre-operative indication, potential intra- and post-operative

complications on more advanced gynecologic surgical procedures
 Provide a comprehensive antenatal care for all pregnant women and
make consultations for senior residents or faculty in case of difficulty.
 Can admit patient with co-signing of senior resident or consultants
 Should teach juniors and share experiences to the team.
 Attends any consultation from the 1st or 2nd year resident.
 Consults the senior residents and Senior physician in charge for any
difficulty.

F. Year IV Residents Responsibility

34
  Supervise the out-patient clinics and attend referral clinics
 Senior resident can be assigned in High risk and gyn referral clinics in
case of program overlaps
 Should teach juniors and share experiences to the team.
 Attends and address any consultation from 3rd year resident.
 Consults the senior in charge for any difficulty.
 Monitor and Evaluates interns and junior residents OPD performance
together with the responsible consultant and faculty members

G. Obstetrician and Gynecologist’s (consultant) and Sub-Specialists’

responsibility

 The most senior and the leader of the team.

 Makes final decisions with regard to the management of patients in the
out-patient department
 Monitor and supervise OPD- activities
 Attend high risk ANC, Gyn referral and Sub-specialty clinics
 Teaches students, interns and residents
 Subspecialty clinics must be run by the specific subspecialists or
fellows.

Labour and Delivery Ward

Obstetrics care is mainly a team work and everyone is responsible for quality
maternal and new born health care. Some of the scope of practice and roles as
follow:

35
 A. Intern’s responsibility

 Evaluates and follow labouring mothers without complications under direct

supervision of GP or R-2
 Can observe and assist normal deliveries, episiotomy repair
 Attend normal delivery when they are confident to conduct and authorized
by GP or residents under direct supervision
 Follow vital signs for women in their immediate post-partum period

B. General practitioner’s (GP) responsibility

 Evaluates labouring women, follow and attend normal deliveries

 Can write orders for augmentations, inductions in communication with the
senior in the absence of residents
 Not authorized to make decisions on patients with obstetrics, medical or
surgical complications and they have to consult timely the responsible
residents or senior
 Can apply vacuum and assist delivery with the team in the L&D ward

C. Year I resident’s responsibility

• Evaluates labouring women, follow and attend normal deliveries under
direct supervision by R-2
• Fill partograph and consult immediate senior whenever there is labour and
FHB abnormalities
• Can assist and attend normal deliveries, episiotomy repair
• Cannot write orders for augmentations, inductions
• Not authorized to evaluate and make decisions on patients with obstetrics,
medical or surgical complications and they have to consult timely the
responsible residents or senior
• Not authorized to perform operative vaginal deliveries

36
 • Should complete all the necessary documentations
D. Year -II resident’s responsibilities
• More responsible for uncomplicated obstetrics conditions and procedures
• Evaluates laboring women, follow and attend normal deliveries under
indirect supervision by R-3
• Fill partograph and consult immediate senior whenever there are labor and
FHB abnormalities
• Can assist and attend normal deliveries, episiotomy repair
• Cannot write orders for augmentations and inductions when there is labor
abnormalities
• Authorized to evaluate patients with obstetrics, medical or surgical
complications but the decision should be made communications with R-3 or
senior resident
• Can apply vacuum and attend assisted breech under direct supervision of R-
3
• Can make decision for cesarean section for those with straight forward
indication but should inform the responsible R-3
• Can do emergency cesarean section for uncomplicated cases
• Consult the R-3 when there are complicated cases

E. Year III resident’s responsibility

• Responsible for overall L&D ward activities
• More responsible for complicated obstetrics conditions and procedures
• Evaluates and make decision for labouring women with obstetrics, medical
and surgical conditions

37
 • Can hand difficult deliveries and procedures with direct or indirect
supervision of senior resident
• Authorized to evaluate patients with obstetrics, medical or surgical
complications but the decision should be made communications with R-3 or
senior resident
• Can decide, apply forceps and attend assisted vaginal breech deliveries
• Can make decision for cesarean section for those patients with obstetrics,
medical or surgical complications
• Can do emergency cesarean section for complicated cases
• Consult the senior resident when there are complications
F. Year IV Residents
• The leader of the team next to the responsible senior
• Responsible for overall L&D ward activities with R-3
• More responsible for complicated obstetrics conditions and
procedures
• Can hand difficult procedures and critical patients
• Can decide and attend assisted vaginal breech deliveries
• Can make decision for cesarean hysterectomies and re-laparotomy
surgeries
• Consult and communicate the responsible senior when there are
complications
G. Consultant’s responsibility
 The final decision maker on the care of patients in L&D ward
 The leader of the team and responsible for overall clinical and
academic activities

38
  Manage administrative issues with responsible bodies
 Final decision maker for cesarean hysterectomies, re-laparotomy
surgeries and other complicated & critical cases

Operative Procedures and Operation theatre

A. Duty hour or Emergency procedures (both minor and major)
During duty hours and in patient with emergency obstetrics or gynecologic conditions,
team work with shared responsibility is crucial in saving lives and better clinical
outcome with the principle of the most senior person in the team should be the
responsible person in the initial handling of such cases. Some of the general role and
responsibilities include:

1. Interns, General practitioners and Junior (R-1 &R-2) residents Roles

 Interns, General practitioners and R-1 resident role should be in
assisting and facilitation for the timely care of such patient by
preparing blood and blood products and necessary preoperative
materials, informing the OR and anesthesia teams.
 Can assist uncomplicated and minor procedures
 Year -II resident can perform primary c-section for women without
medical and obstetrics complications

2. Role of R-III, R-IV and Duty Senior/Ob&Gyn/

 Year-III residents are responsible for most emergency cesarean
sections and gynecologic emergency surgeries including Ectopic
pregnancy, adnexal torsions

39
  Senior resident is responsible for the overall emergency obstetrics and
gynecologic procedures in communications with the duty senior
resident
 Cesarean hysterectomy, surgery for critical patients like HELLP
Syndrome, Obstructed labour, abscess drainage, re-laparotomy should
be performed by the senior residents and duty senior.

B. Elective surgeries

1. Interns, General practitioners and Junior (R-1 &R-2) residents Roles

 Preoperative preparation including timely posting the OR schedule in
communication with the senior resident or consultant
 Prepare blood and blood products
 Complete preoperative laboratory investigations and imaging as per the order and
recommendations by the operating and anesthesia team
 Timely transferring of scheduled patients to the OR on the day of surgery
 Accept post-operative patient, follow and timely consult the senior resident or
senior for any post-op complications
 Order and send basic post-op laboratory investigations and biopsies as per the
order
2. Role of R-III, R-IV and Duty Senior/Ob-Gyn senior & subspecialist/
 For all perioperative counselling, scheduling by priority and deciding
the proposed procedure; the senior resident and/or the responsible
gynecologist/subspecialist are responsible

40
  R-III main role is assisting the procedure (can 1st or 2nd assistant) and
 Ob-Gyn senior and subspecialist are responsible for the overall
operative theatre during major elective surgeries
 They are also responsible for post-operative
 The operative surgeon is responsible for providing information for
patients, attendants or relative despite the outcome of the surgery is
good or bad.
 Should make a visit/business round for their post-operative patients
 All major gynecologic or re-laparotomy procedures should be done in
the presence of the consultant unless specified in the detailed
procedures listed below

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Post-natal, Maternity and Gynecologic wards

A. Interns, GP and Junior Resident’s Role and Responsibilities

o Takes round notes during rounds and makes sure orders are properly
undertaken by the nursing team.
o Collects investigations from the laboratory
o Attends critical patients from wards when they are transported for
imaging and other investigations.
o Responsible for follow up of patients in the respective wards
o R-2 is more responsible for uncomplicated cases in the ward
o R-2 resident should consult the immediate senior

B. Year III, Senior resident’s and Consultants responsibility

 R-3 Evaluates and writes Admission note for newly admitted High risk
obstetrics and gynecologic patients.
 R-3 Follows patients and writes daily progress notes for Critical cases
 Do BPP and bedside procedures
 R-3 Revises orders daily after consultation of the R-4 or ward senior.
 Makes daily round in the ward.
 They Should teach juniors and share experiences to the team.
 R-3 Attends any consultation from the 1st or 2nd year resident.
 R-4 Consults the senior in charge for any difficulty.
 R-4 Evaluates interns together with the consultant
 Evaluates admitted patients in the ward but special attention to the
most critical cases
 Makes daily round in the ward.

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Summary of Service Area specific and Procedural Scope in OBGYN Department

Table 1: Out-patient Services

Out-patient Clinical Services by areas in the Minimum level of

S.N. Out-patient department. HP/Scope of Practice/

1. Pre-conceptional care &counseling for women who have

history of previous pregnancy related complication/Bad At least senior resident
obstetric History/ or at risk of Obstetrics and Non-
obstetrics complications, etc.

2. ANC (Antenatal care clinic)  At least General-

Practitioner or above
 Pregnant women without obstetrics (Interns can evaluate
complication or pre-existing medical or surgical patient under direct
condition. supervision)

 Those with obstetrics complications and pre-  At least senior resident

existing medical or surgical conditions

43
 3. Regular Gynecologic OPD, referral and sub-specialty
clinics
 At least GP or year-I
 First visits and simple gynecologic complaints with

 Patient with confirmed diagnosis and referred  Year 4 &/ or

for specialty services Consultants.

 Gynecologic referral clinics (see cases)  Senior Residents andor

Consultants

 Elective gynecologic admissions for major

surgeries  Consultants /senior
OBGYN specialists

 Sub-specialty clinics
 Run by specific sub-
specialists

4. Obstetric Triage

 Normal Labour (in all stages of labour) without  Midwifes/ Interns +/-
Obstetrics complications/pre-existing disease, Year 1 &/or year 2
term PROM without complications, residents

 Laboring mothers with any Obstetrics or non-  At least Year 2 or above

obstetrics complications, pre-existing medical
conditions

5. High Risk ANC Clinics

44
  All mothers referred to High risk ANC Clinics  Senior Residents &/or
Consultants

 Senior Residents &/or

 Elective admission for cesarean section Consultants

6.  Short term Family Planning methods  At least trained

Midwifes
 Long term Family planning Methods: IUCD &
Implanol (Insertion and Removal)  At least trained
Midwifes
 CAC services (medical management after
 Trained midwife with
decision has been made)
residents

NB: In all programmatic areas including FP services and Comprehensive abortion

care (those running by trained professional) the main roles of medical students,
interns and residents are observation, assisting and performing the procedures
under supervision of the trained personnel. But for the decisions and management
of complication in these service areas, the senior resident or Ob-Gyn specialist are
responsible

7. Consultations from other departments  Senior resident or

Consultants

45
 Table 2: Scope regarding OBGYN Procedures and ward
care
S.N.
Type Cases/Diagnosis Responsible for Surgeon Assistant/s Remarks
Evaluation & decision
making
1.

A. Obstetrics emergencies

1. Primary C/Section  At least Year 2 &  At least Year 2  Interns/

without Obstetrics Above & Above Year 1
Complication or
Medical condition

2. Primary C/Section  At least year 3  At least year 3  Year 1 or

with Obstetrics &/or Above &/or Above year 2
Complications (cord
prolapsed,
Obstructed labour,
APH (AP or PP), C/s
in SSOL/deeply
engaged,
Transverse/Oblique
lie,…) and Medical
condition with
pregnancy (like
Cardiac disease,
Hypertensive
disease, Morbidly
Obese , HELLP
Syndrome,
3. Secondary C/S and  At least year 3  At least year 3  Year 1 or
above &/or Above &/or Above year 2

46
 4. Uterine Rupture  Senior  Senior Resident  Year 2 or
Resident/Consulta +/-Consultant year 3
nt
B. Obstetrics  Senior Residents  At least year 3  Year 1 or
(Elective C/S) &/or Consultants &/or Above year 2

Other bedside Obstetrics procedures

i. Obstetrics  At least R-3 or  Year 3 or 4  Any level
Ultrasound above
(For BPP,
EFW,
Placental
localization)
ii. ECV  At least R-3 or  Senior Resident  Any level R-III
above or Consultant can do
Under
direct
supervi
sion
iii. Amniocente  At least R-3 or  Senior Resident Any level
sis above or Consultant
iv. Obstetrics  At least R-II or  At least R-II or  Any Team
forceps above above members
delivery and
Vacuum
delivery
v. Assisted  At least R-III or  At least R-III or  Anyone
Breech above above
delivery
vi. Craniotomy  Senior Resident or  Year 3 or 4  Interns,
Consultant GP, Year 1
Residents
or year 2
residents
vii. Assisted  Year 2, 3 or 4  Any Team
Vaginal members
Breech
delivery
viii. Manual  At least R-II or  Year 3 or  Any Team
Removal of

47
 the placenta above Senior resident members
for retained
placenta
ix. 3rd and 4th  Year 2, 3 or 4  Year 3 or  Any
degree Senior resident Health
Perineal profession
Tear al in the
delivery
ward
x. Neonatal NB: Anticipation Every intern, GP & resident
resuscitatio and preparation is should have basic skill on basic
n the most Neonatal Resuscitation and be
A. B important involved but when there is a
asic determinant need for advanced resuscitation
resu factors for the most senior person in the
scita successful team should be involved and
tion neonatal communication to
resuscitation pediatricians/Neonatologist
should be made ahead of time

B.Adv
anc
ed
resu
scita
tion

Gynecologic Procedures by Type, timing and Scope

A. Emergency Laparotomy

a. Ruptured Ectopic  At least Year 3 or  Year 3 or R-4  Interns,

pregnancy above GP, Year 1
Residents
or year 2
residents
b. Adnexael/ Ovarian  Year 3 or 4  Year 3 or 4  Interns,
Torsion GP, Year 1

48
 Residents
or year 2
residents
c. Pelvic abscess  Year 3 or Year 4  Year 3 or Year  Year 2 or
Collection/TOA 4 or year 3
Consultants residents
d. Trauma to the pelvic NB:
organs (e.g. Post  At least R-III &  At least  Interns, There
coital Tear) above Year 3 or GP, R-1 or may be
Year 4 R-2 a need
residents to
consult
 Major surger
traumas  At least R- y
 Senior depart
 At least R-III & II or above
resident ment
above
and/or
consultant
B. All Elective Major  Senior Resident  Senior Resident  Year 3 or
Gynecologic Procedures and /or and /or Senior
Consultants Consultants Resident
C. Minor Gynecologic Evaluation & Performing the Assistant
Procedure Decision procedure
a. Biopsy (punch,  Senior Resident  Year 2 or year 3  Any
endometrial, …) and /or residents
Consultants
b. Abscess drainage  Year 3 or Year 4  Year 3 or Year
(eg.Vulvar , 4
bartholin’s gland
abscess,…)
c. MVA (For  Interns under  Interns &/or
uncomplicated, first direct supervision GP, Year1 or 2
TM abortion) of trained residents
professional
 Trained GP, Year1
or 2 residents
d. MVA (For  At least Year 3 or  Year 3 or Year
complicated first TM Year 4 or Seniors 4
abortion e.g. Septic,
Second TM

49
 Abortions)
e. D & C, E&C  At least Year 3  Year 3 or Year
Resident and 4
above

Supervision in medical Teaching- Learning Activities

 Can be direct or indirect

Direct supervision means practice medicine in the physical presence of consultant

senior physician or supervising resident or GP respectively.
Indirect supervision means practice medicine without actual physical presence
consultant senior physician or supervising resident or GP respectively but with
communication by different means.
Supervisors in the context of OBGYN are R-3, senior resident or consultants
NB: Minor modifications are possible according to the medical staff & specialty of the
department

Scope related with ordering advanced laboratory tests, imaging and change in
the treatment regimens/prescriptions of some medications/
 Advanced laboratory tests, imaging like; CT, MRI, should be ordered by at
least 3rd year residents in communication with senior resident or consultant
 When there is a need to change the antibiotic regimens, the treating
physician should be involved with clear reason
 Some expensive drugs including Anti-D should be prescribed by at least R-3

50
Scope in Clinical Teaching-learning Activities

Rounds

Teaching rounds

 Intention of teaching round is to teach students, interns and residents in

the team and it is led by the consultant pediatrician.
 The patient’s case will be analyzed in depth during the teaching process.
 This should be made 3 times per week
 Multidisciplinary involving
- Residents (I to III), Intern, GP, undergraduate students
 Should align with the round protocol of the Hospital and the department

Business rounds

 Intention of business rounds is to make quick and relevant evaluation of

patients in the wards and make decisions, it focuses more on the patient
and less teaching.
 Can be led by the 3rd or senior resident.
 Consultant involvement is optional.
 Should align with the round protocol of the Hospital and the department

Documentation practices

Admission notes

 Admission note from OBT for normal labor should be properly documented
by both the Intern and GP or 1st year resident
 Admission note for abnormal labor or women with complications should be
properly documented by at least 2nd year resident

51
  Admission note from high risk clinics and gyn referral clinics should be
documented by at least by the 3nd year resident and by the responsible R-4
or Senior

Progress notes

 Daily progress note is mandatory for admitted patients

 Should be properly documented daily by the Intern, GP or 1st residents for
stable patients

 Progress notes for high risk patients should be documented daily by at least
by the 2nd year residents

 R-3 and R-4 have to write progress note for critical patients

Operation note and post-operative orders

 The operating surgeon is responsible for timely writing operation Note and
post-operative orders

OR registration books

 The operating surgeon or the assistant is responsible for timely registration

of the required information on the OR registration book
 Data should be complete

Discharge notes

 Should be documented by the intern, GP and R-1 resident for stable

patients from L&D, Maternity and Gyn wards
 For patients with obstetric, medical and surgical complication; the physician
in charge of the care should be involved in the discharge process and
included in the documentation
 For surgical/post-operative patients the surgeon or assistant should decide
and can be documented by interns, GP or residents

Referral notes

52
  Should be documented preferably by the 1st year resident.
 The intern can write referral notes but should cosign with the 1st year
resident.

Death summary

 Should be strictly written by at least by 3nd year resident or above

Consultation notes

 Can be documented by the intern and cosigned by the immediate senior

Monitoring and Evaluation

 All the above-mentioned scopes of practices should be monitored by the
department.
 Methods of M and E
- during morning session and rounds
- Chart review
- Clinical audits, maternal and perinatal death audits
- Check list prepared for this purpose
- Cesarean section and surgical procedures audit
 M and E will be performed by the quality assurance committee which will
be established by the department representative from residents and
interns
 Formal M and E will be done every month and report presented to the
department during morning sessions.
 Feedback will be given and corrective measures implemented accordingly

I. General surgery Scope of practice & duties of Medical

students, Interns, General practitioner’s, residents and Seniors

53
Medical students

1. Student rights

Subject to relevant laws and regulations, students have the right to:

1.1 Learn, enquire, understand and know.

1.2 Protection of their constitutional human rights and freedoms, personal safety and security
of their personal property.

1.3 be evaluated solely on academic basis based on the Federal Hospitals standards.

1.4 Participate in a free exchange of ideas in an open academic environment.

1.5 Have access to patients under the strict supervision of the clinical instructors.

2. Duties of students

Students are duty bound to observe and respect the country’s laws and the rules and
regulations of the Federal Hospital.

2.1 Attend classes, seminars, bedside teaching, clinical conferences, etc., and respect the
individual authority of any academic staff in the leadership and management of the teaching
learning process.

2.2 Interact with members of the hospital community in a respectful and courteous manner.

2.3 Respect the privacy and dignity of all patients they are interacting with.

2.4 Make proper use and care of hospital property.

2.5 Refrain from unlawful and unethical practices.

Interns:

1. Scope of practice

Under indirect supervision by senior residents and/or attending physicians, major

responsibilities include:

1) History and physical examination of patients;

2) Accountability for all patients’ care;

54
3) Instruction of medical students;

4) Proper documentation on charts.

5) Daily examinations of patients on the inpatient services;

6) Issuance of treatment orders in the medical record for hospitalized patients;

7) Assessment and formulation of treatment plans for patients in the emergency department,
family medicine Center, and inpatient units; and

8) Participation in teaching and work rounds as scheduled by supervising physicians.

Technical skills, to include the following under the direct supervision of a senior resident,
credentialed midwife, or attending physician:

1) Bladder catheterization,

2) Gastric lavage and aspiration,

3) Lumbar puncture,

4) Paracentesis,

5) Thoracentesis,

6) Venipuncture,

7) Major surgical assisting,

8) Single- layered suturing;

9) Neonatal circumcision.

Performs duties as required:

1) Night call,

2) Triage of night phone calls from hospital nursing staff.

Interns may interview, examine and direct the further evaluation and treatment of patients in
the Emergency Department. They are expected to review orders and test results with their
supervising resident or attending physician. The intern is required to have the attending

55
physician sign the Emergency Department medical record before the patient is released to
outpatient status, unless the patient has chosen to leave against medical advice.

1. Duties:

1. Reporting to his/her duty station on time according to the schedule worked out by the
department;

2. Respects the rules, policies and regulations of the Federal Hospital

3. Clerking patients as soon as they appear in the outpatient department or admitted to the
ward and keeping clear and concise records;

4. Consulting the resident or the attending physician on the management of the patient and
ensuring that the agreed upon management is carried out;

5. Ensuring that laboratory and other investigations are ordered and carried out and the results
are collected and appropriately documented;

6. Writing periodic progress notes the frequency of which will be dictated by the seriousness of
the patient’s illness;

7. Performing or assist in various clinical procedures in the OPD, emergency, ward operation
theatre or labor ward according to the guidelines of the specific department;

8. Writing discharge summaries which, however, should be countersigned by residents or

attending physicians;

9. Updating his/her knowledge through reading and participation in educational activities of the
department including morning meetings, mortality conferences, journal clubs, etc;

10. Assisting or participating in research activities conducted in the department;

11. Working on night, weekend and holiday duties as per the assignment put up by the
department;

12. Conducting all activities in a professional and ethical manner.

Residents

1. Scope of practice

56
Post-graduation Year 1

1. Complete history and physical on each patient admitted as assigned by the attending
surgeon.
2. Participate in daily ward or Intensive Care Units (ICU) rounds, establish daily treatment
plans for patients in the wards and ICU and carefully revise orders according to the
decisions made by the attending surgeon or senior residents.
3. Assist operating surgeons and senior residents in the operating room in performing
surgery under the supervision of the attending surgeon.
4. Order laboratory and radiological studies on patients admitted to the inpatient service
when indicated as discussed with the attending staff on daily rounds.
5. Make consultations as appropriate to other departments such as pediatrics, Obs-Gyn,
psychiatry etc… And nutrition and social services for total patient care needs under the
direction of the attending surgeon or senior resident.
6. Perform daily evaluation on inpatients with physical examination, review of laboratory
tests and nursing records and write daily progress note
7. Perform specific bed side procedures under supervision.
8. Write admission note, discharge summaries, post op acceptance note, procedure note,
operative notes, post op order, Death certificate and medical certificate after thorough
evaluation of patients
9. Order medications
10. Participate in daily outpatient clinics under the supervision of the senior residents or
attending staff.
11. Participate on daily morning session
12. Present seminar session, death round, journal club and the likes as assigned by the
attending surgeon or senior residents
13. Participate in research activities with senior residents or attending staff
14. Participate in teaching activities of medical students and interns
15. Perform emergency department assessment of the emergency surgical patient.

List of procedures performed by PG year 1 resident

1. Assist all sort of surgeries in major operation theatre when performed by a senior
resident or a surgeon
2. Perform all minor surgical procedures
3. Abdominal Paracentesis Or Pleural Tap
4. Aspiration Of Small Hematoma
5. Appendectomy for simple appendicitis under supervision of senior resident/ Surgeon
6. Breast abscess drainage
7. Emergency Venous cut down procedure

57
 8. Incision and drainage of superficial abscess
9. Posterior gutter for closed fractures
10. Suprapubic cystostomy under supervision of senior resident/ Surgeon
11. Tube Thoracostomy under supervision of senior resident/ Surgeon

Post-graduation Year 2

1. Complete history and physical on each patient admitted as assigned by the attending
surgeon.
2. Participate in daily ward or Intensive Care Units (ICU) rounds, establish daily treatment
plans for patients in the wards and ICU and carefully revise orders according to the
decisions made by the attending surgeon or senior residents.
3. Assist operating surgeons and senior residents in the operating room in performing
surgery under the supervision of the attending surgeon.
4. Order laboratory and radiological studies on patients admitted to the inpatient service
when indicated as discussed with the attending staff on daily rounds.
5. Make consultations as appropriate to other departments such as pediatrics, obs-gyn,
psychiatry etc… And nutrition and social services for total patient care needs under the
direction of the attending surgeon or senior resident.
6. Perform daily evaluation on inpatients with physical examination, review of laboratory
tests and nursing records and write daily progress note
7. Perform specific bed side procedures under supervision.
8. Write admission note, discharge summaries, post op acceptance note, procedure note,
operative notes, post op order, Death certificate and medical certificate after thorough
evaluation of patients
9. Order medications
10. Participate in daily outpatient clinics under the supervision of the senior residents or
attending staff.
11. Participate on daily morning session
12. Present seminar session, death round, journal club and the likes as given by the
attending surgeon or senior residents
13. Participate in research activities with senior residents or attending staff
14. Participate in teaching activities of medical students and interns
15. Perform emergency department assessment of the trauma patient.

Lists of Procedures performed by year 2 resident

58
 1. Assist all sort of surgeries in major operation theatre when performed by a senior
resident or a surgeon
2. Perform all minor surgical and orthopedic procedures
3. Abdominal Paracentesis Or Pleural Tap
4. Appendectomy for simple appendicitis under supervision of senior resident/ Surgeon
5. Aspiration Of Small hematoma
6. Breast abscess drainage
7. Drainage of perianal abscess
8. Emergency Venous cut down procedure
9. Excision of anal skin tags
10. Graham’s omental patch for perforated PUD under supervision of senior
resident/surgeon
11. Incision and drainage of superficial abscess
12. Laparatomy for emergency and non-emergency procedures under supervision of senior
resident/surgeon
13. Modified Bassini’s Hernioraphy for inguinal hernias under supervision of senior
resident/surgeon
14. Posterior gutter for closed fractures
15. Suprapubic cystostomy under supervision of senior resident/ Surgeon
16. Tube Thoracostomy under supervision of senior resident/ Surgeon

Post-graduation Year 3

1. Establish and coordinate diagnosis and treatment plans for all patients and lead daily
ward rounds
2. Participate in teaching activities of medical students and interns
3. Supervise students, interns and junior residents on their daily activities in general
Surgery.
4. Perform specific operations under the supervision of the attending surgical staff as
deemed appropriate by the attending surgical staff.
5. Participate in daily outpatient clinics with final year residents or attending staff.
6. Assist operating surgeons and senior residents in the operating room in performing
surgery.
7. Establish daily treatment plans for patients on the inpatient service including the
Intensive Care Units (ICU).
8. Perform daily evaluation on inpatients with physical examination, review of laboratory
tests and nursing records and write progress note as necessary.

59
 9. Perform specific bed side procedures.
10. Monitor completion of admission note, discharge summaries, progress note, post op
acceptance note, procedure note, operative notes, post op order, Death certificate and
medical certificate.
11. Participate on daily morning session and Present duty activities according to the duty
schedule.
12. Present seminar session, death round, journal club and the likes as assigned by the
attending surgeon
13. Participate in research activities with attending staff

Lists of Procedures performed by year 3 resident

1. Abdominal Hysterectomy With BSO

2. Abdominal Paracentesis Or Pleural Tap
3. Abscess – Large or Small Requiring Incision and Drainage
4. Anal dilatation
5. Anal fistulectomy
6. Anal fistulotomy
7. Appendectomy
8. Aspiration Of Small hematoma
9. Bilateral/Unilateral Inguinal hernia Repair
10. Bilateral Salpingo-Opherectomy
11. Bougi dilatation for urethral stricture
12. Breast abscess drainage
13. Breast debridement
14. Breast lump excision
15. Colostomy – Formation
16. Creation of Gastrostomy or Jejunostomy
17. Cricothyroidotomy
18. Cystolithotomy
19. Debridement of infected wound area, necrotizing fascitis including Fournier’s gangrene
20. Drainage of perianal abscess
21. Excision Accessary Breast Tissue
22. Excision of anal skin tags
23. Excision of Epididymal Cyst Spermatocele, or Epididymectomy
24. External fixation for common orthopedic fractures
25. External Haemorrhoidectomy
26. Freeing Of Major Abdominal Adhesions
27. Gastrojejunostomy

60
 28. Ileostomy Formation
29. Incision and Drainage Of abscess
30. Incision and Drainage Of hematoma
31. Laparotomy
32. Lateral Anal Sphincterotomy
33. Left Hemicolectomy - With Anastomosis
34. Left Hemicolectomy - With Formation Of Stoma
35. Lower extremity amputations
36. Management of acute and chronic osteomyelitis
37. Management of closed fractures(Basic)
38. Management of open fractures (Basic)
39. Management of pediatrics orthopedic problem, eg. Club foot, CHD, etc
40. Minor orthopedic procedures
41. Modified Bassini’s Hernioraphy
42. Open Cholecystectomy
43. Orchidopexy – Unilateral or bilateral
44. ORIF
45. Radical Orchidectomy
46. Rectosigmoidectomy With Formation Of Stoma (Hartmann’s Resection)
47. Removal Of Ectopic Pregnancy
48. Removal of Foreign Body
49. Repair Of Major/Minor Umbilical Hernia – Adult
50. Repair of Spigelian Hernia
51. Resection of small bowel and anastomosis
52. Right Hemicolectomy - With Anastomosis
53. Right Hemicolectomy - With Formation Of Stoma
54. Sigmoid colectomy With Anastomosis
55. Sigmoid colectomy With Formation of Stoma
56. Simple Mastectomy and Axillary Dissection – Bilateral/Unilateral
57. Simple Scrotal Orchidectomy
58. Skeletal traction
59. Skin Lesion Excision with Direct Closure Under GA
60. Skin Lesion Excision with Flap Closure Under GA
61. Skin Lesion Excision with Graft Closure Under GA
62. Skin traction
63. Splenectomy
64. Stripping and multiple ligation of varicose veins
65. Sub areolar duct excision for duct ectasia

61
 66. Subtotal Thyroidectomy
67. Suprapubic cystostomy
68. Tarsal Cyst (Chalazion) Removal in Clinic
69. Total Thyroid Lobectomy
70. Tracheostomy
71. Transverse Colectomy with Anastomosis
72. Transvesical prostatectomy
73. Triple bypass surgery for advanced pancreatic head tumor
74. Truncal vagotomy and drainage procedure
75. Unilateral Hernia - Inguinal Repair
76. Upper extremity amputations
77. Varicocele Repair

Post-graduation Year 4

1. Establish and coordinate diagnosis and treatment plans for all patients
2. Lead daily ward rounds
3. Participate in teaching activities of medical students and interns
4. Supervise students, interns and junior residents on their daily activities in general
Surgery.
5. Perform specific operations under the supervision of the attending surgical staff as
deemed appropriate by the attending surgical staff.
6. Participate in daily outpatient clinics with final year residents or attending staff.
7. Assist operating surgeons and senior residents in the operating room in performing
surgery.
8. Establish daily treatment plans for patients on the inpatient service including the
Intensive Care Units (ICU).
9. Perform daily evaluation on inpatients with physical examination, review of
laboratory tests and nursing records and write progress note as necessary.
10. Perform specific bed side procedures.
11. Monitor completion of admission note, discharge summaries, progress note, post op
acceptance note, procedure note, operative notes, post op order, Death certificate
and medical certificate.
12. Participate on daily morning session and Present duty activities according to the
duty schedule.
13. Present seminar session, death round, journal club and the likes as assigned by the
attending surgeon
14. Participate in research activities with attending staff

62
Lists of Procedures performed by year 4 resident

1. Abdominal Hysterectomy With BSO

2. Abdominal Paracentesis Or Pleural Tap
3. Abscess – Large or Small Requiring Incision and Drainage
4. Anal dilatation
5. Anal fistulectomy
6. Anal fistulotomy
7. Low Anterior Resection Of Rectum with Colo-anal Anastomosis
8. Aspiration Of Small hematoma
9. Bilateral/Unilateral Femoral hernia Repair
10. Bilateral/Unilateral Inguinal hernia Repair
11. Bilateral Salpingo-Opherectomy
12. Biopsy of Liver open, incidental
13. Bougi dilatation for urethral stricture
14. Breast abscess drainage
15. Breast debridement
16. Breast lump excision
17. Caesarian section
18. Choledocho-jejunostomy or choledoco-duodenostomy
19. Colectomy - Total With Ileo-Rectal Anastomosis
20. Colostomy – Closure
21. Colostomy – Formation
22. Creation of Gastrostomy or Jejunostomy
23. Cricothyroidotomy
24. Cystolithotomy
25. Debridement of infected wound area, necrotizing fascitis including Fournier’s
gangrene
26. Drainage of perianal abscess
27. Elevation of DSF
28. Emergency burr hole
29. Emergency craniotomy
30. Emergency thoracotomy
31. Evisceration and inoculation of eye ball
32. Excision Accessary Breast Tissue
33. Excision of anal skin tags
34. Excision of Epididymal Cyst Spermatocele, or Epididymectomy

63
 35. Excision of pilonidal sinus
36. Excision Of Thyroglossal Cyst Or Fistula
37. External fixation for common orthopedic fractures
38. External Haemorrhoidectomy
39. Freeing Of Major Abdominal Adhesions
40. Gastrectomy – Partial
41. Gastrojejunostomy
42. Gastrojejunostomy or Roux-en-Y Anastomosis
43. Ileostomy reversal
44. Ileostomy Formation
45. Ileostomy Revision
46. Incision and Drainage Of abscess
47. Incision and Drainage Of hematoma
48. Incision Of Bladder Neck
49. Inguinal Herniotomy (PPV ligation) - Under 3 Years
50. Internal Haemorrhoidectomy
51. Laparotomy
52. Lateral Anal Sphincterotomy
53. Left Hemicolectomy - With Anastomosis
54. Left Hemicolectomy - With Formation Of Stoma
55. Lower extremity amputations
56. Management of acute and chronic osteomyelitis
57. Management of closed fractures(Basic)
58. Management of open fractures (Basic)
59. Management of pediatrics orthopedic problem, eg. Club foot, CHD, etc
60. Meatoplasty (Urethra)
61. Mesh Hernioplasty
62. Minor orthopedic procedures
63. Modified Bassini’s Hernioraphy
64. Modified radical Mastectomy with axillary LN dissection
65. Near total thyroidectomy
66. Nephrectomy – Partial
67. Nephrectomy – Simple
68. Nephroureterectomy
69. Open appendectomy
70. Open Cholecystectomy
71. Orchidopexy – Unilateral or bilateral
72. ORIF

64
 73. Parastomal Hernia Repair
74. Partial Mastectomy Bilateral/Unilateral
75. Pyelolithotomy
76. Pyloroplasty
77. Excision of Submandibular Gland
78. Radical Orchidectomy
79. Rectosigmoidectomy With Formation Of Stoma (Hartmann’s Resection)
80. Removal Of Ectopic Pregnancy
81. Removal of Foreign Body
82. Removal of One or More Eyelashes for Trichiasis
83. Repair Of Incisional Hernia
84. Repair Of Major/Minor Umbilical Hernia – Adult
85. Repair of Spigelian Hernia
86. Repair Of Umbilical Hernia - Under 10 Years
87. Resection Of Rectum – Abdominoperineal
88. Resection of small bowel and anastomosis
89. Retropubic prostatectomy
90. Reversal of Hartmann’s procedure
91. Revision Colostomy
92. Right Hemicolectomy - With Anastomosis
93. Right Hemicolectomy - With Formation Of Stoma
94. Sigmoid colectomy With Anastomosis
95. Sigmoid colectomy With Formation of Stoma
96. Simple Mastectomy and Axillary Dissection – Bilateral/Unilateral
97. Simple Scrotal Orchidectomy
98. Skeletal traction
99. Skin Lesion Excision with Direct Closure Under GA
100. Skin Lesion Excision with Flap Closure Under GA
101. Skin Lesion Excision with Graft Closure Under GA
102. Skin traction
103. Splenectomy
104. Stripping and multiple ligation of varicose veins
105. Sub areolar duct excision for duct ectasia
106. Sublingual gland excision
107. Subtotal Thyroidectomy
108. Superficial Parotidectomy
109. Suprapubic cystostomy
110. Tarsal Cyst (Chalazion) Removal in Clinic

65
 111. Total Thyroid Lobectomy
112. Total Thyroidectomy Including Parathyroid Transplant
113. Tracheostomy
114. Transverse Colectomy with Anastomosis
115. Transvesical prostatectomy
116. Triple bypass surgery for advanced pancreatic head tumor
117. Truncal vagotomy and drainage procedure
118. Unilateral Hernia - Femoral Repair
119. Unilateral Hernia - Inguinal Repair
120. Upper extremity amputations
121. Ureterolithotomy
122. Urethral Calculus removal
123. Varicocele Repair

2. Duties of residents
1. Respect the rules, policies and regulations of the Federal Hospital
2. Reporting to his/her duty station on time according to the schedule worked out by
the department
3. Evaluating patients in the outpatient, emergency and inpatient departments
promptly and recording relevant information immediately
4. Instituting appropriate investigations and treatment
5. Keeping records of time and date in patient admission, interventions, referral,
consultation, discharge and formal hand- over of cases
6. Consulting supervisor in the management of difficult cases both in regular and duty
hours, failure of which may entail both academic as well as legal consequences
7. Writing discharge summaries, referral letters and death certificates
8. Performing procedures that are commensurate with his/her level of training and
assisting in other procedures
9. Teaching medical students and supervising interns and junior residents
10. Participating actively in all departmental educational activities including reading,
consulting, morning meetings, journal clubs, seminars, grand rounds, mortality
meetings, etc
11. Participating in clinical research conducted in the department
12. Participate in clinical audits and other quality initiatives
13. Taking more clinical, teaching and administrative responsibilities as he/she advances
through the residency training
14. Participating in the administrative activities of wards/outpatient departments in
conjunction with head nurses, Chief Resident and Head of Department
15. As part and parcel of one’s training, working on night, weekend and holiday duties
as per the assignment put up by the department

66
 16. Ensuring that cases during duty hours are properly handed over to the next
personnel on duty
17. Conducting all activities in a professional and ethical manner.
18. Take over classes with the approval of the head of the academic unit in emergencies,
such as sickness or other unavoidable absence of the staff assigned, provided that
such arrangement shall not continue beyond four weeks and provided further that
in the above instance a resident shall not be given the responsibility for more than
half of the course time.

I. Summary of Scope of practice in by site

N Responsible ICU & Emergency Wards Regular Regular Referral Remar

o physicians or emergency OR (cold case) OPDs OPDs k
medical staff departmen OR
ts

1 Senior physicians Attend Attend Attend Attend Attend Attend

2 Senior residents Direct or Direct or Indirect Indirect Attend Attend

indirect indirect supervision supervision
supervision supervision * *
(complicat
(complicat
e & critical
e & critical
case)*
case)*

3 Junior residents/ Direct Direct Direct or Direct Indirect Indirect

GP supervision supervision indirect supervision supervision supervision
* supervision * * *
(complicat
e & critical
case)*

4 Interns & medical Direct Direct Direct Direct Direct Direct

students supervision supervision supervision supervision supervision supervision
* * * * * *

5 Other paramedics Direct Direct Direct Direct Direct Direct

students supervision supervision supervision supervision supervision supervision

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 * * * * * *

Remarks (*)

Direct supervision means practice medicine in the physical presence of consultant senior
physician or supervising resident or GP respectively. Indirect supervision means practice
medicine without actual physical presence consultant senior physician or supervising resident
or GP respectively.

Minor modifications are possible according to the medical staff & specialty of the department.

A. General practitioners

Duties and responsibility

1. Respect the rules, policies and regulations of the Federal Hospital

2. Reporting to his/her duty station on time according to the schedule worked out by
the department
3. Evaluating patients in the outpatient, emergency and inpatient departments
promptly and recording relevant information immediately
4. Instituting appropriate investigations and treatment
5. Keeping records of time and date in patient admission, interventions, referral,
discharge and formal hand- over of cases
6. Consulting residents and seniors in the management of difficult cases both in regular
and duty hours, failure of which may entail legal consequences
7. Writing discharge summaries, referral letters and death certificates
8. Performing minor procedures
9. Teaching medical students and supervising interns

Scope of practice

1. Complete history and physical on each patient admitted as assigned by the attending
surgeon.
2. Participate in daily ward or Intensive Care Units (ICU) rounds, establish daily treatment
plans for patients in the wards and ICU and carefully revise orders according to the
decisions made by the attending surgeon or senior residents.
3. Order laboratory and radiological studies on patients admitted to the inpatient service
when indicated as discussed with the attending staff/senior resident on daily rounds.
4. Perform daily evaluation on inpatients with physical examination, review of laboratory
tests and nursing records and write daily progress note

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 5. Perform specific bed side procedures under supervision.
6. Write admission note, discharge summaries, post op acceptance note, post op order,
Death certificate and medical certificate after thorough evaluation of patients
7. Order medications
8. Participate in daily outpatient clinics under the supervision of the senior residents or
attending staff.
9. Participate on daily morning session
10. Participate in teaching activities of medical students and interns
11. Perform emergency department assessment of the emergency patient.

B. Seniors

Duties and responsibilities

- Leads the OR
- Participate and lead activities which they are assigned by the department
- Leads the team and assumes overall responsibility for the care of the patient.
- Oversees and coordinates the delivery of care, and when appropriate, delegates patient
care responsibilities to other practitioners within their legislated scopes.
- Determines when referral to a subspecialist is needed.
- Attends consultations from residents.
- Moderates seminars, rounds and morning sessions
- Should be available during their duties

Documentation

Admission notes

 Should be properly documented by both the Intern and resident

 Admission note to the ICU should be documented by GP/resident

Round note

 should be documented by the intern and cosigned by the immediate senior

Progress note

 daily progress note should be documented by the interns and residents

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Procedure/operation note

 procedure not should be documented by the individual who did the procedure

Discharge notes

 Should be documented by the intern and GP/resident; intern alone can write discharge
note but it should be cosigned with GP/resident
 In the ICU, transfer note should be written by GP/resident

Referral notes

 Should be documented by the GP/ resident.

 The intern can write referral notes but should cosign with the resident/GP.

Death summary

 Should be strictly written by the GP/resident

Consent form
- Should be filled by operating senior/senior resident
-

Monitoring and evaluation

- It will be monitored and evaluated by quality assurance committee of the department

- 1. Chart revision during rounds
- 2. Clinical audit
- 3. Monthly department audit

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Scope of practice
Pediatrics department
Introduction
The provision of optimal pediatric care depends on a team based approach to
health care involving all health professionals. The team based model of pediatric
care seeks to provide high quality, cost effective care by minimizing duplication of
clinical effort and promoting the appropriate and timely use of all health care
providers on the team. Each member of the team will have a significant input and
valuable contribution in order to maximize the quality of care. All members
should be able to create a uniform line of communication and create a team spirit
while doing their specific jobs. Hence, this document is needed in order to set a
baseline job description (scope of practice) to all the members/ stakeholders of
the pediatric team and promote the team spirit.

This document intends to

 Provide a general overview of the roles, responsibilities and functions of

consultants, residents and interns in the pediatrics department.
 Address issues relating to degrees of independent clinical practice,
interactions with faculty, and performance of procedures.

Duties and responsibilities of the pediatrician (consultant)

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  Leads the team and assumes overall responsibility for the care of the
patient.
 oversees and coordinates the delivery of care, and when appropriate,
delegates patient care responsibilities to other practitioners within their
legislated scopes.
 determines when referral to a pediatric subspecialist is needed.
 Supervises subspecialty follow up clinics.
 Attends consultations from residents.
 Moderates seminars, rounds and morning sessions.

Duties and responsibilities of the chief resident

The chief resident and teaching resident will be appointed based on the
performance of the resident during the period of training and approved by the
departmental meetings. The chief resident is accountable to the department
head.

1. Manage resident and intern rotations

2. Lead morning sessions
3. Make regular meeting with residents
4. Bring areas of quality improvement in the day-to-day activity of the
department by closely discussing with residents
5. Manage problems with residents and strictly control overall duty and other
activities

6. Communicate with head nurses and other coordinators to solve problems

with the postgraduate coordinator
7. Assign presenter for monthly death audit and make sure that it is going on
time

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Duties and responsibilities of the teaching resident
 Arrange and lead residents’ seminars, grand rounds and journal clubs, post
resident schedules, and monitor based on the schedule
 Assign residents for teaching undergraduate residents in communication
with undergraduate coordinator and department head
 Coordinate undergraduate exam in consultation with the undergraduate
coordinator
 Monitor and assist first-year and second-year resident presentations.
 Assign moderator, follow and coordinate intern management sessions
2. Responsible for intern evaluations to be done on time collect and give
proper feedback for interns with the undergraduate coordinator
3. Meet with postgraduate coordinator at least every two weeks

Duties and responsibilities of Year I resident

 Function as primary physician in order to maximize his/her exposure to
pediatric and child health problems
 Responsible for the initial stage of patient evaluation and management
 Responsible for the preparation and presentation of health problems for
the purpose of demonstration and discussion in seminars, tutorials, and
conferences

Duties and responsibilities of Year II resident

 Supervises and assists interns and year I residents.
 Continues to work as a primary physician

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  Runs subspecialty ambulatory clinics under the supervision of consultant
physician
 Demonstrates clinical skills to undergraduates
 Prepares seminars, grand rounds and clinical conferences
 Prepares and presents monthly patient statistics
 Supervises all medical records of patients under his/her care
 By mid-year, initiates a research protocol and initiates a pilot study

Duties and responsibilities of Year III resident

 Consults on all general pediatric and child health problems
 Runs subspecialty clinics in conjunction with the consultant pediatrician
 Supervises undergraduate students, interns, year I and year II residents
 Under supervision of the consultant, conducts bedsides, teaching rounds
and seminars for undergraduate students
 Participates in the evaluations and exams of undergraduates and interns
 Completes research initiated during year II

Duties and responsibilities of the INTERN

• First line patient evaluation, clerks New patients for the first time and
makes his/her own documentation.
• Can order baseline investigations CBC, stool, urine after consultation and
cosigning of the 1st year resident.
• In the wards should Follow patients, writes his/her own admission and
progress notes, collects investigations, facilitates consultations
• Presents cases on Morning sessions, grand rounds and seminars

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 • Should perform Procedures like LP, NG tube insertion, pleural tap,
urinary catheterization under strict supervision.

Duties and responsibilities of the GENERAL PRACTITIONER(GP)

 Attends outpatient clinics and evaluates patients.
 Consults residents for difficulties in decision making on further
management.
 Participates in morning sessions, grand rounds and seminars.
 Assists the team in the ER, wards and NICU
 Should perform Procedures like LP, NG tube insertion, pleural tap, urinary
catheterization.
 N.B – The GP should undertake all the activities of the resident in the
absence of the resident.

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Area specific placement and scope
1. Emergency room (ER)

Intern’s responsibility

 Clerks and at the same time stabilizes New patients with the help and
supervision of 1st year resident.
 Follows patients temporarily kept in the ER.

Year I resident’s responsibility

 Evaluates new patients and decides whether patient needs to be kept in

the ER or not.
 Makes proper documentation of kept patients in the ER
 Can revise orders for kept patients after making round with consultants or
the more senior resident.
 Can make decisions to admit patients to ward after consulting the 2 nd year
resident.
 Communicates with the ward team for admissions and should write
relevant admission note.

Year II resident’s responsibility

 Evaluates new and kept patients in the ER but special attention to the most
critical ones (RED according to the ETAT classification)
 Attends any consultation from the 1st year resident
 Helps in the decision making to admit patients to ward after consulting the
immediate senior resident.

Year III resident’s responsibility

 Makes daily round at the ER for kept patients

 Should teach juniors and share experiences to the team.
 Attends any consultation from the 1st or 2nd year resident.
 Consults the senior in charge for any difficulty.

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  Evaluates interns together with the consultant

Pediatrician’s (consultant) responsibility

 The most senior and the leader of the team.

 Makes final decisions with regard to the management of patients in the ER
 Makes daily round for kept patients in the ER.
 Teaches students, interns and residents.

2. General wards, ICU and NICU

Intern’s responsibility

 Evaluates and writes Admission note for newly admitted patients.

 Follows patients and writes daily progress notes.
 Takes round notes during rounds and makes sure orders are properly
undertaken by the nursing team.
 Collects investigations from the laboratory.
 Attends critical patients from wards when they are transported for imaging
and other investigations.

Year I resident’s responsibility

 Evaluates and writes Admission note for newly admitted patients.

 Follows patients and writes daily progress notes.
 Revises orders daily after consultation of the immediate senior.

Year II resident’s responsibility

 Evaluates admitted patients in the ward but special attention to the most
critical ones.
 Attends any consultation from the 1st year resident
 Helps in the decision making to revise orders after consulting the
immediate senior resident.
 Performs exchange transfusion in the NICU

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  Admits patients in the ICU and daily progress note

Year III resident’s responsibility

 Makes daily round in the ward.

 Should teach juniors and share experiences to the team.
 Attends any consultation from the 1st or 2nd year resident.
 Consults the senior in charge for any difficulty.
 Evaluates interns together with the consultant

3. Outpatient department (OPD)

Intern’s responsibility

 Evaluates patients in the OPD dividing patients together with the GP

 consults the 1st year resident for any difficulty. Not authorized to evaluate
clients referred from other set ups by resident or senior.

General practitioner’s (GP) responsibility

 Evaluates patients in the OPD dividing patients together with the intern.
 Not authorized to evaluate clients referred by resident or senior.
 Not authorized to evaluate or make decisions on follow up patients

Year I resident’s responsibility

 Evaluates patients in the OPD dividing patients together with the team in
the OPD.
 Attends consultations from the GP or intern.
 Consults the 2nd year for any difficulty

4. Follow up clinics

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  Follow up clinics are specifically attended by the pediatrician (consultant) in
charge.
 2nd and 3rd year residents also participate and evaluate patients in
subspecialty follow up clinics.
 Interns and GPs are not authorized to attend follow up clinics.

Rounds

Teaching rounds

 Intention of teaching round is to teach students, interns and residents in

the team and it is led by the consultant pediatrician.
 The patient’s case will be analyzed in depth during the teaching process.
 This should be made 3 times per week
 Multidisciplinary involving
- Residents (I to III), Intern, GP, undergraduate students
 Should align with the round protocol of the Hospital

Business rounds

 Intention of business rounds is to make quick and relevant evaluation of

patients in the wards and make decisions, it focuses more on the patient
and less teaching.
 Can be led by the 3rd or 2nd year resident.
 Consultant involvement is optional.
 Should align with the round protocol of the Hospital

Documentation practices
Admission notes
 Should be properly documented by both the Intern and 1st year resident

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  Admission note to the ICU should specifically be documented by the 2nd
year resident in addition to the 1st year resident and the Intern.
Progress notes
 Should be properly documented daily by the Intern, 1st and 2nd residents.
 In the ICU, 2nd year resident takes lead in writing progress notes.
Discharge notes
 Should be documented by the intern and 1st year resident.
 In the ICU, 2nd year resident documents discharge notes.

Referral notes
 Should be documented preferably by the 1st year resident.
 The intern can write referral notes but should cosign with the 1st year
resident.
Death summary
 Should be strictly written by the 1st or 2nd year resident
Consultation notes
 Can be documented by the intern and cosigned by the immediate senior

Monitoring and Evaluation

 All the above mentioned scopes of practices should be monitored by the
department.
 Methods of M and E
- during rounds
- Chart review
- Clinical audits
- Check list prepared for this purpose

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  M and E will be performed by the quality assurance committee which will
be established by the department.
 Formal M and E will be done every month and report presented to the
department during morning sessions.
 Feedback will be given and corrective measures implemented accordingly

Emergency and Critical Care Medicine Specialty

Harmonized scope of practice
Emergency medicine is a distinct specialty which deals with the care of the acutely sick or
injured patient. It is a field of practice based on the knowledge and skills required for the
prevention, diagnosis and management of acute and urgent aspects of illness and injury
affecting patients of all age groups with a full spectrum of episodic undifferentiated physical
and behavioral disorders; it further encompasses an understanding of the development of pre
hospital and in hospital emergency medical systems and the skills necessary for this
development. The care of the acutely sick or injured starts at the site of scene and goes beyond
the emergency department with peculiar link to critical care. These two disciplines share more
than the linkage in the continuum of care of the very sick or critically injured. The knowledge,
attitude and skills required to practice in both areas overlap as in no other disciplines in clinical
medicine. The care of the acutely sick or injured starts at the site of scene and goes beyond the
emergency department with peculiar link to critical care. These two disciplines share more than
the linkage in the continuum of care of the very sick or critically injured. The knowledge,
attitude and skills required to practice in both areas overlap as in no other disciplines in clinical
medicine.

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Objectives of the scope of
practice
General objectives
This scope of practice is to give a proficient emergency and critical care specialist for patients
with came with undifferentiated and unscheduled acutely ill or injured patient of all spectrum;
design an emergency /critical care system, engage in problem solving research, advise and
advocate on policy issues through self-directed competency based service in an intensively
supervised program in a milieu of patient centered high standard continually improving
practice.

Specific Objectives
 To employs pertinent methods of prioritization, assessment, intervention, resuscitation, and
further management of patients of all age categories who come with emergency condition.
 To enable trainers and practitioners practice evidence-based medicine .
 To enable trainers and Practitioners to do quality improvement activities in Prehospital care and
become a pillar in EMCCS development.
 To enable trainers and practitioners to Provide medical consultancy for Emergency and
intensive Care Unit designing.
 To enable trainers and practitioners to raise and conduct problem solving research and
contribute to the field.
 To enable trainees and practitioners to do disaster preparedness and response plan and leads
disaster response team

emergency and critical care

specialist Profile
Emergency Medicine and Critical care specialist will be able to execute the following roles and
responsibilities competently.

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1) Emergency Medicine and Critical Expertise
 Provide comprehensive, immediate, and stabilizing care in an emergency situation,
independent of the location of the emergency
 Manage situations in which decision making under pressure of time is essential to save lives
 Establish the initial provisional diagnosis and differential diagnoses and rule out life-
threatening situations
 Perform patent triaging at the scene, in the hospital, study effectiveness and improve
triaging protocols
 Able to take history, physical examination, interpreter laboratory and radiologic results and
diagnose and treat life threatening conditions.
 Have skills of conducting appropriate evaluation and management of critically sick patients
 Perform emergency and critical care diagnostic tests
 Provide fast and effective basic and advanced life support, resuscitation and stabilization
 Secure intra osseous lines, perform venous cut downs and conduct central venous and
arterial cannulations, cardioversion/defibrillation, cardiac overdrive pacing, temporary trans
venous and trans cutaneous pacemaker,
 Have appropriate skills to perform emergency surgical and obstetric interventions
 Have the skills to do intubations, cricothyroidotomy, tracheostomy and advanced airway
maneuvers
 Use the ultrasound to detect hemothorax, pneumothorax, hemoperitoneum and early
pregnancy and perform critical care ultrasound.
 Use the ultrasound to do ultrasound guided nerve block, pericardiocentesis,
pleurocenthesis and paracentesis
 Recognize various types of shock and secure peripheral and central lines
 Perform procedures under procedural sedation
 Perform various types of patient monitoring: Arterial blood gas analysis, intracranial
pressure (ICP) monitoring, troubleshooting ICP monitoring, cerebral spinal fluid (CSF)
drainage for raised ICP.
 Insert a temporary hemodialysis catheter, and supervise renal replacement therapy
 Perform gastro-esophageal balloon tamponade insertion
 Determine nutritional plan in critical care setting
 Lead a team in Emergency and ICU for resuscitation or major procedure undertakings.
Perform primary and secondary assessment, conduct timely effective resuscitation, initiate
management of life threatening conditions and perform disposition of the patient and
manage flow in the emergency department

83
 Performs appropriate delegation and referral.
 Perform analgesia and procedural sedation, monitor and provide high quality care of the
seriously sick patient in the ICU.
 Provide emergency care for mass casualties, mass gatherings, natural disaster, advise and
design institutional, regional and national emergency response plans.
 Perform systematic survey of emergency outbreak
2) Manager
 Provide effective leadership in the scene of emergency, pre-hospital setting, emergency
floor and critical care set up
 Design, operate and provide quality pre-hospital care
 Manages resources effectively.
 Perform fair allocation of scarce resources
 Engage in project design, implementation and evaluation.
 Perform preparation of protocols, perform quality improvement projects
3) Scholar and health educator
 Perform problem solving research, critically appraise scientific literatures.
 Design and provide policy advice on establishment and operation of EMS system,
emergency and critical care setups
 Pursue self-directed learning throughout one’s career
 Serve as a mentor and receptor, design educational materials and curricula
4) Communicator and collaborator
 Maintain the spirit of team work
 Collaboration and interdependence while providing care in the emergency department,
scene, pre-hospital and critical care set up.
 Communicate effectively with colleagues and other stakeholders (police, public relations,
mass media and etc.)
5) Professionalism
 Demonstrate professional behavior and attitudes.
 Demonstrate self-integrity the midst of challenging situations.
 Provide care based on ethical principles, the legislation and regulations of the country.
Up hold to a maximum patient safety.
 Demonstrates ability in breaking bad news
 Provide quality emergency care depending on evidence-based practice.
 Involve patients and relatives in the care and decision process.

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Interns:

1. Scope of practice

Under direct supervision by senior residents and/or attending physicians, major responsibilities
include:

1) history and physical examination of patients;

2) accountability for all patients’ care;

3) instruction of medical students;

4) proper documentation on charts, discharge summaries, and legal consents;

5) daily examinations of patients on the inpatient services;

6) issuance of treatment orders in the medical record for hospitalized patients;

7) assessment and formulation of treatment plans for patients in the emergency department
and

8) participation in teaching and work rounds as scheduled by supervising physicians.

Technical skills, to include the following under the direct supervision of a senior or junior
resident, attending physician or credential nurse;

1) arterial puncture,

2) bladder catheterization,

3) gastric lavage and aspiration,

4) lumbar puncture,

5) paracentesis,

6) thoracentesis,

7) venipuncture,

85
8) ATLS and ACLS,

9) neonatal resuscitation,

10) oxygen administration

11) routine low-risk orthopedic procedures like simple fracture reduction and stabilization,
application of cast and gutter;

12) single- layered suturing;

13) Nasogastric or orogastric tube insertion

Performs duties as required:

Interns may interview, examine and direct the further evaluation and treatment of patients in
the Emergency Department. They are expected to review orders and test results with their
supervising resident or attending physician. The intern is required to have the attending
physician sign the Emergency Department medical record before the patient is released to
outpatient status, unless the patient has chosen to leave against medical advice.

2. Duties:

1. Reporting to his/her duty station on time according to the schedule worked out by the
department;

2. Respects the rules, policies and regulations of the Federal Hospital

3. Clerking patients as soon as they appear in the emergency department or kept to the
emergency ward and keeping clear and concise records;

4. Consulting the resident or the attending physician on the management of the patient and
ensuring that the agreed upon management is carried out;

5. Ensuring that laboratory and other investigations are ordered and carried out and the results
are collected and appropriately documented;

6. Writing periodic progress notes the frequency of which will be dictated by the seriousness of
the patient’s illness;

7. Performing or assist in various clinical procedures in the emergency ward, emergency

procedure room, emergency operating theater according to the guidelines of the specific
department;

86
8. Writing discharge summaries which, however, should be countersigned by residents or
attending physicians;

9. Updating his/her knowledge through reading and participation in educational activities of the
department including morning meetings, mortality conferences, journal clubs, etc;

10. Assisting or participating in research activities conducted in the department;

11. Working on night, weekend and holiday duties as per the assignment put up by the
department;

12. Conducting all activities in a professional and ethical manner.

GENERAL PRACTIONER

1. Scope of practice

Complete history and physical examination on each patient admitted to emergency

1. Participate in daily rounds, establish daily treatment plans for patients in the ER and
carefully revise orders according to the decisions made by the attending senior.
2. Assist procedures done by senior physician and residents in the ER;
3. Order laboratory and radiological studies on patients admitted to the ER when indicated
as discussed with the attending staff on daily rounds.
4. Make consultations as appropriate to other departments such as Surgery, internal
medicine, anesthesia, obs-gyn, psychiatry etc.. And nutrition and social services for total
patient care needs under the direction of the attending senior physician or resident.
5. Perform daily evaluation on inpatients with physical examination, review of laboratory
tests and nursing records and write daily progress note
6. Perform specific bed side procedures under supervision.
7. Write admission note, discharge summaries, procedure note, Death certificate and
medical certificate after thorough evaluation of patients
8. Order medications
9. Participate on daily morning session
10. Present seminar session, death round, journal club and the likes as assigned by the
attending physician.
11. Participate in research activities with attending staff
12. Participate in teaching activities of medical students and interns.

2. Duties of GP
1. Respect the rules, policies and regulations of the Federal Hospital

87
 2. Reporting to his/her duty station on time according to the schedule worked out by
the department
3. Evaluating patients in the ER promptly and recording relevant information
immediately
4. Instituting appropriate investigations and treatment
5. Keeping records of time and date in patient admission, interventions, referral,
consultation, discharge and formal hand- over of cases
6. Consulting supervisor in the management of difficult cases both in regular and duty
hours, failure of which may entail legal consequences
7. Writing discharge summaries, referral letters and death certificates
8. Performing procedures that are commensurate with his/her level of training and
assisting in other procedures
9. Teaching medical students and supervising interns and residents
10. Participating actively in all departmental educational activities including reading,
consulting, morning meetings, journal clubs, seminars, grand rounds, mortality
meetings, etc
11. Participating in clinical research conducted in the department
12. Participate in clinical audits and other quality initiatives
13. Taking more clinical, teaching and administrative responsibilities
14. Participating in the administrative activities of ER ward in conjunction with head
nurses, Chief Resident and Head of Department
15. working on night, weekend and holiday duties as per the assignment put up by the
department
16. Ensuring that cases during duty hours are properly handed over to the next
personnel on duty
17. Conducting all activities in a professional and ethical manner.
18. Take over working hours with the approval of the head of the academic unit…… in
emergencies, such as sickness or other unavoidable absence of the staff assigned,
provided that such arrangement shall not continue beyond ………

R-I–Junior Resident ER
88
  Recall the fundamental approach to focused history taking and physical examination
 Apply principles of meticulous history taking and pertinent physical examination in the
emergency and critical care settings
 Employ appropriate documentation and organization of patient’s medical records
 Maintain clear, concise, accurate, and appropriate records of clinical encounters and
plans
 Present oral reports at rounds, clinical evaluations, morning sessions and consultations
 Recall the fundamental principles of medical ethics
 Identify the principles of good medical practice and practice it
 Outline the elements of informed consent and take accordingly
 Demonstrate professional behavior and attributes in the emergency floor and critical
care units
 Recognize the scope of practice in emergency medicine and critical care
 Demonstrate insight into one’s own limits of expertise
 Demonstrate respect to differences, misunderstandings and understanding to the limits
of scope of practice in other professions
 Demonstrate knowledge of and attention to different ethnic, social, and cultural
backgrounds
 Illustrate respect to team ethics, including confidentiality, resource allocation, and
professionalism
 Demonstrate compassionate and respectful patient centered care
 Demonstrate knowledge and understanding of professional, legal, and ethical codes of
practice
 Review locally available health care advance directives
 Define triage and Elaborate basic Principles of triage and do triaging
 Transport patients
 Acquire the knowledge skills and attitudes needed to proficiently resuscitate a patient
with life threatening emergencies and stabilization of critically ill patients and perform
accordingly.
 Do airway assessment & optimizing the patient’s position for airway management.
 Apply airway management with the use of oral/nasal airways.
 Do ventilation using bag valve and mask.
 Apply tracheal suction
 Do a pre-anesthetic patient assessment

89
  Do airway assessment and identify patients who may be difficult to ventilate and/or
intubate and identify patients that may require a different airway intervention.
 Do basic airway management techniques.
 Recognize situations in which intubation is likely to be required
 Distinguish between an immediate need for intubation and an urgent need for
intubation
 Recognize important reversible causes of an impaired airway or ventilation
 Prepare thoroughly for rapid sequence induction (RSI) and tracheal intubation
 position patients optimally to maximize the success of laryngoscopy and intubation
 Prepare equipment and drugs required for RSI and tracheal intubation
 Assess and reassess the patient rapidly and ascertain all the required information before
undertaking RSI
 Identify and use team resources appropriately to maximize team co-operation
 Do rapid sequence induction (RSI) and confirmation of successful intubation
of tracheal intubation under direct supervision of senor physician or senior resident
 Do immediate review of patient physiology after intubation
 Put patients on NIPPV as needed and follow them
 Confirm cardiac arrest, establish Basic Life Support, use defibrillation appropriately and
use appropriate drugs.
 Interpret ECG and identify abnormal rhythm and manage life threatening cardiac
rhythm disturbances accordingly
 Recognize the shocked patient, the likely cause and initiate treatment.
 Recognize common electrolyte and fluid imbalance and initiate treatment.
 Be able to mention principles of Fluid and Blood Resuscitation
 Identify and manage the problems of ventilation and oxygenation.
 List important causes of coma.
 Be able to look after the comatose patient safely and establish the diagnosis and
differential diagnosis by systematic history and examination and appropriate diagnostic
testing.

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  Mention general concepts in the management of the traumatized patient
 Identify the critically ill and injured patient, provide safe and effective immediate care
resuscitative care for trauma patient.
 perform FAST, EFAST and to interpret different radiologic modalities in depth under direct
supervision by senior physician or senior resident


R-1-Junior Critical Care

 Manage both medical and surgical critically ill patient

 Identify the indications for putting a patient on mechanical ventilator, weaning and
extubation
 Contrast the different modes of mechanical ventilation
 Treat complications of mechanical ventilation
 Exercise the different methods to prevent complications in the mechanically ventilated
patient
 Exercise sedation and pain management in the ICU
 Elaborate the principles of fluid, calorie and metabolic substrate requirements of the ICU
patient
 prescribe different drugs used in the ICU,
 Elaborate the classification of arrhythmias and anti-arrhythmic s
 Diagnose and manage ileus
 Identify and manage coagulopathies and bleeding diathesis in the ICU
 Explain the biochemical, cellular, molecular mechanics of neuronal death and secondary
brain injury in critical care
 Differentiate and manage different causes of coma
 Recognize and manage seizure in the critically ill
 Diagnose and manage a case of tetanus
 Diagnose and manage sepsis
 Diagnose and mange ventilator associated pneumonia
 Recognize and mange hormonal disorders in the ICU
 Operate mechanical ventilator and noninvasive oxygenation techniques
 perform FAST, EFAST and to interpret different radiologic modalities in depth under direct
supervision by senior physician or senior resident

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Environmental Emergencies I for junior resident
 treat common environmental emergencies like bites and stings, drowning…
 treat Electrical jury ,Thermal injuries And Lighting injuries

R-II – Senior Year

 Demonstrate competency in appropriate and timely decision making in the emergency
and intensive care units
 Recognize and respond to the ethical dimensions in medical decision-making,
specifically in an Emergency Medicine practice context where obtaining informed
consent is not always feasible
 Demonstrate effective clinical problem solving and judgment to address patient
problems, including interpreting available data and integrating information to generate
well organized differential diagnoses and management plans
 Perform timely and selective clinical reassessments to optimize and facilitate patient
care
 Use sound clinical reasoning and judgment to guide diagnosis and management and
arrive at appropriate decisions, even in circumstances where complete clinical or
diagnostic information is not immediately available
 Demonstrate effective, appropriate, and timely consultation of another health
professional as needed for optimal patient care
 Arrange appropriate follow up care services for a patient and the patient’s family
 Act professionally and tactfully when screening for sensitive issues or information
 Seek out and synthesize relevant information from other sources, such as a patient’s
family, other physicians, police, firefighters, emergency medical services personnel, and
other health professionals
 Communicate effectively during crisis situations in the emergency department
 Engage patients, patients’ families, and relevant health professionals in shared decision-
making to develop a plan of care in an emergency medicine and critical care practice
context
 Demonstrate a commitment to delivering the highest quality care and maintenance of
competence
 Fulfill the regulatory and legal obligations required by jurisdiction
 Manage mass gathering, disaster, mass casualty and outbreak
 Recognize emergency overcrowding, boarding mobilize patients accordingly
 Design emergency and critical care set up

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  Design transfer referral and admission protocols for ICU and emergency set ups
 allocate human resource for different level emergency and critical care set ups
 Perform audit survey and present during audit sessions
 Write project proposal
 Arrange schedule for family visits for in the ICU
 Involve family in the decisions in the ER and ICU
 Elaborate principles of therapeutic team organization
 Explain principles of project design, proposal writing management and evaluation
 Explain the principles of root cause analysis and quality improvement cycle
 Demonstrate motivation to participate in quality improvement projects
 Elaborate the pharmacology of antiarhythmic agents.
 Elaborate pharmachology of vasopressor agents.
 Mention the Principle of Cerebral Resuscitation and therapeutic hypothermia
 Mention and manage specific aspects of the management of cardiac arrest in pregnant
ladies.
 Interpret capnography trace.
 Describe and manage anaphylaxis, acute allergic reactions, and angioedema.
 Mention the algorithm of pain management.
 Describe life threatening complications of pain
 Provide non invasive and invasive ventilatory support.
 Identify correct/incorrect placement of tube, esophagus, right main bronchus.
 Perform needle/surgical cricothyroidotomy and percutaneous transtracheal ventilation
 Identify the difficult or potentially difficult airway.
 Provide Advanced cardiac life support
 Be able to recognize and manage peri- arrest arrhythmias.
 Perform cardioversion, and cardiac pacing.
 Management of post-cardiac arrest patients.
 Apply the principles of hemodynamic monitoring
 Be able to treat the common electrolyte disturbances
 Be able to interpret arterial blood gases and establish the diagnosis or differential
diagnosis.

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  Perform Venous and Intraosseous access in adults
 Demonstrate good communications in multi-disciplinary team working for resuscitation.
 Able to work both within and lead a team to ensure the patient’s needs of resuscitation.
 Demonstrate the skill of pain management
 perform FAST, EFAST and to interpret different radiologic modalities in depth


R-II – Senior Year CRITICAL CARE

 Explain principles of ICU admission and discharge

 Elaborate ICU scoring systems and their correlation with outcome
 Elaborate the principles of respiratory, cardiovascular,electrolyte, acid base, fluid,
neurologic monitoring of the ICU patient
 Interpret acid base analysis result
 Define organ failure for the different systems
 Define acute kidney injury
 Elaborate how age, co- morbid illness affects the care given in the ICU
 Perform interpretation of brain, chest and spinal cord imaging
 Diagnose brain death
 Explain the causes and management of infection in the immunocompromised and
neutropenic patient
 Perform dilatational tracheostomy
 Insert feeding tubes
 Insert arterial and central venous line
 Practice safe analgesia and sedation
 Demonstrate aseptic technique
 Perform CVP monitoring
 Display respect for the dying human being
 perform FAST, EFAST and to interpret different radiologic modalities in depth

Environmental Emergencies II for senior resident

 Treat the above-mentioned environmental emergencies plus treat heat and cold
emergencies

R-III- SENIOR RESIDENT ER

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  Act up as consultants to provide optimal, ethical and patient centered care
 Demonstrate the ability to prioritize professional duties effectively when faced
with multiple patients and problems
 Demonstrate medical expertise in situations other than patient care, including
but not limited to advising hospital and/or regional health authorities, advising
government agencies, or providing expert legal opinions
 Recognize and manage crisis situations and critically ill patients in a calm,
prompt, and skillful manner
 Apply appropriate measures for protection of health care providers during the
entire patient encounter to avoid exposure or contamination, including but not
limited to infectious agents, and biologic, chemical, and radiation hazards
 Present medical information effectively to the public or media about a medical
issue
 Optimize and expedite patient care through involvement of other health care
professionals and delegate appropriately
 Coordinate the activities and interactions of multiple consulting services in
complex cases
 Solicit input from appropriate members of the health care team and keep the
team apprised of management plans and rationale
 Identify delays in therapeutic interventions and propose solutions
 Apply evidence and management processes for cost-appropriate care
 Improve efficiency and performance through appropriate allocation of micro
resources
 Identify opportunities for advocacy, health promotion, and disease prevention in
the communities that they serve, and respond appropriately
 Describe how public policy impacts on the health of the populations served
 Identify points of influence in the health care system and its structure
 Define emergency overcrowding ,emergency boarding
 Explain ways to mitigate overcrowding and boarding
 Define mass gathering ,disaster ,mass casualty and outbreak
 Explain approach to the management of mass gathering ,disaster ,mass casualty
and outbreak
 Demonstrate willing to actively participate off working in cases of mass gathering
,disaster ,mass casualty and outbreak
 Explain the principles of root cause analysis and quality improvement cycle
 Demonstrate motivation to participate in quality improvement projects
 Perform audit survey and present during audit sessions
 Write project proposal
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  Elaborate principles of therapeutic team organization
 Recognize emergency overcrowding, boarding mobilize patients accordingly
 Design emergency and critical care set up
 Apply noninvasive ,invasive and surgical airway management.
 Introduction and checking correct placement of laryngeal mask airway.
 Demonstrate Heimlich maneuver.
 Explain principle of hyperbaric oxygen therapy.
 Manage tracheostomy tube complications.
 Able to manage failed airway , including LMA, needle & surgical
cricothyroidotomy
 Perform emergency tracheostomy
 Be able to lead a resuscitation team
 perform FAST, EFAST and to interpret different radiologic modalities in depth

 Be able to explain ethical issues of resuscitation.

 Perform pericardiocentesis
 Establish the diagnosis and initiate or plan for definitive care.
 Demonstrate working in the difficult and challenging environment of the
Emergency department.
 Be able to re-prioritize and respond to new and urgent situations of
resuscitation.
 Manage ED in situation of mass causality.
 Demonstrate proficiency in using transcutaneous and/or transvenous pacing.
 Demonstrate effective leadership of a treatment team in the emergency
department setting.
 Demonstrate rapid assessment for immediate life threats in a patient presenting
with hematemesis
 Work as a team to achieve good care
 Be willing to reprioritize in the face of changing departmental demands
 Recognize the importance of good time keeping.

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  Help others to prioritize and recognize that other people’s priorities may be
different
 Respect other peoples time by being prompt and completing tasks within agreed
time frame
 Be conscious of the requirement to reduce the number of handovers from junior
doctor to junior doctor without a conclusion being reached
 Make decisions based on logical evidence &avoid bias in making decisions
 Take responsibility for ones decisions.
 Recognize one's own limitations
 Approach people with an open mind
 Listen to the patient & to their family - value their contributions
 Be caring and empathic.
 Encourage patient or family involvement in decision making
 Be sensitive to carriers of children with special needs, recognizing that a
multidisciplinary approach is often required
 Respect cultural and religious wishes of the family and patient
 Respect the team and understand individual responses to stressful situations
 Provide support and assistance for family and staff alike after difficult encounters
 Be able to show compassion and understanding whilst maintaining a
professional position


R-III- SENIOR RESIDENT CRITICAL CARE

 Contrast the evidences for the different lung protective ventilation strategies
 Elaborate on the principles of extra corporal membrane oxygenation
 Management patients with complex mixed acid base disorders
 Compare and contrast the different feeding techniques for the critical patient
 Summarize the principles of renal replacement therapy for acute kidney injury

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 Explain the management of a patient with acute liver failure
 Explain the principles of temporary pacing and approach to the patient with an existing
pacemaker
 Explain the principles of care after neurosurgery
 Follow a critically sick patient after surgery
 Manage the possible brain dead organ donor
 Differentiate DNR order ,advanced directives and cessation of care principles and apply in
the ICU
 Explain basic infection prevention strategies and principles in the ICU
 Indentify strategies to mitigate MRSA,VRE , C. Difficile and other infections related to
irrational use of antibiotics and poor infection control
 Perform transesophageal echocardiography
 Care for the critically ill neonate and child
 Care for the critically ill pregnant lady
 Prepare enteral and parenteral feeding regimens for patients
 Perform intracranial monitoring
 Perform transvenous /cutaneous Pacing
 Assist families to accept the death of a loved one
 Comply with the hospital guidelines and participate in the improvement of the former for
IC
 perform FAST, EFAST and to interpret different radiologic modalities in depth

Environmental Emergencies III Acting up year resident

 treat all environmental emergencies
 accept consultation from the juniors

Orthopedic Emergencies
All residents according to their respective department has to
exercise this

 Explain Pathophysiology of Fractures

 Elaborate Types of Fractures

98
  Explain Fracture healing
 Demonstrate the Evaluation of fractured limb in ED (HX, PE, neurovascular evaluation)
 Types of Immobilization Dressings
 Demonstrate initial ED Management of fractures
(reduction splinting and open fracture management)
 Elaborate injuries which need Orthopedic consultation
 demonstrate and Radiologic description of fractures
 explain Digits Anatomy, evaluation, zones of hand
 be able to manage Ligament us Injuries and Dislocations of the hand
 be able to manage patient with Phalangial fracture
 define Compartment syndrome of the hand
 explain Anatomy, Ligamentous Injuries of the wrist and carpal bone fracture
 define and be able to manage Distal Radius and Ulna Fractures(colles, smith bartens
Fracture
 Explain Anatomy of elbow joint, Soft tissue injury(bisept and trisept rupture,
epicondilitis and Elbow dislocation
 Be able to splint reduce and mange patient with elbow dislocation and fracture
 Explain classification and management option of Distal humeral and supracondilar
fracture
 Explain classification of Particular surface fractures
 Elaborate different Fractures of ulna and radius
 Explain classification and management options of Clavicurar fracture
 Explain classification and management options Scapular fracture and scapula thoracic
dissociation
 Explain classification and management options Acromioclavicular Joint Injuries
 Elaborate classification and management of Glinohumeral dislocation
 Demonstrate reduction method and splinting of Humeral fractures
 Explain evaluating and complication of Brachial plexus injury
 Elaborate classification complication and management of Pelvis fractures
 Demonstrate evaluation, classification and reduction of Hip dislocation and fracture
 Demonstrate evaluation, classification, splinting and reduction Femoral fracture
 Explain anatomy, clinical features, imaging, Knee dislocation and fractures
 Explain anatomy, clinical features, imaging and splinting of Fracture of patella
 anatomy, clinical features, imaging, Fractures of the femoral condils
 explain classification splinting and evaluation of Fractures of the Tibia Spines, Tibia
Plateaus and Ligaments and mensal injury Tuberosity
 Leg Injuries
 Anatomy, compartments, evaluation and radiography

99
  Explain clinical features courses risk factors and management of Achilles tendon rupture
 Compartment syndrome
 Complications of orthopedic devise and reconstruction
 Explain different causes of neck and back pain
 manage patient with neck and back pain
 Describe causes of shoulder pain
 manage patient with shoulder pain
 Explain different causes of hip and knee pain
 Manage a patient with Hip and knee pain
 Diagnose a patient with systemic rheumatic disease emergencies(SLE)
 manage emergencies in systemic rheumatic disease
 manage acute disorders of joint and bursa
 manage soft tissue problems of the foot

Dermatologic Emergency
 Assess patients with dermatological problems.
 Describe dermatological lesions and recognize dermatological emergencies.
 List causes, emergency management and complications
 Recognize precipitating causes associations and complications.
 Mention pathophysiology of urticarial, angioedema anaphylaxis.
 Describe causal microbial agents and appropriate antibiotics for cellulitis, erysipelas,
impetigo, necrotizing infection
 Explain patterns and common precipitants of drug eruption.
 Manage Serious complications of drug reaction and Stevens-Johnson syndrome
 Assess mucosal involvement, especially the airway
 Identify those patients who require admission.
 Identify those who have abscess formation
 Assess airway patency and manage upper airway obstruction and initiate rapid
treatment.
 Recognize of anaphylaxis
 Assess mucosal involvement and systemic effects including estimation of fluid
requirements.
 Manage eczema and seborrheic dermatitis
 Identify, resuscitate, treat and appropriately refer environmental emergencies

psychosocial emergencies

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  Treat patients based on the general approach to a patient in the ED with Behavioral
disorders
 Elaborate the steps in assessment and management of the psychotic and violent patient
 Perform physical and chemical restraints for the violent in the ED
 Explain the approach to the suicidal patient
 Identify the assessment of suicide Risk
 Differentiate patients with medical condition and psychiatric disorders
 Identify the syndromes associated with Alcohol and substance Abuse
 Elaborate the multi axial diagnostic system
 List the common Psychotropic Medication and rapid tranquilization
 Elaborate the common Anti psychotics , their indications and side effects
 Describe the common anti- depressant drugs their indication and side effects
 Explain Panic disorders and it management
 Elaborate conversion disorder and the management

area specific allocation in er

Area in ED PHYSICIANS
Triage R-3(facilitate the triage, accept
consultation, start resuscitation for pts in
need), GP( facilitate the triage, accept
consultation, start resuscitation for pts in
need) (Senior consultant for indirect
consultation)
Front Intern(clerk green and orange patients,
accept orders from the other physician) ,
GP(resuscitate and cleark all kind of
patients, consult residents and seniors), R-
1 (resuscitate and cleark all kind of
patients, consult residents and seniors) ,R-
3(resuscitate and cleark all kind of
patients, consult residents and seniors, do
as a consultant)
Red R-3, R-2,R-1, GP--( resuscitate pts, follow
pts, cleark pts, consult seniors or residents
and carry out the management,consult

101
 other department’s about the pts and
carry out the management and transfer
pts to the respective ward or ICU after
writing admission note, write progress
note), INTERN( follow pts, take order and
carry out, write progress note, collect
investigation), Senior consultant for direct
consultation)
yellow R-2, R-1,GP,--( resuscitate pts, follow pts,
cleark pts, consult seniors or residents and
carry out the management,consult other
department’s about the pts and carry out
the management and transfer pts to the
respective ward or ICU after writing
admission note, write progress note)
Intern(follow pts, take order and carry
out, write progress note, collect
investigation, write acceptance note)
,senior on call
Green R-1, GP,--( , follow pts, clerk pts, consult
seniors or senior residents and carry out
the management, consult other
department’s about the pts and carry out
the management and transfer pts to the
respective ward or area after writing
admission note, write progress note )
INTERN(follow pts, take order and carry
out, write progress note, collect
investigation, write acceptance note)
,senior on call
Isolation R-2,R-1,GP,---( follow pts, clerk pts,
consult seniors or senior residents and
carry out the management, consult other
department’s about the pts and carry out
the management and transfer pts to the
respective ward or area after writing
admission note, write progress note
INTERN follow pts, take order and carry
out, write progress note, collect
investigation, write acceptance
note),senior on call

102
 MONITORING AND EVALUATION
 Death Audit
 Case discussion
 Morning section
 Seminar

Daily activity in the ED

Morning section Monday, Wednesday and
friday
Round Teaching round- 2x weekly
by senior
Clinical round -2x daily by
senior
Specialty round-daily by
their respective senior
Admission decision By senior either directly
during round or through
consultation,

Comments
 Define common professions to all departments after
introduction
 Monitoring and evaluation tool with the quality team
 Monday final date

103
Annex

Documentation and decision

No Documentation and Responsible Supervisor Restricted Remark

decision type to
1 History taking and Intern / General None
evaluation practitioner
2 Order sheet General Resident Intern
practitioner /senior
3 Investigation General Resident See
practitioner /senior investigation
annex
4 Round progress note General Resident / Intern
practitioner senior
5 Progress note Intern
6 Referral note Most senior Interns
resident or GP
7 Consultation Most senior Interns
resident or GP
8 Death note Most senior Interns
resident or GP
9 Discharge summary Most senior Interns
resident or GP
10 Admission note Most senior Intern
resident or GP
11 Medical certificate Most senior Intern

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 resident or GP

Investigation for interns

No Investigation type Indirect Direct

supervision by
1 CBC GP
2 Urine analysis ,,
3 Stool analysis ,,

105