Nurse's Standard Operating Procedure
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Duties & Responsibilities of Nursing Personnel
Nursing personnel play a vital role in delivering safe, compassionate and evidence-based patient care. Every nurse shall perform assigned duties with competence, professionalism and accountability while complying with applicable laws, Hospital policies, Standard Operating Procedures (SOPs) and NABH standards.
"Safe nursing care depends upon timely observation, accurate medication administration and proper documentation."
Applicable Laws & Standards
- Indian Nursing Council Act, 1947.
- Tamil Nadu Nurses and Midwives Council Regulations.
- Clinical Establishments (Registration and Regulation) Act, 2010 (where applicable).
- Biomedical Waste Management Rules, 2016.
- NABH Care of Patients (COP) Standards.
- NABH Human Resource Management (HRM) Standards.
Core Responsibilities
- Provide safe and compassionate nursing care.
- Monitor and record vital signs according to the prescribed schedule or whenever clinically indicated.
- Administer medications strictly as prescribed and at the scheduled time.
- Verify the right patient, right medication, right dose, right route, right time and right documentation before medication administration.
- Observe patients for changes in condition and immediately report abnormalities to the treating doctor.
- Assist in diagnostic and therapeutic procedures.
- Maintain cleanliness, infection prevention and patient safety standards.
- Educate patients and relatives regarding treatment and nursing care where appropriate.
- Maintain confidentiality and respect patient dignity.
Nursing Documentation
- Maintain accurate nursing notes for every patient.
- Record assessments, medications, procedures and patient responses promptly.
- Document all significant observations and clinical events.
- Every entry shall be signed, dated and timed.
Shift Handover, Medication Safety & Professional Responsibilities
"Incomplete handover is a serious patient safety violation."
Shift Handover
Every nursing shift shall conclude with a complete, accurate and face-to-face handover to the incoming nurse. Responsibility for patient care remains with the outgoing nurse until the handover has been completed.
- Current patient condition and clinical status.
- Vital signs and recent observations.
- Medications administered and pending medications.
- Intravenous fluids and ongoing treatments.
- Critical alerts, allergies and high-risk patients.
- Pending investigations and procedures.
- Doctor's instructions and special nursing care.
Medication Safety
- Administer medicines only on valid medical orders.
- Never omit, delay or alter medication without appropriate authorisation.
- Immediately report medication errors or near misses.
- High-alert medications shall be handled in accordance with Hospital policy.
Serious Violations
- Incomplete or inaccurate shift handover.
- Failure to monitor or report deterioration in patient condition.
- Medication administration without proper authorisation.
- Failure to maintain nursing documentation.
- Ignoring doctor's orders without valid reason.
- Leaving duty without proper handover.
Non-Compliance
Failure to comply with this SOP, Hospital policies or professional nursing standards may result in counselling, retraining, competency reassessment or disciplinary action in accordance with Hospital policy and applicable laws. Patient safety shall always take precedence in all nursing activities.