1.

Procedure(s) guide collection, identification, handling, safe transportation, processing Remar

and disposal of specimens.* k
2. Process addresses discharge of all patients including Medico-legal cases and patients
leaving against medical advice.*
3. Documented procedure (s) address care of patients arriving in the emergency
including handling of medico-legal cases.*
4. Documented policies and procedures are used to guide the rational use of blood and
blood products.*
5. Documented procedure for the administration of anaesthesia.*
6. Documented procedure addresses the prevention of adverse events like wrong site,
wrong patient and wrong surgery.*
7. Documented procedure incorporating purchase, storage, prescription and
dispensation of medications.*
8. Documented procedures address procurement and usage of implantable prostheses.*
9. Infection control manual, which is periodically updated and conducts surveillance
activities.*
10. Documented operational and maintenance (preventive and breakdown) plan for
clinical and support service equipment.*
11. The organization has a documented safe exit plan in case of fire and non-fire
emergencies.*
12. Documented disciplinary and grievance handling procedure.*
13. Documented policies and procedures for maintaining confidentiality, integrity and
security of records, data and information.*
14. Documented procedures exist for retention time of medical records, data and
information.*
15. Define process to whom the patient record can be released*
16. Procedure on destruction of medical records*