Administrative

1. JCI KPIs

   1. Employee Exit Interview compliance

   2. Staff Attrition Rate

1. JCI KPIs

   1. Initial Insurance Approval Rejection Rate

2. Document Required

ACC

1. ADMISSION INTIMATION

2. DISCHARGE SUMMARY

3. EXTERNAL TRANSFER FORM

4. INTERNAL REFERRAL FORM

5. MONITORING PATIENT PROFILE

6. PATIENT EXTERNAL REFERRAL FORM

7. PATIENT REGISTRATION FORM 

8. PATIENT TRANSFER CONSENT FORM

9. WAITING TIME NOTIFICATION FORM

AOP

1. DOCTORS ORDER SHEET

2. DR PROGRESS NOTES

3. LAB- TEST REQUEST FORM

4. PROGRESS NOTES

5. RADIOLOGY-REQUEST-FORM

6. REQUEST FOR BLOOD

7. REQUISITION FOR HISTOPATHOLOGICAL EXAMINATION

OPD DR SPECIALTY WISE ASSESSMENT FORMS

1. GENERAL OUTPATIENT ASSESSMENT FORM

PHYSICIAN ADMISSION ASSESSMENT FORMS 

1. IP ADMISSION ASSESSMENT FORM DRS- GENERAL

ASC

1. OPERATION SUMMARY

2. PACU RECORD

3. POST SURGICAL CARE PLAN - FORM

4. PRE-ANESTHESIA CHECKUP CHART

5. PRE-OPERATIVE CHECK LIST

6. PROCEDURAL SEDATION FORM

COP

1. BLOOD PRODUCTS TRANSFUSION MONITORING FORM

2. BLOOD TRANSFUSION REACTION FORM

3. MULTIDISCIPLINARY CARE PLAN

4. TELEPHONE VERBAL ORDER AND CRITICAL RESULT REPORTING FORM

IPSG

1. CRIICAL VALUE, TELEPHONE, VERBAL ORDER RECEIVING FORM

2. CRTICAL VALUE REGISTER TEMPLATE

3. DOCTORS HANDOVER FORM - REVISED

4. NURSING HANDOVER FORM

5. NURSING SBAR

MMU

1. MEDICATION PRESCRIPTON AND ADMINISTRATION RECORD

2. MEDICATION RECONCILIATION FORM

3. PATIENT OWN MEDICATION

4. PHARMACY INTERVENTION REPORT

5. PRESCRIPTION AUDIT FORM

PCC

1. CUSTOMER FEEDBACK, COMPLAINT FORM

2. PATIENT EXPERIENCE SURVEY

3. WAIVER FOR REFUSAL OF TREATMENT, MEDICATION, SERVICE

CONSENT FORMS

1. CONSENT FOR RELEASE OF INFORMATION

2. GENERAL CONSENT -ENG

3. INFORMED CONSENT FOR HIGH RISK

4. INFORMED CONSENT FOR SURGERY OR SPECIAL PROCEDURE

HCT

1. TELEMEDICINE PROCESS FLOW

2. TELEMEDICINE CHECKLIST 

  IT DOWNTIME 

1.PLANNED DRILL

1. IT DOWNTIME PLANNED 

2.UNPLANNED DRILL

• 3. 1. 1. 1. 1. IT DOWNTIME DRILL EVALUATION FORM.

MOI

1. AUTHOIRIZATION FOR RELEASE OF MEDICAL RECORDS

2. MEDICAL REPORT DESTRUCTION LOG 

3. DOCUMENT REQEST FORM

MEDICAL RECORD AUDIT 

1. MEDICAL RECORD REVIEW TOOL

QPS

1. RCA_FRAMEWORK  JCI

2. INCIDENT REPORTING FORM 

3. ACTION PLAN FORM

4. RISK ASSESSMENT TEMPLATE

5. MINUTES OF MEETING 

6. RCA FRAME WORK 

SQE

1. ANNUAL STAFF PERFORMANCE APPRAISAL FORM

2. DEPARTMENT ORIENTATION CHECKLIST

3. EMPLOYEE TRAINING CHECKLIST

4. NEW HIRE ORIENTATION CHECKLIST

5. STAFF FILE COMPLETION CHECKLIST.

6. STAFFING PLAN TEMPLATE

7. TRAINING ATTENDANCE

1. JCI KPIs

   1. Patient Experience Rate - IPD

 2. Document Required

ACC

1. ADMISSION INTIMATION

2. OUT ON PASS CONSENT FORM

PCC

1. CUSTOMER FEEDBACK, COMPLAINT FORM

2. PATIENT EXPERIENCE SURVEY

3. PATIENTS BILL OF RIGHTS-ENGLISH(MODEL)

4. CONSENT FOR NON AVAILABILITY OF ROOM

5. GENERAL CONSENT -ENG

6. WHEELCHAIRS SAFETY CHECKLIST

1. JCI KPIs

   1. IT user Access Violation rate

   2. Compliance rate in evaluating new technologies 

   3. Compliance to Copy and Paste

   4. Compliance to Down time Management

2. Documents Required

FMS

DRILL EVALUATION FORMS 

1. IT DOWNTIME DRILL OBSERVATION

EMERGENCY CODE SCENERIO

1. CODE GREY - TRACKCARE DOWNTIME SIMULATION

HCT

1. DRILL SCENARIO 

2. TELEMEDICINE PROCESS FLOW

3. DRILL EVALUATION 

4. TELEMEDICINE CHECKLIST 

5. NEW SOFTWARE ASSESEMENT CHECKLIST 

6. IT NEW TECHNOLOGY EVALUATION 

IT DOWNTIME 

1.PLANNED DRILL

• 1. IT DOWNTIME DRILL OBSERVATION OPD PLANNED

  2. IT DOWNTIME PLANNED 

2.UNPLANNED DRILL

• 3. IT DOWNTIME DRILL EVALUATION FORM.

  4. IT DOWNTIME UNPLANNED SCENERIO

MOI

1. AUTHOIRIZATION FOR RELEASE OF MEDICAL RECORDS

2. MEDICAL REPORT DESTRUCTION LOG 

3. DOCUMENT REQEST FORM

4. COPY AND PASTE AUDIT TOOL 

MEDICAL RECORD AUDIT 

1. MEDICAL RECORD REVIEW TOOL

2. CLOSEDS RECORD REVIEW AUDIT CRITERIA - NUTRIONIST 

3. CLOSEDS RECORD REVIEW AUDIT CRITERIA -  NURSES

4. CLOSEDS RECORD REVIEW AUDIT CRITERIA - DOCTORS 

5. CLOSEDS RECORD REVIEW AUDIT CRITERIA - OCCUPATIONAL THERAPIST 

6. CLOSEDS RECORD REVIEW AUDIT CRITERIA - PHYSIO

QPS

1. RCA_FRAMEWORK  JCI

2. DOCUMENT REQUEST FORM 

3. INCIDENT REPORTING FORM 

4. ACTION PLAN FORM

5. INCIDENT EXCEL SHEET

6. RISK ASSESSMENT TEMPLATE

7. RCA FRAME WORK 

GLD

1. LAWS & REGULATION 2025

2. LAWS & REGULATION 2025-UAE

3. 1.LAWS AND REGULATION WORKSHEET - INDIA 

SQE

1. EMPLOYEE TRAINING CHECKLIST

2. TRAINING ATTENDANCE

3. DEPARTMENT ORIENTATION CHECKLIST

4. NEW HIRE ORIENTATION CHECKLIST

1. JCI KPIs

   1. Percentage of medical records with Error Prone Abbreviations 

   2. Patient Medical Record Completeness Rate - Close file

   3. Patient Medical Record Completeness Rate - Open file

2. Document Required 

ACC

1. ADMISSION INTIMATION

2. DISCHARGE SUMMARY

3. EXTERNAL TRANSFER FORM

4. INTERNAL REFERRAL FORM

5. MONITORING PATIENT PROFILE

6. MONITORING TRANSFER AND TRANSPORTATION

7. PATIENT EXTERNAL REFERRAL FORM

8. PATIENT REGISTRATION FORM 

9. PATIENT TRANSFER CONSENT FORM

AOP

1. DOCTORS ORDER SHEET

2. DR PROGRESS NOTES

3. ER VITAL SIGNS MORNITORING

4. LAB- TEST REQUEST FORM

5. PROGRESS NOTES

6. REQUEST FOR BLOOD

7. REQUISITION FOR HISTOPATHOLOGICAL EXAMINATION

8. TRAUMA FORM

NURSING ASSESSMENT, REASSESSMENT

1. GENERAL NURSING ADMISSION ASSESSMENT

2. GENERAL NURSING ADMISSION REASSESSMENT

3. GERIATRIC ASSESSMENT FORM - NURSES

4. NEWBORN AT BIRTH NURSING ASSESSMENT FORM

5. NEWBORN INITIAL ASSESSMENT FORM

6. NEWBORN NURSING REASSESSMENT FORM

7. NICU ADMISSION ASSESSMENT

8. PEDIATRIC NSG ADMISSION ASSESSMENT FORM

9. PEDIATRIC NSG REASSESSMENT FORM

10. PICU NSG ASSESSMENT

PHYSICIAN ADMISSION ASSESSMENT FORMS 

1. IP ADMISSION ASSESSMENT FORM DRS- GENERAL

2. PEDIATRIC ADMISSION REASSESSMENT FORM.DOC

3. PEDIATRIC ASSESSMENT FORM.DOCX

4. PEDIATRICS DRS ASSESSMENT.DOC

ASC

1. ANESTHESIA - RECORD

2. OPERATION SUMMARY

3. PACU RECORD

4. POST OPERATIVE - DOCTORS HANDOVER FORM

5. POST SURGICAL CARE PLAN - FORM

6. PRE-ANESTHESIA CHECKUP CHART

7. PRE-OPERATIVE CHECK LIST

8. PROCEDURAL SEDATION FORM

COP

1. BLOOD PRODUCTS TRANSFUSION MONITORING FORM

2. BLOOD TRANSFUSION REACTION FORM

3. BLOOD TRANSFUSION RECORD FORM

4. CARDIOPULMUNARY RESUSCITATION RECORD

5. DIALYSIS RECORD IP

6. MULTIDISCIPLINARY CARE PLAN

7. PAIN FLOW SHEET

8. PHYSICIAN ORDERS FOR END OF LIFE CARE

9. RAPID-RESPONSE-TEAM-RECORD-FORM (1)

10. RESTRAINT CONSENT FORM

11. RESTRAINT MONITORING FORM

12. TELEPHONE VERBAL ORDER AND CRITICAL RESULT REPORTING FORM

EWS TOOL

1. ADULT EARLY WARNING SIGNS

2. MATERNITY EARLY WARNING SIGNS

3. MEWS

4. NEONATE EWS

5. PEAD EWS

TRANSPLANT

1. TRANSPLANT PATIENT FILE CHECKLIST

IPSG

1. CRIICAL VALUE, TELEPHONE, VERBAL ORDER RECEIVING FORM

2. CRTICAL VALUE REGISTER TEMPLATE

3. DOCTORS HANDOVER FORM - REVISED

4. DUTY RMO SHIFT CHANGE HANDOVER FORM

5. ICU CRITICAL CARE AREAS DOCTORS HANDOVER FORM - REVISED

6. NURSING HANDOVER FORM

7. NURSING SBAR

8. POST OPERATIVE - DOCTORS HANDOVER FORM

9. SURGICAL SAFETY CHECKLIST

10. TIME OUT FORM-OUTSIDE OT

MMU

1. ADR MONITORING

2. ADVERSE REACTION REPORTING FORM

3. MEDICATION ERROR FORM

4. MEDICATION ERROR MONITORING

5. MEDICATION PRESCRIPTON AND ADMINISTRATION RECORD

6. MEDICATION RECONCILIATION FORM

7. PATIENT OWN MEDICATION

8. PHARMACY INTERVENTION REPORT

9. PRESCRIPTION AUDIT FORM

PCC 

1. CUSTOMER FEEDBACK, COMPLAINT FORM

2. INTERDISCIPILINARY PATIENT FAMILY EDUCATION RECORD

3. PATIENT EXPERIENCE SURVEY

4. WAIVER FOR REFUSAL OF TREATMENT, MEDICATION, SERVICE

CONSENT FORMS

1. ANESTHESIA PROCEDURAL SEDATION CONSENT FORM

2. BLOOD TRANSFUSION CONSENT

3. CHEMOTHERAPY CONSENT FORM

4. CONSENT FOR ADMISSION IN NICU

5. CONSENT FOR PHOTOGRAPHY

6. CONSENT FOR RELEASE OF INFORMATION

7. ENERAL CONSENT -ENG 

8. INFORMED CONSENT FOR HIGH RISK

9. INFORMED CONSENT FOR SURGERY OR SPECIAL PROCEDURE

MOI

1. 1. AUTHOIRIZATION FOR RELEASE OF MEDICAL RECORDS

   2. MEDICAL REPORT DESTRUCTION LOG 

   3. DOCUMENT REQEST FORM

   4. COPY AND PASTE AUDIT TOOL 

MEDICAL RECORD AUDIT 

1. MEDICAL RECORD REVIEW TOOL

2. CLOSEDS RECORD REVIEW AUDIT CRITERIA - NUTRIONIST 

3. CLOSEDS RECORD REVIEW AUDIT CRITERIA -  NURSES

4. CLOSEDS RECORD REVIEW AUDIT CRITERIA - DOCTORS 

5. CLOSEDS RECORD REVIEW AUDIT CRITERIA - OCCUPATIONAL THERAPIST 

6. CLOSEDS RECORD REVIEW AUDIT CRITERIA - PHYSIO

PCI

1. BLOOD BODY FLUID EXPOSURE FORM

2. NEEDLE STICK RECORD

3. POST SURGICAL FOLLOWUP FORM

QPS

1. DOCUMENT REQUEST FORM 

2. INCIDENT REPORTING FORM 

3. ACTION PLAN FORM

4. INCIDENT EXCEL SHEET

5. RCA_FRAMEWORK  JCI

6. MINUTES OF MEETING 

7. RCA FRAME WORK 

SQE

1. FPPE FORM - JUNIOR DOCTOR

2. FPPE FORM

3. NURSING STAFF CLINICAL PRACTICE EVALUATION

4. PRIMARY SOURCE VERIFICATION TEMPLATE 

5. STAFF FILE COMPLETION CHECKLIST.

HR FILE - CATEGORY WISE REQUIREMENTS

1. HR FILE DOCUMENTS LIST

2. PROFESSIONAL WISE SQE REQUIREMENTS

3. SQE STAFF FILE LIST CATEGORY WISE

1. JCI KPIs

   1. Patient Experience Rate 

   2. Patient Complaints Closure Rate 

2. Document Required

AOP

PHYSICIAN ADMISSION ASSESSMENT FORMS 

1. IP ADMISSION ASSESSMENT FORM DRS- GENERAL

2. PEDIATRIC ADMISSION REASSESSMENT FORM.DOC

3. PEDIATRIC ASSESSMENT FORM.DOCX

4. PEDIATRICS DRS ASSESSMENT.DOC

OPD DR SPECIALTY WISE ASSESSMENT FORMS

1. CARDIOLOGY

2. CARDIOTHORACIC

3. DENTAL

4. DERMATOLOGY

5. ENDOCRINOLOGY  ASSESSMENT FORM

6. ENT

7. GENERAL OUTPATIENT ASSESSMENT FORM

8. GENERAL SURGERY

9. GP, INTERNAL MEDICINE

10. NEONATOLOGY

11. NEPHROLOGY

12. NEUROLOGY

13. NEUROSURGERY

14. OBG-GYNAECOLOGICAL RECORD

15. OBG-MATERNITY RECORD- ANTENATAL

16. OPHTHALMOLOGY

17. ORTHOPEADICS

18. PEDIATRICS

19. PHYSIOTHERAPY ASSESSMENT OP

20. PLASTIC SURGERY

21. PSYCHIATRY

22. PULMONOLOGY

23. SURGICAL ONCOLOGY

24. UROLOGY

ASC

1. ANESTHESIA - RECORD

2. OPERATION SUMMARY

3. PACU RECORD

4. POST OPERATIVE - DOCTORS HANDOVER FORM

5. POST SURGICAL CARE PLAN - FORM

6. PRE-ANESTHESIA CHECKUP CHART

7. PRE-OPERATIVE CHECK LIST

8. PROCEDURAL SEDATION FORM

COP

1. MULTIDISCIPLINARY CARE PLAN

2. PHYSICIAN ORDERS FOR END OF LIFE CARE

3. RAPID-RESPONSE-TEAM-RECORD-FORM (1)

4. TELEPHONE VERBAL ORDER AND CRITICAL RESULT REPORTING FORM

TRANSPLANT

1. COMPOSITION OF MDT

2. JD TRANSPLANT LEADER(1)

3. TRANSPLANT PATIENT FILE CHECKLIST

IPSG

1. DOCTORS HANDOVER FORM - REVISED

2. DUTY RMO SHIFT CHANGE HANDOVER FORM

3. ICU CRITICAL CARE AREAS DOCTORS HANDOVER FORM - REVISED

4. NURSING HANDOVER FORM

5. NURSING SBAR

6. POST OPERATIVE - DOCTORS HANDOVER FORM

MMU

1. PHARMACY INTERVENTION REPORT

2. PRESCRIPTION AUDIT FORM

3. MEDICATION ERROR FORM

4. MEDICATION ERROR MONITORING

PCC

CONSENT FORMS

1. INFORMED CONSENT FOR HIGH RISK

2. INFORMED CONSENT FOR SURGERY OR SPECIAL PROCEDURE

3. GENERAL CONSENT -ENG

4. CONSENT FOR RELEASE OF INFORMATION

GLD

1. CEO DELEGATION LETTER

EVALUATION 

1. MEDICAL DIRECTOR EVALUATION

2. CEO ANNUAL EVALUATION 

MOI

1. AUTHOIRIZATION FOR RELEASE OF MEDICAL RECORDS

2. COPY AND PASTE AUDIT TOOL 

MEDICAL RECORD AUDIT 

1. MEDICAL RECORD REVIEW TOOL

2. CLOSEDS RECORD REVIEW AUDIT CRITERIA - DOCTORS 

QPS

1. INCIDENT REPORTING FORM 

2. ACTION PLAN FORM

3. MINUTES OF MEETING 

4. RCA FRAME WORK 

5. RCA_FRAMEWORK  JCI

SQE

1. FPPE FORM - JUNIOR DOCTOR

2. FPPE FORM

3. PRIMARY SOURCE VERIFICATION TEMPLATE

4. STAFF FILE COMPLETION CHECKLIST.

5. INITIAL EVALUATION FORM

6. ANNUAL STAFF PERFORMANCE APPRAISAL FORM

HR FILE - CATEGORY WISE REQUIREMENTS

1. HR FILE DOCUMENTS LIST

2. PROFESSIONAL WISE SQE REQUIREMENTS

3. SQE STAFF FILE LIST CATEGORY WISE

1. JCI KPIs

   1. Patient Experience Rate - OPD & Health Check up Clinic 

1. JCI KPIs

   1. Compliance Rate to Environmental Sustainability Strategic Plan

   2. Total Energy Consumption

   3. Monitoring Clinical Practices to Reduce Environmental Impact (e.g., Medical and Medication Waste Reduction)

   4. Reduction in Waste (General)

   5. To Monitor Carbon Emissions - Reduction of Vehicle Movement/Fuel Consumption Rate

   6. Water Consumption Rate

   7. Pharmaceutical Wastage Rate