B.
G Hospital, Tiruchendur
Document Name: Procedure for Registration, admission and transfer
Document No.: NABH/SHCO/ BG /
No. of Pages: 26
Date Created:
Date of Updated:
NABH CO ORDINATOR
Name
Prepared By: Signature
Designation: Medical Director
Name Dr. A. Ramamurthy, M.D
Signature:
Approved & Controlled By:
1
Hospital Policy Manual Policy and Procedure on
Registration
NABH SHCO 3nd Edition Standard NABH/SHCO/ BG /
Reference:
Policy /Version No/ Issue Date NABH/ / Ver. No 2/
AMENDMENT SHEET
Sl. Section no Details of the Reasons Signature of the Signature
No. & Page no Amendment preparatory of the
authority approval
authority
CONTROL OF THE MANUAL
Hospital Policy Manual Policy and Procedure on
Registration
NABH SHCO 3nd Edition Standard NABH/SHCO/ BG /
Reference:
Policy /Version No/ Issue Date NABH/ / Ver. No 2/
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 mode.
The holder of the copy of this Manual shall maintain it in current status by inserting latest
amendments as and when the amended versions are received.
NABH Co-ordinator is responsible for issuing the amended copies to the copy holders; the
copyholder should `acknowledge the same and he /she should return the obsolete copies to the
Medical director.
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
Manager Medical Director NABH Co -ordinator
B.G Hospital
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 Medical Director
2 Manager
3 NABH Co-ordinator
4 Relevant Department
Hospital Policy Manual Policy and Procedure on
Registration
NABH SHCO 3nd Edition Standard NABH/SHCO/ BG /
Reference:
Policy /Version No/ Issue Date NABH/ / Ver. No 2/
1. PURPOSE
To define Policy & Procedure for
2. SCOPE
This Policy & procedure is applicable to patient who undergoes.
Procedure
AAC.1.a) SERVICES OFFERED BY BG HOSPITAL
OPD AND IPD SERVICES FOR FOLLOWING DEPARTMENTS
Scope of services
Clinical Services
A. General Medicine
1. Outpatient
2. Inpatient Care
3. Emergency care [casualty]
4. Intensive care unit [ Acute coronary syndrome, shock, cardiac failure & Respiratory
failure, sepsis
B. Neurology super specialty services
1. Outpatient
2. Inpatient care
Hospital Policy Manual Policy and Procedure on
Registration
NABH SHCO 3nd Edition Standard NABH/SHCO/ BG /
Reference:
Policy /Version No/ Issue Date NABH/ / Ver. No 2/
3. Neuro emergency such as stroke, encephalitis, seizure, degenerative diseases,
movement disorders , neuropathies, spinal cord diseases , neuropathies, myopathies,
memory disorder, sleep disorders
4. Neuro emergency [stroke, seizure, delirium Tremon , coma ]
C. Surgical Specialties
1. General Abdominal Surgeries
2. Thyroid Surgery
3. Breast Surgery
4. Hernial Surgery
5. Testicular Surgeries
6. Piles & Fissure Correction
7. Laparoscopic Surgery
8. Biopsies,
9. Abscess drainage
10. Surgical dressing
D. Obstetrics & Gynaecology
1. Antenatal check up
2. High risk assessment
3. Nutritional assessment
4. Natal care - Natural Delivery, Instrumental Delivery , Cessation Section
5. Post -natal care
6. New born care
7. Gynec Surgeries (Hysterectomy , Ovarian & Vaginal Surgeries and laparoscopic Surgery )
8. Medical termination of Pregnancy ( MTP)
9. PAP Studies
10. Endometrial Biopsies
11. Immunization services
E. Clinical laboratory Services
Hospital Policy Manual Policy and Procedure on
Registration
NABH SHCO 3nd Edition Standard NABH/SHCO/ BG /
Reference:
Policy /Version No/ Issue Date NABH/ / Ver. No 2/
1. Bio Chemistry ,
2. Hematology
3. Microbiology,
4. Molecular biology ,
5. Hormone assays,
6. Biopsy Study.
7. Urine analysis
F. Radiology
1. Whole body CT Scan
2. X- Ray ( Contrast X – ray like barium meal, Urethrogram, Hysterosalpingogram )
3. MRI
4. Ultrasound General Abdomen, Vascular Doppler, Musculo-skeletal,
5. OBSTETRIC ULTRASOUND WITH NT SCAN
G. Cardiology
1. Echo Cardiography
2. Treadmill ECG, Routine
6. EEG
H. NEURO
1. EEG
2. NCS
I. GASTRO
1. Endoscopy
J. PULMONOLOGY
1. Pulmonary Function test
K. Supportive Services
1. Ambulance service
2. Pharmacy Services
3. Physiotherapy
Hospital Policy Manual Policy and Procedure on
Registration
NABH SHCO 3nd Edition Standard NABH/SHCO/ BG /
Reference:
Policy /Version No/ Issue Date NABH/ / Ver. No 2/
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AAC.2.a) Procedure for registration
1. Aim:
This terminal deals with the registration of the patient. In this process a
Registration No[UHID] . is given to the patient. The file is created for the
patient and it is continued for any OPD process consultation /
procedure .The registration no. is mandatory for any treatment or
investigation in the hospital.
Hospital Policy Manual Policy and Procedure on
Registration
NABH SHCO 3nd Edition Standard NABH/SHCO/ BG /
Reference:
Policy /Version No/ Issue Date NABH/ / Ver. No 2/
2. Responsible personnel in the department:
1. Front office assistants
3. Rationale:
1. To make a unique identity no for the patient in the hospital for
treatment
2. All the demographic information is captured for statistics.
3. Procedure:
This involves filling up the patient’s details in the registration module.Registration
is mandatory for all patients
· Patient’s details are written the in the IPD/OPD register.
· Patient’s particulars like name, age, address, phone no, payment
category, family physician and consulting doctors name.
· The fields which are mandatory are marked as red in the software.
· The patient’s data is fed in the system and registration no. is
generated.
· After doing registration, that patient’s profile is generated in the
software.
Other duties
1. Ensure registration numbers and other details are accurately written
in the IPD register and patient’s file..
Hospital Policy Manual Policy and Procedure on
Registration
NABH SHCO 3nd Edition Standard NABH/SHCO/ BG /
Reference:
Policy /Version No/ Issue Date NABH/ / Ver. No 2/
2. Educate the patient’s relative about patient’s registration and further
process.
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AAC.2.a)Procedure for Admission
1. Aim:
This terminal deals with the formalities related to admission. Any patient who
comes for admission should be registered with the hospital. If the patient comes
Hospital Policy Manual Policy and Procedure on
Registration
NABH SHCO 3nd Edition Standard NABH/SHCO/ BG /
Reference:
Policy /Version No/ Issue Date NABH/ / Ver. No 2/
back for admission in few days then his discharge summary is retrieved from the
system, (and file if needed)
2. Responsible personnel in the department:
a. Front office assistants
3. Rationale:
a. To make an account in the hospital for treatment.
b. To allot a bed for patient’s stay during the hospitalization.
c. To Ensure Smooth management of treatment at entry level.
3. Procedure:
This involves the admission of the patient by the admission staff based on the
information given by patient/ relative.
· The different categories of bed and the tariffs are explained to the relative.
Hospital Policy Manual Policy and Procedure on
Registration
NABH SHCO 3nd Edition Standard NABH/SHCO/ BG /
Reference:
Policy /Version No/ Issue Date NABH/ / Ver. No 2/
· With the help of occupancy chart, if The room of choice/ward is available ,is
allotted to the patient.
· Facilities are explained to the patient/relative.
· Registration is done
All the patient's details are written in the IPD register (Pvt and WCL) with
compulsory two mobile and one landline no.
· An IPD file is made.
· A general consent for treatment is taken, form is filled up by the relatives, in that
at least 2 relatives mobile no. is taken. The declaration is to be signed by the
patient or his relative / next of kin with the full name written clearly on the
consent.
· Once the Performa is completed, it should be filed in the patient’s record. The
person on duty at admission counter must sign on the admission form for
identification of originator, if the requirement arises.
Hospital Policy Manual Policy and Procedure on
Registration
NABH SHCO 3nd Edition Standard NABH/SHCO/ BG /
Reference:
Policy /Version No/ Issue Date NABH/ / Ver. No 2/
· The patient’s relative is then sent to the I.P billing department, with details of
admission and the bed/ room allotted, for counselling payment of deposit.
· A call is made to the ward regarding the new admission to make the room ready.
Other Duties-
· Patients are often admitted in emergency situation. Ensure that the admission
procedures are quickly completed, consent is taken and the patient’s record is
delivered to the emergency department as speedily as possible.
· Contact various wards from time to time, when ever necessary And keep
yourself updated with the bed situation and expected discharges.
· The occupancy chart has to be updated and kept handy.
· Responding to enquiries regarding admission is duty of front office staff at this
counter. Correct information expeditiously given, is of paramount importance.
Hospital Policy Manual Policy and Procedure on
Registration
NABH SHCO 3nd Edition Standard NABH/SHCO/ BG /
Reference:
Policy /Version No/ Issue Date NABH/ / Ver. No 2/
· In case of out station enquiries for admission, it is advisable to counter check
with wards before confirming bed availability. This is even more significant when
a patient is being transferred under emergency circumstances.
Hospital Policy Manual Policy and Procedure on
Registration
NABH SHCO 3nd Edition Standard NABH/SHCO/ BG /
Reference:
Policy /Version No/ Issue Date NABH/ / Ver. No 2/
AAC.2.d) Procedure to address managing the patients
during non availability of beds.
1. Scope: To provide information and establish guidelines in non availability of
beds in the hospital.
2. Objective:
a. To provide the patients and their relatives the alternate arrangements in the
situation when the beds are not available.
2. Responsible personnel in the department:
a. Front office Assistants
b. Casualty medical officer/casualty sister
c. Transportation team (Patient assistants)
4) Procedure
Hospital Policy Manual Policy and Procedure on
Registration
NABH SHCO 3nd Edition Standard NABH/SHCO/ BG /
Reference:
Policy /Version No/ Issue Date NABH/ / Ver. No 2/
Type of admission
4.1)Stable admission:
If a bed is not available at the time of admission, the patient’s relative are made
aware of the alternative choices in the hospital.
The staff should make a call to the nearest hospital and ask whether the bed is
available or not.
If the Patient is ready to go to the hospital , inform the hospital that the patient is
being referred (tell name of the patient)
Guide the patient about how to go to the hospital, make sure that one relative
accompany the patient while going.
Give the OPD assessment sheet to the patient.
4.2) Unstable admission:
Emergency patient should be taken in the casualty immediately.
Give the patient resuscitation needed for life saving.
Hospital Policy Manual Policy and Procedure on
Registration
NABH SHCO 3nd Edition Standard NABH/SHCO/ BG /
Reference:
Policy /Version No/ Issue Date NABH/ / Ver. No 2/
Arrange the hospital ambulance and refer the patient immediately to the other
hospital.
Give the patient summary and reports if any.
Make a call to the hospital that the patient is coming ( tell name of the patient)
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AAC.3.a)Procedure guide for transferring stable and
unstable patients outside
1. Aim:
To provide guidelines for the transfer of a patient from ward to outside for
diagnostic/treatment purpose.
Hospital Policy Manual Policy and Procedure on
Registration
NABH SHCO 3nd Edition Standard NABH/SHCO/ BG /
Reference:
Policy /Version No/ Issue Date NABH/ / Ver. No 2/
2. Rationale:
1. To ensure that the transfer of the patient takes place smoothly.
2. To ensure patient’s safety & comfort during transfer.
3. Procedure:
The ward staff would confirm the physician’s order for the procedure/ transfer.
Take appointment for the procedure.
Patient and Relatives are explained about the procedure and the time of
appointment.
Consent is taken by the doctor on duty.
The staff would confirm the same with respective hospital/ center before transfer.
Family /relatives should be notified about the procedure.
As per the appointment the transportation team/ward boy is called.
Arrange ambulance according to the condition of the patient. If the patient is
critical arrange critical resuscitation ambulance, it stable then a service van or any
other vehicle.
Hospital Policy Manual Policy and Procedure on
Registration
NABH SHCO 3nd Edition Standard NABH/SHCO/ BG /
Reference:
Policy /Version No/ Issue Date NABH/ / Ver. No 2/
Send the patient to the outside centre along with the housekeeping personnel.
Patient to be accompanied by patient assistant and a relative.
Send the required documents along with the patient.
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AAC.14. a) Procedure for Discharge ( Private/ TPA/
MLC)
Hospital Policy Manual Policy and Procedure on
Registration
NABH SHCO 3nd Edition Standard NABH/SHCO/ BG /
Reference:
Policy /Version No/ Issue Date NABH/ / Ver. No 2/
1. Aim:
To provide guidelines to the ward staff on how to discharge the patient .
Rationale:
1. To ensure that the discharge of the patient takes place smoothly.
2. To ensure patient’s safety, satisfaction & comfort during discharge.
3. To reduce the time involved in planned discharge & physical discharge.
4. To protect the hospital from medico legal issues involved in DAMA.
Hospital Policy Manual Policy and Procedure on
Registration
NABH SHCO 3nd Edition Standard NABH/SHCO/ BG /
Reference:
Policy /Version No/ Issue Date NABH/ / Ver. No 2/
2. Procedure:
1) Consultants write a discharge orders after the consultant finds the patient fit to
get discharge.
2) The resident doctor on duty put the discharge notes and then ward nurse checks
the billing activity , updates it and then send it for billing and summary .
3. Resident doctors check the discharge summary & sign on it & obtain the
signature of the consultant also.
5. Return all required medications to the pharmacy .
10. Remove all blank documents. Collect all pending investigation reports.
If the patient is Pvt then handover all Original copies of investigations to the
patient and keep photocopies in the IPD file.
If the patient is TPA then handover all photocopies of investigations to the patient
and keep Original copies in the IPD file.
(In TPA case all originals are faxed to the TPA)
Hospital Policy Manual Policy and Procedure on
Registration
NABH SHCO 3nd Edition Standard NABH/SHCO/ BG /
Reference:
Policy /Version No/ Issue Date NABH/ / Ver. No 2/
If the patient is MLC then handover all photocopies of investigations to the patient
and keep Original copies in the IPD file.
13. After receiving a call from IP billing about the readiness of the bill, inform
patient to clear all pending bills.
14. After the full and final stamp is put , Director will sign on 3 bills, 2 receipts and
occupancy.
15. Ward staff records the bill no. and the receipt number ( only after seeing the
full and final and sign is done)
16. Check for the hospital property i.e. linen, crockery etc.
17. Handover the discharge summary to the patient and/ or relative only after
checking the final settlement of the bill.
Hospital Policy Manual Policy and Procedure on
Registration
NABH SHCO 3nd Edition Standard NABH/SHCO/ BG /
Reference:
Policy /Version No/ Issue Date NABH/ / Ver. No 2/
18. Obtain signature of the person to whom you are handing over all the documents
in the IP register & Report Acknowledgement Form along with their name &
relationship.
19. If there are any pending reports of the investigations, if the patient party
requests then inform them that the reports would be couriered to them.
20.The on duty doctor will explain the discharge instructions to the patient &/ or
relative & take a feedback.
1. Relieve the patient. If required the patient would be transferred via wheel chair
or stretcher.
2. If required arrangement for transportation would be done through reception.
21. IN CASE OF MEDICO LEGAL CASE (MLC PATIENT DISCHARGE):
Consultants put the discharge order after he finds the patient is fit to get
discharge.
Hospital Policy Manual Policy and Procedure on
Registration
NABH SHCO 3nd Edition Standard NABH/SHCO/ BG /
Reference:
Policy /Version No/ Issue Date NABH/ / Ver. No 2/
Ward RMO prepare return MLC and send it to Dhantoli police station. If the
patient is stable and getting discharge police sign on it and allow to discharge the
patient BUT IF THE PATIENT IS DEATH THEN BODY IS HANDED OVER
TO THE POLICE ONLY.
Document the police officer’s name buckle and name of police station.
DO NOT HANDOVER any original documents to patient including original
discharge summary, original printed reports, original X – Ray, C.T. scan, MRI
films & CDs.
The photocopy of printed reports to be handed over to the patient or his relative.
Obtain signature of the person to whom you are handing over all the documents in
the admission register along with date, their name & relationship.
22. IN CASE THIRD PARTY ADMINISTRATOR (TPA PATIENT
DISCHARGE):
DO NOT HANDOVER any original documents to patient including original
discharge summary, original printed reports, original X – Ray, C.T. scan, MRI
films, ECGS & CDs.
The photocopy/ XEROX of only printed reports to be handed over to the patient or
his relative.
Obtain signature of the person to whom you are handing over all the documents in
the admission register along with their name & relationship.
Hospital Policy Manual Policy and Procedure on
Registration
NABH SHCO 3nd Edition Standard NABH/SHCO/ BG /
Reference:
Policy /Version No/ Issue Date NABH/ / Ver. No 2/
23. IN CASE OF DAMA ( DISCHARGE AGAINST
MEDICAL ADVICE)
1. Procedure:
(FOLLOW THE POLICY AND PROCEDURE FOR FOR NORMAL
DISCHARGE PATIENT BUT FOLLOW THE ADDITIONAL INSTRUCTIONS
GIVEN BELOW)
Consultant put the discharge order after the patient expresses his/her wish to get
DAMA.
The consultant or RMO explain the patient/ relative about the condition of the
patient in their own language.
Hospital Policy Manual Policy and Procedure on
Registration
NABH SHCO 3nd Edition Standard NABH/SHCO/ BG /
Reference:
Policy /Version No/ Issue Date NABH/ / Ver. No 2/
Obtain the consent for DAMA from patient./ relative.
Obtain the High Risk consent from two relatives in case of life threatening
condition.( NEGATIVE COUNSELLING)
Resident prepares the discharge summary stating this discharge as DISCHARGE
AGAINST MEDICAL ADVICE.
Send file for the discharge summary.
RMO checks the discharge summary & sign the same & obtain the signature of the
consultant on it.
Handover the reports to the relatives( if its not MLC case)
Hospital Policy Manual Policy and Procedure on
Registration
NABH SHCO 3nd Edition Standard NABH/SHCO/ BG /
Reference:
Policy /Version No/ Issue Date NABH/ / Ver. No 2/
