MOUs
Refereal and transfer register
BLS, ACLS Training record
Initial assessment form – OP, IP, EMR , Daycare
Initial assessment -TAT – OP, IP, EMR
Critical results register – Lab, Radiology,
QA report out sourced lab
Internal quality control system
CAPA for IQAS
CAPA for EQAS
QA for radiology
AERB safety program guidelines
Training record
Referral slip
No of ED footfalls
Dead on arrival , dying on arrival
Ambulance checklist
Disasters identified
Disaster drill videos
Transfusion guidelines
Blood transfusions date last 3 months
ICU manual
Admission , discharge criteria
Bed shortage policy
Infection control policies ICU
Code pink
Sedation policy
Criteria – OT to ward transfer
ID band
Pressure differential record daily
OT cleaning register
Filter record OT last 6months
SOP renal transplant
Vulnerable patients policy
Document for the end-of-life based on national guidelines.
Drug formulary
Vendor selection criteria
Reorder levels
List of stock outs
High risk medication list hosp wide
LASA
Crash cart pic
Medication order guidelines
Medication dispensing
Tubing misconnections policy
Prescription audit
Consent training record photo
Tariff list
Feedback form 3 with CAPA
Effective enhanced communication policy
High risk activities guidelines
TOR for every committee
ICC surveillance report
ICN appointment order with JD, training record
guideline on transmission based precautions
restricted antimicrobial agents
Air water quality check
ICP during construction and renovation
Outbreak of infection audit
Autoclave , ETO photo
Chemical / biological indicators
Autoclave register photo
Safety manual
Quality manual
QComite mom
Quality Committee audit report
Nursing care quality manual
Clinical audit report – 3nos
Sentinel events policy
Vision mission display photo
Annual budget report – Hospital, HIC, QI each separate
Employee rights display photo
Risk management plan
Facility manual
Condemnation policy
HIRA audit report
Spill plan hazard material
Engineering SOP
Utility management plan
BME SOP
Calibration report
Medical gas policy
Maintenance service report medical gas pipe line
Fire equipment , Testing report, maintenance report, plan doc
Contingency plan staff shortage
Organogram
Recruitment & Selection committee
Grievance redressal
Disciplinary policy
Policy health needs
Policy for reporting data for external agency and its list.
MRD checklist
Guideline of staff list to MRD
Document detailing integrity and security of records
Guideline for retention policy of medical records
Non availability of beds EMR / ICU, Ward
Materiovigilence program of india – MVPI
Ambulance communication
Disaster tested twice a year
Admission criteria EMR
Responsible staff during transfer
IA - emr
DS for LAMA
Hand over format drs , nurses
MLC case prodedure
Triage demonstration
CPR running sheet
Barrier nursing seal
IP
Plan of care
TAT – Admission and discharge
Post transfusion forms
Food trolley
Near miss, medication error, adverse drug event are defined
Feedback form
Isolation , negative pressure room
Smoke detectors, Fire alarm, frie alarm control panel
End of life care policy
Dialyser re use
Hand over – dialysis
Hazmat kit – dialysis
RO, Endotoxin level
HD records
Catheter washing area
APACHE / SOFA scoring - standard mortality rate
Dialysis
CCTV coverage
Humidifiers labeling
Compressed air purity
AHU cleaning record
Filetrs replacing record
Zoning
Alternate sources for OT water & electricity
Bronchoscopy room – negative pressure room
CCTV coverage in OT
Differently abled toilet
Medical gas colour coding
FMS - Table top????
Clinico radiological meeting
Crash carts in Radiology
Cathlab – qualified tech – AERB
Clinicopathological meeting
Work restriction policy with transmissible diseases
CALBSI form
Informed consent for renal transplant surgery – Donor, Recipient
Qualified counselors
Counselling documented in statuatory format
Organ donation awareness posters
Analytical tool for quality improvement
Managerial tool for quality improvement
Qualified nurses
NS – CPR committee, HIC
APEX manual hospital
Organogram dept wise, hospital wide
PROM
Patient safety officers
Feedback form
Grievance form
Qualified admin with experience
Induction traininig record includes safety training,BLS, HIC, appraisal system
Vulnerable patients training
Restraint tech training
Occupational safety training
Fire non fire emergenciy training
Disaster management plan
Provision for appeals in disciplinary cases
DVP committee
DR files
Chronological order – nursing chart
Transfer to other hospital register – MRD
Scope of services bilingual
Medical record audit
Discharge summary register
Notifiable diseases list display and communication display
Disaster backup
Provision for digital signatures if any
Registraion of foreigners
Priority for patient clinical needs
BME – Qualified staff
Medical gas
Asset list
Last three months new equipments and physical locations
BME head interview
Alternate source for gas, vaccum m, compressed air
Formulary
Disposal record for narcotics
Electrical inspectorate report
IPSG implementation
Facility inspection rounds report
Fire Exit doors open always
