1

Pomlum PHC Doc.

No…………………
Address: Mylliem Block, Upper
Shillong 793009

Date of issue:

Issue No-

Revision No-

Prepared by

SN. IBANSARA DOHTDONG

SN. DAPDIANGHUN S
THABAH

POMLUM PHC

Signature & Date

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SOP : 2

Approved by
STANDARD
Dr. D. P. Syiem, Sr. Medical
Officer in-charge OPERATING
PROCEDURES
FOR
INPATIENT
DEPARTMENT
Signature & Date

1. Purpose:
 To establish, implement & maintain a system for patient admission in order to
provide IPD services offered by the hospital.
 To provide guideline instructions for General Nursing care with the aim that
needs and expectations of patients are honoured.
 To enhance patient satisfaction on continual basis.
2. Scope:
It covers all indoor patients admitted and receiving treatment at Hospital.

3. Responsible persons:
 In charge of hospital
 Medical Officer
 Staff nurse/ANM

4. Procedure

A AREA OF CONCERN - SERVICE PROVISION

SL Activity Description Responsibility Ref.

NO Doc. /
Record

The facility provides 24 x 7 Indoor services

The facility provides Maternal Health services like

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 Normal Deliveries.
 Post natal counselling regarding Nutrition,
hygiene, identifying danger sign, family
planning etc.

The facility provides Newborn Health Services

likePrevention of hypothermia and initiation of
breast feeding.

The facility provides Child health Services for

routine childhood diseases like diarrhoea, fever,
pneumonia.

B AREA OF CONCERN - PATIENT RIGHTS

SL Activity Description Responsibility Ref. Doc. /

NO Record

Sensitization of Breast feeding, kangaroo care, care of newborn, Staff Nurse

Patients & visitors Immunisation schedule, family planning etc on Duty
through (Pictorial and chart ) are displayed in the wards.
appropriate IEC /
BCC approaches

PRIVACY: Staff Nurse

on Duty
Screens and curtains are provided in the wards to
provide privacy and it is ensured that women is
Providing visual protected from view of other people.
privacy and
confidentiality of CONFIDENTIALITY:
patient records.
Confidential information about the patient is never
discussed with other staff members or outside the
facility.

Any patient with HIV is not denied services on the

basis of patient’s HIV status. The patient’s HIV
status is kept confidential except to people who are
involved in care.
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C AREA OF CONCERN - INPUTS

Sl Activity Description Responsibility Ref. Doc. /

No Record

Emergency drug The facility ensures availability of Emergency drugs GNM

tray like Inj. Adrenaline, Inj. Hydrocortisone/Inj.
Dexamethasone, InjChlorpheneramine, Inj,
Atropine, Inj. Deriphylline, Inj. Mephentine (for
anaphylaxis -5 Ampoule each), IV fluids, IV set &
Syringes.

D AREA OF CONCERN - SUPPORT SERVICES

Sl Activity Description Responsibility Ref. Doc. /

No Record

Comfortable The facility ensures comfortable environment for

environment for patients and service providers by maintaining
patients and Warmth, Optimal Temperature and Ventilation in
service providers the ward.

Cleaning of  Floors, walls, roof, sinks and corridors GRADE IV

Patient care areas are Clean daily.
 Surface of furniture and fixtures are
clean daily.
 Toilets are clean daily.

Maintenance of Fixtures and Patient Furniture like Patient Beds & GRADE IV
Facility Mattresses are maintained periodically.
infrastructure
No condemned/Junk material are kept in the wards.
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E AREA OF CONCERN - CLINICAL SERVICES

Sl Activity Description Responsibilit Ref.

N y Doc. /
o Record
DEO
 Patient visits the OPD/emergency for
doctor’s consultation.
Depending upon the doctor’s assessment,
he/she advises admission (in writing on
Procedure for
the OPD Slip) to one of the different
inpatients areas of the hospital like
registration of patients
Inpatients Ward, and Labor Room etc.
 IPD Unique identification number is
given to each patient during process of
registration.
 Patient demographic details like Name,
age, Sex, Chief complaint, etc.are
recorded.
Shifting of Patient to concerned Ward GRADE IV
Stable patient is shifted to the concerned
Procedure for inpatient facilities accompanied by an
Admission attendant. Stretcher/wheelchair/Trolley are
used for shifting of the patient as required.
Critical patients who reach emergency are
first assessed and primary treatment is
given at emergency observation ward
only. Patient is referred to higher center
when the patient is stabilized.

Patient warding in- ANM/GNM

 The staff nurse on duty receives the
patient. Patient/Attendant hand over
admission slip or case sheet to the Sister
in-charge.
 Ward nurse confirms the identity of the
patient.
 Ward nurse reviews the admission
notes/instructionsandactson any urgent
instructions by admitting doctor.
 Ward Nurse records the patient details in
the patient admission/discharge register.
 Time of admission is recorded in
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patient’scase sheet.

Bed Allotment ANM/GNM

Bed is allocated based on clinical and personal
needs of the patient and availability of beds.
Bed no of allocated bed is recorded in Case
sheet and admission register.
Patient is shifted to the bed, made comfortable
and is oriented about the layout of ward with
instructions on how to call her in case of
emergency.

Patient Property
Valuables like jewellery, mobile and cash is hand
over to the patient relatives. Patient is instructed
to not keep any valuables with them.

Consent ANM/GNM
Consent is signed by all the patients admitted in
the ward. In case patient/Next to Kin is illiterate
then the thumb impression of the patient is taken
which is witnessed by a neutral person.

PROCEDURES FOR CONTINUITY OF CARE

Initial Assessment ANM/GNM
Once patient issettled in the ward,
nurseconducts a nursing need assessment.
Procedure for initial
She calls the duty doctor who conducts the initial
assessment & assessment if it is not done at emergency/OPD of
Reassessment of the patient records the findings/directions in the
patients Case sheet.
History Taking
 Doctor takes the history including main
presenting problem, past medical history,
history of main presenting problem, family
history, occupational history, habits like MO
smoking & alcohol, allergies, drugs and other
treatment history and other bodily systems
that are not covered in presenting complaint
as required.
 In case of complaint of pain, details including
site, radiation,severity, time course,
aggravating factors, relieving factors and
associated symptoms are asked as required.
 Doctor notes down the relevant history on
the OPD slip.
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 Doctor reads
therereferraldocuments/othertreatment related
documents if any provided by the patient.

Review of ANC  ANC Check-up is done by a trained ANM/GNM

history of pregnant ANM, LHV, Staff Nurse or Medical
women Officer Only.
 At the ANC clinic, Pregnancy is
confirmed by performing urine test using
pregnancy test kit (Nischay kit)
 Calculation of Last menstrual period
(LMP) and Expected date of Delivery
(EDD) on the first visit
EDD = From the date of LMP (9 Months+7 Days)

if Pregnant women is unable to recall the first day of

last menstrual cycle ('Quickening', Fundal Height)

Obstetric History MO
History of Previous pregnancies including
complications and procedures done, if any, is taken.

Current or past history of systemic illnesses

History of current or past systemic illness like

Hypertension, Diabeties, Tuberculosis, Rheumatic
Heart Disease, Rh Incompatibility, malaria, etc. is
taken.

History of Drug intake or allergies & intake of Habit

forming and Harmful substances like Tobacco,
Alcohol, Passive smoking is taken for infertility.

Physical Examination-
General condition including vital signs, conjunctiva
for pallor and jaundice, and bladder, bowel function
and breast examinations for Flat or Inverted Nipples,
Palpation for any Lumps or Tenderness is done and
recorded.

Recording of Dangers signs for post delivery cases

Examination of the perineum for inflammation, status

of episiotomy/tears, lochia for colour, amount,
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consistency and odour, calf tenderness, redness or

swelling is done for post delivery cases.

Dangers signs for other cases like Breathlessness,

Altered sensorium, Diplopia, Acute Abdomen, Chest
Pain, etc are also recorded.

Recording of Danger signs for other cases

Danger signs like Breathlessness, Altered sensorium,

Diplopia, Acute Abdomen, Chest Pain, etc is recorded
for other cases.

Initial assessment and treatment is provided

immediately after patient is admitted.

Initial assessment is documented within 2 hours of

admission.

Schedule for assessment of stable patients ANM/GNM

Monitoring Temperature-
 The timing for measuring the body
temperature is checked from the
Doctor’s order or 6hourly as per nursing
chart.
 Temperature is recorded in nursing
chart. Duty doctor is informed in case of
abnormal values.
Thermometer is disinfected in isopropyl alcohol,
covered with a barrier wrap.

Monitoring Pulse rate- ANM/GNM

Radial pulse is felt and counted for 60 seconds

with elbow and forearm resting comfortably on
the bed/table and the palm of the hand turned
upward. If Radial Pulse is not palpable, other
arteries are palpated. In case of difficulty doctor
on duty is informed. Pulse for the concerned
patient is recorded in nursing chart. Doctor on
duty is informed in the case of abnormal values.
Respiratory Rate
Respiratory rateismeasured and Pattern, effort
level and rate of breathing is observed.
For infants and children less than 6-7years of age
abdominal movements are counted since they are
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abdominal breathers. Signs of respiratory distress

such as nasal flaring, wheezing, use of accessory
muscles of respiration, chest shape and
movement are also looked. If there is any
difficulty in breathing doctor on duty is
informed. Respiratory rate is recorded in nurses
chart. Doctor on duty is informed if the
respiratory rate recorded is abnormal.

Monitoring Blood Pressure-

The timing for measuring the Blood Pressure is
checked from the Doctor’s order or 6hourly as
per nursing chart. The auscultatory method of
BP measurement with a properly calibrated and
validated instrument is used.
An appropriate sized
cuff(cuffbladder encircling at least 80percent of
the arm)is used to ensure the accuracy. Arm of
the patient is positioned at the level of heart and
well supported.
Doctor on duty is informed if recorded BP is
above/ below expected or as mentioned in
doctors‟ order.
BP for concerned patient is recorded in the
nursing chart.

Referral linkages for  During course of treatment if the patient MO

transfer to is required to be shifted to other centre
other/higher facilities then the treating doctor prepares a
referral note.
 Advance communication is done before
referring with higher centre enquiring
about the availability of bed or
specialistdoctor.
 An ambulance is arranged for the referral
of the patient.
Follow up of referred patient is done through
telephonic conversation or visit by ASHA.

PROCEDURE FOR NURSING CARE

ANM/STAFF
NURSE
Identification of Identification tags for mother and baby / foot print
Patients are used for identification of newborns in the ward.

Nursing procedures are performed as per

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Maintenance of protocols/guideline of state STAFF

Treatment chart  Oral Medication NURSE
 Intramuscular Injection
 Subcutaneous Injection
 Steam Inhalation
 Ryle’s Tube
 Oxygen through Nasal Cannula
 Surgical Dressing

Nurse maintains record of the patient progress,

treatment offered, stocks of inventory &
medicines in theward.Ward nurse also change
the linen at defined frequency preferably
inmorning hours.

When the Medical Officer is not available at the

facility due to some unavoidable circumstances,
verbal/ telephonic order is given and signature is
taken on the case sheet when the MO is available.
STAFF
NURSE
Procedure of patient  At the end of each shift nurse on duty
hand over, whenever hands over, the details of treatment
staff duty change provided and patient progress, in writing
happens to the nurse on duty for the next shift.
 Hand over is given in the bed side.

PROCEDURES FOR DRUG ADMINISTRATION, AND STANDARD TREATMENT GUIDELINE

Procedure to check  Drugs are checked for expiry and other STAFF
drug before inconsistency before administration. NURSE
administration/  Single dose vial are not used for more
dispensing than one dose.
 Separate sterile needle is used every time
. for multiple dose vial.
 Any adverse drug reaction is recorded and
reported to the MO.

System to ensure right Medicines are given to the patient following right STAFF
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medicine is given to patient, right drug, right dose, right time, right route, NURSE
the right patient . right reason & right documentation of drug
administration.

Counseling for self Patient is counseled by the MO/ pharmacist about the MO
drug administration. dosages and timings of the medicines to be taken.

Procedure for rational Drugs are prescribed as per the standard treatment MO
use of drugs guidelines by Sangeeta Sharma and G.R. Sethi.

PROCEDURES FOR MAINTAINING, UPDATING OF PATIENTS’ CLINICAL RECORDS AND

THEIR STORAGE

Recording and Day to day progress of the patient is recorded and STAFF
updating of all the updated in the BHT. NURSE
assessments, re-
assessment and
investigations.

Recording of all Treatment plan, first orders are written on BHT STAFF
treatment plan NURSE
prescription/orders
Recording of Any procedure performed on the patient is STAFF
procedures written and recorded on the BHT. NURSE
performed.

PROCEDURES FOR DISCHARGE OF PATIENTS

 Assessment of the patient is made on MO

daily basis.
Assessment of patient  When the patient’s condition is upto the
before discharge level of discharge, the physician writes
discharge note in the patients Case
sheet/IPD file and prepares a discharge slip.
In case of MLC patient, Police is informed
before the patient is discharged.
 Discharge is done by the on duty MO.
Patient / attendants are informed before
being discharged.

Patient / attendants  Patient / attendants are informed before

are informed before being discharged.
being discharged.  Discharge summary adequately mentions
patients clinical condition, treatment
given and follow up.
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 Danger sign of mother: Bleeding, pain

abdomen, Severe headache, visual
disturbance, breathing difficulty, fever &
chill, difficulty in empty bladder, foul
smelling discharge.
 Danger Sign of Baby: Fast/difficulty in
breathing, fever, unusual cold, refusal of
feeding, failure to thrive, less active than
usual & yellow discoloration.

All delivered mother's are informed about the danger

sign of the mother & baby.

LAMA
 During routine visit of doctors, if the
patient wishes to go to home, the
concerned doctor makes assessment of the
patient condition for discharge.
 If the condition is not suitable for
discharge, but the patient still wants to go
home, the patient is allowed to go home
under the category “LAMA”.

Discharge summary is given to the patients going in

LAMA/Referral by the MO on duty.

Counseling of patient  At the completion of the course of MO

during discharge treatment, assessment of condition of
patient is made for the discharge.
 On the basis of discharge advice,
discharge slip is prepared. The discharge
slip contains complete details such as
further mode of treatment, prescribed
medicines, discharge date & time.
 Patient or his attendant is sent home along
with discharge slip, briefing the
patient/attendant about the follow up,
prescribed medicines, precaution to be
taken and diet.
 Instructions on do’s and do not’s is given.
 Pregnant women after delivery is dropped
back by Ambulance. Information about
the nearest health centre for further follow
up is also given to the patient.
 Time of discharge is communicated to the
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patient/attendant in prior.

Procedure for patients  If a patient wants to leave the hospital but MO

leaving the facility as per the treating doctor she/he is not fit
against medical for discharge, a declaration is signed by
advice, absconding, the patient/Next to Kin in the language
etc. she/he understands on the Case sheet.
 In case patient/Next to Kin is illiterate
then the thumb impression of the
patient/attendant is taken on the
declaration which is witnessed by 2
neutral people. LAMA summary is
prepared and the patient/attendant is
handed over the same.

PROCEDURES FOR POSTNATAL CARE

Post partum Care Post Partum Care of Newborn is maintained through STAFF
proper hand hygiene, keeping the baby wrapped, NURSE
maintaining the temperature, Checking the weight,
temperature, respiration, heart rate, colour of the skin
and cord stump.

Initiation of Breastfeeding STAFF

NURSE
 Breastfeeding is initiated within 1 hour.
 The mother is checked on breastfeeding
pattern, emphasizing exclusive and on
demand feeding.
 Tthe proper positioning and attachment of
the baby is demonstrated to the mother.

Post partum care of mother STAFF

NURSE
 Assessment is done for contraction of
uterus, vaginal/perineal tear.
 Sanitary pad is placed under the buttock
to bleeding and for collecting the blood.
 Assessment of blood loss is done by
counting the blood soak pads
 Vitals are monitored at periodic intervals.
 Pregnant women and newborn are kept
together and breastfeeding is encouraged.
 Weight of newborn is measured.
 Information of pregnant women and
newborn is recorded in the labour room
register.
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 Newborn and pregnant women is given

identification tags.

Stay of mother and The mother and the newborn are made to stay for
newborn in the atleast 48 hours after delivery.
facility

Procedure for Post Counseling for Nutrition, Contraception, MO

partum counselling of Breastfeeding , Registration of Birth ,IFA
mother Supplement,Danger Signs and Family planning is
given to the patient by the MO.

F AREA OF CONCERN-INFECTION CONTROL

PROCEDURES FOR ENSURING HAND HYGIENE PRACTICES AND ANTISEPSIS

Hand hygiene  Hand hygiene facilities with running

facilities. water are available at the point of use.
 The facility incharge ensures that there is
uninterrupted water supply in the facility
 Antiseptic soap with soap dish/ liquid
antiseptic soap that is alcohol based hand
rub is available.
 Hand washing instruction at point of use
is also displayed above the hand washing
facility .

PROCEDURES FOR DECONTAMINATION, DISINFECTION AND STERILIZATION OF

EQUIPMENT AND INSTRUMENTS
Decontamination and Decontamination of operating & Procedure surfaces GRADE IV
cleaning of like Examination table is done by
instruments and Wiping with 0 .5% Chlorine solution.
procedures areas

Cleaning and Spill Management GRADE IV

disinfection of patient
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care areas.

Body and Fluid Spill

Large volume (>10ml) of spill

1. Wear personal protective equipment-

Apron, gloves and masks.
2. Get blood & body fluid spill kit to the
spot.
3. Cover the spill with newspaper or
appropriate absorbent material to prevent
from spreading.
4. Pour the spill with 10% chlorine solution
and ensure that both the spill and the
absorbent material is thoroughly wet.
5. Wait for 5 minutes.
6. Wipe the area till all the visible blood or
body fluid is removed.
7. Discard the paper as infected waste.
8. Wipe the area with cloth mop, moistened
with 1% chlorine solution and allow
drying naturally.
9. All contaminated items used during
cleaning should be placed in a yellow bag
for disposal.
10. Proper handwashing is mandatory after
the procedure.

Small Volume (few drops) of spill

1. Wear personal protective equipment-

Apron, gloves and masks.
2. Get blood & body fluid spill kit to the
spot.
3. Cover the spill with newspaper or
appropriate absorbent material to prevent
from spreading.
4. Pour the spill with 1% chlorine solution
and ensure that both the spill and the
absorbent material is thoroughly wet.
5. Wait for 5 minutes.
6. Wipe the area till all the visible blood or
body fluid is removed.
7. Discard the paper as infectious waste.
8. Wipe the area with cloth mop, moistened
with 1% chlorine solution and allow to
dry naturally.
9. All contaminated items used during
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cleaning should be placed in yellow bag

for disposal.
10. Proper handwashing is mandatory after
the procedure.

Mercury Spill GRADE IV

i. Restrict the area to limit the risk of

exposure and also to prevent the spread of
contamination.
ii. Open all doors and windows.
iii. Turn off heating and air conditioning
system.
iv. Wear personal protective equipment –
Apron, Gloves and Mask.
v. Get Mercury spill kit.
vi. With the help of forceps, remove any
broken glasses/sharp. Place all the sharps
in a puncture proof container.
vii. Use two cardboard pieces to scoop all the
mercury spill in one place and to transfer
the spill into a jar half filled with water.
viii. Make sure to clean all the mercury beads
using a syringe.
ix. Tighten the lid of the jar securely and seal
it with an adhesive tape.
x. Use sticky tape or adhesive tape to
remove remaining mercury beads which
couldn’t be removed with a syringe.
xi. Use a flash light to locate any remaining
mercury beads in the room.
xii. Properly dispose all the contaminated
materials such as gloves, syringe,
cardboard pieces and sticky tape in a
sealed plastic.
xiii. Label the Name of the facility and the
Date of generation on the jar containing
the spill. Also mention “HAZARDOUS
WASTE HANDLE WITH CARE”.
xiv. Once the spill has been cleaned, inform
the authority concerned regarding the
incident.
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PROCEDURES FOR SEGREGATION, COLLECTION, TREATMENT AND DISPOSAL OF

BIOMEDICAL AND HAZARDOUS WASTE
Bio Medical Waste.  The Biomedical rules 2016 and 2018, GRADE IV
2019 amendments was implemented at the
facility
 Proper segregation , collection, treatment
and disposal of Biomedical and hazardous
waste was done
 Colour coded bins and plastic bags at the
point of waste generated was carried out
as per guidelines
 Segregation of Anatomical & soiled waste
was done in Yellow category
 Segregation of infected plastic waste in
red bin
 Segregation of sharps in translucent/
white category was done
 Glassware such as slides, vials are
disposed in blue category
 Functional needle cutter is also available
at point of generation
 The bins are not overfilled. It is not filled
more than 2/ 3 of its capacity
 Work instructions for segregation and
handling of Bio Medical waste is also
available.

G AREA OF CONCERN - QUALITY MANAGEMENT

Sl Activity Description Responsibility Ref.
N Doc. /
o Record
Patient satisfaction  The client satisfaction survey is done on MO
survey. a monthly basis.
 Analysis of low performing attributes of
client feedback is done.
 Corrective and Preventive Action
(CAPA) is prepared to address the areas
of low performing attributes.
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PROCEDURES FOR ASSURING AND IMPROVING QUALITY OF CLINICAL & SUPPORT

SERVICES BY INTERNAL AND EXTERNAL PROGRAM

Internal quality  Internal Quality assessment is done MO

assurance quarterly or at periodic interval by the
programme quality team.
 Gap analysis, time bound action planning
and gap closure report is done.

Quality Improvement Methods and Quality

Tools

The facility uses the basic quality improvement

methods such as PDCA and 5S
PDCA: Also called PDSA (Plan DO Study Act),
Deming cycle, Shewhart cycle.
The Plan- Do-Check- Act is a four step model
for carrying out change. Just as a cycle has no
end the PDCAshould be repeated again and
again for continuous improvement.
PDCA Procedures:
 Plan: Identify the problem & analysis the
problem. It may be development of the
procedures
 Do: Develop the solution& Implement
the solution. It may be conduct the
procedure.
 Check: Evaluate the result. It may be
verify and validate the procedure
 Act: Standardize the solution. It may be
improve the procedure.

5’S: 5S is the name of a workplace organization

method that uses a list 5 Japanese words Seiri,
Seiton, Seiso, Seiketsu and Shitsuke. The list
describe how to organize a wok space for
efficiency and effectiveness by identifying and
sorting the items used, maintaining the area and
items and sustaining the new order. 5S is also
name as 5 pillars of the visual workplace
i. SORT- to separate needed tools, parts,
and instruction from unneeded materials
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and to remove the unneeded one

ii. SET ORDER- To neatly arrange and
identify parts and tools for ease of use
iii. SHINE- To conduct a cleanup campaign
iv. STANDARDIZE- To conduct sort, set
order and shine daily to maintain a
workplace in perfect condition
v. SUSTAIN- To form the habit of always
following the first four 5’S

Quality Tools

The department use a minimum of 2 applicable

tools.
The 7 basic tools of quality are:
i. Flow Chart/ Process Mapping
ii. Check Sheet
iii. Cause and Effect / Ishikawa diagram/
Fish bone diagram
iv. Pareto chart
v. Histogram
vi. Control chart
vii. Scatter diagram

H AREA OF CONCERN - OUTCOME

Sl Activity Description Responsibility Ref.
No Doc. /
Record
Data collection,  Preparation of data collection is done on SIS
analysis and use for a monthly basis. INCHARGE
quality  The department measures productivity
indicators, efficiency indicators, clinical
improvements
care & safety indicators and service
quality indicators on a monthly basis.
REFERENCE:
1. National quality assurance standard for PHC, Ministry of Health & Family Welfare ,
GOI.
2. Operational Guidelines for quality Assurance in Public Health Facilities,Ministry of
Health & Family Welfare , GOI.
3. Standard treatment guidelines by Sangeeta Sharma & GR Sethi.