I.

Preface

II. Acknowledgement

III. Introduction

IV. Historical Background of the Hospital

V. Core Values

VI. Organizational Chart of the Hospital

VII. Nursing Service Administration Office

VIII. Philosophy and objective of the NSO

IX. NSO Policies and Guideline

• Employment

• Orientation

• Uniforms

• Communication

• Vacation Leave

• Maternity Leave

• Sick Leave

• Absences

• Performance Evaluation

• Incidental Reports

• Request for Transfer of Personnel from One Nursing Unit to Another

• Staffing Patterns

• Exchange of Duties

• Special Duty Nursing

X. Organizational Chart of the NSO

XI. Station I

XII. Standard Operating Procedures of Nursing Service

• Objective

• Unit Organization

• Availability of Beds

• Admission Policies

• Permit and Consent

 • Length of Stay or Discharge

• Infection Control

• Visitation

• Staff Uniforms

• Special Nurses

• Supplies and Equipment

XIII. Observational Analysis of Station I

• Strength

• Weaknesses

• Conclusion

XIV. Inservice Training Program Design

• Concept

• Objectives

• Lecture Activities

• Evaluation

• Budget Proposal

XV. Readings with Reaction and Conclusion

XVI. Pictures

XVII. Monetary and Time Budget

II. Introduction

III. Historical Background of the Hospital

IV. Core Values

VISION

A Caring, Dynamic and Honest nursing personnel responsive in providing rational,

quality and comprehensive nursing care and training that exceeds the expectations
of the clienteles.

MISSION

To assist in the preservation of the value of human life by providing rational, quality
and comprehensive nursing care to clienteles and training to affiliates through our
caring, dynamic and honest nursing personnel.

OBJECTIVES

In the pursuit to attain our Vision, CDH-NSO aims to:

♣ collaborate with health partners in providing cost effective, conscientious and

compassionate nursing care.

♣ promote professional advancement among nursing personnel that will ensure

confidence and competence.

♣ establish commitment and harmonious relationship among nursing personnel,

clienteles and members of the health team.

♣ provide safe, healthy and satisfying working environment to the nursing

personnel.

♣ create learning opportunities to its affiliates through training and development

program.

V. Organizational Chart of the Hospital

Chairman of the Board:
DR. LUCINO DELFIN, JR.

Chief Executive Officer:

DR. ROSEMARIE JANE GABOR

Hospital Administrator:
DR. MA. LUISA B. MAGSILA

Medical Director:
DR. MA. CRISTINA D. DELFIN

Chief Resident:
DR. MARY JANE CORDOVA

Resident Physician:
DR. MA. MARGIE VILLAFUERTE
DR. RALPH ODRUNIA
DR. QUEENIE SABOLBORA

Chief Nurse:
MR. ROBYNIEL A. ALBA, RN, MAN

Accountant:
MS. JOY THERESE ORILLOS, CPA

Assistant Personnel Officer:

MS. ANNIE AGREGORIO

Social Service Officer:

MRS. LENA FORRO

Medical Records Officer:

MS. MAE BELLOSILLO

VI. Nursing Service Office

Hospital Administrator: Dr. Ma. Luisa B. Magsila

Chief Nurse: Robyneil A. Alba, RN, MAN

Supervisors:

1. Monica Encabo, RN (Senior Supervisor)

 2. Rosario Gallardo, RN

3. Letecia Baril, RN

4. Wyndee Cabacas, RN

HeadNurses:

1. Station I- Sheila Ann Baltero, RN

2. Station II- Cecile Joyce Billones, RN

3. Intensive Care Unit- Joyce Albaladejo, RN

4. Operating Room/ Delivery Room/Neonatal Intensive Care Unit- Martin

Emmanuel Granflor, RN

5. Emergency Room- Jaime Anisco, RN

6. Dialysis Unit- Jose Victor Borja, RN

Staff Nurses:

• Emergency Room

Jaime Anisco, Rn

January Binga-an, RN

Mary Connie Roxas, RN

• ICU

Mcalden Chu, RN

Glenn Concepcion, Rn

Vincent Villaruz, RN

• Station I

Mary Cris Agapin, RN

Ma. Christine Barrios, RN

 Queenie Pimentel, RN

• Station II

Myka Dais, RN

Mary Christ Delos Reyes, RN

Eusebio Alcazar, RN

• Dialysis Unit

Lindsey Badana, RN

Eva Kathrina Anisco, RN

• OR/DR/NICU

Debie Albar, Rn

Liezyl Bendico, RN

Aiza Dorado, RN

Hazel Lamis, RN

Ma. Theresa Miranda, RN

Nursing Aids:

• Station I

Sharon Bernas

Josefa Biaco

Jason Garde

Janice Lorenzo

• Station II

Jose Channel Distor

 • Dialysis Unit

Elles Chelley

• OR/DR/NICU

Gemelie Donado

Rubelyn Fuentes

Rosendo Pionelo

Cris Tianchon

Philosophy and objective of the NSO

NSO Policies and Guideline

• Employment

If there will be a vacant position, the chief nurse will inform the
hospital administrator of the vacancy. The hospital administrator
will instruct the personnel officer to post an announcement of the
said vacancy. A committee will be created to select from the
applicants. They will be interviewed, evaluated and the applicant
with the highest ranking will be considered in the vacant position.
• Orientation

On the first day all trainees will be oriented with regards to the
hospital organizational structures, VMG, policies and standard
operating procedures.

Then they will have a ward/ department exposure. The rotation will
be every 2 weeks and their shifting is every 15 days. There will only
be maximum of 4 volunteers per shift. Trainees are required to
have a good attendance and must follow SOP’s and Policies or else
they will be terminated from the training program. In case of
absences, an excused absence will make up for the missed hours
and an unexcused absence will be recorded and accumulated; 4
absences will mean termination of training.

• Uniforms

a. Nurses are expected to maintain a well-groomed personality.

Nurses should wear a white uniform with sleeves, nursing cap,
stocking, white shoes, and ID or name plate.

b. OR personnel should wear the OR uniform and should put on

their smock gown when they leave the sterile area.

c.

• Communication

• Vacation Leave
 1. An employee who calls the Nursing Office for extension of leave
will be assessed. If her services are needed she has to be
recalled. If her leave is disapproved she is considered on
absence without approved leave (AWOL) and she will not receive
a salary for those days where she does not have approved
leave.

2. If an employee does not notify her absence in the Nursing Office

during office hours from 8:00 to 5:00 P.M or the nurse supervisor
on duty at 3:00-11:00 and 11:00 – 7:00 shift he/ she will be
marked absent

3. A medical certificate is required to employees who are absent

due to illness irregardless of number of days in order to monitor
the causes of illnss

• Maternity Leave

• Sick Leave

- Must be filed at least 5 days before affectivity. Sick leave should

be accompanied by medical certificate. For sick leaves and
emergency leaves filed after, however, a notice of absence
should be made known, the earliest possible to the Chief Nurse.
Sick leave and emergency leave without notice is considered
AWOL. Request for leave should be then submitted to the
Administrative Officer where the employee files up the official
application form for leave. After enjoining any form of leave, the
nursing employee is required to inform the nursing service office
a day before he/she assumes his/her official duty so that he/she
will know her time schedule and place of assignment. This will
prevent disruption of the planned schedule. Extension of leave
should be filed at least 2 days before the termination of
approved leave through channel. Extension of leave however is
subject for approval of the Chief Nurse.

• Absences

Nursing Service Personnel are encouraged to be always present in

their duty schedule. In case of absences. They must submit a
medical certificate. Absences before and after an off duty is
 discouraged. All absences that were incurred before and after days
off is discouraged. The nursing service personnel is required to
submit a written explanation or an anecdotal report immediately
within 48 hours after she will report for duty on the reason why she/
he absent before or after the day’s off after she came from
absence. This is to discourage or reduce the incidence of avoidable
or unnecessary before or after a day off.

The nurse supervisor shall exercise her distention in handling

understaffing problems during her shift. One of the responsibility is
checking of all clinical area or stations must have adequate
personnel to care for patients seeing to it that a nurse or nursing
attendant has an alternate available in the care of patients> They
are also responsible and incharge if there are absentees in the
ward.

• Performance Evaluation

The nursing service office evaluate their nursing personnel twice a

year. Every February and September. A nursing personnel with an
evaluation of 2.0 will be counseled. He/ she will be provided with
HRD scheme which could aid him/her improve his/her performance.
The nursing personnel with 3 consecutive evaluations which are
below 2 will be terminated because of unsatisfactory performance.
They are evaluated through quality assurance program. Evaluation
must be done every quarterly through Evaluating Committee.

• Incidental Reports

a. Nurse and other Nursing personnel guilty of negligence in

their work are required to submit a written report or
explanation about the case.

• Request for Transfer of Personnel from One Nursing Unit to Another

• Staffing Patterns

The timetable indicating planned work days and shifts of the

nursing personnel are prepared every 15 days. The submission of
the monthly schedule is on the 4 th day for the first 15 days and 17 th
day for the next 15 days of the month. The staff nurses and nursing
attendants provides written information to the senior nurse
supervisor regarding her requested off duty schedules, planned
vacation, special privilege leaves, mandatory leaves (force leaves)
for the month. This is submitted to the Chief Nurse for
consideration.

• Exchange of Duties

• Special Duty Nursing

XVIII. Standard Operating Procedures of Nursing Service

• Objective

• Unit Organization
• Availability of Beds

• Admission Policies

• Permit and Consent

• Length of Stay or Discharge

• Infection Control

• Visitation

• Staff Uniforms

• Special Nurses

• Supplies and Equipment

 XIX.Organizational Chart of the NSO

Ma. Luisa B. Magsila, MD

(Hospital Administrator)

Robyneil A. Alba, RN, MAN Affiliating Schools

Chief Nurse

Monica Encabo, RN Rosario Gallardo, RN Leticia Baril, RN Wyndee Cabacas, RN

Senior Supervisor Nurse Supervisor Nurse Supervisor Nurse Supervisor

Dialysis Station I ER Head ICU Head OR/DR/NIC Station II

Head Nurse Nurse Nurse U
Head
Head
Nurse

Station I ICU Staff OR/DR/NIC Station II

Dialysis ER Staff
Nurse U
Staff Nurse Staff Nurse
Staff
Nurse
Nurse

Nursing Nursing Nursing Nursing Nursing Nursing

Aid Aid Aid Aid Aid Aid