outpatient department - infra.nhmmp.gov.in

Outpatient Department

Document No: Date of Issue : ---------------

Version/Issue No: 01 Effective Date: -------------------

Edition : 01 Document Pages: of 24





1. About the Department:

Scope of services

Timings

Types of patients served:-

2. Organogram

3. Quality Policy

4. Quality Objectives





5. Functioning of the Helpdesk Counter

S.

No

Activity Responsibility Record

1. The help desk counter shall be functional 24X7, manned by two

help desk executives working in shifts.

Helpdesk executive

Help desk reference register

2. The help desk counter shall be provided with Telecom & Public

addresal system for convey of information and any public

announcements to be made.

Helpdesk executive


3. The help desk counter executive shall maintain a list of all referral

linkages and ambulance contact number and shall coordinate with

OPD/IPD nursing staff for effective dissemination of information as

required during the process.

Helpdesk executive


4. The help desk executive shall even take-up external calls and

provide required information or channelize the call towards

responsible person

Helpdesk executive


5. The help desk executives shall always maintain up-to date

information regarding the following

About the hospital and its organizational structure

List of services available and their location

Service timings

List of doctors

Services available under various National Health programme

Helpdesk executive


Reference standard - ME G4.2





6. Patient Registration

S. No


Registration of new patient

1. Registration is done for all patients requiring OPD and / or

Emergency services. OPD In-charge shall be contacted for any

clarification or in matter of conflict.

Registration clerk OP Registration slip Registration register

2. Registration timings:

3. Patient/patient relative provides general information such as

Name, Age, Sex, Address etc to the Registration Clerk at the

registration counter and this information is entered in the OPD

registration slip and is provided to the patient, this slip shall even

have the unique registration number that has been allotted to the

patient.

Registration clerk OP Registration slip

4. A registration register shall be maintained with the clerk to record

the details of total registrations done for the day.

Registration clerk Registration register

5. In case of automated registration counter, all information shall be

filled in the system to generate a printed registration slip that is

handed over to the patient.


6. All patient pays fee Rs /- towards out-patient registration and a

payment slip is given for that


7. The Registration Clerk guides the patient towards OPD clinics. Registration clerk Nil

Registration of follow-up patient






7. Patient calling inside OPD

S. No


1. The patient once reaches at the respective OPD OPD clinic Aaya/Staff nurse

Nil

2. The OPD aaya/nurse shall check the registration slip, and ask the

patient to wait for their turn

OPD clinic Aaya/Staff nurse

OPD slip

3. In case the patient has arrived at the wrong clinic, they shall be

guided towards their respective clinic.


Nil

4. The staff nurse/aaya shall ensure that the patient is seated

comfortably and is waiting for his/her turn and there is no

overcrowding in or around the clinic


Nil

5. Patients shall be allowed entrance to the clinic only as per their

turn i.e. “first come first examine” basis.


Nil






8. Receiving of Patient inside clinic, taking consent and OPD Consultation

S.

No


1. Patients shall be allowed entrance to the clinic only as per

their turn i.e. “first come first examine” basis.

Staff Nurse/Doctor OPD Register

2. The doctor shall receive the patient in OPD and ensure he is

comfortably seated and then take his details and complaints

and ensure examination of the patient is carried out in

privacy.

Doctor Nil

Taking Consent

3. The staff nurse inside OPD shall enter Patient’s serial

number, registration number, complaint, etc in the

Out Patient register.

Staff nurse OPD Register

4. Before Assessing the patient, Patient/Attendant signature

shall be taken on the general consent form attached on the

backside of the OPD case paper.

Staff nurse/Consultant

OPD case paper

Clinical Assessment and Reassessment

5. The consultant shall first take Patient’s case history and

undertake an initial assessment to examine the symptoms of

illness.

Doctor OPD case paper

6. In case of medication advice, prescription for medication shall

be written on the medication prescription slip and patient

shall be guided towards the pharmacy to avail the drugs.

Patient may be instructed for a follow up check up if required

after undertaking the course of medication.

Doctor Medication slip (OPD case paper)

7. Investigations (Pathology, Radiology, Ultra Sonography etc) if

required for physical evidence to confirm the disease or

illness shall be ordered in the investigation requisition slip by

the consultant.

Doctor Investigation requisition slip

8. Patients shall be advised to return back with investigation

reports for further consultation.

Doctor OPD case paper

Reference standard – ME G4.2,





9. Patient Referral

S. No


Inter dept referral

1.

Through investigation findings or re- asessment if the need is

felt for a second opinion from another clinical area or the

patient seem to be requiring care from other clinical speciality

then the patient shall be opted for a inter dept

referral.

Doctor, Staff nurse

Referral form Refer In- Out register

2. The consultant shall fill the referral form indicating patient

details, reason for referral and course of treatment provided.

Doctor Referral form

3. The patient shall be guided towards the referral clinic along

with the case sheet.

Doctor, Staff nurse

OPD case paper

Outer referral

4. In case of any certain service/ super speciality care required for

the patient that is not available in the hospital then patient shall

be referred to a higher facility.


5. The consultant shall fill the referral form indicating patient

details, reason for referral and course of treatment provided.


6. The staff nurse shall document the referral details in the Refer

In- Out register and coordinate for the referral process.

Staff nurse Refer In- Out register

7. An advance telephonic communication with the referral centre

shall be done to ensure the required service is available and

intimate the staff of the higher centre about the referral to be

done.


8. Ambulance service for the patient shall be arranged which shall

be free of cost for maternal referrals only for others an amount

of Rs shall be charged


9. Patient along with the referral form and case sheet shall be

referred to the higher centre.

Staff nurse Referral form

10. The nursing staff shall also follow up about the condition of the

patient post referral.


Reference standard – ME G4.2





10. Protecting Patient Rights

S.

No


Addressing gender needs

1. Separate queue for females at registration counter shall be maintained.

Facility – Incharge, Registration desk

Nil

2. The OPD area shall have separate visitor toilets for male and female.

Facility – Incharge Nil

3. There shall be available a Breast feeding corner with comfortable seating arrangement and ventilation provision at the OPD area.


Disable friendly facilities

4. The OPD entrance shall have ramps with railing. Facility – Incharge Nil

5. The OPD entrance shall ensure availability of Wheel chair or

stretcher easy Access to the OPD for non ambulatory &

disabled patients.


6. There shall be provision of a disable friendly toilet in the OPD area.


Maintaining Patient Privacy & Confidentiality

7. All the OPD clinics shall have privacy screen at Examination

Area.

Doctors, OPD staff

nurse, ICTC

counsellor

Nil

8. All OPD clinics shall ensure the presence of a female staff nurse at the examination area whenever a male doctor has to examine a female patient.

Doctors Nil

9. Only one Patient at a time shall be seen at the clinic. Doctor Nil

10. Confidentiality of HIV reports at ICTC shall be maintained. The identity of HIV+ve & leprosy patients shall not be revealed to anyone except the patient, his family and the counsellor/ treating doctor

ICTC counsellor Nil

Patient Counselling

11. The doctor shall inform the patient about his /her clinical condition and the treatment plan, any potential risks/side effects if any concerning the treatment and the options of treatment.

Doctors Health education

handouts if available

12. Counselling of the patient on Diet & Nutrition and preventive measures to be adopted if any is to be carried out.

Doctors Health education

handouts if available

Informed Consent

13. The Patient and his/her family members shall be counselled

and Informed consent shall be taken from the patient before

ICTC testing centre Informed consent form





conducting HIV testing.

14. A printed bilingual informed consent form shall be used for taking the informed consent

ICTC testing centre Informed consent form

Reference standard – ME G4.2





11. Conducting Patient satisfaction survey

S. No


1. Listening to patients' views is essential for providing patient-centred healthcare service. Hence carrying out a satisfaction survey is an essential tool for continuous quality improvement, since the feedback received directly from the users helps in mapping the lacunae in service and provides scope for further improvement.

Facility-Incharge Nil

2. Monthly satisfaction surveys shall be carried to get patient feedback on the services provided.

Facility-Incharge Nil

3. Feedback shall be received from the patient on printed satisfaction survey questionnaires.

Facility-Incharge OPD Satisfaction Survey Questionnaire

4. The patients shall be given print out forms of satisfaction survey forms (In Hindi) and asked to rate their satisfaction for each attribute in terms of Poor, Fair, Good, Very good and Excellent.

Facility- Incharge Satisfaction Survey Questionnaire

5. Monthly analysis of average patient satisfaction survey shall then be carried out and action shall be taken on the lowest scoring parameters to improve the scoring pattern and patient satisfaction survey

Facility- Incharge Satisfaction survey report






12. Equipment management

S.

No


Calibration of Equipments

1. All the measuring equipments/ instrument shall be

calibrated.

OPD -Incharge Nil

2. An ISO certified calibration agency shall be identified to

calibrate the equipments/instruments.

OPD - Incharge Nil

3. Calibration labels/stickers shall be placed on the equipment

denoting the date of calibration and indicating the status of

calibration/ verification when recalibration is due.

OPD - Incharge Equipment register

4. All calibration certificates shall be maintained by the

Incharge or centrally stored by the Store-Incharge of the

hospital.

OPD - Incharge Calibration certificate

5. The OPD shall maintain an equipment register to document

details of equipment and calibration status.


6. It shall be the duty of the Incharge to ensure updation of

calibration for all equipments as per their schedule.


General Maintenance

7. Up to date manufacturer’s instructions for operation and

maintenance of equipments shall be kept in the department

so that the same can be readily available to staff when

required.

OPD - Incharge Manufacturer’s instruction

8. Defective/Out of order equipments shall be labelled and

stored appropriately away from traffic area, until it has been

repaired


9. Daily dusting/ dry wiping of equipments shall be done by

housekeeping staff. The laboratory technician shall do a

daily check on the functioning of equipments every morning

before commencement of testing procedure.

OPD - Incharge Nil

10. An equipment register shall be maintained to document OPD - Incharge Equipment register





details of equipment - name, hospital code, and date of

installation, name of manufacturer, maintained in A

house/maintained by external agency or manufacturer,

Warranty Period, under AMC/CMC.

Preventive and Breakdown Maintenance

Preventive Maintenance

11. All equipments shall be covered under AMC/CMC including

Preventive maintenance.

OPD- Incharge Equipment register

12. The lab-Incharge shall maintain an updated record on AMC

& Preventive maintenance in equipment register this should

include details like :

o Frequency of Preventive Maintenance/Calibration

- As per manufacturer guidelines

- Presently being followed

o Preventive Maintenance/Calibration Done On

o Preventive Maintenance/Calibration Due On

o Expenditure with cost and details

o Remarks with Functional Status


13. Preventive maintenance shall be carried out as per

Maintenance Schedule for each individual equipment based

on manufacturer’s recommendations.


14. The following shall be checked during a preventive

maintenance-

Physical condition of the equipment/ facility

lubrication, calibration, cleaning or replacing parts that

are expected to wear or which have a finite life

Maintenance report verification

Maintenance / Service report shall be obtained from service

agency and after verification marked as O.K. /Not O.K.

OPD -Incharge Equipment Service Report

Breakdown Maintenance

15. Faulty or defective equipment shall not be used regardless

of how minor is the problem and must be reported in the first

instance to the in-house maintenance engineer /outside

agency hired for maintenance as soon as possible and seen

OPD -Incharge Equipment register





that the problem is attended to as soon as possible.

16. A label of “out of order” shall be attached to the equipment

and information regarding breakdown shall be passed to all

staff including any shift changes.

OPD -Incharge Nil

17. On restoration of the equipment, the Equipment Breakdown

Record should be updated. This indicates that the

breakdown/maintenance is performed of the equipment.

The “out of order” sticker shall be removed after the

restoration of the equipment.

OPD -Incharge Nil

18. All the breakdowns occurring in the department should be

maintained in the equipment register and include the

following

o Breakdown Date and Time

o Breakdown Details (Technical fault or other reasons)

o Date and Time of Rectification

o Total Time Taken (Rectification Time – Breakdown

Time)

o Rectification Details with expenditure including cost (if

any)

o Remarks with functional status

o Reasons for delay if any







13. Referral of Patients

S. No


1. In case of any certain service/ speciality care required for

the patient that is not available in the hospital then patient

shall be referred to a higher facility.

OPD Medical Officer Nil

2. However Basic first aid or stabilization of the patient shall be

done prior referral.

OPD Medical Officer, Staff Nurse

Nil

3. The CMO (OPD Medical Officer) shall fill the referral form,

indicating patient details, reason for referral and course of

treatment provided.


Referral form

4. The staff nurse shall document the referral details in the

Refer In- Out register and coordinate for the referral

process.


Refer In-Out register

5. An advance telephonic communication with the referral

centre shall be done to ensure the required service is

available and intimate the staff of the higher centre about

the referral.



6. Ambulance service for the patients is charged for the

transfer as per norms of the RKS except BPL Patient.



7. JSSK patients and 108 patients are not charged. OPD Medical Officer, Staff Nurse

Nil

8. Patient along with the referral form and case sheet shall be

referred to the higher centre.


Referral form

9. The nursing staff shall also contact the referral centre and follow up about the condition of the patient post referral.



Reference Standard: ME G4.2





14. Equipment Management

S.

No


Calibration of Equipments

1. All the measuring equipments/ instrument shall be calibrated. OPD -Incharge Nil

2. An ISO certified calibration agency shall be identified to

calibrate the equipments/instruments.

OPD - Incharge Nil

3. Calibration labels/stickers shall be placed on the equipment

denoting the date of calibration and indicating the status of

calibration/ verification when recalibration is due.


4. All calibration certificates shall be maintained by the Incharge

or centrally stored by the Store-Incharge of the hospital.

OPD - Incharge Calibration certificate

5. The OPD shall maintain an equipment register to document

details of equipment and calibration status.


6. It shall be the duty of the Incharge to ensure updation of

calibration for all equipments as per their schedule.


General Maintenance

7. Up to date manufacturer’s instructions for operation and

maintenance of equipments shall be kept in the department

so that the same can be readily available to staff when

required.

OPD - Incharge Manufacturer’s instruction

8. Defective/Out of order equipments shall be labelled and

stored appropriately away from traffic area, until it has been

repaired


9. Daily dusting/ dry wiping of equipments shall be done by

housekeeping staff. The laboratory technician shall do a daily

check on the functioning of equipments every morning before

commencement of testing procedure.

OPD - Incharge Nil

10. An equipment register shall be maintained to document

details of equipment - name, hospital code, and date of






installation, name of manufacturer, maintained in A

house/maintained by external agency or manufacturer,

Warranty Period, under AMC/CMC.

Preventive and Breakdown Maintenance

Preventive Maintenance

11. All equipments shall be covered under AMC/CMC including

Preventive maintenance.


12. The lab-Incharge shall maintain an updated record on AMC &

Preventive maintenance in equipment register this should

include details like :

o Frequency of Preventive Maintenance/Calibration

- As per manufacturer guidelines

- Presently being followed

o Preventive Maintenance/Calibration Done On

o Preventive Maintenance/Calibration Due On

o Expenditure with cost and details

o Remarks with Functional Status


13. Preventive maintenance shall be carried out as per

Maintenance Schedule for each individual equipment based

on manufacturer’s recommendations.


14. The following shall be checked during a preventive

maintenance-

Physical condition of the equipment/ facility

lubrication, calibration, cleaning or replacing parts that

are expected to wear or which have a finite life

Maintenance report verification

Maintenance / Service report shall be obtained from service

agency and after verification marked as O.K. /Not O.K.

OPD -Incharge Equipment Service Report

Breakdown Maintenance

15. Faulty or defective equipment shall not be used regardless of

how minor is the problem and must be reported in the first

instance to the in-house maintenance engineer /outside

agency hired for maintenance as soon as possible and seen

that the problem is attended to as soon as possible.






16. A label of “out of order” shall be attached to the equipment

and information regarding breakdown shall be passed to all

staff including any shift changes.

OPD -Incharge Nil

17. On restoration of the equipment, the Equipment Breakdown

Record should be updated. This indicates that the

breakdown/maintenance is performed of the equipment.

The “out of order” sticker shall be removed after the

restoration of the equipment.

OPD -Incharge Nil

18. All the breakdowns occurring in the department should be

maintained in the equipment register and include the

following

o Breakdown Date and Time

o Breakdown Details (Technical fault or other reasons)

o Date and Time of Rectification

o Total Time Taken (Rectification Time – Breakdown Time)

o Rectification Details with expenditure including cost (if

any)

o Remarks with functional status

o Reasons for delay if any







15. Other Outpatient Services

S.

No


OUTPATIENT PHARMACY

1. Patient presents the OPD medicine slip at the pharmacy counter. Pharmacist Medicine prescription slip

2. Pharmacist at the counter shall dispense the available drugs /

medicines and also brief the dosage and frequency of medicine at

the time of dispensing to the patient.

Pharmacist Medicine prescription slip

3. If any prescribed medicine is not available in the dispensary it shall

be made available by local purchase.

Pharmacist Medicine prescription slip,

Drug Dispensing Register

4. The quantity of issued medicines shall be entered in the dispensing

register/pharmacy software if available.

Pharmacist Drug Dispensing Register

IMMUNIZATION CLINIC

5. Patient is directed towards injection room by OPD attendant. Staff Nurse Immunization register

6. Patient shows the OPD case paper to nursing staff at injection

register.

Staff Nurse Immunization register

7. Nursing staff at injection room shall administer the injection as

advised and enter the detail in Immunization Register (i.e. name of

pt, pt ID, case, requisition given by, and injection administered).

Staff Nurse Immunization register

8. In case of ARV, separate register (ARV Register) shall be

maintained.

Staff Nurse ARV register

9. Needles, syringes and swabs shall be disposed as per Biomedical

Waste (Management and Handling) Rules, 1998.

Staff Nurse Nil

DRESSING ROOM

10. Patient is directed towards dressing room by OPD attendant Dresser/ Staff Nurse

Dressing room register

11. Patient comes to dressing room and shows OP case paper. Dresser/ Staff Nurse






12. Patient’s details are entered into the dressing register. Dresser/ Staff Nurse


13. The dresser carries the process of wound dressing Dresser/ Staff Nurse


14. Swabs, bandage etc are disposed as per Biomedical Waste (Management and Handling) Rules, 1998.

Dresser/ Staff Nurse

Nil

SERVICES PROVIDED UNDER NATIONAL HEALTH PROGRAMME

15. National Immunization Programme

Revised National Tuberculosis (TB) Control Programme

National AIDS Control Programme

Maternal & Child Health Programme

Family Planning Programme

National Blindness control program

National Leprosy elimination Programme.

National Vector Borne Disease Control Programme

National Tobacco Control Programme

National Flurosis Disease Control Programme

National Iodine deficiency Diseases Control Programme

National Communicable Disease Control Programme

National Non Communicable Disease Control Programme

National Diabetic Control Programme

National Diarrhoea Control Programme

Nodal officer Reporting Formats






16. Updation and storage of records

S.

No


1. All the details of assessments, re-assessment and investigations

shall be recorded and updated in the OPD case sheet by the

consultant/ doctor.

Doctor, Staff Nurse & In - charges

All forms & formats and registers maintained in OPD

2. Any minor Procedures if any like immunization/dressing etc shall

be recorded in the patient case sheet.

Doctor, Staff Nurse & In - charges

3. The facility shall ensure safe and adequate storage and retrieval of

medical records if OPD records are stored in MRD.

MRD In -charge

4. All registers maintained for OPD shall be identified and numbered. In - charge






17. Cleaning of OPD Area

S.

No


1. OPD lobby area shall be mopped with disinfectant added water

solution.

Housekeeping staff

Housekeeping checklist

2. All patient care area shall be first mopped with disinfectant and

then with detergent water.

Housekeeping staff


3. Use of brooms shall be avoided, only dry & wet mopping shall be

followed.

Housekeeping staff


4. Dusting of tables, racks, cupboards and windows shall be done

either before or after OPD timings to avoid dispersion of dust

particles in air and thereby inside nostrils of patient which may

cause them discomfort.

Housekeeping staff


5. Infection Control Nurse shall ensure housekeeping staff is trained for spill management.

Infection control Nurse

Housekeeping checklist & Infection control round checklist





18. No Smoking Policy in OPD

S.

No


1. The hospital has a “No Smoking Policy” according to which

smoking is prohibited inside hospital premises.

Hospital staff, patient, visitors

Signages on No Smoking policy

2. As per the organisation policy, any hospital staff found guilty of

non-adhering to the above policy shall be liable to a fine of Rs

200/-

Hospital staff No smoking Policy

3. If the staff at the hospital come across any patient/patient

attendant with a regular smoking habit shall educate them on the

harmful impact of smoking and motivate them to quit smoking.

Hospital staff No smoking Policy

4. Any patient/attendant if found smoking inside hospital premises

shall be alerted about the No smoking policy and asked to refrain

from the same immediately

Hospital staff No Smoking Policy

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