& CChhatrapti Shahu Maharaj Shikshan Sanstha’s AYURVED MAHAVIDYALAYA & RUGNALAYA Kanchanwadi, Paithan Road, Aurangabad- 431011 (M.S.) << Document Name POLICIES AND PROCEDURES ON CARE OF PATIENT Document No CSMSSAR / NABH / COP / 02 No. of. Pages 6 Date Created 01-05-2021 Date of Implementation 10-06-2021 Prepared By Designation : COP Incharge Name nA. S, Thote ) Signature: Qs ‘Approved By Designation : Medical Superintendent & Principal Name : Dr. $. G, Deshmukh Signature: Geshe Responsibility of Updating | Designation : NABH Coordinator Name :Dr.J.$. Deshmukh Signature } he PRINCIPAL ‘Chhetrapati Shahu Maharaj Shikshan Sanstha's ‘Ayurved Mahavilyalaya & Rugnalaya, Konchenwad, Auzngabed.Chhatrapti Shahu Maharaj Shikshan Sanstha's AYURVED MAHAVIDYALAYA & RUGNALAYA =o Kanchanwadi, Paithan Road, Aurangabad- 431011 (M.S.) AMENDMENT SHEET Section, Sign. of the Sign. of the Sr.No. No& Details of the amendment Reasons Preparatory approval page No. authority authority peabesie 2 PRINCIPAL (Crhetrapati Shabu Maharaj Shikshan Sanstha’ Ayurved Mahavidyaleya & Rugnalaye, Kanchanwadi, Aurangabad,r Cnhatrapti Shohu Maharaj Shikshan Sansthe's G29 AvURVED MAHAVIDYALAYA & RUGNALAYA } Kanchanwadi, Paithan Road, Aurangabad- 431011 (M.S.) CONTROL OF THE MANUAL. ‘The holder of the copy of this manual is responsible for maintaining it in good and safe condition and in a readily identifiable and retrievable. ‘The holder of the copy of this Manual shall maintain it in current status by Inserting latest amendments when the amended versions are received. RMO is responsible for issuing the amended copies to the copyholders, the copyholder should acknowledge the same and she should return the obsolete copies to the RMO. ‘The amendment sheet, to be updated (as and when amendments received) and referred for details of amendments issued. ‘The manual is reviewed once a year and is updated as relevant to the hospital policies and procedures. Review and amendment can happen also as corrective actions to the non- conformities raised during the self-assessment or assessment audits by NABH. ‘The authority over control of this manual is as follows: Preparation ‘Approval Issue RMO Principal, Dr. S.G. Deshmuh, CSMSS ‘Accreditation coordinator ‘Ayurved Mahavidyalaya & Rugnalaya Kanchanwadi, Aurangabad ‘The procedure manual with original signatures of the above on the title page is considered as “Master Copy’, and the photocopies of the master copy for the distribution are considered as "Controlled Copy”. Distribution List of the Manual: Sr.No. Designation 1 Principal / MS 2 RMO Superintend a Nursing Superintendent O_-., ae 3 PRINCIPAL CChhetrapatiShahu Maharaj Shkshan Sanstha’s —— Mehavidyzlaya & Rugnalaya, adi M4 ; Chhatrapti Shalt Maharaj Shikshan Sansth's © AYURVED MAHAVIDYALAYA & RUGNALAY. Kanchanwadi, Paithan Road, Aurangabad- 431011 (M.S.) CONTENTS Sr.No. | Topic Page No. COP 1 | Policy & Procedures On Uniform Care Of Patients 5 COP2 | Policy & Procedures On Emergency Services COP3 | Policy & Procedures On Ambulance Services - 9 COP 4 | Policy & Procedures on care of Vulnerable Patients, iz COPS | Policy & Procedures on Care of Obstetric (Antenatal & Post Natal) 4 cope | Polley & Procedures on Care of Obstetric Patients (Normal Labour & a Caesarean Section) COP7_ | Policy & Procedures on Care of Neonatal Care 18 COPS | Policies & Procedures on Care of Pediatrics Patients 18 Policy & Procedures On Surgery Care of patients, Para surgical, COP 10 | Policy & procedures for care of patients undergoing moderate sedation eB COP 11 | Policy & Procedures On Care Of Patients Requiring Anesthesia - 46 COP 12 | Policy and procedures define rational use of blood and blood products 35 COP 13 | Policy & procedures on care of patients in ICU / HDU 36 cop 14 | Policy and procedures guide the care of patients under 7 restraints COP15 | Policy and procedures guide the appropriate pain management 58 COP 16 | Policy & Procedures of rehabilitative Services 60 COP 17 | Policy & Procedures of research activities @ COP 18 | Policy & Procedures of Therapeutic diet 64 ee PRINCIPAL, ‘Chhetrapati Shahu Maharaj ‘Shikshan Sanstha’s: ‘Ayurved Mahavidyalaya & Rugnalaya, Kanchanwadi, Aurangabad.; CChihatrapti Shahu Maharaj Shikshan Sanstha's Y AYURVED MAHAVIDYALAYA & RUGNALAYA Kanchanwadi, Paithan Road, Aurangabad- 431011 (M.S.) COP 1- POLICY ON UNIFORM CARE OF PATIENTS 1.0 PURPOSE To delineate policy for the planning and providing of uniform patient care, for following ical practice guidelines in line with the laws and regulations prevailing in India. 2.0 SCOPE ‘To ensure uniform care to all patients using the services of the hospital. The scope includes policies and procedures for: + The care of Emergency Patients (COP.2) + Ambulance Services (COP. 3) + Care of Vulnerable Patients (COP 4) © Care of Obstetric patients (COP.5 &6) + Care of Pediatric Patients (COP.7&8) «Care of patients undergoing surgical & Parasurgical patients, Panchkarma(COP.9) ‘© Care of patients requiring Sedation & anesthesia (COP.10 &11) 3.4 POLICY Uniform Care of Patients 3.1 The planning and provision of care shall be based on individual patient assessment and shall focus on the patient's response to actual or potential alterations to health. 3.2 All patients are treated alike irrespective of their religion, cast, social status, financial ability etc. The safety of all patients seeking health care at this hospital is the prime responsibility of this hospital. A uniform patient care system is laid down in all areas so as to provide excellent service. 33 Similar care is given in different settings which are guided by applicable laws and regulations; care delivery shall be uniform in emergency and ambulance services, Cardio Pulmonary Resuscitation, while using blood and blood products, Post-surgical recovery rooms, ete 3.4 CSMSS. Ayurved Mahavidyalaya, Rugnalaya, Kanchanwadi, Aurangabad has the policy for delivering uniform care to all patients irrespective of the care setting right from the admission to discharge for IPD cases, in OPD services and emergency services. (Chhetrapati Shahu Maharaj Shikshan Sanst! Ayurved Mahavidyaloya ® Rugnalay wed, Aurangabad.Chhatrapti Shahu Maharaj Shikshan Sanstha's ae / AYURVED MAHAVIDYALAYA & RUGNALAYA e Kanchanwadi, Paithan Road, Aurangabad- 431011 (M.S.) 3.5 Laboratory facilities, OT facility, Diagnostics, Nursing Care are uniformly provided to all patients irrespective of category of patients. 3.6 All protocols are uniformly given in the same manner to all patients irrespective of the category status, 3.7 Uniform care is guided by all laws & regulations. 3.8 Itis further ensured thatthe care and treatment orders are legibly signed, named, timed and dated by the concerned doctors and nurses, the main idea being that the authors of these orders are identifiable by all and the chronology of care process is maintained, 3.9 Clinical practice guidelines are adopted to guide patient care whenever possible, 4.0 REFERENCE: NABH: Pre Accreditation Entry Level Standards for Hospitals, Second Edition, April 2016. fun (Chhetrpati Shahu Mahara Shikshan Sanetha'y ‘Ayurved Mahavidyalaya & Rugnalaya, Kanchanwadi, Aurangabad.i Chhatrapti Shahu Maharaj Shikshan Sanstha's Ais AYURVED MAHAVIDYALAYA & RUGNALAYA Kanchanwadi, Paithan Road, Aurangabad- 431011 (MS.) ye COP 2 - POLICIES & PROCEDURES ON EMERGENCY SERVICES 1.0 PURPOSE To make Policies and procedures for the guidance of emergency in IPD patients & ‘complications in Pancha-karma. 2.0 SCOPE Al IPD & OPD patients coming for the emergency care. 3.0 PROCEDURE 3.1 To aid clinical diagnosis, samples are collected and sent to lab for analy: and reporting. Reports shall be sent back to the Emergency department on a priority basis. 3.2 Screening and diagnostic tests shall be recommended and carried out as and when required keeping in mind that the patient's immediate medical needs of IPD & OPD. 3.3 Patients are not transferred or admitted or discharged without the RMO reading the reports of all tests recommended by him or the consultant in the Emergency, unless the critical nature ofa patient's condition warrants immediate transfer to the Hospital unit. 3.4 Reception of patient 3.4.1 Emergency staff shall ensure availability of wheelchairs and stretcher trolleys at the Causality. 3.4.2 After examining the patient the residential medical officer (RMO) shall contact to the Consultant on callin the relevant specialty by means of the telephone. 3.43 RMO shall apprise the Consultant of the patient's condition and take instructions regarding investigations and treatment. 3.44 RMO advises admission if the patient requires admission. A patient is to be admitted only when the Consultant advises admission. 3.455 Patients shall be discharged or transferred to the allocated bed at the earliest after screening diagnostic test results are available or earlier if the patient condition so requires. 3.5 Handling Medical Legal Cases: All cases of accidents, burns, assaults, alleged suicide or homicide, poisoning, road traffic re directly referred to the 100 Bed hospital in the campus. pose 7 PRINCIPAL ‘Chhetrapati Shahu Maharaj Shikshan Sans ‘Ayurved Mahavidyalaya & Rugnala Konchanwodi, Av-angabad.Chhatrapti Shahu Maharaj Shikshan Sansthat's AYURVED MAHAVIDYALAYA & RUGNALAYA Kanchanwadi, Pathan Road, Aurangabad- 431011 (MS.) 3.6 Transfer of patients for Diagnostic tests / other hospitals. To aid clinical diagnosis, samples are collected and sent to various labs for analysis and reporting. Reports shall be sent back to the emergency on a priority basis. Screening and diagnostic tests shall be recommended and carried out as keeping in mind the patient's immediate medical needs, for example, in the case of a head injury, the RMO shall have to make a quick appraisal of the criticality of the case and recommend an X-Ray if he so decides. Tests are also carried out in concurrence with the consultant for arriving at the clinical diagnosis. Patients are not to be transferred or admitted or discharged without the RMO reading the reports of all tests recommended by him/the consultant, the critical nature of a patient's condition warrants immediate transfer to the operating theater or a critical care unit. Patient information is transferred between RMOS, nurses and other staff whether concerning transfer, transport or medical condition- from one shift to the next through detailed handovers, which include written or verbal communication, The information includes medical status of the patient, the treating doctor's comments and special information like transport and transfer information, discharge information, etc. And referred patients details are enter in the register. When a transfer within the hospital is done, the patient's condition is communicated to the consultant/ duty doctor (Including floor doctor) of the area where the patient is being transferred to. The medical condition of the patient, his medical care requirements and the reason for his transfer is communicated to the concerned person by the RMO. 4.0 REFERENCE: NABH: Pre Accreditation Entry Level Standards for Hospitals, Second Edi 2016. an sShkshan Sensi (Chhetrepati Sahu Mahere} aye Kanchanwadi ‘Ayurved Mahavidyalaye & Rugna@yé FE \ Aurengabad. Kanchanwadi, Aurangabad.‘Chhatrapti Shahu Maharaj Shikshan Sanstha's : , AYURVED MAHAVIDYALAYA & RUGNALAYA 4 b ; Kanchanwadi, Paithan Road, Aurangabad- 431011 (M.S.) COP 3 - AMBULANCE SERVICES 1.0 PURPOSE ‘To make Policies and procedures for the transfer of Patient in Ambulance Patient . 2.0 SCOPE ‘The ambulance Services are commensurate with the scope of the services provided by the hospital. 3.0 POLICY CSMSS Ayurved Mahavidyalaya & Rugnalaya, Kanchanwadi, Aurangabad provide an ambulance & for occasional purpose on call well-equipped ambulance with emergency medicines and equipment to facilitate efficient and timely transportation of a patient to and from the hospital under the care of trained nursing staff/ doctors. If required, the ambulance calling No. 108 is made available. 4.0 PROCEDURE 4,1 Hospital's ambulance is equipped to ensure smooth, safe and efficient transfer of patient to and froma Health Care Facility. 4.2 Hospital's ambulance shall be available at the hospital for meeting any emergencies. ‘An alternate ambulance shall be made available on call from outside agency. 43. The ambulance drivers and the drivers on call are with cell phones. Drivers shall promptly respond when called upon from the hospital or from the emergency site. 44 In the event of these ambulances being busy, the drivers, front office staff, security staff on duty must cal for help from other private ambulance services. 4.5 Before transporting the patient, hospital shall ensure that appropriate communication regarding the referral of patient is given to the receiving hospital. 46 The complete address regarding the location of referring HCF (Health Care Facility), demographic data of patient, his/her illness and the complete address of referral HCF must be properly communicated to the staff of that ambulance service, 4.7 Designated clinical staff if required shall accompany the patient during the transfer and record in all care and treatment administered during transfer. fh foe 9 PRINCIPAL ‘Ohhetrapati Shonu Maharaj Shkshan Sanst ‘Ayurved Mahavidyelaya & Rugnalay Kancnanwadi, Aurangabad,Chhatrapti Shahu Maharaj Shikshan Sanstha's Ss AYURVED MAHAVIDYALAYA & RUGNALAYA Kanchanwadi, Paithan Road, Aurangabad- 431011 (M.S.) 4.8 Emergency drugs shall be available in the ambulance and ensured that no expired rugs are found available, 4.9 Adequate consumables and drinking water shall be made available in the ambulance 4.10 Availability of adequate number of medical gases cylinder (oxygen cylinder with regulator) shall be ensured. 4.11 The treating doctor shall also ensure that the ambulance equipped to respond to medical emergencies as per the need of the patient. 4.12 While transporting a patient to another destination, if the medical condition of that patient becomes very serious, the driver shall take the ambulance to the nearest Hospital for immediate medical attention to that patient. This shall also be informed to the hospital and concerned doctors. 4.13 The hospital shall ensure that a designated person from the facility will coordinate this, service effectively and ensure the timely transportation of the patients by ambulance in case of emergency. 4.14 The ambulance service contact numbers are displayed in casualty. 4.15 Qualified clinical / paramedical staff must accompany the patient in an ambulance while transportation to the receiving facili 4.16 It is the responsibility of management and staff of the referring/transporting hospital to check that the ambulance is well equipped and all equipment are functional to respond to medical emergencies during the patient transportation in a stipulated time frequency. 4.17 The referring hospital management will be responsible for any delay (if happened) in transporting the patient to the referred health care facility. 4.18 It is the responsibility of management and staff of the referring/transporting hospital to check that the ambulance is well equipped and all equipment are functional to respond to medical emergencies during the patient transportation in a stipulated time frequency. 4.19 The referring hospital management will be responsible for any delay (if happened) in transporting the patient to the referred health care facility. 4.20 After each patient transfer by ambulance, it is the responsibility of the driver / In fawn Jere. | 10 ‘crbetrapatiSrahu Mahar} Shikshan Sansth< Ayunved Matavidyalaya & Rugnalay® anchanwad, AL Charge Nurse to dispose of all used disposable and contaminated items.f Chhatrapti Shahu Maharaj Shikshan Sanstha's PRES. ' AYURVED MAHAVIDYALAYA & RUGNALAYA Kanchanwadi, Paithan Road, Aurangabad- 431011 (MS.) 4.21 The treating doctor shall stabilize the patient and ensure that the treatment given to the patient at the facility is documented and duly named, signed, dated and timed. 4.22 The necessary document shall be sent along with the patient at the time of transportation to the referred facility. 4.0 REFERENCE: NABH: Pre Accreditation Entry Level Standards for Hospitals, Second Edition, April 2016. ) pom PRINCIPAL ‘Crfmtrapati Shahu Mahara) Shikshan Sanstha’s ‘Ayurved Mahavidyalzya & Rugnalaya, Kanchariwadi, Aurangabad. cy{ CChihatrapti Shahu Maharaj Shikshan Sanstha's ¥ AYURVED MAHAVIDYALAYA & RUGNALA bd Kanchanwadi, Paithan Road, Aurangabad- 431011 (M.S.) COP 4: POLICIES & PROCEDURES ON CARE OF VULNERABLE PATIENTS 1.0 PURPOSE + Tomake policies and procedures for the care of vulnerable patients. + Toidentify the groups of patients who shall be considered as “vulnerable” 2.0 SCOPE Vulnerable patients in all patient area of CSMSS Ayurved Mahavidyalaya & Rugnalaya, Kanchanwadi, Aurangabad. 3.0 DEEINITION: A patient who is or may be for any reason unable to protect and take care of him or herself, against significant harm or exploitation. 3.1 VULNERABLE PATIENTS 1. Elderly > 50 Yrs 2. Children & New Born Babies 3. Physically and / or Mentally Handicap 4, Patients Who Are Not Disabled but Are Still Not Able To Walk Properly Due To Some Medical Physical Condition (Arthritis) 5. Patients Who Are Temporary Disabled / Unable To Walk Properly Due To Some Injury (Fracture) 6. Post-Surgery Recovery Stage 7. Patients Under Restraint & Both Physical & Chemical 8. Comatose Patients 9, Patients Under Sedation & Anesthesia 10. Unconscious Patients 11, Patients Immunosuppressive / Chemotherapeutic 12, Bed-Ridden Patients 13, Patients Not Able To Talk / Express Themselves Properly. 14, Patients with Weak Eye Sights & / Weak Healing Ability‘Chhatrapti Shahu Maharaj Shikshan Sanstha's AG, AYURVED MAHAVIDYALAYA & RUGNALAYA : i Kanchanwadi, Paithan Road, Aurangabad- 431011 (M.S.) ag 4.0 POLICY & PROCEDURE: 41 The consultant who is treating the patient will be responsible to identify the vulnerable patient and advice management, 4.2 The hospital provides safe and secure environment for the vulnerable group. 43. Staffis trained to take care of high risk patients of vulnerable groups. 44 Staff nurse knows fal risk assessment tools. 48 The identified vulnerable patients will be under close monitoring at all times during their hospitalization to minimize risks of health care services. 46 Documented procedure exists obtaining inform consent from the appropriate legal representative, 4.7 Within the hospital the all vulnerable elderly and children will be given all necessary care needed with consideration. 4,8 Nurse orientates all patients, parents or caretakers to their bed area, and ward facilities. 4.9. Teaching patients to make position changes slowly. 4,10 Explaining the use for grab bars in toilets to all patients. 4.11 Maintain adequate lighting in patient's room; low level lighting at night, 4,12 If the patient's condition demands further care which is not available in our hospital then patient will be transferred to the other hospitals. 4.13 While transferring the patient a staff nurse will be accompany the patient along with the caretaker. 4,14 If the patient's condition is critical then he / she will be escorted by a doctor and a nurse while transferring from our hospital to other hospital. 5.0 REFERENCE: NABH: Pre Accreditation Entry Level Standards for Hospitals, Second Edition, April hee PRINCIPAL (Chnatrapati Shahia Maharaj Shikshan Sanstha's Ayurved Mahavidyslaya & Rugnalaya, Kanchaniwadi, Aurangabad. 2016.Chhatrapti Shahu Maharaj Shikshan Sanstha's AYURVED MAHAVIDYALAYA & RUGNALAYA Kanchanwadi, Paithan Road, Aurangabad- 431011 (M.S.) COP 5 - POLICIES & PROCEDURES ON CARE OF OBSTETRIC (ANTENATAL & POST NATAL CARE) 1.0 PURPOSE: To Define policies gu 2.0 SCOPE: ing the care of obstetric Patients. All obstetric Patients, excluding high risk cases, 3.0 RESPONSIBILITY: 3.1 Anesthesiologist 3.2 Obstetrician 3.3 Pediatrician 34 Labour room staff 3.5 Matron 3.6 Dietitian 4,0 ABBREVIATION: 4.1 NABH : National Accreditation Board for Hospital and Health care providers 4.2 COP: Care of Patients 4.3 ANC: Antenatal Care 44 PNC: Post Natal Care 4.5 LSCS: Lower Segment Caesarian Section 5.0 POLICY: 5.1 Obstetricians trains post graduate students and staff nurse in care of obstetric cases. 5.2 The assessment of obstetric cases includes Sharir shuddhi by Panchakarma, 5.3 The Assessment of obstetric cases includes ‘+ Ayurved approach to ANC - GARBHINIPARICHARYA + GARBHASANSKAR © Stha chikitsa (local treatment) in obstetric patients in the month of 8 & 9 Like ~ ‘Anuvasan Basti, Yonipichu © Postnatal care by Sutikaparicharya which includes Sarwang Senhan,Sarwang Swedan Yonidhupan 54 High risk obstetrical patients are shifted to csmss Ayurved Mahavidyalaya Rugnalaya in the Campus for Further Managements. pe Me 4i CChhatrapti Shahu Maharaj Shikshan Sanstha's 7 AYURVED MAHAVIDYALAYA & RUGNALAYA Kanchanwadi, Paithan Road, Aurangabad- 431011 (M.S.) 5.5 Definition and Display of obstetrical cases: 1) The hospital has defined and displayed the services it provides for obstetric cases, 2) It Includes- ‘» Preconception Counseling by sharirshudhi by Panchakarma + Qualitative Antenatal Care by Garbhiniparicharya © Garbhasankar © Normal delivery by sulabh prasuti ‘© Sutikaparicharya by qualitative postnatal care 5.6 Facilities for Neonates: Competent Pediatricians attends Normal labour & LSCS For resuscitation of Newborn if needed. 5.7 Initial Assessment of patients: All patients attending the obstetrics OPD After obtaining a detailed history undergoes routine obstetrics examination which includes: General examination for pallor icterus, thyroid swelling, pedal edema followed by examination of breasts, abdomen. This is followed by speculum examination. 6.0 PROCEDURE: 6.1 In Ayurvedic approach towards qualitative Antenatal care we provide- © Garbhiniparicharya © Garbhasanskar classes to pregnant patients © Panchakarma treatment like anuwasan Basti & Yonipichu for sukhaprasav (Normal Delivery) + Postnatal care by sutikaparicharya as sarwang snehan, swedan & yonidhupan. © Garbhasanskar workshops are conducted for obstetric patients. It has various sessions like Pranayam in pregnancy, yoga in pregnancy, music therapy, dietary advice. ‘© Qualitative Antenatal & postnatal care is provided by competent Senior Obstetricians assisted by assistants & an experienced pediatrician, 6.2 Hospital is well equipped and manned by competent doctors, nurses and para-medical staff to provide Panchakarma, local treatment in obstetric & normal labour, LSCS of obstetric patients. 7.0 REFERENCE: NABH: Pre Accreditation Entry Level Standards for Hospitals, Second Edition, April 2016. (7) PRINCIPAL (Chhatrapati Shanu Maharaj Shitshan Sanst Ayurved Mahavidyalaya & Rugnalay Karchanwadi, Aurangabad,Chhatrapti Shahu Maharaj Shikshan Sanstha's AYURVED MAHAVIDYALAYA & RUGNALAYA Kanchanwadi, Paithan Road, Aurangabad- 431011 (M.S.) COP 6- POLICIES & PROCEDURES ON CARE OF OBSTETRIC (NORMAL LABOUR & CAESAREAN SECTION) 1.0 PURPOSE: To define policies guiding the care of obstetric services (Normal Labour & Caesarean Section) 2.0 SCOPE: All Obstetric patients, excluding high risk cases. 3.0 RESPONSIBILITY: 3.1 Anesthesiologist 3.2 Obstetrician 3.3 Pediatrician 34 Labour Room Staff 3.5 Matron 3.6 Dietitian 4.0 ABBREVIATION: 4.1 NABH: National Accreditation Board for hospital and Healthcare providers 4.2. COP: Care of Patients 4.3 1CUsIntensive Care Unit. 4.4 LSCS: Lower Segment Caesarian Section 5.0 POLICY: 5.1 The Assessment of Obstetric patients includes nutrition immunization, education, normal & high risk patients. 5.2 The Consultant caring for high risk obstetric patients are competent but patients are transferred to 100 Bed hospital in the campus, if require ICU care. 5.3 Appropriate peri-natal monitoring is performed by NST & Foetal Doppler 54 Facilities For Neonates : Competent Pediatricians attends Normal Labour & LSCS for Resuscitation of newborn ifneeded. je Area = peo PRINCIPAL ‘Cohstrapati Sahu Mahara Shikshan Sansth Mahavidyalaya & Rugnalay AU ay Aged.CChhatrapti Shahu Maharaj Shikshan Sanstha's AYURVED MAHAVIDYALAYA & RUGNALAYA Kanchanwadi, Paithan Road, Aurangabad- 431011 (M.S.) 6.0 PROCEDURE: 6.1 Prenatal Safety guideline such as monitoring standards, labour augmentation is done. 62 Hospital is well equipped and manned by competent doctors, nurse and para-medical staff to provide Panchakarma, local treatments in obstetric & Normal labour, LSCS of obstetric Patients. 63 The Hospital doesn’t have a NICU but if required immediate transfer of the neonate can be arranged with the help of competent consultants on call from GHATI Hospital or Bajaj Hospital 7.0 REFERENCE: NABH: Pre Accreditation Entry Level Standards for Hospitals, Second Edition, April 2016 ie “PRINCIPAL -Chhetrapati hahu Maharaj Shkshan Sanstna’s ‘Ayurved Mahavidyalaya & Rugnalaya, Kenchanwadi, Aurangabad. vCChiatrapti Shahu Maharaj Shikshan Sanstha's ‘s AYURVED MAHAVIDYALAYA & RUGNALAYA Kanchanwadi, Pathan Road, Aurangabad 431011 (M.S.) COP 7 & 8- POLICIES & PROCEDURES ON CARE OF NEONATE & PEDIATRIC PATIENTS 1.0 PURPOSE- 1.1 To define policies guiding the care of Pediatric patients. 1.2 To give the best service 1.3 To maintain the quality service 14 Try to give quick and good service to save the time of patient as well as doctor. 1.5 To maintain proper hygienic environment to decrease hospital acquired infections. 1.6 To define the framework for the care of individuals attending Kaumarbhritya OPD to facilitate the promotion of health as well as prevention and cure of disease through Ayurved treatment 2.0 SCOPE - All the pediatric and neonate patients undergoing treatment in hospital. 3.0 POLICIES- 3.1 All clinical staff working in the pediatric department shall receive special training in the ‘care of the new born and pediatrics regarding Ayurvedic and modern aspects. 3.2 Patients are offered Ayurved treatment either on OPD or IPD level as per care required. 3.3 All children are assessed for their nutritional status. 3.4 Provisions are made for special care of newborn, children and per adolescent children by competent staff 3.5 Patient assessment includes detailed nutritional and mental assessment of pediatric patients. 3.6 Immunization assessment of pediatric patients. 3.7 To educate parents about safe parenting, successful weaning and to provide complete nutrition as well as safety measures for children. 3.8 To relieve academic and social stress of children by counseling, yoga and meditation. 3.9 To provide high quality panchkarma by trained and competent staff for pediatric patients 3.10 Toestablish protocols of Ayurvedic treatment in various pediatric diseases. 3.11 Child abduction and abuse policies are documented. 312 Suvarnaprashaj (Chhetrapati Shahu Mahara} /Shikshan Sanstha’ Ayurved Mahavidyalaya & Rugnalay@, ‘Kanchanwadi, Aurangabad.CChhatrapti Shahu Maharaj Shikshan Sanstha's AYURVED MAHAVIDYALAYA & RUGNALAYA Kanchanwadi, Paithan Road, Aurangabad 431011 (MS.) 4,0 RESPONSIBILITY: 4.1 Consultant 4.2 Houseman 4.3 Internee, 44 Attendant 4.5 Nursing staff 4.6 Security staff 5.0 PRE-REQUISITE + Examination table, Pediatric stethoscope + Torch, + Thermometer, + X-ray view-box, © Electronic weighing machine, + Infantometer, © Stadiometer, © Measuring tape, © Sphygmomanometer with baby cuff © Tongue depressor, «Refrigerator © Syringes, © Spirit, © Sterile cotton swab Resuscitation kit, * Radiant warmer, © Pulse oximeter, 7 dashes PRINCIPAL ‘Chhetrapati Shahu Maharaj Shikshan Sanstha’s ‘Ayurved Mahavidvalaya & Pugnalaya, ag ‘Kanche 13, Aurangabad. © Pediatric panchakarma table.{ Chihatrapti Shahu Maharaj Shikshan Sanstha's i % AYURVED MAHAVIDYALAYA & RUGNALAYA ier Kanchanwadi, Paithan Road, Aurangabad- 431011 (M.S.) 6.0 PROCEDURE : ‘Sr. Procedure Scope No. Central registration followed by ID number OPD—> examination by registrar > by consultant treatment & 1) _| Pediatric / neonatal services allied services if required > Expert + second opinion if required Importance of immunization administer as per 2) | Immunization schedule + post vaccination care Counseling regarding behavioral disorders like Enuresis, Sibling rivalry, Diet advice: Season and 3) | Child guidance disease wise diet & regimen, Neurological disorders, Developmental disorders, Pica, any kind of stress along with medication and Panchkarma therapy. To check the milestones as per age in patients like delayed milestones in Cerebral palsy or some syndromes etc, counseling, medication and. 4) | Development assessment Panchkarma therapy. Nutritional disorders care : Malnutrition, Under nutrition, Vitamin & Mineral deficiencies Praperation of suvarna prashana — importance of 5) | Suvarna Prashana suvarna prashana give suvarna prashana to children, in pushyanakshtra- assess the child 7.0 REFERENCES- NABH per accreditation entry level standards for hospitals, Second Edition, April 2016 father PRINCIPAL ‘Chhetrapati Shahu Mahara Shikshan Sanstha’s Ayurved Mahavidyalaya & Rugnalaya, Xoncharwadi, Auzangabad.Chhatrapti Shahu Maharaj Shikshan Sanstha's AYURVED MAHAVIDYALAYA & RUGNALAYA Kanchanwadi, Paithan Road, Aurangabad- 431011 (M.S.) COP 9 - POLICIES & PROCEDURES ON SURGICAL CARE OF PATIENTS, PARASURGICAL, PANCHAKARMA AND OTHER TREATMENT PROCEDURES 1.0 PURPOSE. ‘To guide the uniformity of care for patients undergoing surgical procedures. To provide guidelines for care of the patients undergoing surgical, parasurgical, panchakarma and other treatment procedures 2.0 SCOPE ‘The operative procedure is only one part of the total surgical care of the patient. Total surgical care includes establishing or confirming the diagnosis, preoperative preparation, the operative procedure, and postoperative care, Patients undergoing parasurgical, panchakarma and other treatment procedures. 3.0 RESPONSIBILITY: 3.1 Surgeons 3.2 Consultant 3.3 Anesthesiologist 3.4 Medical Officer 3.3 Nursing Staff 3.4 Paramedical staffs 4.0 ABBREVIATION: 4..NABH National Accreditation Board For Hospitals and Healthcare providers 4.2COP : Care of Patients 4307 : Operation Theatre 5.0 REFERENCE: NABH: Pre Accreditation Entry Level Standards for Hospitals, Second Edition, April 2016 PRINCIPAL n (Ohhetrapat Shahu Maharaj Shikshan Sanstt Ayurved Mahavidyal3ya & Rugnalay Kanchanwaci, Aurangahad,r CChhatrapti Shahu Maharaj Shikshan Sanstha's . AYURVED MAHAVIDYALAYA & RUGNALAYA oor Kanchanwadi, Paithan Road, Aurangabad- 431011 (M.S.) 6.0 POLICY: 6.1 Surgical procedures and competency levels: + All surgical procedures shall be undertaken by the surgeons as per the list of surgical procedures prepared by the OT in-charge in consultation with the surgeons and based on the list received from the concerned wards. + The policies and procedures of concerned departments are documented + Allthe staff of concerned departments is trained to do the same. ‘© The informed consent is obtained prior to the procedures of their specialties. Fresh consent is obtained in case of change in care plan. ‘+ Patient assessment is done prior to procedure. ‘+ Personnel qualified by law perform the procedures that they are entitled to perform. * A brief procedure notes are documented prior to transfer of patients from the recovery room. + Post procedural plan is prepared by concerned consultants. + Infection control practices are ensured in procedure rooms. * Guidelines are present for all procedures are present. * Standard precautions and asepsis are followed during procedure. 6.2 Pre-operative assessment and provisional diagnosis: ‘+ All patients undergoing surgical procedure (either routine or emergency) shall have an assessment done preoperatively and a provisional diagnosis and that should be documented, The pre-operative assessment shall be done by the surgeon performing the surgery or a credentialed doctor from the team. ‘+ All patients planned for routine surgical procedure are to get admitted at least 24 hours in advance to monitor their vitals, medical fitness and preparation for procedure by the ward staff, This period is considered as necessary to make available the OT and required staff assisting the surgery. 6.3 Informed consent: ©The concerned surgeon or a doctor member of his team shall obtain an informed consent for Basho 22 FRiNcAL ‘Chhatrapati Shahu Maharaj Shikshan Sanstha’s Ayurved Mahovidvalaya & Rugnalay surgery from the patient/relative prior to the procedure,Chhatrapti Shahu Maharaj Shikshan Sanstha's o 7 AYURVED MAHAVIDYALAYA & RUGNALAYA Kanchanwadi, Paithan Road, Aurangabad- 431011 (M.S.) «The consent shall be sought after proper explanation of the benefits, risks and complications involved performing the said procedure. © The consent shall be in two languages ~ English and Marathi ‘© Incase, the operative plan is changed intra-operatively, a fresh consent shall be sought from the patient / relative. 6.4 Prevention of adverse events: + All patients undergoing surgical procedure shall be properly identified through MRD number and name and preoperative checklist should be verified by the Pre-OP in charge / OT in charge. «Site of surgery on patient shall be marked by surgeon prior to surgery. + Protocols are followed to prevent wrong site, wrong patient procedures. In case of such events, corrective actions and preventive measures are taken. + APreoperative note shall explain the procedure to be performed and should be documented prior to surgery. 6.5 Qualification of performing surgeons: ‘* Doctors qualified by law shall be permitted to perform the procedures. + Such doctors shall be credentialed and given privileges to conduct the said procedures in this hospital » The HR, Credentialing and Privileging Committee shall do the needful. 66 Documentation of procedure-operative note and post-operative plan of care: ‘© Post-operative notes shall be prepared by the surgeon which includes procedure performed, post-operative diagnosis, plan of care and status of the patients and documented prior to transfer out of patient from recovery area. ‘+The post-operative care plan shall be prepared by the operating surgeon in collaboration with the anesthesiologist and shall include advice on: 1.1.1 LV. Fluids 1.1.2. Medications 1.13 Care of wound 114 Nursing care 1.1.5. Monitoring of patient vitals 1.1.6 Observation for any complications 23 PRINCIPAL (Chhetrapati Shahu Mahara) Shikshan Sanstha’ Ayurved Mahavidyziaya & Rugnalaya, Kanchanwadi, Aurangabad.é Chihatrapti Shahu Maharaj Shikshan Sanstha's 3° AYURVED MAHAVIDYALAYA & RUGNALAYA 4 @: Kanchanwadi, Paithan Road, Aurengabad- 431011 (M.S.) 6.7 Infection control protocols: + The theatre layout shall minimize the mix of sterile and unsterile patients. «The OTs shall be cleaned and carbonized after every case. ‘* OT swab shall be sent for anaerobic culture to control OT infection. + All OT staff shall adhere to standard precautions, hand washing, PPEs and safe handling of the patients. ‘Infection control practices are ensured in procedure rooms. + Standard precautions and asepsis are followed during procedure. ‘Surveillance activities are carried out once in a month in all procedure rooms, 6.8 Equipped Operation Theatre: * The Operation Theatre complex shall have the necessary facilities for conducting the said procedures, changing rooms, equipment, appliances and instrumentation. 7.1 PROCEDURE 7.1. All the patients who are to undergo surgery have full details of their medical condition in their case records. 7.2, Depending on his medical condition the patient may need either elective or emergency surgical procedures. 7.3. The elective procedure could either be minor in nature or major. Emergency surgical procedures though usually major, could also be minor in nature. 7.4. Surgical patients have the preoperative assessment and the provisional diagnosis documented p to the surgery. 7.5, Before either elective or emergency procedures, the surgeon examines the patients and makes an assessment of his/her condition based on the cl al presentation of the case, signs and symptoms, and results ofthe investigations. 7.6. A provisional diagnosis is made and this is documented in the patient's case notes before he is taken up for surgery. This is done mainly to avoid adverse events like wrong site, wrong patient and wrong surgery etc. 7.7. All patients admitted for elective major surgery should undergo the following tests: Blood Hb, blood grouping & Rh typing, Random blood sugar estimation, blood urea, serum creatinine, HIV, HbsAg, They should also have ECG and chest X-ray taken (Optional). /Chhatrapti Shahu Maharaj Shikshan Sanstha's AYURVED MAHAVIDYALAYA & RUGNALAYA Kanchanwadi, Paithan Road, Aurangabad- 431011 (M.S.) 7.8. Elective minor cases need to have the following tests done: Hb, Random blood sugar, HIV and HbsAg, They should also have their ECG and chest X-ray taken 7.9, Preoperative initial assessment has to be done for all patients undergoing elective major and emergency operations. 7.40. Ifthe surgeon comes across any abnormal findings in the pre-operative tests, it has to be documented in the patient's records and this has also to be informed to the patient's relatives. 7.1. Patients with obvious ECG changes or patients with history of cardiac problems should be seen by the cardiologist before being taken up for surgery. The patient should be informed by the cardiologist of the potential cardiac risks during or after surgery. 7.12. Patients poor renal function o chronic renal disease should have consultation with the nephrologists. The bystanders or relatives must be informed by the nephrologists about the possible postoperative or intra operative complications. 7.13. Apart from the general consent which is obtained routinely from all in-patients, patients undergoing surgery should be informed about the procedure, its probable outcome, and its possible outcome and its probable rare complications. Following this informed consent from the patient is taken. The name of the surgical procedure, site of surgery and complications of surgery should be written in capital letters. 7.14. Patients with cardiac or renal problems should be given their informed consent in his/her handwriting and signed with a witness other than a hospital staff. One of the witnesses should be the ward nurse in charge. 7.15. The patient is prepared for surgery as follows: 0 The patient should not take anything orally at least 6 to 8 hours before the actual surgery. + The patient's weight is recorded. ‘+ The skin of the operation site is prepared by shaving the hair and cleaning with antiseptic. ‘© Bowel preparation is done by giving enema. + Artificial dentures and jewelry are removed (and receipt given or handed over to authorized people), Nail polish is cleaned. + The patients dress is changed toa clean one. Patients ID tag is kept in place. ¢ The patients depending on their physical condition are shifted to the OT by wheel |e PRINCIPAL ‘Chhetrepati Shahu Maharaj Shikshan Sanst ‘Ayurved Mahavidyalaya & Rugnala: Kanchanwaai, Aurangabad. chair or trolleys.7.16. 747. 7.18, 749. 7.20. 721. 722. . Chhatrapti Shahu Maharaj Shikshan Sanstha's 2 ® AYURVED MAHAVIDYALAYA & RUGNALAYA Kanchanwadi, Paithan Road, Aurangabad- 431011 (M.S.) + Post operates: Monitoring for pain after major operative, minor operative and application of ksharsutra. * AStaff nurse from the ward accompanies the patient with the case sheet to the OT. ‘The OT nurse takes over the patient after checking the case sheet and making identification and documents. © Here after the OT staff is responsible to take care of the patient till he/she leaves the recovery room. © Once the patient has been received at the OT, his / her dress is changed to sterile OT gown / dress supplied by the CSSD. All type of surgeries performed in this hospital are by well qualified, experienced surgeons who have had extensive training and expertise in their particular fields. Complex surgeries are sometimes performed by a team of doctors, each dealing with his/her specialty. Prior to surgery the case file shall be reviewed, the condition of the patient shall be checked and surgical safety checklist before induction of anesthesia, before skin Incision and before the patient leaves the operating room shall be completed by the surgeon and anesthesiologist. After the surgery is completed, before the patient is transferred back to the ward, the surgeon writes down and documents a brief operative note and post-operative plan of care. The anesthesiologist on his/her part also notes down the details of the anesthesia procedure starting with the pre-medication, induction till the end of anesthesia, extubation ete. All the events ring the stages of anesthesia are recorded and documented. The anesthetist will follow the patient in the recovery room and the surgical ICU/ward till the patient fully recovers from anesthesia. Asa quality assurance programme, the OT and its surrounding areas like the recovery room, CSSD etc. are under the strict supervision by the infection control nurse and the hospital infection surveillance team who ensures absolute sterility of the operation areas sos to avoid the risk of transmission of infection. The plan also includes monitoring of surgical site infection rates. All the post operative patients shall be screened for the same. 26 (Chhetrapati Shahu Maharaj Shikshan Sanstha’s ‘Ayurved Mahavidyalaya & Rugnalay3,4 \ Chhatrapti Shahu Maharaj Shikshan Sanstha's ’ AYURVED MAHAVIDYALAYA & RUGNALAYA Kanchanwadi, Paithan Road, Aurangabad- 431011 (M.S.) infected or suspected wound sites to analyze them with the aim to prevent or reduce the risk of hospital associated infections. 7.23, Surveillance of Operation Theatres + Each health care establishment undertaking surgery must have a specific protocol for operating room procedures, including specific requirements for surgical hand ‘washing routines and handling of sharps. «When individuals are being admitted to hospital or presenting at an emergency unit, a detailed medical and surgical history should be collected from them or their careers to identify conditions that may require additional precautions. « Allarticles used in an operation must be sterile, The principles of sterile aseptic technique must be applied to all operating room procedures. The principle of ‘confine and contain’ must be applied at all times for all patients. © Sterile drapes must be used for the patient; staff must wear full sterile operating room personal protective clothing «Patients should inform their doctor of their infectious status. Preoperative testing of patients should be on clinical indication. ‘+ All staff in the surgical team should be vaccinated against hepatitis B, Surgical staff should not perform exposure-prone procedures if they are considered actively Infectious with human immunodeficiency virus, hepatitis B virus or hepatitis C virus. ‘© Staff with dermatitis or skin wounds should be excluded from the operating team © Operating lists should allow sufficient time for adequate infection control activities, including routine cleaning and the appropriate disposal of clinical waste. «The operating room should be cleaned as soon as practicable after surgery, including the correct disposal of sharps and clinical waste and cleaning of all surfaces. ‘© Reusable instruments should be immersed in warm water and detergent as soon as possible after use and must then be thoroughly cleaned in a designated clean-up area before sterilization. ‘© Routinely inspection and maintenance of ksharsutra cabinet & ksharsutra. PRINCIPAL ‘Chhatrapati Shabu Maharaj Shikshan Senstha's ‘Ayurved Mahavidyalaya & Rugnalaya, anchanwacl, Aueangabad.aA ‘Ciatap Shiu Marj Sishan Sats AYURVED MAHAVIDYALAYA & RUGNALAYA, Kaname, Pithn Ron, Aung 431011 MS.) Se ANWEXURE A: SURGICAL SAFETY CHECKLIST HID He. FD No. TO Na. Deparment Name a the Patent Me Years Genders M/F Name Of Prcedre (“Before patentofanesthesia ) ‘Before skin welsion ‘Before patent leaves operating room] TWikatoetsstr anf Tihs hea sao] (With nurse anesthetist and surgeon) Taig re 8 Ntappete enol Septic? Xone ey apnea it © tendeptprenaieane setae ‘so sav test ae? 2S Yecande Neco acsand ie 9 Notarpabi pled Contr al im nena re ea atleipted rtel vete ee Metre iti . 3 Wines andopd lad et iy cag maa en 0 ether egupmentisuesrasyeancers essen aie dyed? arse Verbally Confirms © Thenate ofthe procedure © Campiction af nmrument sponge and feedle counts © Specimen labeling (ead specimen labels aloud, ncucng patient name) ‘©. Whether mere are any equipment problems the addressed ‘ToSurgeon, Anesthetistand Nurse: 10 Whatate the key concern or recovery and management of ths patien? ame sign of Anestes| Namedisige of Asin Named sgn of Surgeo8| Named sign of OT Assistant 28 ‘Name age of Savon Name sige of Anestott Namedsign oO Aastnt CchietrapaiShahu Mahara Srkshan Sanstha ‘Ayurved Mahavidyalaya & Rugnalaya, anehanwadi, Aurangabad.~ Chhatrapti Shahu Maharaj Shikshan Sanstha's AYURVED MAHAVIDYALAYA & RUGNALAYA Kanchanwadi, Paithan Road, Aurangabad- 431011 (M.S.) DEPARTMENT WISE POLICIES AND PROCEDURES: KAYACHIKITSA PURPOSE. To provide exclusive internal medication for curative and preventive purpose in the specialty of Kayachikitsa to ensure provision of appropriate quality services. SCOPE All the patients visiting to Kayachikitsa OPD and IPD. SERVICES: Management of: © Gastro-intestinal disorders «© Neurological disorders «Musculoskeletal disorders «Lifestyle disorders «Psychiatric disorders ‘© Geriatricilinesses © Dermatological disorders © Anemia, Fever, Jaundice © Counseling regarding lifestyle disorders. RESPONSIBILITY 1. Head / In-charge of the department 2, In-charge consultant PG scholars on posting Medical Officers Nursing staff ane Housekeeping staff POLICY 1. Care and Supervision is provided by Kayachikitsa consultants and qualified medical Lhe Ca 29 PRINCIPAL ‘Chhetrapati Shahu Maharaj Snikshan Sansthi Ayurved Mahavidyalaya & Rugnalaya Kanchanwadi, Aurangabad. officers.i Chhatrapti Shahu Maharaj Shikshan Sanstha's AYURVED MAHAVIDYALAYA & RUGNALAYA Kanchanwadi, Paithan Road, Aurangabad- 431011 (M.S.) 2. Patient visit the Kayachikitsa OPD after registration and by the guidance of reception staff. 3. Patients are also referred by other clinicians as per the care needed to the patient. 4. Initial Assessment of the patient is done with proper history taking, clinical examination ofthe patient and necessary investigations. 5. In case the patient needs assessment from other specialties, case is referred to the concerned department for opinion and the needful will be done. 6. After confirming the diagnosis, necessary treatment is given. 7. If the physician feels the need of admission, consultant will explain the patient and family members regarding proposed care, expected results, possible complications and expected cost of medical treatment/procedures, and if they agree, admission is done as per the admission policies of CSMSS Ayurved Mahavidyalaya & Rugnalaya, Kanchanwadi, Aurangabad. 8, The medical officers of the Kayachikitsa department will take the detailed history of the patients and it will be recorded in the IPD case sheet proforma. 9, The consultants will take IPD rounds twice in a day and necessary treatment changes will be made according to the condition of the patient. 10. The changes made by the consultants in medical treatments/procedures will be informed to the Nursing matron/nursing staff. 11, In cases which require emergency management, patients will be referred to the 100 Bed Hospital or GHATI or Bajaj Hospital. 12, If the patient is suitable for Panchakarma, procedures will be carried out by trained therapists under expert supervision, INCIPAL sonar stn Stas jalaya & Rugnalaya, “es nai ‘Aurangabad. 30‘Chhatrapti Shahu Maharaj Shikshan Sanstha's @ AYURVED MAHAVIDYALAYA & RUGNALAYA a , Kanchanwadi, Paithan Road, Aurangabad- 431011 (M.S.) PANCHAKARMA, PURPOSE. To provide comprehensive care in the specialty of Panchakarma to ensure provision of appropriate quality and care for the patients undergoing Shodhana therapies and other Panchakarma procedures in CSMSS Ayurved Mahavidyalaya & Rugnalaya, Kanchanwadi, ‘Aurangabad. SCOPE OPD & IPD patients of CSMSS Ayurved Mahavidyalaya & Rugnalaya, Kanchanwadi, Aurangabad needing the services of Panchakarma SERVICES ‘The total Panchakarma procedure includes establishing or confirming the diagnosis, pre-procedure preparation, the main procedure, and post procedure care for each and every patient. Extends treatment and care of patients seeking Panchakarma treatment which includes the following- ‘© Provision of five cleai ig therapies on IPD basis © Provision of external therapies like Kati Basti, Udvartana, Shirodhara ete © Provision of external therapies on OPD basis RESPONSIBILITY 1. Head/In-charge ofthe department In-charge consultant PG scholars on posting Medical Officers Panchakarma Therapists aa een Nursing staff and Ayah / ward boy POLICY 1. Care and supervision will be provided by qualified Panchakarma physicians and medical officers. 2. Care and supervision in Panchakarma theatre will be provided by trained Panchakay ‘Therapists. 31 Chhetrapati Shahu Maharaj Shikshan Sansti ‘Ayurved Mahavidyelaya & Rugnalay ‘Kanchanwadi, Aurangabad.‘Chhatrapti Shahu Maharaj Shikshan Sanstha's AYURVED MAHAVIDYALAYA & RUGNALAYA Kanchanwadi, Paithan Road, Aurangabad- 431011 (M.S.) 3. Patient visits Panchakarma OPD after registration from reception desk 4, In Panchakarma OPD, patient will be assessed in detail by Consultant/MO which includes patient's present complaints, past medical history, general and systemic examination and routine investigations if necessary. 5. Patients are also referred to other clinicians as per the care needed for the patient. In case, if there is a need of physician assessment prior to Panchakarma (Shodhana procedures), then patient will be referred to the modern physician of Parul Sevashram Hospital. After confirming the patient’s fitness and need for Panchakarma intervention, the plan of care is drawn by the consulting physician. 6. If patient needs Panchakarma procedure; consultant /MO should explain about the procedure in detail, do's & don'ts during procedure and ask the patient to take admission in IPD 7. The procedure which doesn’t need IPD admission can be performed on OPD basis. During OPD basis treatment patient should daily visit screening desk to collect case sheet, Later he should go to OPD for registration of case in OPD procedure register and then he/she should go to IPD. IPD medical officer will direct the patient to Panchakarma theatre on prefixed time everyday till the completion of treatment course. PROCEDURE: 1. All patients undergoing Panchakarma procedures will be assessed preoperatively by the Physician / MO posted in Panchakarma theatre and then it will be documented. 2, All the patients who undergo Panchakarma procedures have full details of thetr medical conditions in their case records. 3. Apart from the general consent which is obtained routinely from all in-patients, patients undergoing Panchakarma ie. Shodhana procedures, should be informed about its probable outcome and its probable complications. Following this, informed written consent will be taken from the patient. 4. IPD patient daily reports the MO and will be directed to PK theatre on the basis of prefixed schedule. 5. Panchakarma therapists are informed! of patients undergoing different procedure every day by the ward staff nurse, 6. Medications required for Panchakarma treatment procedure will be prepared by trained b cpl o 32 en PRINCIPAL ‘Chhetrapati Shahu Maharaj Shikshan Sanstha’s ‘Ayurved Mahavidyalaya & Rugnalaye, Kanchanwadi, Aurangabad.Chhatrapti Shahu Maharaj Shikshan Sanstha's AYURVED MAHAVIDYALAYA & RUGNALAYA Kanchanwadi, Paithan Road, Aurangabad- 431011 (M.S.) 7. Following procedures are being done under Panchakarma Department vi vii. vii, xi xi xili, xiv. xvi xvii. xviii. xin. xX. Vamana Virechana Nirooha basti Anuyasana basti Nasya Snehapana Abhyanga Parisheka Sweda Patra pinda Sweda Shashtika Shali Pinda Sweda Janu basti Kati basti Manya basti Udvartana Shiroabhyanga Shirodhara Shropichu Shirobasti Takradhara Upanaha 33 fake PRINCIPAL ‘Chhetrapati Shehu Mahare} Shikshan Sanstha’s Ayurved Mahavidyalaya & Rugnalaya, Kanchanwadl, AurangabadCChhatrapti Shahu Maharaj Shikshan Sanstha's AYURVED MAHAVIDYALAYA & RUGNALAYA Kanchanwadi, Paithan Road, Aurangabad- 431011 (M.S.) SHALYATANTRA. PURPOSE To provide surgical services to the patients of CSMSS Ayurved Mahavidyalaya & Rugnalaya, Kanchanwadi, Aurangabad SCOPE ‘The policy applies to care of patients through establishing or confirming the diagnosis and various Para-surgical procedures conducted in CSMSS Ayurved Mahavidyalaya & Rugnalaya, Kanchanwadi, Aurangabad. RESPONSIBILTY 1. Head/In-charge of Department 2. Inccharge consultant 3. PG scholars on posting 4, Medical officers 5. Nursing Staff 6. Paramedical staff POLICY 1, Para-sungical care is provided by qualified and experienced consultants. 2, Nursing care in the procedure room is provided by qualified and experienced nursing staff 3. Patient visit the Shalya OPD after registration and by the guidance of reception staff. Patients are also referred by other clinicians as per the care needed to the patient. 4, Initial Assessment includes patient's past medical history, general examination and routine investigations to confirm patient's need for procedural intervention. 5. All parasurgical procedures are undertaken by the concerned consultant after documientation of pre-procedure and provisional diagnosis. 6. Patients and their relatives are informed about the call for procedural intervention, expected outcome, risk involved, prognosis of the patient etc by the concerned surgeon. 7. ‘The date and time of procedural intervention is scheduled and the patient is informed to get admitted a day before or as per the requirement of procedure for undergoing all needed preparation including the needed investigations. 8 Pre procedure mi led by nursing staff as per guidance of the concerned. 34 PRINCIPAL ‘Chivetrapati Shahu Maharaj Shikshan Sansth’ Ayurved Mahavidyalaya & Rugnalaya,CChhatrapti Shahu Maharaj Shikshan Sanstha's 4 AYURVED MAHAVIDYALAYA & RUGNALAYA Kanchanwadi, Paithan Road, Aurangabad- 431011 (M.S.) +e PROCEDURE 1. On the basis of initial assessment, after confirming the patient's need for procedural intervention the plan of care is drawn by the consultant. 2. Provisional diagnosis is made and this is documented in the patient's case notes before he is taken up for procedure. 3. Prior procedure, complete details of the patient regarding their medical conditions is documented in their case records, 4. Apart from the general consent which is obtained routinely from all in-patients, patients undergoing procedural intervention should be informed about the same, it's possible outcome and its probable complications. Following this informed consent from the patientis taken. 5. On OPD basis, after consent patient is asked to make payment for the procedure at reception. Then patient has to report at Shalya procedure room. Procedure is done by surgeon, medical officer, sister and other supporting staf, 6. Incase a new procedure is added to care plan, a fresh consent shall be sought from the patient/relative. 7. Following Procedures are being done under Shalya Tantra Dept. according to the need: ‘* Kshara sutra ligation + Kshara sutra threading © Kshara karma ‘+ Raktamokshana + Agnikarma + Matrabasti / fame (a PRINCIPAL ‘Chhetrapati Shahu Maharaj Shikshan Sanstha's ‘Ayurved Mahavidyalaya & Rugnalaya, Kanchanwadi, Aurangabad. 35Chhatrapti Shahu Maharaj Shikshan Sanstha's AYURVED MAHAVIDYALAYA & RUGNALAYA Kanchanwadi, Paithan Road, Aurangabad- 431011 (M.S.) ‘SHALAKYATANTRA, PURPOSE. To provide a mechanism for the care of outpatient and inpatient undergoing Shalakya Kriya Kalpa procedures in CSMSS Ayurved Mahavidyalaya & Rugnalaya, Kanchanwadi, Aurangabad SCOPE The policy applies to care of patients through establishing or confirming the diagnosis, pre-procedure preparation, the main procedure, and post-procedure care of Shalakya Kriya Kalpa in CSMSS Ayurved Mahavidyalaya & Rugnalaya, Kanchanwadi, Aurangabad. SERVICES Netra Roga Unit: 1. Diseases of Conjunctiva, Eyelids and Lens. 2. Refractive errors and their correction. 3. Procedures of Kriyakalpa - Tarpana, Seka, Putapaka, Anjana, Bidalaka, Aschotana and Pind 4, Regular eye examination. 5, Minor OPD procedures. Karna, Nasa, Mukha and Shiro Roga Unit: 1. Diseases of Ear, Nose, Throat and Oral Cavity. 2. Shalakya procedures- Karnapoorana, Karnadhupana, Kavala, Gandusha and Nasya. 3, Regular ENT examination, 4, Bar syringing for wax and foreign body 5. Foreign body removal- Ear and Nose 7.Minor OPD procedures RESPONSIBILITY 1, Head/In-charge of Department /f 2...» ‘Treating Consultant a Medical Officers 4. Nursing Staff } i at Anan 5. Paramedical staff fy eae — aa PRINCIPAL (Chhetrapati Shahu Maharaj Shikshan Sanstha's ‘Ayurved Mahavidyalaya & Rugnalaya, Kanchanwadi, Aurangabad.{ L Chihatrapti Shatu Maharaj Shikshan Sanstha’s ‘ AYURVED MAHAVIDYALAYA & RUGNALAYA = Kanchanwadi, Paithan Road, Aurangabad- 431011 (M.S.) POLICIES 1, Care and Supervision is provided by qualified Medical Officers and Shalakya Tantra Physician. 2, Care in the Kriya Kalpa theatre is provided by trained and qualified staff. 3. Patient visit the Shalakya OPD either by themselves anticipat guided after initial screening, ig their problem or are 4, Patients are also referred by other clinicians as per the care needed by the patient. 5. Initial Assessment of the patient is done with proper history taking, clinical examination of the patient and necessary investigations. 6. In case the patient needs assessment from other specialties, case is referred to the concerned department for opinion and the needful is done. 7. Ifthe physician feels the need of admission, the patient and his attendants are informed about the same, and if they agree, admission is done as per the admission policies of CSMSS Ayurved Mahavidyalaya & Rugnalaya, Kanchanwadi, Aurangabad. 8. After confirming the diagnosis, necessary treatment is given for prescribed number of days and then patient is asked to come for follow up after completion of the treatment. 9, Ina case where Shalakya procedure/s is needed for a patient, the patient will be first educated about the procedure and an informed consent will be taken from him/her prior to the execution of the procedure. PROCEDURES 1. Before the Kriya Kalpa, necessary sterilization of instruments and procedure room bbe carried out to prevent the infections as per the standards of Hospital infection control. 2. _Intactness of the instrument will be checked prior to their usage each time. 3. Kriyakalpa procedure evaluation is done after the procedure by the Consultant / Medical officer: 4. The post procedure care of the patient is done as plan of the physician. 5. Post procedure complications of Kriya Kalpas will be assessed and monitored by concerned personnel in treatment room, 6. After completion of the Shalakya procedure/s the inpatient is guided to the respective ward by the nurse-in-charge. PRINCIPAL (Chhetrapati Shahu Maharaj Shikshan Sanstha’ Ayurved Manavidyalaya & Rugnalaya, Kanchanwadi, Aurangabad,‘Chhatrapti Shahu Maharaj Shikshan Sanstha's AYURVED MAHAVIDYALAYA & RUGNALAYA Kanchanwadi, Paithan Road, Aurangabad- 431011 (M.S.) PRASUTI TANTRA & STRIROGA PURPOSE To provide comprehensive care in the specialty of Prasutitantra & Striroga to ensure provision of appropriate quality Obstetrical and Gynecological services including nutrition & education. SCOPE All the patients visiting to Prasuti Tantra & Striroga OPD and IPD SERVICES: © Preconception care © Antenatal Care / Garbhini Paricharya © Postnatal Care / Sutika Paricharya * General Gynecological Services © Counseling regarding Contraception * Procedures like Yoni Dhavana, Yoni Pichu, Yoni Abhyanga, Kshara karma and Uttarbasti. RESPONSIBILITY 1. Head of Department of PTSR 2. Consultants 3, Medical Officers 4, PG scholars on posting 5. Nursing Staff 6. Housekeeping staff 7. Other supporting staff POLICY 1, Obstetrical and Gynecological care is provided by qualified medical officers and Prasutitantra & Striroga consultants. 2, Nursing care in the procedure room is provided by qualified and experienced nursing PRINCIPAL CChhatraati Shahu Mahar Shikshan Sanstha’s ‘Ayurved Mahavidyalaya & Rugnalaya, Yeschaowad, Aurangabad. 38( ; CChihatrapti Shahu Maharaj Shikshan Sanstha's == AYURVED MAHAVIDYALAYA & RUGNALAYA Kanchanwadi, Paithan Road, Aurangabad- 431011 (M.S.) 52 # Services and care provided to obstetrical (antenatal and postnatal) patients at Prasutitantra & Striroga OPD are displayed in OPD patient area. 4. Necessary sterilization of instruments and procedure room will be carried out to prevent the infections as per the standards of Hospital infection control and required instruments are made available. 5. Patient visit the Prasutitantra & Striroga OPD after registration by the guidance of reception staff Patients are also referred by other clinicians as per the care needed to the patient. 7. Initial Assessment of the patient is done with proper history taking, clinical examination of the patient and necessary investigations. 8 Incase of any requirement of Prasuti tantra & Striroga procedure, informed consent will betaken and procedure will be executed as per SOP. 9. In case the patient needs assessment from other specialties, case is referred to the concerned department for opinion and the needful will be done. 10, After confirming the diagnosis, necessary treatment is given. 11. Ifthe physician feels the need of admission, the patient and his attendants are informed about the same, and if they agree, admission is done as per the admission policies of ‘CSMSS Ayurved Mahavidyalaya & Rugnalaya, Kanchanwadi, Aurangabad. 12, Regular time of Consultation is in between 9:30 am to 4:15 pm. Consultants are available on call at rest of the time while medical officers / nursing staff are available twenty four hours in the hospital. PROCEDURE 1, Pre-procedure initial assessment and provisional diagnosis is made for all patients and this is documented in the patient's case notes before he is taken up for procedure. 2. Prior procedure, complete details of the patient regarding their medical conditions is documented in their case records. 3. If the consultant comes across any abnormal findings in the pre-operative, it has to be documented in the patient's records and this has also to be informed to the patient's relatives. 4, Apart from the general consent which is obtained routinely from all in-patients, patients undergoing Prasutitantra & Striroga procedure should be informed about the same, it’s ‘Chhatrapati Shahu Maharaj Shikshan Sanst ‘Ayurved Mahavidyolaya & Rugnalay Kanchanwadi, Aurangabad.