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Standard Operating Procedure (SOP) – Doctors Department
This Standard Operating Procedure (SOP) establishes the reporting structure, responsibilities, professional standards and legal accountability for all Medical Officers, Consultants and Specialists working at Sri Lakshmi Multi Speciality Hospital. Every doctor shall comply with Hospital policies, clinical protocols, NABH standards and applicable laws while delivering safe, ethical and evidence-based patient care.
Department Hierarchy
- Medical Director / Chief Medical Officer (CMO)
- Head of Department (HOD)
- Senior Consultant
- Consultant
- Duty Medical Officer (DMO) / Resident Medical Officer (RMO)
- Junior Doctor / Intern (where applicable)
Junior Doctors shall work under the supervision of their respective Consultants and Department Heads. All lawful clinical and administrative instructions issued through the approved reporting hierarchy shall be followed. Any disagreement or clinical concern shall be escalated to the immediate senior without delay.
Key Duties & Responsibilities
- Conduct inpatient rounds at least twice daily or as clinically required.
- Respond to emergency calls immediately and, wherever practicable, within 5–10 minutes.
- Assess, diagnose and prescribe appropriate treatment.
- Maintain complete, accurate and timely medical records.
- Verify informed consent before procedures wherever legally required.
- Coordinate patient care with Nursing, Laboratory, Pharmacy and other departments.
- Maintain professional ethics, patient confidentiality and respectful communication.
Critical Rule
"No treatment shall be provided without appropriate medical documentation, except in life-threatening emergencies where documentation shall be completed immediately after patient stabilisation."
Legal & Professional Responsibility
Every Doctor is personally responsible for ensuring that clinical decisions, treatment, informed consent and medical documentation comply with applicable laws, professional standards and Hospital policies. Failure to obtain valid consent, maintain medical records or exercise reasonable professional care may result in disciplinary action, medico-legal liability and regulatory proceedings.
- National Medical Commission Act, 2019.
- Indian Contract Act, 1872 (Consent Principles).
- Consumer Protection Act, 2019.
- Clinical Establishments (Registration and Regulation) Act, 2010 (where applicable).
- NABH Care of Patients (COP) Standards.
Non-Compliance
Failure to comply with this SOP, Hospital policies, applicable laws or lawful instructions issued by authorised senior medical personnel may result in counselling, retraining, suspension of clinical privileges, disciplinary action or other legal proceedings, depending on the nature and seriousness of the violation.
Department Hierarchy & Reporting Structure
Every Doctor shall work within the approved reporting hierarchy. Junior Doctors shall report to the Duty Medical Officer or Consultant. Consultants shall report to the respective Head of Department, and the Head of Department shall report to the Medical Director / Chief Medical Officer. Clinical concerns shall be escalated through this hierarchy without bypassing authorised supervisors, except during emergencies where immediate patient safety is the priority.
Standard Operating Procedure (SOP) – Nursing Department
This Standard Operating Procedure (SOP) defines the reporting hierarchy, responsibilities, professional conduct and legal accountability of all nursing personnel. Every nurse shall perform duties under the supervision of the authorised reporting officer while ensuring patient safety, quality nursing care and compliance with Hospital policies, NABH standards and applicable laws.
Department Hierarchy & Reporting Structure
| Level | Designation | Reports To |
|---|---|---|
| Level 1 | Medical Director / Hospital Management | Management Committee |
| Level 2 | Chief Nursing Officer / Nursing Superintendent | Medical Director |
| Level 3 | Deputy Nursing Superintendent | Nursing Superintendent |
| Level 4 | Nursing Supervisor | Deputy Nursing Superintendent |
| Level 5 | Ward In-charge / Team Leader | Nursing Supervisor |
| Level 6 | Senior Staff Nurse | Ward In-charge |
| Level 7 | Staff Nurse | Senior Staff Nurse / Ward In-charge |
| Level 8 | Junior Nurse / Nursing Assistant | Staff Nurse |
Every nursing employee shall follow lawful instructions issued by their immediate reporting officer. Clinical concerns beyond their authority shall be escalated through the established chain of command. No junior employee shall bypass the reporting hierarchy unless immediate patient safety requires urgent escalation.
Key Duties & Responsibilities
- Monitor and record patient vital signs as prescribed.
- Administer medications strictly as per the treating doctor's written orders.
- Maintain accurate nursing notes and patient records.
- Provide safe and compassionate nursing care.
- Immediately report changes in patient condition to the treating doctor or Nursing Supervisor.
- Complete proper shift handover before leaving duty.
Critical Rule
"Every shift handover shall include patient condition, medications administered, pending treatments and critical alerts. Incomplete handover is considered a serious patient safety violation."
Legal & Professional Responsibility
Nursing personnel shall administer treatment only in accordance with authorised medical orders, maintain complete nursing documentation and provide care within the scope of their professional competence. Failure to follow written medical orders, maintain accurate records or report deterioration in patient condition may result in disciplinary action, professional negligence claims and regulatory consequences.
- Indian Nursing Council Act, 1947.
- Biomedical Waste Management Rules, 2016.
- Indian Medical Negligence Principles.
- NABH Care of Patients (COP) Standards.
Non-Compliance
Failure to comply with this SOP, Hospital policies, lawful instructions issued by authorised senior nursing personnel or applicable laws may result in counselling, retraining, disciplinary action or other legal consequences depending on the seriousness of the violation.
Standard Operating Procedure (SOP) – Pharmacy Department
This Standard Operating Procedure (SOP) establishes the reporting hierarchy, operational responsibilities, medication management standards and legal accountability for all Pharmacy personnel. Every employee shall ensure the safe procurement, storage, dispensing and documentation of medicines in accordance with Hospital policies, statutory requirements and NABH standards.
Department Hierarchy & Reporting Structure
| Level | Designation | Reports To |
|---|---|---|
| Level 1 | Hospital Management / Medical Director | Management Committee |
| Level 2 | Pharmacy Manager / Chief Pharmacist | Hospital Management |
| Level 3 | Senior Pharmacist | Pharmacy Manager |
| Level 4 | Pharmacist | Senior Pharmacist |
| Level 5 | Pharmacy Assistant / Trainee | Pharmacist |
Every Pharmacy employee shall follow lawful instructions issued by the immediate reporting officer. Junior personnel shall work under the supervision of Senior Pharmacists and the Pharmacy Manager. Any discrepancy relating to prescriptions, stock or medication safety shall be reported immediately through the established reporting hierarchy.
Key Duties & Responsibilities
- Dispense medicines only against a valid prescription issued by an authorised Registered Medical Practitioner.
- Maintain accurate stock registers and inventory records.
- Check medicine expiry dates and storage conditions regularly.
- Ensure proper storage of medicines, including refrigerated and controlled drugs.
- Maintain dispensing records and medication documentation.
- Immediately report medication discrepancies, shortages or adverse drug incidents to the Pharmacy Manager.
Critical Rule
"No medicine shall be substituted or dispensed without a valid prescription or prior approval from the treating doctor where substitution is required."
Legal & Professional Responsibility
Pharmacy personnel are legally responsible for ensuring accurate dispensing, proper storage, inventory control and safe medication practices. Dispensing medicines without a valid prescription, supplying expired medicines or making unauthorised substitutions may result in disciplinary action, regulatory proceedings and legal liability.
- Drugs and Cosmetics Act, 1940.
- Drugs and Cosmetics Rules, 1945.
- Pharmacy Act, 1948.
- Narcotic Drugs and Psychotropic Substances (NDPS) Act, 1985 (where applicable).
- NABH Medication Management (MOM) Standards.
Non-Compliance
Failure to comply with this SOP, Hospital policies, lawful instructions issued by authorised Pharmacy supervisors or applicable laws may result in counselling, retraining, suspension of pharmacy duties, disciplinary action or legal proceedings, depending on the seriousness of the violation.
Standard Operating Procedure (SOP) – Billing Department
This Standard Operating Procedure (SOP) establishes the reporting hierarchy, billing responsibilities, financial accountability and professional standards for all Billing Department personnel. Every employee shall ensure accurate billing, transparent financial transactions and compliance with Hospital policies, statutory requirements and NABH standards.
Department Hierarchy & Reporting Structure
| Level | Designation | Reports To |
|---|---|---|
| Level 1 | Hospital Management / Chief Executive Officer (CEO) | Management Committee |
| Level 2 | Finance Manager / Accounts Manager | Hospital Management |
| Level 3 | Billing Manager / Billing Supervisor | Finance Manager |
| Level 4 | Senior Billing Executive | Billing Manager |
| Level 5 | Billing Executive / Cashier | Senior Billing Executive |
Every Billing employee shall perform duties under the supervision of the immediate reporting officer. Billing corrections, discounts, refunds and financial exceptions shall be approved only by authorised personnel. Financial discrepancies shall be reported immediately through the established reporting hierarchy.
Key Duties & Responsibilities
- Prepare accurate patient bills based on authorised services.
- Ensure all charges are transparent and correctly applied.
- Collect payments and issue official receipts for every transaction.
- Maintain complete billing records and financial documentation.
- Perform daily cash, digital payment and billing reconciliation.
- Coordinate with Reception, Pharmacy, Laboratory, Radiology and Nursing departments for billing accuracy.
Critical Rule
"No bill, discount, refund or financial adjustment shall be created, modified or cancelled without proper authorisation."
Legal & Professional Responsibility
Billing personnel are responsible for maintaining accurate financial records, safeguarding Hospital revenue and ensuring transparent billing practices. Fraudulent billing, unauthorised discounts, misappropriation of funds, falsification of records or disclosure of confidential financial information may result in disciplinary action, civil liability and criminal proceedings where applicable.
- Consumer Protection Act, 2019.
- Goods and Services Tax (GST) Act, where applicable.
- Digital Personal Data Protection Act, 2023.
- Clinical Establishments (Registration and Regulation) Act, 2010 (where applicable).
- NABH Information Management System (IMS) Standards.
Non-Compliance
Failure to comply with this SOP, Hospital financial policies, lawful instructions issued by authorised supervisors or applicable laws may result in counselling, retraining, financial audit, disciplinary action, recovery of losses or legal proceedings depending on the nature and seriousness of the violation.
Standard Operating Procedure (SOP) – Reception Department
This Standard Operating Procedure (SOP) establishes the reporting hierarchy, operational responsibilities, patient registration procedures and professional standards for all Reception Department personnel. Reception staff shall ensure every patient is welcomed, registered and directed efficiently while maintaining professionalism, confidentiality and quality service.
Department Hierarchy & Reporting Structure
| Level | Designation | Reports To |
|---|---|---|
| Level 1 | Hospital Management / Administrator | Management Committee |
| Level 2 | Front Office Manager | Hospital Administrator |
| Level 3 | Reception Supervisor / Team Leader | Front Office Manager |
| Level 4 | Senior Reception Executive | Reception Supervisor |
| Level 5 | Reception Executive | Senior Reception Executive |
Reception personnel shall perform duties under the supervision of their immediate reporting officer. Junior employees shall follow lawful instructions issued by authorised senior personnel. Operational issues, patient complaints or emergency situations shall be escalated promptly through the established reporting hierarchy.
Key Duties & Responsibilities
- Register patients accurately and verify patient information.
- Coordinate inpatient and outpatient admissions.
- Manage patient queues efficiently and courteously.
- Guide patients and visitors to the appropriate department.
- Respond professionally to telephone calls and enquiries.
- Maintain confidentiality of patient information and Hospital records.
Critical Rule
"No patient shall be left unattended at the Hospital entrance or Reception area. Every patient shall be acknowledged promptly and directed appropriately."
Legal & Professional Responsibility
Reception personnel are responsible for ensuring accurate patient registration, protecting confidential information and providing courteous, timely and professional service. Incorrect patient registration, unauthorised disclosure of patient information or failure to respond appropriately to emergency situations may result in disciplinary action, regulatory consequences and legal liability.
- Digital Personal Data Protection Act, 2023.
- Clinical Establishments (Registration and Regulation) Act, 2010 (where applicable).
- Consumer Protection Act, 2019.
- NABH Access, Assessment & Continuity of Care (AAC) Standards.
- NABH Information Management System (IMS) Standards.
Non-Compliance
Failure to comply with this SOP, Hospital policies, lawful instructions issued by authorised supervisors or applicable laws may result in counselling, retraining, disciplinary action or legal proceedings, depending on the nature and seriousness of the violation.
Standard Operating Procedure (SOP) – Laboratory Department
This Standard Operating Procedure (SOP) establishes the reporting hierarchy, operational responsibilities, laboratory testing procedures and professional accountability for all Laboratory personnel. Every employee shall ensure accurate specimen collection, reliable testing and timely reporting while complying with Hospital policies, NABH standards and applicable laws.
Department Hierarchy & Reporting Structure
| Level | Designation | Reports To |
|---|---|---|
| Level 1 | Hospital Management / Medical Director | Management Committee |
| Level 2 | Consultant Pathologist / Laboratory Director | Medical Director |
| Level 3 | Laboratory Manager / Laboratory In-charge | Consultant Pathologist |
| Level 4 | Senior Laboratory Technologist | Laboratory Manager |
| Level 5 | Laboratory Technologist / Technician | Senior Laboratory Technologist |
| Level 6 | Laboratory Assistant / Phlebotomist | Laboratory Technologist |
Laboratory personnel shall perform duties under the supervision of their immediate reporting officer. Junior employees shall follow lawful instructions issued by authorised senior personnel. Critical laboratory findings, equipment failures or specimen discrepancies shall be reported immediately through the established reporting hierarchy.
Key Duties & Responsibilities
- Collect patient specimens using approved patient identification procedures.
- Perform laboratory investigations accurately using approved methods.
- Verify patient details before sample collection and testing.
- Ensure timely release of laboratory reports.
- Maintain laboratory records, quality control logs and equipment maintenance records.
- Immediately communicate critical test results to the treating doctor or authorised clinical staff.
Critical Rule
"No specimen shall be collected, tested or reported without proper patient identification and accurate specimen labelling."
Legal & Professional Responsibility
Laboratory personnel are responsible for ensuring accurate specimen identification, reliable testing, timely reporting and proper documentation. Specimen mix-ups, incorrect reports, failure to communicate critical values or falsification of laboratory records may result in disciplinary action, medico-legal liability and regulatory consequences.
- Clinical Establishments (Registration and Regulation) Act, 2010 (where applicable).
- Biomedical Waste Management Rules, 2016.
- Digital Personal Data Protection Act, 2023.
- Applicable Indian Medical Negligence Principles.
- NABH Laboratory Services (LAB) Standards.
Non-Compliance
Failure to comply with this SOP, Hospital policies, lawful instructions issued by authorised Laboratory supervisors or applicable laws may result in counselling, retraining, suspension of laboratory duties, disciplinary action or legal proceedings, depending on the seriousness of the violation.
Standard Operating Procedure (SOP) – Radiology / Scan Department
This Standard Operating Procedure (SOP) establishes the reporting hierarchy, operational responsibilities, radiation safety requirements and professional accountability for all Radiology Department personnel. Every employee shall perform diagnostic imaging safely, accurately and in compliance with Hospital policies, AERB regulations, NABH standards and applicable laws.
Department Hierarchy & Reporting Structure
| Level | Designation | Reports To |
|---|---|---|
| Level 1 | Hospital Management / Medical Director | Management Committee |
| Level 2 | Consultant Radiologist / Head of Radiology | Medical Director |
| Level 3 | Radiology Manager / Radiology In-charge | Consultant Radiologist |
| Level 4 | Senior Radiographer | Radiology Manager |
| Level 5 | Radiographer / Imaging Technologist | Senior Radiographer |
| Level 6 | Radiology Assistant / Trainee | Radiographer |
Every Radiology employee shall perform duties under the supervision of the immediate reporting officer. Junior personnel shall follow lawful instructions issued by authorised senior staff. Equipment failures, radiation incidents and critical imaging findings shall be reported immediately through the established reporting hierarchy.
Key Duties & Responsibilities
- Perform diagnostic imaging only against a valid medical request.
- Verify patient identity before every imaging procedure.
- Ensure patient safety, comfort and privacy during examinations.
- Operate imaging equipment in accordance with approved procedures.
- Maintain accurate imaging records and examination documentation.
- Immediately report critical findings to the treating doctor or authorised clinician.
Critical Rule
"No diagnostic imaging procedure shall be performed without proper patient identification and a valid medical request. Radiation safety protocols shall be followed at all times."
Legal & Professional Responsibility
Radiology personnel are responsible for ensuring safe radiation practices, accurate imaging, appropriate documentation and timely communication of significant findings. Failure to follow radiation safety regulations, maintain imaging records or perform procedures in accordance with approved standards may result in disciplinary action, regulatory proceedings and medico-legal liability.
- Atomic Energy Act, 1962.
- Atomic Energy (Radiation Protection) Rules, 2004.
- AERB Safety Code for Medical Diagnostic X-ray Equipment.
- Clinical Establishments (Registration and Regulation) Act, 2010 (where applicable).
- NABH Care of Patients (COP) Standards.
Non-Compliance
Failure to comply with this SOP, Hospital policies, lawful instructions issued by authorised Radiology supervisors or applicable laws may result in counselling, retraining, suspension of imaging duties, disciplinary action or legal proceedings, depending on the seriousness of the violation.
Standard Operating Procedure (SOP) – Housekeeping Department
This Standard Operating Procedure (SOP) establishes the reporting hierarchy, operational responsibilities, environmental hygiene standards and professional accountability for all Housekeeping personnel. Every employee shall maintain a clean, safe and hygienic Hospital environment while complying with Hospital policies, infection prevention protocols, NABH standards and applicable laws.
Department Hierarchy & Reporting Structure
| Level | Designation | Reports To |
|---|---|---|
| Level 1 | Hospital Management / Administrator | Management Committee |
| Level 2 | Facility Manager / Housekeeping Manager | Hospital Administrator |
| Level 3 | Housekeeping Supervisor / Team Leader | Facility Manager |
| Level 4 | Senior Housekeeping Staff | Housekeeping Supervisor |
| Level 5 | Housekeeping Attendant | Senior Housekeeping Staff |
Every Housekeeping employee shall perform duties under the supervision of the immediate reporting officer. Junior personnel shall follow lawful instructions issued by authorised senior staff. Cleaning deficiencies, infection control concerns, equipment failures or safety hazards shall be reported immediately through the established reporting hierarchy.
Key Duties & Responsibilities
- Maintain cleanliness and hygiene in all assigned Hospital areas.
- Follow approved cleaning and disinfection schedules.
- Handle biomedical waste according to colour-coded segregation guidelines.
- Use only Hospital-approved cleaning chemicals and disinfectants.
- Wear appropriate Personal Protective Equipment (PPE) while performing duties.
- Immediately report spills, unsafe conditions, damaged equipment or infection control concerns.
Critical Rule
"No patient care area shall be left unclean after the scheduled cleaning and disinfection process. Biomedical waste shall always be segregated and disposed of in accordance with Hospital procedures."
Legal & Professional Responsibility
Housekeeping personnel are responsible for maintaining environmental hygiene, preventing healthcare-associated infections and ensuring the safe handling and disposal of biomedical waste. Failure to follow cleaning protocols, infection prevention measures or biomedical waste management procedures may result in disciplinary action, regulatory penalties and legal consequences for both the employee and the Hospital.
- Biomedical Waste Management Rules, 2016.
- Occupational Safety, Health and Working Conditions Code, 2020 (where applicable).
- Clinical Establishments (Registration and Regulation) Act, 2010 (where applicable).
- NABH Hospital Infection Prevention & Control (HIC) Standards.
- NABH Facility Management & Safety (FMS) Standards.
Non-Compliance
Failure to comply with this SOP, Hospital policies, infection prevention protocols, lawful instructions issued by authorised supervisors or applicable laws may result in counselling, retraining, suspension from duty, disciplinary action or legal proceedings, depending upon the nature and seriousness of the violation.