MSDS IMPLEMENTATION CHECKLIST FOR PHC ACCREDITATION

Functional
Standards Indicators Targets Subtargets
Area
1-AAC AAC-1. Laboratory Ind. 1. Scope of the a notification duly signed by MS that all required tests
services are laboratory services is are supported by hosp /outsourced
provided as per the commensureate to the
requirements of clinical services provided
patients by the organization
(Ind. 1-6)
Ind.2 . Adquately qualified 1)HR According to Lab human resource qualification
and trained personnel criteria
perform and or supervise 2) human resource against each designation should be
the investigations filled upfrom your disricts/ trained

Ind. 3. Policies and 1. histology slide boxes

procedures guide the :1.
First aid kit 1 absorbent compress (32 sq. in. with no 1. availability
Collection, 2. Identification,
side smaller than 4 in.)
3. Handling, 4. safe
transportation, 5.  16 adhesive bandages (1 x 3 in.) 2. location + display of first aid kit
Processing and 6. Disposal  adhesive tape (total of 5 yd.) 3.first aid kit content list display
of specimens
 10 individual-use antiseptic applications (0.5 g each) 4. first aid kit inspection list
 2 pairs of medical exam gloves o 4 sterile pads (3 x 3
in.)
 1 triangular bandage (40 x 40 x 56 in.)
 Antiseptics

3. proper labelling of samples (name, mr#, d/t, cs

4. signages (entry, exit, emergency exit)
5. eye wash station 1. availability
2. specifications
3. display inwritten form n picto9rial form
4. maintainess record
5. training to use eye wash station to lab employees
6. noxious chemical list display
7. portable safety exhaust hood
8. dry chemical fire extinguisher 1.fire extinguisher availability with numbering
2.f ire blanket
3. inspection list
4. display of use (dry + use)
9. hot plates and water bath 1. availability
2. general guide line display in urdu
10. display of lab safety general safety procedures in
pictorial form
11. safe transportaion of samples 1. boxes availability
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Functional
Standards Indicators Targets Subtargets
Area
12. chemical spill clean up kit 1. availability
2. content list + inspection list
13. Shower station in lab 1. equipment and display
2. training of lab employees
3. shower station maintainess record
14. annual vial calculated and procured alog with 10% 1. annaul vial consumption calculation
cushion
2. procurement evidence
15. material safety data sheets 1. yellow folder mounted on wall
2. documented sheets in urdu according to noxious chemicals
3. documented sheets for fire extinguisher, eye wash, shower station
4. spillage material safety data sheet
16 safety measures adopted in terms of head cover,
apron, tied shoes, goggles, PPE
17. primary specimen collection manual
18. lab safety manual
19. solvent chemical waste packing and labelling
20. hazardous waste 1.designated person to segregate
2. collection in disposable non leaking containors
3. complete labelling
4. proper treatment
21. incident/ accident report form
22. silt traps
23. External Quality Assurance
24. high risk area display
25. lab request form
26. lab file maintainence
27. CQI
Ind.4. Laboratroy results 1. display of lab tests(TAT, TATE,cost, In/outsource)
are available within a
defined time frame
2. Record register
3. 1 month compliance report of lab test being reported
in time
Ind.5. Critical results are 1. Display of lab test critical value 1. display of lab test with refference ranges, critical value
reported immediately to
the concerned personnel. 2. critical report register yearly no, date, time, MR,name,age/sex,department,lab test,lab advised by,critical
value,status, reported to,d/t,reported by whom,recheck requested
3. display of doctors list, contact numbers with
refference toconcerned department
 MSDS IMPLEMENTATION CHECKLIST FOR PHC ACCREDITATION
Functional
Standards Indicators Targets Subtargets
Area
Ind.6. Laboratory tests not 1. outsource lab test display(TAT, TATE, cost, reference
available in the range, critical value)
organization are
outsourced to organization
(s) based on their quality
assurance system and
independent accreditation.

AAC-2 Imaging Ind 7. Imaging services 2. External QA weekly and record maintainess
services are comply with legal and
provided as per the other requirements 1. display of radiation danger sign in radiology
clinical requirements department
of the patients. 2.Orientation record of key staff on
(Ind. 7-14) regulatory requirement of radiology
licensing,
3. Radiology request form
4. display of radiographers to use correct
postures
Ind. 8. Scope of the a notification duly signed by MS that all required tests
imaging services is are supported by hosp /outsourced
commensureate to the
clinical services provided
by the organization.

Ind. 9. Adequately 1. qualification criteria for HR in radiology

qualified and trained
personnel perform,
supervise and interpret 2. human resource against each designation should be
the investigations. filled up from your district/ trained, authorization
certificate to perform specific test
3. Orientation record of key staff on JD
Ind. 10. Policies and 1. safe transport of patient 1. spine boards, neck holders in wards and ambulance
rpocedures guide
identification and safe
transportatin of patients to 2. identification of pt. by complete info on paper, banding for indoor pt.
imaging services. 3. training to radiographers for safe transportation
4. display for radiographers for transportation
Ind. 11. Imaging results are 1.display of radiology services in reception, radiology 1. TAT,TATE,cost, inhouse/outsourced
available within a defined department
time frame. 2. reference range with critical value in radiology department
2. display of outsourced radiology services( TAT, TATE,
cost, refference range, critical value)

3. record register
4. 1 month compliance report (time)

Ind. 12. Critical results are 1. consultant contact list with name, department, contact
intimated immediately to no.# in radiology department
the concerned personnel.
 MSDS IMPLEMENTATION CHECKLIST FOR PHC ACCREDITATION
Functional
Standards Indicators Targets Subtargets
Area
2. critical results display in radiologist room and
ultrasound room

3 sops for reporting critical results

4. critical report register in radiologist room
Ind. 13. Quality Assurance 1. adverse event 1. adverse event register in radiology department, yearly no,d/t, mr no,name,age/sex,
activities are evident in the adverse event, reffered department,radiological test,advised by
Imaging Department.

2. equipment for QC program in radiology department 1. availability

(sensitometer, densitomete, brass and cu mesh,box of
film, Al step wedge,measuring tape, non mercury
thermometer, cleaning equipment, fluoroscopic tool test)
2. checklist for daily inspection of functional radiology QC equipment
Ind. 14. Imaging tests not 1. PNRA licensure of outsourced company
available in the
organization are
outsourced to organization 2. quality control program in manual and available
(s) based on their quality
assurance system and 3.daily surveillance o test results record register
compliance with (grading of x- rays)
applicable laws and
4. testing reagents and solutions (expiry any specific
regulations.
indicator
5. CPA
6. validation of equipment and test method 1. authenticated procurement
2. biomedical maintainance
3.packing and proper lablling
4. monthly observation of personeells methodology
conducting tests
8. re-dos form
9. calcualtion of reject rates on monthly basis
Care of Patients (COP)
COP-1: Emergency ind. 15 Policies and 1.code blue 1. speakers
services are guided Procedures for Emergency
by policies Care are Documented 2. phone line
procedures and code blue implementation ER code blue/resuscitation record register
applicable laws and complete resuscitation forms for last 3 months
regulations. ABC Categorization display on board in emergency
(Ind. 15-20) mock drill for code blue evidences
2. resuscitation trolley in every vicinity 1. contents

2.content list display

 MSDS IMPLEMENTATION CHECKLIST FOR PHC ACCREDITATION
Functional
Standards Indicators Targets Subtargets
Area
3.content list inspection list

4. crash cart display

5. resuscitation form

3. Duty replacemnet record 1. notification

2. duty replacement record register
3. duty replacement record for last 3 months
4. monthly on call consultant roster with their phone
numbers and home address
monthly on call consultant roster with their phone
numbers and home address last 3 months
3. clinical SOPs from consultants 1.• Blood borne pathogen exposure in patients presenting to ED
2.• Poisonings , pesticide poisonings

3.• Tetanus prophylaxis

• Rabies prophylaxis

4.• Reporting of criminal injury

5. major adult trauma, paedriatric trauma
6. hypovolemia

7. internal bleeding

8. cardiac arrest
9. MI

10. Cardiac arrythma

11. hypertensive/hypotensive emergencies

12. anaphylaxis

13. acute urticarial

14. pulmonary embolism
6. implied consent in udu displayed
CMO should provide data regarding resuscitation In
emergency in CQI meeting and it should be discused in
meeting and action advised should be acted upon

file maintainence in emergency ER code blue file

MLC file
training file
inspection file (resuscitation trolley, ,,,)
on call consultant roster file
roster file (including triage)
 MSDS IMPLEMENTATION CHECKLIST FOR PHC ACCREDITATION
Functional
Standards Indicators Targets Subtargets
Area
Emergency registers Emergency control register
Refereal register
MLC registers
Emergency blood transfusion forms
30 min display
compatibility stickers
Ind. 16. Polices also 1. MLC record register
address handling of MLC record of previous month
Ind. 17. The patients 1. training of emergency staff on manual policies and 1. training attendance sheets and trainer feed back orm
receive care in consonance SOPs with training record 2. trainee feedback form
with the policies. 3. training need assessment and impact form
4. training log
madadgar counter
nursing counter clean with displays
HAND WASHING TECHNIQUE AND STATION
display that patient is assessed on the basisi of severit of
disease
EMERGENCY EXIT PLAN AND ENTRY EXIST
curtain b/w beds
ER surgical trays
observation area
sample collection tray
Ind. 18. Policies and 1. triage area
procedures guide the 2. nomination for triage assessment duty on monthly
triage of patients for roster
initiation of appropriate 3. triage asessment area
care. triage pockets
triage area with boads
triage area coloured bedsheets
Ind. 19. Staff members are 2. trainings with training attendance, both feedbacks 4. training on triage
familiar with the policies
and trained on the
procedures for care of training on manual and SOPs
emergency patients.
Ind. 20. Admission or ER patient record 1.ER history form
discharge to home or
transfer to another 2. ER referrel form
organization is
documented. 3.Discharge summary

COP-2: Pplicies and Ind. 21. Documented 1. blood bank refrigerator 1. thermometer
procedures define Policies and procedures 2. data coder placement
rational use of blood are used to guide ratinal 3. refrigerator content list
and blood products. use of blood and blood 4. temperature regulation sheet
(Ind. 21-25) productgs. 2. blood bag record register
3. blood bank donor pool
4 blood bag issuing register
5. bloog bag cross match register

6. blood baag expiry register

7. blood bank waste register
 MSDS IMPLEMENTATION CHECKLIST FOR PHC ACCREDITATION
Functional
Standards Indicators Targets Subtargets
Area
8. bloog bag daily current status

9. manual in blood bank

10. screening for 5 odds
11. Blood bag return 11. Dangerous to patient label
12. bolod bag return form/ incident form
13. display of statement of blood bag return
14. blood bag return record register
12. compatibility label sticker
13. pre requisite form for blood transfusion
14. patient transufusion record sheet
15. Display regarding screening of donated blood for
Hepatitis B, C, HIV, MALARIA AND Syphilis.
16

Ind. 22. The transfusion 1) PBTA registeration 1. ACLS

services are governed by 2) compatibility form 2. BLS
the applicable laws and 3. ensuring compliance with criteria of blood bank
regulations. lisencing procedures
Ind. 23. Informed consent 1) informed consents 1) informed consent or attyia khoon
is obtained for donation
and transfusion of blood 2) informed consent for intiqal e khoon
and blood products.
2) designated person or donor examination

3. Donor examination form filled by MO

Ind. 24.Staff members are 1) training 1) training to phelobotomist

trained to implement the
2) Training of BTO
policies
3) Training of staff nurses on administration o blood

4) Training of staff nurses and blood bank staff on management of blood transfusion
reaction
Ind. 25. Transfusion 1. blood transfusion reaction 1. blood transfusion reaction report, demographic data,diagnosis, indication of
reaction are analyzed for transfusion,blood transfused by,cause of reaction,patient status,CPA
preventive and corrective 2. blood transfusion reaction register
actions.
2. prepare SOPs and incorporate in blood bank manual 1. STAT Versus NON-STAT orders
2. Surgical blood order shedules
3.• Medical indications for the transfusion of red cells, platelets, plasma and other blood
components
4. Uso of multi component versus pooled or single unit platelet
transfusion
5. Decision between targeted or universal leucodepletion
3. document Management of massive blood transfusions

4. • Integrated plan for the management of blood

shortages.

• Integration with hospital risk management

5. Response to external disaster

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Functional
Standards Indicators Targets Subtargets
Area
6. Integration with hospital risk management
7. blood bank meeting 1. meeting memo
2.minutes of meeting
3. meeting record register
4. CPA and CPA log sheet
COP-3: Policies and Ind. 26. The organization 1. defining and displaying high risk obs cases in gynae Antepartum haemorrhage  Post partum haemorrhage  Prolonged or obstructed
procedures guide the defines and displays ward and labour room labour  Postpartum sepsis  Complications of abortion  Pre-Eclampsia or Eclampsia 
care of high risk whether high rish Ectopic pregnancy  Ruptured uterus  Fetal Distress  Malpresentation  Twin
obstetrical patients obstetric cases can be pregnancy  Pregnancy with scarred uterus  Obstetrical shock / collapse  Pregnancy
(Ind. 26-30) cared for or not. with medical disorders

2. delivery room equipment availability, fetoscope,ultrasound machine, delivery table which can be turned to
tredelenberg position, anesthesia machine with emergency oxygen supply,ETT &
laryngoscope, incubator with separate o2 supply,mother privacy for breast feeding,
resuscitation trolley,suction machine, CTG,weighing machine for baby, intravenous
crystalloid and plasma expanders
2. display
3. checklist for daily inspection of Labour room equipment
3. isolation room for eclampsia in labour room
4. list of facilities refereing cases to facility
5. scope letter to facilities about gynae services
Ind. 27. Persons caring for 1. posts according to qualification criteria
high risk obstetric cases 2. verification of credentials
are competent.
3. display of gynae unit with qualification
4. gynae trainings with specialist involvement 1. documented plan
2. sheduling of staff for training
3. EmNOC
4 ENC
5. IMNCI
6. IMPAC
7. FP surgical and counselling
8. client centeredness
9. BLS
10. ACLS
11.General first aid
12. correct and appropriate use of biomedical equipment
5. guideline for medical assisstance
6. roster for on call and anesthetist
7. Display of SOPs dealing with hugh risk pregnancy

8. High risk cases markeing in labour room or pre op 1. high risk case stamp on file
2. high risk pregnancy wall hanging on bed side
Ind. 28. High-risk obstetric 1. maternal nutrition assessment chart
patients's assessment also
includes maternal
Ind. 29. The organization 1. NICU equipment 1. availability, emergency resuscitation drugs, ambu bag, appropriate neonatal size face
caring for high risk mask, selection of neonatal size ETTs, o2 and suction source, warmer work station,
obstetric cases has the incubators, trays to allow cannulation of umbilical artery, exchange transfusion trays,
facilities and technically infusion pumps to assure no volume over load
competent staff to take
2. display
care of neonates of such
 MSDS IMPLEMENTATION CHECKLIST FOR PHC ACCREDITATION
Functional
Standards Indicators Targets Subtargets
Area care of neonates of such
cases. 3. daily check list of NICU equipment

2. neonatal banding( name, age, mr #, date time)

3. temperature 1. maintainess
2. record
4. humidity 50% 1. maintaineance
2. record
5. methods to stop cross conatmination 1. air curtain
2. double door entry
3. shoe rack or changing area
4. handwashing facility inside and outside both with displays
5. training in hand washing techniques
5. visual signs
6. mother education sessions 1. record with responsibilty
2.pamphelets
7. posters 1. breast eeding poster 1 ( sonay ki boond)
2. breast feeding poster 2 (colostrum ater birth)
3. breast feeding poster 3 (6 month thoos ghaza)
4. breast feeding poster 4 (formula milk promotion prohibited)
5. breast feeding poster 5 (protection of breast feeding act)
Ind. 30. No treatment 1. patient identification 1. patient banding with name, age/sex, , mr#
should be administered
unless the identity of the 2. colour bands
patient can be guaranted.
3. techniques special for NICU

COP-4: Policies and Ind. 31. There is a

procedures guide the documented policy and
admnistration of procedure for the
anaesthesia admnistration
Ind. of for
32. All patients 1. pre anaesthesia assesment form
(Ind. 31- 40 anaesthesia have a pre-
anaesthetic assessment by
a qualified individual.
Ind. 33. The pre- 1. documented anaesthetic plan
anaesthesia assessment
results in formulation of an
anaesthetic plan for each
patient, which is
documented.
Ind. 34. An immediate 1. Pre op anesthesia check list
preoperative (pre-
induction re-evluatin is 2. who pre op anaesthesia checklist
Ind. 35. Informed consent 1. informed consent for anaesthesia by anesthesia team
for administration of
anaesthesia is obtained by
a qualified member of the
anaesthetic team.
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Standards Indicators Targets Subtargets
Area
Ind. 36. During 1. intraoperative anaesthesia form
anaesthesia, monitoring
includes regular and
periodic recording of heart
Ind. 37. No anaesthetic
should be administered
unless the identity of the
patient can be guaranteed.

Ind. 38. Each patients's 1. post anaesthesia monitoring form

post anaesthetic status is
monitored and
documented.
Ind. 39. A qualified 1. patient transfer recovery form
individual applies defined
criteria to transfer the
patient from the recovery 2.responsibilty of qualified personell display
area. display of sop who will transfer patient and according to
which criteria
3. GCS scale display
Ind. 40. All adverse 1. adverse event register yearly no, date, time, MR,name,age/sex, procedure name, anesthetist, surgeon,adverse
anaesthesia events are event, management,out come, inquiry, result.
recorded and monitored.
2. do not disturb" display on sentinel event

3. resuscitation form
COP-5: Policies and Ind. 41. The surgery- 1. notiication of OT incharge with responsibility
procedures guide the related policies and 2. OTMC notification with responsibility
care of patients procedures are 3. surgeons register
undergoing surgical documented. 3. ANAESTHESIST register
procedures. 4. stock register for electro medical equipment
(41-50) 5. prosthesis register
7. criteria selction by OTMC for OT performance analysis

8. operating theatre effeciency measurement tool by

OTMC
9.daily operation theatre effeciency monitoring
10. monthly OT performance for elective cases
11. monthly OT performance for emergency cases
12. daily operation theatre performance report
10. OTMC meeting 1. meeting memo
minutes of meeting
meeting record register
CPA and CPA log sheet
11. displays high risk area
restricted area also in urdu
identifiers for patient identification
12. display of changing area and formation of changing
area
 MSDS IMPLEMENTATION CHECKLIST FOR PHC ACCREDITATION
Functional
Standards Indicators Targets Subtargets
Area
13. floor mapping in OT red line

14. changing area linked with OT for doctors and nurses

with proper display
Ind. 42. Surgical patients 1. Surgery pre-op assessment form
have a pre-operative
assessment and a
provisional diagnosis
documented prior to
surgery.

Ind. 43. An informed 1. informed consent in urdu

consent is obtained by a
qualified medical member
of the surgical team prior
to the procedure.

Ind. 44. Documented 1. preventing patient from wrong surgery protocol ,name,age/sex, telephone no,id card number,DOB, adress , ID band with MR, surgical site
policies and procedures marked before ptient preparatrion, thumb of that site marked, consent in case of patient
exist to prevent adverse refusal to mark.
events like wrong site,
wrong patient and wrong 2. time out protocol
surgery. 3. display : correct operative site is responsibilty of
surgical team members
4. patient identification stamp
Ind. 45. Persons qualified 1. surgeon list display 1.notification and displayed
by law are permitted to
perform the procedures
that they are entitled to 2. credential verification form in surgeon personal file
perform.

Ind. 46. A brief operative 1. operating note

note is documented by the
surgeon or a doctor in the
surgical team prior to
transferring the patient
out of the recovery area.
2. surgical specimen examination request form

Ind. 47. The operating 1. post op plan of care sheet

surgeon or their surgical
assitant documents the 2. call bell in lights in recovery room
post-operative plan of
care. 3. sequence compression devices in revovery room

monitoring file
Ind. 48. A quality document plan
assurance program is 2. surgical safety check list
followed for the surgical 3. MIS 1 number of surgeries performed by individual surgeons
services. 2 swab culture reports
3 quantity of medicines and consumables used
 MSDS IMPLEMENTATION CHECKLIST FOR PHC ACCREDITATION
Functional
Standards Indicators Targets Subtargets
Area
Ind. 49. The surgical 1. daily monitoring of humidiy and temperature
quality assurance program 2. MONTHLY MONITORING Of pressure differential
includes surveillance of the
operation theatre 3. Six monthly monitoring of integrity of filter
environment. 4. Medical equipment maintainance
5. Monitoring of OT Cleaning and disinfection processes ???

Ind. 50. The plan also 1.SSIS committee notification with responsibility
includes monitoring of 2. SSIS register
surgical site infection 3. CPA and Cpa log sheet
rates. 4. cause analysis report from all surgery specialities on
monthly basis
5.meeting memo
6. minutes of meeting
7. preventive guide lines for SSIS
Management of MOM-1: Policies and Ind. 51. Documented 1. manual training Training log sheet
Medication procedures exist for policies and procedures Training attendance sheet
(MOM) the prescription of exist for the presciption of Trainer feed back
medications. medications. Trainee feedback
(Ind. 51-57) Training need assessment and impact form
2. patient record contain a list of medication taken prior
to admission on history form
3, approved abbreviations display in all wards
4. drug comitee formulation with JD
5. Meeting record of drug committee 1.meeting memo
2. minutes of meeting
meeting record register
4. CPA form and CPA log sheet
Ind. 52. The organization 1)policy regarding who can prescribe orders in terms of
formally determines who notification
can write orders. 2) policy distribution to all ward incharges , HOD, with
receiving signatures
Ind. 53. Orders are written 1) out door slip
in a uniform location in the 2) emergency slip/ discharge discharge form
medical records. emergency slip
3) indoor treatment sheet
4) medication summary for pharmavist review
Ind. 54. Medication orders 1) display of order writing instructions
are clear, legible, dated, 2) observational record on order writing instructions
timed, named and signed.
3. display of 5 rights of medication
Ind. 55. Policy on verbal 1) display on verbal order
orders is documented and 2) observational record on verbal orders
Ind. 56. The organization 1. labelling of high risk medication
defines a list of high-risk
medication.

2. Display of high risk medication at 3 places ; doctor

office, nursing counter, pharmacy, storage area
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Standards Indicators Targets Subtargets
Area
3. high risk medication should include: conc. Electrolytes,
very high cost drugs, lasa, physcotropics etc

3. humidity temp device and maintainance of high risk

medicine storage
Ind. 57. High risk 1. display of high risk medication double check sop
medication orders are
verified prior to
dispensing. 2. Training for high risk medication double check SOP

4. pop up msgs for look alike and sound alike drugs

5. high lighted stickers on packaging

6. high lighted drug storage areas
7. tall man lettering
8. separate storage for high risk medication
Ind. 58. Documented 1. bin cards
policies and rpcedures 2. medication storage area temp and humidity control 1. device for monitoring temp and humidity
guide the safe storage and 2. record maintainance
dispensing of medications. 3. drug storage optimum temp list should be prepared and displayed at storage sites

3. conc. Electrolytes stored separately with label, where

it is not possible to keep separate make boxes with label
for temporary partition
4. storage area inspection sheet/form
5. storage area inspection area report with CPA and CPA
log sheet
6. training of staff in aseptic techninques whle preparing
sterile products
7. area for drug preparation should be cleaned
periodically and checklist duty signed
8. displya for patient, medication, route, dose and 1. display in urdu
method identification duly signed by hospital
administration
9. labelling of prepared medication prior to preparation
of seond drug
10. display for verification of medication before
dispensation
MOM-2: Policies and Ind. 59. The policies 1. medication recall form
procedures guide the include a procdfor 2. medication recall record register
safe dispensing of medication recall. 3. medication problem investigation form
medications. CPA with log sheet
(Ind. 58-61) Ind. 60. Expiry dates are 1) medicine dispensation record register with expiry
checked and documented
prior to dispensing.

Ind. 61. Labelling 1. labelling requirements displays 1. bedside medication check list
requirements are 2. medication check list
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Ind. 62. Medications are 1. list notified and displayed in wards
administered (dispensed)
by those who are
permitted by law to do so.

MOM-3: There are Ind. 63. Prepared 1. display

defined procedures medications are lebelled
for medication prior to preparation of a
administration. second drug.
(Ind. 62-71)
Ind. 64. Patient is display
identified prior to
administration.
Ind. 65. Medication is display
verfied from the order
prior to administration.
Ind. 66. Dosage is verfied display
from the order pior to
administration.
Ind. 67. Route is verfied display
from the order prior to
administration.
Ind. 68. Timing is verfied display
from the order prior to
administration.
Ind. 69. Medication 1) medication administration sheet
administration is
documented.
Ind. 70. Policies and display
procedures govern
patients's self-
administration of
medications.
Ind. 71. Policies and display as above
procedures govern Electricity backup with record maintainance
patients's medications A UPS backup
brought from outside the Drug therapy problem forms
organization. Temperature, humidity check lists. Pasted on
refrigerators as well as record keeping.
Temperature, humidity devices attached with
refrigerators and also in pharmacy rooms
Follow dress code with ID badges
Medication content list/Inventory list
Displays of High risk mediation
POP UP messages for high risk medication
Tall man lettering display
LASA display
Inventory, stock in & stock out record register
Pharmacist medication dispensation proper packing,
labeling and dispatching to wards.
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Standards Indicators Targets Subtargets
Area
Patient Rights PRE-1: A Ind. 72. General consent 1) general consent form in urdu
and Education documented process for treatment is obtained
(PRE) for obtaining patient when the patient enters
and or family the organization. Patient
consent exists for and or their family
informed decision members are informed of 2. Interpreter list display with contact number in ward
makein about their the scope of such general
care. consent.
(Ind. 72-75)
Ind. 73. The organization 1. display of situations requiring informed consent on
has listed those situations various places
where specific informed
consent is required.

Ind. 74. Informed consent 1. informed consent form in urdu

includes information on
risks, benefits, and
alternatives and as to who
will perform the requisite
procedure in a language
that they can understand.

Ind. 75. The policy notification regarding consent in case of incapacitation

descirbes who can give of patient to make informed decision making
consent when patient is
incapable of independent
decision-making.

Ind. 76. There is uniform 1. urdu statement display about pricing policy
pricing policy in a given
setting (out-patient and
ward category).

PRE-2: patient and Ind. 77. The tariff list is 1) tariff charges inquiry statement display
families have a right available to patients.
to information on 2) deignate a resource person for providing an estimate
expected costs. of the expense before treatment
(Ind. 76- 79)

3) tariff rates and list in printed form are required at

designated counter

Ind. 78. Patients aned

family are educated about
the estimated costs of
treatment.
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Standards Indicators Targets Subtargets
Area
Ind. 79. Patients and family
are informed about the
financial implications
when there is a change in
the patient condition or
treatment setting.

PRE-3 Patient Rights Ind. 80. The organizatioin 1. patient right and responsibility in urdu display
for Appeals and infroms the patient of
Complaints his/her right to express
(Ind. 80-83) his/her concern or
complain either verbally or
in writing.

Ind. 81. There is a 1) complaint management systm 1) complaint register

documented process for
collecting, prioritizing,
reporting and 2) complaint processing register
investigating complaints,
which is fair and timely. 3) complaint boxes with display in urdu with statement

4) complainent orm in urdu

Ind. 82. The organization

informs thepatient of the
progress of the
investigation at regular
intervals and informs
about the outcome.

Ind. 83. The organization 1. feed back form in urdu

uses the results of 2. CPA form used for complaint and feed back
complaints investigations 3. CPA log sheet
Hospital HIC-1 The Ind. 84. The hospital 1) HIC program documented 1. documented plan
Infection Organization has a infection control
Control (HIC) well designed, programme is documented
comprehensive & which aims at preventing 2.survellence activities
cordinated ICP and reducing risk of 3.hand hygiene procedures
aimed at reducing / nosocmial infections. 4. isolation procedures
eliminating risks to 5. infection control committee
pts, visitors & 6.responsibilities of ICC
providers of care. 7. authorities of ICC
(Ind. 84-89) 8. departmental infection control plan implementation
2. drinking water 1. display
2. analysis report of drinking water
3. CPA WITH CPA log sheet
3. weekly syringe utilization report
hep c control records 1. screening register
2. treatment register
3. treatment deferment register
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4 hepatitis b vaccination register
5 pcr requisition register
Ind. 85. The hospital has a 1) infection control committee 1) notification with TORs
multi-disciplinary
infection Control meeting notification
Committee. 2. minutes of meeting forms
3.HIC meeting record register
cpa with cpa log sheet
HIC meeting file
PPE MEETING
Ind. 86. The hospital has 1)infection control team 1)notification with TORs
an infection control team.
2. HIC team round report register
Ind. 87. The hospital has 1) ICN/ICO with diploma atleast or training
designated a qualified
infection control nurse(s) 2. HR record of ICN qualification or criteria
Ind. 88. The establishment 1) signages no smoking,wet floor, no mobile phones
has appropriate
consumables, collection 2. handwashing technique display 1. display in urdu
and handling systems,
equipment and facilities to 2. availability washing station
manage the control of 3. PPE 1. availability of gloves
infection. 2. availability of masks
3. sharp collection conatainer
4. washroom cleaning checklist
5. patient care equipment 1. single use syringes
6. pathway for waste disposal
7. trainings 1. Use of PPE
8. calculation of daily requirements of gloves, gowns,
masks
9. bed pan washer/ disinfector in ward
10. high temperature washing up machine ?
11. disinfection of accessories 1. hard surfaces with phenolic/ hypochlorite solution,
2. equipment with 70 % alcohol
3. sphyngomanometer cufs with low temp steam
4. thermometers in isolation room until pt is discharged
13. colour coded linen bags for transfer of infected linen. 1. linen bags foe infected lined
With labelling o hazard e.g hep b 2. labelling
14. waste management personnel vaccinationr records
of hep B, tetanus and register
15. prick investigation record register for WM record register
employees 2. incident record form
2 . Notification of vaccination and prick investigation
16. bed pan usage 1 display of usage of bed pans/ urinals
2. training of usage of bed pans and cleaning
Ind. 89. All staff involved in 1)Waste segregation table display in urdu
the creation, handling and
disposal of medical waste 2. 3 coloured baskets with lids and foot handle
shall receive regular
training and ongoing
educatin in the safe 2) washing station 1) hand washing technique display in urdu
handling of medical waste.
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2) hand drying technique with display

3) santinizer
4) liquid soap
3. designating a hospital waste management officer with
resposibilty/JD
4. Designate a hospital waste management team WMT
5. Hospital waste management plan
6. Trainings 1) hazards and safe management of different types of waste(collection, segregation at
source, storage,
2. assessing transportation)
requirement / sheduling/ resheduling, reviewing impact of training
ppe training
7. report format of waste management 1. daily infectious waste generation in wards/units
2. daily glass/sharp waste generation inwards/ units
3 daily domestic waste generation in wards/units
4. daily data collection format for gynaecological waste / anatomy waste/ OT
5 daily data collection format for anatomic/ pathological waste/ OT
6 daily injection waste collection formate
7 monthly report format
8. waste consigment note waste transportation from yellow room to disposal site
waste at disposal site
9. waste management audit list
10. meetings ON PPE and safe and hazardous waste meeting memo
segregation minute f meetings
cpa with cpa log sheet
WM meeting record register
11. waste management program  Collection
 Segregation at source
 Storage
 Transportation
 Disposal leading to incinerator or contract with outsource company
 Staff Training
 Availability of SOP’s
 Equipment regarding waste management (Globs, apron , goggles, long
boots, etc)
 Documentation (Register, form)
 Employee prick incident follow
HIC-2: There are Ind. 90. There is adequate 1. Proper zoning of CSSD sterilization 1. proper zoning
documented space available for 2. floor mapping
procedures for sterilization activities. 3. zones display for clean, dirty, sterile , disinfecting, storage, washing etc
sterilization hidayat nama about sterilization
activities in the RO filtration plant
organization. DISINFECTANTS
(Ind. 90-92) disinfection concentration daily checklist
4. physical barriers separating all zones
4. Displays 1. display of sterilization cycle
2. display of low process of CSSD
3. Wrapping technique
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4. Packaging 1. wrapping material
2. training of packaging technique
3. sealer printer availability
4. date of sterilizarion and expiry printed by sealer
5. pressure air flow maintainess 1. exhaust fan
2. AC
uv light lamps
Ind. 91. Regular validation 1. availability of CSSD validation tests
tests for sterilization are
carried out and 2. CSSD validation test record
documented.
4. CSSD audit list
3. sterilization unit incharge notification with
responsibility
Ind. 92. There is an 1. Breakdown recall procedure forms
established recall
procedure when 2. breakdown recall register record
breakdown in the
sterilization system is 3. breakdown complaint orm
identified.
4. Pressure airflow maintainance 1. AC in clean zone
2. exhaust fan in dirty zone
3. Air curtain on entry
5. training on breakdown recall procedure with forms
evidence
6. test strips bottles are dated when opened
7. autoclave daily checklist
Continuous CQI-1: There is a Ind. 93. The quality 1) QA committee with responsibility
Quality structured quality improvement programme
Improvement improvement and is developed, implemented 2. clinical audit committee with TORs
(CQI) continuous and maintained by a multi- 2) coordinaters for all department designated to ensure
monitoring disciplinary committee. implementation and display list in all departments
programme in the
organization documented CQI plan  committee with terms of reference,
(Ind. 93-98)  CQI methodology to be used,
 reporting structure of CQI results,
 minutes of meting and relevant progress,
 TORs of committee,
 review frequency of program,
 Coordinator for all department
 Risk Management
Ind. 94. The qaulity 2. CQI Meeting topics should cover following heads Diagnostic services
improvement programme Clinical Services
is documented. Blood Bank Services
Surgical Services
MOM
HIC
Waste Management
Sterilization Unit
ROM
Biomedical
Security Services
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Area
HR
Appraisal System
Clinical Audit & Mortality Analyses (Clinical Audit Committee Reports)
Medical Record Review Report (Medical Record Review Committee)
Operation Theater efficiency monitoring & surveillance
Ind. 95. There is a notification of designated person should be health
designated individual for professional with TORs
coordinating and
implementing the quality
improvement programme.

Ind. 96. The quality

improvement programme
is comprehensive and
covers All the major
elements related to quality
improvement and rishk
management.

Ind. 97. The designated CQI program training to all members 1. training notification
programme is 2. training attendance sheet with trainer feed back
communicated and 3. trainee feed back
coordinated amongst all 4. training need and assessment form
Ind. 98. The quality review of CQI program meeting notification for review of CQI program
improvement programme minutes of meeting
is a continuous process meeting attendance sheet
and updated at least once cpa with cpa log sheet
Ind. 99. Monitoring Review the CQI committee minutes about Time for initial assessment of patient both in emergency and outdoor
includes appropriate % of indoor cases with nutritional assessment screening and nutritional assessment
patient assessment. carried out mandatory for paeds and Gynae and burn unit and dialysis unit

% of indoor cases with documented nursing plan

% of indoor cases with positive outcomes
Time for initial assessment of patient both in emergency Triage for emergency
and outdoor Compare admission slip time & ward admission receiving notes time
Perform sample based file assessment
% of indoor cases with nutritional assessment screening Medical record review form
and nutritional assessment carried out mandatory for Nutritional assessment form
paeds and Gynae and burn unit and dialysis unit Calculate percentage Report
% of indoor cases with documented nursing plan Healthcare plan
Surgical Post of care documented & counter signed by clinician
Evidence in medical record review form
Calculate percentage Report
% of indoor cases with positive outcomes Review filled nursing plans
Evidence in medical record review form
Calculate percentage Report
CQI-2: The Ind. 100. Monitoring quality audit report of lab
organization includes safety and quality quality audit report of Rad
identifies key control programmes of the Lab investigaiton form with filled provisional
indicators to monitor diagnostic services. diagnosis/relevant clinical details and differential
the clinical diagnosis on them
structures, processes
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Standards Indicators Targets Subtargets
Area
structures, processes Rad investigaiton form with filled provisional
and outcomes which diagnosis/relevant clinical details and differential
are used a s tools for diagnosis on them
continual Trainning Documentation of Lab & Radiology service 1. training notification
improvement. 2. training attendance sheet with trainer feed back
(Ind. 99-105) 3. trainee feed back
4. training need and assessment form
CQI meeting (training need and assessment)
CQI Minutes of meeting includes discussion on sbove Minutes of meeting
parmeters cpa with cpa log sheet
Ind. 101. Monitoring 1. % of unplanned invasive procedures 1. monthly OT performance for emergency cases
includes ALL invasive 2. monthly OT performance for elective cases
procedures.. 3. daily operation theatre effeciency monitoring
2. % of resheduling of invasive procedures 1. operating theatre efeciency measurement tool by OTMC
2. daily operation theatre efeciency monitoring
3. % of cases where organization produces to prevent
adverse events like wrong patient and wrong procedure
have been adhered to
4. % of cases who received appropriate prophylactic
antibiotics within the specified time
Ind. 102. Monitoring
includes adverse drug
events.
Ind. 103. Monitoring Mintues of CQI Meeting includes reporting of anesthesia
includes use of adverse event and follow up
anaesthesia. % of modification of aneaesthesia plan should be
recorded from both anaesthesia assessment and pre
anaesthesia assessment plan
% of unplanned ventilation following anaesthesia
% of adverse anesthesia events provide %
adverse event anesthesia register
% of anaesthesia related mortaily rate
Ind. 104. Monitoring % of transfusion reaction
includes use of blood and % of wastage of blood with reason Blood Bag issuance / Wastage record register
blood products. provide monthly % of wastage / issuance of blood with reason
Display of turn around time for issuance of blood in urdu

Monthly sample based analyses or blood bag issuance

turn around time
Yearly blood running cole
Ind. 105. Monitoring 1. death anaylsis register
includes availability and Departmentlal Sub recorded review commettee
content of medical records. mega reward review committee
record review committee presented in CQI meeting Minutes of meeting

cpa with cpa log sheet

CQI-3: Sentinel Ind. 106. The organization
events are has defined sentinel
intensively analysed. events. 1. notify list of sentinel events to departments
(Ind. 106-107)
Ind. 107. Sentinel events 1. sentinel event report form
are intensively analyzed
when they occur.
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when they occur. 2. sentinel event record register

3. sentinel event record maintainess

Responsibilitie ROM-1: The Ind. 108. Those 1. prepare mission statement 1 provide proposed mission statement
s of responsibilities of responsible for governance
Mangement the management are lay down the 2. minutesof meeting for prep of mission statement
(ROM) defined. organization's mission 3. minutes of meeting on mission statement provided by PMU
(Ind. 108- 116) statement. 4. Display of mission statement
5. employee oriented with mission statement
Ind. 109. Those 1. conduct and document SWOT analysis
responsible for governance
lay down the strategic and 2. long term planning
operational plans. 3. short term planning
Ind. 110. Those 1. finance oficer prepares worksheets
responsible for governance 2. admin oficer calls meeting for manager, meeting
approve the organization's notiication with minutes of meeting
budget and allocate the 3. budgets presented by managers
resources required to meet 4. justiication o budget both internal and external
the organization's mission. 5. finance management information
6. internal budgeting quarterly
Ind. 111. Those 1. activity evaluation peroma 1. plan/ program evaluation performa
responsible for governance 2. PHC reports
monitor and measure the 3. QA audit reports both internal/ external
performance of the 2. Record register of activities
organization against the 3. minutes o meeting
stated mission. 4. presentations regarding progress/ annual report

Ind. 112. Those 1. organogram display old organogram

responsible for governance new organogram display with funcional/line authority
Ind. 113. Those 1. NTS based appointments
responsible for governance 2. annual ACR system
Ind. 114. Those 1. trainngs 1. training attendance sheets and trainer feed back orm
responsible for governance
support research activities
and quality improvement 2. trainees feed back form
plans.
2. coordinators for manuals
3.manual rack
4. BB hep c, hep b, hiv status report monthly
5. suggestions regarding Hep c , heb etc plans
Ind. 115. The organization 1. provide required laws to MSs eg PHC,….
compiles with the laid
down and applicable
legislations and
regulations.
Ind. 116. Those rsponsible 1. camps every 6 months
for gvernance address the 2. displays, pamphelets for public info 1. TB
organization's social and 2. maternal nutrition
community 3. Hep C
responsibilities. 4. Diabetes
5. asthma
3. disaster plans documented
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4. propsed strategies to govt every year for social
improvement
ROM-2: A suitably Ind. 117. The designated 1. JD compliance report
qualified and individual has requisite 2. 3 monthly analysis
FMS FMS-1: The Ind. 118. The management 1) key box
organization is is conversant with the
aware of and relevant laws and 2) floor mapping
compiles with the regulations and knows 3) hospital map display map displayed at every junction
relevant rules and their applicability to the
regulations, laws and organization.
by laws and facility you are here
inspection 4. required laws from above stated eads have been
requirementws implemented
under the relevant 5. enlist the legal affairs
building and 6. enlist the legal affairs including out sourcing contracts
associated codes with external agencies
applicable to Central Telephone line exchange across the hospital
hospitals. Ind. 119. The management
(Ind. 118-121) regularly updates any
amendments in the
prevailing laws of the land.

Ind. 120. The mangement

ensures implementation of
these requirements.

Ind. 121. There is a

mechanism to regularly
update licenses
/registrations
/certifications.
Ind. 122. The organization 1. details of high tech equipment
plans for equipment in
accordance withits
services and strategic plan.

FMS-2: The Ind. 123. Equipment is 1. vendor assessment

organization has a slected by a collaborative
program for clinical process.
and support service Ind. 124. Qualified and
equipment trained personnel operate
management. and maintain the
(Ind. 122-125) equipment.
Ind. 125. Equipment is 1. numbering or colour coding of equipment
periodically ispected,
serviced and calibrated to 2. equipment audit committee
ensure their proper
function. There is a 3. equipment maintainence shedule
Ind. 126. The organization 1) fire safety alarm 1) adequate at each junction
has plans and provisions
for 1. Early detection, 2.
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for 1. Early detection, 2. 2)fire alarm display pictorial and urdu statement
Containment and 3.
Abatement of fire and non-
fire emergencies. 2) smoke, heat, sui gas detectors

3) oxygen signs displayed

4) fire safety designated oficer notification with
responsibility
5) fire buckets with sand 1. availability on numrous spaces

display of usage in urdu

6) ensure atleast two exit paths
FMS-3: The Ind. 127. The organization 1) fire exit plan 1) wet fire plan from 1122 ( documented fire, non- fire safety plan)
organization has has a documented safe exit
plans for fire and (evacuation) plan in case 2) fire extinguishers record register(location, type,expiry, refiling date, inspection date,
non-fire emergencies of fire and non-fire inspection status, checked by)
within the facilities. emergencies.
(Ind.126-129) 3) signages for emergency entry/ exit, assembly area

4) expiry dates on fire extinguishers

5) display of fire extinguisher use in urdu

2) documented disaster plan

3) documented hospital internal disaster plan (patrtial/

complete)
Ind. 128. Mock drills are 1. fire drill report
held at least once in a year. 2. fire drill shedule notification

3. fire drill record

4.fire drill attendees record

Ind. 129. Staff members

are trained for their role in
case of such emergencies.

Ind. 130. Each staff 1. documented participation of employees in orientation Monthly orientation session record
member, employee, FAQ in orientation session
Human HRM-1: The staff Ind. 131. Each staff 1. staff strength
Resource members joining the member is made aware of
2. Prepare monthly report of employees joined, transferred
Mangement organization are hospital wide policies and
(to/from), promoted, retired and relieved from service along-
(HRM) oriented to the procedures as well as 1)Prepare a list of daily inward (letters received inter or intra departmental) & outward (letters
with their current status and remaining proceedings.
hospital relevant department / dispatched inter or intra departmental),
environment, the unit/ service/ program 1)Prepare a list of daily inward (letters received inter or intra departmental) & outward (letters
3. inward/ outward record
institutioin, policies and procedures. dispatched inter or intra departmental),
respective 2)find the gaps if exists and make sure that no delay is exists in the overall process, also
departments and 4. audit report of inward/outward mention the date of receiving the outwards, if there exists any delay then mention the cause of
their individual jobs. delay, and present to the higher authority, on daily, weekly and monthly basis.
(Ind. 130-133)
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(Ind. 130-133) 5. list of union or assosciations or socities active in a health
care establishment
6. statement of ethics
7. confidentiality agreement
8. health questionaire
9. refference forms
Ind. 132. Each staff 1. Prepare a descriptive report of variations in actual and
member is made aware of written responsibilities of the employees of healthcare
his /her rights and establishment
responsibilities. 2. provision of written JDs to every employee with
distribution list
Ind. 133. All employees are 2. provision of written rights and reponsibilities to every
educated with regard to employee with distribution list
patients' rights and
responsibilities.

HRM-2: An appraisal Ind. 134. A well- 1. KPIs for doctors and nurses should be included in the
system for documented performance appraisal system
evaluating the appraisal system exists in All employee files should complesury ACR attached
performance of an the organization.
employee exists as Ind. 135. The employees
an integral part of are made aware of the
the human resource system of performance
management appraisal at the time of
process. induction.
(Ind. 134-137) Ind. 136. The appraisal
system is used as a tool for
further development.

Ind. 137. Performance

appraisal is carried out at
pre-defined intervals and
is documented.
HRM-3: There is a Ind. 138. Personnel files
documented are maintained in respect
personnel record for of ALL employees.
each staf member.
(Ind. 138-141) Ind. 139. The personnel Curriculum Vitae II. Photograph (two, blue background, passport size) III. CNIC copy IV.
files contain personal Copies of documents pertaining to all academic and professional qualifications V. Copies
information regarding the of trainings/certifications VI. Salary slip/certificate (previous employer) VII. Experience
employee's qualification, certificate VIII. Offer letter IX. Contract copy and JD X. Joining report XI. Official email
disciplinary background account issuance form XII. Reference form/background check XIII. Medical/personal
and health status. information form XIV. Information for employee/business card XV. Leave forms (if any)
XVI. Notice (if any) XVII. Performance Evaluation Form XVIII. In-service trainings XIX.
Salary Increment/Promotion XX. Resignation/termination letter (whichever is received
in the HRD) XXI HEp B, C status

Ind. 140. All records of in- 1. file checklist on first page

service training and
education are contained in
the personnel files.
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1) personal file maintainess 2) file evidence

Ind. 141. personal files

contain results of all
employee evaluations.
HRM-4: There is a Ind. 142. Only medical 1) notification
process for professionals permitted by
collecting, verifyinglaw, regulation and the
and evaluating the hospital are to provide
credentials patient care without
(education, supervision.
registration, trainingInd. 143. The 1. Education, 1) renewal of expired registeration PMDC, PHARMACY COUNCIL, PNC, PUNJAB MEDICAL FACULTY
and experience) of 2. registration, 3. Training
medical and 4. Experience of the
professionals identified health
including physicians, professionals is
nurses, pharmacists documented and updated
and others permitted periodically.
to provide patient
Information care without
IMS-1: The Ind. 144. Every medical 1. credential verification And record keeping
mangement organization has a record has a unique
System (IMS) complete and identifier.
accurate medical 1. MR# linking with lab and radiology both evidences 1. lab
record for every 2. radiology
patient.
(Ind.144-148)
2. new born infant finger printing and foot printing to
confirm ID

3. policy identifying authorization to make entries in 1. notification

medical record with notification and circulation 2. receiving evidence
4. unique identifier for every patient
Ind. 145. Organization office order regarding authorization of who can make
policy identifies those entries in medical record. (doctors in prescription,
authorized to make nurses in medication sheet ward registers, IT officers
entries in the medical in medical record entry in IMS
record..
Ind. 146. Every Medical 1. Employee hospital ID
Record is dated & timed 2. entries daed, timed, initialed with employee ID
especially in ICU
3. medical record entry in IMS with IT officer name
date and time of entry
Ind. 147. The author of 2. entries daed, timed, initialed with employee ID
the entry can be especially in ICU
identified. 3. medical record entry in IMS with IT officer name
date and time of entry
Ind. 148. The record provide sample of medical record file
provides an up-to-date
and chronological
account of patient care.
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IMS-2: The medical Ind. 149. The medical 1)history form
record reflects record contains 2) exam form,
continuity of care. informationregarding 3) diagnosis
(Ind. 149- 155) reasons for admission, 4) plan of care form
diagnosis and plan of 5) patient ticket form
care. 6) lab reporting
7) receiving notes
8) outcome
9) medication chart
10) order form
Ind. 150. Operative and following surgical record should be maintained in pre op assessent form
other procedures surgery cases templates have already been provided
performed are
incorporated in the anaesthesia assesment form
medical record. intra op
post op monitoring
consent forms
pre op reassesment form
Ind. 151. When a patient refferel form 2 copies both in patient ile and handed
is transferred to another over to patient also
hospital, the medical
record contains the date
of transfer, the reson for
the transfer and the name
of the receiving hospital.

Ind. 152. the medical discharge form given to patient and copy in file
record contains a copy of
the discharge note duly
signed by appropriate and
qualified personnel.

Ind. 153. In the case of death certificate with 2 copies (one in file, one
dath, the medical record provided to relative)
contains a acopy of the
dath certificate indicating
the cause, date and time
of death.
Ind. 154. Whenever a 1. maintainance of autopsy report
clinical autopsy is carried 2. autopsy review/audit
out, the medical record 3. audit committee with JD
contains a copy of the autopsy record register
report of the same. mortilaity analysis / clinical audit committee of every
department with tor
Death record register
Clinical audit/death committee reports presented in
CQI meeting
Ind. 155. Care providers notification regarding authorize access to current and
have access to current past medical record
and past medical records.
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IMS-3: The Ind. 156. The medical notification defines frequency of audit of record
organization records are reviewed keeping
regularly carries out periodically.
review of medical Ind. 157. The review uses 1. every hospital defines its policy for medical record 1. sample criteria i-e 3 files from each department on random basis but one file from
records. a representative sample review. Every deptt indoor should be inspected on one month
(Ind. 156-162) based on statistical sample based quarterly. 3. frequency of audit defined in notification
principles. 4. cmplete/ partial analysis
2. record retrieval of discharrged patient by specific identifier number and specific file
location
Ind. 158. The review is 1. record review committee with responsibility
conducted by identified 2. meeting memo
care providers and health 3. minutes of meeting
professionals. 4. meeting record register
5. CPA
6. CPA log sheet
Medical checklist record review form
Ind. 159. The review 1. medical record review performa with report
focuses on the timeliness,
legibility and
completeness of the
medical records.
Ind. 160. The review 1. sample criteria includes 2 discharged and 1 active
process includes records patient also
of both active (current)
and discharged patients.

Ind. 161. The review 1. medical record review register

identifies, and documents 2. meeting memo
any deficiencies in the 3. minutes of meeting
record. 4. meeting record register
5. CPA
6. CPA log sheet
Ind. 162. Appropriate 1. CPA
corrective and preventive
measures undertaken are 2. CPA log sheet
Clinical general guide line for
Displays
tooth extraction
dental opd
dental call
dental radiograph
Dental Registers
dental inventory
medical store
annual stock register
informed consent forms
Forms
history form/ exam form
ICU Displays
registers Admission Register
Call Register
Bed Statement Register
Lab. Register
Bed Assignment
Crash Cart & Emergency
Doctors Round Register
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Accessories Register
Dead Body Linen Register
Record Book for Breakage
Instrument
Expense Register
Procedure Record Register
Round Book for Internal ICU
Helper Over Register
Narcotics Register
forms ICU Treatment Chart
1. pt record sheet
2. pt. treatment chart
CCU
Dialysis
Burn unit
Orthopaedics Displays 1. display of skeleton
2. display of spinal column
3. display of spinal nerve function
4.display of osteoprosis
5. display of vitamin D Importance
Registers 1. admission register
2. on call patient register
3. lab register
4. dr. round register
5. stock inventory register
6. annual stock register
7. prosthesis register
8. biopsy specimen register
9. duty register
Forms history/ examination room
Physiotherapy advantage poster
advantage standee 1
Displays advantage standee2
advantage leaflet
advice poster
opd register
indoor patient register
Registers
stock inventory register
annual stock register
reception card physiotherapy
cervical evaluation form
lumbar sacroiliac
Forms
evaluation form
shoulder evaluation form
knee evaluation form
medicine
nursing
paeds
opthalmology
derma
tb
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Functional
Standards Indicators Targets Subtargets
Area
urology
non Clinical PTS
store and purchase manual training training on manual
Prepare daily indent
report (both item &
employee wise) on excel
sheet sign it and present
to the MS of concerned
HCE, get countersigned
on next day morning and
maintain the record of the
same

Please include last issue

date and quantity in every
indent form and enforce
rigid implementation

Prepare a comparative
report on purchases and
status-quo of furniture &
fixtures, present to the
MS of concerned HCE,
and get decision on gaps,
if exists. Review
depreciation of same
items and hold
responsibility if found
condemn & / auction
without or with improper /
unjustified depreciation.
Also keep the
condemnation and
auction record in the
ampit.

Develop an internal audit

mechanism; arrange
internal audit for store on
monthly basis by utilizing
hospital internal sources
i.e. Audit Officer /
Accounts Officer, prepare
the report and present to
the MS of your HCE for
further proceedings.

Arrange asset coding and

paste on every asset of
HCE / DHA / P&SHCD
 MSDS IMPLEMENTATION CHECKLIST FOR PHC ACCREDITATION
Functional
Standards Indicators Targets Subtargets
Area
Please demand asset
utilization / allocation
report and staff strength
status. Critically examine
the both and present the
analysis to the MS HCE /
CEO DHA before any
major procurement.

audit and accounts manual training

procurement manual training

planning manual training