SAMPLE OF PRIVATE CLINIC POLICY AND CHART

UKAPS, JKNS, 2008

WRITTEN CLINIC POLICY (SAMPLE)

1 PROCEDURE OF PATIENTS REGISTRATION, ATTENDANCE AND

REFERRALS

All new patients shall be registered in patient register.

Follow up patients shall be registered in the follow-up continuation sheet upon
arrival.
All patients who are referred shall have their available information recorded in the
referral and death register.

2 PROVISION MEDICAL RECORD

Patients and clinic’s staffs shall be made aware of the strict confidentiality of the
medical records and information contained in them.

No staff should divulge any information to any third party

All patient information shall be strictly private and confidential

Each patient will have individual medical record. Data will include name,
registration number, identification card number, age, gender, weight, height,
history of allergy or chronic illness and each visit findings of weight, height (for
growing-age patients), last menstrual period (Fertile age female patients), blood
pressure, temperature (if appropriate) laboratory/x-ray results if relevant,
treatment plan, presumptive or definitive diagnosis and return appointment if
needed.

Medical records are kept according to the legal requirement of record keeping of
the country.. The record is to be kept 7 years after the last one year of the
record’s active use for normal cases A record can be moved to a deceased file
once the clinic has the legally valid evidence of the patient’s death.

The person in-charge is responsible to review records in the clinic periodically for
quality control.

It is the responsibility of the holder of certificate or person in charge to comply

with DG directives with regards to preservation of patients medical record when
he intends to cease operation.

The healthcare professional who had provided any health care to a patient shall
be allowed to access or inspect patient’s medical record for defence in any civil
action brought against him.

3 PATIENTS GRIEVANCE MECHANISM PLAN

All patients will be informed of their right to air grievances. All patients grievances
shall be investigated within 14 days upon which if the patients will get the reply if

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the complainant is dissatisfied with reply the complainant may refer the matter to
Ministry Of Health.

4 PATIENTS’ RIGHTS

- Patients has the right to be

- Informed the estimated services charges prior of care or treatment.
- Provided with information of the nature of his medical condition, any
proposed treatment, investigation or procedure and related charges of the
processes that might take place before the patient gives consent.
- Treated decently.
- Request for referral to other healthcare facilities at any time they wish.
- Be given the medical report within reasonable time upon patient’s request
and payment of a reasonable fee.
- Make any complaints or suggestions to the clinic or relevant agencies

5 FEE SCHEDULE

All fees charged to the patients is following the list as in the Seventh Schedule
as follows
(please refer to seventh schedule in the regulation book)

BILLING
Consultation fees with medications:
RM XX – RM YY
Consultation fees without medications:
RM AA – RM BB
Procedures:
RM CC – RM DD
Investigations:
RM EE – RM FF

6 STAFF IDENTIFICATION

Staff identification is through the name card and the pictures on the organization
chart at the waiting area.

7 INCIDENT REPORTING

In the event of unforeseeable or unanticipated incident in the premise i.e.

patients death, fires or robbery, assault or battery of patients and malfunction or
intentional or accidental misuse of patient care equipment during treatment or
diagnosis of patients shall be reported to the person in charge immediately

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Person i-charge will write report to the Authority in Ministry of Health and/or
police within 10 working days or immediately.

The report will include information on date and time and the possible reason or
factors involved, statement of incident happened, signature of witness, person
involved and person in-charge during incidents.

Original and copies of report with relevant attachments shall be kept in separate
file for safe keeping and future reference. A receipt of the report shall be
requested.

8 INFECTION CONTROL

Person-in-charge is fully responsible in establishing the infection control system

and practise in the clinic and shall fully comply to the guidelines by Ministry Of
Health.

1. Controlling system

All notifiable diseases treated in the clinic must be notified to the Authority
Using the Standard Notification form by Ministry Of Health within the
required period.

Any staff detected to have or a carrier of any infectious or communicable

disease must take off any duty from the clinic until permitted to so by a
registered doctor. Any contaminated equipment during treatment of
infectious disease patient must not be used until it is properly disinfected.

2. Practise Among Staff

A valid updated contract and the monitoring record with the relevant
Private Clinical Waste Disposal Company must be well kept by the
Person in-charge or the Assistants.

Practise standard precautions;

1. Proper Hand-washing
2. Appropriate use of gloves, mask, eye protection, gown, face-
shield, boots.
3. Housekeeping and mange spillage properly.
4. Disinfect & sterilize patient- care equipment.
5. Manage soiled and contaminated linen properly.
6. Dispose sharps and infectious waste properly.

9 STERILE SUPPLIES

All sterile supplies will be stored properly. No sterile supplies will be stored on
counter or open surface. All supplies sterilized within the clinic will be labelled
with date of sterilization and expiration date. No outdated sterile supplies will be

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used. A schedule for regular inspection will be posted, initialled by the person
inspecting the supplies and kept for monitoring and quality control.

10 EMERCENCY AND DISASTER PREPAREDNESS

The clinic shall provide medical emergency procedures as a first response to

common life threatening injuries and acute illnesses on patients who come to the
clinic.

It is the policy of the clinic to have an effective plan to save the patients in any
disaster or fire. All staff will receive training on how to respond to emergencies.

A suitable area of the clinic will be prepared to receive and provide basic life
support for emergency patients.

The nature and scope of such emergency care services rendered by this clinic is:
- Basic life support.
- Any other measures as per the available person-in-charge’s and clinic’s
abilities
- Notify ambulance service to transfer patient to nearest hospital if
necessary

Once the patient is stable enough to leave, the relevant hospital will be notified of
the forthcoming emergency. Any referral to of patient to another healthcare
facility shall be recorded into the Referral Register

11 TRANSPORTATION OF LAB SPECIMEN

All the sample from the patients to be transported to the laboratory shall be kept
in the appropriate bottles and container following the requirement from the
laboratory

All specimen shall be kept in the appropriate place before it is transported,

12 MAINTENANCE & HOUSEKEEPING

The person-in-charge is fully responsible to ensure the cleanliness and order of

the clinic at all time.

No drinking or eating inside the clinic premise by patients. Staff shall only eat at
the rest area. No food is allowed at the clinical areas or medication refrigerator.

Mops will be cleaned only at the janitor’s area and done so every time being
used. Mops and cleaning equipments shall be kept strictly in the janitor’s closet.

13. WASTE MANAGEMENT :

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The medical waste will be transported in a leak proof, tightly sealed, fully
enclosed container ;waste must be properly handled, containerized prior to
disposal. Used and unused sharps should be disposed in an appropriate sharps
container that is puncture resistant, leak proof and able to be tightly sealed to
prevent the sharps from spilling.

14. ELECTRICAL & PLUMBING FACILITIES

The assistants shall record any malfunction of air-conditioning system, lighting,
power outlets and plumbing facilities. They shall the inform the person in charge
immediately and call relevant company for repair or service. Any work carried out
by and billing to any private company, shall be recorded.

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INCIDENT REPORTING

Sec.13 regulations Akta 586

1. Any unforeseeable or unanticipated incident that has occurred at any private

clinic shall be reported in writing to the Director General of Health or any other
person authorized by the DG.

2. It shall be reported the next working day or the day after the incident occurred.

3. The unforeseeable or unanticipated incident shall include :-

3.1 deaths of patients of the private clinic from unexplained cause or under
suspicious circumstances that are required to be reported to the police.

3.2 fires in the private clinic resulting in death or personal injury.

3.3 assault or battery of patients in the private clinic by staff.

3.4 malfunction or intentional or accidental misuse of patient care equipment that

occurs during treatment or diagnosis of patient in the private clinic. This can have
an adverse effect on the patient or staff.

4. A privte clinic shall retain all reports on investigations and findings in any incident
as required by the law.

5. The Director Generalequest any further information if necessary.

6. The holder of COR or PIC shall not discriminate or retaliate against anybody who
in good faith provides any information.

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EMERGENCY CARE SERVICES

Disaster preparedness

Section 73 regulations Akta 586

1. The holder of COR or PIC shall maintain a written plan on disaster preparedness.

2. All the staff should understand the plan.

3. The plan shall be readily available for inspection.

4. All staff shall assist relevant authorities in evacuation of mass casualties during
disasters located within their vicinity.

Emergency call information

Section 74 regulations Akta 586

1. Emergency call information shall be exhibited at a conspicuous part of a clinic.

2. Emergency call information shall include the following information:-

3. Tel no. of fire and police departments.

4. Information and contact no.’s of all staff to be contacted in case of an emergency.

5. Telephone no.’s of hospitals within the locality

6. Telephone no.’ s of ambulance services.

Basic emergency care services

Section 75 regulations Akta 586

1. All clinics shall have a well defined care system in providing basic outpatient
emergency care services.

2. The nature and scope of such emergency care services shall be in accordance of
their capabilities.

3. All private clinics shall provide immediate emergency care services which include
life saving procedures.

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4. Assesment of a patients condition to determine the nature, urgency and severity

of the patients immediate medical need shall be done by a registered medical
officer.

5. There should be proper SOP’s to follow when providing emergency treatment.

6. There shall be proper record keeping.

7. Prior to transferring a case to another healthcare facility they should be notified of

the impending transfer.

8. Emergency resuscitative and life support procedures pending transfer of the

critically ill shall be provided.

(GUIDELINES FOR POST REGISTRATION INSPECTION.)

EMERGENCY CARE FACILITIES AND SERVICES.

PHFSA (PMC & PDC) REG. 2006, Part X, Chapter 2

Emergency Call Information. (Reg.74.(1) & (2))

EMERGENCY PHONES NUMBERS(shall be available in the clinic

Ambulance
Hospital
Fire Department
Police Station
Person or Staff as determined
by PIC.
Others (NGO)

Basic Emergency Care Services

1 Basic outpatients emergency care services to cater Reg.75.(1)

any occasional emergency patient brought in by chance.

2 Assessment of patient shall be done by RMP or RDP. Reg.75.(4)

3 Maintained appropriate record for each patient who Reg.75.(6)

present for emergency services.

4 To provide equipment and services to render Reg.75.(8)

emergency resuscitative and life-support procedures
pending transfer to other facilities.

5 Minimum capability provided, unless specified Reg.75.(9)

otherwise, shall include equipment, apparatus, materials,
pharmaceuticals, substances or any other things deemed
necessary.

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Grievance Mechanism

S 26 : Holder of COR or PIC shall provide a grievance mechanism plan.

Patients should be made aware of his rights to air his grievance and the
grievance procedures.

S27 : grievance procedure

1. Patients/relatives can complain orally or in writing

2. Identify staff who will be responsible to take or accept any grievance

3. All complains need to be received and documented immediately

4. All complains to be forwarded to holder of COR or PIC by the next working day

5. The holder of COR or PIC shall cause for an investigation to be made and
provide a reply to the complaints within fourteen days from date of receipt of
complain.
The reply should include:
i) result of the investigation
ii) if the complaint is dissatisfied with the reply he may refer the matter to the DG
in writing

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GUIDELINE ON INFECTION CONTROL FOR

PRIVATE HEALTHCARE FACILITIES AND SERVICES

INTRODUCTION

Standard Precautions are considered as the most important strategy in controlling

infection successfully in a healthcare setting, regardless of patients’ diagnosis and
perceived infection status.

Standard precautions apply to all patients assumed to be infectious to:

i. Blood
ii. All body fluids, secretions and excretion except sweat, regardless of whether
contains visible blood
iii. Non-intact skin
iv. Mucous membranes

OBJECTIVES

The objectives of this guideline are:

1. To protect and minimize the risk of patients getting nosocomial infections and
other infections related to either the nature of their disease or other causes.

2. To protect healthcare workers, carers and visitors from infection in a healthcare

setting.

3. To assist and facilitate the private healthcare providers in complying with the
provisions and the needs of the Private Healthcare Facilities and Services Act
1998.

4. To assist and facilitate the enforcers of the Private Healthcare Facilities and
Services Act 1998 in post registration inspection and Surveillance Audit.

STANDARD PRECAUTIONS AND ADDITIONAL PRECAUTIONS – GENERAL

i. Hand Hygiene

Proper hand washing technique should be practiced by all healthcare providers

under these circumstances:
• Before and after coming into contact with patient
• Before and after each patient care procedures
• When there is contamination with blood and blood fluid
• After removing gloves
Hand rub with Alcohol not less than 60% emollient can be used when hands are
not visibly dirty. Other disinfectants that can be used are chlorhexidine
preparations e.g. Hibiscrub, obstetric cream, 0.5% aqueous chlorhexidine etc.

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Appropriate handwashing facilities must be available in all healthcare facilities at

appropriate locations such as wards, treatment rooms etc. These include suitable
sinks (deep with no overflow hole), hands free tap, hands free towel and soap
dispensers.

ii. Personal Protective Equipment (PPE)

Gloves
• Sterile gloves are a must for all aseptic procedures.
• Disposable gloves are used when touching blood, body fluids, secretions,
mucous membranes, non-intact skin, excretions and contaminated items.
• Gloves should be discarded or changed after touching these materials,
between procedures and between patient contacts.

Mask/goggles/face shields
• Should be used when performing procedures which generate splashes of
blood, body fluids, secretions and excretions.

Plastic aprons and rubber boots (overshoes)

• Use disposable plastic aprons and change after every patient/procedure
• Rubber boots should be used if gross contamination or spillage is expected

iii. Housekeeping and Management of Spillage

As a general rule, all private healthcare facilities and services must be cleaned
regularly. Sinks and toilets should be cleaned once daily or when necessary.

Whenever there is spillage, area of spillage should be quarantined with proper

signage to avoid further contamination. Recommended dilutions of Sodium
Hypochlorite for spill management are:

• 1.0% (10,000 ppm available chlorine) for heavy spillages of blood and
body fluids
• 0.1% (1000 ppm available chlorine) for general cleaning when disinfection
is required

Chlorine releasing granules (2-3% hypochlorite) can be used for direct

application to spillage of blood and body fluids.

All equipments used for cleaning should be kept in a janitor area or an area
equivalent. Cleaning solutions must be kept in a safe place.

iv. Disinfection and Sterilization

The principles of cleaning are using detergent and hot water followed by
thoroughly drying. Where sterilization is required, heat methods such as
autoclaving are most appropriate. All reusable instruments and items must be
thoroughly cleaned, disinfected and sterilized after each use.

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Cleaning

Cleaning with moist heat, for example boiling or washing with hot water and
detergent, followed by drying is often adequate.

Disinfecting

Chemical disinfectants are often used for disinfecting instruments and items
where sterilization is not required and when heat treatment is possible. However,
they may not work properly when they are:

• used on dirty objects

• not freshly made up (never top up)
• made up with wrong concentration
• mixed with incompatible chemicals
• expired

Never disinfect single-use disposable items. These items should be discarded

the proper way. Examples of chemical disinfectants are Presept, Mythelated
Spirit 70%, Hibitane and Amphyl (different concentration for different items or
equipments). Other method for disinfecting is by thermal heat at:

• 70˚C with minimum heating time 15 minutes

• >80˚C with minimum heating time 2 minutes
• 90˚C with minimum heating time 1 minutes

Sterilization

Sterilization is required for instruments, equipment and dressings that are to be

used for surgical procedures or that come into contact with open wounds or
sterile body sites (semi-critical and critical items). The following methods are
used:

i. High Temperature (Heat)

• dry heat in the oven at 160˚ C with heating time 2 hours or 180˚C with
heating time 1 hour
• Steam under pressure/moist heat at 134˚C with heating time 3- 3.5
minutes for fabric and 121˚C with heating time 7-12 minutes

ii. Low Temperature

• Gas plasma sterilization at 50-57˚C with heating time 6-10
minutes
• Ethylene Oxide sterilizer

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v. Management of Soiled/Contaminated Linen

Appropriate laundry bags, hampers or trolleys which ensures no leakage and

made from impervious materials must be used for transportation of clean and
dirty linens.

• Red alginated and labeled (Biohazard) laundry bags should be used for
contaminated/infected linens.
• White bags should be used for ordinary linens.
• Grossly contaminated, heavily soaked linen must be placed in a yellow plastic
bag and sent for incineration.

Contaminated linen should be washed under running water, soaked with Sodium
Hypochlorite 1 in 80 for 30 minutes then launder as usual.

vi. Sharps and Wastes Disposal

In general, wastes can be segregated as follows:

• Clinical waste - yellow plastic bags

• Sharps, syringes and needles - Sharp containers
• General domestic waste - Black plastic bags
• Radioactive waste - Advice to be sought from Environmental
Department

Appropriate sharp bins and infectious waste bins should be provided next to the
work place in appropriate areas in any healthcare facilities. Bins must be yellow
coded, labeled and made from impervious materials for easy cleaning.

The principles of sharp disposals are:

• Discard only sharps in sharp bins

• Sharp bins should not be more than 2/3 full
• DO NOT recap or manipulate sharps
• Use forceps if you need to pick up sharps
• ‘You use it, you throw it’

Blood and soiled dressings should be discarded as clinical waste. Excreta and
other body fluids should be discarded into sluice.

ADDITIONAL PRECAUTIONS IN SPECIFIC HEALTH FACILITIES

i. General Wards

All wards must adhere to general Standard Precautions outlined above. In

addition, Isolation Practices and Specimen Collection and Handling Guidelines
must also be followed.

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ii. High Risk areas

High risk areas are as stated below:

• Intensive Care Unit

In addition to Standard Precautions, closed system for blood taking must be

practiced. Additional face shield must be used for procedure which may
generate aerosols.

• Labour Room

In addition to Standard Precautions, long sleeved aprons/gowns must be

used. All placentas are handled as clinical waste and must be placed in
yellow bags and incinerate if unclaimed. For contaminated placenta, place it
in Biohazard labeled bags.

• A&E, Treatment Room and Dental Clinic

In addition to Standard Precautions, surgical hand scrubbing must be

practiced and use disposable items as much as possible.

• Operation Theatre

In addition to Standard Precautions, surgical hand scrubbing must be

practiced. Infectious cases must be last in list.

• Renal Dialysis Unit

In addition to Standard Precautions:

- All patients must be screened for Hepatitis B, Hepatitis C and HIV
- All staffs must be screen against Hepatitis B, Hepatitis C and HIV and
immunized for Hepatitis B.
- Use disposable or heat labile items

STANDARD PRECAUTIONS FOR LABORATORY SERVICES INCLUDING BLOOD

TRANSFUSION SERVICES

All laboratory staffs are at risk for all types of infections. Therefore strict compliance with
Standard Precautions and Additional Precautions guideline are important to prevent
occupational exposure.

In addition to the general Standard Precautions, additional precautions as stated below

should be practiced:

• Personal Protective Equipment

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 Lab coat to be buttoned and worn at all times

 Change lab coats regularly at least once a week, if contaminated
to be changed immediately
 Contaminated coat to be soaked with Sodium Hypochlorite 1 in 80
for 30 minutes before laundering
 Remove coat when leaving laboratory

• Laboratory activities
 Laboratory activities should be carried out in a bio-safety cabinet
 Wash hands with antiseptic cleanser after removing gloves
and before leaving laboratory

• Collection, dispatch, reception and disposal of specimens

 Treat all specimens as potentially infectious
 Specimens must be collected in screw-capped and leak-proof
container in upright position and properly labeled
 All specimens should be discarded as clinical waste
 Left over specimen in reusable container should be
decontaminated by autoclaving before the content is discarded

MAINTENANCE OF EQUIPMENTS FOR STERILIZATION

1. Yearly certification of fitness from JKKP is needed for all autoclaves.

2. Mechanical tests should be carried out routinely e.g. Dummy Run, Bowie Dick
and B.I. once a week, during installation, after major repair and for validation.

3. Maintenance and usage should follow manufacturer’s instructions.

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ACT 586 REGULATION 87 ( 5 )

Essential Message to maintain Cold Chain

1 Refrigerator type : use the correct type of refrigerator

Use a two door refrigerator or top loading refrigerator*

2 Dedicate this refrigerator only for storing vaccine.

Do not store drugs , specimens, food or drinks in this refrigerator

3 Locate your refrigerator appropriately.

Refrigerator to be placed 40cm away from the wall.

Do not place refrigerator under the sun , near the stove, microwave or fire.

4 Place your vaccines in the apppropriate area.

Do not store vaccines in door shelves or freezer, or in the compartment directly

under the freezer.

Do not store vaccines at lowest compartment of the refrigerator.

Place thermometer in the centre of refgerator, so that it can be read without moving
the thermometer.

Place in whole containers and space of 1 to 2cm between rows of vaccines to allow
free movements of air.

Solvent for freeze- dried vaccines shall not be stored at the freezer compartment.

Removed vaccines from the refrigerator when expired.

5 Maintain refrigerator temperature at 2 degree c to 8 degree c all the time

Do not open the refrigerator unnecessarily. If your refrigerator requires defrosting, do

iit at least monthly. Have an action plan in the event of power failure.

Placed icebag and bottles of cold water to maintain the appropriate temperature
during power failure.

Cold Box for transportation and temperary storage.

6 Monitor the refrigerator temperature daily

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Use dial or Minimax thetmometers.

Chart the refrigerator temperature at least twise every working day.
If temperature is persistently below 2 degree C or above 8 degree C;
i. Check refrigerator regulator
ii. Set regulator higher if above 8 degree C
iii Set regulator lower if below 2 degree C

iv If this does not work, defrost your refrigerator

v If defrost does not work, get a technician to service your refrigerator

7 Action plan when power failure;

For top loading refrigerator -
Do not open the refrigerator if temperature can maintain for 70 hours at not more
than 5 degree C.
If power failure less than 70 hours shifting of vaccines is not required
If power failure more than 70 hours shifting of vaccines to another refrigerator is
required

8 Practised sterile procedure while giving vaccines.

9 Disposal of used vaccines and ampouls;

Dispose into sharp bins

Refrences

1. Akta Kemudahan Dan Perhidmatan Jagaan Kesihatan Swasta 1998 (ACT 586)
2. Peraturan - Peraturan Kemudahan Dan Perhidmatan Jagaan Kesihatan Swasta
(Klinik Perubatan Swasta Atau klinik Pergigian swasta) 2006
3. Panduan Untuk Rancangan Immunisi
4. Six Essential Messages to Maintain Cold chain
5. Who Booklet Safe Vaccine Handling Cold Chain and Immunization

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STAFF ROSTER

Attending Doctor
___________________________________________________

Morning Afternoon Night Standby /

Shift Shift Shift On Call
Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday /
Public Holiday

Drs-on-Leave

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REFERRAL REGISTER

Patient’s
Referral Referred Person-in-
Date Patient’s Name Registration
Form No. to charge
No.

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PATIENT’S MEDICAL RECORD

MOVEMENT REGISTER

Date

Person-in-charge

Clinic Name

Clinic Address

Patient’s Reference
No.

Patient’s Name

I/C No.

Reason for Movement

Records moved to

Approved by
(signature)

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PATIENT’S MEDICAL RECORD

Registration No.

Name

I/C No.

Address

Date of Birth

Gender

Next of Kin / Legal

Guardian

Clinical Notes

Medication Orders

Known Allergies and Drug

Sensitivities

Current Medication

Results of Relevant
Diagnostic Tests

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NOTIFIABLE INFECTIOUS DISEASE REGISTER

Diagnosis of
Name of Date / Name of Staff / Date /
Clinic Name / Notifiable
Person- Time of Type of Time of
Address Infectious
in-charge Report Equipment Detection
Disease

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FEEDBACK FORM

Name of Clinic

Name of Patient

I/C No.

Address

Telephone No.

Date and Time of

Incident

Patient’s Comments

Signature

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EMERGENCY PHONE NUMBERS

Nearest Police Department

Ambulance

Nearest Hospital

Nearest Fire Department

Doctors / Staff Members

Contact details as
determined by the Person-
in-charge

FOOT NOTES

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DEATH REGISTER

Time Name of Cause of

Date Registration Person-
of Patient I/C No. Death
No. in-charge
Death (if known)

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VOLUNTEER REGISTER

Name of Volunteer

I/C No.

Address

Telephone No.

Completed Questionnaire
on Health Status

Records of Assignment
and Work Hours

Current Job Description

In-service Training and

Orientation Records

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