Entry Level COP8

COP 8: Documented procedures guide the care of patients undergoing surgical procedures.

a)   The surgeon does assessment and provisional diagnosis is documented prior to the surgery. For patients having specific health issues like diabetes, hypertension, renal disease, etc. are advised to take fitness certificate from their treating doctor who needs to be specialist.

b)  Informed consent is obtained by the surgeon prior to the procedure. _______Hospital maintains a list of consent forms that are frequently used in the set up. The updated list is available with the Hospital Administrator.

c)    _______Hospital has following SOP for prevention of adverse events like wrong side/eye, wrong patient and wrong surgery besides other likely errors.

SOP to prevent Adverse Events during Surgery
Sr. No.	Process Flow	Responsibly
1	It is verified from the patient that he has stopped the medicines as per the advice of the doctor.	Treating Doctor
2	The surgery site is marked with micropore tape, area was cleaned.	Nurse Asst./ OT incharge
3	Pre-operative check list is filled in.
4	OT nurse while receiving the patient verifies from the patient his/her name and type of surgery that is planned.
5	Doctor asks the patient his/her name and the chief complaint or the type of surgery that is going to be performed.	Doctor
6	Before starting the surgery/ induction of anesthesia, TIME OUT done, the OT Nurse loudly announces the name of the patient, the type of surgery, and Implant availability.	Nurse Asst.
7	If any discrepancy at any point of time arises, the surgery is withheld until the discrepancy is resolved.	Treating Doctor

d)  _______Hospital ensures that qualified persons are permitted to perform the procedures that they are entitled to perform. The hospital maintains a list of Consultants along with their qualifications certificates and Medical Council Registration No. The up to date list is available with the Hospital Administrator.

e)      Post-operative notes are prepared by the surgeon who includes procedure performed, post-operative diagnosis, plan of care and status of the patient. Post-operative plan of care includes

a.    Medications

b.   Care of the area

c.    Do’s & Don’ts during initial period

d.   Infection control practices to be observed at home

e.    Observations for any complications

f)       The operation theater is adequately equipped and monitored for infection control practices. The list of equipment is available with the Hospital Administrator. Following Infection Control practices are observed.

a.    The staff is trained on OT cleaning, fumigation and other precautions to be observed.

b.  The OT is normally closed after fumigation and only opened during surgeries.

c.    All the instruments used are autoclaved

d.   All articles used in OT are sterilized.

e.    Sterilized drapes are used for the patients.

f.     Staff wears sterile clothes and OT footwear.

g.    All surgical staff is vaccinated against Hepatitis B.

h.   Staff having wounds or cuts should be excluded from the OT team

i.     Reusable instrument are immersed in a tray.

j.  Before entering OT all the occupants change to OT clothes, does surgical hand wash and change to OT footwear before entering.