DOCUMENT NAME : DOCUMENT CONTROL POLICY NABH SHCO 3rd Ed

TSH/2023/IMS/01 Hospital Formulary

Issue Date: 01 Jan 2023 Rev No: 01

Policy applies

Documented corporate and clinical policies and guidelines assist the organisation to provide
quality care.

Rationale
Service provision at HOSPITAL is guided by policies and procedures that enable the organization
to deliver safe effective care to our patients, and engage in appropriate employment, legislative
and contractual practices.

These policies set out HOSPITAL objectives, principles, guidelines and processes to be applied
consistently across the organisation.

Definition
Document Control refers to the process whereby all HOSPITAL policies, processes and
guidelines are systematically written, reviewed, ratified and stored to maintain document integrity.

A policy is a set of principles used as a guide for action; the principles most often relate to
legislation a standard or best practice. Policy regulates, directs and controls actions and conduct.
A policy provides high level direction and guidance, establishes key principles and
responsibilities, and sets fundamental requirements. Policies can range from broad philosophies
to specific rules and include method and time frame for evaluation.

Process/procedure is a series of actions necessary for accomplishing a particular goal; course of action.
Informs users how to, and who will, implement a policy. Procedures are specific, factual, succinct and to
the point. Procedures are a particular way of accomplishing an objective; generally
referring to the process rather than the result. Procedures describe the and responsibility
methods
for implementation of a policy, statute or regulation.

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A guideline outlines the detailed steps for carrying out tasks within a procedure, or to define a rule
that is specific to a local organizational area.
Objectives
That the organization’s policies, processes, guidelines and associated documents:
 Are current, reflect best practice and meet legislative and / or compliance standards and
regulations.
 Are relevant, clear, easy to use and appropriate to the organisation.
 Are developed with input from relevant staff and external stakeholders (where appropriate
/ possible).
 Are authorised and updated through a robust policy committee framework.
 Are easily accessed by staff
 Are reviewed according to the risk rating policy with sufficient regularity to
ensure currency. At a minimum however, all policies will be reviewed three
yearly.

Implementation
Resources are available to ensure currency of documents e.g. Buddle Findlay, Lippincott
Procedures.

A policy template is in place and is adhered to.

A policy /process/guideline framework is in place which identifies processes by which;

 All policy documents, associated documents and guidelines are reviewed at a minimum
every three years.

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TSH/2023/IMS/01 Hospital Formulary

Issue Date: 01 Jan 2023 Rev No: 01

 The implementation of new policy or changes to existing policy requires discussion,

review and sign off from the policy group, with designated accountabilities for the
appropriate education and or update of staff.

There are designated document controllers who are able to make changes to documents.
Following Policy Committee ratification all policies will be listed to HOD meeting for
dissemination to all staff
The updating of area specific guidelines and work manuals is the responsibility of the staff who
work in an area. This process will be led by the HOD/Manager/Clinical Shift leader.

Access and Repository

 Policies with associated process and forms are on-line on SharePoint.
 All documents are in read only format.
 All new and updated policies are listed to the monthly HOD meeting, following ratification
by the Policy Committee and reported to staff via weekly newsletter.
 A printed set of policies is updated as new or amended policies are developed and these
are kept at Reception (see below) in case of a computer or power failure. This is the
responsibility of the Document Controllers.
 Most policies are able to be accessed on the Mercy website. The process of adding / updating
policies on line is managed by the designated document controllers.

Evaluation and Review

 Staff are able to access policies appropriately.

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DOCUMENT NAME : DOCUMENT CONTROL POLICY NABH SHCO 3rd Ed

TSH/2023/IMS/01 Hospital Formulary

Issue Date: 01 Jan 2023 Rev No: 01

 All policies, procedures and guidelines have been reviewed as a minimum every 3 years.
 Policies, processes and guidelines have been reviewed or developed using the
agreed framework.
 All approved changes to policy are uploaded to SharePoint via the Document Controllers
 ,Compliance with key policies are audited on a regular basis

Resources
 Buddle Findlay regular updates
 Documented corporate & clinical policies and procedures assist the organisation to provide
safe, high quality care & service

Process of Document Control

1. Policy owner identified by the policy group if it is a new policy or as the ‘Reviewed by’
position when the policy is to be updated.

2. Reminder of policies due for review is an agenda item at each monthly policy meeting

3. This list can be automatically generated by clicking on ‘review due’ on SharePoint

4. Under review designation is ascribed to the associated policy by a document controller

5. Document owner edits document in ‘tracked changes’ on SharePoint

6. Policy/process or guideline developed as per framework

7. Guidelines / appendices filed with appropriate policy via document controller

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8. Policy, process and any related forms are within a document set under the policy title

LIST OF DOCUMENT CONTROL

S.No. Name of Document DOCUMENT CONTROL

1 OPD Sheet TSH/FORM/OPD/ 01
2 Admission Sheet/Registration Sheet TSH/FORM/AS/02
3 General Consent for Admission TSH/FORM/GC/03
4 Progress notes of Doctor TSH/FORM/PND/04
5 Medication Reconciliation Form TSH/FORM/MRF/05
6 Intake output chart TSH/FORM/IOC/06
7 Vital Chart TSH/FORM/VC/07
8 Initial Assessment Sheet Doctor TSH/FORM/IA/08
9 Financial Counseling Form TSH/FORM/FCF/09
10 ICU Chart TSH/FORM/ICUC/10
11 Drug order sheet TSH/FORM/DOS/11
12 Fluid Assessment TSH/FORM/FA/12
13 Nutrition Screening & Assessment Progress notes TSH/FORM/NSA/13
14 Nutrition Therapy plan Form A (Oral Diet) TSH/FORM/NT/14
15 Nursing Initial Assessment TSH/FORM/NIA/15
16 Nursing Daily Assessment TSH/FORM/NDA/16
17 Pain Assessment TSH/FORM/PA/17
18 MEWS & VIP Score TSH/FORM/MEWS/VIP/18
19 Fall Risk Assessment Form TSH/FORM/FRA/19

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20 Pressure Ulcer Risk Assessment form TSH/FORM/PURAF/20

21 ISBAR & Nurses Notes TSH/FORM/NH/21
22 Nursing Care Plan TSH/FORM//NCP/22
23 Patient Education Form TSH/FORM/PEF/23
24 Medication Error Chart TSH/FORM/MEC/24
25 ICU Admission & Discharge Form TSH/FORM/IA&D/25
26 SOFA form TSH/FORM/SF/26
27 DVT Form TSH/FORM/DF/27
28 Bundle Checklist : a) SSI TSH/FORM/BC/SSI/01
29 b) VAP TSH/FORM/BC/VAP/02
30 c) CAUTI TSH/FORM/BC/CAUTI/03
31 d) CLABSI TSH/FORM/BC/CLABSI/04
32 HIV form TSH/FORM/HIVF/28
33 Informed Consent for operation TSH/FORM/SC/29
34 Informed Consent for Anesthesia TSH/FORM/AC/30
35 High Risk Consent Form TSH/FORM/HC/31
36 Pre-Operative Checklist TSH/FORM/POC/32
37 Surgical Safety Checklist TSH/FORM/SSC/33
38 Anesthesia Record Sheets TSH/FORM/ARS/34
39 Operative Notes TSH/FORM/ON/35
40 Aldrete Score TSH/FORM/AC/36
41 Restraint Consent Form TSH/FORM/RC/37
42 Blood Transfusion Consent form TSH/FORM/BCF/38
43 Blood Transfusion Monitoring Chart TSH/FORM/BMC/39
44 Emergency Initial Assessment Form TSH/FORM/EIAF/40
45 NICU Chart TSH/FORM/NICUC/41
46 Antenatal, Intranasal and Post natal Assessment TSH/FORM/AIPI/42
form
47 Immunization Chart TSH/FORM/IC/43

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48 Internal patient Transfer Form TSH/FORM/IPTF/44

49 Checklist for Inter Hospital Transfer TSH/FORM/IHT/45
50 LAMA Form TSH/FORM/LF/46
51 MLC FORM TSH/FORM/MLCF/47
52 CPR FORM TSH/FORM/CPRF/48
53 Discharge Summary TSH/FORM/DS/49
54 Feed Back Form TSH/FORM/FF/50

POLICY
01 ACCESS, ASSESSMENT, CONTINUITY OFCARE TSH/AAC/01-08
02 CARE OF PATIENT TSH/COP/01-13
03 MANAGEMENT OF MEDICATION TSH/MOM/01-09
04 PATIENT RIGHTS AND EDUCATION TSH/PRE/01-06
05 HOSPITAL INFECTION CONTROL TSH/HIC/01-06
06 PATIENT SAFETY AND QUALITY IMPROVEMENT TSH/PSQ/01-05
07 RESPONCIBILITIES OF MANAGEMENT TSH/ROM/01-04
08 FACILITY MANAGEMENT AND SAFETY TSH/FMS/01-05
09 HUMAN RESUORCE MANAGEMENT TSH/HRM/01-09
10 INFORMATION MANAGEMENT SYSTEM TSH/IMS/01-06

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