SOP IPD WARD

PURPOSE

❖ To establish, implement & maintain a system for patient care.

❖ To provide guideline instructions for General Nursing care with the aim
that the needs and expectations of patients are honoured.

❖ To enhance patient satisfaction on a continual basis.

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SCOPE
It covers all the patients admitted in IPD wards

RESPONSIBILITY:
❖ Officer In-charge (nursing): For Administrative Responsibility of
ward and Supervision.

❖ Consultant-on duty: For Clinical responsibility - visiting in the ward.

❖ Qualified doctor on duty: Posted as senior resident or medical

officer

❖ Trainee: PG Junior Resident,Nursing student

❖ Staff nurse on duty: Staff nurse posted in the ward as per duty roster

❖ Nursing sister: Sister in charge of the unit

❖ Housekeeping - Refers to the management of duties and chores

involved in the running of a department, such as cleaning, assisting in
nursing work like sending samples to the lab, helping patients when
required, preparation of bed for new patients.

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Procedure outline
❖ Receiving And Initial assessment
❖ Admission, shifting
❖ Collection of reports-routine and investigations
❖ Maintenance of patient rights and dignity.
❖ Maintenance of records and consent documentation.
❖ The discharge procedure includes counselling, drug
distribution and follow- up care.
❖ Environmental cleaning and processing of equipment.
❖ Procedure for end-of-life care.

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Procedure
S. Activity Responsibility Referring
no. document /record

1 Admission advice Treating doctor OPD slip, patient file

Depending upon the doctor's assessment

the patient is advised for the admission.

2 Inpatient registration OIC or Nursing IPD ward Admission

Inpatient registration and allocation of staff working in receipt and patient
beds is done as per the admission receipt incharge in case file
bought by the patient from PRC. of OIC non-
OIC nursing staff working in charge availability
records the patient details in
the patient admission/discharge register.

3 Patient warding in Housekeeping

The housekeeping staff will prepare the staff , nursing
bed on the advice of the OIC or nursing staff
staff.

The ward nurse receives the patient.

Ward nurse reviews the admission notes/

Instructions

4 Bed allotment Nursing staff Patient file

Bed no of allocated bed is recorded in
Case sheet and admission register.

The patient is shifted to the bed, made

comfortable and should be oriented
about the layout of the ward with
instructions on how to call her in case of
emergency.

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5 Patient Property Nursing staff Patient staff

Valuables like jewellery, Patient communication
mobile and cash are handover to the attendant register
patient relatives. The patient should be
instructed to not
keep any valuables with them.

6 Initial assessment Nurse, resident Patient file, nursing

doctor on duty notes, TPR sheets
Once the patient is
settled in the ward, the nurse should
conduct a
nursing need assessment
Resident doctor should assist in the
assessment as directed by the consultant
in OPD which is mentioned on the patient
file

7 Rights of patients Doctor on Duty/

Simple and clear language is Ward Nurse/OIC
Used while communicating to patients
preferably the regional language.
No shortcuts or technical words should be
used while communicating.

• Before any examination

permission is taken from patients
and the procedure is explained to them.

• During the examination privacy of

the patient is maintained. Screens
and curtains are provided in
the examination area and it is ensured
that woman is protected from
the view of other people.

• Confidential information about

patients should never be discussed with
other
staff members or outside the facility.

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8 If the patient is HIV positive in that case

● Confidentiality of such patient is

maintained in all cases.
● Patients Should not be made to
feel discriminated against.
● Beds / Case sheets of such patients
are not labelled which denotes
their HIV positive status.
● Status of such patients is not
discussed with anybody who is not
involved in the direct care of
patients.

9 Preparation of the patient for Surgical Surgeon, ward Surgery consent

Procedure- nurse and form.
● The procedure going to be patient, patient
performed and its purpose should attendant
be explained to the patient. if the
patient is unconscious, it has to be
explained to their family/attendant.
● Informed consent for the
procedure should be obtained from
the patient/attendant.

Patient care

1 Monitoring temperature Ward nurse TPR sheet

The timing for measuring the body
temperature is checked from the Doctor's
order or as per the T`PR chart.
Temperature is recorded in the TPR chart.
The duty doctor is to be informed in the
case of abnormal values.
The thermometer had to be disinfected
with
Alcohol.

2 Monitoring Pulse rate- Ward nurse / Nursing order sheet

The pulse of the concerned patient is Doctor
recorded in the nursing chart. In case of
difficulty doctor on duty is
informed.

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3 Monitoring Blood Pressure- Ward nurse/ Nursing order sheet

The timing for measuring the Blood doctor
Pressure is checked from the Doctor’s
order or as per time interval indicated in
the nursing chart.

4 Blood Transfusion: Consultant/ward Consent form for

- Blood transfusion may be required in nurse/patient/pat blood transfusion /
conditions like blood-related ient attendant Patient file
infection/cancer/anaemia or after
operative procedure
• Cross-matching of donor and recipient
Blood is mandatory before transfusion.

For High Risk & elective

surgeries/chemotherapy of the patient,
attendants are told to arrange blood in
Advance.
It had to be made sure that the blood
transfusion consent form is signed by
the patient, accepting the term and
conditions. Otherwise, the process should
not be carried out.

5 Environment cleaning and processing OIC/housekeepin Daily cleaning

of g checklist
the equipment:
Ward in charge makes sure that the
cleaning and Mopping should be done in
a unidirectional manner and instructs
strictly that broomsticks and unhygienic
mop sticks are not used in the Ward.
Make sure that sodium hypochlorite
solution is prepared in the correct ratio.

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6 Handling of medical devices Biomedical HIC manual/

● All medical devices and technician/OIC/ Biomedical
instruments are cleaned after each ward Nurse Equipment register/
patient uses them in accordance Checklist for
with procedures for hospital disinfecting the
infection control. equipment
● All the measuring equipment used
inpatient care are regularly
calibrated in accordance with
manufacturer‘s instructions.
● All medical devices and equipment
are appropriately stored with
access All medical devices and
equipment are appropriately stored
with access to authorised
individuals only.

7 Administration of Medication Ward Nurse/ Patient file/doctor

doctor on duty order sheet
Essential check - /medication chart
● before administering any
dmg name of the drug time of
administering the medication, dosage,
route of administration and in case of
oral drugs, whether to give before or
after food is thoroughly checked from
the medication chart of the concerned
patient.
● In case of any discrepancy in name
doctor on duty /Pharmacist is consulted
and generic names are matched.
● It is made sure that medication is
not
discontinued in the Medication Chart.
● The drug is checked for proper
storage
procedure and any sign of damage which
may harm the efficacy. Parenteral drugs
are
checked for any turbidity in the container.
● The date of expiry and batch no. of
the drug is checked arid in case of
any discrepancy head nurse and
Pharmacists are informed.

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8 Monitoring/ Recording- Doctor on duty/ Medication chart

After ensuring the drug has been ward nurse
administered the nurse records the time
and dose that has been given in the
medication chart. If a complete dose is
not given because of any reason (I like
vomiting of oral drugs) it is recorded in
the nursing chart and informed to the
doctor on duty.
Patient is watched for adverse effects and
if any Doctor on Duty is informed.
Disposal of remaining drugs is done as
per Bio Medical Waste Rules.

9 Medical documentation Doctor on Patient file/ doctor

Patients complete medical records are duty/ward nurse order sheet/ nursing
available at all the times during their stay notes
in
Hospital.
Documentation within the medical record
follows the logical sequence of date, time.
Drug prescription chart, diagnostic
results,
nursing notes plan and should be kept as
separate sections for prompt easy access.

Every entry in the medical record is

dated, timed (preferably in 24-Hour
format), legible and signed by the person
making the entry.
Deletion and alterations are
countersigned.

Entries to medical records are made as

soon
as possible after seeing or intervention
(eg. Change in clinical state, ward round,
diagnostic) and before the relevant staff
members go off duty.

An entry is made in the medical records

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whenever a patient is seen by a doctor.

Consent form
statements must be clearly recorded in
medical records.

10 Nursing Care OIC

Ward Nurse
Nurse spends most of the time with
patients, Therefore, it is expected that all
the responsibilities of nursing care are
performed smoothly by the nursing
staff.The responsibility comprises both
clinical and non clinical practices. The
ultimate goal of the services provided is to
achieve maximum patient satisfaction

11 Diet Ward Doctor order sheet/

Nurse informs the dietary department / nurse/dietician/ki Nursing notes / diet
Kitchen for patients diets according to the tchen register
doctor advice. management
The dietician has to confirm the
communication and direct the kitchen
supervisor to prepare meals as per
requirement.

12 Inventory Ward nurse /OIC Inventory book

Crash cart checklist
Nurse maintains record of stocks of Material
Inventory,crash cart & medicines in the Management
ward. System(HIS)
When required the nurse has to indent Indent register
the items in order to maintain the
inventory.

13 Duty Handover system OIC & Sending referral

Ward nurse book
At the end of each shift nurse on duty Joining The Shift Inventory book
hands over, the details of treatment And Leaving The I.V fluid book

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provided and patient progress, in writing Shift Admission and

to the nurse joining duty for next shift. discharge book

14 Inter departmental/Floor Transfer OIC/ward nurse Admission and

If patient is required to be shifted to discharge register
other floor for any reason, the sister
incharge of the other ward is informed
and the patient is sent to the ward with
all the medical records and drugs. Nurse
incharge of both the wards has to enter
the same in their register.

15 Diagnostics and therapy Ward nurse/OIC Microbiology form

If any test is required to be done for Bio imaging form
the patient admitted in ward - Nuclear medicine
The patient sample or patient itself has to form
be transferred to the respective lab or Cytopathology form
department. The billing for the same has X ray forms
USG form
to be done through the smart card.
CT form
MRI form
The guideline of lab
or department to be
followed while
transferring

16 Counselling and Discharge of patient: Treating doctor Patient file

Assessment of the patient is done on OIC/ward Nurse Discharge card
daily basis. PRC Feedback form
● When the patient is declared Feedback form
discharged by the consultant, the register
nursing staff has to send Discharge
Information to the PRC.
● PRC will give discharge slips to
patient attendants . Once the slip is
received to the department,the
final discharge entry has to be done
in the admission-discharge register.
● Patient has to be provided with a
feedback form , the form has to be

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maintained in the feedback form

register within the department .
● Patient discharge card has to be
prepared.
● Patient has to be counselled about
the intake of the diet and medicine
and follow up instructions given to
the patient.
● The patient has to be advised to
meet the doctor before leaving the
hospital to get endnotes or next
OPD appointment date.

Nurse has to ensure all the items issued to Ward nurse

the patient are returned back.

17 End of life care

Respect the dignity of both patient

and caregivers
; Be sensitive and respectful with the
patients and wishes;
• Use the most appropriate measures
that are consistent with patient
choices
• Assess and manage psychological,
social, and spiritual/religious problems:

• Provide access to any therapy

which may realistically be
expected to improve the patients
quality of life, including
alternative or non-traditional
treatment.
• Provide access to palliative care
and hospital care.
• Respect the right to refuse
treatment;

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18 Management of death Duty doctor/ OIC Departmental

Ward nurse Death register
If the patient is dead, the death protocol Security staff MS office death
has to be followed in order to discharge & register
Form 2
handover the body attendant.
Form 4

19 Visiting hours Security personal

The visiting hours had to be followed as / ward nurse
per the hospital decision.

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