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Outpatient Department
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Outpatient Department
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Edition : 01 Document Pages: Page 3 of 24
1. About the Department:
Scope of services
Timings
Types of patients served:-
2. Organogram
3. Quality Policy
4. Quality Objectives
Outpatient Department
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5. Functioning of the Helpdesk Counter
S.
No
Activity Responsibility Record
1. The help desk counter shall be functional 24X7, manned by two
help desk executives working in shifts.
Helpdesk executive
Help desk reference register
2. The help desk counter shall be provided with Telecom & Public
addresal system for convey of information and any public
announcements to be made.
Helpdesk executive
Help desk reference register
3. The help desk counter executive shall maintain a list of all referral
linkages and ambulance contact number and shall coordinate with
OPD/IPD nursing staff for effective dissemination of information as
required during the process.
Helpdesk executive
Help desk reference register
4. The help desk executive shall even take-up external calls and
provide required information or channelize the call towards
responsible person
Helpdesk executive
Help desk reference register
5. The help desk executives shall always maintain up-to date
information regarding the following
About the hospital and its organizational structure
List of services available and their location
Service timings
List of doctors
Services available under various National Health programme
Helpdesk executive
Help desk reference register
Reference standard - ME G4.2
Outpatient Department
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6. Patient Registration
S. No
Activity Responsibility Record
Registration of new patient
1. Registration is done for all patients requiring OPD and / or
Emergency services. OPD In-charge shall be contacted for any
clarification or in matter of conflict.
Registration clerk OP Registration slip Registration register
2. Registration timings:
3. Patient/patient relative provides general information such as
Name, Age, Sex, Address etc to the Registration Clerk at the
registration counter and this information is entered in the OPD
registration slip and is provided to the patient, this slip shall even
have the unique registration number that has been allotted to the
patient.
Registration clerk OP Registration slip
4. A registration register shall be maintained with the clerk to record
the details of total registrations done for the day.
Registration clerk Registration register
5. In case of automated registration counter, all information shall be
filled in the system to generate a printed registration slip that is
handed over to the patient.
Registration clerk OP Registration slip
6. All patient pays fee Rs /- towards out-patient registration and a
payment slip is given for that
Registration clerk OP Registration slip
7. The Registration Clerk guides the patient towards OPD clinics. Registration clerk Nil
Registration of follow-up patient
Reference standard - ME G4.2
Outpatient Department
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7. Patient calling inside OPD
S. No
Activity Responsibility Record
1. The patient once reaches at the respective OPD OPD clinic Aaya/Staff nurse
Nil
2. The OPD aaya/nurse shall check the registration slip, and ask the
patient to wait for their turn
OPD clinic Aaya/Staff nurse
OPD slip
3. In case the patient has arrived at the wrong clinic, they shall be
guided towards their respective clinic.
OPD clinic Aaya/Staff nurse
Nil
4. The staff nurse/aaya shall ensure that the patient is seated
comfortably and is waiting for his/her turn and there is no
overcrowding in or around the clinic
OPD clinic Aaya/Staff nurse
Nil
5. Patients shall be allowed entrance to the clinic only as per their
turn i.e. “first come first examine” basis.
OPD clinic Aaya/Staff nurse
Nil
Reference standard - ME G4.2
Outpatient Department
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8. Receiving of Patient inside clinic, taking consent and OPD Consultation
S.
No
Activity Responsibility Record
1. Patients shall be allowed entrance to the clinic only as per
their turn i.e. “first come first examine” basis.
Staff Nurse/Doctor OPD Register
2. The doctor shall receive the patient in OPD and ensure he is
comfortably seated and then take his details and complaints
and ensure examination of the patient is carried out in
privacy.
Doctor Nil
Taking Consent
3. The staff nurse inside OPD shall enter Patient’s serial
number, registration number, complaint, etc in the
Out Patient register.
Staff nurse OPD Register
4. Before Assessing the patient, Patient/Attendant signature
shall be taken on the general consent form attached on the
backside of the OPD case paper.
Staff nurse/Consultant
OPD case paper
Clinical Assessment and Reassessment
5. The consultant shall first take Patient’s case history and
undertake an initial assessment to examine the symptoms of
illness.
Doctor OPD case paper
6. In case of medication advice, prescription for medication shall
be written on the medication prescription slip and patient
shall be guided towards the pharmacy to avail the drugs.
Patient may be instructed for a follow up check up if required
after undertaking the course of medication.
Doctor Medication slip (OPD case paper)
7. Investigations (Pathology, Radiology, Ultra Sonography etc) if
required for physical evidence to confirm the disease or
illness shall be ordered in the investigation requisition slip by
the consultant.
Doctor Investigation requisition slip
8. Patients shall be advised to return back with investigation
reports for further consultation.
Doctor OPD case paper
Reference standard – ME G4.2,
Outpatient Department
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9. Patient Referral
S. No
Activity Responsibility Record
Inter dept referral
1.
Through investigation findings or re- asessment if the need is
felt for a second opinion from another clinical area or the
patient seem to be requiring care from other clinical speciality
then the patient shall be opted for a inter dept
referral.
Doctor, Staff nurse
Referral form Refer In- Out register
2. The consultant shall fill the referral form indicating patient
details, reason for referral and course of treatment provided.
Doctor Referral form
3. The patient shall be guided towards the referral clinic along
with the case sheet.
Doctor, Staff nurse
OPD case paper
Outer referral
4. In case of any certain service/ super speciality care required for
the patient that is not available in the hospital then patient shall
be referred to a higher facility.
Doctor Referral form
5. The consultant shall fill the referral form indicating patient
details, reason for referral and course of treatment provided.
Doctor Referral form
6. The staff nurse shall document the referral details in the Refer
In- Out register and coordinate for the referral process.
Staff nurse Refer In- Out register
7. An advance telephonic communication with the referral centre
shall be done to ensure the required service is available and
intimate the staff of the higher centre about the referral to be
done.
Staff nurse Refer In- Out register
8. Ambulance service for the patient shall be arranged which shall
be free of cost for maternal referrals only for others an amount
of Rs shall be charged
Staff nurse Refer In- Out register
9. Patient along with the referral form and case sheet shall be
referred to the higher centre.
Staff nurse Referral form
10. The nursing staff shall also follow up about the condition of the
patient post referral.
Staff nurse Refer In- Out register
Reference standard – ME G4.2
Outpatient Department
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10. Protecting Patient Rights
S.
No
Activity Responsibility Record
Addressing gender needs
1. Separate queue for females at registration counter shall be maintained.
Facility – Incharge, Registration desk
Nil
2. The OPD area shall have separate visitor toilets for male and female.
Facility – Incharge Nil
3. There shall be available a Breast feeding corner with comfortable seating arrangement and ventilation provision at the OPD area.
Facility – Incharge Nil
Disable friendly facilities
4. The OPD entrance shall have ramps with railing. Facility – Incharge Nil
5. The OPD entrance shall ensure availability of Wheel chair or
stretcher easy Access to the OPD for non ambulatory &
disabled patients.
Facility – Incharge Nil
6. There shall be provision of a disable friendly toilet in the OPD area.
Facility – Incharge Nil
Maintaining Patient Privacy & Confidentiality
7. All the OPD clinics shall have privacy screen at Examination
Area.
Doctors, OPD staff
nurse, ICTC
counsellor
Nil
8. All OPD clinics shall ensure the presence of a female staff nurse at the examination area whenever a male doctor has to examine a female patient.
Doctors Nil
9. Only one Patient at a time shall be seen at the clinic. Doctor Nil
10. Confidentiality of HIV reports at ICTC shall be maintained. The identity of HIV+ve & leprosy patients shall not be revealed to anyone except the patient, his family and the counsellor/ treating doctor
ICTC counsellor Nil
Patient Counselling
11. The doctor shall inform the patient about his /her clinical condition and the treatment plan, any potential risks/side effects if any concerning the treatment and the options of treatment.
Doctors Health education
handouts if available
12. Counselling of the patient on Diet & Nutrition and preventive measures to be adopted if any is to be carried out.
Doctors Health education
handouts if available
Informed Consent
13. The Patient and his/her family members shall be counselled
and Informed consent shall be taken from the patient before
ICTC testing centre Informed consent form
Outpatient Department
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conducting HIV testing.
14. A printed bilingual informed consent form shall be used for taking the informed consent
ICTC testing centre Informed consent form
Reference standard – ME G4.2
Outpatient Department
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11. Conducting Patient satisfaction survey
S. No
Activity Responsibility Record
1. Listening to patients' views is essential for providing patient-centred healthcare service. Hence carrying out a satisfaction survey is an essential tool for continuous quality improvement, since the feedback received directly from the users helps in mapping the lacunae in service and provides scope for further improvement.
Facility-Incharge Nil
2. Monthly satisfaction surveys shall be carried to get patient feedback on the services provided.
Facility-Incharge Nil
3. Feedback shall be received from the patient on printed satisfaction survey questionnaires.
Facility-Incharge OPD Satisfaction Survey Questionnaire
4. The patients shall be given print out forms of satisfaction survey forms (In Hindi) and asked to rate their satisfaction for each attribute in terms of Poor, Fair, Good, Very good and Excellent.
Facility- Incharge Satisfaction Survey Questionnaire
5. Monthly analysis of average patient satisfaction survey shall then be carried out and action shall be taken on the lowest scoring parameters to improve the scoring pattern and patient satisfaction survey
Facility- Incharge Satisfaction survey report
Reference standard - ME G4.2
Outpatient Department
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12. Equipment management
S.
No
Activity Responsibility Record
Calibration of Equipments
1. All the measuring equipments/ instrument shall be
calibrated.
OPD -Incharge Nil
2. An ISO certified calibration agency shall be identified to
calibrate the equipments/instruments.
OPD - Incharge Nil
3. Calibration labels/stickers shall be placed on the equipment
denoting the date of calibration and indicating the status of
calibration/ verification when recalibration is due.
OPD - Incharge Equipment register
4. All calibration certificates shall be maintained by the
Incharge or centrally stored by the Store-Incharge of the
hospital.
OPD - Incharge Calibration certificate
5. The OPD shall maintain an equipment register to document
details of equipment and calibration status.
OPD - Incharge Equipment register
6. It shall be the duty of the Incharge to ensure updation of
calibration for all equipments as per their schedule.
OPD - Incharge Equipment register
General Maintenance
7. Up to date manufacturer’s instructions for operation and
maintenance of equipments shall be kept in the department
so that the same can be readily available to staff when
required.
OPD - Incharge Manufacturer’s instruction
8. Defective/Out of order equipments shall be labelled and
stored appropriately away from traffic area, until it has been
repaired
OPD - Incharge Equipment register
9. Daily dusting/ dry wiping of equipments shall be done by
housekeeping staff. The laboratory technician shall do a
daily check on the functioning of equipments every morning
before commencement of testing procedure.
OPD - Incharge Nil
10. An equipment register shall be maintained to document OPD - Incharge Equipment register
Outpatient Department
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details of equipment - name, hospital code, and date of
installation, name of manufacturer, maintained in A
house/maintained by external agency or manufacturer,
Warranty Period, under AMC/CMC.
Preventive and Breakdown Maintenance
Preventive Maintenance
11. All equipments shall be covered under AMC/CMC including
Preventive maintenance.
OPD- Incharge Equipment register
12. The lab-Incharge shall maintain an updated record on AMC
& Preventive maintenance in equipment register this should
include details like :
o Frequency of Preventive Maintenance/Calibration
- As per manufacturer guidelines
- Presently being followed
o Preventive Maintenance/Calibration Done On
o Preventive Maintenance/Calibration Due On
o Expenditure with cost and details
o Remarks with Functional Status
OPD- Incharge Equipment register
13. Preventive maintenance shall be carried out as per
Maintenance Schedule for each individual equipment based
on manufacturer’s recommendations.
OPD- Incharge Equipment register
14. The following shall be checked during a preventive
maintenance-
Physical condition of the equipment/ facility
lubrication, calibration, cleaning or replacing parts that
are expected to wear or which have a finite life
Maintenance report verification
Maintenance / Service report shall be obtained from service
agency and after verification marked as O.K. /Not O.K.
OPD -Incharge Equipment Service Report
Breakdown Maintenance
15. Faulty or defective equipment shall not be used regardless
of how minor is the problem and must be reported in the first
instance to the in-house maintenance engineer /outside
agency hired for maintenance as soon as possible and seen
OPD -Incharge Equipment register
Outpatient Department
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that the problem is attended to as soon as possible.
16. A label of “out of order” shall be attached to the equipment
and information regarding breakdown shall be passed to all
staff including any shift changes.
OPD -Incharge Nil
17. On restoration of the equipment, the Equipment Breakdown
Record should be updated. This indicates that the
breakdown/maintenance is performed of the equipment.
The “out of order” sticker shall be removed after the
restoration of the equipment.
OPD -Incharge Nil
18. All the breakdowns occurring in the department should be
maintained in the equipment register and include the
following
o Breakdown Date and Time
o Breakdown Details (Technical fault or other reasons)
o Date and Time of Rectification
o Total Time Taken (Rectification Time – Breakdown
Time)
o Rectification Details with expenditure including cost (if
any)
o Remarks with functional status
o Reasons for delay if any
OPD -Incharge Equipment register
Reference standard - ME G4.2
Outpatient Department
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13. Referral of Patients
S. No
Activity Responsibility Record
1. In case of any certain service/ speciality care required for
the patient that is not available in the hospital then patient
shall be referred to a higher facility.
OPD Medical Officer Nil
2. However Basic first aid or stabilization of the patient shall be
done prior referral.
OPD Medical Officer, Staff Nurse
Nil
3. The CMO (OPD Medical Officer) shall fill the referral form,
indicating patient details, reason for referral and course of
treatment provided.
OPD Medical Officer, Staff Nurse
Referral form
4. The staff nurse shall document the referral details in the
Refer In- Out register and coordinate for the referral
process.
OPD Medical Officer, Staff Nurse
Refer In-Out register
5. An advance telephonic communication with the referral
centre shall be done to ensure the required service is
available and intimate the staff of the higher centre about
the referral.
OPD Medical Officer, Staff Nurse
Refer In-Out register
6. Ambulance service for the patients is charged for the
transfer as per norms of the RKS except BPL Patient.
OPD Medical Officer, Staff Nurse
Refer In-Out register
7. JSSK patients and 108 patients are not charged. OPD Medical Officer, Staff Nurse
Nil
8. Patient along with the referral form and case sheet shall be
referred to the higher centre.
OPD Medical Officer, Staff Nurse
Referral form
9. The nursing staff shall also contact the referral centre and follow up about the condition of the patient post referral.
OPD Medical Officer, Staff Nurse
Refer In-Out register
Reference Standard: ME G4.2
Outpatient Department
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14. Equipment Management
S.
No
Activity Responsibility Record
Calibration of Equipments
1. All the measuring equipments/ instrument shall be calibrated. OPD -Incharge Nil
2. An ISO certified calibration agency shall be identified to
calibrate the equipments/instruments.
OPD - Incharge Nil
3. Calibration labels/stickers shall be placed on the equipment
denoting the date of calibration and indicating the status of
calibration/ verification when recalibration is due.
OPD - Incharge Equipment register
4. All calibration certificates shall be maintained by the Incharge
or centrally stored by the Store-Incharge of the hospital.
OPD - Incharge Calibration certificate
5. The OPD shall maintain an equipment register to document
details of equipment and calibration status.
OPD - Incharge Equipment register
6. It shall be the duty of the Incharge to ensure updation of
calibration for all equipments as per their schedule.
OPD - Incharge Equipment register
General Maintenance
7. Up to date manufacturer’s instructions for operation and
maintenance of equipments shall be kept in the department
so that the same can be readily available to staff when
required.
OPD - Incharge Manufacturer’s instruction
8. Defective/Out of order equipments shall be labelled and
stored appropriately away from traffic area, until it has been
repaired
OPD - Incharge Equipment register
9. Daily dusting/ dry wiping of equipments shall be done by
housekeeping staff. The laboratory technician shall do a daily
check on the functioning of equipments every morning before
commencement of testing procedure.
OPD - Incharge Nil
10. An equipment register shall be maintained to document
details of equipment - name, hospital code, and date of
OPD - Incharge Equipment register
Outpatient Department
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installation, name of manufacturer, maintained in A
house/maintained by external agency or manufacturer,
Warranty Period, under AMC/CMC.
Preventive and Breakdown Maintenance
Preventive Maintenance
11. All equipments shall be covered under AMC/CMC including
Preventive maintenance.
OPD- Incharge Equipment register
12. The lab-Incharge shall maintain an updated record on AMC &
Preventive maintenance in equipment register this should
include details like :
o Frequency of Preventive Maintenance/Calibration
- As per manufacturer guidelines
- Presently being followed
o Preventive Maintenance/Calibration Done On
o Preventive Maintenance/Calibration Due On
o Expenditure with cost and details
o Remarks with Functional Status
OPD- Incharge Equipment register
13. Preventive maintenance shall be carried out as per
Maintenance Schedule for each individual equipment based
on manufacturer’s recommendations.
OPD- Incharge Equipment register
14. The following shall be checked during a preventive
maintenance-
Physical condition of the equipment/ facility
lubrication, calibration, cleaning or replacing parts that
are expected to wear or which have a finite life
Maintenance report verification
Maintenance / Service report shall be obtained from service
agency and after verification marked as O.K. /Not O.K.
OPD -Incharge Equipment Service Report
Breakdown Maintenance
15. Faulty or defective equipment shall not be used regardless of
how minor is the problem and must be reported in the first
instance to the in-house maintenance engineer /outside
agency hired for maintenance as soon as possible and seen
that the problem is attended to as soon as possible.
OPD -Incharge Equipment register
Outpatient Department
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16. A label of “out of order” shall be attached to the equipment
and information regarding breakdown shall be passed to all
staff including any shift changes.
OPD -Incharge Nil
17. On restoration of the equipment, the Equipment Breakdown
Record should be updated. This indicates that the
breakdown/maintenance is performed of the equipment.
The “out of order” sticker shall be removed after the
restoration of the equipment.
OPD -Incharge Nil
18. All the breakdowns occurring in the department should be
maintained in the equipment register and include the
following
o Breakdown Date and Time
o Breakdown Details (Technical fault or other reasons)
o Date and Time of Rectification
o Total Time Taken (Rectification Time – Breakdown Time)
o Rectification Details with expenditure including cost (if
any)
o Remarks with functional status
o Reasons for delay if any
OPD -Incharge Equipment register
Reference Standard: ME G4.2
Outpatient Department
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15. Other Outpatient Services
S.
No
Activity Responsibility Record
OUTPATIENT PHARMACY
1. Patient presents the OPD medicine slip at the pharmacy counter. Pharmacist Medicine prescription slip
2. Pharmacist at the counter shall dispense the available drugs /
medicines and also brief the dosage and frequency of medicine at
the time of dispensing to the patient.
Pharmacist Medicine prescription slip
3. If any prescribed medicine is not available in the dispensary it shall
be made available by local purchase.
Pharmacist Medicine prescription slip,
Drug Dispensing Register
4. The quantity of issued medicines shall be entered in the dispensing
register/pharmacy software if available.
Pharmacist Drug Dispensing Register
IMMUNIZATION CLINIC
5. Patient is directed towards injection room by OPD attendant. Staff Nurse Immunization register
6. Patient shows the OPD case paper to nursing staff at injection
register.
Staff Nurse Immunization register
7. Nursing staff at injection room shall administer the injection as
advised and enter the detail in Immunization Register (i.e. name of
pt, pt ID, case, requisition given by, and injection administered).
Staff Nurse Immunization register
8. In case of ARV, separate register (ARV Register) shall be
maintained.
Staff Nurse ARV register
9. Needles, syringes and swabs shall be disposed as per Biomedical
Waste (Management and Handling) Rules, 1998.
Staff Nurse Nil
DRESSING ROOM
10. Patient is directed towards dressing room by OPD attendant Dresser/ Staff Nurse
Dressing room register
11. Patient comes to dressing room and shows OP case paper. Dresser/ Staff Nurse
Dressing room register
Outpatient Department
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12. Patient’s details are entered into the dressing register. Dresser/ Staff Nurse
Dressing room register
13. The dresser carries the process of wound dressing Dresser/ Staff Nurse
Dressing room register
14. Swabs, bandage etc are disposed as per Biomedical Waste (Management and Handling) Rules, 1998.
Dresser/ Staff Nurse
Nil
SERVICES PROVIDED UNDER NATIONAL HEALTH PROGRAMME
15. National Immunization Programme
Revised National Tuberculosis (TB) Control Programme
National AIDS Control Programme
Maternal & Child Health Programme
Family Planning Programme
National Blindness control program
National Leprosy elimination Programme.
National Vector Borne Disease Control Programme
National Tobacco Control Programme
National Flurosis Disease Control Programme
National Iodine deficiency Diseases Control Programme
National Communicable Disease Control Programme
National Non Communicable Disease Control Programme
National Diabetic Control Programme
National Diarrhoea Control Programme
Nodal officer Reporting Formats
Reference Standard: ME G4.2
Outpatient Department
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16. Updation and storage of records
S.
No
Activity Responsibility Record
1. All the details of assessments, re-assessment and investigations
shall be recorded and updated in the OPD case sheet by the
consultant/ doctor.
Doctor, Staff Nurse & In - charges
All forms & formats and registers maintained in OPD
2. Any minor Procedures if any like immunization/dressing etc shall
be recorded in the patient case sheet.
Doctor, Staff Nurse & In - charges
3. The facility shall ensure safe and adequate storage and retrieval of
medical records if OPD records are stored in MRD.
MRD In -charge
4. All registers maintained for OPD shall be identified and numbered. In - charge
Reference Standard: ME G4.2
Outpatient Department
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17. Cleaning of OPD Area
S.
No
Activity Responsibility Record
1. OPD lobby area shall be mopped with disinfectant added water
solution.
Housekeeping staff
Housekeeping checklist
2. All patient care area shall be first mopped with disinfectant and
then with detergent water.
Housekeeping staff
Housekeeping checklist
3. Use of brooms shall be avoided, only dry & wet mopping shall be
followed.
Housekeeping staff
Housekeeping checklist
4. Dusting of tables, racks, cupboards and windows shall be done
either before or after OPD timings to avoid dispersion of dust
particles in air and thereby inside nostrils of patient which may
cause them discomfort.
Housekeeping staff
Housekeeping checklist
5. Infection Control Nurse shall ensure housekeeping staff is trained for spill management.
Infection control Nurse
Housekeeping checklist & Infection control round checklist
Outpatient Department
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18. No Smoking Policy in OPD
S.
No
Activity Responsibility Record
1. The hospital has a “No Smoking Policy” according to which
smoking is prohibited inside hospital premises.
Hospital staff, patient, visitors
Signages on No Smoking policy
2. As per the organisation policy, any hospital staff found guilty of
non-adhering to the above policy shall be liable to a fine of Rs
200/-
Hospital staff No smoking Policy
3. If the staff at the hospital come across any patient/patient
attendant with a regular smoking habit shall educate them on the
harmful impact of smoking and motivate them to quit smoking.
Hospital staff No smoking Policy
4. Any patient/attendant if found smoking inside hospital premises
shall be alerted about the No smoking policy and asked to refrain
from the same immediately
Hospital staff No Smoking Policy
Outpatient Department
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