2.  AAC.1: THE ORGANIZATION DEFINES AND DISPLAYS THE SERVICES THAT IT CAN PROVIDE..  THE SERVICES ARE DISPLAYED PROMINENTLY IN AN AREA VISIBLE TO PATIENTS  BILINGUAL DISPLAY

3.  THE SCOPE OF SERVICES IS DEFINED AND DISPLAYED  SIGNAGES,PAMPHLETS AND SIGNBOARDS DISPLAY THE INFO ABOUT THE SERVICES PROVIDED  THE SCOPE IS DEPENDENT ON THE FACILITIES,STAFF AND INFRASTRUCTURE

4.  THE SERVICES PROVIDED ARE DISPLAYED AND SHOULD BE ACTUALLY AVAILABLE  PERMANENT DISPLAY BOARD  RECEPTION STAFF AND OPD AND IPD STAFF ARE ORIENTED THROUGH TRAINING  RECORDS OF TRAINING

5.  AAC.2: THE ORGANIZATION HAS A DOCUMENTED REGISTRATION, ADMISSION AND TRANSFER PROCESS

6.  HOSPITAL POLICIES ARE DOCUMENTED WITH PROCEDURE TO BE FOLLOWED FOR REGISTRATION,ADMISSION IPD PATIENTS AND EMERGENCY PATIENTS

7.  THE STAFF IS ORIENTED TO THE SCOPE OF SERVICES  SAFE TRANSFER OR REFERRRAL OF PATIENTS POLICIES AND PROCEDURES GUIDE THE PROCESS IF THE PATIENT REQUIRES SERVICES NOT AVAILABLE.  AMBULANCE SERVICES ARE MADE AVAILABLE IF REQUIRED.  TRANSFER SUMMARY IS GIVEN  INVESTIGATION AT ANOTHER CENTRE ALSO SHOULD BE MANAGED IN SAFE MANNER

8.  AAC.3 PATIENTS CARED FOR BY THE ORGANIZATION UNDERGO AN ESTABLISHED INITIAL ASSESSMENT. A.

9.  A STANDARD FORMAT IS USED FOR INITIAL ASSESSMENT IS DONE IN OPD AND IPD AND EMERGENCY PATIENTS  ALL ASPECTS OF ASSESSMENT NEED TO BE MENTIONED

10.  ASSESSMENT IS PERFORMED BY STAFF ACCORDING TO THEIR QUALIFICATIONS AND AUTHORIZATION BY HOSPITAL  HR DEPT GIVES JOB DESCRIPTION TO STAFF OUTLINING THEIR DUTIES AND AUTHORIZATION

11.  DEPENDING ON THE CONDITION OF THE PATIENT INITIAL ASSESSMENT IN IPD HAS TO BE DONE AT THE EARLIEST AND DOCUMENTED WITHIN 24 HOURS  EMERGENCY PATIENTS REQUIRE EARLY ASSESSMENT

12.  NURSING ASSESSMENT IS DONE AT TIME OF ADMISSION AND WILL IDENTIFY NURSING NEEDS OF THE PATIENT  NUTRITIONAL ASSESSMENT IS ALSO INCLUDED

13.  PATIENT IS REASSESSED AT REGULAR INTERVELS AND IS DOCUMENTED  PLAN OF CARE IS DOCUMENTED

14.  ALL ASPECTS OF CARE ARE TAKEN CARE OF AND THE TREATING CONSULTANT AND WARD MO COORDINATE CARE OF THE PATIENT

15.  PATIENTS ARE REASSESSED AT REGULAR INTERVELS  DISCHARGE PLANNING IS DONE AT THE TIME OF ADMISSION ALONG WITH THE PLAN OF CARE

16.  AAC.5 Laboratory services are provided as per the scope of the hospital’s services and laboratory safety requirements. a. 

17.  THE LAB SERVICES MAY BE OUTSOURCED OR IN HOUSE  AVAILABILITY ROUND THE CLOCK IS ENSURED  EMERGENCY TEST AVAILABILTY ROUND THE CLOCK SHOULD BE ENSURED

18. .DOCUMENTED PROCEDURES GUIDE THE ORDERING,COLLECTION,IDENTIFICATION,HANDLING,TRANSPORT ATION,PROCESSING AND DISPOSAL OF SPECIMANS  SAMPLE COLLECTION MANUAL AND LAB MANUAL  SOPS AND WI ARE THE GUIDLELINES  VALIDATION AND VERIFICATION AND EXTERNAL AND INTERNAL QUALITY ASSURANCE IS ENSURED

19.   TAT IS MAINTAINED  CRITICAL RESULTS ARE MADE AVAILABLE ON URGENT BASIS  VERBAL REQUEST POLICY IS FOLLOWED ACCORDING TO PROTOCOL

20. . PPE ARE MADE AVAILABLE AND USED  STANDARD PRECAUTIONS ARE FOLLOWED  BMW DISPOSAL IS ACCORDING TO REGULATIONS  SAFETY TRAINING IS GIVEN TO STAFF INCLUDING EQUIPMENT HANDLING

21.  AAC.6 Imaging services are provided as per the scope of the hospital’s services and established radiation safety programme.

22. .. THE AVAILABILITY OF RADIOLOGY SERVICES IS COMMESURATE WITH THE SCOPE OF SERVICES  OUTSOURCING OF TEST IS TO CENTRES WITH QUALITY ASSURANCE METHODS FOR CREDIBILITY  RELEVANT IMAGING SIGNAGES ESP FOR RADIATION HAZARDS ACCORDING TO AERB GUIDELINES IS ENSURED

23.  TURNAROUND TIME IS DECIDED BY MANAGEMENT DEPENDING ON URGENCY,TYPE OF TEST AND AVAILABILITY  ADEQUATE AND TRAINED STAFFF AND EQUIPMENT IS ENSURED TO KEEP MAINTAINRESULTS IN TAT  CRITICAL RESULTS ARE AVAILABLE ON URGENT BASIS

24.  RADIATION SAFETY MEASURES ARE TAKEN ACCCORDING TO AERB  STAFF IS TRAINED IN RADIATION SAFETY  PROTECTION DEVICES ARE MADE AVAILABLE  DOSIMETERS ARE MADE AVAILABLE  RSO IS APPOINTED  QA TESTS ARE DONE

25. .THE ORGANSIATION HAS A DEFINED DISCHARGE PROCESS

26.  DISCHARGE POLICY AND PROCEDURES ARE DOCUMENTED  THEY INCLUDE MLC CASES,LAMA,DEATH CASES 

27.  DISCHARGE SUMMARY CONTAINING ALL RELEVANT DETAILS OF IPD STAY IS GIVEN TO ALL PATIENTS  ALL PATIENTS INCLUDING LAMA,TRANSFER ARE GIVEN A SUMMARY

28.  DISCHARGE SUMMARY IS GIVEN IN STANDARD FORMAT WITH ALL DETAILS OF ADMISSION,IMP FINDINGS,INV RESULTS,DIAGNOSIS,PROCEDURE NOTES,TREATMENT GIVEN,AND COURSE OF TREATMENT IN HOSPITAL

29. . DISCHARGE SUMMARY CONTAINS  FOLLOW UP ADVICE  MEDICATION  DIET  WHEN TO OBTAIN URGENT CARE

30.  FOR DEATH CASES A DEATH SUMMARY IS WRITTEN AND FORM FOR INTIMATION OF DEATH IS FILLED  HANDDING TAKING OVER OF BODY  ID PROOF AND ATTENDENTS RECORDS ARE KEPT  COPY OF DEATH CERTIFCATE IS KEPT