Tarlac Provincial Hospital 2014 Manual New

TARLAC PROVINCIAL HOSPITAL (OVERVIEW)
I. VISION: A medical center for the delivery of excellent hospital and health care services,
training, teaching and research
II.
MISSION:
(1) To provide accessible, affordable and adequate quality health services.
(2) To train and develop competent, dedicated, humane and ethical
professional health workers.
(3) To develop a well dynamic networking system with other government
and non-government health organization.
(4) To provide to its clientele clean and green environment and physical
facilities by adopting measures to make the hospital well ventilated,
with well-maintained buildings, well equipped for basic services, safe
and clean and properly managed waste disposal.
(5) To be a training and clinical research center.
III. GOALS To provide sustainable short term and long term best quality medical care
consisting of observational, therapeutic, curative and rehabilitative,
nursing and other support services to both in-patients and out-patients and
aimed at lowering hospital morbidity/mortality rate, increase of bed
occupancy rate and allowing patients to have a better quality of life.
IV. OBJECTIVES
General: To make available health services that are safe and responsive to
the needs of the community.
Specific:
1
2
3
4
5
6
7
8
Improvement of revenue thru increase in universal Philhealth

coverage and pay patients.
Provide the best medical facilities, equipment and instrument
capabilities and adequate hospital supplies and medicines for
the management and treatment of patients.
Provide an adequate manpower complement to allow the
maintenance of a continuing 24 hrs. coverage of hospital
services.
To provide a continuing manpower development program for
all personnel.
To institutionalize culture of unity/ teamwork and
responsibility among the health service providers.
Encourage hospital staff to do research work related to their
particular jobs.
To mold hospital personnel towards the ethical practice of their
professions.
To develop output oriented health service providers through
training of undergraduate medical clerks and interns, medical
technologists, nurses, midwives, physical therapists, radiologic
technologists, pharmacists, care givers and medical residencies.
V. VALUE STATEMENTS
1
2
To maintain a harmonious working relationship among the hospital

personnel and with the general public and other government and non
government organizations and private/religious organizations.
Inculcate in every personnel work values like commitment and
dedication to the delivery of quality patient care, loyalty to the service
and other core values like integrity, excellence, compassion,
professionalism, teamwork and stewardship.
A.K.O ATENSYON, KALINGA, OBLIGASYON
VI. PROGRAMS/ PROJECTS/ ACTIVITIES

I. Delivery of Quality Patient Care
1. Clinical Services for the In-Patient Care
1
Medicine
1
2
3
4
5
6
7
8
9
10
11
12
General Medicine
Nephrology
Gastroenterology
Pulmonology
Diabetology
Cardiology
Intensive Care Unit
Oncology
Endocrinology
Infectious Diseases
Toxicology
Physical Rehabilitation Medicine
1.1.12.1 Physical Therapy
Obstetrics and Gynecology

1
Obstetric (Normal and Cesarean Deliveries)
2
Gynecology
3
Perinatology
4
Endocrinology and Infertility
5
Family Planning
6
Mother-Baby Friendly Program
7
Oncology
8
Ultrasonography
Surgery
1
2
3
4
5
6
7
8
9
10
General Surgery
Orthopedics
Ophthalmology
Neuro Surgery
Head and Neck
ENT
Urology
Pediatric Surgery
Gastro Intestinal Surgery
Thoraco-Cardiovascular Surgery
Pediatrics
1
2
3
4
5
6
General Pediatrics
Nutrition/ Rehabilitation
Oral Rehydration
Neonatal Intensive Care
Hematology
New Born Screening
2. Clinical Services for Out-Patient Care

2.1 Medicine
2.1.1
2.1.2
2.1.3
Consultations
General Medicine
Nephrology
2.1.4 Gastroenterology
2.1.5 Pulmonology
2.1.6 Diabetology
2.1.7 Cardiology
2.1.8 Oncology
2.1.9 Endocrinology
2.1.10 Infectious Diseases
2.1.11 Toxicology
2.1.12 Physical Medicine and Rehabilitation
2.1.12.1 Physical Therapy
2.2Surgery
2.2.1
2.2.2
2.2.3
2.2.4
2.2.5
2.2.6
2.2.7
Consultations
Breast Clinic
Colorectal Clinic
Orthopedic Clinic
Hepabiliary Clinic
ENT Clinic
Eye Center
2.2.7.1 Consultations
2.2.7.2 Surgery
2.2.7.3 Diagnostic
2.3 Maternal and Child Clinic

2.3.1 Obstetrics and Gynecology
2.3.1.1 Pre-natal Consultation
2.3.1.2 Gynecology Consultation and Post Natal
Consultation
2.3.1.3 Family Planning and Women Counseling
2.3.2
Pediatrics
2.3.2.1 Consultations
2.3.2.2 Well Baby Clinic
2.3.2.3 Under Five Clinic
2.3.2.4 Hematology Clinic
2.3.2.5 Immunization
.
2.4 Nutritional Counseling
3.Emergency Services
3.1 Consultation
3.2 Observation
3.3 Minor Surgery
3
4. Ancillary Support Service

4.1 Dental Services
4.2 Laboratory Services
4.2.1 Blood Collecting Unit
4.2.2 Histopathology
4.2.3 Bacteriology
4.3. Radiology Services
5. Nursing Services
5.1 Ward Services
5.2 Out-Patient Services
5.3 Emergency Services
5.4 Special Services
5.4.1 Operating Room and Post Anesthetics Care Unit
5.4.2 Intensive Care Unit
5.4.3 Delivery Room-Neonatal Intensive Care Unit
6. Administrative and Financial Services
6.1 Human Resource
6.2 Accounting
6.3 Budget and Finance
6.4 Admitting
6.5 Billing and Claims
6.6 Procurement
6.7 Property and Supply Management
6.8 Linen and Laundry
6.9 Housekeeping
6.10 Nutrition and Dietary
6.11 Security Services
6.12Motor Transport Unit
6.13 Central Information Hospital Management
6.14 Medical Records
6.15 Medical Social Services
6.16 Pharmacy
7. Training and Research Service
7.1 Residency Training
7.2 Post-Graduate Medical Rotating Internship
7.3 Clinical Clerk Ship
7.4 Radiological Internship
7.5 In Service training for all other categories of personnel
7.6 Nursing and Midwifery Affiliation
7.7 Post Graduate Nursing/Midwifery Training
7.8 Pulmonary Student Affiliation
7.9 Laboratory Student affiliations
7.10 Physical Therapy Student Affiliation
7.11 Pharmacy Student Affiliation
8. Special Project
8.1 Cataract Operation
8.2 Goiter/Thyroidectomy Operations
8.3Cleft Palate/ Hare Lip Surgery
8.4 Diabetes Control
8.5 Medical and Surgical Outreach Program
8.6 Blood Letting
8.7LinawTingin
4
9. Indigency Program
9.1 Senior Citizen
9.2 Cultural Minority
9.3 Veterans
9.4 Special Project
9.5 Indigent Patients
9.6Service Patients
ORGANIZATIONAL STRUCTURE
1.1 The Provincial Government of Tarlac, headed by its Chief Executive, the Provincial
Governor, assisted by the Provincial Health Board of which the Provincial Health
Officer II is the co-chairman to the Provincial Governors Chairmanship, is the
governing body of the TARLAC PROVINCIAL HOSPITAL, whose primary
functions are the formulations of the hospital policies and procedures in consonance
with the policies and programs of the national government, and to verify and approve
the annual operating budget submitted by the Provincial Health Officer II who is also
the Chief of Hospital.
1.2 The primary duties of the Provincial Health Officer II/Chief of Hospital, are to
execute policies and procedures formulated by the governing body and to coordinate
efficiently the medical, nursing, administrative, financial support/ancillary, and
training and research functions of the hospital in order to provide safe treatment and
care to all patients attended in the Hospital.
There are six main services of personnel under him, namely:
I. The Medical Service, headed by the Chief of Clinics, is
primarily responsible for proper diagnosis, treatment and
medical care of Hospital patients.
II. The Nursing Service, headed by the Chief Nurse, whose main
concern is the proper nursing care for patients, nursing
education and training, and the promulgation of standard
nursing procedures for the guidance of the staff.
III. The Administrative Service, headed by the Administrative
Officer is responsible for the efficient administrative
management of the hospital, proper upkeep of the personnel,
information technology, physical plant and equipment of the
hospital.
IV. Financial Management Service headed by the Administrative
Officer , who is responsible for the effective and efficient
financial management of hospital resources which includes
supplies and materials, income generating facilities and the
sourcing of funds for hospital operations,medical records and
the provision of the dietetic, therapeutic and physical facilities
compatible with safe patient care.
V. Support/Ancillary Services, which provides specific clinical
and diagnostic facilities which are valuable aids in the
diagnosis and treatment of diseases, composed of clinical
laboratory, radiology,and dental.
VI. Training and Research is composed of medical specialists,
resident physicians, nurses and other personnel of the five
main services who participate in the various programs of the
hospital like the residency training, internship, clerkship,
nursing, laboratory, pharmacy, x-ray and others.
The duties and responsibilities of these services are defined,
maintained and limited only into medical, nursing,
administrative, financial management, training and research

and ancillary support services. It is the main responsibility of
the Chief of Hospital/Provincial Health Officer II to
coordinate effectively the various activities of these services
toward the attainment of efficient scientific hospital patient
care.
The Chief of Hospital shall meet in conference these Heads of
Services at least once a month to thresh out problems and plan
out remedies to such problems and to improve the hospital
services.
1.3 The Medical Service which is headed by the Chief of Clinics is divided into six
clinical departments, namely Internal Medicine, Surgery, Obstetrics and Gynecology,
Pediatrics, the Out-Patient Department, and Anesthesia. The above departments are
headed by Medical Specialists, Medical Officers and Consultants.
1.4 The Nursing Service which is headed by the Chief Nurse together with the Assistant
Chief Nurse, is manned by Nurses, ward attendants and for supervision purposes,
housekeeping personnel.
1.5 The Administrative Services, headed by the Administrative Officer takes charge of
General Administration which is further subdivided into Personnel, Information
Technology, Motor Transport, Maintenance, Linen and Laundry, Security Service,
and Housekeeping Service, is manned by Computer Programmer, Administrative
Aides, Maintenance Foreman, Laundry Workers, Seamstress, etc.
1.6 Financial Management Service is headed by the Administrative Officer and
subdivided into Billing and Claims manned by Administrative Aides; Collection and
Disbursement manned by Administrative Aides and Detailed Revenue Collecting
Clerks; Budget and Accounting manned by Administrative Officer; Admitting and
Medical Records manned by Administrative Aides; Medical Social Services manned
by Medical Social Worker and Administrative Aides; Dietary manned by NutritionistDietician, Cook, Food Service Worker and Administrative Aides; Pharmacy manned
by Pharmacist and Administrative Aides; Supply and Property is manned by
Administrative Officer, Storekeeper and Administrative Aides.
1.7 The Ancillary/Support Services include the following Services:
1. Laboratory, headed by the Medical Specialist manned by
Medical Technologist, Medical Laboratory Technicians,
Laboratory Aides and Administrative Aides.
2. Radiology, headed by the Medical Specialist manned by
Radiologic Technologist, Medical Equipment Technicians
and Administrative Aides
3. Dental Services headed by a Dentist manned by Dental
Aide.
B. DUTIES AND RESPONSIBILITIES OF KEY PERSONNEL

2.1 PHO II
a. Create policies and procedures that will integrate and link the preventive,
rehabilitative and promotive aspects of wellness of the public health services with
the curative functions of the provincial health facilities particularly the Tarlac
Provincial Hospital which serves as the referral center of the provincial health
system.
b. Oversee the Provincial Health Office, and formulate program implementation
guidelines and rules and regulations for the operation of the said office for the
approval of the governor; submits the annual budget of the Provincial Health
Office and the various health facilities for approval of the Sangguniang
Panlalawigan.
c. Provide technical assistance and support to the governor in carrying out activities
to ensure the delivery of basic services and provision of adequate facilities
relative to health services in the province.
d. Develop policies, plans, programs and strategies to promote the health of the
people of Tarlac and upon approval thereof by the governor, implement the same
particularly those that have to do with health programs and projects which the
governor is empowered to implement and which the Sangguniang Panlalawigan
(SP) is empowered to provide for under the Local Government Code.
e. Provides leadership and strategic direction for the development of services and
products for the health facilities of the PGT.
f. Advise the Governor and the SP on matters pertaining to health; recommend to
the SP, through the local health board, the passage of ordinances deemed
necessary for the preservation of public health.
g. Execute and enforce all laws, ordinances and regulations relating to public health.
h. Direct the sanitary inspection of all business establishments selling food items or
providing accommodations such as hotels, motels, lodging houses, pension
houses, and the like, in accordance with the Sanitation Code; recommended the
prosecution of violators of sanitary laws, ordinances regulations.
i. Direct the conduct of health information campaigns and the rendering of health
intelligence services.
j. Coordinates with the DOH Representative for Tarlac Province to ensure that DOH
programs are efficiently implemented in the province.
k. Coordinates with other government agencies and non-govermental organizations
involved in the promotion and delivery of health services.
l. Exercise general supervision over health officers of component cities and
municipalities.
m. Be in the frontline of health services delivery, particularly during and in the
aftermath of man-made and natural disasters and calamities.
n. Exercise such other powers and perform such other duties and functions as may
be prescribed by law or ordinance.
CHIEF OF HOSPITAL
a. Provides strategic direction and leadership to the Tarlac Provincial Hospital,
ensuring efficient coordination of the medical, nursing administrative and other
diagnostic and patient support functions of the hospital in order to provide proper
treatment and care for all patients admitted and attended to in the hospital, seeking
to constantly improve service delivery.
b. Oversee the various services at TPH (Medical Services, Nursing Services,
Hospital Operations and Patient Support Services, Finance Services) in the
performance of their respective duties, ensuring that all service heads comply with
and implement TPH policies and guidelines; ensures that the hospital has the
8
c.
d.
e.
f.
g.
h.
i.
j.
needed equipment/ facilities for the proper diagnosis, treatment and care of
patients, for medical and nursing education, for scientific studies and research and
for health and welfare of hospital employees.
Set out the directions for TPH in terms of markets, marketing thrusts and
profitability targets.
Ensure adequacy in number, mix, and capability of hospital manpower to meet
accreditation and licensing standards and to ensure the provision of quality health
care; monitor the manpower productivity and equipment efficiency of the various
units in the hospital.
Endorse hiring, training and promotion of hospital personnel, and recommend
disciplinary action on erring employees after due process
Together with leads of services, prepare the annual budget of the hospital for
submission to the governing body.
Prepare submit performance reports and other documents required by
management, regulatory and licensing bodies as needed, and make
recommendations for the improvement of operations.
Ensure that hospital operations comply with laws and other government
regulations, and with accreditation standard.
May disapprove any daily, weekly or periodic schedule or assignments of staff
and personnel, medical and nursing or administrative, as made by the staff or
department heads for a cause.
Coordinate with PHO I for Public Health Services for the efficient referral and
eventual management of patients from the community; collaborate with all other
hospitals in the province, both government-owned and private; promote goodwill
with local medical practitioners, local civic organizations and the community in
general.
2.2 CHIEFS OF CLINICS

a. Head of the Medical Staff and next in rank to the Chief of Hospital.
b. Responsible to the Chief of Hospital for the efficient performance and ethical
conduct of the medical staff of the hospital.
c. Shall coordinate all the clinical activities of the hospital so as to bring out the best
possible professional and scientific patient care.
d. Shall stimulate research work and coordinate the care of patients with any
graduate physician or nursing training programs of the hospital.
e. Shall arrange and schedule scientific conferences for the professional growth of
the staff and maintain a continuing program of in-service training of his staff.
f. Shall take care of standardization, as much as possible, hospital clinical records
and charts.
g. Shall require all heads of clinical services to prepare a standard of Manual of
Procedures for the guidance of staff members under them and submit the same for
approval to the Chief of Hospital.
h. Shall take charge of the Medical Records of the hospital and see to it that they are
properly accomplished, filed and kept in such a way as to facilitate research and
issuance of same whenever needed for consultation and certification.
i. Shall conduct periodic medical audits of the scientific work of the hospital and
suggests measures to improve patient care.
j. Shall evaluate the work of the members of his staff and recommend measures for
improving their efficiency.
k. Shall have the power to recommend through the Chief of Hospital, appointments
and disciplinary actions of the personnel under him.
l. Shall assist the Chief of the Hospital in the administrative management of the
hospital and shall perform the duties of the Chief of Hospital during the latters
temporary absence or incapacity.
m. Shall meet in conferences the members of his staff at least once a week and thresh
out problems of the service and plan out improvements.
9
2.3 THE CHIEF NURSE

a. As head of the Nursing Service, she is the over-all supervisor of the nursing
service, and responsible for the implementation of proper nursing care to patients.
b.
Shall prepare a practical Nursing Procedure Manual to guide her staff and
submit the same to the Chief of Hospital for approval; and maintain a continuing
In-Service Training Program for the professional growth of her staff.
c. Should conduct regular rounds of patients and nursing units to attend to their
needs and improvements.
d.
Shall be responsible to the Chief of Hospital for the execution of rules and
regulations relating to the Nursing Service and the proper care of patients, upkeep
of wards, operating rooms, and delivery room.
e. Shall initiate the performance evaluation of nurses and ward attendants and
recommend measures to improve their efficiency. She has the power to
recommend through the Chief of Hospital, appointments, promotions and
disciplinary action of personnel under her.
f. Should conduct immediate investigation of complaints or irregularity involving
her staff and submit her findings and recommendations to the Chief of Hospital.
g.
Shall see to it that each sick employee under her staff is properly attended
and confined in the hospital, if necessary.
h.
The Chief Nurse is assisted by a qualified member of her Nursing Staff,
the Assistant Chief Nurse.
i. Attends management meetings as representative of the nursing service.
j. Performs other related functions as maybe assigned.
k. Promotes and maintain harmonious relationship among the staff.
2.4 THE ADMINISTRATIVE OFFICER
a. Head of the General Administrative Service.
b. Assists the Chief of Hospital in coordinating hospital functions and recommends
needed changes in the administrative policies and the operation of the institution.
c. Regularly inspects buildings, facilities, equipments, supplies and materials to
determine needs and recommends appropriate action.
d. Studies procedures of hospital operations and recommends new and better ones to
keep operation costs as low as possible without sacrificing service efficiency.
e. Determines distribution and work schedule of personnel.
f. Helps the heads of other services/groups in solving managerial problems.
g. Assists the Chief of Hospital in enforcing all orders, rules and regulations
promulgated by the governing body.
h. Responsible for the performance evaluation as to the efficiency of the
Administrative Staff for General Administration and may recommend for their
disciplinary actions.
i. Recommend to the Chief of Hospital for qualified applicants for hiring and
promotions for qualified employees.
j. Shall maintain a continuing program of the In-Service training for the
professional growth of the staff.
2.5 THE ADMINISTRATIVE OFFICER FOR FINANCIAL MANAGEMENT
a. Plans and directs the implementation of policies pertaining to financial
management and hospital operation.
10
b. Ensures the provision of uninterrupted logistic support to effectively and

efficiently deliver quality service.
c. Provides technical assistance to the Chief of Hospital in the promulgation and
formulation of policies, standard operating procedures and strategies to improve
the hospital system and its operation.
d. Directs the evaluation and analysis of procedures and cost of operations and
recommends changes to improve the work system.
e. Recommends approval of work and financial plan and the annual procurement
program of the hospital.
f. Plans and directs purchase and inventory control of required resources.
g. Directs the preparation and submission of required reports and official
communication.
h. Reviews and signs/initials financial reports and other documents.
i. Identifies and recommends the need for revision of policies, system and
procedures.
j. Monitors programs/projects and activities.
k. Shall have administrative supervision over official records of the hospital.
2.6 DIETITIAN-NUTRITIONIST III
a. Shall plan, organize, supervise, and evaluate all activities of the Nutrition and
Dietetics Service.
b. Recommends, interpret Dietetics Service objectives, policies and standards to the
administration.
c. Plan an effective budget for patient.
d. Plan, organize, direct and evaluate the total food service to the patient: purchasing
specifications and materials: food production: sanitation and safe standards.
e. Develop and maintain an organization chart of the Nutrition and Dietetic Service
showing the responsibilities and authorities of all personnel.
f. Supervise the maintenance of cost control, personnel, record and reports.
g. Participate in conferences of department head meetings.
h. Prepares work schedule of staff.
i. Prepares Performance Evaluation System of personnel.
j. Provides counseling and in service training in principles of nutrition.
k. Report all concerns to the Administration.
2.7 HEADS OF CLINICAL DEPARTMENTS
a. Shall be responsible for proper diagnosis, treatment and medical care of patients
under his/her service.
b. Shall have immediate technical supervision of all physicians, resident staff
(Medical Officers) and adjuncts and technicians under him.
c. Shall conduct regular rounds of all patients under his service with members of the
house staff and discuss with them problems in diagnosis and treatment.
d. Shall prepare a standard Manual of Procedures for the guidance of his staff
members and attend to their periodic assignments in the service and submit such
Manual to the Chief of Hospital.
11
e. Shall evaluate the work of members of his staff and recommend measures for
their improvement to the Chief of Hospital through the Chief of Clinics, all
appointments, promotions, and disciplinary action on personnel under him.
f. Shall verify all statistical reports of the Medical Officers under him.
g. Shall attend to the needs of his service and see to it that they are properly
provided for.
h. Shall meet his staff in conference at least once a week to discuss administrative
and medical problems and plans out remedies of such problems in his service.
i. Shall cooperate in maintaining admission into the hospital service within the
authorized bed capacity and appropriations of his department.
j. Shall stimulate research work and coordinate any graduate physician or nursing
training program in his service.
2.8 CONSULTANTS
a. Responsible for the diagnosis, treatment and medical care of all patients under his
department or service, to the Head of Department and also for patients referred to
him by the Medical Officers.
b. Shall assist the Head of the Service in the supervision and training of Medical
Officers/Resident Physicians, adjuncts, observers, nurses or technicians under his
service.
c. Shall make regular rounds of patients under his care and participate in staff
medical conferences and research.
d. Should make general rounds of patients and must be available to consultation
when on 24 hours duty as consultant of the department.
2.9 SENIOR RESIDENT PHYSICIAN
a. Shall assist the Head of the Service, Chief of Clinics, Chief of Hospital in the
technical and administrative supervision of all resident physicians and
technicians.
b. Shall make daily rounds of patients; attend to their needs, diagnosis and treatment.
c. Shall see to it that the patients charts are properly accomplished by all concerned
within the required period from admission to discharge and properly coursed to
the Medical Records for safekeeping.
d. Shall be responsible for reporting all statistics and may do other duties when
needed in the exigencies of service.
e. Shall be in charge of the ambulance service pertaining to the transport of patient
to other hospital.
2.10 SENIOR HOUSE OFFICER (SHO)
a. Shall be responsible in the whole operation of the hospital after office hours in the
absence of the Chief of Hospital, Chief Nurse and Administrative Officer.
b. Shall be responsible for the presence of the Triage Officer and resident/intern-induty for each department which includes the Emergency room.
c. Shall be responsible for the availability of Emergency Drugs in the Emergency
Room at all times, as well as in the procurement of blood as needed for inpatients.
d. Shall see to it that all patients brought in especially emergency cases; be attended
to immediately, by any resident / intern-on-duty regardless of department.
e. Shall be responsible for the approval of all emergency procedures/operations,
after office hours on regular days, and on Saturdays, Sundays and Holidays and
may however call on the department head concerned in controversial cases.
f. Shall be responsible for the disposition of the patients in the Emergency Roomas
well in the Observation Room and may call on the department head concerned in
the controversial/difficult/serious cases.
12
g. Shall have the discretion to decide on emergency administrative matter when such
could not be transmitted to the Administrative Officer or to the Chief of Hospital.
h. Shall VISIT ALL SERVICES during his/her 24 hours tour of duty, check and
monitor attendance of hospital personnel in the afternoon and night shift.
i. Shall be responsible for the coordination of all activities in the Emergency Room
and must see to it that orders are left in the care of patients, arrangements of
admissions and other related functions shall be carried out or endorsed to the
incoming SHO.
j. Shall make rounds of all floors before going off-duty in the following morning, as
well as collect the daily reports of residents-on-duty of all departments,
consolidate and submit them to the Chief of Hospital.
k. Shall be responsible for the implementation of the policies on the admission and
care of patients in the Emergency Room.
2.11 RESIDENT AND JUNIOR PHYSICIANS
a. Shall attend to the diagnosis, treatment and medical care of patients assigned to
him but under supervision of the Head, Senior Resident and Consultant of the
Service.
b. Shall be responsible in accomplishing the history and other pertinent data in the
chart and performing all routine laboratory examinations within the required time.
c. Shall do charting of the daily observation regarding the progress of patients
during their stay in the hospital.
d. Shall make daily rounds of all patients and upon call at anytime whenever
required to do so.
e. Shall follow all assignments and perform other required duties to meet the needs
of the Service by the Head, Consultant and/or Senior Resident Physician.
2.12 ADJUNCT RESIDENT PHYSICIAN (VOLUNTEER)
a. Shall assist the resident physician in the performance of the latters duties.
b. All services are limited for one year, without compensation and must observe
strictly the office hours of the hospital, comply with the 24 hours duty and attend
all conferences called for by his superior.
2.13ASSISTANT CHIEF NURSE
a. Responsible in assisting in the administration and supervision of the Nursing
Service, being next in rank to the Chief Nurse
b. Acts as the administrative head in the absence of the Chief Nurse.
c. Assists in the administrative and supervisory activities as delegated, such as
preparation of the schedule, requisitioning supplies and equipment, keeping
records, supervision of personnel and the nursing services to patients.
d. Assists in the orientation of new personnel and in conducting education program
in coordination with the Training Officer of the hospital
e. Assists in all other functions of the Chief Nurse.
2.14 NURSE SUPERVISOR
a. Operates at a level between the Chief Nurse and the Senior Nurse and is in charge
of one or more units.
b. Plans for the effective management of the units assigned.
c. Analyzes and evaluates the nursing services required in the department in
cooperation with the Senior Nurses.
d. Supervises all nursing activities of the assigned units.
e. Interprets hospital and ward policies and assure their implementation.
13
f. Helps Senior Nurses plan assignments and duties to nursing personnel that will
ensure support, prompt and effective performance.
g. Analyzes and evaluates the educational resources of the department and make
these resources available for the related learning experiences of the affiliates.
h. Plans and participates in programs of staff development.
i. Participates in research activities to advance nursing and other services.
j. Prepares and submits required reports.
2.15
SENIOR NURSE
a. One to who is delegated authority to provide nursing care to patients in a given

unit, the immediate supervisor and unit manager responsible for the effective
management of the nursing services.
b. Plans for adequate provision for nursing care of patients in the assigned unit.
c. Assigns specific duties of staff nurses, nursing aids and helpers.
d. Evaluates nursing services rendered to patients.
e. Assists in the orientation of new members and students.
f. Plans teaching programs in cooperation with the clinical instructors utilizing all
opportunities to enrich clinical experiences of students.
g. Directs, coordinates and evaluates activities of professional and non professional
workers.
h. Requisitions and distributes supplies and equipments and conduct periodic
inventory of the time.
i. Acts as supervising nurse in the absence of supervisor
j. Rotates with or relieve Staff Nurse if necessary.
k. Prepares and submits required reports
2.16
STAFF NURSES
a. Responsible for rendering bedside care to patients in their assigned units.

b. Assessment of its problems and needs, prepare, implement plan and evaluates
result. Provides direct patient care.
c. Observes, records and reports symptoms and conditions of patients. Administers
medication, treatment and notes reaction.
d. Assists physicians in administering highly specialized therapy with complicated
equipment.
e. Bath and feeds acutely ill patients.
f. Assists in the orientation, provides incidental teachings.
g. Supervises non-professional workers.
h. Plans and give health education to patients.
i. Acts in the capacity of the Senior Nurse the latters absence.
j. Coordinates with other services regarding patients management and treatment.
k. Does other related work as delegated.
2.17
NURSE TRAINING OFFICER
a. Responsible in planning the training program for all levels of personnel in the
Nursing Service
b. Plans, organizes, conducts, training programs and other activities related to staff
development in cooperation with the supervisors and senior nurses,
c. Acts as liaison between the nursing service and affiliates.
d. Conducts orientation programs for new personnel and affiliates.
e. Secure instructional materials and resource persons for the training.
f. Evaluates results of training.
g. Does other related work as delegated.
2.18
SUPERVISING OPERATING ROOM NURSES

14
a. Responsible for the management and supervision of nursing and related Operating
Room activities
b. Directs and supervises nursing and related activities of the Operating Room.
c. Plans assignments of staffs
d. Supervises layout of table for various operations considering surgeons
requirements and supplies available.
e. Prepares general procedures and list requirements of each type of operations
performed and standardized packs and draping of patients for each operation.
f. Informs staffs of new procedures, administrative charges, special instruments or
sutures required of scheduled operations and problems in asepsis by issuing daily
reports, conferences, and other methods.
g. Periodically discusses their staff major problems and proposes solutions to the
same.
h. Conducts orientation and in-service training programs to provide good patient
care and efficient aid to surgeons
i. Ensures that Operating Room is kept clean always.
j. Coordinates operating room activities with other units and services of the medical
staff.
k. Coordinates with Supply section in selection of new instruments, supplies and
equipments.
l. Participates in the formulation of administrative/personnel policies pertaining to
operating room activities.
m. Directs and maintains required records and reports including working
performance.
n. Evaluates performance of personnel and service of the department.
2.19
SENIOR OPERATING ROOM NURSE
a. Responsible for extending assistance to various types of surgical operations,

during the pre-operative, intra-operative and immediate post-operative phases;
b. Plans, organizes, directs and coordinates activities in the operating room and
evaluates performance.
c. To ensure that effective nursing services is maintained at all times.
d. Provides guidance to medical and nursing students.
e. Operates or supervises operation of complicated equipment.
f. Requisitions of supplies, materials and equipment.
g. Assists in research work related to improvement of surgical nursing.
h. Observes strict compliance/implementation of aseptic techniques in the Operating
Room.
i. Provides assistance to surgeons during the operations.
j. Assists as supervisor in the absence of the latter.
2.20
OPERATING ROOM NURSE
a. Responsible for extending assistance to the various types of surgical operations

and does related jobs/works.
b. Provides care to surgical patients during the pre-operative, intra-operative and
immediate post-operative phases.
c. Acts as a scrub or sterile nurse;
Prepares supplies and instruments according to type of operation to be
done.
Directly assists surgeon during operations.
Observes patients during surgical procedures for unusual manifestations.
Checks all materials, instruments used during operations.
15
Wash, dry and packs the instruments used after the operation for
sterilization.
d. As circulating nurse:
Maintains proper positioning of patients
Prepares table and other devices required
Prepares operative area by sterilizing skin
Prepares specimen for laboratory analysis
Observes progress of surgery and provides additional needs of surgeons
and scrub nurse.
Regulates I.V. fluids
Accompanies patients to and from the Operating Room.
2.21
DIETITIAN NUTRITIONIST II / DIETITIAN NUTRITIONIST I
2.21.1 Nutritionist Dietitian II- assists in the supervision of all ND service activities
particularly in the management of the food service.
a. Evaluates food the management of the food service
b. Inspect and accept all deliveries of foodstuff for accurate quantity and proper
quality in accordance with the specification set by the service.
c. Maintain complete and accurate records of daily purchase inventories of food
supplies and requisition; equipments and utensils.
d. Supervise and evaluate preparation, cooking and apportioning of food for patients
and staff.
e. Maintain and improve high standards of sanitation, safety and accuracy.
f. Recommends improvement of facilities and equipment.
g. Provide counseling and in service training principles of nutrition.
h. Report all concerns to supervisor.
2.21.2 Nutritionist Dietitian I- assist in the supervision of all ND Service activities.
a.
b.
c.
d.
e.
f.
g.
h.
i.
2.22
Inspect and accepts deliveries of food stuffs for accuracy.

Supervise food production and serving of meal in the ward.
Record meal census.
Conducts nutrition education to patients referred by physicians
Verify accuracy of diet served to patient.
Maintain high standard of sanitation.
Participate in the in-service education for ND staff
Assist in the preparation and completion of reports and other supporting papers.
Report all concerns to supervisor.
CHIEF PHARMACIST
a. Prepare and submits Project Procurement Management Plan (PPMP) for drugs
and medicines and supplies.
b. Prepare list of drugs and medicines and supplies to be procured quarterly.
c. Monitors stock level of drugs and medicines and supplies.
d. Assure compliance with all legal and regulatory requirements to effectively render
hospital services (FDA and PDEA).
16
e. Prepare and submits semi-annual report to PDEA.

f. Review and submits the prepared monthly statistical (number of filled and
unfilled prescriptions), malaria and consumption report.
g. Participate actively in the implementation of the medication policies and
procedures of the hospital.
h. Orient pharmacy interns on the hospital policies, hospital organization and on the
Standard Operating Procedures (SOPs) of the pharmacy.
i. Instruct, train and supervise employees of the hospital pharmacy.
j. Check, evaluate and approve performance ratings of the pharmacy staff.
k. Prepares monthly pharmacy staff schedule of duties.
l. Perform other related functions.
2.23MEDICAL TECHNOLOGISTS III / II
a. Shall monitor all work performed in the laboratory and determine that reliable
data are being generated;
b. Ensure that there are sufficient qualified personnel with adequate documented
training and experience to meet the needs of the laboratory. He/ she shall convey
to the Head, the need for additional staff as the need arise
c. Address complaints, requests or suggestions from users.
d. Must be in active communication with the Head of the Laboratory on the various
concerns that need to be immediately addressed
e. Shall be aware of the basic principle of the test or part of the test he/she is doing;
f. Shall perform the test as described in the manual for standard operating procedure
g. Must comply with all safety and bio-safety policies;
h. Must report unsafe practices and accidents to his/her immediate supervisor;
i. Shall monitor laboratory equipments.
j. Shall foster and adopt Professional work ethics with peers
2.24 RADIOLOGIC TECHNOLOGISTS
a. Overall supervision of the Department activities Radiology, Ultrasound and
Administrative Services, including mobile unit.
b. Recommend policies and procedures relative to the Departments operation;
c. Develop and implement training program for radiology staff; and
d. Accomplishes performance appraisal and ratings of supervisors and reviews/
confirms performance rating of staff;
e. Prepares propose budget of the Department;
f. Reviews and updates existing Department Guidelines, Standard Operating
Procedures and Policies;
g. Review and approve work schedule of the Department;
17
h. Establish and maintain effective communication system within and inter

Department;
i. Ensure completion and compliance with requirements to operate X-ray facility;
j. Conduct Quality Circle of the Department;
k. Perform other related functions that may be required.
2.25
a.
c.
d.
DENTIST III
Establishes department procedures and methods of operations;

b. Conducts dental examinations and makes diagnosis, performs oral prophylaxis,
including removal of calcium deposits, secretions and stains from exposed surface
of the teeth; fills cavities with composite fillings and does other minor surgery;
Requisitions dental equipment and supplies;
Maintains proper cleanliness or clinic, equipment and supplies.
C. HOSPITAL POLICIES AND PROCEDURES
HOSPITAL SUMMARY FLOW CHARTS
I. FLOW CHART -ADMISSION TO DISCHARGE
HOSPITAL OPERATIONS SUMMARY FLOW
A patient may enter the hospital system through the OPD or ER. From these two
units, a patient may be sent home, advised to stay for observation or admitted to the
wards. In the ward, the patient receives care from doctors and nurses and services from
different support units like Pharmacy, Dietary, CSR, Laboratory, Radiology, Medical
Social Service and Medical Records, upon admission or while in the ward, the patient is
classified in terms of his capability to pay. Before the patient is discharged, he must pass
through the Billing Section and Collection Unit for his financial obligations to the
Hospital. In case the patient cannot afford to pay his bills, he may seek the help of the
Medical Social Worker / Indigency Committee of the Hospital which Committee has the
power to decide on how much payment the patient will be obliged to shoulder based on
his classification, then said patient returns to the Collection Clerk for payment. A
clearance certificate will be issued thereafter.
18
II. OUT-PATIENT DEPARTMENT

POLICIES AND PROCEDURES
RULES AND REGULATIONS
POLICIES:
1
2
3
4
5
6
7
8
9
Residents of the different department assigned at the OPD must be at their post at all
times.
All interns and clerks must bring their own medical instruments, i. e. stethoscope and
sphygmomanometer, etc.
New patients must be registered in the patients record book for their assigned number
which must be presented whenever their medical record is needed;
Patients must be attended to on first come first served basis.
All problems pertaining to the inability to pay should be referred to the Medical
Social Worker;
Minor surgical procedures must be done in the afternoon.
All OPD records must be signed/countersigned by the resident on duty;
Locator card should be properly indexed;
Out-Patient Department clinical records should be managed as follows:
a
b
c
d
e
Only authorized personnel of the OPD should be allowed in the OPD Clinical
Records and Hospital Medical Records Section to secure records of patients;
It is the responsibility of the Medical Records Officer for the OPD safekeeping of
all medical records and answerable to the Chief of Hospital designate and/or
Chief of the OPD for losses and unauthorized issuance of information pertaining
to patients clinical records and data;
The contents of the clinical records of patients should not be divulged to anybody
without proper request from authorized person;
Medical Certificate is issued only upon request of the patient concerned properly
signed by the attending physician with the seal of the hospital affixed to the
certificate;
Only the Medical Records Section can issue medical certificates;
10 Consultation hours and days:

Services
Hours
Pre-Natal
8:00 AM -12:00 PM
1:00 PM - 5:00 PM
Post-Natal
8:00 AM -12:00 PM
1:00 PM - 5:00 PM
19
Days
Mondays,
Wednesday, Friday
Tuesday
Thursday
Gynecology
Family Planning
Internal Medicine
Pulmonary Clinic
(TB DOTS)
Surgery
(Orthopedic, ENT)
Pediatric
Well Baby Clinic
Sick Babies
Immunization
Under Five Clinic
Dental Clinic
Medical Social Service
Physical Therapy
Ultra Sonography Service
Blood Collecting Unit
8:00 AM -12:00 PM
1:00 PM - 5:00PM
8:00 AM - 12:00PM
1:00 PM - 5:00PM
8:00 AM - 12:00 PM
1:00 PM - 5:00 PM
8:00 AM - 12:00 PM
1:00 PM - 5:00 PM
8:00AM - 12:00PM
1:00PM - 5:00PM
8:00AM - 12:00PM
1:00PM - 5:00PM
8:00AM - 12:00 PM
8:00AM 12:00PM
1:00PM 5:00PM
1:00PM 5:00PM
8:00AM 12:00PM
1:00PM 5:00PM
8:00AM 12:00PM
1:00PM 5:00PM
8:00AM -12:00PM
1:00PM - 5:00PM
8:00AM -12:00PM
1:00PM - 5:00PM
8:00AM -12:00PM
8:00AM - 5:00PM
8:00AM - 5:00PM
8:00AM - 5:00PM
Thursday
Monday
Monday to Friday
Monday to Friday
Monday to Friday
Monday to Friday
(AM only on Wednesday)
Monday to Friday
Tuesday and Thursday
Monday, Wednesday, and
Friday
Tuesday and Thursday
Every last Thursday of the
Month
Monday to Friday
Monday to Friday
Monday to Friday
Saturday
Monday to Friday
Monday to Friday
Monday to Friday
Consultation fee is P50.00

PROCEDURE:
I
1
PROCEDURES OF THE OUT-PATIENT DEPARTMENT

Blood Donor
Responsibilities of a nurse:
Assists the possible donor in filling up of blood donation form.
Take vital signs and weight of donor.
Accompany patient to the laboratory for blood typing and hemoglobin count.
If donor is physically fit and qualified to donate blood, prepare him for extraction.
-
Place him in comfortable lying position.
Prepare the blood bag extraction site.
Assist physician during extraction, observe proper asepsis during

procedure.
Observe donors reaction during and after extraction of blood.
20
a
b
c
d
Label blood bag with donors name, blood type and date of extraction.
Forward to the laboratory.
Minor Operations
a
Secure consent of patient (legal age) or nearest kin and explain the procedures
to be done.
Check and prepare the medicines and instruments needed for the procedure.
Prepares the operative site and drape patient properly.
Performs minor operations.
Assists the Surgeon during the operations.
Collect specimen for pathological examination such as biopsy, if any.
Advice on prescribed medication, wound care and follow-up check-up.
Vaginal Examination
a Secure consent of patient or nearest relative and explain the procedure to be
done.
b Performs vaginal examination.
c If the procedure is assisted by the nurse:
-
Prepare the perineum, paint it with antiseptic solution.

Drape patient properly.
Have all instruments ready.
Collect specimen for pathological examination.
Label specimen properly and send to laboratory.
SERVICE PROCEDURE
PROCEDURE
Register name and other patient data
in the record section
Prepare chart and issue OPD card
(new patient)
Retrieve patient chart (old patient)
Record the chart in the OPD
logbook.
Collection of fee
e Bring the chart to the assessment

area
PERSON RESPONSIBLE
Records clerk
Records clerk
Records clerk
OPD Collector
Patient
OPD nurse/ Nursing aid
*Call patients name

*Get the vital signs
*Classified patients based on their
complaints
21
*Give/ provide number to Specific

unit/clinic
f
Forward OPD chart to the respective

OPD clinic
patient/nurse/nursing aide
Examines patient, evaluates and

determines the medical care needed.
Asses the patient for any medical or
surgical invention needed.
*If the patient is for medical care,
give prescription and provide
g
instruction.
*If the patient is for work-up orders
ECG and CXR etc., Once result is
available, evaluate document and
give appropriate management and
instruction.
*If patient is for referral, refer
accordingly.
Record observation impression,
diagnosis and treatment rendered to
h OPD chart.
Advised follow-up PRN
Discharge patient with proper
instructions.
i Filling of charts / records
Resident on Duty
physician/OPD nurse
physician/nurse
III. EMERGENCY ROOM POLICIES AND PROCEDURES

1. General Policy:
a.
b.
There should be at least one resident physician per department at all times;
There should be adequate supplies, medicines, materials and other things needed
for the management of cases;
c.
No follow-up of out-patient cases;
d.
To be of service to the sick should be the primary guiding principle;
e. Proper decorum should be exercised at all times;
f. A triage officer coming from the Department of Surgery must always be available.
2. Policies in the Care of Patients:
a. All patients who come to the emergency room for emergency medical evaluation
or treatment will receive care in a timely manner consistently and must be
attended to immediately.
b. In emergency cases, whether the patient has money or none should not be
prejudiced by administration of medicines, fluids and other therapeutic and
supportive measures (lab., x-ray, etc.);
c. The need for blood should be referred to the laboratory department.
22
d. In case of difficult administrative controversies in the admission, management of

disposition of patients in the ER must be referred by the Resident on duty to the
Senior House Officer.
e. The clinical management, admission or disposition of patients in the ER which
are considered controversial in nature should be referred to department
head/chairman.
f. All medico-legal cases should be referred to and must be seen by the resident on
duty.
g. During mass casualties residents from different clinical departments are required
to assist.
h. Administrative concerns should be referred to Senior House Officer after office
hours.
3. Observation Room:
a. To avoid congestion, if within four hours patients are unable to recover from their
complaints, they should be admitted to the corresponding ward. No cases of
communicable diseases should be placed at the observation room;
b. The disposition of patients in the observation room as to whether to admit or not
into the ward, shall be referred to the Senior House Officer, the SHO may further
refer the case to the department head concerned, but in no case shall the resolution
of such controversy exceeds twenty-four hours.
4.Admission:
a. No patient seeking admission ,must be refused regardless of:
1. financial status
2. availability of space (except for pay patient with private physician)
b. The patient/patients relative who refuses admission shall sign the waiver form.
REFUSED ADMISSION must be annotated on the doctors order sheet.
5. Policies regarding Use of Minor Operating Room:
a.
Only emergency cases should be done.

6. ER Procedures:
PROCEDURES
PERSON/S RESPONSIBLE
a. Attends to the patient immediately for

emergency measures;
b. Obtain and record vital signs, and refers
patient to the physician on duty;
c. Examines patient and writes down orders
for medication/medical care;
d. If vital signs are absent, gives
resuscitative measures and refers to
physician on duty;
d.1. If resuscitative measures fail,
pronounces patient as dead on
arrival (DOA)
d.1.1 Perform post-mortem care.
ER Nurse
Physician
ER Nurse/ER Staff
Physician
Nursing Attendant
23
d.2. In case of medico-legal refer to

Resident on Duty
d.3. If patient is for admission, writes and
signs admitting orders and instruct
relative to proceed to the admitting
unit.
d.3.1 Instruct relatives to go back to
E.R with room assignment given to
patient.
d.3.2Notifies the ward regarding
admission.
Nurse
Physician/ Nurse
Admitting Clerk
Nurse
d.3.3 If needed, patients who are not
emergency cases must be brought to
laboratory for blood extraction and
X-ray.
d.4 If patient is for surgery, writes stat
orders on the patients chart for
immediate work-up like complete
blood count, urinalysis and/or
special procedures;
d.5 Prepares and signs request and gives
it to the nurse;
d.6 If patient is for referral to other health
facilities, prepares referral documents;
and
d.7If patient is for discharge, instructs
patient/relative to comply with the
discharge requirements.
Physician
Physician
Physician
Physician
IV. ADMISSION POLICIES/PROCEDURES

1
Admission of patient is centralized at the Admitting Section. Patients for admission

come from:
a.
b.
c.
Out Patient Department referred by the resident on duty,

Emergency Room for patients with emergency conditions.
Patients brought in by visiting physicians.
Only patients with doctors order for admission and with complete charts are
admitted to the Clinical Units:
a.
b.
c.
d.
e.
f.
g.
Patient Data Sheet is completely filled up;

Admission number and case no. recorded;
Consent for hospitalization is signed by responsible relative of the
patient;
Hospital rules and regulations are explained;
Room accommodation and hospital charges are explained;
Consent for admission is signed for all admissions,
Informed consent is signed by the authorized nearest of kin, if the patient
is for surgery and witnessed by a hospital staff.
24
h.
3
Stat orders are implemented by nurses before patient is transferred to the

room of choice.
Patients data is recorded at the Patients Admission Book. If patient has a health
insurance, privileges are explained and supporting papers are required to be
submitted within 24 hours.
4. The Admitting Clerk notifies the Emergency Room nurse of the availability of
rooms.
V. WARD PROCEDURES
I. Admission to Ward:
Upon notice of admission:
PROCEDURES
prepares assigned bed, individual
patients need for supplies and
materials based on the information
from the E.R nurse.
prepares patients unit like bed,
linen, bedside table, etc.
Ward Nurse
Nursing Attendant
Upon arrival of the patient in the ward:
PROCEDURES
25
a. accompanies patient to his/her designated

unit;
Nurse
b. Assess patients condition and records

findings in the chart;
Nurse
c. Orient patient/relative about the hospital

policies;
Nurse
d. Plans nursing care of patient, performs

admission and carry out orders.
Nurse
e. Follow-up results to other units such as the

laboratory, pharmacy, x-ray, etc. of the need
and requirements of the patients.
f. Discuss with the patient or relative the
medical/nursing care and the extent of his
participation;
g. Checks chart to ensure that consent for
medical/surgical intervention has been signed
by the patient or his/her nearest of kin;
Nurse/ Nursing Attendant
h. Record observations, treatment and

medications administered to patients;
i. Encode patients name in the daily ward

census, Kardex and Diet List;
j. Updates ward directory and prepares diet list

and forwards to the Dietary Service.
2. Carrying out Doctors Orders:

PROCEDURES
a. after doctors rounds, receives and copies
medical management from the patients
chart to the nurse book or Kardex;
b. Prepares Drug Utilization Form to be
forwarded to the pharmacy;
c. carries out medication/treatment orders;
Ward Nurse
Ward Nurse
Ward Nurse
3. Daily Patient Care

PROCEDURES
26
a. Endorses to the incoming nurse the

shifts activities and special procedures,
medications, which need to be carried out;
Ward Nurse
(Outgoing Nurse)
b. Makes rounds with the incoming nurse

and introduces the latter to newly admitted
patients and those needing intensive care;
Ward Nurse
(Outgoing Nurse)
c. Takes note of patients needing special

attention and care;
Incoming Nurse
d. Endorses drugs to the incoming nurse

and signs out;
e. Reads Kardex and analyzes reports;
Outgoing Nurse
Incoming Nurse
f. Prepares plan of work and determines

resources and priorities;
Incoming Nurse
g. Provides nursing care and carries out

medical treatment;
Incoming Nurse
h. Records patient care activities and

observations made;
Incoming Nurse
i. Refers patient to the physician on duty

when necessary;
Incoming Nurse
j. Discusses management of the patient to

the physician;
k. Monitors activities and patients status;
Incoming Nurse
Incoming Nurse
l. Makes round of patients;
Supervising/
Senior Nurse
m. Supervises nursing care provided by the

ward nurse
Supervising/
Senior Nurse
n. Observes the ward nurse to determine

their level of competency;
Supervising/
Senior Nurse
o. Observes utilization of ward supplies

and equipment; and,
Supervising/
Senior Nurse
p. Assists ward nurse in carrying out

patient care when needed.
Supervising/
Senior Nurse
4. Pre-operative Procedures
A day before the operation:
27
PROCEDURES
a. Prepares elective schedule for surgery

and forwards it to the ward nurse;
Surgeon / Ob Gyne
b. Forwards schedule for surgery to OR

Nurse, Anesthesiologist and Chief of
Hospital for approval;
Ward Nurse
c. Inspects chart to see that the consent for

surgical intervention has already been
signed by the patient or his nearest kin.
Ward Nurse
d. Forwards approved schedules to the OR

Nurse;
Ward Nurse
Operating Room
Nurse
e. Ensures that all OR needs are complete

f. Prepares patient psychologically and
spiritually, and orients his/her on the
procedures to be done;
Physician/Nurse
g. Instruct patient/watcher on NPO

(Nil per Orem)
starting at midnight,
Ward Nurse
h. Checks preparation made for patients

operation;
i. Prepares patient:
- Performs procedures as needed, (e.g.
enema)
- Conducts preliminary preparation for the
operative site;
- Reminds patient on NPO;
- Reassures the patient;
Supervising Nurse
Senior Nurse
Ward Nurse/
Nursing Attendant
j. Fills up and signs checklist of preoperative

preparations and gives it to Nurse II
(Senior Nurse)
Ward Nurse
l. Attached checklist in the patients chart
Ward Nurse
Hours before the operation:
PROCEDURES
r. Removes jewelleries, contact lenses,
prosthetic teeth, etc. and gives them to
patients companion for safekeeping;
Ward Nurse
28
s. Gives cleansing enema, if ordered;

t. Inspects operative site and checks
completeness of pre-operative medications;
Ward Nurse
u. Rechecks the checklist of pre-operative

medications;
Ward Nurse
v. Takes vital signs (BP/ temperature/ Pulse

rate/ Heart rate/ respiratory rate/ and level
of consciousness;
Ward Nurse
w. Gives pre-operative medications as

scheduled;
Ward Nurse
x. Transfers patient to the OR with the

chart and other needed medications and
supplies and with Ward Nurse endorses
to OR.
OR Attendant/
Ward Utility Worker
VI. OPERATING ROOM

POLICIES & GUIDELINES SERVICE
I.
OPERATING ROOM AVAILABILITY

1. The Tarlac Provincial Hospital has 3 functioning Operating Rooms which
will be used for all Emergency and Elective surgical cases of the hospital.
2. One (1) Operating Room will be allotted each for Surgery and OB-Gyne
Departments respectively wherein they will do their Elective Service
Cases. One (1) Operating Room will be allotted exclusively for
Emergency cases.
Operating Room I Surgery Elective Cases
Operating Room II OB-Gyne Elective Cases
Operating Room III Surgery Elective Cases
II.
POLICIES FOR ELECTIVE PROCEDURES

1. Operating Rooms for Elective Procedures shall be available Monday to
Friday (except on official non-working holidays) from 8:00am to 2:00pm.
2. Time table for Elective Procedures will be as follows and shall be
STRICTLY observed:
7:00 am Patient received at the Operating Room
29
7:30 am Anesthesia Induction Time

8:00 am Surgical Procedure Cutting Time (1st Case)
2:00 pm Cut-off time
Surgery Safety Checklist will be done at all times by the surgical

team
a. Before induction of anesthesia (Sign in)
b. Before skin incision (Time out)
c. Before the patient leaves the Operating room (Sign out)
Surgeons should be within the Operating Room premises at the
time of Anesthesia Induction
Residents are expected to be punctual however this may not be
possible in some instances. Thus, cases (especially the 1st
scheduled case for the day) are allowed to have a maximum of 30
minutes delay. If the residents in charge of the case are not yet
around after this allowable time of delay, the case will either be
deferred or bumped-off and be done as the last case provided it is
still within the allotted elective time (8:00am-2:00pm).
3. Surgeons are expected to make reasonable schedules of their Elective

Procedures i.e. potentially long cases and Pediatric cases should be
scheduled first and minor cases scheduled last.
4. The duly approved ELECTIVE SCHEDULE FORM must be submitted
by the Chief Residents (or their designated representative) of the
respective departments to the Operating Room Head Nurse before 12:00nn
of the day prior to the scheduled procedures. Otherwise, NO ELECTIVE
SURGERIES will be scheduled for the day; instead EMERGENCY
BACKLOGS can be done.
5. Department Conferences should be prioritized over cases on Wednesdays.
As such, one elective procedure isscheduled to be done from 8:00 am to
12:00 nn.To give time for Residents to prepare and attend department
conferences.
6. Should there be No Elective cases scheduled on the Operating Room on a
particular day, Emergency cases can be done upon the discretion of the
respective departments (Surgery and OB-Gyne) concerned provided it is
within the time allotted for Elective Cases i.e. 8:00am is cutting time;
2:00pm is cut-off time.
7. Each department can do Emergency procedures in their respective ORs in
lieu of their Elective cases, however, OR time shall not be extended to let
them finish their bumped-off cases.
III.
POLICIES FOR EMERGENCY PROCEDURES

1. One (1) Operating Room shall be allotted for elective operations and one
(1) for Emergency operation.
2. Surgeons should notify the Operating Room nurse on duty of their
proposed procedures. The nurse on duty, on the other hand, shall inform
the Anesthesiology Resident on duty regarding the said procedure.
3. In cases of Disasters, rules of the Hospital on Disaster Preparedness
shall be followed.
30
4. Procedures previously scheduled as Elective cases cannot be done as

Emergency unless extremely warranted and with permission from their
respective Department Chairman and/or Training Officer.
IV.
POLICIES FOR POST-ANESTHESIA CARE UNIT (PACU)
The Post-Anesthesia Care Unit (PACU) is as important as any other unit of the
hospital (i.e. Intensive Care Unit, Emergency Room, and Operating Room). It is
where majority of post-anesthetic morbidities and mortalities happen. This is the
reason it is imperative that the PACU should have a 24/7 PACU Nursing Service.
1. Service Cases, Elective or Emergency, shall not be induced by the
Anesthesiology Resident unless there is at least one (1) nurse on duty
exclusively at the PACU.
2. All Post-operative patients (except those given only local anesthetics
without any form of sedation) are required to stay at the PACU for a
minimum of 2 hours for observation and monitoring.
3. Problems concerning patients admitted in the PACU should be referred to
the Attending Anesthesiologist and/or the Anesthesiology Resident on
duty.
4. Patients shall not be discharged from the PACU unless the patient is
properly assessed by the Attending Anesthesiologist &/or Anesthesiology
Resident on Duty and a written order for transfer to ward/room was given.
5. PACU Nurse shall prepare and forward Drug Utilization Form (DUF) to
the Pharmacy for replacement of the used drugs and medicines and
supplies.
V.
SANCTIONS
All personnel who continually disregard the approved policies shall be
reported to OR Supervisor for proper notation in the logbook. Their names shall
in turn be submitted to their respective Department Heads and the Chief of
Hospital for proper disciplinary actions.
VI. OPERATING ROOM PROCEDURES

1
Preparation for Operating Room
PROCEDURES
Disinfects OR before and after use
Nursing Attendant
Opens OR pack
Operating Room Nurse
Prepares set-up for the particular

31
operation;
Arranges pack on top of the instrument

table;
e
Opens additional packs needed for the

particular operation;
f. Continuous setting up as needed;

g. Prepares suturing set and sponges;
h. Counts and writes on the board the
number of sponges, instruments and
needles; and
i. Rechecks counting.
Patient Care in the Operating Room:
PROCEDURES
a. Receives patient and checks if all the
pre- operative requirements are
administered;
OR Nurse/Anesthesiologist
b. Checks patients operative site, sterilizes

the skin, and drapes the patient;
c. Places patient in the prescribed position
to protect nerves from undue pressure;
OR Nurse
d. Sets instruments and supplies according

to the specified order and the type of
operation to be performed.
OR Nurse
OR Nurse
e. Counts sponges and instruments and

dictates
to Circulating Nurse who
writes on the board the number of
sponges and instruments to be used;
f. Anticipates other needs;
OR Nurse
OR Nurse
g. Checks medicines needed for the
operation.
Anesthesiologist
h. Prescribes substitutes for medicines
which are not available;
Anesthesiologist
i. Inducts anesthesia;
Anesthesiologist
32
j. Anticipates the needs of the surgeon

during the operation.
OR Nurse
Before the surgeon closes the operation:
PROCEDURES
a. Checks all, tallies number of the
instruments and sponges used;
OR Nurse
b. Checks vital signs and logs them in the

anesthesia records;
Anesthesiologist
c.Record vital signs in the patients chart;

OR Nurse
3. Post-operative Procedures:
PROCEDURES
a. Removes all straps, cleans, and covers
the patient;
OR Nurse
b. Takes vital signs of the patient;

OR Nurse
c. Takes patient to the Recovery Room;
With Nursing Attendant
d. Disinfects Operating Room after use

Nursing Attendant
e. Specimen/tissues removed from patient
must be place in appropriate container
with proper labelling for histopath
examination.
Nursing Attendant
4. Recovery Room (RR)
PROCEDURES
a. Monitors patients condition and
records in the patients chart all
observations made;
RR Nurse
b. Refers to the physician on duty when

needed.
RR Nurse
c. When patient regains consciousness

informs Ward Nurse on the Patients
RR Nurse
33
transfer to the ward;

d. With the Nursing Attendant/Utility
Worker, endorses patient to the Ward
Nurse.
RR Nurse
VII. STANDARD OPERATINGPROCEDURES IN LABOR/DELIVERY

ROOM/NEONATAL INTENSIVE CARE UNIT
Preparation of the LR/DR:
34
PROCEDURES
a. Disinfects LR/DR before and after
use;
b. Open packs for DR use;
Nursing Attendant/Utility
DR Nurse/ Nursing Attendant
c. Prepares set-up for the particular

procedures;
DR Nurse
d. Opens and arranges additional packs

on top of the instrument table.
DR Nurse
e. Counts and writes the number of

sponges, instruments and needles;
DR Nurse
Admission of Patient to the Labor Room

PROCEDURES
a. Patient must be accompanied and
transported via wheelchair/stretcher to
the DR/LR by hospital personnel and
properly endorsed.
b. Interview patient and do initial
assessment. Check the chart for
completeness of data..
c. Check the following if already done in
the ward.
perineal shaving
nail polish removed
jewelries removed
dentures removed
Jewelries and dentures must be given to
relatives immediately.
d. Monitor and record data, vital signs,
and progress of labor.
Note FIID:
Frequency
Interval
Intensity
duration
e. Monitor and record fetal heart rateFHR.
f. Require patient to urinate to empty the
bladder. Distended bladder may impede
progress of labor.
g. Develop and display a helpful and
accommodating attitude and provide
emotional support all throughout the
patients stay in the unit. Do not leave
patients unattended.
h. Prepare sterile instruments needed for
35
D.R. Nurse
D.R. Nurse
D.R. Nurse
D.R. Nurse
D.R. Nurse
D.R. Nurse
D.R. Nurse
delivery including the diapers for the

baby and medicines needed during and
after delivery.
D.R. Nurse
Patient Care
PROCEDURES
a. Assess and records patients condition
including vital signs, POL and FHT.
b. When patient is ready for delivery, call
the Obstetrician
DR Nurse
DR Nurse
c. Records medical
intervention/management.
d. Carry out Doctors order.
Obstetrician
DR Nurse
Intrapartum
PROCEDURES
a. Transfer patient from L.R. to the DR. via
wheelchair/stretcher.
DR Nurse/Attendant
b. Place patient on a lithotomy position.

DR Nurse
c. Clean perineum and paint with antiseptic
solution, include vulva, upper inner thighs,
pubis and anus.
DR Nurse
d. Place St. Marys drapes.

DR Nurse
e. Assist during the process of delivery,
cutting of the cord and episiotomy if
applicable.
* Suction new born if needed.
* APGAR scoring
f. Routine Early care of Normal Newborn
Infants
Deliver on mothers abdomen
Dry thoroughly with dry warm

cloth then remove all wet linen
Place on uninterrupted skin to

36
DR Nurse
DR Nurse
skin contact in prone position
Sterile cord clamping once

pulsation stops
Encourage breastfeeding once

with feeding cues
After 60 mins of skin-to-skin

contact and adequate latching on:
DR Nurse
o Erythromycin ophthalmic
ointment OU
o Vit K 1mg IM (0.5mg for
preterms)
o Hepa B 0.5 ml IM
o Anthropometric
measurements and record
o Initial P.E. and Maturity
Scoring and record
Minimize handling of the

newborn unless necessary
Room in with mother
Keep with mother on skin to skin

contact and cover with warm dry
blanket & bonnet
Encourage direct breastfeeding

per demand
Keep normothermic at all times
Bathe only after the 6th hour of life
Watch out for difficulty of

breathing, early jaundice, feeding
difficulties
Refer accordingly
g. New born screening after 24 hours of life.
NICU Nurse
Episiotomy
PROCEDURES
37
a. Explain to patient what will be done

and what she can expect to feel.
DR Nurse
b. Prepare the instruments and

anesthetics.
c. Perineal flushing and cleaning with
antiseptics.
DR Nurse
DR Nurse
d. Place sterile drape.
DR Nurse
e. Assist obstetrician during the

procedure.
DR Nurse
Health Teachings
Encourage breast feeding

Personal hygiene
Diet
Proper care of the newborn to include: precautions regarding hypothermia,
aspiration precautions, feeding per demand and burping
OPD visits for check up
Immunization for baby
Family planning for mother
Medicines to be continued if available.
Umbilical Catheterization
a.
b.
c.
d.
e.
PROCEDURES
Secure consent of mother, explain
procedure.
Prepare umbilical catheterization set
Assist the Pediatrician during the
procedure.
Asses respiratory rate,
colortemperature and general
condition of the baby.
Evaluate effectiveness of procedure.
NICU Nurse
Gastric Lavage
PROCEDURES
a. Prepare feeding tube Fr. #8 for term
babies and Fr. #5 for pre-term babies;
sterile syringe. Normal Saline Solution
and sterile gloves
b. Insert feeding tube gently thru the nose
to the stomach.
c. Check if the tube is in the stomach by:
aspirating gastric content, using a
syringe
introducing 2-3 cc of air using a
syringe.
Auscultate
with
stethoscope and if there is a
38
NICU Nurse
gurgling sound the tube is in

stomach.
d. Introduce 2.5 cc Normal Saline Solution
then aspirate it. Repeat the procedure
until the return flow is clear.
Gastric Gavage
PROCEDURES
a. Wash hands aseptically
b. Have the things needed ready such as

gloves, syringe and milk and the feeding
tube (If not yet in place).
c. Insert the tube gently thru the nose to the
stomach.
d. Check if tube is in place by aspirating
gastric content or by use of the
stethoscope listen for the gurgling sound
after introducing 2-5 cc air thru
nasogastric tube.
NICU Nurse
Care of High Risk Neonate.

PROCEDURES
a. Maintain patent airway
b. Maintain body temperature to 36.5 to
37.2 degree centigrade
c. Monitor and record vital signs and
report to pediatrician for any
abnormalities
d. Suction secretions as necessary
e. Monitor HGT as per doctors order.
f. Regulate I.V. fluids as ordered.
g. Frequent hand washing by healthcare
worker.
h. Promote parent-child bonding by
allowing mother to visit/hold baby
encourage breast feeding.
39
NICU Nurse
POLICY ON ADMISSION OF NEWBORN AT THE NEONATAL INTENSIVE

CARE UNIT
1. Pediatric resident on duty will catch the baby whether a simple or complicated
case.
2. Pediatricians will be notified by the Nurse on duty.
3. Direct rooming-in policy of the Department of Health is implemented, for babies
delivered via Normal Spontaneous Delivery and 2 hours for those delivered by
Caesarean Section.
4. Pediatricians are advised to attend all deliveries especially the high risk ones.
40
VIII. CENTRAL SUPPLY ROOM PROCEDURES

Requisition of Supplies from Supply Office to Central Supply Room
PROCEDURES
a. Checks stock levels or supplies and
their availability;
a.1 For supplies below 50% stock level,
prepares a consumption report and
Requisition and Issue Voucher to be
submitted to the supply officer.
b. Prepares requisition and issue voucher
and forwards to Administrative Officer
or Chief of Hospital for approval.
c. Release the approved RIV
CSR Head
CSR Head
Supply Officer
Supply Officer
Requisition of Supplies from Central Supply Room to Different Wards
Policy
a. Issuances of supplies are strictly made between 7:00 AM to 9:30 A.M except
for emergency cases.
Issuances of requests to offices are strictly made on Tuesday.
Stock level of at least 30% must be maintained in the ward.
Instruments borrowed must be signed out by the person taking it and
signed in when returned.
All supplies transaction will be recorded on the requisition slip.
Items that are lost or stolen must have an incidental report for
replacement.
End user shall prepare daily consumption report.
Procedure
PROCEDURES
a. Receives supplies from Supply Officer
Nursing Attendant
(CSR Personnel)
Nursing Attendant
b. Fill up requisition slip for supplies

41
c. Issues items requested by the different

wards.
CSR Personnel
d. Encode items requested from the CSR.
CSR Clerk/ Encoder
Receiving and Sterilization of Used Articles

PROCEDURES
a. Brings used articles to the CSR from
different clinical areas;
b. Receives and checks used articles;
Nursing Attendant/Borrower
b.1Indicates missing items, if any in the

borrowers slip
b.2 Acknowledges missing items, if any;
b.3 Rewashes, dries and packs articles;
CSR Personnel
c. Labels packs indicating the contents and the

date of sterilization
CSR Personnel
d. Arrange articles inside the autoclave for

sterilization;
CSR Personnel
e. Sorts sterilized pack articles;
CSR Personnel
f. Informs units / end-users that sterilized

articles are ready for use.
CSR Personnel
g. Records returned and borrowed items for

documentation;
CSR Personnel
Issuance of Sterile Articles

PROCEDURES
a. Prepares articles and supplies listed in

the logbook;
CSR personnel
b. Issues articles to the Ward Nursing

Attendant/borrower;
c. Receives and checks sterilized items.
CSR personnel
Nursing Attendant
Ward Nursing
Attendant/Borrower
d. Sign returned/borrowed items in the

logbook.
Articles for Condemnation
42
PROCEDURES
a. Delivers items to be condemned to the
CSR with proper documentation;
b. Lists condemned articles and return to
the Supply Office with proper
documentation.
c Updates inventory logbook.
Ward Nursing Attendant/
Borrower
CSR Personnel
CSR Recorder / CSR Clerk
IX. REFERRAL PROCEDURES

Referral to Other Health Facilities
PROCEDURES
a.
Physician
Coordinates with referring institution
Prepares clinical abstract, accomplishes
referral form and gives it to the nurse.
Physician
If necessary arranges for ambulance

conduction of patient.
Nurse
Follow discharge procedures.
Nurse
To Other Departments within the Hospital
PROCEDURES
a. Accomplishes interdepartmental referral

form.
Physician
b. Forwards the referral form to concerned

department
Nurse
43
X. DISPOSITION OF PATIENT PROCEDURES

Discharge of Patient
PROCEDURES
a) Examines and evaluate patient;
Attending Physician
b) Indicates, in patients chart that he/she

may
go home;
c)
Prepares
discharge
plan
and
prescriptions needed for home treatment;
d) Completes final diagnosis including the
necessary documents needed for patients
discharge.
Attending Physician
Attending Physician
Attending Physician
e) Reviews chart for completeness;

f) Gives health education discharge
instructions to the patients/ relatives.
g) Presents duly accomplished clearance.
h) Sees to it that all equipment/items
previously
issued to the patient are returned;
Ward Nurse
Ward Nurse
Patient/Relative
Ward Nurse
i) Discharges patient, cancel name from the

ward directory and diet list;
Ward Nurse
j) Attaches Clearance Certificate to the

patients chart
Ward Nurse
Discharges of Patient against Medical Advice

PROCEDURES
a) Requests discharge against medical
advice
b) Refers request to attending physician;
c) Explain to patient/relative on the
implications and consequences of
discharge against medical advice
Patient/Relative
Ward Nurse
Attending Physician
44
d) Indicates HAMA on patients chart
Attending Physician
e) Fills up HAMA form and request

patient/ relative to sign;
Ward Nurse
f) Signs HAMA form.

g) Reviews chart for completeness;
h)Follow discharge procedures
Patient/relative
Ward Nurse
Ward Nurse
Discharge Procedures
PROCEDURES
a) Writes discharge orders and forwards to
the
Ward Nurse;
b) Checks patients record for discharge
instructions and physician signature;
c) Prepares Clearance;
Physician
Ward Nurse
Ward Nurse
d) Forward the clearance to the other units

concerned for signature to check patients
accountabilities
e) Forward clearance to the billing section.
f) Prepares, computes patients bill
g) Forwards to collecting clerk for
payment.
h) Receives payment and indicates OR
number
in the Clearance Certificate;
Nursing Attendant
Nursing Attendant
Billing Section
Billing Section
Collecting Clerk
i) Issues Official Receipt (original copy) to

the patient/relative and signs and issue
Clearance Certificate in quadruplicate;
Collecting Clerk
j) Instruct patient/relative to forward

Clearance Certificate to the Ward Nurse,
Ward, Central Post and Main door Guard ;
Collecting Clerk
45
XI. DISPOSITION OF CADAVER PROCEDURES

Preparation of the Cadaver in the Ward:
PROCEDURES
a. Removes everything attached to the
patient and endorses personal belongings to
the relative/ watchers;
b. If unidentified, deposits personal
belongings to the Cashier;
Nursing Attendant
Nursing Attendant
c. Provides post-mortem care;
Nursing Attendant
d. Sends cadaver to the morgue;

d.1 For abandoned cadaver coordinate
with the Medical Social Service for
appropriate action.
Nursing Attendant
Cadaver Disposal
PROCEDURES
a. Prepare the cadaver, perform post

mortem care. Attach name tag to the
body.
Nurse Attendant
b. Prepare and sign cadaver disposition

form. Handover the same to the nurse
attendant.
Nurse on Duty
c. Bring cadaver to the morgue//Cadaver

Holding Room.
d. Give the cadaver disposition form to the
central post guard on duty.
Nurse Attendant
46
Nurse Attendant
e. Verify the entries on the form with the

cadavers identity.
f. Attach signature to the form and forward
the same to the laboratory personnel on
duty.
g. Inform the relative to settle the account
and contact funeral service of choice.
*As extension of service, the Laboratory
personnel on duty may contact the
funeral service in behalf of the relative.
But it should be t he relative who will
negotiate with the funeral service.
h. Submit forms and clearance to the central
post guard on duty.
Central Post Guard on Duty

Laboratory Personnel
i. Settle the hospital bill. Secure clearance.

* Billing/Pharmacy/MSS/SHO
Patients Relative
j. Verify hospital bill clearance.

k. Verify and release the cadaver to the
nearest kin. Let the relative sign the form
and affix signature. Issue clearance form
duly signed by laboratory personnel and
relative. Retain duplicate copy of the
clearance form.
l. Inform admitting section.
m. Receives the cadaver. Give clearance

(hospital bill & clearance) to the guard.
Patients Relative
n. Receive clearances
o. Assist the relative in loading the cadaver
p. Check and retrieve the linen used.

Autopsy
PROCEDURES
a. Prepares and secures consent of the

patients Relative for post-mortem
examination;
Ward Nurse
b. Informs pathologist;
Ward Nurse
c. Takes cadaver to the Autopsy rooms;
Nursing Attendant
d. Performs autopsy on the cadaver;

prepares autopsy report and files it;
Pathologist
47
explains autopsy report to the family of the

deceased; and
e. Follow disposition of cadaver procedure.
Nursing Attendant
XII. LABORATORY CLINICAL LABORATORY
1.
MANAGEMENT OF PHYSICAL FACILITIES

The laboratory shall provide physical facilities with adequate space for the
services rendered and ensures the safety and security of the staff, patients and visitors.
2.
LABORATORY SPACE AND FACILITIES

The laboratory shall have adequate functional space commensurate its workload
and related activities. These are provided in a well outlined and structured architectural
design, scaled, labeled and identified.
3.
FACILITIES FOR PATIENT AND PERSONNEL

Areas in the laboratory shall be properly designated and identified for patients
comfort. The patients are not allowed to directly go inside the laboratory unless given
authority to get inside by the senior medical technologists for a specific purpose in the
laboratory. A pantry for personnel shall be allocated for their meals.
4.
FACILITIES FOR STORAGE

Facilities for storage space and conditions shall be provided for laboratory
specimens, documents, records, manuals, equipment, reagents, supplies, slides and
blocks. These are properly labeled and identified sections in the laboratory.
5.
WASTE MANAGEMENT ON HAZARDOUS MATERIAL

The laboratory shall follow standards and procedures set by the hospital for the
proper disposal of waste and hazardous / infectious substances.
The Laboratory maintains a monthly budget allocation on maintenance material
such as disinfectant spray / solutions, garbage plastic, etc. and ensures availability at all
times.
DISPOSAL OF BIOLOGICAL WASTE - All biological waste except urine
must be placed in appropriate containers labeled with Biohazard symbol.
This includes not only the specimen but also all the necessary materials
with which the specimens come in contact. The waste is then
48
decontaminated following institutional policy like incineration,

autoclaving or pick-up by a certified hazardous waste company.
SHARP HAZARDS - Sharp objects in the laboratory such as needles,
lancets, and broken glass wares must be disposed in a puncture-resistant
container that is conveniently located within the work area.
CHEMICAL HAZARDS - The same general rules shall apply for handling
bio-hazardous materials to chemically hazardous materials. Every
chemical in the work place should be presumed hazardous.
The laboratory ensures that the policy on waste segregation of wet, dry and
infectious material shall be done in accordance with the government laws and properly
informed the garbage collector at all times.
EQUIPMENT AND INSTRUMENTS
The laboratory shall have an adequate number of operational equipment and

instruments required for the provision of services.
There shall be a system of technical validation, procurement and acquisition of
equipment and instruments used in the laboratory. Technical validation shall be
accomplished by the provider in the presence of the end users who shall signify the
truthfulness of the technical validation of the machine. Procurement and acquisition of
the equipments and instruments used in the laboratory.
Shall be upon the recommendation of the Head of the Laboratory with proper
documentation of the endorsement stating herein the need, usefulness and accuracy of
performance of the equipment.
As entered into a contract with the suppliers, the preventive maintenance will be
scheduled or as the need arises. Upon installation, the equipment shall be checked,
calibrated and undergo performance validation before it shall be put into use. The
calibration schedule shall be documented on a logbook and or folder located in the
section where the machine is placed and the performance validation shall be certified by
the provider. Calibration of the equipments shall be done every six months or on a case
to case basis. Repair shall be maintained by the provider as scheduled in the stipulated
contract.
Only authorized and trained personnel shall operate all equipment and shall
calibrate and maintain them periodically and whenever indicated though sound
management requires multi- tasking, each section of the laboratory shall be headed by a
Medical Technologist who shall oversee the performance, calibration and quality control
of the equipments and reagents.
49
Up-to-date instructions on the operation and maintenance of the equipment

( including manufacturers manuals) shall be readily available for the use of by the
appropriate laboratory personnel. These are appropriately assigned in the section where
the machine is and periodic review of said manual shall be done.
There shall be written procedures for proper care, maintenance and cleaning of all
laboratory equipment performed by trained personnel. The cleaning and maintenance of
the laboratory and laboratory equipments shall be within the area of the responsibility of
the section head or his designate. For proper monitoring the following policies shall be
followed:
a. Adequate lightning of the laboratory and the sections must be
maintained
b. Floors should be cleaned daily with appropriate cleaning
agents. Walls are to be cleaned regularly.
c. Drains should be of an adequate size and provided with
adequate traps to prevent back sippage
d. All refrigerators and freezers should be defrosted and cleaned
thoroughly at least once a month or as necessary. Appropriate
temperature shall be maintained at 2-6 degrees. Food and other
drinks shall not be stored in refrigerators intended for reagents.
e. Electrical equipments necessitating grounding following

manufacturers instructions. All electrical plugs, outlets and
cords must be left in goodcondition. Frayed cord, exposed
wires and damaged outlets shall immediately be repaired.
f. Fire extinguishers shall be located in an accessible place.
g.
Fire exits should be clearly identified and an evacuation plan

should be in place.
Any equipment that is reported as defective and non-functional shall be taken out
of service and shall be clearly labeled as being out of service, until it has been repaired
and functional. It shall be the responsibility of the Department Head to turn in the
condemned equipment to the DISPOSAL COMMITTEE for proper disposition.
REFERRAL OF EXAMINATIONS OUTSIDE OF THE CLINICAL
LABORATORY. (OUTSOURCING)
To assure that laboratory tests requested by attending physicians are carried out
although the laboratory does not offer such assay, the medical technologists on duty shall
50
still draw blood sample to the patient, properly labeled the blood sample and give the
sample to the relatives of the patient. The attending physician may give suggestions
where the relatives of the patient could send their blood sample for the specified test that
is not available in the local laboratory.
SERVICE DELIVERY
CUSTOMER NEEDS AND REQUIREMENTS
Laboratory services shall select that will meet the needs and requirements of
patients, doctor and other users of service
The laboratory has a document that describes the following:
1) Range and scope of the services
2) STAT services available
3) Type of sample and amount needed for each type of test
4) Containers and preservative to be used for each test
5) Special preparation of patient, if any
6) Conditions of transport
The document is distributed to all users of the services, and available in hospital
nursing units, emergency room, and out-patient departments and physicians offices
This document is updated on a regular basis (at least once a year).
CONTRACT
Agreement with another clinical laboratory regarding provision of services shall
be documented in a contract (MOA).
If another licensed laboratory provides laboratory services to the clinical

laboratory, a procedure for the selection of and documenting contracts with a laboratory
is established. This procedure ensures that requirements, including methods to be used,
are adequately defined, documented and understood.
Policy
51
The head of the laboratory with the chief medical technologists shall review
annually all existing Memorandum of Agreement to make sure that both parties are
faithfully following the agreement.
If another hospital or laboratory refers lab examinations to the clinical laboratory,
a procedure to ensure the quality of laboratory services is followed.
In the instances where inter laboratory referrals are received the Laboratory
ensures that appropriate specimen sample identification and preparation is met before
acceptance of the sample. The receptionist shall be responsible for this and makes sure
that all pertinent data are herein provided in the request.
Receiving of Laboratory Request
The laboratory request shall contain all the information pertinent to the patient
and his laboratory needs. The receiving of laboratory requests assures that pre analytical
variables are intact meaning there is a one is to one correspondence with the patient
identification and the specimen received. Hence forth, proper reception must indicate the
following ;
a. Name, age and sex of the patient
b. Indicate OPD or In patient with the room number for in patient
indicated
c. Attending Physician
d. Date and time request was received
e. Date and time sample was collected
f. State whether the test is a routine, STAT, ASAP
g. Type of test procedure/s to be done
h. For fasting specimens, indicate the time of last meal
i. When appropriate current medications taken
Rejection Criteria
The sample collected should be sufficient to meet the amount of specimen
required for the test. The laboratory reserves the right to reject the following
The amount of the specimen should be proportional to the mount of anticoagulant
If the specimen does not conform to the quantity required by the test like 5-10 ml for
urine, pea sized for stool exam
If the collection receptacle is not appropriate like matchboxes or cotton diapers for stool,
contaminated urine sample
Hemolyzed, icteric, lipemic samples as the same will interfere with certain laboratory
determination
For histopathologic examinations, in appropriately fixed specimens or non formalinized
specimens
1 Improperly filled request
2 All grossly contaminated samples
In all of the above cases, the patient shall be informed immediately

concerning his sample and repeat collection shall be suggested If the patient
refuses to have the repeat collection all charges shall be reimbursed and
apology is in order
SAMPLE COLLECTION
52
Sampling plan (e.g. timing, frequency ) and procedure for sampling will be
developed and made available to laboratory staff and customer as can be reflected from
the standard operating procedures (SOP) per section.
The following standards shall be adapted for the purpose.
1
2
3
The phlebotomist shall introduce himself to the patient and state his
purpose.
The patients name should be asked directly to the patient, ask
assistance of a relative or refer to the name tag in cases where the
patient cannot verbalize.
The patient shall be asked if she has complied with the preparations
needed for the test.
SAMPLE COLLECTION PROPER

The following guidelines shall be followed
1 The phlebotomy technique will be performed after locating the site of
extraction
2 A 70 % Isopropyl alcohol will be applied at the site of puncture
3 A tourniquet will be applied on the forearm
4 Blood extraction proper will be done and the sample is placed on color
coded tubes for the intended test
5 Pressure on the venipuncture site shall be applied after extraction for ten
minutes
6 Samples should be labeled appropriately after extraction
7 Time of collection and the person who took the sample must be indicated
in the request
8 The sample is thus directed to the appropriate section where the test will
be performed
9 Details of the request shall be entered in the worksheet
10 After specimen processing preservation shall be done according to the
sample type and in accordance with SOP
It is imperative that the Chain of Custody shall be maintained
Sample Custodian
An authorized person(s) will be identified as the sample custodian. This person
will be responsible for sample
receipt and sample storage, and for assuring that
chain of custody requirements are met. Sample custodian includes the following;
Phlebotomist - a registered medical technologist who will perform blood
extraction of Out-Patients.
Warder a registered medical technologist who will perform blood
extraction of In-Patients.
MTOD a registered medical technologist on duty to a particular
section who will receive the laboratory request and specimen, and who
will also perform the requested laboratory test to a particular specimen.
53
Section Head a registered medical technologist who is responsible in

monitoring the implementation of standard protocol for specimen
handling to ensure specimen integrity.
LOGGING AND RELEASING OF LABORATORY RESULTS
1
Laboratory results should be logged on the corresponding record book

provided for each test. The complete details of the result should be indicated
including pertinent data concerning the patient.
After logging the result in a record book a result form shall be properly filled
up and signed by the medical technologists who performed the assay. Any
questionable laboratory result shall be referred to the chief medical
technologists or the head of the laboratory.
Panic values should be immediately verified and official results released to the
receptionist.
The patients should present their official receipt when claiming their result.
SECURITY AND CONFIDENTIALITY OF LABORATORY RESULTS

Security and confidentiality of laboratory results
1
Laboratory results are strictly confidential and only attending physician, nurses, floor
attendant and patients relatives are allowed to get the patients result.
Out-Patients should present their official receipt and ID in claiming their result. Letter of
authorization should be preferably given by the representative of the patient including the
official receipt and ID in case he is not available or is not ambulatory.
Laboratory results for In-Patients are logged-out and properly signed by floor nurse as
well as floor attendants on duty to make sure that the result is received and in good hands.
To preserve the integrity of laboratory results and ensure its confidentiality, unauthorized
person is strictly prohibited inside the laboratory. This can be read on the entrance door
of the laboratory.
Records of entry and exit of personnel/visitors and related data can be reflected on the
logbook and time card located on the side gate and front lobby.
The guards are
responsible in monitoring the personnel and visitors of the hospital.

6
Laboratory personnel are not authorized to release laboratory results on other purposes
without the permission of the patient and the Department Head. As the need arise, this
should be referred to the Department Head.
Only Medical Technologists and Consultants of the department are allowed to handle
laboratory procedures and records.
54
Laboratory result logbooks and worksheets shall not be borrowed by unauthorized

personnel and are not allowed to be brought outside the laboratory even by laboratory
personnel.
Documents needed to be prepared at the Tarlac Provincial Hospital, Department
of Pathology and Laboratory Medicine shall include quality control manual (QCM),
standard operating procedure (SOPs), worksheets, log books, equipment preventive
maintenance, calibration records and training records.
All documents relevant to the laboratory system shall be uniquely identified to include;
a Title of document
b date of issue;
c edition;
d the current revision date and/or revision number;
e number of pages and
f prepared by:
g reviewed by:
h approved by:
It is required that:
a. All documents issued to laboratory personnel as part of the quality system are
reviewed and approved by authorized personnel prior to issue;
b. A list or equivalent document control log that identifies the current valid revisions
and their distribution is maintained;
c. Only most recent versions of appropriate documents are available at locations
where operations needed for effective functioning of the laboratory are performed;
invalid or obsolete documents are promptly removed from all points of use, or
otherwise assured against unintended use; and
d. Documents are periodically reviewed, where necessary revised and approved by
authorized individual(s).
MONITORING PERFORMANCE
The laboratory shall have a system for collecting, recording and analyzing data to
monitor quality performance.
INTERNAL QUALITY CONTROL
55
The laboratory shall establish an internal quality control program to verify that,
for every batch of examinations, the intended quality of results is achieved.
Performance of Internal Quality Control

The laboratory runs appropriate control samples with every batch of
examinations, reviews the results and releases the results if the control samples are within
the control range.
Action when results of control samples are within control

When the results of the control samples are within control range, the results of the
batch are reported.
Action when the results of the control samples are out of control
When the results of the control samples are outside the control range, the results
of the batch of examinations are held and an investigation is done on the reagents,
technique, calibration, control, etc. to determine the cause(s) of out of control. A LeveyJennings or the Multiple Westgard Rules shall be consulted for sources of errors.
Elimination of cause(s) of out of control

When the cause(s) is (are) found, action is taken to eliminate the cause(s) and
examinations on the batch are repeated. When the results of the control samples of the
repeat examinations are within control range, the results of the batch are reported.
PERFORMANCE INDICATORS
There shall be regular monitoring of performance indicators such as turn-aroundtime.
Monitoring of turn-around-time of laboratory procedures
The turn-around-time of selected laboratory procedures are monitored.
Agreement of turn-around time with the users
56
The turnaround time set for each test group is acceptable to the Medical Staff and these is
conveyed to the users.
INTERNAL QUALITY AUDIT

There shall be a system for Internal Quality Audit (IQA)
Policies and procedures for Internal Quality Audit
To ensure accurate laboratory results Internal Quality Audit shall be performed regularly.
Designation of Internal Quality Audit personnel
The chief medical technologists shall randomly perform internal quality audit by
checking the logbook and randomly verifying results with elevated values.
Internal audit criteria, scope and method
As mentioned above the internal audit will deal mostly on elevated results for
such result may cause panic to the clinician as well to the patients. Such random review
of the logbooks of different sections shall be performed to assess the accurateness of the
results.
Internal Quality Audit Checklist

An Internal Quality Audit checklist shall be formulated and be used in the future.
Internal Quality Audit Plan and Schedule

The other units of the hospital may also perform internal quality audit to the
laboratory as the need arises. This is to remove the bias between auditors and the
department being audited.
Conduct of IQ Audits
The IQ Audits are conducted according to IQ Audit plan and schedule set by the
management. The management of the Department that has been audited ensures that
actions are taken without undue delay to eliminate detected nonconformities and their
causes.
57
Internal Quality Audit Reports

Reports on Internal Quality Audits conducted by other units shall be kept on file.
Summaries with recommendations are submitted to management for appropriate action.
EXTERNAL QUALITY ASSESSMENT SURVEYS

The laboratory shall participate in External Quality Assessment Surveys
Participation in External Quality Assessment Surveys
The laboratory applies and participates in the External Quality Assessment Surveys
(EQAS) conducted by the National Reference Laboratories (NRL) and the Philippine
Council for Quality Assurance in Clinical Laboratories(PCQACL)
There is a record of receipt of samples for EQAS from the NRL/PCQACL.
Performance of appropriate tests on EQAS samples
The laboratory performs appropriate examinations on the EQAS samples received
Submission of Results from EQAS samples
The laboratory submits the results from EQAS samples to the organization
running on the EQAS.
Action after receipt of analysis of laboratory performance in EQAS report

Upon receipt of the EQAS report, the evaluations of the performance of the
laboratory are reviewed and corrective actions are taken when needed.
QUALITY IMPROVEMENT ACTIVITIES
The laboratory shall develop and implement a system for quality assurance
through continuing quality improvement activities.
MANAGEMENT OF QUALITY IMROVEMENT ACTIVITIES
The clinical laboratory shall establish a system for Managing Quality
Improvement Activities.
Plan for Quality Improvement
58
The clinical laboratory documents its plan for quality improvement which
includes policies and procedures for identifying problems. Problem solving and primary
preventive measures are herein established.
Identification of problems or poor delivery of services
The clinical laboratory shall establish a system for identifying problems or poor
delivery of services.
Records of complaints and negative customer feedbacks
Records of negative customer feedbacks shall be kept and regularly reviewed.
Reports on Monitoring Laboratory performance
The clinical laboratory monitors indicators of laboratory performance
Continuous Quality Improvement (CQI) or problem solving
The clinical laboratory shall develop and implement a system for continuous
quality improvement
Structure for Quality Improvement
The clinical laboratory designates a Quality Improvement Committee to perform
QI studies
Training of staff in QI Methodology
The clinical laboratory sends designated staff for appropriate training in Quality
Improvement methodology.
The clinical laboratory shall participate in an EQAP administered by designated
NRL or in other local and international EQAP approved by the DOH. The following are
the designated NRL;
1. Research Institute for Tropical Medicine Infectious
2. East Avenue Medical Center- Drug Testing
3. Heart Center of the Philippines Cardiac
4. SACCL- HIV/AIDS
5. National Kidney Center Hematology
Performance of QI studies
The QI teams undertake QI studies to continually improve the quality of
laboratory. Under this the laboratory shall maintain Inspection tools/SOP manual, Quality
Control Reagents, Calibrated machines. Every activity shall be monitored and recorded in
appropriate log books.
Submission of Recommendation to the Management
The QI teams submits its recommendation for the improvement of services to
management.
Implementation, Monitoring and Institutionalization
59
The QI team shall implement the approved recommendations, monitor the

implementation and institutionalize of the successful recommendations
Implementation of approved recommendation
The QI team implements the approved recommendations for corrective measures
Monitoring of implementation of approved recommendations
The QI team monitors the implementation of the approved recommendations
through appropriate indicators
Analysis of monitoring data on indicators
The QI team records and analyzes the monitoring data on indicators and submits
recommendations on successful corrective measures
Action of management for institutionalization of successful corrective measures
The clinical laboratory management reviews and takes the necessary action for
the institutionalization of successful corrective measures
Primary Preventive Measures
The clinical laboratory shall establish a system for the development and
implementation of primary preventive measures
INFORMATION MANAGEMENT
CUSTOMER RELATIONS
The laboratory shall develop, establish and implement a system for ensuring
proper communications with customers
To achieve these there are memo/letter that communicate to the floors the
available tests done in Tarlac Provincial Center, Department of Pathology and Laboratory
Medicine.
60
There are policies and procedures that support the provision of services to
the physicians.
To communicate laboratory services to its Physician stakeholders, sample request
forms are provided in each clinic to assure and assist Physicians in their decision when
and what to use diagnostic modalities in the treatment of their patients. Such request shall
be duly accomplished and signed by the attending physician
There are policies and procedures that support the provision of services to
patients. Similar request forms are provided in the out- patient division of the
laboratory.
To communicate laboratory services to its Patients stakeholders, the same are
provided in a laboratory request on an out-patient basis and accompanied by appropriate
instruction for patient preparation based on the specific test. The same shall be processed
in the reception area and check for conformity with standard operational procedures.
There are policies and procedures for promoting customer satisfaction. The
laboratory provides for a customer satisfaction questionnaire form at its out-patient.
To assist the laboratory of its systems and processes, a patient and stakeholders
customer satisfaction form is provided by the hospital. The same are collected on a daily
basis, evaluated and assessed based on a point score. All aspects in the customer
satisfaction form that do not meet a satisfaction rating above 8 shall be subject to
Department review in a regular and or in a special meeting. The same shall be acted upon
with dispatch with a letter of apology and corrective measures done to the concerned
stakeholders.
There are policies and procedures for measuring and ensuring customer
satisfaction.
A feedback form may be asked at the hospital information area for assessment of
the different unit of the hospital. Such is important for the development and improvement
of services of the different unit of the institution.
COMMUNICATION
The laboratory shall establish, implement and monitor a system for ensuring
appropriate and effective External and Internal Communication
External Communication (Inter- department communication)
For the purpose of orderliness in Laboratory processes, it is a policy that all
official results are conveyed in a duly authenticated, verified, signed by the Medical
61
Technology staff and validated by the Chief Medical Technologist/ Senior Staff and or
Head Pathologist. This will ensure that post analytical processes have been completed
and certified to be correct. Any discrepancy in the original and final drafts of the report
shall be immediately corrected. Should a result has inadvertently reached the attending
physician, an immediate cell/ phone call be made before any untoward and inappropriate
management is rendered.
INTERNAL COMMUNICATIONS (intra- department communications)
The laboratory shall maintain a system of communication in a special log book
provided for in the form of an endorsement log book. All that transpired in the shift shall
be legibly written and if an endorsement needs emphasis an asterisk be appropriated
before the said concern. Such endorsement shall contain the following information
WHO is endorsing ex. Section Head of Clinical Microscopy
WHAT is being endorsed ex. repeat stool specimen collection
WHEN should the endorsed activity be accomplished ex. as soon as the specimen is
submitted
WHY is the endorsed activity not accomplished ex. previous specimen is insufficient
and or contaminated
HOW should the endorsed activity be completed- ex. notice to the floor nurse be
followed up
A monthly meeting shall be conducted by the Head of the Laboratory and the
minutes of the said meeting be transcribed for documentation and future reference. All
corrective measures for laboratory procedures and processes that do not conform to the
standards set by the Department shall be reviewed and acted upon. Any new laboratory
tests shall be assigned to a staff for presentation.
All immediate communications shall be documented by the Chief Medical
Technologist and the same be communicated to the Head for appropriate action.
62
DOCUMENT AND RECORD CONTROL

There shall be a system for the management and control of all policies,
procedures , laboratory forms and results
Material/Record
General Laboratory
Accession log
Maintenance/instrument maintenance records
Quality control records
Period of Retention
2 years
2 years
2 years
Surgical Pathology (including bone marrows)

Wet tissue
Paraffin blocks
Slides
Reports
2 weeks after final report

10 years
10 years
10 years
Cytology
Slides (negative-unsatisfactory)
Slides (suspicious-positive)
Fine needle aspiration slides
Reports
5 years
5 years
10 years
10 years
Non-Forensic Autopsy
Wet tissue
Paraffin blocks
Slides
Reports
3 months after final

10 years
10 years
10 years
Clinical Pathology Records

Patient test records
2 years
Serum/CSF/Body fluids (except urine)
48 hours
Urine
24 hours
Peripheral blood smears/body fluid smears
7 days
Permanently stained slides microbiology (gram, trichrome, 7 days
etc)
Cytogenetics Records
Permanently stained slides
Final reports
Diagnostic images (digitized, prints or negatives)
3 years
20 years
20 years
Blood Bank
Donor and recipient records
10 years
Patient records
10 years
Records of employee signatures, initials, and identification 10 years
63
codes
Quality control records
5 years
Records of indefinitely deferred donors, permanently deferred Indefinitely
donors, or donors placed under surveillance for the recipients
protection (e.g., those donors that are hepatitis B core positive
once, donors implicated in a hepatitis positive recipient)
Specimens
from
blood
donors
units 7 days post-transfusion
and recipients
XIII. RADIOLOGY DEPARTMENT

RADIATION SAFETY MANAGEMENT
Purpose:
To provide a safe and effective environment of care consistent with the hospitals
mission, services and with statutory legislations by managing the risks associated with
radiation.
To provide a framework for the conduct of assessment of radiation exposure.
To provide a mechanism for the education and training of hospital personnel on
radiation safety.
Policy:
1. Shall have a radiation safety officer responsible for the conduct of the radiation
safety program.
2. Shall have a radiation program, procedures to ensure the protection of patients,
personnel and the general public.
3. Shall provide for the training and education of its personnel in regards to radiation
safety.
4. Shall have and maintain adequate equipment and facilities to ensure the safety of
individuals.
5. Shall conduct periodic review and assessment of hospital facilities and equipment
adequacy as part of the overall plan on the hospital safety manual.
6. Shall put into place a system to document and record all radiation safety activities.
7. Shall have and maintain adequate communication and coordination systems with
local authorities in regards to radiation safety.
8. Radiation safety policy and plan shall remain consistent with and serve as a part
of the Hospital Safety Manual.
Procedures and Guidelines:
Preventive Maintenance Program
1. A monthly inventory and assessment of equipment shall be conducted by the
imaging head with the admin staff.
2. Problems noted such as malfunctioning shall be immediately reported and
requested for action.
3. Corrective measures are to be undertaken immediately and documented.
4. Complete documentations are to be submitted to the Supply Officer.
64
Hazard Surveillance and Risk Assessment

1. The Safety Committee together with the imaging Head and maintenance staff
shall conduct a semi-annual walk through of the facility and its surrounding
premises to determine hazards and identify risks associated with this.
2. A comprehensive report on the findings of the walk through shall be prepared by
the team with recommendations on the team.
3. If need be, professional consultation shall be made.
4. Corrective actions to reduce the risk shall be made.
5. A monthly inspection of the identified hazards shall be done in order to determine
risk level.
6. Documentation for all activities shall be done.
Personal Protective Equipment
1. Personal protective equipment shall always be used by radiology staff whenever
an exposure shall be made.
2. Patients must also be instructed to wear / use applicable personal protective
equipment.
Radiation Protection:
a) A RED warning light bulb that is automatically illuminated when x-ray
machine is switched on shall be installed outside the x-ray examination room
above the room door.
b) Door leading to the x-ray room shall be closed during examination.
c) The useful beam shall be collimated to the area of clinical interest.
d) In order to minimize the intensity of unintentional irradiation of the embryo or
fetus. This advisory notice should be posted IF IT IS POSSIBLE THAT YOU
MIGHT BE PREGNANT NOTIFY YOUR PHYSICIAN BEFORE YOUR XRAY EXAMINATION.
e) Radiography of areas remote from the fetus, such chest, skull or extremities,
can be done safely anytime during pregnancy. If the x-ray equipment is
properly shielded and if proper x-ray beam is used.
Sensitive body organs (LENS OF THE EYE, GONAD) shall be provided that
such shielding does not eliminate useful diagnostic information. When patient
must be held during examination, all efforts shall be undertaken to avoid
having assistance provided by the person who works with in the x-ray
department. No pregnant woman or person under the age of 18 years old shall
be permitted to hold the patients. Person holding the patient shall wear
protective aprons and gloves. Even in protective clothing is worn make sure as
far as practicable that no part of their body is in the path useful beam.
For The Protection of The Patient:
abcdefghi-
Proper choice of exposure factors.

Correct positioning of the patient.
Limiting the beam to the area of clinical interest.
Use of gonadal shielding.
Use of lead rubber apron.
Use of x-ray filters.
Use of intensifying screen.
Proper instruction to the patient.
Proper darkroom procedure.
65
The Protection of The Radiation Workers:

1)
2)
3)
4)
5)
Avoid repeat examination.

Proper collimation of the beam.
Use of protective barrier.
Use of lead rubber apron.
Never nor hold the patient during diagnostic examination unless in an
emergency.
For The Protection of The General Public:

A- Design of x-ray facility.
B- Location of x-ray room.
SAFETY POLICIES
1. Door leading to x-ray room should be always closed specially during
examination.
2. Useful beam shall be collimated to the area of interest.
3. Sensitive body organ shall be shielded whenever they are likely to be exposed
to the beam provided that shielding does not eliminate useful diagnostic
information.
4. Person holding the patient shall wear protective aprons and gloves.
5. When performing fluoroscopy procedures protective aprons shall be worn by
each person with in the exposure areas, except the patient.
6. No person below 18 years old or pregnant is allowed to hold patient.
7. When pregnant women are to undergo x-ray procedures the following are to
be noted:
a. X-ray examination in which the beam irradiates the fetus directly,
special care to be taken to ascertain that the examination is indeed
indicated at that time and that it should not be delayed until after
pregnancy. Greater than the usual care should be taken to minimize
that absorbed dose in the fetus for each irradiation. Alternations of
technique should not be reduced unduly the diagnostic value of x-ray
examination.
b. Radiography of areas remote from the fetus such chest, skull, or
extremities, can be done safely at anytime during pregnancy, as long as
the equipment is properly shielded and proper x-ray beam limitation is
used.
8. A Red warning light bulb is illuminated when the x-ray machine is switched
on and it also warns the people NOT TO ENTER WHEN THE RED LIGHT
IS ON.
66
XIV. DENTAL
DENTAL SERVICE POLICIES AND STANDARD PROCEDURE

Policies
1.
The affairs of the service shall be conducted in accordance with the established
administrative procedures of the hospital.
2.
Dental operative and surgical work shall be performed if it will aid the physical
and general conditions of the patient as determined by consultation with the
attending physician. Accurate and complete dental records shall be incorporated
in the history of the patient.
The attending dentist should know the medical condition of the patient and should
have a working knowledge of the drugs administered or previously taken by the
patient.
3.
Treatment of patients shall be on a first come, first serve basis except in cases
of emergency which should be treated in the order of priority or exigency.
4.
Shall be on call in cases of emergency.
5.
Reports and records, in addition to hospital records shall be kept.
6.
Shall not diagnose cause of death or sign the death certificate.
7.
Shall provide emergency treatment for traumatic injuries involving the jaw or the
temporary fixation of fractured facial bonesbefore transfer of patient to a more
specialized hospital.
TREATMENT OF PATIENTS
PROCEDURES
1. Present registry card.
Patient
2. Fill out Individual Dental Health Record

(IDHR)
3. Give Dental Health Record to Dentist
4. Examine patient and determine
treatment needed.
5. Accomplished IDHR indicating
treatment to be given and give to Dental
Aid.
6. Prepare Charge Slip and give the
original to patient.
Dental aid
67
7. Instruct patient to pay amount

corresponding to the treatment to be given
as indicated in the charge slip.
If patient cannot afford to pay, refer
him to Medical Social Worker.
Interview and classify patient
Medical Social Worker
Indicate in the charge Slip amount
patient agreed to pay.
If fully indigent, have the certificate of
indigency signed.
8. Pay required amount to the cashier.
Patient
9. Received payment and issue official

receipt
10. Indicate official receipt number and
amount on the charge slip.
Cashier
11. Present official receipt or certificate of

the indigency to the Dental Aid.
12. Refer patient to Dentist
Patient
Dental Aid
13. Treat or perform extraction as the case

may be.
14. Fill out the prescription for the
medicine and indicate on the individual
dental health record the dental treatment
done.
Dentist
15. Record in the logbook the service or

treatment rendered.
16. Give the official receipt to patient.
17. Leave chart and charge slip for file.
Dental Aide
Reporting Procedures
PROCEDURES
1.Consolidate daily record or treatment and
examination.
2. Submit reports to the Dental Head,
Dental Aide
3. Review and sign submitted report.

4. Give to dental Aide
Dental Head,
5. File documents for reference.
Dental Aide
68
XV. FINANCIAL MANAGEMENT SERVICES

FINANCIAL MANAGEMENT DIVISION
PURPOSE:
To manage the hospital financial activities and keep administration (provincial
health officer) informed of financial condition of institution for purpose of hospital
planning and control, and to admit patients to hospital in accordance with policies and
regulations established by local government unit and administration (provincial health
officer).
RESPONSIBILITIES:
Responsible for the financial activities of the hospital which encompass
receipts of revenues and expenses.
Responsible for the preparation of income and expense comparisons of gross
earnings and costs of revenues producing department and is also responsible
for preparation of reports to outside agencies (local government units).
Responsible for developing administrative systems and procedures; this can
include responsibility for determining a patients ability to pay, established
rates for services, and making necessary financial adjustments if patient cannot
meet his full obligation.
ROLE AND IMPORTANCE OF FINANCE DEPARTMENT
Ensure that there are adequate funds available to acquire the resources needed
to help the organization achieve its objectives.
Ensure costs are controlled, adequate cash flow; establish and control
profitability levels.
FUNCTION:
69
The financial management services ensures adequate and timely financial report
by providing services related to accounting, billing, budget, cashiering and health
maintenance.
GENERAL POLICIES:
Existing government budgeting, accounting and auditing rules and
regulations shall govern the financial transactions and operations of the
hospital.
Existing government directives on patients rights, benefits and privileges,
whenever applicable, shall be incorporated in the patients billing and claims.
Income shall be properly monitored.
For purposes of cost recovery, proper cost-finding and rate-setting of services
shall be done.
BUDGET
FUNCTION:
Directs and coordinates with the different departments concerned in the
consolidation and preparation of the budget proposal, work and financial / operational
plans including its implementation and monitoring.
POLICIES:
Expenditures of government funds shall be in accordance with the commission
on audit rules and regulations.
Availability of allotment shall be certified in accordance with the general
appropriations act.
All financial transactions shall be based on the work and financial plan with
duly supported documents.
RESPONSIBILITIES:
Prepares annual budget calendar by coordinating department schedules,
complying with laws requiring special notifications and time periods.
Recommends strategies and works with departments to develop schedule and
instruments to facilitate departmental budget preparation and serves as the
liaison with finance and other departments to implement budget objectives.
70
Monitor budget and financial reports and completes detail account analysis for
irregularities, account limits, to ensure fiscal goals set by management are
being met.
Designs, develops and implements system and procedures for projecting,

monitoring and analyzing budgetary expenditures.
Assists in projecting revenues for the budget, analyzes projections for
consistency, completeness and accuracy for each department.
Coordinates with departmental representative to review plans, determine
budgetary needs, gather information, monitor programs, and make
recommendations on budget preparation, presentation, implementation and
interpretation.
Prepares reports on departmental budget activities, and provides support in the
development of short and long term budget plans.
STANDARD OPERATING PROCEDURES

RECEIVES / RECORDING OF ALLOTMENT:
PROCEDURES
1. Receives / Records the approved budget.
Releasing Staff
2. Prepares / Posts the allotment in the

corresponding registries.
Budget Officer
REQUEST FOR FUNDING:
PROCEDURES
1. Receives / Records Purchase Requests,

Payroll and et al.
Budget Officer
2. Examines / Verifies completeness of

supporting documents.
Budget Officer
3. Determines / Verifies the availability of

funds.
Budget Officer
4. Assigns appropriate expense code.
Budget Officer
5. Forwards all documents

Administrative Officer for initial.
to
the
71
Budget Officer
6. Forwards to the Chief of Hospital for

signature.
Administrative Aide III
7. Forward to the Provincial Capitol for

processing and final approval.
Liaison Officer
BUDGET PREPARATION:
PROCEDURES
1.
Arranges
Budget
Meeting
with
Administrative Officer, Provincial Health
Officer, and Units/Section Heads.
Budget Officer
2. Give instructions on the details of the budget

call
Budget Officer
3. Request Unit/Section Heads to submit their

respective plans of operations to the Supply
Officer.
Budget Officer
4. Submits plans of operation based on specific

objectives including justification for proposals
to the Budget Officer.
Units/Section Heads
5. Discuss plans and proposals with the

respective Units/Section Heads to ensure
conformity with hospital objectives and
targets.
Budget Officer
6. Prepares and submit final plans and

proposals to the Budget Officer.
Units/Section heads
7. Reviews and consolidates plans and

proposals
and
accomplishes
Budget
Preparation Forms, then forwards such forms
to the Administrative Officer.
Budget Officer
8. Recommends approved and forwards to the

Provincial Health Officer for approval.
Administrative Officer
9. Signs Budget and returns to the Budget

Officer.
Chief of Hospital
10. Gets file copies and submit them to the

Provincial Budget Officer.
Budget Officer
PREPARATION OF THE WORK AND FINANCIAL PLAN
72
PROCEDURES
1. Prepares Work and Financial Plan for the

Hospital using appropriate forms, then forward
to the Administrative Office for review.
Budget Officer
2. Initials the Work and Financial Plan and

forwards to the Chief of Hospital.
3. Reviews and signs work and financial plan

and return it to the Budget Officer.
Chief of Hospital
4. Gets file copies and submits to proper

authorities, Provincial Budget Officer.
Budget Officer
PREPARATION OF COMMUNICATION / REQUESTS ON BUDGETARY

MATTERS:
PROCEDURES
1. Prepares draft of request for additional /
allotment / realignment of funds.
2. Forwards the draft to the Chief of Hospital
3. Receives / Records the correct draft.
Budget Officer
Budget Officer
Budget Officer
4. Finalize the request and forwards to the

Chief of Hospital for approval.
5. Forwards to the Provincial Capitol for final
approval.
Budget Officer
Budget Officer
ACCOUNTING
FUNCTION:
Directs and coordinates the systematic recording of all financial transactions,
preparations of financial statements and relevant reports.
POLICIES:
Shall be accountable in safeguarding government resources against loss or
shortage.
All financial transactions shall be supported with complete documents in
compliance with existing accounting and auditing rules and regulations.
Public accountability shall be strictly observed in the conduct of government
activities and operations.
73
RESPONSIBILITIES:
Implements the generally accepted accounting and auditing principles.
Implements and monitors a systematic recording of financial transactions.
Ensures that the implementation of accounting practices as to disbursements of
funds is in accordance with commission on audit rules and regulations.
Provides data to the budget section, the analyzed financial statement.
Provides financial information that would help in making decisions involving
the effective and efficient allocation and control of government resources.
Provides financial statements, income statements and cost reports to reflect
financial condition of hospital. Traces errors and records adjustments to correct
charges or credits posted to incorrect accounts.

Processing of purchase requests and order / market order and other supplies:
PROCEDURE
1.Receives / Records Purchase Requests

Order / Market Order and other supplies.
Supply Officer
2.Reviews completeness and appropriateness

of supporting documents.
3.Checks and verifies computations.
4.Forwards to the Administrative Officer for

initial.
5.Forwards to the Chief of Hospital for

signature.
6.Forwards to the Provincial Capitol for

approval.
Liaison Officer
PROCESSING PAYMENT / CLAIMS:

1. Processing of payroll, first salary and other personnel benefits.
PROCEDURE
1. Reviews appropriateness of supporting

74
documents as to computation and in

compliance with Commission on Audit rules
and regulations.
2. Reviews ALOBS and amount in the voucher

/ payroll.
3. Forwards the documents to the

Administrative Officer for initial.

signature.
5. Forwards to the Provincial Capitol for

processing.
Liaison Officer
b. Processing of Vouchers and Bills

1. Training and Travel Expense
PROCEDURE
1. Attachment of necessary documents from

different agencies regarding seminars,
conventions and meetings.
2. Approval of Travel Order
Governor
3. Submission of Official Receipts, Certificate

of Appearance/Attendance, Accomplishment
Report and approved Travel Order.
Different Department
4. Prepares Appendix A and B, Obligations

Request and Disbursement Vouchers and duly
signed by Chief of Hospital/Provincial Health
Officer.
Budget Officer

processing.
Liaison Officer.
2. Billing Statements/ Statements of Accounts

PROCEDURE
1. Receives Billing statement
75
2. Prepares Obligations Request and

Disbursement Vouchers and duly signed by
Chief of Hospital/Provincial Health Officer.
processing.
Liaison Officer.
BILLING AND CLAIMS
FUNCTION:
This section implements proper charging system, by recording all hospital
procedures, services, medical supplies, drugs and medicines including claims fees and
use of facilities incurred to patients regardless of patients classification.
POLICIES:
Proper billing of patients and hospital services shall be based on applicable
policies, rules and procedures.
a. TPH and PHO Personnel are directed to refrain from following up
of patients bill; personally accompanying patients / relatives to the
Medical Social Service and making unauthorized transactions with
hospital patients.
b. Discount for Pay Patients 5% to10% discretion of the Chief of
Hospital.
b.1. Pay ward except private room
b.2. House case (attending doctor is a resident or employed
consultant of the hospital).
b.3. Immediate members of the family i.e. children,
husband or wife if not covered by the PhilHealth
Insurance.
Basis Lack of Funds
Courtesy accommodation to Public Officials and
Members of the Media.
c. Senior Citizen Base on Senior Citizen Law.
Admitted Patient: Pay Patient 20% discount
Service Ward Full discount
Out Patient 20% discount
d. Cultural Minority and Malnourished patient full discount
e. PhilHealth PhilHealth requirements
e.1. Excess Bills
76
- no excess payment on PhilHealth Sponsored

Program (PhilHealth Sa Masa program)
- for TPH employees 20% discount.
For admitted patients all drugs, medicine and supplies shall be provided for the
1st 24 hours regardless of their classifications.
Philhealth patients/members should comply with the requirements within 24
hours, non compliance are obliged to pay for their daily bills.
Patient / client shall be assured of prompt access to billing information
(progress billing) for all services provided.
All hospital diagnostic and therapeutic procedures and other services rendered
including drugs, medicine and supplies issued to patients shall be properly
charged.
RESPONSIBILITIES:
Posts and records the actual bill rendered and actual amount paid in accordance
with their category classification level I, level II, service, pay, Philhealth,
veterans, cultural minority and senior citizens.
Prepares the monthly, quarterly, semi-annual and annual report.
Prepares the monthly census.
Monitors and evaluates the monthly consumption report of different
department.
Prepares periodic analysis of receivables versus collections.
Reviews and processes PHIC and other claims
Monitors account receivables and follow up outstanding and overdue accounts.

DISCHARGING OF PATIENT
PROCEDURES
1. Receives all clearance for discharged for the

day, duly signed by the Pharmacist, Laboratory
& X-Ray to make sure that all charges of the
patient are already forwarded to the Billing
Office.
Billing Clerk
2. Receives discharge notice of patients from

nurse station.
Billing Clerk
77
3. PhilHealth patients are required to submit all

necessary documents.
4. Computes the patients bill.
Admitting Clerk
Billing Clerk
5. Forwards the bill to the collector

5.1. Pay patients can settle their obligations
anytime during office hours.
5.2. Service patients in case the patient
cannot afford to pay their bills he/she is
advised to go to the Medical Social Worker for
evaluation.
6. Issues statement of accounts of the patient.
( as per request)
Billing Clerk
Billing Clerk
PREPARATION OF REPORT
PROCEDURES
1. Prepares monthly, quarterly, semi-annual

and annual reports
Designated Staff
2. Reviews / Certifies as to the correctness of

the report.

approval.
Designated Staff
PREPARATION OF PHIC CLAIMS
PROCEDURES
1. Submit PhilHealth
Form
and
other
Patients Relatives
2. Receives and checks forms and other

Reviewing Clerk
3. Computes the allowable PhilHealth benefits

of patients.
Billing Clerk
4. Fills up the required data in the PHIC form

as to the breakdown of drugs, medicine and
others.
PhilHealth Clerk
5. Received medical chart to be paired with the

PhilHealth claims for processing.
PhilHealth Clerk
6. Process PhilHealth Claims
PhilHealth Clerk
7. Forwards the PhilHealth Claims to the
PhilHealth Clerk
78
Administrative Officer for signature.

8. Transmit and submit the signed claims to the
PHIC.
Liaison Officer
COLLECTION AND DISBURSEMENT

FUNCTION:
This section directs controls and ensures the proper disbursement and collections
transaction of the hospital.
POLICIES:
All collecting / disbursing officers shall be properly bonded.
All collections shall be properly receipted, safe kept and deposited intact daily.
Records of all monetary transactions shall be properly maintained in the cash
book.
Preparation and submission of required reports shall be observed before dead
line.
Official receipts should be recorded in numerical sequence; cancelled official
receipts should be reflected.
Cash advance and its liquidation shall be in accordance with the commission
on audit rules and regulations.
No officer or employee shall be granted a cash advance unless he/she is
properly bonded.
RESPONSIBILITIES:
Implements the prescribed disbursement systems and procedures.

Monitors the receipts of collection and deposits
Pays other monetary benefits of hospital employees.
79
Maintains records of cash collections, deposits, disbursements and other related

transactions.
Verifies the accuracy of the cash collections.

RECEIPTS / REPORTS OF COLLECTION AND DEPOSITS
PROCEDURES
1. Issues Official Receipts to acknowledge

receive of cash / check.
Collecting Clerk
2. Indicates OR number in the Order of

Payment
Collecting Clerk
3. Prepares report of collection
Collecting Clerk
PAYMENTS OF CLAIMS
PROCEDURES
1. Receives payroll
Cashier
2. Verifies the completeness and correctness of

the signatories and source of funds.
Cashier
LIQUIDATION
PROCEDURES
1. Checks / Reviews completeness
correctness of documents
and
Cashier
2.
Checks the appropriate boxes for received

portion and signed.
Cashier
3.
Stamped PAID of disbursements.
Cashier
ADMITTING SECTION
FUNCTION:
Directs and controls the centralized registration and documentation of admission
and discharges of patients and ensures the confidentiality of documents.
80
POLICIES:
The hospital shall designate a room for patient registration to be known as
admitting section.
The admitting section shall be provided with adequate staff and facilities to
effectively perform the required functions.
The hospital shall implement a centralized documentation system of admission
and discharged patients.
All important documents shall kept in the admitting section pertinent to DOH
and PHIC requirements.
Patients rights shall be respected at all times.
RESPONSIBILITIES:
Encodes the personal data of admitted patient and assigns hospital I.D.
Number.
Coordinates with the ward nurses in updating the status of the patient and
monitors the vacant beds for immediate use/assignment to facilitate admission
of new patient.
Coordinates with the concerned department/sections, namely:
Medical Social Service classification and the capacity of the

patient/family to pay.
Medical Records statistics
Billing and Claims supporting documents of Phil Health and

Patients Bill.
Nursing Service Availability of beds and completion of important

documents/charts.
Provides relevant information to authorized persons.
STANDARD AND OPERATING PROCEDURES

ADMISSION OF PATIENT
PROCEDURES
81
1. Receives notice of Admission.
Admitting Staff
2. Verifies patients record:

If old, retrieves Patients Record to get
the Case # of previous confinement.
If new, assigns and/or issues patients
Hospital I.D. # and prepares patients
data.
Admitting Staff
3. Prepares patients data in 2 copies for

distribution to Medical Records and file copy.
Admitting Staff
4. Records the patients admission.
Admitting Staff
5. Collects and records patients admitting

diagnosis in the Clinical Cover Sheet.
Admitting Staff
6. Validates information and secures signature

of patient/informant in the Clinical Cover
Sheet.
Admitting Staff
7. Coordinates with the ward nurses for bed

assignment/patients admission.
Admitting Staff
8. Coordinates with the Medical Social Service

patient classification and the billing and Claims
for billing requirements.
Admitting Staff
RESERVATION
Policy:
Reservation can be done anytime. On a first come first serve basis.
Reserved room should be paid in advance and is non-refundable.
PROCEDURES
1. Informs the patient/relative
availability of rooms and room rates.
of
the
2. Advice the patient/relative to pay the

reservation fee at the billing section.
Admitting Staff
Admitting Staff
DISCHARGED OF PATIENT
PROCEDURES
1. Receives Discharged Clearance Slip from

the Billing Section.
Admitting Staff
82
2. Records patients discharged.
Admitting Staff
MEDICAL RECORDS SECTION

Function
Provides an organized system of measuring quality patient care and ensures that
sufficient data is written in sequence of events to justify the diagnosis, evaluates the
treatment and end results. This section is responsible for the processing and analyzing,
maintenance and safekeeping of all medical records created/maintained in the hospital in
the course of giving medical care to patients.
Policies
The Medical Records Section shall serve as an archive of all patients records in
accordance with the principles and practices of efficient and effective medical
records management.
It shall be maintained with complete statistical and clinical data of patient for
future references in accordance with legal, accrediting and regulatory
requirements.
The confidentiality of patients medical records shall be strictly observed.
Aging of medical records for appraisal and disposal shall be done in accordance
with approved Records Disposal Schedule.
Responsibilities
Prepares and implements a Comprehensive Medical Records Management Plan.

Maintains all patient records in accordance with the principles of an effective and
efficient medical record management and safeguards the confidentiality of the
medical records.
Reviews records for completeness and accuracy and ensures that all reports and
results are promptly and accurately filed in the corresponding patient record.
Provides records of patient data for use in approved research programs as an
educational tool in the training of and feedback to the staff,
Responds to subpoenas issued by regular court of law and other competent
authorities.
Standard Operating Procedures (based on DOH Manual)

A. An accurate record is maintained to facilitate optimal patient care and allow for
evaluation of the care provided.
The record is sufficiently detailed to enable:
83
The patient to receive continuing care

Effective communication within the health team
The Attending Physician to have available information required for
the consultation
Other medical practitioners and health personnel to assume the
patient care
Concurrent or retrospective evaluation of patient care
Entries into the records are made only by duly authorized persons of the
facility and are dated and signed, containing designation.
All entries, including alterations, must be eligible.
Only abbreviations and symbols approved by the Medical Record
Committee are tobe used.
If possible, original copies of all reports made by medical, nursing, and
allied healthprofessionals are filed in the record.
Each record should at least contain the following data:
A unique medical record number or reference

Patients full name
Address
Date of birth
Sex
F. Person to notify in case of an emergency
An ALERT notation, for the conditions such as allergic responses and

drugreactions, is prominently displayed on the face sheet of the record.
The record contains a written admission diagnosis by the medical
practitioner.
The record contains a patients history, pertinent to the condition being
treated, including relevant details of:
Present and past medical history

Family history
Social considerations
A sufficiently detailed report of a relevant physical examination (PE),

performed by a medical practitioner, should be included for the purpose of
admission.
Evidence that the patient has given informed consent is available.
Drug orders are written in the record by the medical staff.
Therapeutic orders and orders for special diagnostic test are noted in the
record.
There is evidence in the medical record that patient care plans were made.
84
Progress notes, observations, and consultation reports are written by

medical, nursing, and allied health staff to record all significant events
such as alterations in the patients condition and responses to treatment.
The front sheet is completed at the time of discharge or as soon as the
relevant information is available. It contains all relevant diagnoses and
procedures using the terminology of a current revision of the International
Classification of Diseases(ICD).
A discharge summary for each patient should be completed within 48
hours of patients discharge, with a copy remaining in the medical record.
The discharge summary should at least include the following:
Discharge diagnosis
Procedures performed
Follow-up arrangements
Therapeutic orders
Patient instructions (where necessary)When a patient is transferred
to another facility, a discharge summary should accompany
him/her.
When an autopsy is performed, a provisional diagnosis is noted in the

medical record within 72 hours and the medical record is completed
within 15 days following the death. A copy of the autopsy report is filed in
the medical record.
RECORD COMPLETION
The medical record should be completed within 48 hours after the
discharge of the patient.
Complete History and PE should be completed within 24 hours after
admission.
An incomplete chart, not completed within 15 days after patients
discharge, shall be considered a delinquent chart.
The attending physician has the final and major responsibility for
completeness and accuracy of the data entry in the record. He is also
encouraged to raise the level of quality of the individual health record and
sustain high level of recording.
Residents and interns may be delegated the duty of recording medical
information as history, PE, and discharge summaries. Their entries have to
be reviewed, corrected, and countersigned by the attending physician.
The Medical Record Officer assists the attending physician in reviewing
records for completeness by checking for omissions and discrepancies and
helps ensure that medical records comply with set policies and standards.
RELEASE OF INFORMATION
85
Release of health information is a very sensitive issue in several respects. The

confidentiality of the medical records should always be the concern of people involved in
the release of health information.
General Policies
The hospital shall safeguard all information contained in the health
record against loss, destruction, or unauthorized use.
All information in the health record shall be treated as confidential and
shall be disclosed only to authorized individuals.
It shall be the policy of all government hospitals not to use the medical
record in any way which will jeopardize the interest of the patient. But
the hospital may use the record to defend itself against any
accusations.
The release of information is delegated to the Medical Records Officer.
But in cases where the medical record officer encounters problems
regarding the release of information, the matter should be referred first
to Administrative officer (AO), or to the Chief of Hospital (COH) for
proper solution.
No release of information with clinical value shall be done without
written Consent from the patient himself.
The medical record is the physical property of the hospital. However,
since the information written on the record is the patients personal
history, he/she also has a right to the said record.
In cases where litigation is likely to happen and is intended against the
hospital or any other personnel or the health care facility, the COH
may refuse or deny access to the record even with the patients written
authorization, until the court declares otherwise.
Request for medical certificate or clinical information when the
patient is still confined shall be referred to the attending physician.
Should the AP decide to release the certificate while the patient is still confined, a
Certificate of Confinement shall be issued.
No Certificate of Confinement shall be issued where the patient concerned is
already discharged, instead, a medical certificate shall be issued.
No medical certificate shall be released without the signature of the attending
physicians and the hospital seal.
On the other hand, no medico-legal certificate shall be released without the
signature of the attending physicians and the hospital seal.
Information of no clinical value can be disclosed by the staff of the

healthcare facility. However, hospital policy should first be consulted and utmost care
taken into consideration before the release of non-clinical information includes the
following:
Name
Address
Attending Physician
86
Name of relative with patient during admission

Admission and Discharge dates
Where the patient is a minor, consent of either one of the parents or

the legal guardian shall be secured before any information of
clinical significance is released.
The record shall not be taken out of the hospital premises except
on court orders.
Those authorized to do research and studies shall use the records inside
the Medical Records Section.
Incomplete medical records shall be referred to the attending
physician before entertaining any request to access and review the
medical record.
In cases where the patient is in critical condition and does not have
someone with him/her to give consent, the medical record
officershall release information only after consultation with the
Chief of Hospital.
Verbal request for clinical information shall be discouraged in
favor of written requests.
The staff of the Medical Social Service (MSS) shall have access to
the medical records for purposes of establishing patient
classification. They may also reveal the social content of the record
to organize and reputablesocial agencies who have a legitimate
reason for inquiry.
Information may be released to other health care facilities, upon
writtenrequests, that the patient is now under care.
Hospital management may, at its discretion, permit the use of
medicalrecords for research and studies, only stressing that no
information whichwill directly identify the patient shall be
published.
POLICIES FOR DOCTORS RELEASE OF INFORMATION

Doctors and members of the allied health profession may review
records of patients presently under their care.
Doctors who are members of the medical staff but not members of
the team assigned to the patient shall be armed with a written
authorization signed by the patient before they are given access to
the record.
The privilege against disclosure belongs to the patient and not the
treating physician, therefore, the patient has the right to claim for it
or waive it. In which case, the approval is technically not
necessary. But it would be a good practice to notify the doctor
prior to release of any information, as a sign of courtesy.
The hospital management may permit use of the medical record for
research and studies, the medical record being the physical
property of the hospital. The hospital may also withhold access to
the medical record until a subpoena is issued.
Outside doctors intending to do some research/studies in a
particular hospital shall seek the written approval of the
management before they are given access to the medical record.
87
Insurance company doctors shall need proper written authorization

from the patient, a duly accomplished insurance waiver, before
they are given access to medical record.
Company physicians who are presently caring for a patient shall be
given medical information only upon presentation of a formal
request addressed to the Medical Records Section.
Consultants shall have access to records of patients referred to
them.
Resident doctors and the rest of the medical staff may request the
Medical Records Section for records needed for their research and
studies. But in cases where there is suspicion that their wish to
access will jeopardize the right of the patient, doctor, and the
institution, access shall be denied by the medical record staff.
It shall be the responsibility of the attending physician to inform
his patient about his medical condition.
POLICIES FOR NURSES ON RELEASE OF INFORMATION

Nurses may borrow/sign-out old records per doctors instruction for ward
use.
In the ward, student nurses shall have access to the records of patients
assigned to them.
Private Nurses shall only be allowed to review records of those patients
assigned to them.
All staff nurses may be given access to medical records not assigned to
them for purposes of conferences and case presentations. After the
conference, the record shall be returned to the Medical Records Section.
Ward nurses may review all records for purposes of compliance to
requirements before forwarding said records to the Medical Records
Section.
Ward nurses should always see to it that charts are in a secure place away
from the patients or patients relative.
OTHER PEOPLE CONCERNED
The lawyer representing a patient shall only be given access after
presenting a written authorization duly signed by the patient.
An insurance verifier shall be required a waiver before being given access
to the record/information about a patient. The original copy of the waiver
shall also be filed with the record.
Researchers from other medical institution could again access to medical
records only after complying with requirements set by the institution
concerned.
Patients relative making inquiries about their patient shall be referred to
the attending physician.
Law enforcement agents shall need a written request duly signed by the
Chief/Director of their respective agency before being given access to the
record. Should it be possible however, to get the written consent of the
patient and attending physicians.
88
Patients also have a right to their record. But to prevent misinterpretation

of medical information which may lead to litigation, patient may not be
allowed access to his own record. However, his physical and mental
condition shall be explained only by the attending physician.
The health care facility may, in some situation, release health information
even without the written authorization. Such situations are as follows:
Court Order
A hospital or other health care facility must release health information
in response to court orders.
Administrative Agency Order

A provider must release health information when there is an
adjudicative order from an administrative agency authorized by law.
Subpoena
In a court proceeding, a party or an administrative agency may issue a
subpoena, subpoena duces tecum, or notice to appear covering health
information held by a health provider. Where the subpoena is valid, the
hospital must disclose the health information.
Arbitration Order
Either an arbitrator or an arbitration panel may issue an order
authorizing the discovery of health information in an arbitration
proceeding.
Search Warrant
A government law enforcement agency which has been issued a search
warrant is entitled to receive any health information covered by the
warrant.
Medical Research
Health information may be disclosed to public agencies, clinical
investigators, health care research organizations or accredited education
or health care institutions for purposes of bonafide research. But before
the medical information is released, the medical record staff should take
reasonable steps to ensure that the research is legitimate, and proper
safeguards in the release of information are instituted.
Preparation of Hospital Census

PROCEDURES
a) Collates 24-hour census forwarded by
the Nursing Service;
b) Prepares census report (4 copies);
c) Reviews and signs census report;

d) Enters report in the worksheet for the
monthly report; and
Medical Records Officer
e) Files hospital census report.
Issuance of Medical and Medico-Legal Certification

PROCEDURES
PERSON RESPONSIBLE
89
a) Receives formal request for medico-legal

certification from authorized party or law
enforcement agents;
b) Retrieves medical records from file;
c) Seeks clearance from the attending physicians;
d) Instructs requesting party to pay fee to the
Cashier;
e)Types certification on the Medical Certification
Form in triplicate;
f) Forwards it to the attending physician and other
physicians concerned for review and signature;
g) Signs certification and returns to the Medical
Records Section;
h) Affixes seal of the hospital on the certification
and forwards it to the COH (only for Medico-legal
certification)
i) Attest and signs certificate and returns it to the
Medical Records Section:
j) Presents official receipts to the Medical Records
Section Clerk;
k) Indicate the official receipt number and releases
the certificate to the Authorized Party; and
l) Files copy on the patients chart.
Attending Physicians &Other

Physicians Concerned
Chief of Hospital
Requesting/ Authorized Party
Preparation of Birth Certificate

a) Fills up draft form;
b) Interviews parents and verifies data;
c) Signs blank official birth certificate form;
d) Types data into the official form and forwards to
the Ward Nurse;
e) Checks the official birth certificate form and
forwards to the attending physician;
f) Signs birth certificate and return to Ward Nurse
who in turn gives the BC back to the Medical
Records Section;
g) Prepares list of BC and transmittal letter to the
Local Civil Registrar duly signed by the Medical
Records Officer.
h) Forwards BC and transmittal to the Local Civil
Registrar; and
i) Upon receipt of the registered BC files the copy
in the patients medical record.
Ward Nurse
Attending Physician
Issuance of the Death Certificate

PROCEDURES
PERSON RESPONSIBLE
a) Prepares Death Certificate and forwards it to the

attending physician;
b) Completes and signs death certificate and
returns It to the nurse;
c) Checks accuracy and completeness of the data
and forwards it to the Releasing Medical Records
Clerk;
90
Nurse on Duty
Attending Physician
d) Records and released to the official logbook

e) Acknowledges acceptance of the Death
Certificate and signs in the logbook;
f) Advises patients relative to register the Death
Certificate to the Local Civil Registrar;
g) Files Death Certificate accordingly.
Patients Relative
Release of Information to Insurance Verifier

PROCEDURES
PERSON RESPONSIBLE
a) Receives written request (waiver) from the

authorized insurance verifier.
b) Retrieves patients chart from the permanent
files;
c) Authentic signature of the patient on the waiver
d) Informs the attending physician of the request;
e) Determines whether or not the information may
be released;
f) Authenticates photocopy, affixes hospitals seal;
g) Records and release photocopied information to
the insurance verifier in the official logbook;
h) Files waiver/request in the patients permanent
file after insurance verification acknowledges the
receipt of the information.
Retrieval of Patients Chart for Requesting Party/Authorized Borrower

PROCEDURES
PERSON RESPONSIBLE
a) Submits duly accomplished request to the

Medical Records Clerk;
b) Verifies patients number from their masters
index for patients;
c) Retrieves chart from files;
d) Records in the book/logbook, indicating the
name of the patient, the requesting
party/authorized borrower, the date when
borrowed, and the name of recipient of the
patients chart.
e) Signs logbook.
Requesting Party/Borrower
Authorized borrower
7. Processing of Medical Records Received for File

PROCEDURES
PERSON RESPONSIBLE
a) Checks all charts received against the list of

discharges reflected in the Daily Census Report;
b) Records all charts received;
c) Prepares the master patient index based on the
list of admission
d) Rearranges the record according to the standard
format
e) Analyses data on patients chart;
f) If data are incomplete, fills in the deficiency
91
slips, attaches it to the chart and returns it to the

Ward clinical concerned.
f.1 Upon receipt of incomplete chart and
deficiency slip (Medical) Ward Nurse fills in the
data required and returns to the Medical Records
Clerk,however, most of the time the Medical
Records Clerk does the procedure herself;
g) Completes the data and forwards completed
chart to the Coding and Indexing Clerk;
h)Codes and indexes diseases and operations as

per prescribed code tools;
i) Forwards coded chart to the Filing Clerk;
j) Sorts out coded chart according to the terminal

digit filing system and prepares folders; and
k) Files chart
NUTRITION AND DIETETICS SERVICE

FUNCTIONS
As a major aspect of total health care and as integral part of hospital organization,
the Nutrition and Dietetic Service is committed to perform Administrative, Clinical,
Education and Research functions.
Administrative functions are aimed at:
Establishment of policies and standards.

Implementation and procedures concerned with budget and financial control.
Developing and planning menu.
Purchasing, receiving and proper storage of food.
Production and provision of safe, sanitary, nutritious and palatable food.
Utilization of available man power and other resources.
Accuracy of update records and report.
Clinical functions are aimed at:

Provision and promotion of high quality nutritional care.
Nutrition screening and assessment.
Interpretation and implementation of diet prescription.
Provision of individual and group counseling to patients.
Monitoring the calorie and other nutrient intake of patients either orally, on tube
feeding or parenteral nutrition.
Documentation in the patients chart. Example: nutrition care, patients tolerance to
prescribe diet, nutritional status.
Education and research functions aimed at:

92
Nutrition education of the patients and hospital personnel.

Research and development in nutrition and dietetics.
Update on the knowledge and skills of personnel in the food service management
and nutrition and dietetics.
Training of student affiliate on nutrition and dietetics service.
STANDARDS
To achieve the vision and mission of the Nutrition and Dietetics Service standards
are established in order to serve as a guide or tool in the evaluation and monitoring of the
performance of the said service.
RECORDING AND DOCUMENTATION
All pertinent nutrition and dietetics information shall be recorded in the patients
chart (Nutrition Progress)
PROCEDURES
Confirmation of diet orders
PERSON RESPONSIBLE
Doctors
Dietary history/ nutrition assessment
Nutritionist Dietitian
Assessment of patient nutrient intake and

tolerance
Description of the diet instruction given to the
family.
MENU PLANNING:
Is the basic and essential activity in the ND Service. Important policies and
procedures as well as guidelines should carefully be considered.
POLICY:
All must be planned to ensure that patients receive nourishing meals that a variety
of food is provided and that efficient economic use is made of supplies, labor and
equipment.
The following tools are needed in menu planning:
As set standardized recipes arranged according to categories ( soups, entries,
vegetables, salads, and desert)
A copy of the Food Pyramid, RENI for different age groups.
Market quotation sheets showing current prices of food commodities available
in season.
MENU PLANNING PROCEDURES:
Take into account the time, day, weather and temperature
Consider food supplies available in the market.
Avoid repetitive menus.
93
Consider the appearance of food on the plate.

Utilized correct menu patterns.
Price menu items correctly.
Maintain proper balance between high and low cost items.
Consider the type and amount of labor for various menu items.
PURCHASING
Is an operational procedure through which food items and other goods
needed in the service are required.
POLICY:
All foodstuffs for use in the Dietary Service are requested at least 30 days
before the period covered. Quality is the first consideration. Foodstuffs
ordered should be according to specifications.
PURCHASING PROCEDURES:
Purchase sufficient supplies
List detailed set of specifications for quality
Maintain proper cost budgets for purchasing
Use fixed orders instead of flexible orders
RECEIVING
Is a management responsibility which involves making certain that items
ordered are satisfactorily received in terms of quantity and quality.
POLICY:
All food deliveries for inspection must be in at 8:00 in the morning every
Monday, Wednesday and Friday. The inspection team comprises of
Nutritionist-Dietitian on duty and Supply Officer.
RECEIVING PROCEDURES:
Install measures to prevent theft among receiving personnel
Have an updated record of price trends
Receive items according to set specifications
Observe proper receiving methods and procedures
Use adequate facilities and proper receiving equipments such as weighing
scales
94
Record and check goods received diligently

STORING:
The proper storage of food immediately after it has been received and checked is an
important factor in the prevention and control of loss or waste.
GUIDELINES:
Trained reliable ND Staff shall be in charge of the store room, under the
supervision of the ND.
Upon delivery, foodstuffs shall be properly labeled before storage. Perishable
items should be placed in the refrigerated storage and non-perishable items in
a dry storage.
All storage areas should be kept locked for adequate control against loss and
pilferage.
Dry storage areas should be cleaned and well-ventilated. Windows should be
screened, walls and floors should be rat proofed.
Overcrowding of foods stuffs should be avoided, to avoid circulation of cold
air.
The storeroom should be cleaned and sprayed regularly.
STORAGE FOR SPECIFIC FOODS
A. STAPLES AND CANNED GOODS
1. Groceries and canned goods should be stored in shelves and grouped.
First-in First-Out policy must be followed.
FOOD SERVICE
A. Meals are included in your room accommodation.
Meal Distribution
Tray collection
Breakfast: 6:30-7:30 am
8:00 am
Lunch: 11:30-12:00 pm
1:00 pm
Supper: 5:00-6:00 pm
6:00-6:30 pm
Consume your meals after delivery. If you prefer to take it later, you may have
it transferred to your personal china wares.
Return all dining wares and utensils after each meal these are being checked
for inventory purposes. Do not bring your tray outside your rooms, our food
service worker will pick it up after an hour.
Hot water is provided daily at the Dietary Service every 6:00-7:00 in the
morning.
ISSUING
Observe proper control in the recording foods issued from the storeroom
95
Identify proper authorities or persons responsible for requisition and issuances of

foods the storeroom
Ensure proper pricing of foodstuffs and supplies issued
Update record book
PREPARING
Provide adequate mechanical equipment, for deboning, slicing, cutting, curving,
trimming and peeling
Avoid excessive trimming of vegetables and meats
Check raw yields properly
Utilized leftover foodstuff properly
COOKING
Use standardized recipes to avoid over production
Use proper cooking equipment and utensils
Clean in small batches, if possible
Cook at proper temperature
Avoid long cooking time
SERVING
Use standard portion sizes
Use standard size utensils for serving
Consider leftovers for recycled menu
Record food served before it leaves the kitchen
Bring or serve food to consumers on time
Avoid spoilage, waste, etc.
Maintain desirable temperature of food before serving
MEAL SERVICE FOR PATIENTS
A. DIET LIST
Different diet list are printed out on the following schedules:
Breakfast 5:00 am
Lunch 10:00 am
Supper 3:00 pm
The diet list should be clear including the full name of patient, his diet, ward, bed
number and pertinent information.
96
The diet list and all subsequent changes are signed by the person who prepared it
and should always be countersigned by the nurse on duty.
A check by the ND should be made with the wards for erroneous and/incomplete
diet list.
B. ADMISSIONS, CHANGE OF DIET, DISCHARGES
The diet of new admissions, after the diet list has been printed out, takes effect
immediately upon receipt of notice.
The NDs should be notified by the nurse on duty of the discharge of the room
and bed of their patient before meal hours to facilitate effective food distribution.
Change of diet received between:
6:00 10:00 am will take effect on lunch
11:00 3:00 pm will take effect on supper
5:00 6:00 pm will take effect immediately if there is still
food available for specific order
C. PATIENT MEAL CENSUS AND NOURISHMENT
Patients diet follows the prescription of doctor. A diet as prescribed appears in
the diet list
No trays served to patients on NPO (nil per orem) and MF (milk formula)
Meal hours
o Breakfast: 6:30 7:30 am
o Lunch: 12:00 1:00 pm
o Supper: 5:00 6:00 pm
An allowance is given for each, after which all trays are collected and brought
back to the Nutrition and Dietetic Service.
All the personnel assigned in the tray line refrain from talking. They must be
wearing mask and plastic gloves. They must start only in the presence of ND
assigned to supervise that everything conforms to the QA policy.
D. DIET ORDER PRESCRIPTION
Diet orders requiring computation should be calculated by referring the chart and
interviewing patients. The computation is filed and copy should be accessible to
dishing area for reference.
All diet orders should be preferred to existing diet guide or NDAP diet guide.
Doubtful diet prescription should be clarified with the attending physician.
E.
DISHING OUT AND FOOD PREPARATION

97
Food should be tasted before dishing out particularly the therapeutic diet by the
ND on duty.
All diets should be dished out on individual trays/lunch box except those in
isolation and psychiatric room where we use disposable containers.
All trays/lunch boxes should be covered.
Patients name are called to receive their food trays.
F.
LUNCHBOX COLLECTION
All food trays should be collected after an hour.

Patient name shall be called to return their empty food tray.
Patients who prefer to eat late are requested to transfer their food to their own
personal container.
All food waste in the wards are collected and packed in green bag containers.
All trays collected should tally the number of trays distributed.
G.
DISHWASHING
All food particles should be removed from food containers.

Rinse the food containers with little water in a basin. Collect all fluids and throw
it back at the back of the compost pit.
Wash it with dish washing liquid with anti-bac and water.
Rinse twice with flowing water.
Rinse once with hot water.
Arrange and dry.
H.
RECORDING OF DAILY CENSUS
A daily census of full, soft, liquid and other therapeutic diets must be recorded in a
logbook. The census should be posted on the bulletin board every meal.
REQUEST FOR PURCHASE OF FOOD ITEMS/INGREDIENTS
OBJECTIVES:
SCOPE:
To ensure required ingredients and food stuff are promptly

requested to be purchased.
This procedure covers activities in requesting for ingredients and
food stuffs to be used in preparing daily menu for patients.
ACTIVITIES
PERSON RESPONSIBLE
a. Checking of Menu for the day
98
b. Checking of ingredients and foodstuffs
c. Prepare Market order and purchasing

request
d. Submit PR, ALOBS, SAI to Supply Office,
Budget, PHO II, Capitol
Nutritionist-Dietitian
NOTE:
Determine the requirements for various types of diets
Check any leftover cooked/uncooked foodstuffs
Check patients census
NOTE 2: Determine quality to be purchased based on the data gathered above
RECEIVING AND STORAGE OF PURCHASED FOOD ITEMS

Objectives:
Scope:
food items.
To ensure safety of food and ensure that food products or ingredients

passed the Inspection and is properly stored.
This procedure covers activities in receiving and storage of purchased
ACTIVITIES
PERSON RESPONSIBLE
Check items received
Assigned Nut-Dietitian
List all items on the Statement of Daily

Market Purchases
Assigned Nut-Dietitian
Inspect Items
Dietary Section Head
Record all purchased items and amount

incurred
Store food items in their proper places
Dietary Section Head
Assigned Dietary Staff
FOOD PREPARATION
Objectives:
Scope:
a
b
To ensure adequacy and appropriateness of food for the patients.

This procedure covers activities in preparation of food and post
preparation activities.
PROCEDURES
Determines number of persons and
types of diets to be served
Determines equivalent quantity of food
to be prepared or cooked
99
c
d
e
Requisition all items needed

cooking
Prepare and cook menu item
Clean the cooking area
for
Cook
Cook
Cook
NOTE 1:
Determine number of persons and types of diets to be served, based in daily meal
census.
NOTE 2:
Instruct Cook/Food Service Worker/Utility on the quantity of food and the menu
to be prepared.
SERVICE AND DISTRIBUTION
Objectives:
SCOPE:
To ensure that patients are served with food and that food is delivered to
the right person.
This procedure covers activities in the distribution of food during meal
time.
PROCEDURES
Check meal census
Prepare diet tags accordingly
Administrative Aide
Administrative Aide
Dish out and apportion cooked food on

the patients tray
Load, dish out trays to the respective
food conveyors
Distributes food to patients
Monitor Distribution
Administrative Aide
Administrative Aide
MEAL SERVICE FOR PATIENTS

PROCEDURES
a. Review approved meal census
b. Coordination
Nutritionist-Dietitian&
Project Coordinator
c. Posting/Scheduling of Special
d. Quantity food cookery
e. Meal Preparation
Nutritionist-Dietitian& cook
Administrative aide/cook
f. Meal Presentation and Service
Administrative aide &

MEAL SERVICE FOR GUEST

PROCEDURE
PROCESSING TIME
1. Review the approved meal 5 10 Minutes
request.
100
PERSON RESPONSIBLE
Nut. Dietitian
2. Coordinate with the assigned

coordinator for the:
- Date
- Venue
- No. of guest
1 Hour
- Food preferences
- Meal time
- Type of service (dine in or
take out)
3. Posting of special functions in
the bulletin board.
4. Quantity food cookery
5. Meal preparation
6. Meal presentation and service
Coordinator of said project
Nutritionist-Dietitian/Cook
Administrative Aide
Administrative Aide
INFECTION CONTROL / FOOD SAFETY

POLICY:
Safe and sanitary handling practices should be observed in entire food service
operation to prevent serving contaminated food.
STANDARD OPERATIONS THAT MUST BE OBSERVED IN DIFFERENT
AREAS
1. RECEIVING
*Food is inspected immediately upon receipt for spoilage or insect infestation
*Perishable food is immediately put inside refrigerator and freezer.
*Empty containers and packages are promptly discarded at disposal area.
*The receiving area is kept clean and free of food particles and debris.
2.
DRY AND COLD STORAGE AREA

*All food particularly rice should be stored at least six (6) inches off the floor.
*The floor must be clean and dry.
*Shelves are high enough off the floor away from the wall to permit cleaning and
ventilation.
*Food supplies are stored in a manner to insure first in first out rule and to
avoid overcrowding.
*Empty cartons and trash are removed regularly.
*There should be no evidence of insects or rodents.
*Refrigerator and freezer should be clean and free from objectionable odor.
PHARMACY PROCEDURE
PRODUCT RECALL
PROCEDURES
a. Once a notice of product recall has been
received, an immediate action should
be done.
101
Pharmacist
b. The product should be returned by

taking them out of the shelves and be
recorded for proper identification.
c. Shall be the one responsible for
reporting and demanding the reason for
the recall of the product from client to
supplier.
Pharmacist
Chief Pharmacist
PROCUREMENT OF STOCKS
PROCEDURES
a. Must provide a list of drugs and
medicines needed by their
department to the pharmacy
and must be based on the
Project
Procurement
Management Plan and on the
PNDF. Once a product is not
included in the PPMP, a
justification letter coming from
the department is required.
b. Consolidates
drugs
and
medicines by their generic
name
with
complete
specification and submits to the
supply officer.
Department Heads
Chief Pharmacist
c. Prepares the purchase request

and other documents and
forwards it to the pharmacist
for initial and then to the
Administrative Officer.
Supply Officer
d. Reviews
and
prepares
recommendation to the Chief of
Hospital.
e. Approves the request and

forwards it to the Supply
Officer.
Chief of Hospital
f. Forwards the approved request

to General Services Office for
procurement.
Supply Officer
REPORTING OF ADVERSE DRUG REACTION/ADVERSE DRUG EVENT
PROCEDURES
102
a. If in case an incidence of
ADR/ADE has occurred the first
thing to know is the cause of
the ADR/ADE.
b. The
product/s
should
be
identified properly and sample
of the same product should be
kept for further investigation.
Nurse
Pharmacist
c. An investigating team lead by

the Therapeutics Committee
shall conduct an investigation.
Therapeutics Committee
d. All possible finding should be

documented and filed.
e. Shall be responsible for the

report of ADR/ADE.
DAMAGED STOCK
a. Once a damaged stock has been
encountered, the pharmacist should track
down and record the incident and notify the
supplier.
Pharmacist
b. A replacement then of the stocks should be

made by the supplier.
c. If in case the damaged happened during
dispensing, then the pharmacist should take
the sole responsibility of replacing or
paying for the damaged medicine.
Pharmacist
RETURNED
PROCEDURES
a. Once an item is returned at the
pharmacy,
the
pharmacist
should first check properly the
item according to the batch
and lot number of the drug .its
label and how long it had been
dispensed from the pharmacy
together with the charge slip if
it was from a Philhealth patient
and receipt if it was been
bought.
b. If the item corresponds to its
proper identification and it was
103
Nurse/ Pharmacist
from philhealth patient, then it

would be deducted from their
account .If it was a cash
transaction, the receipt should
be surrendered together with
the returned item.
c. If it was bought on the same
date, the receipt will be
cancelled and corresponding
amount paid will be returned. If
a day after or more, then a stub
shall be issued on the returnee
containing the patient name,
cost of the medicine returned,
Official Receipt and charge slip
number to be deducted from
the hospital bill of the patient.
Pharmacist
Pharmacist/ Collecting Clerk
STACKING OF VACCINES AND BIOLOGICAL PRODUCTS
PROCEDURES
a. Should ensure that the biological or
pharmaceutical refrigerator thermostat
is maintaining the required temperature
for the proper storage of products.
Pharmacist
b. The different vaccines and biological

products should be properly stored
according to temperature requirement.
c. The vaccines and biological products
must be stacked in such a way that the
products with near expiration dates are
the first to be taken out.
Pharmacist
Pharmacist
d. Biological products and vaccines

should be properly and nearly arranged
in the shelves of the refrigerator.
Pharmacist
e. The shelves in the door of the

refrigerator should not be used
for stacking.
Pharmacist
f. Proper care of the vaccines and

biologicals should be done
during
defrosting
of
the
refrigerator.
Pharmacist /Utility Worker
PROPER DISPOSAL OF EMPTY USED VIALS
104
PROCEDURES
a. Responsible for properly collecting the
empty used vials on all wards every
other day and transports it directly to
the MRF for proper recording, crashing
is done every month and transported to
landfill.
b. Empty vials that are used as specimen
bottle for laboratory must be properly
recorded.
c. All inventories and disposal shall be

done under the supervision of the Chief
Pharmacist and duly authorized
representative
of
the
waste
management committee.
Utility Worker / Chief Pharmacist/

Representative Health Care Management
Committee
Utility Worker
Utility Worker
MAINTENANCE AND CARE OF THE BIOLOGICAL OR PHARMACEUTICAL

REFRIGERATOR
PROCEDURES
a. Should ensure that the bio refrigerator
is intended only for such biological or
pharmaceutical products, thus food and
beverages should be strictly prohibited
for storage.
Pharmacist
b. A representative from the supplier

should check the condition of the bio
refrigerator quarterly or as necessary.
Maintenance Staff
c. There should be a yearly calibration

done with corresponding certificate of
calibration.
d. Proper cleaning of the refrigerator
should be done by the utility worker as
needed.
e. Proper temperature monitoring should
be recorded twice a day and that should
only range from 2 degrees to 8 degrees
Fahrenheit.
Supplier
Utility Worker
Utility Worker / Pharmacist
COLD CHAIN PROCEDURE EMPLOYED IN DISPENSING

PROCEDURES
a. Must ensure that the vaccines and
biological products are place in a
plastic bag with ice pack before giving
to the Medication Nurse.
105
Pharmacist
b. Responsible for receiving

and
transferring the vaccines and biological
products for proper storage.
Nurse
MONITORING AND ADJUSTING OF TEMPERATURE OF THE BIOLOGICAL

OR PHARMACEUTICAL REFRIGERATOR
PROCEDURES
a. The vaccines and biological products
should be stored in accordance with the
temperature requirement.
b. The temperature of the bio refrigerator
sets between 2 degrees to 8 degrees
Fahrenheit.
Pharmacist
Pharmacist
EMERGENCY AND SAFETY MEASURE IN CASE OF BREAKAGE OR OTHER

INCIDENT THAT MAY ARISE DURING HANDLING AND STORAGE
PROCEDURES
a. In case the pharmacist, nurse and
patient accidentally break an ampoule
or vial, he / she should inform the
utility worker to clean the mess to
prevent improper handling and
disposal.
b. If the breakage happens during
delivery, the pharmacist should record
and inform the supplier immediately
for the replacement.
c. Proper handling and disposal of the
breakage.
Pharmacist
Pharmacist/Supplier
Pharmacist / Utility Worker
DISTRIBUTION OF STOCKS TO DIFFERENT DEPARTMENT

DONATED PRODUCTS
PROCEDURES
a. Issue
medicines
that
are
considered emergency on each
ward.
b. Receive the medicine with a
copy of the listing and shall
affix his/ her signature in the
list of medicines issued to
them.
c. Every 15th and end of the
month a designated pharmacist
106
Pharmacist
Nurse Supervisor
will make an inventory on the

medicine stocked in their
emergency
kit
for
proper
accountability.
d. If there are lost items in the
emergency kit, the pharmacist
will charge the lost items
among the nurse supervisor of
the section.
e. Must
provide
a
regular
utilization
report
to
the
pharmacy to ensure availability
of supply at all times.
Pharmacist
Nurse Supervisor
Nurse Supervisor
DONATED PRODUCTS
PROCEDURES
a. Record and file the Requisition and
Issue Voucher of all donated medicines
and its corresponding donors.
b. Shall file and record all prescriptions of
donated
products
for
proper
accountability purposes.
c. Must make sure that it is registered
with the FDA.
Pharmacist
Pharmacy Clerk
Pharmacist
CONTIGENCY PLAN IN CASE OF COLD CHAIN EMERGENCY

PROCEDURES
a. Once a mechanical or power failure
occurs, the pharmacist on duty should
automatically transfer the vaccines at
the biological / pharmaceutical
refrigerator stored at the supply room
for proper storage.
b. Small quantities of each product should
be stacked at a properly temperature
monitored cold carrier with ice pack for
dispensing and be refilled by the
pharmacist on duty.
c. Strict temperature monitoring of the
cold carrier with ice packs should be
done on a regular basis.
d. A staff from the supply office and from
maintenance department should be
available all the time for emergency
107
Pharmacist
Pharmacist
Pharmacist
Supply Office Staff
situation.
GOOD STORAGE PRACTICE
PROCEDURES
a. The storage area of the pharmacy and
the main pharmacy provided with an air
condition unit with digital thermometer
monitored and recorded twice a day.
b. Biological products and vaccines are
stored in the Bio refrigerator with
calibration certificate done quarterly,
monitored and recorded twice a day.
c. Pharmaceutical products are stored in a
condition which assures that the quality
is maintained. We strictly follow the
FEFO principle. First to Expire First
Out.
d. Pharmaceutical products are stored off
the floor with pallets, provided with
wall shelves.
Pharmacist
Pharmacist
Pharmacist
Pharmacist / Utility Worker
e. Narcotic drugs are stored in a double

locked cabinet.
Pharmacist
f. Main pharmacy, (2) stock rooms

provided with adequate lighting.
Pharmacy Personnel
g. Clean, dry and free from vermin.
Utility Worker
GOOD DISPENSING PRACTICE

PROCEDURES
a. Orders drugs based from the CPG and
PNDF only. Only in extreme
circumstances, a non-CPG non-PNDF
drug may be used. A written consent from
the Chairman/ Training officer allowing
Residents the use of such drug.
PERSON RESPONSIBLE
Physician
b. Orders drug for the patient on a daily

basis. Note: Orders such as Same IVF,
For 1 week, Continue Meds are not
acceptable.
Physician
c. Accomplishes the Drug Utilization Form

(DUF) based on the Doctors order in the
chart.
d.Directly forwards the DUF to the
108
Ward Nurse
Pharmacy.Trainees are not allowed to bring

DUF to the Pharmacy. No Drug Utilization
Form (DUF) must be given directly to the
patient/watcher. The number of DUF is per
doctors order.
e.Informs the Medication Nurse of the
changes in the patients medication such as
Shifted to/ D/C / Defer.
f.Oral medications are given for the first 24
hours, cases of NSD. Wherein cases of
Caesarean Section, oral medications are
given for the first 48 hours
g. NICU patients needing more than 1 dose
of Prophylactic Antibiotic must be
admitted.
h. All drugs to be administered to the
patient must come from the hospital
Pharmacy. checks the DUF with the name
of the patient, ward, classification, dose,
dosage form, frequency must be properly
checked, otherwise DUF will not be
dispensed.
i.Issues all the drugs needed by the patient
within 24 hours upon admission. If the
patient did not comply with the Philhealth
requirements within 24 hours, the
Pharmacy would then refer to the Medical
Social Worker/ Medical Director, and
beyond office hours, Saturday, Sunday &
Holidays to the Senior House Officer if the
Pharmacy can still issue medicines for the
patient.
j. A 24-hour supply of drugs, except IV
fluids, IV sets & Emergency medicines are
prepared for each patient based on
individual drug profile. They can be
replaced every shift or as needed. Nurses
should use their emergency medicines
including IV fluids at the ward and shall be
replaced every shift or as needed.
k. Medicines are delivered in the
medication room counter checked with the
use of charge slip and DUF.
l. In case of unavailability of the medicine
in the hospital Pharmacy and inform the
Doctor who ordered the drug.
m. Makes the necessary prescription of the
109
Ward Nurse / Nursing Attendant
Ward Nurse
Medication Nurse
Medication Nurse
Pharmacist
Pharmacist
Pharmacist
Pharmacist/Medication Nurse
Pharmacist
unavailable drug that will be purchased

outside of the Pharmacy.
n. Instructs the patients watcher to buy
outside, return it back to the pharmacy for
checking & recording and forwards it to the
medication room.
o. In Emergency cases, will be the one to
procure the drug for the patient.
p. Returns the unused drugs to the
Pharmacy
for
proper
accounting.
Discontinued and unused medicines are
returned to the pharmacy and deducted in
the patients account. A log book for
returned medicines properly signed are
required when patients are for discharged.
If the medicine was bought in cash in TPH
Pharmacy, they must present the official
receipt and deducted to their hospital bill.
q. Narcotics are excluded in the daily
distribution of medicines. It can be
obtained from the pharmacy with
Requisition
for
Dangerous
Drug
Preparation form together with the empty
used ampules, vials and S2 license of the
physician.
Medication Team Doctor
Pharmacist
Pharmacy Personnel/Encoder
Medication Nurse
Nurse/Nursing Attendant
GOOD HOUSEKEEPING
PROCEDURES
a. Cleaning must be done daily.
Utility Worker
b. Proper segregation and disposal of

waste, including vials, ampoules, and
needles strictly followed.
Utility Worker
c. For Pest management, this treatment is

done by spraying insecticide as needed.
Utility Worker
EXPIRED STOCK
PROCEDURES
a. Once an expired drug has been
encountered, the pharmacist should
track down and record all expired
drugs.
b. Inform the supplier about the incident
and proper disposal should be made.
Pharmacist
Pharmacist / Supplier
PRODUCT COMPLAINT
110
a.
PROCEDURES
Should know the reason of the complaint.
Pharmacist
b.
Should take appropriate action.
c.
If the situation is regarding defective

products, it should be replaced
immediately returning back the defective
product for proper reporting to the supplier.
d.
An incident report should be submitted to

the Chief of Hospital thru the Pharmacist
on duty for proper action.
Pharmacist
Supplier
Physician/ Pharmacist/ Chief of Hospital
MEDICAL SOCIAL SERVICE

FUNCTIONS
Is primarily concerned with helping patient and their families affecting illness and
which interferes in obtaining maximum benefits from medical care.
Does casework to patient referred with social, emotional and environmental

problems through interview with patients and members of the families.
Consultation with other discipline in the setting concern with patients problems.
Skilful use of community resources to meet the medical needs of patients and
their families which is not available in the hospital.
Classify patients according to their ability to pay.

PURPOSE OF THE SERVICE
To help the patient in adjusting himself to the hospital situation as to it scope of
services limitations, policies, rules and regulations.
To help the patients solve his/her problem that directly or indirectly affects their
medical condition while in the hospital.
To promote continuity of family relationship to present family maladjustment

during and after illness.
To assist the physician and other members of hospital staff on further

understanding of patients social, emotional, environmental and financial
condition for earlier diagnosis and suitable medical management.
111
PROCEDURE FOR OUT-PATIENT

PROCEDURE
a. Seeks assistance
Patient / Relative
b.
Orient patients / relative about the purpose

of the classification system.
c. Evaluates and classifies the patient using the
hospital approved protocol
d. Informs patients and/ or relative of the
approved action
e. Stamps charge slip with classification and
indicates discount.
f.
Receives charge slip and collects payment if

there is any and issues an official receipt to
the patient and/ or relative.
Billing / Cashier
EMERGENCY ROOM PATIENT

PROCEDURES
a.
Seeks assistance
Patient / Relative
b. Receives referral, provides crisis

intervention, and if necessary performs
advocacy role for the patient.
c. Orients patient/relative about the purpose of
the classification system.
d. Classifies patient based on hospital approved
protocol or other issuance.
e. Informs the patient/family and ER Staff of
the approved action.
f. Makes proper endorsement to the different
services/units concerned using the
Assessment and Referral.
g. Taps resources for other needs of the patient.
h. Documents all activities and files them
accordingly.
IN-PATIENT PROCEDURE
112
PROCEDURES
a.
b.
PERSON/SRESPONSIBLE
Conduct ward rounds.

Determine if the patient is new or old
if new conducts intake interview
if old update the record
c. Classifies the patient according to their economic

status
d.
Interviews, classifies patients and registers in the

logbook
e.
Informs / orient the patient/ relative about their bill

and the coverage of MSWD assistance.
f. Family counselling to relatives / patient.

g. Evaluates and approves patients hospital bill.
h. Records evaluation of patients for documentation.
SUPPLY AND PROPERTY
FUNCTION
Procurement, storage, inventory, distribution and disposition of hospital supplies,
materials and equipment.
Accounts for all hospital properties, supplies and equipments.
Directs and coordinates the conduct of regular physical inventories of supplies
materials and equipment.
Directs and coordinates the maintenance and updating of all records of hospital
properties, vehicles, equipment, facilities and other related items.
Directs and coordinates the registration and/or insurance of hospital vehicles,
equipment and other properties.
Recommends and coordinates the disposal of unserviceable properties and waste
materials.
POLICY
Accountable Officer should be properly bonded
All procurement shall be based on the approved Annual Procurement Program.
Items not included in the APP maybe amended as the need arises, subject to
approval.
RIVs shall be numbered so that all requisition are accounted for. It shall be
posted on the stock cards on the day the items were issued.
First-in first-out method of costing and issuances shall be adopted.
Monthly supplies adjustment report shall be prepared to summarized actual
consumption of supplies.
Physical inventories of equipment, supplies and materials, drugs and medicines
shall be done monthly, quarterly, semi-annually and annually.
Preparation of Annual Procurement Program:
113
a)
b)
c)
d)
e)
f)
PROCEDURE
Require different departments to submit
their annual needs.
Reviews and evaluates the submitted
request based on their annual
consumption.
Prepares a draft and coordinates with
units on the final annual procurement
program.
Makes the final copy of the annual
procurement program on the appropriate
LGU form.
Reviews and signs the program, together
with all the unit/section heads
concerned.
Submit to the Administrative Officer IV.
g) Reviews and recommends the approval

of the program by affixing his/her
initials and forwards to the Chief of
Hospital.
h) Signs the program.
Administrative Officer III
Administrative Officer V
Chief of Hospital
Purchase Request Procedures

PROCEDURE
a. Prepares the quarterly Purchase

Request based on the Annual
Procurement Plan with duly supported
Obligation Request.
b. Forwards the Purchase Request and the
Obligation
Request
to
the
Administrative Officer IV for funding.
c. Forwards the documents to the
Administrative Officer V for review
and initial.
d. Forwards to the Chief of Hospital for
approval.
e. Forwards to the General Services
Office for processing.
Receipt/Acceptance Procedures
PROCEDURE
a. Properties are delivered to the supply

warehouse with the attached transferred
document of supplies, materials and
equipment
114
General Services Office
b. Checks inspects, accepts, signs the

transfer document.
c. Returns transfer documents.
d. Records the accepted items and pertinent
information and endorses the delivered
item to the Hospital Storekeeper if for
Hospital consumption and to the Public
Health Storekeeper if for Field Health
consumption.
e. Identifies if the delivered items are
equipment or semi-expandable and
endorses to the Property Clerk.
f. Arranges them properly in the warehouse
cabinets and posts the delivered items to
their individual supplies ledger cards.
Storekeeper/Administrative Aide III
Issuances/Distribution
PROCEDURE
a. Submit list of items to be requested

with attached consumption report
b. Evaluates consumption report and
prepares RIV
Different Departments
c. Approves Requisition and Vouchers
Chief of Hospital
d. Issues items base on approved RIV
e. Files and posts in their individual

supply ledger card
Storekeeper/Administrative Aide III
PROCEDURES ON DISPOSAL OF UNSERVICEABLE PROPERTY

Notifies the Maintenance personnel to check the status of the defective hospital,
medical and office equipment.
Checks and recommends on the status of the equipment.
Considers property as condemned if found beyond economical repair.
Return the defective equipment to the Supply Office.
115
POLICY ON DISPOSAL OF SUPPLIES OR PROPERTY

The Accountable Officer is responsible for the return of the Unserviceable
Properties to the Supply Officer for the cancelation of Memorandum Receipt.
The Supply Officer shall be responsible for the inventory of all condemned
properties to be approved by the Chief of Hospital.
The Supply Officer shall be responsible for the return of the Inventory and
Inspection report of Unserviceable Properties to the General Services Office.
XVI. ADMINISTRATIVE SERVICES

PERSONNEL UNIT
FUNCTION:
To develop and administer comprehensive Human Resource Management Plan
which includes recruitment, selection, promotion, separation, welfare and benefits,
training and other personnel actions and transactions.
POLICIES:
Recruitment and Selection Plan shall be consistent with the standard and
guidelines set up by the Civil Service Law and Rules and shall provide equal
opportunity to all qualified applicants;
Permanent and casual employees shall be rated on their performances semiannually while Job Order employees shall be rated quarterly each year.
Records of attendance should be maintained in accordance with Civil Service
Rules and Regulations;
Applications for vacation/sick/maternity and other leaves shall be recommended
by the immediate supervisor. Absences should be covered by application for
leaves. The Accounting must be notified immediately for salary deduction due to
exhausted leave credits;
Any notice to the cashier to withhold the incentives of an employee shall be made
in writing by the Chief of Hospital; and
116
Complaints and grievances of employees shall be acted upon in accordance with

the grievances procedures.
This section shall maintain the safety, security and confidentiality including
updating of personnel records.
OTHER RELATED POLICIES
Signature on all hospital documents should always be affixed over printed names
of the original copies of the documents. A rubber stamped facsimile of the
signature of the official should only be used on duplicate copies.
All personnel on off-duty days are prohibited from roaming around hospital
premises unless for justifiable reasons.
Observance of house rules in the various designated official quarters of the Tarlac
Provincial Hospital such as the following to wit:
Prospective occupants must first seek the permission of the Chief of

Hospital.
All new occupants of the various designated official quarters of the

Hospital are required to register to the Hospital Dormitory Manager;
Cooking, gambling and smoking are prohibited;
Only hospital personnel are allowed to occupy the designated official

quarters.
Installation of unnecessary appliances are prohibited; and
Vendors are not allowed to enter these designated official quarters.
RESPONSIBILITIES
Prepares comprehensive manpower development program which includes
appointments, promotions, transfer, detail, welfare and benefits, and training of
personnel.
Maintains and ensures confidentiality of personnel records.
Acts on personnel actions and transactions in accordance with Civil Service Law
and Rules.
Coordinates training and research needs with the other services.
Provides counseling and/or gives advice on referred cases.
Reviews and submits required reports.
Acts as Liaison Officer to the Provincial Human Resource Management Office.
117

PREPARATION OF APPOINTMENTS
Upon receipt of the approved request for renewal of appointments or upon
instruction to prepare appointment papers from the Provincial Human Resource Office:
PROCEDURES
a. Requires prospective appointee to properly
and completely accomplish the following:
- Personal Data Sheet (PDS),
- Statement of Assets, Liabilities and
Network,
- Transcript of Records,
- Diploma,
- Board Rating,
- PRC or certification of appropriate
eligibility,
- NBI Clearance,
- Medical Certificate.
Administrative Aide IV
b. Submits all of the above documents.

c. Prepares the following:
- -Appointment paper,
- -Position Description Form (PDF),
- -Oath of Office,
- -Certificate of Assumption to Duty;
d. Have the prospective employee sign the
Appointment Papers and Position Description
Form;
Prospective Employee
e. Forwards the same to the Department or

Service Head.
f. Signs Position Description Form
Department
and returns
Head / Service Head
to Administrative Aide IV
g. Forwards all documents to the
h. Reviews all papers and other related
documents for their completeness and set
initials
i. Forwards the Position Description Form and
Assumption to Duty to the Chief of Hospital
for signature
j. Signs Position Description Form, Assumption
Chief of Hospital
to Duty and certifies photocopies of all
documents
k. Hands document to Secretary for release to
the Liaison Officer.
l.Releases documents to Liaison Officer.
m. Records in logbook and forwards to the
118
Secretary
Provincial Human Resource Management

Liaison Officer
Office for processing
PROMOTIONS
PROCEDURES
a. Writes a letter of recommendation to the

Chief of Hospital for possible promotion of
staff
Head of Service
b. Makes final decision and sends approved

papers to the Administrative Aide III for the
preparation of indorsement.
Chief of Hospital
c. Prepares indorsement and attaches

supporting documents and forwards to the
d. Reviews all papers and other related

documents for their completeness and set
initials and forwards to the Chief of Hospital
e. Signs indorsement.
Chief of Hospital
f. Releases to the Liaison Officer for

submission to the Office of the Governor thru
the Provincial Human Resource Office
g. Forwards documents to the Office of the
Governor thru Provincial Human Resource
Office properly receipted on the file copy.
Secretary
Liaison Officer
KEEPING ATTENDANCE AND TIME RECORD

POLICIES ON TIMEKEEPING AND ATTENDANCE USING THE BIOMETRIC
DEVICE
For all TPH employees compliance the following policies concerning timekeeping and
work arrangements in using the Biometrics device will hereafter be adopted:
1. Service/Sections are required to record their attendance every working day as follows.
119
2. Request for exchange of duties for personnel under various shifts should be submitted
three (3) days before the exchange of duty supported by a request letter approved by the
immediate supervisor. Non compliance shall not be approved.
3. Offsetting of absences for J.Os may be considered on a case to case basis depending
on the Call of Duty prior approved of the immediate supervisor.
4. J.Os can render service on Holidays provided they will not exceed the 22 working
days.
5. Personnel on seminar, convention or field work shall present an approved Travel
Order, Certificate of Appearance or Exemption Form on the said date as supporting
document.
120
6. Previous flexible working hours (flexi-time) prior to the issuance of this Memorandum
are considered null and void.
7. Application for vacation/forced leave for permanent and casual employees shall adhere
to the CSC policy that it should be filed five (5) days before the said date. Noncompliance shall not be approved.
8. Sick Leave should be applied immediately upon reporting back to duty. A Medical
Certificate is required for five (5) days absences and above. Failure to submit appropriate
documents, the said leave shall be considered unauthorized.
9. Time in and out policy should be strictly followed. Incomplete Time in and out is
considered Half Day.
10. Monthly schedule of the Department or Section shall be submitted to the
Administrative Office at least five (5) days in advance.
11. In case of system failure, the employee shall Log in or out in their respective logbook.
12. Employees rendering overtime work shall also use the biometrics device to record
their attendance.
13. Employees who do not go on rotation/shifting, the schedule shall be from 8:00 AM to
5:00 PM with lunch break from 12:00 PM to 1:00 PM.
14. Some employees by nature of their function, that is, On-Call, are exempted. To wit;
- Provincial Health Officer II
- Provincial Health Officer I
- OIC Chief of Hospital Operations
- Chief of Clinics
- Administrative Officer V
- Chief Nurse
- Contractual and Part-Time Consultants
- Resident Doctors*** Subject to re-evaluation
TIMEKEEPING PROCEDURE
PROCEDURES
a. Registers time of arrival and departure
following the policy on Biometrics Device
b. Prints out bioscript at the end of the month
for Permanent employees and on the 16th
and 1st of the month for Casuals and JOs
c. Sorts bioscript as to Service and compares
from filed leave of all personnel
d. Prepares monthly report on the absences of
all employees.
e. Attaches bioscript on payrolls as supporting
document.
f. Submits a copy of the bioscripts to the
Provincial Human Resource Office and files
another copy as reference.
121
Employee
PAYROLL PREPARATION
PROCEDURES
a. Coordinates with the PHRMO regarding

adjustment in payroll.
b. Double checks adjustments in payroll,
encodes and prints draft payroll,
c. Hands draft to the Liaison Officer for
submission to the Provincial Human Resource
Office
d. Prepares final payroll and remittances
e. Releases final payroll and remittances to the
Liaison Officer
f. Receives, reviews, arranges and initials the
final payroll and remittances
g. Prepares Obligation Request
h. Forwards to the Administrative Officer IV
for funding and recording
i. Funds and records Obligation Request and
set initials
j. Forwards documents to the Chief of Hospital
for signature
k. Signs final payrolls and remittances.
Administrative Aide VI
Human Resource Personnel

Administrative Aide VI/IV
Administrative Officer IV
Chief of Hospital
l. Releases documents to Administrative Aide

IV.
m. Receives duly signed payrolls and
remittances
n. Releases to Liaison Officer
o. Forwards to Provincial Human Resource
Office for processing
Liaison Officer
Secretary
LEAVE APPLICATION
PROCEDURES
a. Gets internal use leave form and Civil

Service Commission official leave form
Employee
b. Properly fills up and signs both forms

c. Forwards to immediate supervisor for
approval recommendation
d. Signs Recommending Approval Caption and
forwards to the Head of Service
e. Signs Approval Recommendation Caption
and forwards to the Leave Clerk
(Administrative Aide VI)
122
Immediate Supervisor
Head of Service
f. Hands to Leave Clerk for recording and

typing activities
g. Types CSC Leave Form and records in
employees Leave Cards and forwards to
Admin Officer V
Leave Clerk/Administrative Aide VI
h. Reviews, initials and forwards to the Chief

of Hospital
Admin Officer V
i. Signs CSC Leave Form and returns to

Secretary
Chief of Hospital
j. Records and releases to Liaison Officer
Secretary
k. Submits to PHRMO and requests recipient

to sign on the Log Book
Liaison Officer
ISSUANCE OF EMPLOYMENT AND RESIDENCY INTERNSHIP TRAINING

CERTIFICATES
PROCEDURES
a. Fill up the request form and submit it at the
Personnel Unit
Requesting Employee
b. Reviews completeness of information

written in the request form. If in doubt, asks
the requesting employee about lacking data.
c. Instructs requesting party when to come
back to get the document. Allots time for
verification of the validity of data given and
for the signatories to review and sign
certification.
d. Verifies validity of information given by
comparing with existing file
e. Prints the certificate and mark it with a
control number and logs on record book
f. Forwards to the Administrative Officer for
review and initial
g. Reviews and set initials
h. Forwards to the Head of Office and the
Chief of Hospital for signature
i. Signs certificate
j. Attaches dry seal on certificate when
necessary
k. Releases the certificate to the requesting
employee by signing on the record book to
avoid duplication of certificate issuance.
Administrative Aide IV/III
Head of Office/Chief of Hospital
Administrative Aide IV/III
PREPARATION OF SERVICE RECORD

123
PROCEDURES
a. Request for an updated service record
Employee
b. Prepares a updated service record and

forwards to the Administrative Aide VI
c. Reviews and set initials and forwards to the

Chief of Hospital
d. Signs and forwards to secretary
Administrative Aide VI
Chief of Hospital
e. Releases to Administrative Aide III
Secretary
f. Records and releases to employee
124
ASSISTANCE TO PERSONS COMING TO THEOFFICE OF THE CHIEF OF

HOSPITAL
PROCEDURE
a. Upon presentation of complaint,

problem or query, records in the Log
Book and refers to Chief of Hospital
b. Studies matters and refers to
Administrative Officer using the
Referral Slip
c. Studies further and refers to the Head
Unit concerned for appropriate action
d. Studies the matter thoroughly and gives
recommendation to Administrative
Officer
e. Prepares communication needed after
consultation with the Unit Head
f. Sends communication to Chief of
Hospital
g. Reviews and signs communication and
hands to Secretary
h. Records in the logbook, gets file copy
and indicates therein the date of release
i. If hand-carried, asks recipient to sign
on file copy, if mailed, indicates date of
release on file copy
Secretary
Chief of Hospital
Unit Head Concerned
Chief of Hospital
Secretary
ASSISTANCE TO HOSPITAL PERSONNEL WITH PROBLEM

PROCEDURE
a. Presents his problem and seeks advice

and assistance from immediate
supervisor or from section head
b. Listens to the problem which may be
either personal or official
c. Finds solution to the problem within
reasonable time
d. If the employee is not satisfied with the
solution, accompany him/her to the
Administrative Officer, especially if the
problem is official
e. Confers and reaches a solution of
theproblem
f. If the problem cannot be resolved,
consult the Chief of Hospital
g. Threshes out difficulties and institutes
remedial measures
h. If the problem cannot yet be resolved
because employee is not satisfied,
endorse to the higher authority
125
Employee
Supervisor
Administrative Officer,
Employee and Supervisor
Chief of Hospital
APPLICATION, RECRUITMENT AND SELECTION

PROCEDURE
a. Submits application letter addressed to

Chief of Hospital, attaches pertinent
credentials needed
Applicant
b. Interviews applicant
c. Refers to personnel unit through
Secretary
d. Records in the logbook, the name of the
applicant, date of receipt and referral
and the position applied for
e. Takes application to personnel unit
f. Receives application, together with
Chief of Hospital instructions
g. Prepares and initials endorsement letter
to the Office of the Governor
h. Forwards to Chief of Hospital for
signature
i. Signs endorsement and forwards to the
Provincial Human Resource Office.
Chief of Hospital
Secretary
Personnel Unit
Chief of Hospital
COMMUNICATION PROCEDURES
PROCEDURE
a. Upon receipt of correspondence from

various sources either through mails,
couriers, hand carried etc. and
addressed to the office, records open
correspondence in the logbook
indicating therein the date of receipt,
origin, subject matter and date of
correspondence, verifying if stated
enclosures are attached and if not put a
notation on the face sheet.
b. If communications are addressed to
employees, hands the same directly to
the concerned employee.
c. If communications are closed, hands
the same to Chief of Hospital just like
the open communication.
d. Reads communications and returns the
same to the secretary with instruction to
hand the same to the concerned
officials or the Administrative Officer
after recording.
e. Sends communications to the
concerned Official
f. Studies and analyzes the contents,
126
Secretary of the Chief of Hospital
Chief of Hospital
Secretary
prepares response/endorsement, initials

it and sends to the Chief of Hospital
through the Secretary.
g. Receives response to incoming
communications and hands to the Chief
of Hospital
h. Reviews and signs communication
Chief and
of Hospital
gives to the Secretary
i. Records action taken and sends toSecretary
the
Concerned Official
j. Receives outgoing communications,
Concerned
if Official
to be sent by mail, retains a file copy, if
for personal delivery, hands to Liaison
Officer
k. Delivers communication to theLiaison Officer
concerned office, asking recipient to
sign the file copy returning the same to
the Concerned Official
l. Files communication
Concerned Official
127
Concerned Official
Secretary
HOSPITAL INFORMATION MANAGEMENT SYSTEM

The IT Department is a significant part of the Hospital when it comes to
document retrieval since its operation involves acquisition, management and timely
retrieval of large volumes of information since it manages the Hospital Information
Management System. This system automates all hospital tasks and transactions.
Moreover, it is the Departments duty to direct the operations of computer and
related equipment like data networks. It is also involves in the development,
maintenance, and use of computer systems, software, and networks for the processing
and distribution of Tarlac Provincial Hospitals data and services. The divisions mandate
is to ensure that Technology and Information management is in alignment with the plans
and strategies of the government.
OBJECTIVES:
To standardize data that will result in fewer corrections or missing data.
To centralize data storage ensuring data integrity and providing a database for
future statistical and management reporting.
To reduce the time spent by staff filling out forms, freeing resources for more
critical tasks.
To speed up the billing process by having accurate, timely data resulting in

quicker payments and a better cash flow.
To reduce the amount of time spent by administration creating and publishing

schedules.
To process claims at the least possible time and maximize revenue collections.
To keep data in secure place and controls who can reach the data in certain
circumstances.
FUNCTIONS
Repairs and maintains software, hardware and network connections.
Effectively utilizes hospital facilities and improves inventory control
Provides information required to support patient care
Safeguards data integrity, security and accessibility
Captures and analyses clinical data
Captures the progress of treatment of individuals and gauges the response to
treatment and drugs for groups of patients
Makes data collected available for research purposes
Generates MIS reports, which help the management in making policy decisions.
Maintains records necessary for statutory requirements
Assist the administrative offices in better planning, monitoring and control of
medical and health services.
Benefits of HIMS
128
Easy access to doctors and hospital personnel, data to generate varied records,
including classification based on demographic, gender, age, and so on. It is
especially beneficial at ambulatory (out-patient) point, hence enhancing
continuity of care. As well as, Internet-based access improves the ability to
remotely access such data with authorization.
It helps as a decision support system for the hospital authorities for developing
comprehensive health care policies.
Efficient and accurate administration of billing, diet of patientand distribution of

medical aid. It helps to view a broad picture of hospital growth
Improved monitoring of drug usage, and study of effectiveness. This leads to the
reduction of adverse drug interactions while promoting more appropriate
pharmaceutical utilization.
Enhances information integrity, reduces transcription errors, and reduces

duplication of information entries.
Hospital software is easy to use and eliminates error caused by handwriting. New
technology computer systems give perfect performance to pull up information
from local server.
HOSPITAL STANDARD OPERATING PROCEDURES

PROGRAMMING/CODING
MODULES
OF
HOSPITAL FORM
PROCEDURE
a. Receives request or report from
Department Heads or Officer in charge
b. Reviews copy to amend.
c. Prepares
File
for
Coding
&
Programming
d. Review and testing of finished program
results
e. Integration to the system modules
f. Forward to Officer in charge for review
and corrections
g. Deployment of updated Module to
Department.
AMENDMENTS
OR
HIMS Staff
Programmer
Programmer
HIMS staff
Programmer
Programmer
HIMS staff
REQUEST FOR ADDITIONAL MODULE ACCOUNT

PROCEDURE
a. Receives request or report from the
person or Officer in Charge
b. Verification of the identity/validity of
the Hospital employee through HR or
Department Head.
c. Creation of additional module account
to the database
129
HIMS Staff
Programmer/ Programmer Assistant
REQUEST
FOR
CORRECTION/EDITING
SYSTEM/DATABASE
PROCEDURE
a. Receives request or report from the
person or Officer in Charge
b. Verification of the validity of request
c. Reviews system logged
d. Once cleared, correct/edit data.
OF
DATA
IN
THE
HIMS Staff
REQUEST FOR SOFTWARE/HARDWARE OR NETWORK REPAIR

PROCEDURE
Receives request or report from the person
or Officer in Charge
Attend to the report.
Pull out softwares/hardwares for repair
Repairing procedures
Testing ,monitoring and dispatching
HIMS Staff
Technical Support
Programmer/ Technical Support
REQUEST FOR THE ISSUANCE OF TPH IDENTIFICATION CARD (ID)

PROCEDURE
Employee fills up ID Form
Processing of ID
Distribution of ID
HIMS Staff
Technical Support
Technical Support
Technical Support
REQUEST FOR BIOMETRICS ACCOUNT

PROCEDURE
Verification of the identity/validity of the
Hospital employee through HR or
Department Head.
Creation of additional biometric account to
the database.
130
HIMS Staff
HOSPITAL MAINTENANCE UNIT
POLICIES:
1. Responsible for the provision of optimum physical environment for patient care.
2. Should update manual of policies and procedures to facilitate hospital operations
and comply with the numerous local, national, international codes, standardsand
regulations on the construction and operation of the hospital facilities and utilities.
3. Shall establish and implement a Comprehensive Preventive Maintenance Program
and Disaster Preparedness Plan to avoid uninterrupted service.
4. Shall have proper training for handling and repairs of equipments.
5. Shall maintain good relations with other hospital departments andoutside
organizations concerned with regulations and development of the field.
6. Work orders/request for construction, repairs and maintenance service must be
processed bythe Maintenance Unit. All work orders shall be recorded and
monitored toensure efficient service delivery and reporting.
7. Notices for cleanliness and sanitation shall be posted in conspicuous areas.
PROCEDURES:
REQUEST FOR REPAIR WORKS
PROCEDURES
a. Presents written request to undertake

the repair work.
b. Examines and determines the extent of
repair works to be done.
c. Prepare evaluation report and materials
needed in the repair.
If the materials are not available,
prepares RIV and forwards to
Supply Officer who will start with
the procurement process.
131
Requesting Unit
Concerned Maintenance Unit
If the repair service cannot be

provided by CMU, prepares
recommendation to have it repaired
by outside service provider through
the Supply Officer.
d. Prepares
and
forwards
the
accomplished
job
order
to
duly
the
e. Reviews and initials job order andforwards

to Chief of Hospital.
f. Approves job order and returns to
concerned maintenance unit for appropriate
action.
g. Undertakes the repair if the CMU is
capable of doing.
If not forwards it to the outside service
provider
h. After the repair, have the requesting unit
acknowledge the completion of repaired
service in the job order form
i. Acknowledge the repaired item and/or the
completion of repair service
j. 10. File job orders as a basis for the
monthly report for submission to the
Chief of Hospital

Requesting Unit
MOTOR TRANSPORT UNIT

POLICIES:
Travel of hospital vehicles shall be covered by trip tickets and posted for
information.
All hospital vehicles shall be regularly inspected for repair and maintenance
needs. A logbookon repairs and maintenance conducted shall be maintained and
updated.
POLICY FOR THE USE OF AMBULANCE
Shall be used in conducting or fetching from Tarlac Provincial Hospital and to
other hospitals.
Request for the use of ambulance should be coursed thru the Department Head
concerned forproper evaluation of the patient. The prescribed ambulance transfer
slip shall be used in makingthe request, subject to the approval of the Chief of
Hospital or Senior House.
Shall be used exclusively for patients and shall be on a 24-hour service.
A hospital physician shall accompany the patient, if necessary.
Only two relatives / companions shall be allowed to accompany the patient in the
ambulance.
Only indigent patients shall be conducted free-of-charge.
Patients coming from / going home to different municipalities should request the
ambulance oftheir municipalities or district hospital in the area.
132
REQUEST FOR THE USE OF AMBULANCE

PROCEDURES
a. Inquire the availability of the

ambulance from the Ambulance
Custodian.
Fill-up request form and forwards it to
the Chief of Hospital/Senior House
Officer for approval
b. Approve and sign the request form
Requesting Party/NOD
Chief of Hospital
c. Present the signed request form to the
nurse on duty
d. Inform the ambulance driver on duty
regarding the request
Requesting Party
Nurse on Duty
e. Prepares trip ticket for approval to the

Chief of Hospital
Ambulance Custodian
f. Ask the passenger to sign the trip ticket

after the travel
Ambulance Custodian
g. Files approved trip ticket for

monitoring purposes
Ambulance Custodian
SECURITY SERVICES
FUNCTION:
Shall protect lives, properties and critical infrastructure from threats, harm and
losses within the hospital premises.
POLICIES:
Preparation, implementation and monitoring of approved comprehensive security
plan shall be done.
A key management system shall be adopted by the hospital and enforced by the
security section.
SPECIFIC:
Shall establish and maintain maximum degree of security within the hospital.
Responsible for promoting security and peace and order in the hospital.
Shall have a security manual to guide hospital personnel in the performance of
their duties and responsibilities.
Shall be adequately manned and armed to perform their duties effectively.
Shall monitor and record traffic of patients, visitors, personnel and vehicles in the
hospital.
133
Issuance of keys shall be limited to responsible officials. A written record of key

authorized and issued shall be maintained by the security unit.
Shall maintain an adequate patrol of the hospital premises. A logbook of
inspection and patrols conducted shall be maintained. Any accident or incident
occurring during the shift shall be reported and investigated.
Shall establish and implement a Hospital Security Program and conduct security
education to obtain cooperation from hospital personnel.
Shall maintain an adequate and accurate documentation and inventory of arms
and ammunitions.
Shall coordinate with the Housekeeping and Maintenance Units in the preparation
of Disaster Preparedness Plan.
Guard on duty shall not leave his post without a reliever.
DEPLOYMENT OF SECURITY GUARDS:
PROCEDURES
a.
Prepares schedule of duty
Head Security
b. Checks posted guards
Head Security
c. Inspects entry/ exit point of employees,

patients and public including bags/
luggage.
Posted Security Guard
d. Inspects / records incoming and out going

vehicle.
e. Records and submits unusual/ incident

reports.
f. Conducts rounds and inspects buildings,

facilities and premises to ensure safety of
patients and hospital personnel.
Roving Security Guard
g. Makes report and forwards to the Chief of

Hospital.
Head Security Guard
CONDUCT OF INVESTIGATION:
134
a.
PROCEDURES
Receives and reviews incident report.
Head Security
b. Conducts preliminary
report of incidents.
investigation
of
Head Security
c. Submits report to the Chief of Hospital.
Head Security
VEHICULAR ACCIDENT WITHIN A PREMISES

PROCEDURE
a. Investigates Accident
b. Takes note of time of occurrence.
c. Reports accident to Security Head for
investigation and take note of the real
names of parties concerned and plate
numbers of vehicles
d. Takes note of damages sustained by both
e. Prepares report and submits to the
f. Forwards report to Chief of Hospital for
information
Guard on Duty
VIOLATION OF PEACE AND ORDER

PROCEDURE
a. Pacifies erring parties

b. If not settled amicable, records the names
of both parties, nature of offense
committed, and time of occurrence
c. Reports to the Security Head
d. Prepares affidavits for signature of
aggrieved parties
e. Prepares report and submits to
f. Forwards report to Chief of Hospital for
information
LINEN AND LAUNDRY
135
Guard on Duty
FUNCTION:
Provides laundry services and ensures adequate supply of clean linen for patients
and other hospital units.
POLICIES:
Universally accepted infection control, occupational health and safety
standards for hospital laundry services shall be strictly observed and
implemented.
Availability of clean linens shall be assured at all times to meet the daily and
emergency needs of the hospital.
Perpetual inventory of serviceable and condemned linen, supplies and
materials shall be enforced.
Safe working area and properly ventilated to prevent the spread of
contaminants.
Appropriate personnel protective equipment shall be enforced for the safety
and protection of the staff.
Clean linen shall be properly handled and stored to lessen contamination from
surface contact or airborne deposits.
Secured storage area for clean linen shall be provided.
Soiled linens shall be segregated and kept from clean linens at all times.
RESPONSIBILITIES:
Prepares comprehensive plan for laundry and linen services.

Ensures the efficient collection of soiled linen and timely issuance of clean
linen to different units of the hospital.
Monitor the implementation and observation of the universally accepted
infection control, occupational health and safety standards among the linen
and laundry staff.
Makes raw materials into desired linen and repairs or recycles damaged linen.
Undertakes disinfection of soiled linen.
136
ISSUANCE OF CLEAN LINENS:
PROCEDURES
a. Submits request slip for required linen.
Nursing Attendant
b. Checks availability of linen and issues

requested linen.
Linen Staff
c. Records Issuances.
Linen Staff
COLLECTION AND LAUNDRY OF SOILED LINEN:

PROCEDURES
a. Sorts, accounts, lists and returns soiled linen.
Nursing Attendant
b. Verifies and records the returned soiled linen

from the wards/ other units.
Linen and Laundry receiving Staff
c. Informs Nursing Attendant on missing linen.
Linen and Laundry receiving Staff
d. Forwards to laundry area.
Linen and Laundry
e. Disinfects and washes soiled linen.
Laundry Staff
137
f. Sorts, records and stores clean linen.
Laundry Staff
INVENTORY OF LINENS:
PROCEDURES
a. Records and updates stock cards.
Linen and Laundry
b. Conducts physical inventory of linen and

identifies linen for condemn or recycling.
Linen and Laundry
c. Prepares and submits reports of inventory.
Linen and laundry
INVENTORY OF LINEN (CLINICAL AREAS):
PROCEDURES
a. Conducts monthly inventory of linen.
Nurse Staff concerned
b. Reconciles records of linen receipt and

returned.
Linen and Laundry Head
c. Reports missing or unaccounted linen to

immediate head.
PRODUCTION OF LINEN:
PROCEDURES
a. Determines the linen requirements.
b. Prepares purchases request for raw materials

and supplies.
c. Inspects and accepts deliveries of raw

materials and supplies.
d. Instructs linen staff for the desired finished

product.
e. Inspects sewed linen in conformity with

specification together with the coding/
marking.
138
f. Maintains inventory log book of all hospital

linen with corresponding costs.
DISPOSAL OF CONDEMNED LINEN:

PROCEDURES
a. Sorts and inspects torn and worn - out

linens.
Linen and Laundry
b. Separates torn/ worn-out linen for recycling

or condemn.
Linen and laundry
c. Prepares itemized list of linen for condemn

and forwards to Property and Supply
Linen and Laundry
HOUSEKEEPING SERVICES
Primary Function and Responsibility:
Responsible in cleaning and maintaining of assigned work

Coordinates all cleaning activities to immediate superior
Reports defective equipment to immediate superior or office for
immediate action or repair
Report to Hospital Maintenance personnel of any of the following:
Busted bulbs
Water leaks
And other hospital problem issues
Wear a smile while performing duty
Observe courtesy at all times
Clean all equipments, gadgets and tools after use
Reports untoward incident to immediate superior or Hospital
Maintenance personnel within the areas of responsibility
Practice self-discipline and personal hygiene
Practice supplies and materials control
Relation to clients:
Be Respectful and Courteous:
Knock at the door before entering the room.
Greet GOOD MORNING, GOOD AFTERNOON, or GOOD
EVENING to a person inside
Speak in direct and clear language your purpose in going there.
Answer surely and clearly when you are ask a question
Do not wander inside the room, do what is being told you to do, if
instruction are not clear, ask for the clarification only once
Leave the room with a permission and a smile
Qualities and Values
139
Honesty
* Return things that are not yours;
* Do not forge documents;
* Admit errors, accept faults, and learn their corrections.
Trustworthy
* Do not lie.
Diligent
* Give your work the interest, enthusiasm and efficiency it
deserves
* Do your job professionally, with effectiveness and with
commendable results
Punctual
* Reports on-time or earlier
* Always visible on post
Disciplined and God fearing:

Refrain the indulging in vices for it destroys your body and mind.
It gives bad effect in your works and depletes your income and
savings.
Be cautious and avoid other things that may obstruct bodily
functioning your own good and our companys goodwill.
Follow instruction with accuracy and correctness.
Be a Law abider, and above all always fear God.
Remember disciplined is an endowment from God.
Always obey and follow company rules and regulation
In reporting to your place of work, you have to be in the
companys complete uniform. Wearing your uniform together with
together with proper identification lets the people around you
know who you are and the company you represent.
CLEANING PROCEDURE AND METHODS:

I.
FLOOR STRIPPING PROCEDURE

A. Chemicals
Wax Stripper
B. Equipment
Wet Floor Sign
Two Mop Squeezers
Floor Machine (Low Speed)
Vacuum Cleaner
C. Tools & Materials
Stripping Pad
Putty Knife
Soft Broom
Dustpan
Mop
Rags
Water Pail
D. Procedure
House Keeping Supervisor

needed.
-Requisition of Supplies and Materials
Supply Officer
-Issues supplies and materials as requested.
House Keeping Personnel
-request supplies and materials needed.

140
House Keeping Supervisor
-Issues supplies and materials as requested.
Duties and Responsibilities of House Keeping Personnel
Assemble your chemical, equipment, materials and tools

Remove any free-standing objects from the floor, vacuum or clean walkoff mats and set aside
Sweep or dust mop the area. As you are sweeping or dust mopping, take
note of any potential problem areas. Remove any gum or debris that may
be stuck to the floor.
Mix or dilute stripping solution in accordance with the label instructions
Post wet floor signs. There should be more than one sign posted, it must
indicate which areas are being worked on
Liberally apply the diluted stripping solution to the floor. Do not work in
an area larger than 10 feet x 10 feet. If you are stripping problem floors
like grouted tiles or heavy build up dirt, it is necessary to work in a small
section. Allow the stripping solution to stay on the floor for 7 to 10
minutes before scrubbing.
Note: Do not allow the stripper to dry on the floor.
Scrub the floor with floor machine. If heavy build-up dirt is present, reapply the stripper before scrubbing to increase contact time. Allow it to
stay on the floor and then scrub.
Pick-up the solution with a wet vacuum or with a mop.
Rinse the floor with clean water and a clean mop. Apply liberal amount of
water and pick-up with wet vacuum or mop. Repeat this step twice or trice
Clean your equipment and return it to appropriate area.
Do not remove the wet floor sign until the floor is completely dried.
II.
SEALING / FINISHING PROCEDURE

A. Chemicals
Sealer
B. Equipment
Wet Floor Sign
Mop Squeezer
C. Materials & Tools
Mop (clean)
Plastic Pail
Dust Pan
Soft Broom
Plastic Trash Liner
Trash Bin with color coding
III.
MAINTENANCE PROCEDURE (Dust and Damp Mopping)

A. Chemicals
Cleanser, Disinfectant
B. Equipment
Wet Floor Sign
Mop Squeezer
Vacuum Cleaner
C. Materials and Tools
Clean Mop
Putty Knife
Soft Broom
Dust Pan
D. Procedure
Remove any free-standing objects. Vacuum walk-off mats and set aside
Sweep or dust mop the entire floor. Remove any gum or other debris that
may stick to the floor with putty knife
141
Post the wet floor signs. It should be more than one sign posted. The signs
must indicate the area that is wet.
Mix chemical according to label directions with cool water
Damp mopping Light Soils:
Dip mop head into the cleaning solution and wring-out.
Apply the cleaning solution and wring-out. Apply the
cleaning solution to the floors, allow drying.
Wet Mopping Heavy Soils
Dip the mop head into the cleaning solution and lightly
tamp in mop squeezer. With heavy soils, be sure to get into
the corners and along the edge. Change the clean solution
when it become heavy soiled.
Allow the cleaning solution to remain on the floor for five (5) minutes,
then pick-up with mop head or wet vacuum.
Rinsing well is necessary in heavily soiled areas. Used a clean mop head
and clean water. Apply the rinse water and pick-up with a mop or wet
vacuum. Change the rinse water as it becomes soiled. Allow the floor to
dry.
Thoroughly rinse your mop heads, buckets and wringer. Return them to
their appropriate place.
IV.
TOILET CLEANING PROCEDURE

A. Chemicals
Toilet Bowl cleaner
Powder soap
B. Equipment
Mop squeezer
C. Materials & Tools Hand brush
Push brush
Scouring pad
Rubber hand gloves
Rags
Spray gun
Stick broom
Dust pan
Mop
D. Procedure
Remove all trashcans, collect trash liners within the contents from the
trashcans. Close liner and place in trash bag for disposal.
Sweep and pick up litter with the dust pan and broom, start from the end
going back to the entrance door. Take note of problem areas and remove
sums, tar or any substance from the floor with putty knife
Note: Do not sweep trash into the corridor or adjourning area.
Post wet floor sign at the entrance of door to indicate the area is being
cleaned and serviced. Mix and dilute cleaning solutions in accordance
with the label instructions.
Liberally apply bowl cleaner into toilet and urinal bowls, allow the
cleaning solution to stand for a while
Going back, scrub the toilet bowl and urinals using oval brush or scouring
pad thoroughly from rim to the water line. Flush water twice and repeat
using powder soap. Clean and scrub exterior of bowls with powder soap
and include the walls and cubicles. Rinse and wipe dry.
Clean and scrub floor tiles, make several passes on the grouts if necessary.
Rinse and mop dry before leaving and place back all trash cans with new
liners.
142
Take note of any busted bulbs, leaky fixtures and other defective items to
report to the supervisor or to Maintenance.
WORK METHODS
o There is a basic approach that applies to the cleaning of almost any kind of area
in the building. We say DAILY to indicate routine, respective service required
to restore the cleanliness of any area after a period of use. The normal period of
use of any areas varies with the purpose of the area. Such as the following:
In an office cleaning must be done at the beginning and the end of the
working day.
In a certain kind of area which in use of 24 hours a day, everyday of the
week, cleaning should be done as often as once per eight-hour shift? It is
the cycle of used area that determines the frequency with which the
restorative cleaning procedure must be followed.
o The best procedure is to perform each of the four groups in the 3 sequence given.
143

Tarlac Provincial Hospital 2014 Manual New

Caricato da

Informazioni sul documento

Copyright

Formati disponibili

Condividi questo documento

Condividi o incorpora il documento

Opzioni di condivisione

Hai trovato utile questo documento?

Questo contenuto è inappropriato?

Copyright:

Formati disponibili

Tarlac Provincial Hospital 2014 Manual New

Caricato da

Copyright:

Formati disponibili

TARLAC PROVINCIAL HOSPITAL (OVERVIEW)

Improvement of revenue thru increase in universal Philhealth

To maintain a harmonious working relationship among the hospital

VI. PROGRAMS/ PROJECTS/ ACTIVITIES

Obstetrics and Gynecology

2. Clinical Services for Out-Patient Care

2.3 Maternal and Child Clinic

4. Ancillary Support Service

administrative, financial management, training and research

B. DUTIES AND RESPONSIBILITIES OF KEY PERSONNEL

2.2 CHIEFS OF CLINICS

2.3 THE CHIEF NURSE

b. Ensures the provision of uninterrupted logistic support to effectively and

a. One to who is delegated authority to provide nursing care to patients in a given

a. Responsible for rendering bedside care to patients in their assigned units.

NURSE TRAINING OFFICER

SUPERVISING OPERATING ROOM NURSES

SENIOR OPERATING ROOM NURSE

a. Responsible for extending assistance to various types of surgical operations,

OPERATING ROOM NURSE

a. Responsible for extending assistance to the various types of surgical operations

DIETITIAN NUTRITIONIST II / DIETITIAN NUTRITIONIST I

Inspect and accepts deliveries of food stuffs for accuracy.

e. Prepare and submits semi-annual report to PDEA.

h. Establish and maintain effective communication system within and inter

Establishes department procedures and methods of operations;

II. OUT-PATIENT DEPARTMENT

10 Consultation hours and days:

Consultation fee is P50.00

PROCEDURES OF THE OUT-PATIENT DEPARTMENT

Take vital signs and weight of donor.

Place him in comfortable lying position.

Prepare the blood bag extraction site.

Assist physician during extraction, observe proper asepsis during

Observe donors reaction during and after extraction of blood.

Forward to the laboratory.

Prepares the operative site and drape patient properly.

Performs minor operations.

Assists the Surgeon during the operations.

Collect specimen for pathological examination such as biopsy, if any.

Advice on prescribed medication, wound care and follow-up check-up.

Prepare the perineum, paint it with antiseptic solution.

e Bring the chart to the assessment

*Call patients name

*Give/ provide number to Specific

Forward OPD chart to the respective

Examines patient, evaluates and

III. EMERGENCY ROOM POLICIES AND PROCEDURES

d. In case of difficult administrative controversies in the admission, management of

Only emergency cases should be done.

a. Attends to the patient immediately for

d.2. In case of medico-legal refer to

IV. ADMISSION POLICIES/PROCEDURES

Admission of patient is centralized at the Admitting Section. Patients for admission

Out Patient Department referred by the resident on duty,

Patient Data Sheet is completely filled up;

Stat orders are implemented by nurses before patient is transferred to the

Upon arrival of the patient in the ward:

a. accompanies patient to his/her designated

b. Assess patients condition and records

c. Orient patient/relative about the hospital

d. Plans nursing care of patient, performs

e. Follow-up results to other units such as the

Nurse/ Nursing Attendant