MAKILALA MEDICAL SPECIALISTS HOSPITAL, INC.

Document Control No.:

Medical Records Department
Volume IV- Administrative
Services
Policy Control No.:

Title of this Document:

Manual of Operations and
Procedures

Effective Date:
September 1, 2009

Title of this Policy:

No. of Pages

Submitted by:
Medical Records In Charge

Reviewed by:
Hospital Administrator

Authorized by:
CEO/ President/Chairman

Effective
Date:

ARTICLE I: VISION, MISSION AND PURPOSE

Section 1.

Vision

The Medical Records Department aims to support proper recording and to

develop progressive report all the years to come and to maintain confidentiality of
patients record.
Section 2.

Mission

To serve AMSHI clients, by ensuring the safety and privacy of patients records.
And maintain a comprehensive recording of relevant information through time.
Section 3.

Purpose

a. To maintain all medical records in accordance with the principles and

practices of efficient and effective medical record management.
b. To help in conducting a review of records for completeness and accuracy,
coding of diseases, operations, and special therapies according to
approved nomenclature and classification.
c. To maintain a comprehensive and up-to-date record for hospital patient to
ensure that all relevant information on each patient is collected, placed in
the record and filed accordingly.

d.

To produce statistical reports required by DOH and respective hospital

management through the compiled data.

e. To provide records, upon request, for patients attendance to OPD and the
wards.
f. To help in preparing periodic reports on morbidity, birth and death,
utilization of hospital beds, rate of bed occupancy, out-patient services
rendered, as well as compilation of statistical reports on type of surgery
performed and types of diseases treated.

ARTICLE II:

ORGANIZATIONAL CHART

BOARD OF DIRECTORS

CHIEF EXECUTIVE OFFICER

HOSPITAL ADMINISTRATOR

MEDICAL RECORDS CLERK

Section 1.

MASTER STAFFING PLAN

Name of Department:

Medical Records Department

General Policy:
1. The health facility appoints and allocates personnel who are suitably
qualified, skilled and/ or experienced to provide the service and meet
patients needs.
2. Each personnel is qualified, skilled and/or experienced to assume the
responsibilities, authority, accountability and functions of the position.
3. Professional qualification are validated, including evidence of
professional registration/license, where applicable, prior to employment.
4. An organized medical and nursing staff shall be responsible for the
quality of patient care and for the ethical conduct and professional
practices of its members.

Position

Medical
Records
Clerk

DOH
Minimum
Requirement

Internal
Manpower
Plan

Compliance

Status
(FT if Full
Time)
(PT if Part
Time)

Remarks

FT

ARTICLE III:

DUTIES AND RESPONSIBILITIES

Officer In-charge
a.

Received, checked and arrange patients chart.

b.

Checks all patients chart for proper indexing and file it to permanent
shelves.

c.

Checks and monitor patients charts returned and back to file.

d.

Check discharge patients chart on general logbook and summary of daily

discharge patients.

e.

Check discharged patients charts if completely filled-up by NOD with

date/time discharge, iv flow sheet, nurses notes and doctors order, etc.

f.

Segregates complete and incomplete patients chart.

g.

Makes daily list of incomplete chart for completion of doctors/ consultants

and nurses.

h.

Checks returned patient chart and classify according to coding, recording

and filing.

i.

Prepare Medical certificate and medical records as requested by patient for

personal claims/ follow check-up.

k.

Prepare and process Birth Certificate and Death Certificate.

l.

Entertains patients request, such as:

1. fill-up personal insurance claims
2. laboratory examination and results
3. Medical/ Clinical records

m.

Retrieves and pull-out patients chart requested for the use of:
1. study purposes of doctors and students
2. HMO/ Insurance
3. Philhealth / DOH
4. MRD

ARTICLE 3.a. Work Schedules and Meeting

The Officer In-charge must be in his post 8:00 am 5:00 pm with
1 hour lunch break from 12:00 1:00 pm and 15 minutes break every
morning and afternoon.
Working day is from Monday Sunday with 1 day off.
Regular meeting with NS and Administrative Department is scheduled at
least once a month for evaluation, updates and implementation of the
policies and procedures.

ARTICLE IV:

POLICIES AND PROCEDURES

Section 1. Record Storage

(Safe Keeping and Maintenance)
1. Proper Lighting
a. The light in the storage and filing area should be situated in between cabinets
and should run parallel with the arrangement of the cabinet.
b. Medical record in charge tend to work efficiently and effectively in well
lighted working areas.
2. Proper Ventilation
a.

The important thing to consider in planning for a good medical record

layout is good ventilation, it is not only considered for health reasons but
also protection of records.

b.

Filing and storage areas with very humid conditions also had bad effects
on the medical records, papers absorb moisture to some extent and this
could affect the quality of the record.

3. Proper Temperature
It is fact that the temperature affects the performance of a person, it
shouldnot be too warm nor too cold, and conducive for working should be
provided.
4. Retention of records
a.

Hospital Licensure Act, otherwise known as a Republic 4226, which

requires hospitals to maintain medical records for 10-25 years.

b.

DOH came up with ministry Circular 77, series 1981 which further
qualifies the 25 year retention period for all hospitals under the DOH
regardless of its category/ classification.

4. 1. The medical record is also influenced by the following factors:

a. Activity/ Usage of Data
This can be assessed by determining the number the number of
requests for information from the records as well as the type of
information requested; it reflects the clinical value of the medical
record.
b. Available Space and Alternatives
1. Medical Record Service with small filing area must maintain a
secondary filing for

inactive records.

2. Active records are usually maintained for (5) years after which
they are transferred to the inactive file until they reach the required
retention period.

c. Attitude
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The people involve in medical records influence record retention

(in

terms of its used for patient care, clinical research, and

education).
Section 2.

Disposal Schedule for Medical Records Service

Document type
Admission and Discharge
Birth Register
Correspondence Log Book for MRS

Disposal Schedule
Retain permanently
Retain permanently
Seven (7) years after date of the
last entry

Daily Census Report

Death certificate (file copy)
Death register
Disease Operation Index
ER Blotter/ER Register

One (1) year after.

Retain permanently
Retain permanently
Retain permanently
Retain permanently

In-patient Record
ADULTS
* Teaching-training and Research,
And Provincial Hospitals
* District/Community Hospitals

MINOR (All)
* Psychiatric Hospital

25 years
25 years

until the child reaches the age

of maturity (18) years plus an
additional 5 years
Retain permanently

Laboratory Report Copies

If filed in the in-patient, retain as for

in-patient record

Labor Room Register

Number Register
Out-patient Records
Operating Room (OR) Register
Master Patient Index/
Patient Master Index

Retain permanently
Retain permanently
Retain as in-patient records
Retain permanently
Retain permanently

Research Request

10 years

Subpoenas
If no record
X-ray Result/Report
* If filed with the chart
* If no Record
Section 3.

Retain as for in-patient

Retain as for correspondence
Retain as for in-patient record
Retain for 10 years

Filing of Chart

Section 3.a. Purpose

For efficient and effective filings system to establish sequence to ensure the
rapid location and retrieval of records. An efficient filling system is vital
requirement .All records should be filed in one established sequence. A filing
area which will ensure the rapid location and retrieval of records must be
maintained.
Section 3.b. Policies
1.

All patient charts should be checked properly by the Record in

charge before filing it to their permanent shelves, check the
following;
a.
b.
c.
d
e.
f.
g.
h.
i.

2.

Final diagnosis
ICD-10 coding
Patient Index Card
Report of Operation (if any)
ECG reading (if any)
Anesthesia record (if any)
IV flow sheet complete
Correct carry out of nurses notes
complete checklists of patients chart.

All records of discharged patients should be filed in Alphabetical

order from A to Z.

3.

All charts ready for filling should be stamp by MRD Head at the
right upper portion of Medical Examination Sheet or above the
date of admission with corresponding signature of MRD in charge.

4.

All Charts endorsed to MRD in charge should be in logbook or

make a hard copy list with signature of person endorsing the chart
for records purposes.

5.

MRD in charge should monitor the in and out of patients chart.

Make a separate logbook for incoming charts received, and separate
logbook for pull out or borrowed charts. All transactions should be
properly documented in order to check the movement of patients chart.

6. No one is allowed to enter the records stockroom without the presence

or permission of the MRD in charge, because any loss of patient chart
in charge is the one liable or responsible.

Section 3.c. Different Methods in Numbering and Filing

a. Filing
1. ALPHABETICAL- all records of discharged patients are filed in
strict alphabetical order from A to Z.

This is otherwise

known as the dictionary arrangement of filing.

2. NUMERICAL- all records are filed by their admission number.
3. BY YEAR - charts maybe filed alphabetically or numerically by
year or discharge.
b. Numbering
1. Serial Numbering - This method entails assigning a new register
number to each patient at time of admission. Charts
maybe filed separately under number as assigned or
together under the most recent number.

2. Unit Numbering

- This is the assignment of one number to a

patient on first admission using the same number of

subsequent admissions. All records of the patient
are kept on one jacket regardless of the number of
admissions of the patient.
MRD department plans for the future that each patient had their own patient index
card.

Section 4.

Retrieval of Chart

a. PHIC office
PHIC office pull-out discharged charts 2 days after patients discharge for
their claims processing. Signed the daily discharge list prepared by MRD
staff for records purposes. Returned the charts borrowed 3 days after date
borrowed then counter check MRD in charge for checking of complete
charts returned.
b. HMO office
HMO Office pull-out discharged charts for claims processing purposes.
List all borrowed chart at logbook countersigned by HMO staff for record
purposes.

Returned chart to MRD counter check by in charge for

checking of complete charts borrowed.

c. OPD clinic
ER nurse will call via intercom charts for pull-out for study purposes of
physicians for follow up check up of the patient. All borrowed chart by
OPD clinic should be in logbook counter signed by the person who

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received the chart. Returned the chart immediately at MRD, in charge will
note the logbook for the chart returned.
d. MRD in charge pull-out chart for personal insurance claims and patient
requesting for clinical summary, laboratory results, Xray, operating report,
etc.
1.

For strict compliance, patients chart will not easily be

pulled-out by anybody unless it is needed by attending physician,

PHIC/DOH personnel and any other healthcare providers.
2.

MRD agreed that chart retrieval for current charts is within

20-30 minutes, while on old charts year 2007and below, chart

retrieval is within 2 hours or more due to records at computer
corrupted and MRD will scan record at General logbook.
Section 4.1 Procedures in Retrieval of Chart

a. Authorized person must fill up borrowers slip form in MRD.

b. MRD in charge receives and verifies the borrowers slip.
c. MRD in charge shall pull out the patients record from its permanent
file.
d. Retrieve chart ready for release must be recorded in the logbook.
e. Insert the tracer card in the place where the record was pulled out to
easily locate its original post when returning the chart after.
f. For students who will conduct case study they must present a letter
from the school to be address to the Chief Nurse or Hospital
Administrator for approval and it will then follow the sequence of A to
E.

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Section 4.2 Important Factors for Easy Retrieval of Chart

1. Efficient and Effective Filing System
This is an important factor that makes retrieval easy because it is
adaptable to the type or records maintained. To be truly effective, it
needs to adapt the corresponding unit numbering system.
2. Time
Time element is very crucial in medical records. Retrieval should be
as quick as possible because the information that may be retrieved
from the chart might be affecting the patients life or death.
3. Monitoring of Chart Movement
Another important factor to consider in the efficient management of
medical records is the full knowledge of the movement of the records.
This is why the medical record department should maintain an
effective tracking or follow-up system. The use of such as system,
coupled with the full knowledge of the work-flow will help the
medical record staff control the records more effectively.
4. Good Physical Layout
For good physical layout, the medical record department should
consider flexibility and functionality. The arrangement of the
employees should follow the workflow, facilitate smooth flow of
paperwork, and improve coordination between employees. The
physical location of medical record department should be near the
OPD and ER as the activity rate of medical records is considered high
in these services.

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ARTICLE V:

RECORDING AND RELEASING OF DOCUMENTS

IN-PATIENT

Section 1.

Issuance of Medical Certificate

a. Patient must fill up request form provided by medical records.

b. For inpatient:
1. Patient should be discharge first at the nurse station before Medical
records can print a medical certificate.
2. Patient must present an official receipt from the cashier signifying
payment of medical certificate.
3. Medical records cannot print a Medical Certificate if patient still
admitted unless on case-to case basis or emergency case depending on
patients need.
c. All released medical certificate should be properly signed by attending
physician specially for our in-house consultants except for visiting
physician, patient have the option to choose if they will be the one to go to
doctors clinic for physicians signature or come back

2-3 days for

completion.
d. Medical Certificate should be release immediately within 10-20 minutes
depending on physician availability.
e. In case, attending physician is not available/ out of town, patient is
scheduled to comeback 2-3 days after date of requisition.
f. In case patient send a representative to get his/her medical certificate,
patient should make an authorization letter and bearer should present
Identification Card for verification and records purposes.
g. MRD in charge should explain to patient/ any representative the
confidentiality of patients record.
h. MRD in charge should logbook all patients request forms and released of
medical certificates.
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Section 2.

Issuance of Medico - Legal Certificate

a. Fill up request form as provided by medical records.

b. Requesting party should bring a copy of subpoena from court.
c. In the absence of subpoena, requesting party should bring a letter of
request from Police station or from the lawyer handling the case.
d. MRD in charge should inform attending physician regarding the request of
the patient.
e. Attending Physician should sign the Medico-Legal certificate in two (2)
copies, 1 for patients copy and the other 1 for MRD Records file.
f. MRD should attach the duplicate file to the request or letter for proper
record purposes.
g. Logbook all request/ and released medico-legal certificate.
h. File the duplicate file at the permanent file.

Section 3.

Issuance of Medical Certificate with Vehicular Accident

Related Cases

a. Fill up request form as provided by medical records.

b. If the patient is the one requesting for medical certificate, he/she can
immediately get medical certificate depending on the availability of
attending physician.
c. In case attending physician in not available, he/she advised to comeback
2-3 days after date of requisition or depending on when the attending
physician is available specially when AP is out of town
d. In case the third party is the one requesting the medical certificate, they
should submit a copy of Affidavit of Desistance.

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e. Medical Certificate should be in two (2) copies, one for the patient and
one for the medical records for proper records purposes.
f. Duplicate file should be filed, together with the copy of the Affidavit of
Desistance.
g. All request and released Medical Certificate should be in logbook for
records purposes and signed by patient/ representative for confirmation of
the released certificate.
Section 4.

Issuance of Clinical Records with Insurance Claims

a. Fill-up request form as provided by medical records.

b. Classify or verify what he/she needed for the claim.
c. In case he/she needed clinical records, laboratory results/ operating
technique/report, he/she is advice to wait for 30 minutes to 1 hour or
advised to comeback for the next day depending on the availability of the
records needed.
d. In case of personal insurance claims for filled-up, they are advised to
comeback on 2-3 days or depending on the availability of the attending
physician.
Section 5.

Issuance of Birth Certificate

a. DR Nurse will pick-up daily the newborn footprint at delivery room and
endorses it to MRD for issuance of MBFH (Mother Baby Friendly
Hospital certificate.
b. MRD in charge will give the parents a Birth Certificate Information
Sheet.
c. Information Sheet should be properly filled-up by parent with Signature
over printed name below noted by MRD in charge.
d. MRD in charge then will fill up the final Birth Certificate Form as
provided by National Statistic Office.

15

e. Parent should check first the data encoded before signing the birth
certificate.
f. A certificate of confirmation should be properly filled-up and signed by
the parent of the baby for confirmation of records of the baby.
g. MRD in charge , is the one assigned to complete the forms with:
a. signature of OB-Gyne
b. receiving and processing at local civil registrar.
h. Parent must receive the Birth Certificate as soon as possible or before
discharged.
i. Original copy will be given to the parent and a duplicate file will be left to
the hospital for record purposes.
j. In case an error or changes in any data given after typing/printing birth
certificate, a corresponding charge of the form will be implemented.
k. For strict compliance, all released Birth Certificate must be complete and
received by the LCR.
l. All request and released certificates should be in logbook with
corresponding signature of any representative for records keeping
purposes.
Section 6.

Issuance of Death Certificate

a. Requesting party should fill-up an Information Sheet.

b. They are advised to wait for at least 1-2 hours or comeback on the next
day, depending on the availability of the attending physician.
c. MRD in charge will fill up the data written on the information sheet at the
Death Certificate Form as provided by the NSO.
d. MRD in charge released the form to any representative with complete:
a. signature of attending physician
b. causes of death
e. A duplicate/photocopy of death certificate will be left for records
purposes.

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f. Families of the deceased will be the one to finished all the signatures
needed for the form, with the following:
a. funeral/ embalmer
b. city health officer
c. receiving at the local civil registrar
g. All request and released death certificate should be in logbook with
corresponding signature of any representative for records purposes.
ARTICLE VI:

MEDICAL RECORDS MANAGEMENT SYSTEM

Medical Records is a compilation of pertinent facts of patients life history including

past and present illness (es) and treatment(s) entered by health professionals contributing
to the patient care.
Section 1.

Three Basic Principles of Medical Records

a. must be accurately written

b. properly filed
c. easily accessible
1.

The basic principles involved in obtaining adequate medical

records and maintaining smoothly functioning medical records
department are similar in all hospital regardless of size.

2.

The patients record should contain complete and accurate set of

information to facilitate effective patients care and its evaluation.
Entries into medical record are made only by duly authorized
person. All entries including alterations must be legible. Only
abbreviations and symbols approved by the Medical Record
Committee are to be used.

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3.

Any person making an entry in the medical record must date and
sign his entry or properly authenticate the entry made.

The

medical record is a legal document, so no form maybe detached

once it is filed with the charts. There should be no erasures of any
sort.

To correct:
a.

Draw single line through the information to be corrected or

change.

b.

Write an initial M.E for mistaken entry and affix initial

and date.

c.

Section 2.

Write the correct entry near the information to be corrected.

Important General Rules in Medical Records

a. No one is allowed to enter the records stockroom without the presence or

permission of the MDR in charge.
b. Patients chart will not easily be pulled out by anybody unless it is needed
by Attending Physician, PHIC/DOH personnel and any other healthcare
providers.
c. MRD agreed that chart retrieval for current charts is within 20-30 minutes.
d. For patients upon discharged, attending physician should immediately
write or give the final diagnosis of the patient.
e. ECG strips should be attached at the chart with complete reading.

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f. In case ECG strips had no reading upon discharge, MRD will forward the
chart to at OPD section for completion.
g. Operating report/technique if possible should be properly filled up and
attached at the patients chart before or upon discharge.
h. All discharged charts should be forwarded daily by NS Head nurse or the
head of the shift in the absence of the head nurse.
i. All discharged chart should be properly checked by NS head nurse or
supervisor before endorsing at MRD office.
j. NS will make a logbook for all patients endorsed to MRD and MRD will
also make separate logbook for records purposes and verification of chart
received.
k. Medical Records must be maintain the privacy, accuracy and prevent loss
and destruction of patients record.
l. All errors of patient identification data during admission must be notarized
and a joint affidavit should be presented to the Medical records Department
for changing of data.

Section 3.

Various Forms for Medical Records

For the medical record of patient to be complete, it must include the

following forms, properly accomplished, signed and dated;

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1. Medical Examination Sheet - this form contains the;

a. Name of patient, address, age, date/time of admission and status and
patient number.
b. Admitting and final diagnosis, as well as description of any operation and
procedures performed.
c. History Sheet:

- contains chief complaint, personal and family history

(past and present)

d. Past History records the previous operations and illness of the patient and
particularly those that might be related to the present illness.
e. Social History present facts about patients file and habits that might affect
his condition. If, for example, he has an allergic condition, it maybe
important to know his diet, the pets he own, the plants that grow around
his house, and the materials he comes in contact with at work and at home.
f. Family History records the diseases which members of the patients
immediate family have or have had. Most important are those that might
directly affect the patient either through heredity or contact.
g. Physical Examination Sheet - contains all pertinent (positive and
negative) findings and impressions.
2. Patients data sheet - includes patients personal data like name, address, age,
sex , birthday, fill up completely consent for admission, signed completely waiver
of loss, medication consent and hospital policy.
3. Laboratory Result Sheet

contains all results of all diagnostics, laboratory,

2D echo, CT scan, x-ray procedures and etc.

4. Vital Sign Sheet- contains name of patient with attending physician, date and
time of temperature, B.P, pulse, resp. Intake and output urine/hour with signature of
nurse on duty.

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5. TPR Sheet

contains name of patient, physician, room no. hospital no. and

complete graphic of patient.

6. IV Flow Sheet - records the IV fluids consumed by the patient with description
and no. of bottle consumed, rate, no. of hours, date/time started, signature of
NOD, date/time consumed/discontinued with signature of NOD.
7. Physicians Order - contains all doctors order.
8. Progress Note Sheet - includes doctors positive and negative observations and
comments. It gives a chronological picture of the clinical condition of a patient.
9. Medication Sheet

- contains data of name of patient, room no. and hospital

no. Records all medicines given by NOD to patient with date ordered, name of
medicines & treatment, time given, signature of NOD and date/time discontinued
with signature of patient/representative at the right lower portion of the form.
10. Nurses Notes - contain the notes of all nurses who tended the patient. These
include their observations of the patient, the treatment given, the response to the
treatment, and unusual occurrence. The first page shall always contain a record of
checking the patient in the unit and recording his physical condition at the time.
The admission portion is completed when the patient first admitted to a particular
nursing unit; while the discharge portion if completed when the patient is
discharged from the unit. The discharged notes should include basic information
such as time of discharge with signature over printed name of NOD and condition
upon discharge.
11. Discharge Instruction Sheet - summarizes the significant findings and events
occurring during patients hospitalization, final diagnosis, date of discharge, home
medication with complete dosage, time and duration of intake, recommendation
and arrangement of future care (OPD follow-up treatment), special instructions (if

21

any), NOD signature over printed name, signature over printed name of any
representative and name of attending physician
12 Anesthesia Report Sheet (if any)
13. Report of Operation Sheet - record and authenticate a pre-operative diagnosis
before surgery. The record should contain a report of all findings, a description of the
technique used, description of any tissue removed, and a post-operative diagnosis,
date of operation and signature of the surgeon.
14. Birth and Death Certificate , if either of these events occurred.
15. Other Sheets - OB-gyne History form, Physical Therapy Note form, consent for
operation(if any) and Trauma Form.
16. Consultation Reports - adequately record the consultants findings on physical
examination of the patient, as well as his opinion and recommendations.
17. Birth and Death Certificate , if either of these events occurred.
18. Other Sheets - Medication and treatment, vital sign sheet, graphic chart sheet,
referral form and ETC.
19. Information Sheet- for preparation of birth and death certificate. Patient must
fill up this sheet with correct and complete data.

ARTICLE VII:

PHOTOCOPIER CONTROL SYSTEM

The Medical Records Department in charge shall also be the one

authorized to operate the photocopier machine. Daily checking of the machine status in
number pages should be done to monitor the movement of photocopy services.
Basic rules are the following:

a. All charged photocopies must pass through the approval of Hospital

administrator by submitting a filled up in charge slip.

22

b. Indicate the persons name requesting it, date, purpose and numbers of copies in
the charge slip.
c. Approved charged slip must be presented to MRD before it will be
performed by the in charge.
d. All sales from the photocopy service for the day must be remitted to the cashier
with corresponding official receipt.
e. Photocopier in charge must provide a logbook for all sales and charge photocopy
including the errors for proper control system.
f. This report must be verified by the accounting officer and with an actual checking
on the machine to confirm the accuracy of the report.

ARTICLE VIII:

SERVICE STANDARDS

Antipas Medical Specialist hospital, Inc believes that the best way to give quality
care to patient is by satisfying their needs. And begin this by caring for ourselves
and each other. The way we treat each other within AMSHI sets the way on how
we treat our patients and guests. We need to treat each other with courtesy, respect
and kindness. All employees are therefore expected to pledge to provide and
uphold the following service standards.
1. Smile

smile warmly and introduce yourself

make eye contact
welcome patients/customers in a friendly manner
rudeness is never acceptable
apologize for problems and inconvenience
thank patients/customers for choosing our hospital

2. Telephone and Ramp Etiquette

when answering calls, identify your department and yourself

ask callers how may I help you
ask permission to place caller on hold
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allow patients and visitors the right of way in the ramp, stairs, hold door open
for those trying to enter the room
politely ask others to wait for the next wheelchair or stretcher if transporting
patients on beds.
always practice patient confidentiality including clinical discussions in the
hallway, ramp and all public areas.
acknowledge with a nod or smile to patients/watchers guests.

3. Accident Free Environment

follows all policy and procedures for emergency claims

report any hazardous or suspicious things / people to security guard
immediately
use protective dress wear
return all equipment to its proper place
pick up and dispose of any litter you find
clean up spills and debris immediately
place any equipment or supplies on one side of the hallway in the patient care
units.
keep exits clear

4. No Waiting

acceptable waiting time for a scheduled appointment is 30 minutes. For a nonscheduled visit, every effort will be made to see the patient within an hour.
apologize if there is a delay, offer to reschedule the appointment if possible.
if delay is over an hour, update patient about their status at least every 30
minutes.
update family members at least hourly while patient is still on procedure.

5. Dress Professionally

always wear NAME TAG keeping name clearly visible

take pride in your personal appearance
never chew gum or eat while interacting with patients or customers
adhere to hospital and department specific dress code policy
male employees are not allowed to wear earrings, body tattoos, body piercing
female employees are to wear jewelleries appropriately

6. Address Patients Needs

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address patient by name, maam , sir, nay, tay or any comforting name/address
to patient.
do not leave the floor until patients requests have been conveyed to
appropriate nurse/attendant.
appropriate nurse must respond to patient call or request within 3 minutes.
before leaving the patient, ask. is there anything else I can do for you
maam / sir?
check patients an hour before shift change to minimize patients requests
during endorsement.
before leaving the floor for breaks or meals, notify patients of when you will
return, inform patient who will cover in your absence.

7. Respect Patients Privacy

always knock before entering a patient room

interview patients in privacy, close curtains or doors when available.
never discuss clinically related issues in a public area, or in the presence of
others.
provide blanket, sheets, patient gown when patients are ambulating or in a
wheelchair or stretcher.

8. Direct Communication

if someone appears to need directions, offer help

escort patients/customers to their destination, or get someone else to
immediately escort them
provide explanation about patient care using understood and appropriate
language
collaborate with physicians to reinforce the information provided to patients
avoid technical or professional jargon

9. Speak positively

treat everyone like a VIP, because everyone is important

smile warmly and introduce yourself by name and title
extend a warm greeting
use positive body language
listen to what the patient/customer is saying and offer feedback if appropriate
speak positively about AMSHI to make our patients safe and confident.

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