CARE OF PATIENT (COP)CHECK LIST FOR NABH ENTRY LEVEL SHCO

 

INTENT OF CHAPTER

 

§  This chapter aims to guide and encourage patient safety as overall principle for providing care to patients.

§  Specific services such as intensive care, surgery, blood transfusion, and emergency, Anesthesia, Obstetrics and Pediatric are addressed.

§  The organizations are encouraged to identify and adapt clinical guidelines to maintain uniformity in patient care.

REQUIREMENTS

1.  STANDARD OPERATING PROCEDURES (SOP’S)

 

 

Sr.No	Standard Reference	Name of SOP’s	Expected Content
1	COP 2	Documented procedure to guide emergency services including ambulance.	-Procedure for handling MLC -Procedure for Admission, Discharge and referral. -Procedure for use and maintenance of ambulance
2	COP 3	Documented procedures defines rational use of blood and blood products	-Indications for use of blood components. -Procedure for Requesting for blood products. -Obtaining inform consent for donation transfusion. -Procedure of transportation, administration and monitoring blood transfusion services. -Reporting and   recording   of   blood transfusion reaction.

3	COP 4	Documented procedure to guide the care of patient in intensive care and high dependency unit.	-Admission and transfer of patient. -Monitoring, Reporting and recording of patient care events. -Staffing and equipment management.
4	COP 5	Documented procedures to guide the care of obstetrics services.	-Procedure includes regular antenatal check-up,      maternal                     nutrition    and postnatal care.
5	COP 6	Documented procedures guide the pediatric patients.	-Nutritional assessment, Immunization assessment. -Procedure addresses identification and security measures to prevent child abduction and abuse. - Mechanism of educating children’s and family about nutrition, immunization and safe parenting.
6	COP 7	Documented services to guide the administration of anesthesia	-Procedure for pre-anesthesia assessment and documentation of anesthesia plan. -Immediate post operative re- evaluation. -Obtaining informed consent for anesthesia. -Procedure of intra-operative monitoring, post anesthesia status and documentation.
7	COP 8	Documented Procedure to guide the care of patient undergoing                              surgical services	Procedure includes documentation of pre-operative assessment, and diagnosis. Obtaining the informed consents, Prevention of adverse events, Documentation of post operative notes, post operative plan of care, infection control practices in OT.

2.  FORMS AND FORMATS

 

 

Sr. No	Standard Reference	Name of form and format	Expected Content
1	COP 2 c	Transfer referral form to another organization	Patient demographics, Chief complaints, course in hospital, Investigations, treatment given, reason for referral, special recommendations for further management. Contact Details of hospital, Signature and stamp of referring doctor.
2	COP 3b	Blood transfusion Consent form	This should include reason for blood transfusion, expected benefits and risk.
3	COP 3	Blood component request form	Patient demographics, previous history of transfusion, Indication of transfusion, blood component required, name and signature of phlebotomist.
4	COP 3	Blood transfusion monitoring form	Patient demographics, Check point for patient name, ID No, Label for blood group etc. Name of component, Transfusion start time, vitals during transfusion (monitoring at least for every 30 min), Transfusion end time, adverse reaction if any, Total volume infused, signature of doctor and signature of nurse.
5	COP 3c	Reporting of adverse blood reaction	Details of blood component, time of start and end, details of reaction, analysis which includes errors in transportation, storage, administration and post transfusion biochemistry and microbiology report, corrective and preventive action (if any)
6	COP 7 b	Pre            anesthesia assessment (PAC) form	Patient demographics, diagnosis, proposed surgery, chief complaints, allergy, past history, general examination, airway examination, systemic examination, routine or special investigation results, special advices, plan of anesthesia with ASA grade, signature of anesthesiologist

			with date and time. Immediate preoperative assessment can be incorporated in the last part of PAC which should include level of consciousness, pulse rate, BP and SpO2.
7	COP 7 e	General anesthesia consents	Name of surgery, name of anesthesia planed, benefits and risk, signature of patient, relative, anesthesiologist with date and time.
8	COP 7 e	High              risk anesthesia consents	Name of surgery, name of anesthesia planed, reasons for high risk, signature of patient, relative, anesthesiologist with date and time.
9	COP 7 f	Anesthesia Monitoring Form	Regular and periodic recording of heart rate, cardiac rhythm, respiratory rate, blood pressure, oxygen saturation, airway security and potency and level of anesthesia.
10	COP 7 g	Post    anesthesia status monitoring form.	This should result in fitness of patient for transfer from recovery room after anesthesia. Aldrete’s score is one of the good references.
11	COP 8 b	Informed consents       for surgery	Name of proposed surgery, name of surgeons, Possible outcome, possible complications and risk signature of patient, relative, surgeon with date and time.
12	COP 8 b	High              risk consents       for surgery	Name of proposed surgery, name of surgeons, reason for high risk, signature of patient, relative, surgeon with date and time.
13	COP 8 c	Surgical   Safety check list	As per WHO guidelines as given in references of this document

 

 

3.  TRAININGS

 

1.      Training on Security Measures to prevent child abduction and abuse ( Code Pink)

2.      Implementation of Surgical safety check list

3.      All other necessary trainings as per the scope and need of the organization

4. REGULATORY REQUIREMENTS

 

1.   License for blood bank or blood storage centre. (If any)