Standard Operating Procedures (SOPs)

Standard Operating Procedures (SOPs)

Introduction

• Definition: SOPs are written, standardized instructions that describe how to perform routine activities and operations in a consistent and safe manner.
• Purpose:
• Ensure quality and consistency in care.
• Maintain legal and accreditation compliance (e.g., NABH, JCI).
• Provide clarity on roles/responsibilities.
• Minimize errors and promote patient safety.
• Key Components:
• Title & Objective
• Scope & Applicability
• Responsibilities
• Procedure Steps
• Documentation & Records
• References & Review Dates
• Importance:
• Promotes standardization
• Reduces variability in service delivery
• Enhances training and orientation
• Assists in audits and quality assurance

SOPs by Department/Function

A. Outpatient Department (OPD)

• Patient registration and demographic entry
• OPD card generation
• Queue system and appointment handling
• Consultation flow and follow-up
• Referral to diagnostics or inpatient
• Documentation and billing
• Emergency identification and action

B. Inpatient Department (IPD)

• Admission process (planned/emergency)
• Bed allotment and patient shift-in
• Patient orientation and consent forms
• Daily care documentation
• Drug administration & vitals charting
• Handover process (nurses/doctors)
• Discharge planning and summary creation

C. Surgery / Operating Theater (OT)

• Pre-operative assessment and checklist
• Informed surgical consent
• Sterilization protocol and hand hygiene
• Instrument count and sponge tracking
• Anesthesia safety checklists
• Post-operative transfer and recovery monitoring
• OT cleaning and turnover procedure

D. Nursing Services

• Shift handover/takeover
• Drug chart review and administration (5Rs)
• Nursing care plans (based on condition)
• Monitoring vitals and escalation
• Pressure sore prevention protocol
• Fall risk assessment and prevention
• Documentation in nursing records

E. Laboratory Services

• Sample collection SOP (blood, urine, etc.)
• Labeling and transport protocol
• Calibration and maintenance of equipment
• Test processing (e.g., CBC, LFT, etc.)
• Quality control and documentation
• Reporting and critical value notification
• Biomedical waste disposal SOP

F. Radiology

• Patient verification and consent
• Radiation safety protocol (lead aprons, dosimeters)
• Imaging SOPs (X-ray, CT, MRI, USG)
• Contrast administration protocols
• Film/report processing and dispatch
• Equipment maintenance logs
• Emergency during scan SOP (e.g., allergic reaction)

G. Rehabilitation (Physiotherapy/OT)

• Referral process and assessment SOP
• Goal-setting and therapy planning
• Patient education and documentation
• Infection control and hygiene
• Use and care of equipment
• Discharge advice and follow-up planning

H. Pharmacy

• Drug procurement and verification SOP
• Storage guidelines (cold chain, labeling)
• Prescription validation and dispensing
• Narcotic drug handling SOP
• Expiry monitoring and disposal
• Patient counseling (as needed)
• Stock audits and inventory control

I. Dietary Services

• Dietician referral and assessment
• Diet chart preparation (based on disease)
• Food preparation hygiene SOPs
• Meal distribution SOP (timing, quantity)
• Special diet handling
• Feedback collection and action
• Kitchen cleaning & food safety protocol

J. CSSD (Central Sterile Supply Department)

• Collection of used instruments
• Cleaning and disinfection SOP
• Sterilization process (Autoclave/ETO)
• Packing and labeling
• Dispatch to respective departments
• Monitoring sterility indicators
• Documentation and traceability logs

K. Material Management

• Purchase requisition and approvals
• Vendor selection and tender process
• Receiving goods and inspection SOP
• Inventory management and reordering
• Storage guidelines (FIFO/FEFO)
• Distribution to user departments
• Return/damage handling

L. Laundry Services

• Collection of soiled linen (from wards/OT)
• Segregation (infected/non-infected)
• Washing, drying, ironing SOPs
• Disinfection protocols
• Packing and dispatch to wards
• PPE use for laundry staff
• Wastewater disposal and linen records

M. Engineering/Maintenance

• Daily inspection rounds
• Preventive maintenance schedule (ACs, lifts, generators)
• Complaint registration and resolution
• Biomedical equipment calibration
• Water supply and HVAC checks
• Fire safety equipment testing
• Power backup SOP

N. Disaster Management

• Code protocols (Red, Blue, Pink, etc.)
• Evacuation SOP and mock drills
• Fire safety and firefighting SOP
• Communication protocol during disaster
• Emergency triage and transport
• Backup utilities and coordination plan
• Recovery and debriefing

O. Housekeeping

• Cleaning schedules (daily, weekly, terminal)
• Disinfection of patient care areas
• Spill management (blood/body fluids)
• Toilet cleaning SOP
• Waste segregation and disposal (BMW)
• Linen management
• Monitoring via checklist & supervisor rounds

Video Description

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