SOP 6.

General Administration
Pomlum PHC

Doc. No - 2

Date of issue:
19/12/2024
Pomlum PHC
Issue No- 12

Address: Mylliem Block, Revision No- 0

Upper Shillong 793009
Prepared by

1. Dr. D. P. Syiem, Sr.M

&HO
2. Smti B. Donmom,
Staff Nurse
3. Smti B. Hinge,
Pharmacist

Approved by
Dr. D. P. Syiem, Medical STANDARD
Officer in-charge
POMLUM PHC

OPERATING
PROCEDURES FOR
GENERAL
ADMINISTRATION

Signature
 SOP 6. General Administration
Pomlum PHC

Introduction

To deal with all general administration of the facilitywhich includes:

a. Overall administrative Procedure

b. Drug dispensing counter (Pharmacy)

c. Bio Medical Waste Management and Infection control

d. Medical Records

A. SOP for Overall Administrative Procedure

1. Purpose

It covers overall administrative procedure such as Infrastructure maintenance, support

services, Grievance Redressal mechanism and Financial entitlements etc.

2. Scope
POMLUM PHC

The Scope of the SOP is applicable to the general administration of the facility

3. Responsibility: Medical officer in Charge

4. Procedure

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s/records
4.1 Infrastructure maintenance MO,RKS RKS
Minor maintenance work is done through outsourcing committee Meeting
as per approval of the RKS Committee of the minutes
hospital.
Major maintenance work is done by Public health
engineering wing as per the requirement from time to
SOP 6. General Administration
Pomlum PHC

time
4.2 Administrative procedure
Monitoring & supervision of activities of Sub Centre MO,LHV/
is done by the designated staffs of the PHC MPW/HA
Monitoring & supervision of the activities of ASHA MO &
ANM,PHN,L
HV
Monthly review meeting by ANM at Sub-centre to MO
review the performance of the facility & field
performance & to take necessary measures for
preventive & corrective action
Supporting & supervising VHNDs is done to oversee MO,Supervis
the quality of VHND Services provided on fix days at ors
VHND site
4.3 Support Service MO
Laundry service is outsourced by the PHC.PHC
monitors the equality of the laundry service to
POMLUM PHC

continue or discontinue the party

Dietary service is outsourced through annual contract MO
,The Service quality is monitored through patients
feedback provided by IPD patients & this guides the
facility to continue contract with the outsourced
party/agency

4.4 Grievance redressal procedures MO Grievance

Facility has two complain box one at reception & redressal
another at Adolescent health clinic policy
Phone no of the grievance redressal authority is
displayed at the notice board
The complaints can be either dropped in the
complaint box or should be given in writing to the
MO in charge & RKS Committee
Every day the complaint box is checked & the
SOP 6. General Administration
Pomlum PHC

grievances are addressed either by PHC itself & the

grievances that cannot be addressed at the facility are
referred to the district medical & health officer, East
Khasi Hills & the complainant is informed about it
The grievances that can be settled at facility are
addressed immediately
Grievances & the status of redressal are recorded
Redressal Register

4.5 Referral Service Procedure MO, Staff Referral

1. The timely referral is critical for timely care Nurse policy
of patients at appropriate facilities ,to ensure Referral In
that facility has established it’s referral policy Register
to refer those patients can’t be managed at the Referral
facility Out
2. Facility maintains list of higher centres Register
3. Documented reasons for Higher
POMLUM PHC
centre
referral in the case sheet of client referred
4. Free transportation for Sick neonates &
infants & women for complications from
conception ,during intra partum period till 42
days after delivery under JSSK
5. Patients are referred by 108 ambulance&
hospital ambulance free of cost for maternity
complications, sick neonates & infant, BPL,
MLC cases.
6. Follow up of referral cases through ASHA &
ANM

4.6 Procedure for timely reimbursement of MO Procedure

entitlements and compensation for timely
reimburse
4.6.1 JananiSishuSurakshaKaryakram (JSSK): ment of
SOP 6. General Administration
Pomlum PHC

Ante Natal-Intra Natal-Post Natal Period entitlemen

Free Transportation ts and
Pick up from catchment area compensat
Drop back for all cases ion
Referral from primary to secondary care for
complicated cases
Free Drugs & diagnostics (Pregnancy, labour, post-
partum)
Drugs is free of cost
Diagnostics service available at facility or through
outsourcing is free of cost
Free Diet
Free diet through outsourcing for 3days @Rs 100 per
day for 3 days
4.6.2 Entitlements for Sick Neonates & Infants
Free Entitlements for Sick Neonates & Infants
Provision of Free drugs, diagnostics & referral
POMLUM PHC

transport (home to institution, institution to home as

drop back service & between health facilities in case
of referral) under JSSK.
No user charges for sick neonates & sick infants.
4.6.3 Entitlements for Institutional Delivery under
MHIS
-As per Megha Health Insurance Scheme of Govt. of
Meghalaya, the women who deliver at the hospital
any amount of money that has been incurred for
purchase of medicines is reimbursed through cash if
it below Rs 1000 & above Rs 1000 for purchase of
medicines, the cheque payment is made. The
conditionality’s to avail the benefit is subject to
availability of MHIS Card by the beneficiary & she
should be either BPL,APL but this benefit is not
applicable to the women from families who are in
SOP 6. General Administration
Pomlum PHC

regular govt. service at state or central govt.

4.6.4

JananiSurakshaYojna
Criteria
The women completed 3 ANC & delivered at
hospital will be credited Rs 700 for Rural
beneficiaries &Rs 600 for Urban beneficiaries
The bank account no of the beneficiary is mandatory
for Direct benefit transfer as it is the only mode of
payment
Documents required from beneficiary
The documents required are discharge certificate,
MCP card, JSY Card & bank account no of
beneficiary

4.7 Procedure on maintaining Privacy Dignity & MO,

POMLUM PHC
Staff
Confidentiality nurse
The hospital will not breach any norms related to the
privacy, dignity & confidentiality of each patients
The staffs will be sensitized on gender issues
periodically as an step to ensure that Gender
sensitivity is established
The medico legal records will be in lock & key & in
the custody of the person identified by the hospital
administrator & patient’s identity including treatment
status will not be disclosed without patients consent
& in case of minor without caregiver/guardians
consent.
The female patients(adult & child) will be seen by
doctors (male) in the presence of female
attendants/staffs only
The survivors of rape will be checked preferably by
SOP 6. General Administration
Pomlum PHC

female doctor & in absence of female doctor, a male

doctor can examine but it is to be ensured that the
examination is done in the presence of female staff
Hospital will not share any confidential information
about patients
Screen between labour tables to maintain visual
privacy of the women in labour
Respectful care, courteous behaviour by the service
providers

4.8 Procedure on Local purchase MO In charge

1.PHC places indent to the district store if the RKS
required article is not available then NOC is taken by Committee
MO In-charge from the district Medical &Health
Officer, East Khasi Hills, Meghalaya following that
quotations are invited & t & the contract is made with
POMLUM PHC

the bidder who is found to provide items of good

quality at least price than other bidders
4.9 Procedure on Preventive maintenance of MO In charge
equipment
It is done through state health society but MO in
charge has to inform to the state outsourced agency in
case of breakdown of any equipment. In case of non-
timely actions undertaken by the outsourced agency
the matter is intimated to the district authority in
writing by the MO In charge

4.10 Training need assessment procedure MO In charge Training

Facility does the training need assessment & Register
intimates district authority for requirement of In
service training
4.11 Fire safety procedure MO In charge Training
 SOP 6. General Administration
Pomlum PHC

Fire extinguishers in strategic locations & regular Register

refilling, Fire exit signs displayed in critical areas,
Mock drill for fire safety, etc.

B. SOP for Drug Dispensing Counter (Pharmacy)

1.Purpose

 To establish, implement and maintain a system for dispensing of drugs as prescribed

to all the patients.
 To maintain a system for proper issuing and indenting of drugs as per the need of the
hospital.

2. Scope
POMLUM PHC

It covers all patients as well as staffs involved in drug dispensing counter

3. Responsibilty :
MO – Incharge & Pharmacist

4. Procedure

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4.1 Indenting of Drugs: Pharmacy Indent
Indenting of drugs is done base on the Essential Drug form
List (EDL) given by the state. voucher,
EDL
As for NHM indenting is done through Drug and
Vaccine Distribution Management System (DVDMS) DVDMS
which is implemented already
system

4.2 Receipt of Drugs: Pharmacist Receipt

SOP 6. General Administration
Pomlum PHC

Voucher
Drugs are received in the hospital through DMHO
office based on the requirement generated and sent
by the hospital/PHC.

The drugs received are identified and their quantity is

checked. The drugs are received through
acknowledgment on the voucher slip.
Record of drug is maintained at the stock register
along with the name, quantity and date of
manufacture and expiry date etc.

A list is also prepared for the drugs received as

damaged or expired. Such drugs are segregated and
enter in a register for noticed.

4.3 Storage of Drugs: Pharmacist Stock

register,
 Stock is arranged neatly with name and expiry Temperatu
date facing the front.
re Register
 Products of similar name and different strength
are stored separately
 Heavy items are stored in lower shelves
 Fragile items are not stored at the edge of the
shelves POMLUM PHC

 Near expired drugs are segregated and stored

separately
 Items requiring refrigeration are stored
appropriately
 Temperature book are maintained for monitoring
and recording the temperature of the refrigerator.
 Look alike and sound alike drug are stored
separately.
 Medications that are considered light sensitive as
labelled by their respective manufacturers will be
stored in closed drawers.

4.4 Disposal of drugs: Pharmacist

Record of drugs expired during the month is

maintained in the Expired medicine register.

Expired drugs and damaged drugs are disposed off as

per the guidelines of the hospital and record of
disposal are maintained in Expired Medicine
Register. (i.e, date , quantity of expired drugs etc).

4.5 Supply of Drugs from store/ Pharmacy Pharmacist Stock

SOP 6. General Administration
Pomlum PHC

Drugs are supplied to the indoor / ward/ emergency Register

as per the indent of demanded drugs from these
locations.

The record of issued drug is maintained in the stock

register at the store.

The Pharmacist supplies the drugs to these locations

and keeps the duly signed Register to the staff
nurse/ANM who receives the drugs.

A list of available drugs is prepared and intimated to

doctors. The list is periodically updated.
List of available drugs are displayed outside the
pharmacy counter.

The strip of the drug is cut and kept in marked boxes

ready for dispensing according to prescription.

The drugs which are to be kept in controlled

temperature are kept in controlled condition

4.6 Dispensing of drugs: Pharmacist OPD

Register
The patients visit the pharmacy to receive the
POMLUM PHC

prescribed medicine along with the Prescription slip

from the doctor.

The pharmacy makes sure that the drugs prescribed

by the MO is available and if not it is intimated soon
to the MO.

Fist Expiry First Out (FEFO) principle is followed

while recording the drugs in stock.

Patient is informed of the method of taking the

medicine as prescribed by the physician.

4.7 Local Purchase: MO-Incharge Stock

Register
Lifesaving medicines/ emergency medicines required
for day to day functioning are purchased from
registered local venders after approval from the MO
in-charge and RKS committee. Local purchase is
based on Quotation and three quotationsis procured
and the least quotation is being selected for purchase.
 SOP 6. General Administration
Pomlum PHC

Sr.No Name of Records Record No Minimum Retention Period

1 Stock Register 7 10 years

Sr.N Activity Process Efficiency Benchmark/Standard/

o Criteria Target
1. Percentage of stock Total stock outs for
out of vital drugs essential commodities
(RMNCH+A) each day added for a
month

5. References

1. NHSRC draft SOP

C. SOP for Bio Medical Waste Management Procedure

1. Purpose

To outline safe and efficient practices for the segregation, collection, storing, transport
and disposal of biomedical and general waste generated by the hospital as per Biomedical
Waste guidelines.
POMLUM PHC

2. Scope

The scope of the procedure is applicable to all concerned staff involved in the
segregation, collection and storage of waste before it is collected by concerned
agencies for suitable disposal.

3. Responsibility

Overall – MO In charge
 Segregation- Process Owner (Doctors, Nurses, Paramedics.)
 Collection, Transportation & Storage- Housekeeping Staff and concerned agencies.
 Disposal – Housekeeping Staff.

4. Procedure

Sl.n Activity Responsibili Reference

o ty documents/re
cords
4.1 Bio Medical Waste Management Procedure Grade IV
Recyclable waste is handed over to state
outsourced agency,annual report is submitted to
SOP 6. General Administration
Pomlum PHC

the state pollution control borad,Meghalaya

4.2 Segregation of Hospital Waste

Segregation of Bio-Medical Waste is done
at point of generation as per Biomedical
Waste (Management & Handling) rules
2016 and 2018 amendment in different colour
coded bins with liners
While separating the waste it is specially
taken into consideration that infectious
waste does not mix with non-infectious
waste.
Adequate number of bins and liners for
proper segregation and collection of
biomedical waste are provided at point of
use
All the departments adhere to their POMLUM PHC

respective guidelines for handling

biomedical waste
Needles and other sharps are handled and Nursing Work
disposed as per standard protocols to avoid Staff/ instructions
accidental sharp injuries Grade IV for
handling and
disposing
sharps
Liquid Waste and blood spillage is handled Grade IV Work
as per standard guidelines instructions
for
handling
liquid waste
Liquid Waste and blood spillage is handled Grade IV Work
as per standard guidelines instructions
for
SOP 6. General Administration
Pomlum PHC

handling
liquid waste
Laboratory waste is handled as per standards Laboratory Work
protocols Technician/ Instructions
Grade IV for
Handling
Laboratory
Waste
Contaminated Plastic waste is handled as Process Work
per standard protocols Owner Instructions
for
Handling
Plastic Waste
4.3 Collection Of Waste: Grade IV Work
Waste is collected by housekeeping at the instructions
respective department in two shifts; morning for
and evening (or as required) preferablyPOMLUM PHC
collection of
when there is minimum traffic, except in OT Biomedical
where the waste is collected after every waste
Operation.
Waste will be collected in two shifts or when Grade IV Work
waste bin is ¾ full. instructions
for
collection of
Biomedical
waste
4.4 Transport of Waste: Grade IV Work
Waste is transported to disposal site in instruction for
closed container through a pre- defined Transporting
route avoiding crowded area Waste
A large plastic bag is used to line the wheelable Grade IV Work
bin to prevent any liquid leaks from the instruction for
waste bags from soiling the bin. Transporting
SOP 6. General Administration
Pomlum PHC

Waste
This plastic bag is to be replaced in each Work
shift. instruction for
Transporting
Waste
4.5 Storage of Waste: Grade IV Work
Blue, Red Yellow and Translucent waste are held Instructions
in the bins kept permanently in waste for
holding room. Sufficient no. of bins is kept Storing Bio
to store waste for a period of 48 hrs. Medical
Waste
Kitchen waste will be placed in designated Grade IV Work
bins and will be stored for a maximum of 48 instructions
hrs. for
storage of
General
POMLUM PHC
Waste

4.6 Safe Disposal of BM Waste: Grade IV Work

Anatomical waste (yellow bag) disposed in instructions
deep burial pit/Incineration. for
disposal of
Waste
Deep Burial Pit is constructed as per Hospital Work
specifications of BMW (Management & Manager Instructions
Handling Rules. for
construction of
deep
burial pit
Sharps(Translucent) in puncture proof box Grade IV Work
disinfected instructions
and disposed in sharp pit. for
disposal of
SOP 6. General Administration
Pomlum PHC

Waste
Contaminated solid waste (Red bag) Grade IV Work
Disinfected, mutilated, storage and disposed of. instructions
for
disposal of
waste
Waste is disposed usually disposed same Grade IV Work
day. Maximum time limit is 48 hours instructions
for
disposal of
waste
General waste (Light Green and Light Blue bin) is Banshakri Work
collected from the facility and disposed by the Self SHG, instructions
Help Group Banshakri SHG, Mawlai Kynton Mawlai for
Massar. disposal of
waste
Hospital abides to all the clauses of POMLUM PHC
Medical Bio- Medical
Biomedical Waste (Management & officer / staff Waste
Handling Rules) 2016 and Amendment 2018. nurse (Management
&
Handling)
Rules 2016
and
Amendment
2018.
Hospital has a valid authorization for Medical Bio- Medical
Handling & Treating Bio-Medical Waste as officer / Staff Waste
per BMW (Management & Handlin Rules nurse (Management
2016 &
Which is renewed at prescribed interval? Handling)
Rules 2016
A annual report is submitted to Pollution Medical Form II, Bio-
Control Board, by 31st January of every year officer/staff Medical
 SOP 6. General Administration
Pomlum PHC

nurse Waste
(Management
&
Handling)
Rules 2016
Any major accident during handling & Medical Form III, Bio-
transportation is reported to prescribed officer / staff Medical
authority nurse Waste
(Management
&
Handling)
Rules 2016
All the containers are labelled with bio Medical Schedule III
hazard sign as per schedule III of BMW officer / Bio-
(Management & Handlin Rules 1998. Grade IV Medical Waste
(Management
POMLUM PHC
&
Handling)
Reference Activity Process Efficiency Benchmark/Standard/
Rules 2016
No. Criteria Target
4.7 Monitoring & Quality Control
Hospital manager takes round of entire Medical Observation
Renewal of The renewal of
hospital to assess the process flow and Officer Report
authorization authorization shall be
compliance of Bio medical Waste
Done with in specified
regulations, once a week. Observations are
time i.e. before expiry
recorded and corrective and preventive
of authorization.
action is taken.
Storage of BMW The BMW should not
On the basis of observations Biomedical Medical BMW Score
be stored for
waste Score card is filled on monthly basis Officer Card
more than 48 hrs.
and reported in MIS.
Annual Report Annual report of
BMW generated is

Sr.No Record Name submitted

Record No. to State Retention Period
1 BMW Waste Pollution
1, 2 and 9Control 5
Register Board, Bihar on or
before 31st March
every year.
BMW Score Score of 10
SOP 6. General Administration
Pomlum PHC

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4.8 Infection Control Procedures
Training of staff at regular intervals, periodical health
check-up & immunization od staffs
Monitoring, Following the universal precaution, strict
adherence to the infection control protocol
4.9 Development of Infection Control Medical List of
Programme: Officer Infection
It includes formation Control
of infection control committee, Committe
Infection control team and infection e
Control nurse at healthcare facility. POMLUM PHC
members,
Infection Control Committee: Infection
Medical Officer control
Sister in-charge & Staff nurse team
c) Pharmacist, members
d) Lab Technician
e) House Keeping/grade IV Staff

4.10 Responsibility of ICC: Chairman

To determine the criteria for ICC
reporting of infections
To ensure the development
of forms or data sheets used
for collecting and reporting of
data for the infection control
programme.
To prepare and update
SOP 6. General Administration
Pomlum PHC

procedure manuals of
aseptic techniques used in
the hospital
To determine the policy on
screening and immunization
of hospital staff
To determine the content
and methodology of training
programme for hospital staff
in prevention and control of
Hospital infection.
To develop action plan and
assigning work accordingly
4.11 Responsibility of infection Chairman ICT
control Team:
Advise management of at-risk patients.
Carry out targeted POMLUM PHC

surveillance of hospital
acquired infections and act
upon data obtained.
Provide a manual of policies
and procedures for aseptic,
isolation and antiseptic
techniques.
Investigate incidence of
reported infection and take
corrective measures.
Assist in training of all new
employees as to the
importance of infection
control and the relevant
policies and procedures.
Surveillance of infection,
SOP 6. General Administration
Pomlum PHC

data analyses, and

implementation of corrective
steps. This is to be based on
reviews of lab reports,
reports from nursing in-charge etc.
Waste management.
Monitors employee health
programme.
4.12 Responsibility of sister in-charge/staff nurses :
The duties of the sister in-charge/staff nurses are
primarily associated with
ensuring the practice of
infection control measures
by nursing and
housekeeping staff.
Identify problems in
implementation of infection POMLUM PHC

control polices and provide

solutions.
In addition, the sister in-charges / staff nurses
conducts
infection control rounds and
monitors the following
practices on daily basis:
 Bio Medical Waste.
 Autoclave log book in OT.
 Linen segregation is
 done or not (dirty and contaminated).
 Hand washing.
 Sharp disposal in wards.
 Use of needle cutter.
 Preparation ofHypochloride solution.
The sister in-charge/staff nurses
SOP 6. General Administration
Pomlum PHC

is also to be
involved in training of
paramedical staff including
nurses and housekeeping staff
4.12 Meeting of sister in-charge/staff nurses : Minutes of
The infection control team meets meeting
once in a month and otherwise as necessary.
In-charge of Infection Control Team
keeps the Management Review
Team updated on the states of
Infection in the Hospital.
4.13 Staff health plan: Hospital
To control spread of infection from infection
staff to patient or to protect staff control
from occupational hazards annual committee
medical check-up of staff will be
done for staff of hospital along with POMLUM PHC

vaccination for Hepatitis B/any

other immunization required is
provided to all staff members
4.14 Infection Control Measures:
Following infection control
measures shall be followed in the
hospital.
4.15 Hand Hygiene: On duty
Adequate hand washing facility is doctor,
available in all patient care areas. staff nurse
Elbow operated taps and and all
washbasin and soap are available paramedic as
in service provider’s room & inpatient well
care areas. as
If water facility is not available housekeeping
alcohol rub may be provided in staff involved
SOP 6. General Administration
Pomlum PHC

patient care area. in

patient care.
4.16 Segregation of contaminated Staff nurse on
materials and instruments: duty &
Contaminated pieces of linen, housekeeping
sputum cups, bedpans, instruments staff
and biomedical waste are kept
separately to avoid mixing with the
clean ones.
4.17 Disinfection: Housekeeping
Disinfection of equipments and staff
furniture are carried out with or General
bleaching powder solution duty
At least once a day or based on the attendant
procedure done/ contamination
4.18 Sterilization practices: Staff nurse on
The efficient CSSD ensures the POMLUM PHC
duty /
supply of properly sterilized article housekeeping
to all users of the hospital. staff
The unsterile items are stored
separately from the sterile items.
4.19 Good housekeeping: Housekeeping Housekee
staff ping
Biomedical waste are collected, Check list
segregated, transported, stored and Biomedica
disposed off as per BMW l waste
management& handling rule, 2016. Managem
(Procedure 24, Hospital waste management) ent &
handling
rule, 2016
Prevention of injury with sharps
Precautions to be observed:
Needles should not be
SOP 6. General Administration
Pomlum PHC

recapped, bent or broken

by hand.
Disposable needles &
other sharps should be
discarded into puncture
proof containers at the
site of procedure
Sharps should not be
passed from one HCW
(Health Care Worker) to
another. The person
using the equipment should discard it. If
necessary a tray can be
used to transport sharps.
All sharps containers to
be discarded when 3/4ths
full. POMLUM PHC

4.20 Infection Control Audit Infection

The infection control audit shall be Control
carried out on periodical basis. Committee.
Timely actions shall be taken
against the observations raised
during the audit.
The Infection Control team
members shall conduct inspection
periodically.
Records are maintained by head of
infection control team.
 SOP 6. General Administration
Pomlum PHC

D. SOP for Medical Records

1. Purpose

To provide guideline instructions & process of Data and Information of Hospital Statistics
and Medical Records with the aims that

 Hospital Statistics and Medical Records are readily retrievable, properly maintained
and
 Feedback loop is established for continuous improvements of Health Indicators.

2. Scope

It covers all patient medical records and Statistics in the hospital.

3. Responsibility

MO Incharge, Staff Incharge & Administrative office staff.

POMLUM PHC

4. Procedure

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s/records
4.1 Objective: The Primary objective of the Medical
Record Department is to develop good Medical
Records containing sufficient data written in
sequence of events to justify the diagnosis, treatment
and end result of all patients treated in a hospital,
keep them under safe custody and make them readily
available as and when required for
 The Patient.
 The Doctor
 Hospital Administrators.
 Medico Legal Purposes.
 External Reporting.
4.2 For Patient, it
 Serves to preserve the documents involving
the clinical history and activities of patient
treatment.
 Serves to avoid omission or repetition of
SOP 6. General Administration
Pomlum PHC

diagnostic and therapeutic measures.

 Assists in continuity of Care even in future
illness whether it requires attention in or out
of the Hospital.
 Serves as evidence in Medico-legal Cases.
 Gives necessary certification for employment
purposes.
4.3 For The Doctor, it
 Assures quality and adequacy of diagnostic
and therapeutic measures undertaken.
 Serves as an assurance of continuity of
medical care.
 Evaluates Medical Practices.
 Protection in litigation.
4.4 For Hospital Administration
 To document the type and quantity of work
undertaken and accomplished.
 To evaluate proficiency of Medical Staff for
administrative and clinical purposes.
 To evaluate the services of the hospital in
terms of accepted norms and standards.
 To serve as an Administrative record and
Performance.
 To assist in futures Programmes for Planning
and developments of hospital.
POMLUM PHC

4.5 For Medico Legal Purposes, it serves

 As a documentary evidence
 To dispose claims of the Insurances.
 For Patient‟s WILL to indicate if the patient
was of normal mental state or not.
 Malpractice Suits.
 Authorization for operation etc.signed
document for consent for operation will prove
that the Patient/ Relative have allowed the
performance of such Procedure.
 Criminal cases – as a Potential document
4.6 Development of Hospital Performance Nurses on KPI
Statistics Duty
Statistical and epidemiological Data are
needed to implement and manage medical care
planning and to obtain Health Indicators to monitor
and evaluate their effectiveness for Hospital
Management as follows:
 Bed Occupancy Rate
 Average No. of Out Patients
 Average No. of Admissions
 Sex wise Admissions
 Average Length of Stay of Patients.
 Gross and Net Death Rate.
SOP 6. General Administration
Pomlum PHC

 Laboratory Tests.
 Information about Institution Deaths (Deaths
occurring over 48 hrs.)
 Total Number of Babies born in a hospital.
 Daily Census of the Hospital etc
4.7 Reporting to state Authorities MO I/c Monthly
 This is the responsibility of the department to Report
submit the following Diagnostic Reports to
Health Agencies like D.H.S, and other
departments under the Health & Family
welfare department
 Weekly / Monthly Malaria and other National
vector Borne diseases and also all the diseases
that falls under IDSP cases to the DMHO
office.
 All Communicable Diseases to the D.H.S.
 Notifiable diseases are reported immediately
to control room to Nodal Medical officer.
 Monthly Leprosy Cases to the District
 Morbidity / Mortality Statistics to the District,
on monthly basis.
4.8 Process of creating Medical Records

Medical Record contains different sections

for recording the information as POMLUM PHC

 Identification Section
 Medical Section
 Nurses Section.
All entries made in the medical and nursing section
of the patient record are entered by authorized care
provider.
4.8.1 Identification
This section fills up the Bio Data / Socio economic
data / Patient Identification Data
at the time of Registration and Admission. OPD file
is generated at OPD registration counter; on the
Admission Request of the
Doctor Indoor patient Admission record is
generated. Personal data for following particulars are
provided at Admission
counter by the Patient / Relatives.
 Name of Patient
 Father‟s / Husband‟s Name
 Age & Sex
 Occupation
 Permanent / Emergency Address.
 Telephone / Mobile Numbers
 Nationality
 Religion
SOP 6. General Administration
Pomlum PHC

 Medico Legal Case if any.

These details are filled in the admission register and
the patient is given an identification number.
4.8.2 Medical Section MO I/c and
The Medical Section is filled up by the Nurses on
Attending Doctor, and pertains to History, duty
Physical examination, Treatment /
Procedures carried out for the patient, all the
information is recorded in the IPD booklet/BHT
Basic:-
 Consent Form
 History Record (current & Past)
 Physical Examination Record
 Diagnosis Record
 Progress And Treatment Record
 Different Investigations Report from the Lab

Discharge summary is given in case of

Discharged – cured, LAMA, Discharge on
request or Death. A copy of the same is
preserved in the patients‟ medical record.
i. In case of death, Medical certification of
cause of death forms is to be filled up by the
attending Doctor or emergency medical
officer under Registration of Birth and Death
POMLUM PHC

Act 1969.
ii. A copy of the death certificate is preserved in
the patient‟s medical records file.
4.8.3 Nurses Section Nurses on
The Nurses Section is responsible for filling up the duty
following
 Medication Record Forms
 T.P.R. Chart.
 INTAKE and OUTPUT Record Form.
 Discharge summary is given in case of
discharge cured, LAMA, DOR or death
4.9 Flow of Medical Record from Admission to Post
Discharge
The Medical Record Department ensures a smooth
flow of Medical Record of the patient from the day of
his admission to the day of his discharge and onward
maintenance till the retention period.(as per state
government norms)
Admission request form is filled by the treating
doctor of the patient. Formalities for admission of the
patient are carried in the registration counter (during
working hours) or in the emergency department of
the hospital (during non peak hours) .The general
inpatient case sheet/IPD booklet for patients is
SOP 6. General Administration
Pomlum PHC

prepared at the time of admission at admission

counters.
All data pertaining to the patients stay in the hospital
and care provided are preserved in the patient’s bed
head ticket/IPD booklet. This booklet is maintained
by the nursing staff of the
concerned ward.
After getting the orders of discharge of
the patients from the treating Doctor, the on duty
Nursing Staff get the discharge summary prepared
from the Doctor/Medical officer.
In case the patient is transferred or referred to another
hospital the medical record contains information
regarding reasons for transfer, name of the hospital
where the patient is being
Transferred
After discharge of patient, medical record is checked
for its completeness and sends it to MR department
by on duty ward nurse.
4.10 Midnight Census:
Ward Census Reports from each ward is Nurses on
generated by nursing staff at night duty. The reports duty
are submitted individually to the Emergency Medical
Officer on duty
The record clerk collects the data from the
POMLUM PHC

Emergency Department/ nurse station the next

morning and compiles the same for preparing the
census report.

The census report is submitted to the I/C

of hospital on a regular basis by the medical record
clerk
4.11 Confidentiality and Integrity of Record

The hospital identifies its responsibility as MO I/c and

custodian of medical records and observes the nurses on duty
following procedure to maintain its confidentiality,
security and integrity
Patient is the owner of his medical record
and no form of it would be made available
to any third party without written authorization from
the patient. The hospital observes the following
guideline instruction for the purpose:
4.12 Retrieval / Accessibility of Medical Administrativ
Record: e staff and
 Maintain records in proper accessibility nurses on duty
manner.
 Hand over the records as & when required by
I/C of hospital for administrative purposes by
SOP 6. General Administration
Pomlum PHC

getting slip signed by the person receiving the

record.
 Physician for follow up purposes by getting
permission from I/C of hospital and get the
records.
 Records required for Medico Legal Cases in
the Court of Law by the Doctor.
 For Follow up of In-patients by the Doctors as
well as by the Patients.
 As & when they require Discharge Summary,
Investigation Reports etc.
 Patient’s relatives will require a written
authorization from the patient for obtaining
information from the medical records.
However such information would not be
given in original, a xerox of the same would
be handed over to the patient and signature
taken in specific format.
In case of loss or tampering of patient’s MO I/c
medical record data, the medical record clerk
would immediately inform the same to the
MO I/C of hospital. The Medical Officer
would then carry out the appropriate actions
that includes an internal enquiry in reality and
take the necessary steps in retrieval of loss
POMLUM PHC

data.
In case any sort of negligence or discrepancy
on part of any hospital employee, I/C of
hospital would inform the same to higher
authorities of the Health and Family Welfare
Department for further action.
The Medical Record Department is
responsible for proper storage, retrieval and
maintenance of confidentiality and security of
the record.
At the end of the day medical record clerk
is responsible to lock the department in the
presence of a security staff. The key is handed
over to the MO office. There after the security
department is made responsible for the
protection of the medical record room.
4.13 Retention Policy

The Department is responsible for

consolidation of all Forms belonging to a
patient and is then sent for storage in a
manner with the help of Admission Number,
which is assign at the time of Admission.
 SOP 6. General Administration
Pomlum PHC

These records are stored in the Medical

Record Departments for the following
Retention period as per state guidelines.
Security of record:
a) Access to Medical Records Department is
limited to only person authorized department
staff.
b) In case any record is issued to any designate
individual as per the retrieval policy; the
same is recorded in the outgoing patient
record entry register for accountability.
c) No form of record is issued to any person
without proper authorization from the
designated authorities.
d) During non-working hours the security staff
is responsible for safety of the department
At the end of the designated retention period the
medical record clerk will seek written approval from
the top management for destruction of the medical
records who have crossed the retention period. Only
after obtaining written from the designated hospital
authority, the medical records will be destructed by
the MR department.
Hospital statistics like IMR, MMR, birth rate,
death rate etc. to be documented and POMLUM PHC

Reported.

Reporting of all the details to be done as

per hospital and state Govt. norms.

Sr.No Name of Records Record No Minimum

Retention Period

1. Mid Night Census Register Indoor - 28 10 years

2. Birth & Death Register Office 1,2 Lifetime

3. LAMA Register Indoor - 28 10 years

Process Efficiency Criteria

Sr.No Activity Process Efficiency Benchmark/Standard/Target
Criteria

1. Medical Audit No. of cases audited

2 Death Audit Proportion of deaths

occurred in hospital
 SOP 6. General Administration
Pomlum PHC

audited
3 Retrieval Retrieval time for medical
records

5. Reference Document -

1. Medical Record Manual –WHO

2. NHSRC draft SOP

Uniformity of the color of signages

 Direction to PHC is displayed from the access road

 Facility lay out with direction to different departments are displayed

 Facility name is prominently displayed at front of building with illumination at night

 Entitlements under different schemes are displayed

 Important phone nos. are displayed, i.e., phone no of MO I/C, ANM, ambulance, nearest
FRU POMLUM PHC

 Display of list of Sub centres under PHC with details of ANM(phone no of ANM & mobile
no)

 Display of citizen charter near entrance or OPD with information on cycle time for critical
processes, role & responsibility of patients

 All information in local language

 Provision of providing copy of medical records e.g., BHT on request of patient or next of kin

 Grievances’ redressal Process displayed with contact details of grievance redressal

authority .Complain box available to patients to drop their grievances. Grievance are
collected monthly at the end of every month.

 Records of grievance maintained

 Periodic review of grievances received for taking action & evidence maintained in records
on action taken

 No discrimination to patients on any ground

 Courteous behavior of staffs to patients & visitors

SOP 6. General Administration
Pomlum PHC

 Maintaining privacy & confidentiality of patients with HIV, Leprosy, domestic violence &
adolescent pregnancies

 Free drop back, referral services under JSSK, free diet, drugs & diagnostics service under
JSSK

 Timely payment of JSY

 No other use of patient care area

 Seismic safety of infrastructure ,periodic check of electricity installation,nonstructural

components are properly secured

 Restricted access to electrical panels, danger signs displayed at high voltage electrical
installation

 Display of fire exit signs

 Periodic refilling of fire extinguisher & fire extinguisher with expiry date

 Training on use of fire extinguisher, periodic mock drill for fire safety at facility

 Drugs & consumables provided at point of use

 Equipment’s covered under AMC including preventive maintenance

POMLUM PHC

 Contact list of agencies responsible for preventive maintenance are available at facility

 Up to date Instructions for operating ILR/deep freezer readily available

 No outdated/unwanted posters on hospital boundary/building

 Safe disposal of general waste, schedule of cleaning is defined & implemented

 Periodic maintenance of building

 No clogged/overflowing drains

 Arrangement for Disposal of waste is established

 Vehicle parking in the places earmarked for it

 No condemned & junk materials in the corridors, storage & administrative spaces

 Periodic removal of junk & junk/condemned materials kept in designated covered place

 Pest control measures to control pest ,no stray animals in facility

 Restriction on entry of vendors &hockers

SOP 6. General Administration
Pomlum PHC

 Visitors’ entry as per visitor’s policy. Restricted entry by visitors at indoor &labour room

 No female staffs posted at night alone

 Male & female to be posted if only male employees or male patients are there

 Estimation, indenting & procurement of drugs & consumables to ensure no stock out of drugs

 Provision of local purchase during emergency situations

 Drugs stored in pharmacy in specified place

 Narcotic medicines are kept in double lock i.e,2 keys with 2 locks kept by 2 different persons

 Management of expiry & near expiry drugs

 Physical verification of inventory periodically, FEFO followed, use of bin card system,
categorization of drug storing in categories vital, essential & desirable

 Storage of vaccines & other drugs in controlled temperature & temperature chart is
maintained for ILR & deep freezer. Vaccines kept in 2 nd generation ILR and work instruction
displayed

 Water tanks kept tightly closed, period cleaning of water tank

POMLUM PHC

 clean linens to all the occupied beds

 community participation through RKS

 proper fund utilization, proper planning & requisition of resources based on need

 contract management for out sourced services .deduction of payment in case of poor quality
of services

 admission to patients even after routine working hours

 list of higher centers maintained for appropriate referral linkage

 safe & secure place to keep patient records with policy of retention period of different records

 safe disposal of records

 in disaster situation facility has plan to accommodate high case load

 periodic medical check-up & immunization of staffs

 monitoring infection rates(cases of delivery ,episiotomy, IUD insertion etc.)

 Generation, handling, disposal of BMW as per guideline

SOP 6. General Administration
Pomlum PHC

 Quality policy, objectives defined & implemented

 Review of quality services at quality team meetings

 Patient & employee satisfaction survey for corrective action & to sustain good practices

 Internal audits(QA),Medical audits/prescription audits, community audits(maternal & child

death)undertaken

 Use of quality tools for quality improvement.

POMLUM PHC