Plan for the Month of January 2021

Time of Completion of
Departments Responsibility Secondary Responsibility
Records

Pharmacy Mr.Pradeep 23rd January 2021 Ms.Sarika

MRD Ms.Pooja 23rd January 2021 Ms.Sarika

Laboratory Dr. Chaitra 28th January 2021 Ms.Sarika

COMMITTEE MEETINGS
Committee Responsibility Date Secondary Responsibility

PTC Mr.Pradeep 1/27/2021 Ms.Sarika

MRD Ms.Pooja 1/27/2021 Ms.Sarika

HIC Ms.Nagaveni 1/30/2021 Ms.Sarika

Safety Committee Ms.Sarika 1/30/2021 Ms.Sarika

Mock Drills
Name of Code Date Responsibility Secondary Responsibility

Code Blue Ms.Nagaveni 1/19/2021 Ms.Sarika

Code Pink Ms.Nagaveni 1/20/2021 Ms.Sarika

Code Red Ms.Sarika 1/20/2021

Statutory Compliance - List is Prepared ( Annual Report as per Schedule IV is pending which shall be completed
by 31st January 2021)
MoU's are pending for renewal - Same has been discussed with the Accounts Head for the renewal

S.N Records
1 Equipment Caliberation Log
2 Temperature Monitoring Checklist
3 Sample Rejection Register
4 Lab Redo's
5 Sample Discarding Register
6 Crital Values list & Escalation Register
TAT is defined. Data is not captured
Turn Around Time for Inhouse and Out house
7 Action Point: Explained the staff to capture system
Investigation
generated data from January month
8 Equipment Cleaning Checklist
9 Environment Cleaning Checklist
Staff Personal File and Training records
( Trainings Required are: Hand
Hygiene,BMWM,PPE,NSI,Post Exposure
Prophylaxis , Spill Management, Emergency
Codes, Awareness on Patient
10 Identification,Sample
Collection,Storage,Transportation and SOP's
Quality Indicators :
a. Waiting Time for Sample Collection (OPD)
11
b. Percentage of Lab Redo's
c. Reporting Errors
Display of Hand Hygiene Poster , BMW
12 Management
Laboratory
Status
Cliberation of Equipments are Validated and Stickers
are pasted on all the equipments
Checklist Is followed and maintained the file
Register is Maintained but the reason for rejection is
not documented.The importance of documentation
and Escalation is explained to staff.
Action Point: Data shall be
captured from January Month
Lab Redo's Register Maintained
Register Maintained
Critical Value list is displayed and Value alerts
register maintained with necessary information.
Avaialble for each Equipment seperately
Available but not
Staff Personal files shall be collected from CDL and
maintained in Laboratory. Mandatory trainings shall
be provided & attendance sheets need to be placed
in staff personal file.
Manual Register is mentained
Data need to be captured
Data need to be Captured
Hand Hygiene Poster not Available. BMWM Poster is
displayed. NSI and PEP poster not displayed
Responsibility Date of Closure
 MRD
S.N Records Status
1 MRD Manual Avaialble
Inpatient files are not Checked from the Started checking the files and all the files
2
month are scanned and stored as soft copy.
Deficiancy Checklist is modified and
3 Followed
Implemented

In-patient file and Out patient file

4 Followed
dispatch register is maintained.

Deficiancy track Started

5
6 ICD Coding ?

List of Communicable disease & details

7 Available
are uploaded monthly in website.

List of All forms and formats Not Available

8
9
Medical Records Audit Started - Deficiencies documented
10 MRD Committee Meeting Meeting is Pending - Shall be conducted
by this month
Available - Same is followed for
11 Medical Records Dispatch Register
dispatching medical records

Quality Indicators:

11 Percentage of Missing Records Data need to be captured

Percentage of Medical Records not Data need to be captured

having discharge summary
Responsibility Closure Date
 Pharmacy
Date of
S.N Records Status
Closure
1 Pharmacy Manual Available

Prepared Need to take approval End of the

2 Hospital Formulary
in committee meeting January Month

3 List of High Risk Medications List is not finalised 25th Jan 2021

List is not finalised and Storage

4 List of LASA Medications 25th Jan 2021
of LASA need to be chnaged

5 List of Refrigirator Drugs List is not prepared 25th Jan 2021

6 Temp.Monitoring Checklist Checklist is Maintained NA
Details of Expiry drugs is
7 Expiry Drugs
maintained

8 Stock Register /Template Maintained in Soft Copy

9 Drug Recall details, Incidence Reporting, Explained to pharmacy staff and
Adverse drug reaction and Medication data need to be kept whenever
prescription thr is any Incidences

11 Medication Audit Medication Audits are

conducted by Nursing Inchage
and the same data is discussed
in PTC Committee
Responsibility

Mr.Pradeep

Mr.Pradeep

Mr.Pradeep

Mr.Pradeep
Mr.Pradeep

Mr.Pradeep

Mr.Pradeep

Mr.Pradeep
 Department - Nursing
Forms: Registers:
1. Nursing Assessment 1. Admission and
Form 2. Vital Signs Record. Discharge register
3.Blood Transfusion 2. Biomedical
Record 4. Nurses Record Equipment Register 3.
5. Intake & Out Complaints Log book
Put Record 6. Hourly 4. Crash Cart Register
Monitoring record 7. 5.
Infection Control Worksheet Handover Book
8.Investigation Transfer record 6. Doctors Rounds / Orders
9. Daily Fall Assessment Record book 7. Reports Register
10. Daily Skin Assessment Record 8. Procedure
Book 9.
Staff communication book
10. Lab sample sending Book
11. Stock Register
ursing
Audit tool :
1.HAPU
2. Fall
3.
Medication Error
4. Hand Hygiene 5. Phebitis
6. Patient Identifiction
7. Infectin Control
8. BMW Management
9. Medical
Records Audit
 Front Office / Billing
S.N Records Status Responsibility Date of Closure
1 Feed back forms
2 Communication Book
Patient Rights And responsiblities
3
Brochures

4 List of Nearby Hospitals

5 General Admission Consent form

6 Consent for tariff
7

10

11

12