STANDARD OPERATING

PROCEDURE (SOP)
FOR QUALITY IMPROVEMENT

Quality Improvement Secretariat

HEU, Health Service Division, MOHFW
www.qis.gov.bd
STANDARD OPERATING
PROCEDURE (SOP)
FOR QUALITY IMPROVEMENT

Quality Improvement Secretariat

HEU, Health Service Division, MOHFW
www.qis.gov.bd
Planning & Coordination:
Dr Md Aminul Hasan
Director Hospitals & Clinics. DGHS
& Focal Person
Quality Improvement Secretariat
Ministry of Health of Family Welfare

Advisor:
Director General
Health Economics Unit
Ministry of Health & Family Welfare

Published on 2019

Network partner:
UNICEF, UNFPA, SCI, USAID, WHO

Design & Desktop Editing:

QIS team
Quality Improvement Secretariat

Printing & Publishing:

Jerin Efaz Enterprise
8/3 (2nd floor), Katabon, Nilkhet, Dhaka.
Cell : 01712713985
E-mail : [email protected]
 Preface
A standard operating procedure (SOP) is a set of step-by-step instructions
compiled by an organization to help service providers carry out complex
hospital routine operations. SOPs aim to achieve efficiency, quality output and
uniformity of performance, while reducing miscommunication and failure to
comply with health service standard and clinical Quality.

Many hospitals are currently providing quality clinical services, which is a new
intervention in the practice of health service delivery in the country. However,
the services are not being provided in a standardized and uniform manner.
Therefore, this standard operating procedures (SOP) manual has been
developed to standardize and formalize the provision of Quality clinical services
in the health service delivery. SOPs on how to provide clinical services for OPD,
IPD, Emergency etc and to document and report the services provided are
addressed in this manual.

It is a written procedure prescribed for repetitive use as a practice, in

accordance with agreed upon specifications aimed at obtaining a desired
outcome.

This document has developed after literature reviewed, then draft has develop,
reviewed by the relevant stakeholder by holding series working group meetings
& finalized in a national workshop.

This SOP describes specific step by step procedures in clinical management like
OPD, IPD Housekeeping, Emergency services, OT services, Radiology Services &
Pathology services. It should be used as a hands-on reference for service
providers providing services, thereby helping to standardize the practice in all
hospitals, with the ultimate goal of optimizing the quality & standard patient
care. The manual may also be used as a reference for health service providers
for effective health management.

Finally the SOPs will ensure that standardizedQuality clinical services are
provided in all health facilities and at all times, Clarify roles and responsibilities of
the service providers for clinical care, Provide a detailed description of how to
perform clinical activities, Improve the standards for clinical services on a
continual basis, at end it will ensure the client satisfaction in health service
delivery.

Dr Md Aminul Hasan
Director Hospitals & Clinics. DGHS
& Focal Person
Quality Improvement Secretariat
Ministry of Health of Family Welfare
 Table of Contents

1 Introduction 05

2 Standard Operating Procedure (SOP) for OPD Services 09

3 Standard Operating Procedure (SOP) for IPD Services 19

4 Standard Operating Procedure (SOP) for House keeping Services 35

5 Standard Operating Procedure (SOP) for Emergency Services 41

6 Standard Operating Procedure (SOP) for OT services 49

7 Standard Operating Procedure (SOP) for Pathology Services 57

8 Standard Operating Procedure (SOP) for Radiology Services 63

 Introduction
The Standard Operating procedure (SOP) are developed for the healthcare
facilities based on the Health Care Standards involved in the health service
providers and experts. The SOPs include separate sets of procedures for the
healthcare facilities of various levels. SOPs reflect the difference in opportunities,
capacity and vulnerability of the healthcare staff in different levels of the
healthcare system.

The purpose of the Standard Operating Procedures is to provide clear and

detailed description of step by step routine actions of the service providers
providing services in the facilities.

Many hospitals are currently providing quality clinical services, which is a new
development in the practice of health care in the country. However, the
services are not being provided in a standardized and uniform manner.
Therefore, this standard operating procedures (SOP) manual has been
developed to standardize and formalize the provision of Quality clinical services
in the health service delivery. SOPs on how to provide clinical services for OPD,
IPD, Emergency etc and to document and report the services provided are
addressed in this manual.

SOP is a written procedure prescribed for repetitive use as a practice, in

accordance with agreed upon specifications aimed at obtaining a desired
outcome.

These are a specific set of practices that are required to be initiated and
followed when specific circumstances arise. For example, emergency room
physicians have SOPs for patients who are brought in an unconscious state;
nurses in an operating theater have SOPs for the forceps and swabs that they
hand over to the operating surgeons; and laboratory technicians have SOPs for
handling, testing, and subsequently discarding body fluids obtained from
patients.

In present day medicine, clinicians are familiar with SOPs in restricted contexts.
Service providers are also aware of the use of SOPs in the context of clinical trials,
either with regard to the functioning of ethics committees or with regard to
screening, consenting, assessing, and treating patients across the course of the
clinical trial. An idea whose time has now come is the introduction of SOPs into
routine clinical practice; that is, not for special patients (e.g. those who are
unconscious) or for special circumstances (e.g. clinical trials), but for every
patient in everyday clinical care.
05
Standard Operating
Procedure (SOP)
SOPs are more specific than guidelines and are defined in greater detail. They
provide a comprehensive set of rigid criteria outlining the management steps for
a single clinical condition or aspects of organization.

Guidelines are rigorously developed using evidence-based medicine criteria

and consist of two distinct components: the evidence summary and the
detailed instructions for the application of that evidence to patient care. For the
common health care provider, guidelines require local adaptation to suit local
circumstances and to achieve a feeling of ownership, both of which are
important factors in guideline uptake and use. SOPs therefore, help bridge the
gap between evidence-based medicine, clinical practice guidelines, and the
local realities at the point-of-care.

SOPs are necessary to remind clinicians of the need for medical evaluations
such as ultrasonography of the ovaries in young women advised valproate,
physical and metabolic monitoring in patients advised olanzapine, and thyroid
assessments in patients with mood disorders. Incorporating reminders in the form
of SOPs can improve the rate of compliance with the relevant guidelines.

SOPS are necessary to incorporate aspects of treatment which are not

highlighted in guidelines or which are parts of different guidelines. This will ensure
that attention is paid to areas as diverse as problem-solving, communication,
social support, family burden, and caregiver stress. SOPs are necessary to ensure
that easily implemented strategies that benefit mental health are not
neglected; examples of behavioral targets are diet, exercise, sleep, stress
management, and the pursuit of leisure and pleasure activities. SOPs are
necessary to monitor medication compliance, a variable that can make or
break the success of a psychopharmacological treatment plan.

The use of SOPs will have the added advantages of utilizing an optimized
process for care, implementation of best evidence-based medicine,
cost-effectiveness, improved continuing medical education, improved
induction of new hospital staff, integrated quality control, transparency and
enhanced protection from malpractice. When all these SOPs are in place, the
quality of patient care will substantially improve.

Scope of the Manual

This SOPs manual describes the specific steps providingclinical services to the
patients . It contains SOPs for the provision of clinical services to the patient in
facility level, with the necessary documentation and reporting systems.

06
Standard Operating
Procedure (SOP)
Purpose of the Manual
This manual describes specific procedures in clinical care practice. It should be
used as a hands-on reference for service providers providing services, thereby
helping to standardize the practice in all hospitals, with the ultimate goal of
optimizing patient care. The manual may also be used as a reference for health
system managers, policymakers, health care providers, academicians,
researchers, and pharmacy students.

Objectives of the Manual

General Objective: The general objective of these clinical SOPs is to standardize
the provision of Quality clinical services, thereby optimizing patient outcomes
by ensuring the rational use of medicines.

Specific Objectives
• Ensure that standardized Quality clinical services are provided in all hospitals
and at all times.
• Clarify roles and responsibilities of the service providers for clinical care.
• Provide a detailed description of how to perform clinical activities.
• Serve as a source of guidance for new service providers.
• Improve the standards for clinical services on a continual basis.

• Provide evidence of commitment to improvements in the quality of patient

care.

07
Standard Operating
Procedure (SOP)
08
Standard Operating
Procedure (SOP)
 Chapter-1
1. SOP for OPD Services
1.a. Introduction:

O
ut patient departments (OPD) provide Medicare services to the
ambulatory patients. Acute and seriously ill patients must not be
referred to the OPD. Majority of the patients received services from the
OPD. So it is of maximum importance to serve the people with highest possible
quality services to fulfill their need and reduce their sufferings. Efficient OPD
service can greatly reduce the burden to the other sections of the hospital
services. Out patient services are rendered through the Male / Female / Children
/ Dental & Family planning out patient departments.

As majority of the people come in contact with the OPD services of the hospitals
so it is the area of importance to satisfy and address the people demand
accordingly and in an effective way.

Rural peoples come to the Government Hospitals with high expectations and in
many situations it was observed that peoples expectations superset the real
situation which gives raise to many problems and often confrontation with the
service providers. So the mentioning of standard operating procedure with
setting up of norms and standards for the OPD will be helpful for both the clients
and service providers to be realistic. It will also help the supervisors to measure
their institutional service standards.

09
Standard Operating
Procedure (SOP)
 1.b. Standard Operating Procedure (SOP)
of OPD

Alternate Compli
Responsible
Activities Time/No Responsible ance
Persons
Person rate
GENERAL a) Time table Before Superintendent RMO *
display, sign intervention
posting & Display
around
registration desk.
b) Registration 1.00 PM Superintendent RMO *
counter remain
closed--
c) Ticket will be Before Superintendent RMO *
marked intervention
-- by colour pen or
providing
colourde
ticket/seal for
each area
STEP-1 A. Registration 1 Minutes Clerk Second clerk *
counter/Desk responsible for
x Registration in registration
waiting place
of OPD area
x Ticket will be 9-00 AM Clerk assigned Second clerk *
provided to for registration
patient as
x Patient can be 2 Minutes Clerk assigned Second clerk *
sent to ORT for registration
comer or
emergency
directly if
necessary
STEP-2 Waiting Place Male-10 Superintendent RMO *
a) Sitting Femel-10
arrangement (for 20
person 5
b) Waste basket According Do RMO *
to monthly
c) Sputum box Two Do RMO *

d) Safe drinking One Do RMO *

water facilities
e) Toilet facilities one for Do RMO *
male one
for female
F) Health 9.00 AM to Do RMO *
education’s 2.00 PM
---- Audio
---- Video
---- Poster

10
Standard Operating
Procedure (SOP)
 Alternate Compli
Responsible
Activities Time/No Responsible ance
Persons
Person rate
g) Sign marking All activities Do RMO *
with same colour will be done
ticket/seal or before
room/area number intervention
towards respective
OPD
STEP-3 Consultation/Exami Do RMO *
nation room
a) Privacy
arrangement
b) Examination Before Superintendent RMO *
facilities— intervention
---- BP. instrument
---- Stethoscope
---- Tongue Do Do Do *
depressor
---- Thermometer
with
antiseptic lotion
---- Weight
machine
---- Height tape
---- Torch light
---- Hammer
---- Aural speculum
---- Gloves
---- Vaginal
speculum
Examination white
table covered with
Clean white cloth
c) Sitting Before Superintendent RMO *
arrangement for intervention
Doctor, chair &
table covered with
cloth
d) Dental surgeon
- Dental chair &
instrument
e) Sitting Before Superintendent RMO *
arrangement for intervention
patient
f) other facilities— One for Superintendent RMO *
--- Waste basket each
--- Basin
--- Soap
--- Light
Examination : clearly Concerned RMO *
a) Second written 2Min physician
registration with sl-
no, name, age, sex,
address, timing of in
& exit date

11
Standard Operating
Procedure (SOP)
 Alternate Compli
Responsible
Activities Time/No Responsible ance
Persons
Person rate
b) Filled up histories 4—6 Concerned RMO *
sheet minutes Physician
y Chief complaints
y History of present
illness
-- History of past
illness
y Family History
y Physical
examination
y Investigation
y Provisional
Diagnosis
y Treatment &
y Advice clearly
written
y Counseling by
providers
STEP-4 (A) X-ray Services Radiology RMO *
a) Registration & Technician
code number is
properly filled on
investigation slip
with brief history
b) First come first
serve
c) Maintain Que.
STEP-5 Dispensing of
Drugh:
a) First come First 2—3 Concerned Second *
serve minuets pharmacist Pharmacist *
b) Patient will be in
Queue by sex
c) Pharmacist
collect ticket & Regularly
Register the ticket
number
d) Dispense drugs &
with dose written
clearly
e) Proper
counseling
d) Reports are sent Next day
back to respective
Doctor:-
* Plain X-ray, Within 6 Medical RMO *
--- Chest hours Technologist
--- abdomen
--- Bone & joint
--- Special X-ray
--- Others Within 30
* Emergency X-ray minutes

12
Standard Operating
Procedure (SOP)
 Alternate Compli
Responsible
Activities Time/No Responsible ance
Persons
Person rate
(B) Pathology 4 Hours after Medical Other MT
a) First come first collecting Technologist
serve sample (Senior person)
b) Maintain Que.
c) Registration with after 72
code number with hours
arrival time
d) Routine Exam:- Same day
--- Stool R/E
--- Urine R/E
--- Blood for TC. DC.
ESR & Hb %
--- Sputum AFB
--- MP
--- Blood group and
cross matching
STEP-6 A. Admission Same day Admission Superintendent *
a) All patients is board/RMO/M
respective of their O on duty
income are eligible
for admission
b) Acutely ill.
patients are
admitted on priority
basis
c) Admission board
will admit the
patient
B. Referrals from Same day Admission Superintendent *
OPD board/RM/MO
a) Exact problem on duty
for which the
patient is being
referred, write
properly the area
of referral including
the documents &
short history

* Compliance rate:
Quality of care will be measure by Compliance rate is
Excellent : 91—100%
Very Good : 76—90%
Good : 50—76%
Bad : < 50%

13
Standard Operating
Procedure (SOP)
 1.c. Patinet Flow Chart In OPD Services
Ambulatory
patients
arrival

Registration

Need
No Yes In
further ORT
Discharge Need of
management Provision ORT

No

Waiting
Yes

History &
physical exam

Diagnostic
Diagnosed Procedures
Lab / X-ray

Management

Need
No further
Discharge
management

Yes

Yes Management
Discharge
available
in IPD

Referral

14
Standard Operating
Procedure (SOP)
 Working Procedures of
1.d. Out Patient Department
Registration
There should be a central desk at the OPD where patients will be provided OPD
slips after preliminary registration. This desk may also serve as the booth for
hospital information and health education. One nurse/relevant staff with skill in
human interactions may be deployed there. After taking brief history of patient's
illness he/she will direct them to the respective OPDs. Final registration of patients
will be done in the concerned OPDs.

Working rules
The patient treated in the OPD are usually ambulatory. Acutely ill patients must
not be referred to the out patient department. They must be management in
the emergency. In OPD, a short clinical examination is done and documented
in the OPD slip. It must include a clearly written provisional or clinical diagnosis as
well as the advice and treatment given to the patient. A list of investigation
planned may also be written on the slip for convenience of the patients. The
patients are given correctly and completely filled investigation forms. It must be
explained to the patients where Investigation Center is located for all the OPD
investigations (blood, urine and stool etc.), and the time when samples are
collected, and also how the reports are distributed at the OPD. As in usual
procedure, a patient will require to wait till the next OPD day. A way should be
found out in consultation with the clinical laboratory and radiology department
so that reports of majority of investigations may be available on the same day.
This will enable the clinicians to advice treatment to the OPD patients on the
same day without awaiting too much. for X-rays, the patients should be clearly
directed to communicate to the respective counter in the department and to
follow the preparatory instructions which will be given there.

In case of an emergency arising in the OPD, the in charge should be provided

with necessary first aid, drugs and investigations. After the first aid given, it is
advisable to shift the patient to the emergency department immediately.

To make things easy for the patients, it is advisable to fix a definite date
mentioning time & place for the next appointment which should be written
down on the slip. It must be remembered that quality of care provided at the
OPD should be comparable to in-patient care, and it should be the aim of the
hospital to deliver significant medical care to the community through the OPD.

15
Standard Operating
Procedure (SOP)
Necessary patient information must be written in the CPO register and
acceptable out-patient record with diagnosis be available.

Referrals from OPD

Reminders for Unit Heads
For obtaining the opinion of The (RMO/Superintendent)
Consultant the exact problem
for which the patient is being
Please...............
referred must be written down
on the OPD slip and the patient " Display up-to-date organgram
should be directed to the " Display other information charts, viz.
relevant OPD. While referring schedules general and visitors' policy,
the patient to any other activity report Service data for
specialty, please make sure guidance and transparency
that the result of the
" Schedule for routine daily and weekly
investigations done and-the list activities at fixed time
of investigations requested
" Monitor and supervise staff
should accompany by the
performance, cleanliness, equipment
patient. This will save repetition
maintenance and resources at the unit
of the investigations, time,
as per checklists
laboratories' time and also save
further discomfort to the " Send daily bed statement along with
patient. serious patients' list

" Maintain staff morale, punctuality,

interpersonal relationship, quest for
Admission of patients sound professional knowledge &
from OPD practice and their good behavior to
patients and people
A patient needing admission to
the wards for further " Maintain records properly
management will be admitted " Apply mechanism to receive
from the OPD through the feedback on users' feelings and
admission board and send the complaints
patient to the respective ward.
" Hold regular co-ordination meeting
Keep minutes and ensure follow up

" Send report to Director (Hospital),

DGHS & HCQA office by 6th day each
month as per specific report form.

16
Standard Operating
Procedure (SOP)
 1.e. OPD Service Monitoring Checklist

Sl As per SOP
Services Remarks
No. Yes No
Whether provided attention to patients and listed
1
their complaints?

2 Whether given answers to present Question?

3 Whether asked chief complaints?

4 Whether asked present history of illness?

Whether asked past history of illness and related

5
family history?

6 Whether patient checked for vitals signs?

7 Whether conducted related physical examinations?

8 Whether reached a provisional diagnosis?

Whether ordered condition related laboratory tests

9
or X-rays?

Whether provided to the patients / relatives

10 information about the condition and treatment
plan?

Whether discussed about the importance of

11
compliance with drug?

Whether adequate time spent for patient

12
consultation?

Whether provider wash hands before and between

13
patient examination?

Whether soiled covers are removed and replaced

14
before examining new patient?

Whether thermometer and tongue depressor are

15 kept soaked in antiseptic solution before examining
next patient?

16 Whether maintained patients discipline (Que)?

Whether patient counseling & health education

17
done?

18 Whether admission procedure SOP followed?

19 Whether referral procedure SOP followed?

17
Standard Operating
Procedure (SOP)
18
Standard Operating
Procedure (SOP)
 Chapter-2
2. In Patient Department (IPD Services)
2.a. Introduction:

F
rom Emergency and Out Patient Departments patients are admitted into
the In-Patient Department for further management by keeping the
patient under close monitoring. In Upazila Level Hospitals IPD is divided
mainly into male ward and female ward with 6 beds for MCH. All the male
patients> 12 years age are admitted into the male ward and all the female
patients and children age bellow 12 years are admitted into the female ward.
At Upazila level hospitals the duty doctor, nurses and the supporting staffs in the
IPD are accountable to RMO for their responsibilities and through RMO to TH &
FPO.

Usually the more sick, acute and seriously ill patients are admitted into the IPD for
immediate and supervised treatment protocol. They may also need to undergo
various diagnostic and or operative procedures and multiple inter related
activities are performed to serve an admitted patient. So, it is very much
important to coordinate and standardize these various components of IPD
services and also the various departments (i.e. doctors, nurses and support
service staffs).

During admission, patients and their relatives highly depend on the doctor and
other hospital staffs for the well-being and comfort of the patient and they are
psychologically more sensitive and vulnerable to various emotional matters. So,
beside clinical management of the patient, it is also important to look after
various behavioral aspects of the patient and their relatives for their satisfaction
and confidence. All concern staffs should be well concern about their dealings
with the patients and their attendants by considering the psychological status of
the respective person. They should be well tempered and skill in managing
emotional and critical situations.

Mention of standard operating procedure with norms and standards will be of

great importance to improve the IPD services as well as satisfy the patients
expectation and make them more rational about the real situation of the
hospital. By be informed about the available services and limitations will give a
more harmonious relation between service providers and their clients. It will
further improve human relationship, make people confident on the hospital
services and also improve the providers satisfaction to serve.

19
Standard Operating
Procedure (SOP)
 2.b. Standard Operating Procedures (SOP)
For in Patient Services (IPD)

Alternate Compli
Responsible
Steps Activities Time/No Responsible ance
Persons
Person Rate
GENERAL
A. House keeping 3 Times/24 hrs Cleaner/ Ward RMO
y Mopped & Swept the and when in-charge /On
floor necessary duty SSN †

y Clean toilets 1/shift & when Ward RMO †

y Fans, Walls, Roots, required boy/Sister /
Doors & Windows are Nursing
cleaned dusted. 2 times / week Supervisor †
y Tap water supply 24 h
y Attendant (Full time)
for serious patient
y Visitors as per
schedule

A. Facilities All the time Aya / wardboy RMO †

y Doctors/Nurese/Aya / Sister /
wear their dress & Nursing
badges Supervisor

y Investigation 1/patient Do RMO †

forms/Registers Report, Should
Record in registration maintain fixed
History sheet. visiting hour
for hospital

y Discharge forms, During Sister incharge RMO

Death certificates, working / Nursing
Temp chart, intake & period Supervisor
output chart, Height &
Weight chart, Digoxin
chart, Diabetic chart, All time Sister in charge RMO
Paragraph for labour
Patient

y Bed linen, pillow, All the time Sister in charge

pillow cover, Bedside / Wardboy /
locker, Mosquito net, Aya / Nursing
Mosquito net stand Supervisor
available according to
need.

y Stock ledger & All the time

required register, like
handover & take over
of charges (shift wise)
made available.

y Diet All the time

20
Standard Operating
Procedure (SOP)
 Alternate Compli
Responsible
Steps Activities Time/No Responsible ance
Persons
Person Rate
STEP-1 Reception and 3-5 min: SSN
Registration
y First attend duty room
y Registration in IPD
Register
y Bed allocation &
Preparation
y Health education &
instruction sheet
y Send the Patient to
bed
y inform Doctor on duty
STEP-2 A. Examination 8-10 min: Respective RMO *
* Check case sheet doctors
supplied from
emergency / OPD
* Ask chief complaints
* History
„ Present
„ past
„ Family
„ Personal
„ Menst. & Obst Respective RMO *
history of female doctors
patients
Physical examination
„ Pulse
„ BP
„ Temperature
„ Dehydration
„ Anaemia
„ Cyanosis
„ Oedema
„ Jaundice
„ Clubbing
„ Koilonechia
„ Height & Weight
„ Heart
„ Lung
„ Liver
„ Spleen
„ Kidney
„ Other systemic (within Two Pathologist / RMO *
examinations if hours) Radiaologist/
needed. Medical
„ Obst & Same day technologist/
Gynaecological (within 24 hrs) Doctors
examinations
when mecessary 10-15 minutes Respective Nursing *
(Examination doctors Supervisor
y Investigations. to Diagnosis & RMO
* Necessary treatment)
investigations:

„ Urgent Within 8 a.m SSN RMO

„ Routine 12 noon-1p.m.
Within 8 p.m

21
Standard Operating
Procedure (SOP)
 Alternate Compli
Responsible
Steps Activities Time/No Responsible ance
Persons
Person Rate
B. Diagnosis
* Provisional diagnosis
(Clinical diagonosis)

* Dignosis written clearly

C. Treatment
Treatment will be given
after

Signature of Doctor

D. Diet & Nutrition

Break fast

Lunch

Dinner
STEP-3 A. Further treatment
„ Counseling to the
patients need Respective RMO *
surgical doctor
investigation
„ Inform patient /
attendants well 24 hours
ahead of surgical before at
procedure once
RMO *
-Routine Case

-Emergency case at Boctors, SSN, Respective

once Aya, Do doctor
Continuously
B. Labour Case

„ Place in labour 24 hours

room when pain before
starts
„ Follow up
„ Maintenance of Following
pantograph morning

C. Transfer
„ If the patient is RMO *
improved then After one Respective
inform the patient week or if doctor
regarding needed
discharge.
„ Verbal advice 6 hrs before
and explanation
needed for ISSN/Doctor on RMO
illiterate patient At once within duty *
one hour
„ Follow up

„ If the patient
requires
specialized

22
Standard Operating
Procedure (SOP)
 Alternate Compli
Responsible
Steps Activities Time/No Responsible ance
Persons
Person Rate
services refer with
information
-----Routine case
-----Emergency

„ If death, sent to
mortuary/death
house/isolation
place/handed
over to relatives.

Compliance rate:
Quality of Care will be measured by compliance rate.
The Rated is Excellent : 91-100%
Very Good : 76-90%
Good : 50-75%
Bad : <50%

23
Standard Operating
Procedure (SOP)
 2.c. Flow Chart of IPD Service

Patient arrival
to nursing
duty room

Registration

File preparation

Bed preparation

Medical exam.
by the physician

Need
Lab or Yes for
X-ray /
investigation
Imaging

No

Management &
progress record

Surgical Yes
Operation
need

No

Yes No Stabilized
Referral Still
Alive health
status

No

Mortuary
Relative Discharge &
follow up

24
Standard Operating
Procedure (SOP)
 Working Procedure
2.d. In-Patient Ward
Under the new intervention program, the clinical in-patient units Male, female &
Children at Thana Hospital, will play independent and broader role. RMO will
have to shoulder the responsibilities to co-ordinate the over all activities. All
doctors, nurses and other staff will be accountable to TH & FPO.

Case sheet maintenance

Factors involved in good ware
Case sheet is an important management
document for patient care,
medical records and medicolegal Planning and fixing all regular
purposes. Therefore, it should be activities into program and listed in
looked after properly. The final ward policy book
responsibility for the case sheet Making a planned program for
upkeep is that of the statistician. each day’s work, in acquaintance
Please note that it is important to of all
adhere to the following sequence
Encouraging everybody to plan
in arranging .the case sheet:
next days work before leaving the
" Case sheet: particulars of ward
patient (including transfers)
Starting day on time
" Chief Complaints
Discourage interruption while one is
" History (present, past, family engaged in a particular task
and others)
Establishing of ward routine and
" Physical examination/Special policies which enable easy and
examination efficient work
" Investigations Orienting new staff

" Current treatment orders Maintaining suitable environment:

privacy, noise, proper ventilation,
" Previous treatment orders
temperature, smoothing light,
" Progress notes (including cleanliness, care of stores and utility
transfer notes) rooms
" Paretograph for labour patient Providing constant supplies and
equipment for efficient work:
" Consultant/Board
adequate supply should be kept in
" Opinion of consultant hand all times conveniently
" Opinion of other consultant (s) located and in good condition

25
Standard Operating
Procedure (SOP)
" Progress report
Clean cut doctor's order: in clear
" Discharge summary legible handwritings and complete
" Morning and evening round Accurate and complete records
should be ensured. Establishing good working
relationship among all members of
ward
Delegating certain responsibilities
Well planned assignments of staff:
interesting to staff, regarded as
education experience to them
Patient satisfaction: good care to
patient, readily available
consultation, feedback about
patients' and visitors' feelings and
comfort.
Transparency: Display the for
routine activities and visitors' policy
Monitoring and supervision
Evaluation

Progress report
Descriptive progress report should be written at intervals. Abbreviations should
better be avoided. Following guidelines are suggested for writing progress
report: Attending doctors should write his/her name distinctly.
• For acutely ill patients progress of pulse, respiration, temperature, blood
pressure, intake-output, treatment given, investigation reports and other
relevant facts regarding patient's illness must be written round the clock
(hourly, 2 hourly, 4 hourly, etc.).
• DI (Dangerously ill patient) list should be maintained .
• For routine patients, progress report may be written in SOAP headings after
the report of a certain investigation: when accident such as fall from bed
have occurred or if certain complications occur;
• When special procedures are carried out; when the patient undergoes
surgery (pre, per and postoperative). * Under certain circumstances, it is
advisable to make a flow chart of important parameters in addition to the
descriptive progress report, e.g. BP chart in hypertension, platelet,
reticulocyte, TC, DC blood count, blood urea, electrolytes, creatinine and
intake-output chart with renal failure.
26
Standard Operating
Procedure (SOP)
• Maintains of partograph for labour patient .

• Preparation for anesthesia, preoperative orders, written informed consent of

patient and post operative instructions.

Preparation for anesthesia and post operative instructions

Preoperative orders should be written well in advance so that sister can take
written informed consent of patient, and also other preparation, bowel washes,
enema etc. before patients retires to sleep. The nature of the procedure.
expected outcomes and the possibility of isolation/postoperative ventilation
should be explained thoroughly to the patient and attendant. Adult patient
should remain fasting from midnight. Children need to be kept fasting only 4-6
hours and can have milk between 4-5 a.m. Postoperative instructions should be
written clearly and the postoperative ward sister should be notified for special
instruction, e.g. hourly urine output, oxygen therapy, etc. Anesthesia deaths
must carefully be recorded and investigated.

Investigations and bed-side procedures

• All investigation forms must be completely filled in the previous night and
handed over to, the night nurse so that she gets ready for collection of
various samples and also be able to collect the morning samples of urine,
stool, sputum, etc.

• No regular or routine procedures may be done or ward round taken while

the meals are served to patients at the following hours. Breakfast, Lunch and
Dinner.

• All routine dressings and procedures should be done in the morning hours as
the maximum nursing staff is available in these hours. Only emergency
procedures should be taken up in the evening or at night.

• The instructions of the doctors to the nurses must be given in writing on the
case sheets as well as entered in doctors' instruction book of the ward.

The following guidelines may be regarded as ideal:

• Requisition for emergency investigations must be kept to a bare minimum.
An urgent investigation may be requisitioned only when truly urgent (ESR is
never an urgent investigation).

• The so called routine work-up investigations must be kept to a minimum.

Overloading the laboratory with irrelevant and unnecessary investigations is
one of the most important causes of unreliable report. An over burdened
laboratory can not function properly. Please remember, just as a clinician
has a right to ask for an investigation.

27
Standard Operating
Procedure (SOP)
• The investigations must be planned in such a way that a minimum number
of pricks are given to the patients.

• There can not be any excuse for giving several pricks a day to the patient.

• If a particular investigation requires the patient to be fasting, under no

circumstance should he/she be kept waiting. Such a patient must get
priority over all other routine works.

A sample should be accompanied by correct labeling of container with Name.

Reg. No. Age, Sex, Place of origin, Provisional diagnosis. Sometimes the
corroborative data is mandatory for the correct interpretation of the test.
Another important point to remember is that the doctor's name should be
written in block letters below the signature you may display a chart in the ward
showing amount of sample and method of collection for each test. This will be a
great help for the nurses who work in the ward for making such a chart, you
should better consult your own hospital laboratory. Below is an example of how
to make the chart.

Test Sample Amount Method of collection

Glucose (F) Blood 1 ml Collected in sugar tube prepared in
lab with anticoagulant and fluoride
Blood gas & Blood 1 ml Collected in anaerobic condition in
acid-base liquid paraffin, test tube kept in ice
cold water

Concerns of result for treatment

The treatment plan should be such that there remains concern for end results.
The number of patients recovered, not recovered, improved, not improved, not
treated, admitted for diagnosis only, or died, etc. are be carefully evaluated
and constant efforts are diverted for improvement of the figures. All tissues
removed at operation should be sent to pathologist and report of examination
should be placed in records. Appropriate procedures in relation to infection
control, sterile supplies and safety precautions are to be followed. Postoperative
infection rate and postoperative death rate must also be under vigilance. Delay
before operation must be reduced significantly, by doing preoperative
investigation in the out patient department. Every opportunity of health
education of patients and their visitors should be utilized by all personnel and
staff.

28
Standard Operating
Procedure (SOP)
Patient diets
It is very important part of the doctors working RMO on the ward to see that their
patients are getting the correct diet prescribed by them. Diet should be tasty.
However, if the patient is suffering from PEM and/or loosing protein due to illness
then he will need high protein diet should be categorized according to patients
need example high protein, diabetic, salt, restricted, diet, etc.

The following may be the general rule: When protein requirement is more than
100 gm a day, then extra egg may be added over regular diet. Fruits may be
added with milk diet, semisolid diet or those with tube feeding. Additional butter
may be added to patients needing more than 2400 calories a day. But before
prescribing extra, every body should be rational, because unnecessary extra
may cause pilferage in allocation for diet, which will cause sufferings of the
deserving patients. It is requested that the doctors in charge of the patient will
check the diet of his/her patient is getting. If any discrepancy is noticed, this
should be brought to the notice of nurse and dietitian.

Patients' attendants and attendant pass

In the general wards, no more than one attendant should usually be allowed to
stay with each patient. However, attendants should not be allowed to enter the
treatment room, operation theaters. Storage of food at the bed side should be
restricted. The attendants must leave the ward and wait at verandah during the
consultant's round. In pediatric ward, one attendant; preferably the mother,
may stay with the child even during the rounds. Identity card paper should be
provided to the attendant who will stay with patient. Other relatives and friends
can visit the patient only during the visiting hours. However, the doctors will
decide weather they will allow or not allow visitor(s) for a particular patient
depending upon their condition. The relatives of the patient must be informed of
the progress of the patient daily after the wards rounds. If needed, the
consultants may also discuss the problem of the patient with relatives after the
ward rounds. Each patient, irrespective of whether he/she is admitted to
general/paying bed is issued one attendant pass. This pass is issued by the ward
doctors. Only one attendant having the pass is permitted to stay with the patient
in the ward.

Discharge and follow up

For the convenience of patients it is suggested that they must be informed
about their contemplated discharge at least 24 hours in advance. It is advisable
to get a clearance of other consulting units if they have also been closely
involved in the patient's management. The discharge must be planned in such
a way that the patient acute bed by 11-00 a.m.
29
Standard Operating
Procedure (SOP)
This timing is helpful in many ways. The transportation of patient is easier during
the day rather than night. Patients are admitted from the OPD usually during
around noon time and they will be able to occupy the vacated bed
immediately rather than to wait for hours. A complete summary of the patient's
medical records duly signed by the authorized doctors of the unit is given to the
patient at the time of discharge. Discharge summary is the only official
documents given by the hospital to the patient. Therefore, it must truly reflect the
highest standards of medical care being given to patents in this hospital. It must
be exact, factually correct and concise. It must include the identity of the
treating unit, registration number, date of admission and discharge, diagnosis in
capital letters, summary of investigations, and clearly written instruction
regarding the follow-up management and the date, time, place and identity of
OPD where the patient should report for follow-up.

Transfer of patient to other

Reminders for Unit Heads
hospitals
Please..............
It is possible that due to the special
type of medical problem for which " Display up to date unit organ
specialized hospitals are earmarked, gram
or due to the shortage of bed, the " Display other information charts,
patients may be required to be
viz. Schedule, general and
transferred to some other hospitals. In
visitor’s policy, activity reports,
all such cases, it must be ensured that
etc. for guidance and
detailed case records, investigations
transparency.
and treatment done accompany the
patient; also the patients and their " Schedule routine daily and
relatives are properly explained the weekly activities at fixed time
reason of transfer to other hospital. " Monitor and supervise staff
Death Certificate performance, cleanliness,
equipment maintenance and
The death certificate must be filled
use of resources at your unit as
correctly as per the original case
sheet. it is signed by the authorized per checklist.
doctor of the unit with his .full name in " Maintain staff morale,
block letters. All case records duly punctuality, interpersonal
completed must be passed on relationship, quest for sound
promptly (within 24 hours of discharge professional knowledge and
or death) to the Medical Records practice and their good
Section. Incomplete records bring
behavior to patients and
bad name to the treating unit.
people.

30
Standard Operating
Procedure (SOP)
Availability of doctors and
" Maintain records properly
sisters
" Apply mechanism to receive
Doctors and sisters must always be
feedback about users feeling
available in the duty room in the ward
and complaints
round the clock. The nurse in charge
will be responsible for providing for " Hold regular coordination
good nursing care for all patients. She meeting each week. Keep
will be responsible for carrying out the minutes and ensure follow up.
medical advice given by the doctors " Send report to Hospital Director
and co-ordinating patients care at 6th day of each month as per
activities with all other departments.
specific Report from.
She will also instruct, supervise and
evaluate the performances of all " Medical audit must be done
other nursing personnel in the ward. regularly.

Patient satisfaction and transparency

Superintendent should motivate his personnel and staff to be particularly careful
to ensure patients satisfaction. Sympathetic and helping attitude and behavior
towards. patients and their relatives are important factors. Explanations of
patient's condition and reassurance may establish good rapport with the
people. Display of hospital drug list, list of available investigations, different
schedules, such as, ward round, meal time, visitor's policy, statistical data of
unit's patient care services during the last few months and in money value, etc.
may create scope for establishing transparency as well as building strong public
support for hospital.

Scheduling different activities

For the sake of easy and comfortable delivery of medical care to patients. it is
expected that all the activities of the ward will be carefully scheduled and the
different responsibilities will be assigned properly. A display of such schedule in
the ward will work in favour of transparency. and if followed property, will
enhance trust and image of the health care providers to the public.

Supervision checklist
To ensure sound delivery of medical care to patients, maintenance of sound
environment, including cleanliness and sanitation, equipment maintenance,
judicious use of materials and resources, staff morale and punctuality. specific
supervision checklist and feedback forms based on standard which is prepares
for this hospital and is agreed upon by all concerned should be strictly followed.

31
Standard Operating
Procedure (SOP)
Infection control
Infection among all patients, surgical, medical and obstetrical must be
investigated. Precaution should be taken to reduce infection brought in by
patients and visitors. Proper attention should be paid to house-keeping,
equipment, sterile techniques and supplies. periodic bacteriological tests of
appropriate items should be routinely carried out.

Co-ordination meeting
Each week, the institution head will organize a co-ordination meeting at his
office where all personnel and staff will participate. Review of performance and
issues for further improvement will be included in the agenda. Views will be
exchanged upon open discussion. Keeping of proper minutes and their
follow-up will be given special attention.

32
Standard Operating
Procedure (SOP)
 2.e. IPD Service Monitoring Checklist
Sl As per sop Score as
Services Remarks
No. Yes No N/A per SOP
Whether mopping/sweeping materials
1
supply adequate?
2 Whether toilet facilities satisfactory?
Whether fans, walls, doors, windows
3
clean and in good condition?
4 Whether supply of safe water adequate?
Whether display of visiting hours and
5
visiting policy displayed?
Whether Doctor/Nurse and other staffs
6
use of official dressed?
Whether forms, registers, history sheets,
7
records book are available supply?
Whether temperature chart, Ht/Wt chart,
8 Digoxin Chart. Diabetic chart,
partograph are used when necessary?
Whether patient registration done
9
properly?
Whether preparation and allocation of
10
bed accordingly?
11 Whether giving health education?
12 Whether following instruction sheet?
13 Whether using of case sheet properly?
14 Whether asking for chief complaints?
15 Whether taking history of the patient?
Whether physical examination done
16
properly?
Whether urgent investigation report
17
ensured within 2 hrs?
Whether routine investigation report
18
ensured within 24 hrs?
19 Whether diagnosis written clearly?
Whether treatment schedule written
20
clearly with signature of the doctor?
21 Whether food served as per schedule?
Whether counseling the patient before
22
surgical treatment?
Whether informing patient and
23
attendant before surgical procedure?
Whether maintain of pantograph in
24
labour case?
Whether procedure of discharge
25
followed properly?
Whether procedure of referral followed
26
properly?
Whether regarding death, hand-over of
27
dead body as per procedure?

33
Standard Operating
Procedure (SOP)
34
Standard Operating
Procedure (SOP)
 Chapter-3
3. House-Keeping
3.a. Introduction:

G
ood House keeping is an art of utmost importance of the hospital
services. No standard service can be provided without good house
keeping. Good house keeping can improve public relation and
psychological effect on patients, visitors and service providers. In Upazila Level
Hospital House Keeping is supervised by UH&FPO, RMO and QA facilitator. All
personal related to House Keeping should know the characteristics and qualities
of cleaning agents, their selection and proper use.

Primary activity of House Keeping includes the cleaning, dusting, moping and
related domestic duties involved in maintaining a high standard of cleanliness of
hospital. General sanitation, Mosquitoes, insects and other rodent control are
among the most important duties of House Keeping. The House Keeper acts as
an inspector and reports to respective supervisor. Routine work schedule should
be co-ordinate with other departments in order to provoke a minimum
disruption of other services. A system that involves water supply, ventilation,
sewerage and waste disposal etc. are of major concerns of good House
Keeping.

35
Standard Operating
Procedure (SOP)
 3.b. Standard Operating Procedure (SOP)
at Upazila Hospital on House-Keeping
Responsible Alternate Compliance
Activities Time/No
person person Rate
Step: A. Floor
1 „ Routine cleaning 2 times/working Cleaner, RMO Ward In *
day & when Charge
necessary
*
„ Dusting of wall & 1/week & MLSS/Aya Ward In
Roof, Door, necessary Charge
Window RMO

„ Furniture, Fan, 2times/day Cleaner, RMO Nursing *

Equipments Supervisor
Mopping
B. Scrubbing Once in a Cleaner, QI, Nursing *
week (Holiday) Facilitator & Supervisor
RMO
A. Bathroom & 1 time / day & Cleaner, RMO Nursing *
toilet when Supervisor
„ Cleaning necessary
„ Scrubbing 1 time / week
B. Segregation 2times/day & Cleaner, QI, Nursing *
Disposal of when needed Facilitator & Supervisor
waste: (hazardous) RMO
General, Sharp, Once daily
infectious wastes to (non
be collected hazardous)
separately.
C. Disposal of Cleaned once Cleaner, QI, Nursing *
waste from daily Facilitator & Supervisor
„ Waste basket RMO
Once / daily or
„ Sputum box
when needed
D. Maintenance of Once/month Cleaner, RMO Nursing *
waste basket Supervisor
sputum box
(colour & Repair)
E. Waste must be When Cleaner, QI, Nursing *
chemically necessary Facilitator & Supervisor
treated before RMO
disposal if it is
infectious. For
this purpose
chemicals
(phenyl, lysol,
carbolic acid,
bleaching
powder, etc.)
may be used.
F. OT : Keep ready All time RMO, QI Nursing
for all time. Incharge Supervisor

* Compliance rate :
Quality of Care will be compliance rate. The Rated is Excellent : 91-100%
Very Good : 76-90%, Good : 50-75%
36
Standard Operating
Procedure (SOP)
The above procedures can be applied in all areas of Upazila Hospitals,
Emergency, ward, OT, Labour room, kitchen and campus, where the following
activities will be done and in addition to above activities.

STEP : 2
Cleaning activity Expected Frequency Norm
Garbage removed from 2 Time/day or whenever
3
wards needed
Garbage removed from 2 Time/day or whenever
3
OTs needed
Garbage removed from
1 Once daily
Campus
2 Time/day or whenever
Kitchen 2
needed
Wards mopped and
3 3 Time/day
swept

Note : Garbage : staining Materials, Soiled Linen, Blood stain Gauge & Bandage.

Rules of detergent use

STEP : 3
Name Time
„ Lysol 30 ml/Liter of water/15bed ward
„ Vim 20 mg/ward/day (to clean basin & pans etc)
„ Soap 100 gram/week/500 Sq. ft floor space

After chemical treatment disposal hazardous/infectious waste shell be made by

dumping / burning every week or when needed.

Following may be considered :

Upazilla level hospital

1. Burning and dumping tools and facilities should be made available locally
or centrally.

2. Proper place for burning (incineration) and dumping should be specified.

3. Low cost incinerator may be considered for near future.

Non infectious sharps, plastics and metals may be brought for use by recycling
process and metals may be brought for use by recycling process if feasible. In
this respect hospital waste should be classified in certain criteria.

37
Standard Operating
Procedure (SOP)
 3.c. Working Procedure of House-Keeping
Good House-Keeping is an asset. No hospital can afford to be without. This is, not
only because of its public relations and psychological effects upon patients,
visitors and employees, but also from the standpoint of economy. The respective
TH & FPO/RMO/SSN/ Aya/Ward boy/Sweeper are mainly responsible for House
Keeping activities. Head of the housekeeping department should know the
characteristics and qualities of cleaning agents, their selection and proper use.
Since he/she will direct a fairly large
staff comprising unskilled workers he Several Tips of
should be capable of carrying out House-Keeping
continuous guidance and teaching. • Use, clean and care equipment
The primary activities of the • Give special attention In
housekeeping include the routine cleaning of special areas such
cleaning, dusting, mopping, and as male & female suit etc.
related domestic duties involved in
• Be careful in selection,
maintaining a high standard of
measurement and proper use of
cleanliness of the hospital. General
house keeping materials.
sanitation, are among the most
• Maintain cleaning schedule.
important duties. Housekeeping
employees are in the best position, in • Apply techniques for evaluation
their daily, intimate tours of duty, to of cleaning effectiveness.
assist all employees. Particularly the • Maintain liaison with infection
nursing staff and administrator, to control committee.
establish and maintain many aspects
of an adequate safety program. The housekeeper acts as an committee.
Inspector for and reports to the authority any repairs needed, such as damage
to floors or walls, peeling paint, or cracking plaster. He may initiate requisitions for
repairs of these and for various items of equipment and furniture. Routine work
schedules should be co-ordinated with those of other departments in order to
provoke a minimum disruption of all services. Systems that involve water supply,
ventilation, sewage, waste disposal, etc. are of major concerns.

Water supply
The water to be tested every month, treated to make it safe and potable for
drinking, hand washing, bathing, cooking, washing eatables and utensils,
preparation and processing of food.

38
Standard Operating
Procedure (SOP)
Ventilation and other equipment, furniture and bedding
Must be maintained carefully under a regular system of preventive
maintenance by keeping them clean, free from dust, dirt, etc. Critical address
like operation theater. post operative room, deliver room, new born nursery, are
be scrupulously clean, free from dust, dirt, etc. and preferably fitted with
ventilation system with controlled filtered air.

Storage areas
Storage areas, roof and staircase shall be clean the space under the staircases
shall not be used for storage. The store should be free from insects, rodent.

Waste disposal
Reminders for Manager
Solid wastes are ideally
Please.................
packed or wrapped at site
¾ Display up to date unit organogram of origin within minimum
¾ Display other information charts, viz, handling. patient care
schedules, general and visitors, policy, potentially hazardous.
activity reports etc. for guidance and isolation wastes and
transparency. materials contaminated
with secretions, excretions
¾ Schedule routine daily and weekly activities
or blood are to be
at fixed time.
collected in impervious
¾ Monitor and supervise staff performance, containers for handling
cleanliness, equipment maintenance and within hospital, Cover,
use of resources at your unit as per Tubes, sputum cups,
checklists. swabs, etc. are to be
preferably sterilized by
¾ Maintain staff morale, punctuality,
autoclave, prior to
interpersonal relationship, quest for sound
washing or discarding or
professional knowledge & practice and
incinerated.
their good behavior to patients and people.
¾ Maintain records properly.
¾ Apply mechanism to receive feedback
about users feelings and complaints.
¾ Hold regular co-ordianation meeting each
week. Keep minutes and ensure follow up.
¾ Send report to hospital Director (DGHS) &
HCQA office ant 6th day each month as per
specific Report Form.

39
Standard Operating
Procedure (SOP)
 3.d. Service Monitoring Checklist for
House-Keeping
Sl Response/ Result SOP-
Question / Observation Remarks
No. Yes No N/A Score
1 Whether clean of the floor
routinely?
2 Whether dusting of wall,
roof done routinely?
3 Whether dusting of
furniture done routinely?
4. Whether mopping of the
floor done routinely?
5 Whether scrubbing?
6 Whether cleaning of bath
room & toilets?
7 Whether scrubbing of bath
room & toilets?
8 Whether disposal of solid
waste?
9 Whether disposal of liquid
waste?
10 Whether disposal of waste
from waste basket &
spitting box?
11 Whether maintenance of
waste basket & spitting
box?
12 Whether chemical
treatment of the waste
done when necessary?
13 Whether removal of
garbage from the wards?
14 Whether removal of
garbage from the
campus?
15 Whether removal of
garbage from the
kitchen?

40
Standard Operating
Procedure (SOP)
 Chapter-4
4. Emergency
4.a. Introduction:

E
mergency department of hospitals is often the point of major public
interest and is the most vulnerable to criticism. The reputation of a hospital
rests to a very large measures on two important factors, i.e. the
emergency & OPD. The sudden and unexpected nature of the emergency
produces panic and psychological disturbance of relatives which must be
appreciated and born in mind in organization and management of services.
Emergency department is primarily meant for the immediate medical attention
and resuscitation of seriously ill patients. They should have priority over, less
serious patients. All patients attending the emergency are to be registered after
a quick preliminary assessment of the severity and urgency of their ailment by
the Medical Officer on duty. This is particularly an important point; clerical work
involving registration, etc. should never take priority over the urgent attention to
the acutely ill patient. All particulars as per the standard format should be
recorded in the emergency register. The emergency ticket should be clearly
filled up for name, age, sex, date, time, emergency registration number and
clinical diagnosis clearly. A summary of all the relevant clinical findings along
with the medical aid given, consultations and the progress of the patient is to be
noted down on the emergency register (register should contain clear
description of treatment details) by the attending doctor(s) before he/she is
admitted or discharged or referred to secondary or tertiary hospital. The original
emergency ticket is handed over to the patient.

41
Standard Operating
Procedure (SOP)
 4.b. Standard Operating Procedure (SOP)
of Emergency Services

Responsible Alternate Complian

Activities Time Limit
Persons Person ce rate
GENERAL x Waste basket in Before UH & FPO RMO †
Reception and waiting intervention
area
x Sputum box
x Toilet facility
x Safe drinking water
x sign posting & display
STEP : 1 x Reception Within-10 Medical Other †
[Managem x Registration Min Assistant / Medical
ent of x Ticket will be Pharmacist Assistant
patient Provided to patient
should x Ticket will be marked
take by a separate colour
precedenc or by emergency
e above seal
everything] x Call the M.O. on duty
STEP : 2 Resuscitation Immediately MO/Consult Other †
Examination ant MA MO
Diagnosis & Treatment 1hour Medical
x Resuscitation Technologist
x History taking (on call)
(Present, past,
families)
x Examination
x Investigation as
necessary
x X-ray if any
x Clinical Diagnosis
x Treatment & advice
STEP : 3 Further treatment 2 Hours Doctor on Other †
x Minor Injury : Send duty Doctor
the patient into OT
for repair
x when patient
requires plaster send
the patient to plaster
room / OT
x Labour case to
labour room
x IPD
x Referred to
secondary or tertiary
hospital
x Discharge / Follow-
up

† Compliance rate :
Quality of Care will be measure by Compliance rate :
The rate is Excellent : 91 – 100%
Very Good : 79 – 90%
Good : 50 – 75%,
Bad : < 50%

42
Standard Operating
Procedure (SOP)
4.c. Patient Flow Chart in Emergency Services

Patient arrival

Assessment by
receptionist

No
Ticket provision
Urgent
Waiting

Yes

Resuscitation History &

Physical exam.

Diagnostic No
procedures Diagnosed
Lab / X-ray

Yes

Management

Handed over No Pt. Further Yes Need

to relatives/ still local further
mortuary alive management management

No
Yes

Further Discharge
Local Yes management
referral available in
hospital

Distal
referral

43
Standard Operating
Procedure (SOP)
 4.d. List of Equipment, Materials and
Medicines for Emergency

Name of equipment Name of drugs and supplies

Patient table Autoclave
Stethoscope & BP instrument Naso-gastric tube
Thermometer Patient trolley & stretcher
Glucometer Screen & stand
Tongue depressor Inj. Antispasmotic
Injection Mg. Sulphate (For
Auroscope
Eclampsia)
Measuring Tape Injection Gardenal Sodium
Weighing machine Injection Hydrocortisone
Height scale Injection Diazepam
Torch light Injection Antihistamine
Filled up Oxygen cylinder with Flow meter Injection Pathedine
IV infusion stand and set Injection Atropine
Suturing materials Injection Aminophylline
Canula Injection Frusemide
Tourniquet Injection Quinine (on demand)
Disposable syringe and needles Injection Dexamethasone
Gloves Injection Lignocaine (2%)
Sterile gauze, bandage, micropore,
Inj. Ergometrin
plaster, splint etc
Sterilizer Injection Amoxycillin
Emergency trolley (with minor surgical
Antiseptic liquid
sets)
Emergency generator (Alternate Power Lignocaine jelly (for
supply) cathaterisation)
Suction machine Cap. Amoxycilin
Nebuliser Tab. Paracetamol
Tab. Tri-nitroglycerine, Tab.
ECG
Aspirin, Nifecap
IV fluids, Cholera fluids , DNS,
Stomach tube
DA
ORS, Glucose

44
Standard Operating
Procedure (SOP)
 4.e. Working Procedure of
Emergency Services
Patients requiring ambulatory care
Patients needing only ambulatory care should be given necessary first aid
treatment and sent home with appropriate advice written on the emergency
ticket. If they are referred to any OPD, the days, timing and location must be
properly explained to patients and written down on emergency ticket.

Patients requiring short term

Reminders for UH & FPO
observation
Please.............
Patient requiring close observation
to determine the further line of • Please Display up-to-date organ
management are to be admitted in gram
IPD. • Display other information charts,
i.e. schedules, general and visitor's
Patient requiring hospitalization policy, activity reports, etc. for
from emergency guidance and transparency.
Only the seriously ill patients and the • Schedule routine daily and
patient who cannot wait for the weekly activities at fixed time
regular OPD clinic should be • Monitor and supervise staff
admitted in the hospital. performance, cleanliness,
equipment maintenance and use
Transfer of patients to other of resource as per checklists.
hospital • Maintain staff morale, punctuality,
It is possible that due to interpersonal relationship, quest
non-availability of beds or because for sound professional knowledge
of nature of the medical problem & practice and good behavior to
patients and relatives.
requiring specialist care, the patient
may be transferred to the • Maintain records properly
concerned hospital. In all such • Apply mechanism to receive
cases, it must be ensured that feedback about user's feelings
proper first aid has been given and and complaints.
the reason of transfer is explained to • Hold regular co-ordination
the patient and relatives. Efficient meeting each week. Keep
ambulance service is essential for minutes and ensure follow up.
the quick transfer of patient. • Send report to Hospital Director,
(DGHS) & HCQA Project at 6th
day each month as per specific
Report Form.

45
Standard Operating
Procedure (SOP)
Emergency staff and administration
The staff posted in the emergency will work on shift basis. At the beginning of
every shift, the doctor and other staff must check and ensure that the
equipments are in working order. He/She should also know the emergency drugs
are in adequate supply.

General administration of emergency room

MO on duty will be responsible for the clinical management of the patient in the
emergency room. The general administration and control of other staff,
cleanliness, equipment maintenance, etc. will be looked after by the Resident
Medical officer. He will be responsible for the overall management of the
emergency room.

General conduct and behavior of the emergency staff

When a relative comes to the emergency room with a seriously ill patient, he/she
is emotionally upset and slightest apparent delay/ misdemeanors may trigger off
a violent reaction. All the staff are therefore required to be tolerant and should
extend due courtesy and sympathy to them.

46
Standard Operating
Procedure (SOP)
 4.f. Emergency Service
Monitoring Checklist

Sl Response/ Result SOP-

Question / Observation Remarks
No. Yes No N/A Score
1 Is the level of cleanliness
satisfactory?
2 Are signs & posting displayed
clearly?
3 Is the furniture & equipment’s
arrange well?
4. Is the staffing attendance?

5 Is the staff dressing properly?

6 Are waste basket & sputum

box available?
7 Is the patient received
properly
8 Does the patient wait less
then 10 minute?
9 Is the ticket provided marked
by specific colour seal?

10 Is resuscitation in case of
need done immediately?
11 Is history taken & examination
done properly?

12 Are the necessary

investigation done?
13 Are the urgent investigation
done within 1 hour?
14 Is the patient send to the
proper place for further
treatment?

47
Standard Operating
Procedure (SOP)
48
Standard Operating
Procedure (SOP)
 Chapter-5
5. SOP of Operation Theater
5.a. Introduction:

A
n operating theater is a facility within a hospital where surgical
operations are carried out in an aseptic environment.

Operating rooms are generally windowless and feature controlled

temperature and humidity. Special air handlers filter the air and maintain a
slightly elevated pressure. Electricity support has backup systems in case of a
black-out. Rooms are supplied with wall suction, oxygen, and possibly other
anesthetic gases. Key equipment consists of the operating table and the
anesthesia cart. In addition, there are tables to set up instruments. There is
storage space for common surgical supplies. There are containers for
disposables. Outside the operating room is a dedicated scrubbing area that is
used by surgeons, anesthetists, and nurses prior to surgery. An operating room
will have a map to enable the terminal cleaner to realign the operating table
and equipment to the desired layout during cleaning.

Several operating rooms are part of the operating suite that forms a distinct
section within a health-care facility. Besides the operating rooms and their wash
rooms, it contains rooms for personnel to change, wash, and rest, preparation
and recovery rooms(s), storage and cleaning facilities, offices, dedicated
corridors, and possibly other supportive units. In larger facilities, the operating
suite is climate- and air-controlled, and separated from other departments so
that only authorized personnel have access.

Objective of OT flow chart is to:

a) Standardize the pathways from entry of a patient to be operated as
well as going out.

b) It will give opportunity to get prepared for an operation well ahead with
necessary articles and actions.

c) It helps synchronized and harmonious actions by the OT team to have

desired outcome

49
Standard Operating
Procedure (SOP)
 5.b. List of Equipment, Materials and
Medicines for OT
Name of equipment Name of drugs and supplies
OT table Autoclave
Stethoscope & BP instrument Naso-gastric tube
Thermometer Patient trolley & stretcher
Glucometer Screen & stand
Laryngoscope Inj. Antispasmodic
OT light Injection Mg. Sulphate (For
Eclampsia)
Measuring Tape Injection Gardenal Sodium
Weighing machine Injection Hydrocortisone
Height scale Injection Diazepam
Torch light Injection Antihistamine
Oxygen cylinder with Flow meter Injection Pathedine
IV infusion stand and set Injection Atropine
Suture materials Injection Aminophylline
Canula Injection Frusemide
Tourniquet Injection Quinine (on demand)
Disposable syringe and needles Injection Dexamethasone
Gloves Injection Lignocaine (2%)
Sterile gauze, bandage, micropore, Inj. Ergometrin
plaster, splint etc
Sterilizer Injection Amoxycillin
Emergency medicine trolley Antiseptic liquid
Emergency generator (Alternate Lignocaine jelly (for
Power supply) cathaterisation)
Suction machine Cap. Amoxycilin
Nebulizer Tab. Paracetamol
ECG Tab. Tri-nitroglycerine , Tab. Aspirin,
Nifecap
Stomach tube IV fluids , Cholera fluids , DNS, DA
Anesthesia machine ORS, Glucose
Gloves

50
Standard Operating
Procedure (SOP)
 5.c. Flow Chart for Operation Theatre

Pt will be sent to the OT from ward or

emergency department with proper information

OT in charge will check the

information of patients operation

Emergency OT Routine OT
No

YES
Check for OT Cancel
PACU Not Ok

Arrangement for OT
Ok

Maintain Safe Surgery Checklist

Successfully Reevaluation /
completition of OT Death
No

Yes

Send the pt. to post operative ward

Observe the pt for

24 hours

Send to the ward /

Discharge

51
Standard Operating
Procedure (SOP)
 5.d. Standard Operating Procedures (SOP)
for OT
ALTERNATE
RESPONSIBL COMPLIAN
STEPS ACTIVITIES TIME/NO RESPONSIBL
E PERSONS CE RATE
E PERSON
GENERAL
A. House keeping 3 Times/24 Cleaner/ OT in
y Mopped & Swept the floor hrs and Ward in- charge
y Walls, Roots, Doors & when charge /On
Windows are cleaned necessary duty SSN OT in
dusted. 2 times / Aya / ward charge
y Tap water supply week boy / Sister
Facilities Regularly / Nursing OT in
y Doctors/Nurse/Aya wear Supervisor charge
their dress & badges
STEP-1 Reception and 3-5 min: SSN OT in
Registration charge
y First attendees in duty room
y Registration in IPD Register
y Bed allocation &
Preparation
y Health education &
instruction sheet
y Send the Patient to bed
y inform Doctor in duty
STEP-2 A. Examination 5-10 min Doctor
* Check case sheet
supplied from emergency
/OPD
Step-3 A. Further treatment 5-10 min Doctor
„ Cunselling the
patients need
surgical investigation
„ Inform patient /
attendants well
ahead of surgical
procedure
-Routine Case
-Emergency case at once
B. Follow up
If the patient required
specialized services
referred with information
-----Routine case
-----Emergency
If death sent to
mortuary/death
house/isolation
place/handed over to
relatives.

Compliance rate:
Quality of Care will be measure by compliance rate.
The Rated is Excellent : 91-100%
Very Good : 76-90%
Good : 50-75%
Bad : <50%

52
Standard Operating
Procedure (SOP)
 5.e. OT Service Monitoring Checklist

Sl As per sop Score as

Services Remarks
No. Yes No N/A per SOP
Whether mopping/sweeping
1
materials supply adequate?
Whether satisfactory walls, doors,
2 windows clean and in good
condition?
Whether use of OT dress by
3
Doctor/Nurse and other staffs?
Whether forms, registers, records
4
book are available?
Whether patient record done
5
properly?
Whether following instruction
6
sheet?
Whether checking of case sheet
7
properly?
Whether use safe surgery check
8
list routinely?
Whether cleaning of equipments
9
properly?
Whether autoclaving of
10
equipments properly?
Whether maintaining of
11
equipments list properly?
12 Whether disposal of solid waste?
13 Whether disposal of liquid waste?
Whether disposal of waste from
14
waste basket & spitting box?
Whether maintenance of waste
15
basket & spitting box?
Whether maintaining of AC
16
properly?
Whether use 0f consent form
17
routinely?
Is there 24-hour OT service
18
available for inpatients?
Is there available guideline for
19 different operation
procedure available?
20 Is the SOP on OT available?
Is the danger sign displayed in the
21
OT?

53
Standard Operating
Procedure (SOP)
Location:
The OT complex should be located on the ground floor as the OT department
should be easily accessible to the CSSD, Emergency and surgical wards.

Size:
• Optimum size of OT should be 18ft X 18ft.

• Wall: the floor height (tiling on the walls) must be 7-10 ft so that it can be
easily cleaned and Disinfected.

• Doors and Windows: Doors should be of 2 leaf type and self closing, at least
5ft wide. Windows should be 3ft and 4 inches above the floor and should be
covered with glass panes.

• Floor: The floor should be easily washable and non-staining.

Zoning in OT:
The OT complex should comprise of following zones:

1) Protective zone: this is the outermost zone and includes the changing room,
toilets etc. this is the area where everyday clothes can be worn.

2) Clean zone: Anesthesia preparation, pre medication, anesthetists’ office,

stores for sterile supplies, laying of sterile equipments, and scrubbing facility
is provided. Sterilization room with autoclave is also a part of the zone.

3) Sterile zone: The main OT remains in this zone where patient and staff enters
only after changing into sterile clothing.

4) Disposal zone: It comprises of the area where used instruments, waste

material and soiled linen are temporarily stored before being collected. The
zone must have separate passage from OT and should have independent
connection to outside. All the taps inside the OT should be elbow operated
taps.

Advantages of Zoning:
1) Minimizes the risk of hospital infection
2) Minimizes unproductive movement of staff, supplies and patients.
3) Increases efficiency of staff working in the operation suites and ensures
smooth workflow.
4) Reduces hazards in the operating suites.
5) Ensures proper positioning of the equipment.
6) Ensures optimum utilization of the operating suites.

54
Standard Operating
Procedure (SOP)
Items required:
1) Slipper stand

2) Clean slippers

3) Emergency tray with drugs (Drug list along with expiry dates to be pasted
above it)

4) Drug trolley (this should have anesthetic drugs as well as emergency drugs
and IV fluids)

5) Instrument Trolley

6) Hub cutter

7) Macintosh for OT tables

8) Cupboards for storing instruments

9) Bio Medical Waste Bins

10) Generator/ Invertor

55
Standard Operating
Procedure (SOP)
56
Standard Operating
Procedure (SOP)
 Chapter-6
6. Standard Operating Procedure (SOP)
of Pathology and Microbiology
6.a. Introduction:

T
he pathology service is an essential organization that assists doctors to
diagnose and treat illness. Clinical pathologists test tissue and body fluid
taken from patients for abnormalities and infection. It tells about how the
pathology and microbiology service is structured, the kind of work are
accomplished. There are many disciplines within pathology an almost all
pathology laboratories have several different departments. Four key
departments are Biochemistry, Hematology, Microbiology and Pathology. There
are some other variation in the way different hospital laboratories are organized
and run.
The SOP of pathology and microbiology tell about how specimens are
processed including, health and safety considerations, how the specimen is
collected and stored/transported, the tests that are carried out on the
specimen, how the specimen is recorded/tracked through the process, how
results are processed, the safeguards in place to protect patient information.
Microbiologists working in the pathology service routinely test patient samples
for bacterial infections. For most patients it is enough to identify the general type
of bacterium, for example E. coli or Streptococcus sp. but the specific strain isn’t
important. The patient’s samples are then checked for antibiotic sensitivity so
that treatment can be recommended.
In a hospital laboratory, microbiologists will test many samples at the same time.
In this case study you will carry out the procedure for one sample.
Aseptic technique is the most important skill a microbiologist needs to learn.
Using aseptic technique makes it unlikely that samples are contaminated with
micro-organisms from the environment (in the air or on surfaces) and the
micro-organisms being studied do not escape to cause infection.
Objectives:
- To provide a guide to services offered at the pathology and microbiology
department.
- To assist physicians to diagnosis.
- To ascertain sensitivity of organism.
- To guide aseptic techniques.

57
Standard Operating
Procedure (SOP)
 6.b. Standard Operating Procedure (SOP)
of Pathology and Microbiology

Responsible Alternat Compliance

Activities Time Limit
Persons e Person rate
GENERAL
x Necessary signage Before Rmo/Cleaner/ Patholo †
should present intervention MLSS of gy &
x Time schedule Pathology microbi
display department ology in
x Price list display charge
x Waste basket in
Reception and
waiting area
x Mopped & swept the
floor
x Fans, walls, roof,
doors & windows are
cleaned dusted.
x Toilet facility
x Sputum box
x Safe drinking water
x Health education –
how Pathological
sample collection
done.
x Sitting arrangement
of patients in waiting
room
x Sitting arrangement
of Pathologist,
doctors)
STEP : 1
x Reception (patient Within-05 Receptionist Other †
arrival in Pathology Min of Pathology Medical
department ) & Assistant
x Registration microbiology
x Issued charge slip will department,
be provided to
patient
x Ticket will be marked
by a separate colour
or by emergency
seal
STEP : 2
x Short history taking Within-10 Medical Patholo †
x Patient will be Min, Technologist gy in
prepared mentally of Pathology charge
x Should have the (For female
procedure explained patient-
to them female
x Concern about attendant
complication (if any) should
present)
STEP : 3
x Sample taking done With in 30 Pathologist & Alternate †
quickly for Urgent minute, microbiology Patholo
patient department gist /

58
Standard Operating
Procedure (SOP)
 Responsible Alternat Compliance
Activities Time Limit
Persons e Person rate
x Other patient- Or next doctor.
according to day/fixed
serial(on Pathology delivery
waiting room) date.
x Prepare the sample-
marking, identity,
drying and filing
x Examination/interpre
tation of film by
Pathologist
x Decision making
x Review the sample
x Confirmation of
disease
x Report typing
x Signature of
Pathologist/doctor
x Put the result in
register
x Give the report to
patient
x Advice for follow up
test (if needed)
STEP : 4
x Examination/interpre With in 30
tation of film by minute ,
Pathologist
x Decision making Or next
x Review the sample day/fixed
x Confirmation of delivery
disease date.
x Report typing IF C/S
x Signature of report will
Pathologist/doctor be
x Put the result in provided
register after 72
x Give the report to hours.
patient
x Advice for follow up
test (if needed)

† Compliance rate:
Quality of Care will be measure by Compliance rate:
The rate is Excellent : 91 – 100%
Very Good : 79 – 90%
Good : 50 – 75%
Bad : < 50%

59
Standard Operating
Procedure (SOP)
 6.c. Flow Chart of Pathology
and Microbiology
Pathological & microbiology test
requisition form generated by doctor

Patient arrival in Pathology&

microbiology department

Assessment by receptionist of Pathology& microbiology department

Registration complete

For IPD patient no charge

Issue charge slip applicable

Paid to cashier

Go to Pathology& microbiology or
sample taking room with receipt History taking

Quick YES NO Sample taking according to serial of

sample URGENT
patient (On Pathology waiting room)
taking

Sample examined

Interpretation of results by Pathologist & microbiology / Doctor

Preservation of samples
for one month
Decision
making

Waste disposal by
appropriate ways Reviewing of results

Typing the report with signature Preserved the report as a

document/data

Patient and a copy of

report arrive

60
Standard Operating
Procedure (SOP)
 6.d. Service Monitoring Checklist for
Pathology and Microbiology

Sl Response/ Result SOP-

Question / Observation Remarks
No. Yes No N/A Score
1. Is the Pathology & microbiology
department including rooms are
labeled?

2. Is the wall of Pathology &

microbiology room structured
according to law?

3. Is the level of cleanliness like roof,

wall, windows & floor satisfactory &
good condition?

4. Is the Pathology & microbiology

department free from unwanted
materials?

5. Are the signage system displayed

clearly?

6. Is the furniture & equipment

arranged well?

7. Whether display of time schedule

perfectly?

8. Has the patient waiting space

sufficient Sitting arrangements
(Male & female separate space)?

9. Whether is clean toilet?

10. Is the stuff adequate for Pathology

& microbiology?

11. Is the staff skilled enough?

12. Is the waste basket available?

13. Is the registration of patient done

properly?

14. Is the consent of patient taken?

15. Is the short history taken properly?

16. Whether counseling of the patient

before sample taking?

61
Standard Operating
Procedure (SOP)
 Sl Response/ Result SOP-
Question / Observation Remarks
No. Yes No N/A Score
17. Are the urgent test/procedure
done quickly?

18. Whether supply of safe water

adequate?

19. Whether forms, registers, films &

records book are in available
supply?

20. Whether giving health safety

instruction?

21. Whether diagnosis written clearly?

22. Is there 24-hour Pathology &

microbiology service available for
inpatients?

23. Is the guideline of Pathology &

microbiology available?

24. Is the SOP on Pathology &

microbiology department
available?

25. Is the danger sign displayed in the

Pathology & microbiology
department?

62
Standard Operating
Procedure (SOP)
 Chapter-7
7. Standard Operating Procedure (SOP)
of Radiology
7.a. Introduction:

T
he Department of Radiology and Imaging is nationally and internationally
recognized as the premier center for leading-edge musculoskeletal,
orthopedic and rheumatologic clinical and research imaging. Our mission
is to provide the highest quality diagnostic imaging for musculoskeletal
conditions and to provide image-guided treatment options to support
restoration of function and mobility. Our goal is to enhance the quality of patient
lives through cutting-edge research in diagnostic imaging – in MRI, CT,
ultrasound and interventional radiology – through the development of new
techniques that optimize the early detection and treatment of musculoskeletal
conditions.

Radiology is the medical specialty that uses medical imaging to diagnose and
treat diseases within the body. A variety of imaging techniques such as X-ray
radiography, ultrasound, computed tomography (CT), nuclear medicine
including positron emission tomography (PET), and magnetic resonance
imaging (MRI) are used to diagnose and/or treat diseases. Interventional
radiology is the performance of (usually minimally invasive) medical procedures
with the guidance of imaging technologies.

The modern practice of radiology involves several different healthcare

professions working as a team. The Radiologist, Nurses and Radiology
technologists usually work as a team.

Objective:
a) It provides steps to follow to get radiology done.
b) It helps to prepare general environment for radiology.
c) To ascertain fitness of patients for radiology.
d) It will guide to prepare patients for doing radiography

63
Standard Operating
Procedure (SOP)
 7.b. Standard Operating Procedure (SOP)
of Radiology
Responsible Alternate Compliance
Activities Time Limit
Persons Person rate
GENERAL
x Necessary signage Before Cleaner/ Radiology †
should present intervention MLSS of in charge
x Time schedule radiology
display department
x Price list display
x Waste basket in
Reception and
waiting area
x Mopped & swept the
floor
x Fans, walls, roof,
doors & windows are
cleaned dusted.
x Toilet facility
x Sputum box
x Safe drinking water
x health education –
how x-ray/imaging
done /procedure
x Sitting arrangement
of patients in waiting
room
x Sitting arrangement
of radiologist,
doctors.
STEP : 1
x Reception (patient Within-05 Min Receptionist Other †
arrival in radiology of radiology Medical
department ) department, Assistant
x Registration
x Issued charge slip will
be provided to
patient
x Ticket will be marked
by a separate colour
or by emergency
seal
x Urgent patient will
scan quickly
x Other patient-scan
according to
serial(on radiology
waiting room)
STEP : 2
x Short history taking Within-10 Medical Radiology †
x Patient will be Min, Technologist in charge
screened, dressed of radiology,
x Should have the If multiple x-
procedure explained ray of a
to them single Apply

64
Standard Operating
Procedure (SOP)
 Responsible Alternate Compliance
Activities Time Limit
Persons Person rate
x Preparation of patient/ protective
patient for unconscious guard(for
corresponding patient radiation)
scan(like- CTSCAN, (time may
MAMOGRAPGY, MRI) vary)
x X-ray/imaging done (For female
x Get dressed back patient-
into the cloth female
x Scan completion attendant
x Concern about should
complication (if any) present)
x Prepare the film-
marking, identity,
drying and filing.
STEP : 3
x Examination/interpre With in 30 Radiologist Alternate †
tation of film by minute , radiologist
radiologist/ ultra- / doctor.
sonologist Or next
x Decision making day/fixed
x Review the delivery
film/image date.
x Confirmation of
disease
x Report typing
x Signature of
radiologist/doctor
x Put the result in
register
x Give the report to
patient
x Advice for follow up
x-ray / scaning (if
needed)

† Compliance rate:
Quality of Care will be measure by Compliance rate:
The rate is Excellent : 91 – 100%
Very Good : 79 – 90%
Good : 50 – 75%
Bad : < 50%

65
Standard Operating
Procedure (SOP)
 7.c. Flow Chart of Radiology
Imaging request form
generated by doctor

Patient arrival in radiology

department

Assessment by receptionist of radiology department

Registration complete

Issue charge slip For IPD patient no charge applicable

Paid to cashier

Go to imaging room with

receipt

YES NO
Quick Scan according to serial of patient
URGENT
scan (on radiology waiting room)

Short history taking

Send for Patient will be screened, dressed and have their

examination explained to them

X-RAY CTSCAN MRI OTHER ULTRASOUND

(Preparation need for CTSCAN, MRI AND USG patient) After completion of scan

Get dressed back into the cloth

Film exposed

Interpretation of film by radiologist / ultrasound

Decision
making

Reviewing of image

Typing the report with signature Preserved the report as a document/data

Patient and a copy of report arrive

66
Standard Operating
Procedure (SOP)
 7.d. List of Equipments, Materials and
Medicines for Radiology

SL NO EQUIPMENT AND MATERIALS

01. X-Ray Unit—
Table,
Tube Assembly,
Spot Film Device,
Compression Device,
Image Intensifier and TV System,
X-Ray Generator,
Ambient Conditions,
Power Connection,
X-ray protection.
X-Ray Film processor
X-ray Film Viewer
Portable x-ray machine
Contrast media / injection
02. Ultrasound-
Viewing Monitor,
Image Display Modes,
Measurement and Analysis,
Probe connectors,
Probes-
General abdomen OB/GYN 2.5-6.0 MHz.
Small parts, PV (steered linear) 5.0-10.0 MHz.
Adult heart (harmonic echo) 2.1-3.8 MHz.
03. CT-scanner (compact tomography scan)-
Patient table,
Gantry -- Number of slices per rotation,
Detector,
X-ray subsystem,
Scanning parameters.
04. MRI (magnetic resonance of imaging)
05. Echocardiography
06. Mammography
07. Linear accelerator- used in radiotherapy for cancer
08. Positron emission tomography (PET Scan)
09. Interventional radiology- angioplasty, TIPS.
10. Radio-isotope scan or nuclear scintigraphy
11. SPECT scan

67
Standard Operating
Procedure (SOP)
 7.e. Service Monitoring Checklist
for Radiology
Sl Response/ Result SOP-
Question / Observation Remarks
No. Yes No N/A Score
Is the radiology department including rooms
1. are labeled?
Is the wall of radiology room structured
2. according to law?
Is the level of cleanliness like roof, wall,
3. windows & floor satisfactory & good
condition?
Is the radiology department free from
4. unwanted materials?
5. Are the signage system displayed clearly?
6. Is the furniture & equipment arranged well?
7. Whether display of time schedule perfectly?
Has the patient waiting space sufficient
8. Sitting arrangements (Male & female
separate space)?
9. Whether are clean toilets?
10. Is the stuff adequate for radiology?
Is there any radiation protection measures
11.
taken (lead gown)?
12. Is the waste basket available?
13. Is the registration of patient done properly?
14. Is the consent of patient taken?
15. Is the short history taken properly?
Is the privacy of the patient ensured during
16.
radiological procedure?
Are the urgent test/procedure done
17.
quickly?
18. Whether supply of safe water adequate?
Whether forms, registers, films & records
19.
book are in available supply?
20. Whether giving health safety instruction?
21. Whether diagnosis written clearly?
Whether counseling of the patient before x-
22. ray, ct-scan, mri & usg?
Is there 24-hour radiology service available
23.
for inpatients?
Is the guidelines of atomic Energy
24. Commission (AEC) available?
Is the SOP on radiology department
25.
available?
Is the danger sign displayed in the
26.
radiology department?

68
Standard Operating
Procedure (SOP)
Quality Improvement Secretariat
HEU, Health Service Division, MOHFW
www.qis.gov.bd