Organization defines and documents the content otf the initial assessment for the OP, IP & ER.*

Organization determines who can perform the initial assessment.*

Organization defines the time frame within which the initial assessment is completed based on patients needs.*

The initial assessment for IP is documented within 24 hrs or earlier as per the patients conditions, as defined in the organisations policy.*

The initial assessments of IP includes nursig assessment which is done at the time of admission and documented.*

The initial assessments includes screening for nutritional needs.

The initial assessment results in a documented care plan.*

The care plan reflects desired results of the treatment, care or service.

The care plan is counter signed by the clinician in-charge of the patient within 24hrs.

Patients are reassessed at appropriate intervals.

Out-patients are informed of their next followup, where appropriate.

For IP during reassessment the care plan is monitored and modified, where found necessary.

Staff involved in direct clinical care document reassessments.*

Patients are reassessed to determine their response to treatment and to plan further treatment or discharge.

During all phases of care, there is a qualified individual identified as responsible for the patients care.

 Care of patients are coordinated in all care settings within the organisation.

Information about the patients care are response to treatment is shared among medical, nursing and other care providers .

Information is exchanged and documented during each staffing shift, between shifts, and during transfers between units/departments.

Transfers between departments / units are done in a safe manner.

The patients record(s) are available to the authorised care providers to facilitate the exchange of information.

Documented procedures guide the referral of patients to other departments / specialities.*

The organisation ensures continuity of care while adhering to defined timelines and informs the caregiver and / or the patient / family whenever there is a change in schedule.

The organisation adapts evidence-based medicine and clinical practice guidelines to guide uniform patient care.

Documented policies and procedures guide the uniform use of resuscitation throughout the organisation.

Staff providing direct patient care are trained and periodically updated in cardio-pulmonary resuscitation.

The events during a cardiopulmonary resuscitation are recorded.

A post-analysis of all cardiopulmonary resuscitations is done by a multidisciplinary committee.

Corrective and preventive measures are taken based on the post-event analysis.

Informed consent is taken by the personnel performing the procedure, where applicable.

Documented policies and procedures are used to guide the care of patients in the intensive care and high dependency units. *

The organisation has documented admission and discharge criteria for itsintensive care and high dependency units. *

Staff are trained to apply these criteria.

Adequate staff and equipment are available.

Defined procedures for the situation of bed shortages are followed. *

Infection control practices are documented and followed. *

A quality assurance programme is documented and implemented.*

Patients and families are counselled by the treating medical professional at periodic intervals and when there is a significant change in the condition of thepatient, and same is documented. *

Care of vulnerable patients - Policies and procedures are documented and are in accordance with the prevailing laws and the national and international guidelines. *

Care is organised and delivered in accordance with the policies and procedures.

The organisation provides for a safe and secure environment for the vulnerable group.

A documented procedure exists for obtaining informed consent from the appropriate legal representative. *

Staff are trained to care for the vulnerable group.

Documented policies and procedures guide the care of patients under restraints.*

The policies and procedures include both physical and chemical restraint measures.

The reasons for restraints are documented.

Patients on restraints are more frequently monitored.

Staff receives training and periodic updating in control and restraint techniques.

Documented policies and procedures guide the management of pain. *

All patients are screened for pain.

Patients with pain undergo detailed assessment and periodic reassessment.

Patient and family are educated on various pain management techniques, whereappropriate.

Sound inventory control practices guide storage of the medications in all areas throughout the organisation.

Look-alike and Sound-alike medications are identified and stored physically apart from each other.*

The list of emergency medications is defined and is stored in a uniform manner.*

Known drug allergies are ascertained before prescribing.

The organisation determines who can write orders.*

Orders are written in a uniform location in the medical records which also reflects patient’s name and unique identification number.

Medication orders are clear, legible, dated, timed, named and signed.

Medication orders contain the name of the medicine, route of administration,dose to be administered and frequency/time of administration.

Documented policy and procedure on verbal orders is implemented.*

Expiry dates are checked prior to dispensing.

Medications are administered by those who are permitted by law to do so.

Prepared medication is labelled prior to preparation of a second drug.

Patient is identified prior to administration.

Medication is verified from the order and physically inspected prior to administration.

Dosage is verified from the order prior to administration.

Route is verified from the order prior to administration.

Timing is verified from the order prior to administration.

Medication administration is documented.

Documented policies and procedures govern patient’s self-administration of medications. *

Documented policies and procedures govern patient’s own medications brought from outside the organisation.*

Documented policies and procedures guide the monitoring of patients after medication administration.*

The organisation defines those situations where close monitoring is required.*

Monitoring is done in a collaborative manner.

Medications are changed where appropriate based on the monitoring.

Documented procedures guide the use of narcotic drugs and psychotropic substances which are in consonance with local and national regulations.*

These drugs are stored in a secure manner.

A proper record is kept of the usage, administration and disposal of these drugs.

These drugs are handled by appropriate personnel in accordance with the documented procedure.

An appropriate antibiotic policy is established and documented. *

Surveillance activities are appropriately directed towards the identified high-risk areas and procedures.

A collection of surveillance data is an on-going process.

Verification of data is done on a regular basis by the infection control team.

The scope of surveillance activities incorporates tracking and analyzing of infection risks, rates and trends.

Surveillance activities include monitoring the compliance with hand-hygiene guidelines.

Appropriate feedback regarding Healthcare Associated Infection (HAIs) rates are provided on a regular basis to appropriate personnel.

There is internal and external sign postings in the organisation in a language understood by the patient, families and community.

The provision of space shall be in accordance with the available literature on good practices (Indian or international standards) and directives from government agencies.

Equipment are inventoried and proper logs are maintained as required.

Equipments are periodically inspected and calibrated for their proper functioning.

There is a documented operational and maintenance (preventive and breakdown) plan for equipment. *

Initial assessment includes screening for nutritional needs.

During all phases of care, there is a qualified individual identified as responsible for the patient’s care.

Care of patients is coordinated in all care settings within the organisation.

Information about the patient’s care and response to treatment is shared among medical, nursing and other care-providers.

Information is exchanged and documented during each staffing shift, between shifts, and during transfers between units/departments.

Transfers between departments/units are done in a safe manner.

The patient’s record(s) is available to the authorised care-providers to facilitate the exchange of information.

Documented procedures guide the referral of patients to other departments/specialities. *

The patient’s discharge process is planned in consultation with the patient and/or family.

Documented procedures exist for coordination of various departments and agencies involved in the discharge process (including medico-legal and absconded cases). *

Documented policies and procedures are in place for patients leaving against medical advice and patients being discharged on request. *

A discharge summary is given to all the patients leaving the organisation(including patients leaving against medical advice and on request).

Discharge summary is provided to the patients at the time of discharge.

Discharge summary contains the patient’s name, unique identification number,date of admission and date of discharge.

Discharge summary contains the reasons for admission, significant findings and diagnosis and the patient’s condition at the time of discharge.

Discharge summary contains information regarding investigation results, any procedure performed, medication administered and other treatment given.

Discharge summary contains follow-up advice, medication and other instructions in an understandable manner.

Discharge summary incorporates instructions about when and how to obtain urgent care.

In case of death, the summary of the case also includes the cause of death.

Care delivery is uniform for a given health problem when similar care is provided in more than one setting. *

Uniform care is guided by documented policies and procedures.

The organisation adapts evidence-based medicine and clinical practice guidelines to guide uniform patient care.

Documented policies and procedures guide the uniform use of resuscitation throughout the organisation. *

Staff providing direct patient care are trained and periodically updated in cardiopulmonary resuscitation.

The events during a cardiopulmonary resuscitation are recorded.

A post-event analysis of all cardiopulmonary resuscitations is done by a multidisciplinary committee.