Operating Manual and SOPs for Siburan Union Clinic

1. Company Profile
2. Policy Statement
3. Organization Chart
4. Plan of Organization
5. Consultation Hours
6. Emergency call information
7. Written Policy
a. Registered Medical Practitioner
b. Procedure for Patient Registration, Attendance and Referral
c. Use of antibiotics
d. General Maintenance of Clinic
e. Transport of Laboratory Specimens
f. Consent
g. Incident Reporting
h. Infection Control
8. Staff identification
9. Order for Diagnostic Procedure, Medication and Treatment Orders
10. Patient’s Medical Record Register
11. Billing Procedure
12. Fee schedule
13. Referral Form
14. Basic Emergency Care
15. Procedure for BLS1 and BLS2
16. Flow chart for BLS1
17. Patient’s Rights
18. Grievance Procedure
19. Feedback Form
20. Incident Reporting Form
21. Disaster Preparedness
22. Use of volunteers
23. Volunteer Application Form
24. Volunteer Health Questionaire
25. Pharmaceutical services
26. Registers and Records of Patients (Radiological or Diagnostic Imaging Services)
27. Clinic Procedures
28. Housekeeping
29. Social & Welfare Contribution
30. Staff Assessment
31. Acknowledgement by staff

COMPANY PROFILE
Siburan Union Clinic was established on 1 November 1990.
The clinic is a sole-proprietorship and it is managed by Dr. Lim Meng
Lang, a graduate from the University of Nottingham Medical School.
He is assisted by a dedicated and competent team of 5 clinic assistants
some of whom have more than 10 years experience on the job.

We provide comprehensive medical care for all age groups at the

primary level. We have in-house facilities for ultrasonography,
electrocardiography, nebulization, random blood glucose analysis and
routine urinalysis.

POLICY STATEMENT
OUR MISSION IS TO PROVIDE COST-EFFECTIVE
HEALTH CARE WITH THE SUPPORT AND
COOPERATION OF OUR PATIENTS.

OUR PATIENTS CAN EXPECT THE HIGHEST LEVEL

OF INTEGRITY, RESPECT, EMPATHY AND
EFFICIENCY FROM OUR STAFF.

1. Our staff shall wear a badge for identification.

2. We will, upon request, provide estimated charges
prior to treatment. We will inform the patient of any
unanticipated charges. We will, upon request,
provide itemized billing at no extra cost. Our
professional fees shall conform to the Fee Schedule
as in the Private Healthcare Facilities and Services
(private Hospitals and Other Private Healthcare
Facilities) Regulations 2006.
3. All patients shall be informed of their medical
treatment and care.
4. All patients shall be entitled to a reply as set out in
our grievance procedure.
5. All patients shall be provided with a medical report
with the payment of the appropriate fee and only with
written consent from the patient concerned.

Organization Chart
 SIBURAN UNION CLINIC

Plan of Organization

1. The Doctor shall be in overall charge of all activities in the clinic.

2. The chief clinic assistant shall assist the doctor in all matters pertaining to the smooth
running of the clinic. She will prepare the invoices and bills at the end of each month.
She will assist the doctor in maintaining the duty roster and record of the annual leave
and sick leave of all staff.
3. The senior clinic assistants will assist the chief clinic assistant and the doctor in all the
above tasks.
4. The clinic assistants will assist fellow staff and the doctor in the smooth running of the
clinic.
5. All clinic assistants of whatever grade shall be involved in all tasks pertaining to the
smooth and efficient running of the clinic. Such tasks including registration of patients,
keeping necessary records, assisting the doctor in the consultation room, dispensing
medications under the direct supervision of the doctor, general housekeeping work,
making bill payments and the like, accompanying the doctor on home visits and any
other activity that the doctor may direct.
6. The Person-in-charge may appoint any staff on a contract basis to advise him on
strategies for the organization and to assist him in the preparation of accounts and the
like. Such a person shall not have any direct contact with patients or be involved in
clinical patient care.
 SIBURAN UNION CLINIC
The official clinic hours in this clinic are:

Monday 8am – 2pm

Tuesday to Friday 8am – 12noon 1.30pm – 7.30pm
Saturday 8am – 12noon 1.30pm -4pm
Sunday/Public Holiday 8am – 12noon
EMERGENCY CALL INFORMATION

POLICE/FIRE/AMBULANCE 999
RESCUE 991

HOSPITAL UMUM SARAWAK 276666

TIMBERLAND MEDICAL CENTRE 234466
NORMAH MEDICAL SPECIALIST CENTRE 440055
KUCHING SPECIALIST HOSPITAL 365777

_____________________________________________
Dr and staff ADDRESSES AND TEL/hp NUMBERS

RED CRESCENT SOCIETY 428228

ST JOHN’S AMBULANCE 240907
 WRITTEN POLICY OF CLINIC
1. Registered Medical Practitioner

Only a registered medical practitioner registered under the Medical Act 1971 and
holding a valid practicing certificate shall be allowed to practice in this clinic.

Only registered practitioners who have a valid written contract between himself/herself
and the clinic shall be allowed to practice in this clinic.

All registered medical practitioners practicing in this clinic shall be responsible for the
quality and compassionate care and treatment of all patients seen by him/her and shall
at all times act in compliance with all relevant laws and regulations of Malaysia.

2. Procedure for Patient Registration, Attendance and Referral

All new patients shall be registered in the Patient Register.

Patient’s information shall be entered as per regulation in the front sheet. Any
information that the patient has refused to divulge/or unable to provide shall be entered
as “Not Available” or “N/A”.

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 register.

No staff shall divulge any patient in formation to any third party.

All patient information shall be treated with the strictest confidentiality.

3. Use of Antibiotics
 In the event of a notifiable infectious disease infection, the Person-in-charge may order
appropriate cultures to determine the sensitivity of the appropriate organism.

Appropriate antibiotics prescribed for treatment of the reportable infectious disease

shall be recorded.

4. General Maintenance of the Clinic

This clinic shall be kept in good repair and shall provide a safe and comfortable
environment for all its staff,

All equipment will be regularly checked and maintained on a schedule determined by

the Person-in-charge.

5. Transportation of Laboratory Specimens

Laboratory specimens shall be transported to an authorized laboratory as determined by

the Person-in-charge.

All specimens shall be collected and kept in the appropriate container supplied by the
laboratory.

All specimens shall be duly labeled with the patient’s name, registration number and
date of collection.

Specimens shall be sent to the laboratory within 24 hours of collection in sealed plastic
bags provided by the laboratory and accompanied by the completed test request form.

All staff handling laboratory specimens must wear protective gloves and take all
necessary precautions to prevent direct contact with the specimen and to avoid needle-
stick injuries.

No food shall be kept in the refrigerator where laboratory specimens are kept.

6. Use of Volunteers

This clinic will allow volunteers to work at its premises provided the volunteer has the
relevant qualification, training and experience in the relevant healthcare profession.

All volunteers will have to apply in writing and appear for an interview with the
Person-in-charge.

Upon approval, the volunteers shall be registered in the Volunteer Register.

 Volunteers shall undergo a period of orientation and supervision as determined by the
Person-in- charge.

Volunteers shall only be allowed to assist or perform professional care as determined by

the Person-in-charge.

7. Consent

For any special procedure, minor operation or anaesthesia, the patient shall be required
to give written consent in the form and manner as set out in the Consent Form.

The Person-in-charge performing the special procedure, minor operation or anaesthesia

shall ensure the Consent Form is duly signed before undertaking the above.

8. Incidental Reporting

Any unforeseeable or unanticipated incidents such as death of patient, fires in clinic,

assault or battery of patient, malfunction, intentional or accidental misuse of patient
care equipment shall be reported to the Person-in-charge.

Clinic staff shall immediately inform the Person-in-charge of the incident upon
occurrence.

The Person-in-charge will document the details of the incident and obtain a written
statement from witness(es) if a witness(es) is present.

Original and copies of report, relevant patient notes, relevant documents shall be kept in
separate files for safe-keeping and future reference.

A copy shall be sent the Director-General of Health by registered post (within 10

working days) following the incident.

A receipt of the report shall be requested.

9. Infection Control

All staff must be diligent and take the necessary measures to prevent, identify and
control infection acquired in or brought into the clinic. Such measures include wearing
face masks, using rubber gloves and cleaning the various surfaces and equipment with
an appropriate disinfectant.

All infections amongst staff must be reported to the person-in-charge so that

appropriate evaluation, analysis and recording can be carried out.
 Any reportable infectious disease among patient or staff shall be reported to the
Ministry of Health in the infectious disease notification form or any other form supplied
by the State Health Department.

All infections amongst patients will be closely monitored by the person-in-charge

during the course of his clinical work and if there is unusual increase in the rate of
infections, the Health Department will be informed.

All staff with any infectious or communicable disease will be taken off duty until he or
she is no longer contagious to other people.

Any equipment that has become contaminated during the treatment of an infectious
patient shall be withheld from use and appropriately disinfected under the supervision
of the person-in-charge.

All staff must regularly wash their hands properly and practice good hygiene.

Disposable rubber gloves must be used by all staff when dealing with biological
hazards.

The clinic shall comply with any directives or guidelines issued by the Director General
or any appropriate government authority.

STAFF IDENTIFICATION

All clinic staff shall wear staff identification nametags during clinic hours

ORDER FOR DIAGNOSTIC PROCEDURE, MEDICATION OR

TREATMENT ORDERS
All diagnostic procedures, medication or treatment will be given upon receipt of a written or
verbal order of a registered medical practitioner.

The generic or trade name and dosage of all medications prescribed and dispensed in this clinic
will be labeled upon the instructions of the Person-in-charge. The person-in-charge shall
inform the patient about its administration.

PATIENT’S MEDICAL RECORD REGISTER

All patients’ medical records shall be kept in a safe and orderly fashion in the clinic.
No records shall be transferred out of the clinic without expressed approval of the Person-in-
charge.

Any movement of patient’s medical record shall be entered into the Patient’s Medical Record
Movement Register.

BILLING PROCEDURE

If requested by the patient, it is the policy of the clinic to inform the patient details of their
medical bills prior to treatment. It is also the policy of this clinic to issue itemised bills upon
request by the patient.

A copy of the Seventh Schedule (Professional Fees) shall be made available for the patient’s
reference.

PRIVATE HEALTHCARE FACILITIES AND SERVICES ACT.

FEE SCHEDULE (PROFESSIONAL FEES) (Seventh Schedule)
Consultation RM10 – RM35
Consultation after clinic hours Up to 50% above usual rate

ECG RM35
PAP SMEAR RM45
URINE PREGNANCY TEST RM15
STRIP URINE TEST RM10
BLOOD GLUCOMETER TEST RM10
CATHERISATION RM85
ULTRASOUND
(Antenatal Level 1) RM55

MEDICAL EXAMINATION
(excluding X Ray, ECG, lab tests) RM40 – RM200

MEDICAL REPORT RM50 – RM200

The full fee schedule (Seventh Schedule) is available for viewing upon request
 REFERRAL FORM
Date:
Time:
SIBURAN UNION CLINIC
62 Siburan Bazaar
17th Mile Kuching-Serian Road
94200 Kuching
Sarawak
Tel: 082-863395 Fax: 082-863758
To:
_____________________

_____________________

_____________________

Dear Dr

Provisional Medical Diagnosis: ____________________________

Current Medications:

Known Allergies:
Patient’s Condition on Transfer:
Yours sincerely,
 DR. LIM MENG LANG
BMedSci (Hons), BM, BS(Nottingham, UK)

BASIC EMERGENCY CARE SERVICE

1. Any emergency patient when brought to this clinic will be accorded emergency care
immediately. Such care shall commensurate with the capability of this clinic and the
expertise of the staff involved.
2. The nature and scope of such emergency care services provided by this clinic are:
i. Basic life support (as per UK standard)
ii. Any other measures in accordance with the clinic’s capabilities as
determined by the Person-in-charge
3. Prior to the transfer of the patient to another healthcare facility, the receiving
healthcare facility shall be notified of the impending transfer.
4. Upon transfer of the patient to another healthcare facility, appropriate record of the
patient shall be kept in the Referral Register.

THE PROCEDURE FOR BLS1 IN THIS CLINIC IS AS FOLLOWS:

1. Lie patient flat in an open space, and feel for the pulse and observe the respiration.
If there is a pulse, take the BP. If there is no pulse, begin BLS.
2. Take brief history from any accompanying persons. Exclude anaphylaxis.
3. Instruct available staff to get more help immediately. Telephone ambulance service.
4. Loosen all the patient’s clothes, and thump patient’s chest as hard as possible
(thumpversion).
5. Commence oxygen via a mask if patient is breathing spontaneously, using an
oropharyngeal airway + mask.
6. If no spontaneous breathing, breathe hard into the mouth. Maintain airway at all
times.
7. Arrange transfer of patient to nearest hospital as soon as possible.
8. Telephone Emergency Department of the nearest hospital and inform receiving
person. Record name of receiving person, time of call, time of transfer and patient’s
condition.

THE PROCEDURE FOR PATIENTS REQUIRING BLS (2) (FOR PATIENTS REQUIRING
INTRAVENOUS SUPPORT)

1. Lie patient flat in an open space, and feel for the pulse and observe the respiration.
If there is a pulse, take the BP.
2. If peripheral vein is accessible, insert IV needle/cannula immediately.
3. Take brief history from any accompanying persons. Quickly assess blood loss and
injuries.
4. Apply pressure bandages/tourniquet (if possible) to decrease major bleeding.
5. Instruct available staff to call for help immediately. Telephone ambulance service.
6. Administer oxygen by mask. If patient is in respiratory distress, use an
oropharyngeal airway + mask.
 7. If no spontaneous breathing, breathe hard into the mouth. Maintain airway at all
times.
8. If no pulse or spontaneous respiration, commence BLS1 immediately.
9. Arrange transfer of patient to the nearest hospital as soon as possible.
10. Telephone Emergency Department of the nearest hospital and inform receiving
person. Record name of receiving person, time of call, time of transfer and patient’s
condition

FLOW CHART FOR BASIC LIFE

SUPPORT (BLS1)
COLLAPSED PATIENT
↓
SUMMON HELP
↓
CHECK RESPIRATION –VE
↓
CLEAR AIRWAY → +VE → REFER
↓
CALL AMBULANCE
↓
30 CHEST COMPRESSIONS
↓
MOUTH TO MOUTH
↓
2 BREATHS, 30 COMPRESSIONS
↓

TELEPHONE:

AMBULANCE SERVICE (SGH) 230689

SARAWAK GENERAL HOSPITAL 276666

PATIENTS RIGHTS
It is the policy of this clinic to inform the patient concerned about the nature of his/her medical
condition(s) and any proposed treatment, investigation or procedure and the likely costs of the
treatment, investigation or procedure as part and parcel of his consultation.

It is the duty of the patient to ensure that he/she has understood all relevant information with
respect to the above at the end of the consultation.

All patients in this clinic will be treated with strict regard to decency and professionalism.

A medical report shall be forwarded within two weeks upon written request and upon payment
of the fee as per the Seventh Schedule (Professional Fees – Medical Report Fee)

GRIEVANCE PROCEDURE
It is the policy of this clinic to have a grievance mechanism for patients. The mechanism shall
be as follows:-

Any patient with a grievance shall be asked to first discuss his/her with the Person-in-charge.

If this fails to resolve the problem, he/she shall then be requested to lodge his/her grievance in
writing by filling in the FEEDBACK FORM which will be provided by this clinic for the
convenience of the patient concerned.

Upon completion of the Feedback Form, he/she shall then inform the senior staff of this clinic
who shall then receive and acknowledge receipt of the completed form.

The same staff shall inform the patient that investigation shall be completed within two weeks.

The staff shall then forward the FEEDBACK FORM to the Person-in-charge as soon as
possible.

The Person-in-charge shall conduct an investigation within two weeks upon receipt of the form
and shall record his findings in the Grievance Investigation Report.

Upon completion of his investigations, the Person-in-charge shall inform the patient of the
findings.

If this does not resolve the matter, the Person-in-charge shall then inform the patient that the
clinic will arrange for the services of a mediator from the local Private Practitioner’s
Association or any other mediator that is agreeable to both parties to resolve the matter.

If this fails, the Person-in-charge will then refer the matter to the Director-General for
adjudication.

FEEDBACK FORM
Name of Patient: _____________________

I.C. No.: ____________________________

Address: ____________________________

___________________________________

___________________________________

Tel. No.: ___________________________

Date and Time of Incident: ____________________________

PATIENT’S COMMENTS :

______________________
Signature

INCIDENT REPORTING FORM

Name of Doctor-in-charge: ___________________________

Designation:_______________________________________

I/C No:___________________________________________

Clinic Address:
_________________________________________________________________

Date/ Time: ______________________________________

Nature of Incident:

Action Taken:

Witness Statement:

Name of Witness:
IC No.:
Address:
Tel. No.:

DISASTER PREPAREDNESS
In the event of a disaster in the vicinity of this clinic, the Person-in-charge or an appointed
member of the clinic shall immediately inform the relevant authorities.

All staff who are contactable shall be called back to the clinic. All leave for shall be cancelled.

The clinic shall be cleared of all non-emergency patients.

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

Ambulance and the nearest hospital will be informed of the transport and arrival of patients.

All staff and resources from this clinic shall be made available to the relevant authorites in the
event of any disaster

USE OF VOLUNTEERS
This clinic will allow volunteers to work in its premises provided the volunteer is a person with
such qualification, training and experience in the relevant healthcare profession.

All volunteers will have to apply in writing and appear for an interview with the person-in-
charge.

Upon approval, the volunteers shall be registered in the Volunteer Register.

Volunteers shall undergo a period of orientation and supervision as determined by the person-
in-charge.

Volunteers shall only be allowed to assist or perform professional care as determined by the
person-in-charge

VOLUNTEER APPLICATION FORM

NAME:
I.C. NO.:
ADDRESS:

SEX:
MARITAL STATUS:
QUALIFICATIONS:

RELEVANT JOB EXPERIENCE:

REASON FOR VOLUNTEERING:

PERIOD OF AVAILABILITY:

VOLUNTEER HEALTH QUESTIONAIRE

NAME

IC NO

ADDRESS

SEX
MARITAL STATUS

OCCUPATION

DATE OF BIRTH

Date of last consultation

Reason

Name of Dr consulted
Are you on any form of
medication at present?
If yes, please state type
of medications
Have you at any time
consulted a
psychiatrist?

If Yes, please elaborate

Have you EVER been told or been treated for the following conditions?
Epilepsy or seizures or
mental conditions?

Heart problems?
Chest or Lung
problems?
Diseases of liver and
gallbladder?

Urological problems?

Venereal diseases?
Cancer, cysts or
growth?

Disease of the Eye?

Diseases of the Ear,
Nose and Throat?
Any infectious
diseases?
Diabetes Mellitus or any
endocrine problems?
Any illness not
mentioned above?

Do you smoke?
 If so, how many?

Do you drink?

If so, how much?

Have you ever used
habit forming drugs or
narcotics?
Are your family
members in good
health?

If not, please elaborate

Have your weight
changed more than 5 kg
in the past year?

Females only.

Are you pregnant now?

Have you ever had any

breast or gynaecological
problems?

I, the undersigned, hereby confirm that the above answers are full, complete and true.

_______________________ ________________________(date)

PHARMACEUTICAL SERVICES
The Person-in-charge shall be the Head of Pharmaceutical Services in this Clinic.

He is responsible for the coordination and supervision of all activities relating to

pharmaceutical services which includes the compounding of drugs and he shall ensure the
provision of a comprehensive pharmaceutical service within the private medical clinic.

All medications shall be purchases from authorized pharmaceutical companies and shall be
duly recorded in the Stock Register by the Person-in-charge.
The prescription and dispensing of all scheduled poisons/medications under the Poisons Act
shall be recorded in the Poison Book as prescribed.

No medications shall be dispensed to any patient without authorization of the Person-in-charge.

All medications shall be stored in clean and sanitary area and shall not be subjected to
detrimental changes in temperature and humidity. The manufacturer’s recommendation with
respect to storage shall be strictly adhered to.

All expired, discontinued or contaminated medicine shall be disposed of in accordance with the
relevant laws and regulations

The cold chain for vaccines shall be properly maintained at all times and the storage of
vaccines shall strictly comply with the manufacturer’s recommendations and that of the WHO.

REGISTERS AND RECORDS OF PATIENTS

(RADIOLOGICAL OR DIAGNOSTIC IMAGING SERVICES)

This clinic shall maintain a record in relation to the radiological or diagnostic-imaging studies
performed on any patient as follows:

Name of Clinic /Dr requesting Test:

Name of Patient:
Patient Clinic Number:
Date of Request:
Date of Receipt:
Name of radiologist/radiographer
Test results:
Other particulars:
 CLINIC PROCEDURES

1. All clinic assistants shall be involved in the registration, attendance and referral of
patients. The appropriate data must be accurately entered into the registers, computer
and medical card.
2. All staff must report any untoward incident or accident to the Doctor.
3. All staff must wear an identification badge at all times while at work
4. All staff must be punctual for work
5. All staff must practice good hygiene and wash their hands properly
6. All staff must wear the uniform provided or dressed appropriately
7. All staff must be pleasant and be professional in their dealings with patients
8. All staff must use disposable gloves and other protective clothing while dealing with
hazardous material
9. All staff must be proactive in keeping the clinic premises clean and tidy
 10. All staff must take the necessary precautions to keep themselves and patients away
from infections
11. All staff must produce a medical certificate from a registered medical practitioner if
they are unable to work
12. All antibiotics used can only be prescribed by the doctor and this will be done with due
care and according to the best clinical practice guidelines.

HOUSEKEEPING

1. Senior clinical assistant (RR) has been appointed to supervise the housekeeping
services. This appointment will remain in effect until further directive by the person
–in-charge.
2. The clinic shall be cleaned every week on Tuesday. If this is not feasible for any
other reason, the cleaning shall be carried out the following day(s).
3. All staff shall assist the supervisor in the housekeeping services.
4. All surfaces and floors shall be properly cleaned with special emphasis to infection
control.
5. All equipment including the computer should be cleaned in accordance to the
manufacturer’s recommendations.
6. All staff must wear the appropriate attire to protect themselves while cleaning.
7. Additional cleaning or disinfection may be carried out if and when the need arises.
8. The toilet shall be inspected and cleaned if necessary every half-hourly by a clinical
assistant who should ordinarily be the clinic assistant performing chaperoning
duties on that particular day. The toilet should at all times be adequately stocked
with toilet paper.

SOCIAL & WELFARE CONTRIBUTION

The person-in-charge shall decide on the quantum any of any contribution in the form of
money or any services rendered to any charitable organization or to any individual on a case-
to-case basis. The Person-in-charge may request for supporting evidence to justify the request
for discounts or exemption of fees. Any request on behalf of a patient by a highly respectable
member of the medical profession or society will be given special consideration.

Persons considered eligible for discount or exemption from charges or fees include the
homeless, inmates of old folks’ homes and orphanages. Discount or exemption may be applied
to professional fees, medical report fees and in the provisional of emergency care.

This clinic when specially requested and with sufficient notice will provide public education,
talks and participate in activities organized by NGOs and government-linked organizations.
Public education talks involve talks to school children, pregnant mothers and patient support
groups.
This clinic will provide donations and assistance to associations and organizations engaged in
healthcare activities, non-government or charitable organizations in their healthcare activities
and the quantum of such donation or assistance shall be decided by the Person-in-charge

There shall be no publicity in any form when such contribution is made.

Staff Assessment Form

Confidential

Staff Assessment for the Year _______________________

Name of Staff: ______________________________

GRADE

PUNTUALITY

PRESENTATION

KNOWLEDGE
WORK ATTITUDE

COMMENTS