RMO’s Meeting Points (Revised as per NABH 5th Edition Guidelines)

 

RMO’s Meeting Points (Revised as per NABH 5th Edition Guidelines)

1. Diagnosis Documentation:
   The provisional and/or confirmed diagnosis must be clearly documented in the patient file, especially for all newborn cases.
2. Labour Patient Files:
   For all labour cases, the duty doctor must initiate the patient file immediately upon admission.
3. Newborn Files:
   A separate newborn file must be created by the duty doctor immediately after delivery.
4. Daily Rounds:
   Floor doctors must conduct daily rounds and record progress notes in the Inpatient Department (IPD) file with date, time, and signature.
5. Shift Handover Protocol:
   During shift changes, ensure the outgoing RMO waits for the incoming RMO to take full charge. Do not leave the department unattended to prevent delay in patient care.
6. Bedside Rounds:
   During rounds, doctors must physically visit and examine the patient at the bedside, not just review the file at the nursing station.
7. Patient Complaints:
   All patient complaints must be addressed promptly and respectfully by the duty RMO. Proper documentation of the complaint and action taken is mandatory.
8. Informed Consent:
   Informed consents must be taken by the RMO, ensuring the patient and/or relative understands the procedure, risks, and alternatives. The acknowledgment section must be signed appropriately.
9. Blood Transfusion Protocol:
   During blood cross-checking, the patient’s blood group report must be verified and matched with the blood product before transfusion. Follow dual-check protocols.
10. Patient Admission and Transfers:
    Inform the respective consultant during patient admission and when transferring patients between departments or to other facilities.
11. Emergency Care:
    All emergency cases must be attended immediately by the on-duty RMO, and the consultant must be informed promptly.
12. Initial Assessment:
    During admission, the patient’s assessment must be conducted thoroughly by the RMO, based on clinical examination and not solely on the attendant’s history.
13. SNDT Documentation:
    As per NABH 5th Edition, all patient files must have proper SNDT (Signature, Name, Date, and Time) for every entry.

14. Clinical Handover Record:
    A structured clinical handover must be documented during every shift change to ensure continuity of care.
15. Medication Reconciliation:
    At admission, discharge, and internal transfer, reconcile medications to avoid discrepancies and ensure patient safety.
16. Patient Identification Protocol:
    Follow the two-identifier rule (e.g., name and UHID) before any procedure, medication administration, or sample collection.
17. Incident Reporting:
    Any unusual occurrence (clinical or administrative) must be reported immediately as per hospital policy, and documented appropriately.
18. Confidentiality and Rights:
    Patient information must be kept confidential at all times. Ensure patients are informed about their rights and responsibilities.
19. Discharge Summary:
    Discharge summaries must be complete, including final diagnosis, treatment given, condition at discharge, and follow-up instructions. Review and sign off by RMO is essential before handing it to the patient.
20. Infection Control Practices:
    RMOs must follow standard precautions and infection control guidelines at all times (e.g., hand hygiene, PPE usage).