NURSING SERVICE POLICIES AND GUIDELINES

Health is a right of every Filipino citizen and the State is duty-

bound to ensure that all Filipinos have equitable access to
effective health care services (Philippine 1!" #onstitution$
MISSION:
%he &ursing Service ensures to provide equitable' sustainable
and quality health for all Filipinos' especially the poor' and to
lead the quest for e(cellence in health)
CORE VALUES:
*ntegrity
+(cellence
#o,passion
The implementation of Universal Health Care Kalusuan
Pan!alahatan" is directed towards ensuring that all Filipinos,
especially the disadvantaged group, have equitable access to health
care. The Nursing Service Policies, Guidelines and Procedure
therefore should gear towards the achievement of the health system
goals of
-etter health outco,es
.esponsive health syste,
+quitable health financing
S%./%+0*+S1
!. HUMAN RESOURCES " ensure availability of adequate, competent health
care providers by hiring highly qualified staff and enhancing their capabilities
and values thru training. Provide mechanism for the development of
professional nurses.
#. HEAL#H $INANCING " advocate the shift to new provider payment
mechanisms, secure fiscal autonomy and financial ris$ protection. %dvocate
enrollment to P&'(&)%(T& and other means of health financing. )nsure
appropriate utili*ation of resources.
!
+. DRUGS AND #ECHNOLOG% " regulation and availability of affordable
quality drugs and medical equipment. )nsure proper use and maintenance of
equipments and regular inventory of drugs and supplies. 'mplement Generic
%ct to secure affordable quality drugs.
,. IN$ORMA#ION S%S#EM " ma-imi*e information system technology for
immediate and efficient provision of health services. .evelop systems in
documentation.
/. GOVERNANCE " establish mechanisms for efficiency and accountability0
conduct performance evaluation, gather feedbac$ from clients and maintain
quality audit and management systems.
PAR# I& ADMINIS#RA#IVE POLICIES
Arti'le I& GUIDING PRINCIPLES
!. 't is the responsibility of all nursing personnel to strictly observe the
&ospital and Nursing Service policies.
#. The general administration of nursing service personnel, policies and
practices is the responsibility of the 1hief Nurse.
+. The 1hief Nurse, %ssistant 1hief Nurse and Supervisors have full
authority to delegate duties and responsibilities to their staff.
Arti'le II& RECRUI#MEN#( SELEC#ION( HIRING O$ EMPLO%EES
S)1T'2N !. Nursing applicants should meet the following requirements
a. 3ust be a Filipino citi*en0
b. 3ust have graduated from an accredited school or college of Nursing0
c. 3ust have passed the Nurse4s 5oard )-amination and licensed to
practice nursing in the Philippines by the Professional 6egulation
1ommission 5oard of Nursing0
d. 3ust be in good physical and mental condition0
e. 7ith good moral character0 and
f. 3ust have passed the written and oral e-am to be given by the Nursing
2ffice8Personnel Selection 1ommittee.
g. Preferably with 5asic (ife Support 95(S: and 'ntravenous Therapy
Training 9';T:
h. Preferably between #!<+/ years old for first level 9Nurse !, 3idwife 8
Nursing %ttendant: position.
S)1T'2N #. )mployees shall be selected on the )asis of their fitness to perform their
duties and assume their responsibilities.
Criteria *+r Evaluati+n
%. Performance87ritten 82ral )-am...===.=..#/>
5. )ducation and Training=========.#/>
1. Physical 1haracteristics ? %ttitude====..#/>
.. Potential===============#/>
!@@>
#
S)1T'2N +. EMPLO%MEN# PROCEDURE $OR NURSING PERSONNEL
+.! Nursing .ivision
a. %ccepts applicants0
b. 6ecommends appointment for interview0
c. Gives oral and written e-amination.
+.# Screening 1ommittee of .6AN63&
a. )valuates general professional and personal qualification0
b. 'nterviews and screens applicants0
c. 6ecommends acceptance or reBection of applicants
+.+ %dministrative 2ffice8Personnel 2ffice
a. 'nforms applicants who have satisfactory met the requirements0
b. 'nforms applicants of the other requirement papers for appointment0
c. Prepares appointment papers 9%ll requirements and processing
should follow the procedure set by the 1ivil Service 1ommission:.
S)1T'2N ,. Un,er Arti'le VI( Se'ti+n -. of the 1ivil Service 6ules and (aws on
6ecruitment and Selection of )mployees
State that
2pportunity for government employment shall be open to all qualified
citi*ens and positive efforts shall be e-erted to attra't the )est /uali*ie, to enter the
service.
S)1T'2N /. 'n hiring new employees, the Nursing .ivision 2ffice can give
consideration for those who have been rendering voluntary service and possesses the
desired qualifications0 however, being a volunteer is not an assurance that she8he will
be hired.
Arti'le III& 0O1 DESCRIP#IONS O$ NURSING SERVICE PERSONNEL
POSI#ION #I#LE: CHIE$ NURSE 2NURSE VI3
%..)F'N'T'2N 1hief Nurse is the e-ecutive head of the Nursing .ivision.
5. A25 SC33%6D Cnder .irection
1arries full administrative responsibility and authority for the entire
nursing service of the hospital Participates in formulating hospital policies, in
+
developing and evaluating programs and services %ssume full authority and
responsibility for the development of nursing service policies0 organi*es, direct,
coordinates, evaluates activities of the Nursing .ivision Staff which allow for
patient4s satisfaction and professional growth Provides means and methods by
which nursing personnel can interpret the goals and policies of hospital and nursing
service to the patient and to the public 'nitiate and directs studies, evaluates
procedures for the improvement of nursing relation to the total care of the
patients. .irects planning and implementation of staff development programs for
different categories of nursing personnel .irects nursing personnel in functions
related to the clinical training program of nursing students and other affiliates.
Prepares with her supervisory staff budget proposal for the nursing personnel
.efines Bob description for each category of nursing personnel recruits and
recommends personnel for appointment, promotion or dismissal depending on
staffing needs of the services.
C& 4UALI$ICA#ION RE4UIRMEN#S:
!. )ducation 3aster of %rts in Nursing %dministration.
#. Training and )-periences
a: 1&')F NC6S) % minimum of / years e-perience which has been spent
in supervisory position as a Supervisor and8or %ssistant 1hief Nurse.
.emonstrated professional competence in clinical practice and
administration. 1ompleted 1hief Nurse Training 1ourse or its equivalent
and a graduate of 3aster of %rts in Nursing %dministration.
+. Aob Enowledge.
7ith broad $nowledge and understanding of principles of nursing practice
based on physical, biological and social sciences and their application to nursing care
for the solution of nursing problem. 7ith adequate $nowledge and understanding of
the principles of supervision, administration and research and thorough $nowledge of
the organi*ational structure of nursing service as well as organi*ation, functions,
policies, regulations and procedures of hospital. Enowledge and e-perience in
reconciling needs and goals of nursing practitioners, with the obBective of nursing
service.
D& 0O1 RELA#IONSHIPS
!. Source of wor$ers<Professional Nurses ? Nursing %ttendant83idwives
E& SPECI$IC AND AC#UAL $UNC#IONS AND AC#IVI#IES
!. Plans, organi*es and supervises the nursing service in order to provide adequate
nursing care to patients.
#. 1oordinates all activities of the Nursing .ivision with other services
,
+. Prepares Nursing .ivision budget to provide adequate personnel, equipment and
physical facilities needed and submits to administrative office.
,. 'nterviews and screens all applicants for the nursing division and evaluate their
qualifications and e-periences.
/. 2bserves and evaluates the performance of personnel, as well as analy*es and
evaluates the nursing activities to determine whether they are meeting desired
standards.
F. Formulates and recommends policies for improvement of patient care,
participates in planning of personnel policies and interprets to the 1hief of
&ospital the needs and interest of the nursing personnel.
G. Promotes and maintains cordial relationship with patient, their families and the
community and provides opportunities for nursing staff to wor$ with other
groups so that the aims of the hospital can be interpreted to mean good
interpersonal and interdepartmental relationship.
H. Promotes individual growth and development by maintaining a program of staff
education, conducts monthly meetings of nurses and nursing aides.
I. Participate in the hospital outreach program8medical missions.
!@. Participates in professional meetings as the representative of the nursing division
personnel. SubBect Jto call Jas need arises.
!!. .aily ward rounds to gain insight to the problems and needs as presented by the
patient and the family, the nurses and other health disciplines
!#. %pproves schedule of duties and off duties prepared by the %ssistant 1hief
Nurse8Supervisor.
!+. Signs .aily time records.
!,. Performs other duties as required by the 1hief of &ospital.
!/. %ttends local and national seminar wor$shops.
!F. 1onducts monthly meetings for nurses and nursing aides.
!G. &elps promote healthful living condition for nursing personnel.
POSI#ION #I#LE: ASSIS#AN# CHIE$ NURSE 2NURSE V3
Cnder the direction of the 1hief Nurse, with the same qualification requirements and
performs specific and actual activities of the 1hief Nurse as directed, or in his8her
absence.
SPECI$IC AND AC#UAL $UNC#IONS AND AC#IVI#IES
!. %ssist the 1hief Nurse in the planning of over all activities on the nursing
service.
#. %ssist in the formulation, revision, and implementation of hospital and
nursing policies.
+. %ssist in the budget preparation for equipment, supplies, physical facilities
and personnel.
,. 3a$es general rounds to all wards and special departments noting down
the needs and problems of patient, personnel and unit as a whole.
/
/. 1hec$s and review the #, hour report on the actual total number of
patients4 admission, discharges, deaths, number treated, and number of
surgery done.
F. %ssist in planning and organi*ing continuous staff development program.
G. %ssist in screening applicants for the nursing service.
H. %ssist in budget preparation in the nursing service.
I. %ssist in monitoring discipline through proper counseling of nursing
personnel.
!@. %ssist in the preparation and evaluation of personnel performance rating.
!!. %ssist in performing 1K' activities in the hospital.
!#. %ssume function of the 1hief Nurse as delegated by the 3edical 1enter
1hief in the absence of the 1hief Nurse.
POS#ION #I#LE: SUPERVISING NURSE 2NURSE III3
EDUCA#ION5#RAINING5E6PERIENCE RE4UIREMEN#S
5SN graduate with I units in 3aster of %rts in Nursing %dministration, at least # years
e-perience in supervision.
SPECI$IC AND AC#UAL $UNC#IONS AND AC#IVI#IES
'. Supervision of Patient 1are
1hec$s the Senior Nurse4s plan for patient care and sees to it
that they are properly e-ecuted.
Eeeps herself informed of patient4s needs and problems.
6einforces health instructions given to patients and their
families as the need arises.
;erifies implementation of request of referrals to evaluate
continuity of care.
Serve as consultant and adviser to the Senior Nurse in
developing, devising and adopting wor$ techniques and
methods for the solution of problems related to patient care.
''. Personnel 3anagement
'nterprets standard operating and new procedures and policies,
review wor$ performance of personnel to determine if it
conforms to the recogni*ed standards.
Plans the programs and wor$ of all the nursing personnel.
.irects arrangements of schedule of duties, off<duties, vacation
leaves, etc., of all nursing staff assigned in the unit.
)valuates wor$ accomplished by each nursing employee in the
ward.
F
Prepares the plan for counseling of co<wor$ers0 this is done
individually especially to personnel with problems.
Promotes harmonious relationships and self<discipline among
nursing personnel under her supervision.
Cpdates $nowledge and s$ills of personnel on modern trends in
management and other related nursing techniques.
)stablish standards of care and procedures and recommends
short and long range nursing programs for providing quality<
nursing care.
'''. &elps in improving an adequate and safe environment by guiding and
helping &ead Nurses in providing and maintaining a safe, orderly and clean
environment for patients.
';. &elps in providing adequate supplies and equipment by
.etermining the needs for supplies and equipment based upon
past e-perience and future plans for programs of patient care.
3a$ing proper representation to the management for the needs
of the department.
1oordinating with the other departments 9maintenance and
properly: to meet the needs for supplies and equipments.
;. 6eport daily to the 1hief Nurse regarding all activities in the area and
everything that matters to the nursing division. Cnder supervision of the 1hief
Nurse, plans, organi*es, directs and controls the nursing programs of activities
0O1 RE4UIREMEN#S: CSR NURSE SUPERVISOR
%. Kualifications
!. General )ducation " 3ust possess at least I units in management in addition to
her 5SN.
#. Professional Preparations " 'n addition to the preparation of general supervisor,
she should have had special training in the 1entral Supply 6oom with ample
$nowledge in nursing procedures and operating room technique.
+. )-perience
a. %t least three 9+: years of nursing e-perience with one 9!: year as a
head nurse in which she has demonstrated administrative and teaching
ability and special interest and competence in the 1entral Supply
6oom.
b. 3ust be s$illed in the handling of the autoclave and other equipment
used in the 1entral Supply 6oom.
G
A25 P)6F263%N1)
!. %dministrative head of the 1entral Supply 6oom Cnit and gives assignment to
her personnel.
#. Plans, directs and supervises the activities of the 1entral Supply 6oom.
+. Supervises the effective use of sterile supplies and equipment in the wards and
frequently chec$s all equipment for immediate repair or replacement.
,. 1onfers with department heads in order to answer their needs.
/. 'n charge of all equipment, apparatus, instruments and supplies in the 1entral
Supply 6oom Cnit.
F. Supervises the dispensing and handling of sterile supplies and equipment.
G. Standardi*es the pac$ing of linens, instruments, gloves, etc., for Treatment
6oom, 2perating 6oom, .elivery 6oom, 2ut<Patient .epartment, )mergency
6oom and ward use.
H. 6equisition and follow<up supplies through the Property 2fficer.
I. 6esponsible for the observance of strict aseptic technique in the 1entral Supply
6oom.
!@. 3aintains and determines the adequacy of stoc$ on hand in the 1entral Supply
6oom.
!!. Eeeps a systematic record of all equipment, apparatus, instruments and
supplies for hospital use.
!#. Train students and orient new staff in the principles of proper sterili*ation, care
and use of special equipment.
!+. 3aintains and promotes good inter<personal and inter<departmental
relationship.
!,. Participates in the planning and preparation of the hospital budget.

POSI#ION #I#LE: SENIOR NURSE 2NURSE II3
SPECI$IC( AC#UAL $UNC#IONS AND AC#IVI#IES
!. 6epresents her ward in the nursing division meetings and other hospital
meetings when necessary.
#. %cts as supervising nurse when delegated.
+. 6enders directs nursing care if the unit is under staff.
,. Supervises cleanliness and orderliness in the ward.
/. Provides environment that is conducive to the physical, spiritual and emotional
well< being of the patients and personnel.
F. Participates in formulation, interpretation and implementation of hospital
philosophy, obBectives and policies.
G. )stablishes, promotes and maintains good interpersonal relationship.
H. 'dentifies nursing problem in the wards.
I. )valuates nursing staff in her units, and gives assignments according to their
capacity.
!@. %cts as liaison between patient and member of the health team.
!!. 3a$es patient rounds and sees to it that all in<patients get the necessary care.
H
!#. Sees to it that all equipment is in order and properly $ept and supplies are
available.
!+. 3a$es wee$ly schedules and daily assignment.
!,. 1hec$s and countersigns recording done by the staff nurses.
!/. 2rients the clinical instructor on all department policies and evaluate their
performance every three months.
!F. Sees to it that doctor4s orders are carried out properly and intelligently by the
staff.
!G. Plans and supervises all nursing activities in her ward.
!H. )valuates performance of her staff every si- months.
!I. 1oordinates ward activities in the administration of nursing division with all
hospital services.
#@. Participates in the orientation of new staff and nursing students.
POSI#ION #I#LE: S#A$$ NURSE 2Nurse I3
S#A$$ NURSE #linical /reas
Kualification 6equirements
)ducation % holder of a 5achelor of Science in Nursing
.egree
(icensure ;alid and current licensure in the Philippines
3embership PN%8National (eague of Government Nurses
Training and )-perience 2rientation upon entrance to duty
Aob .escription
!. 2rients patients8relatives to the room8ward, its facilities, including unit
policies, personnel and hospital rules and regulations and the patient4s bill of
rights0
#. 3a$es frequent rounds to all patients, identifies problems and implements
appropriate nursing action according to priority of needs0
+. 'nvolves the patient and family in the plan of care0
,. Provides s$illful, safe, effective nursing care to patients0
/. %dministers prescribed medications following the ten 9!@: rights, procedure
and technique in drug administration based on his8her $nowledge of action,
dosage, side effects and nursing implications0
F. %dministers prescribed treatments following the correct procedures based on
scientific principles0
G. 3a$es referrals to other members of the health team0
H. 1ommunicates effectively with incoming shifts regarding status of the unit and
the patient 9proper endorsement:0
I. 'nforms immediate superior of problematic8difficult situations0
!@. %ssists physician with diagnostic and therapeutic procedures0
I
!!. 'nstructs patient8family about rationale for the limitation of activities, dietary
regimen, measurement of inta$e and output0
!#. Ta$es vital signs, urine and stool records accurately0
!+. 6ecords pertinent observations, medications and treatments, its reaction and
evaluation of nursing care 9documentation:0
!,. Gives health teaching related to home care management upon discharge of
patient0 and
!/. %cts as a head nurse when so delegated.
S#A$$ NURSE 2Nurse I3 +,ergency .oo,
Kualification 6equirements
)ducation % holder of 5achelor of Science in Nursing
(icensure ;alid and current license to practice Nursing in the
Philippines
3embership PN%8National (eague of Government Nurses
Training ? )-perience 3ust have e-perience in the 1linical %rea as Nurse ' for
one or more years
Aob .escription
!. %ssess vital signs, chec$ %51 Ls .Provides the immediate physical and
psychological needs of patients0
#. Prepares instruments, supplies and equipment for surgical procedures0
+. %ssists surgeon in surgical8emergency procedures0
,. 6ecords patient4s data, treatment8management and medications accurately0
/. )ndorse admitted patient to ward nurse0
F. Preserves and labels operative specimen for laboratory analysis0
G. 1oordinates nursing activities with medical and paramedical staff0
H. 1hec$s inventory of supplies and equipment every shift0
I. )nsures that area is clean, orderly and
!@. .isseminates information to public see$ing assistance and information.
S#A$$ NURSE 2NURSE I3 Out7atient De7art8ent
Kualification 6equirements
)ducation % holder of 5achelor of Science in Nursing
(icensure ;alid and current licensure to practice nursing in the Philippines
6egular renewal of license.
Physical .emands Physically and mentally fit, has stamina to wor$ effectively under
adverse conditions.
!@
3embership PN% ? National (eague of Govt.Nurses
Training and )-perience 3ust have an e-perience in the clinical area as Nurse '
9!: or more years.
Aob .escription
SP)1'F'1 %N. %1TC%( FCN1T'2NS %N. %1T';'T')S
!. Gives direct nursing care to patients in the area assigned 9treatment, surgery,
medication:
#. 'dentifies nursing needs of patients and report observation to proper individuals.
+. Gives emotional and spiritual support to patients.
,. 1ommunicates and acts as liaison between patients and the hospital personnel.
/. 'nterprets to the patient and his family, their role in promoting successful therapy
and rehabilitation.
F. 1arries out doctor4s order in conformity with hospital policies and its legal
limitations.
G. %ssists the physician when e-amining patients.
H. Prepares accurate records pertaining to 2P. patients, programs and activities.
I. 2bserves aseptic technique in preparing and assisting treatments, e-aminations,
and sterili*ation of instruments.
!@. Participates in maintaining the unit clean at all times.
!!. Participates in the dissemination of information regarding hospital rules and
regulations.
!#. 1onduct health education activities and implement .2& program thrust.
!+. 3onitor medical equipment and supplies, maintain proper inventory.
!,. %ssists patients in moving, maintaining proper alignment of patient body using
body mechanics.
!/. 2bserves signs and symptoms, institutes remedial action when appropriate and
records these in her chart.
!F. Performs irrigations, catheteri*ation and gives enemas.
!G. %dministers medications to patients.
!H. 'nstructs patient and families.
!I. )nsures proper care and maintenance of equipments.
#@. Teaches and directs non<professional nursing personnel.
#!. %cts as senior nurse when so delegated.
##. 6eceives and endorses 2P. equipments and supplies.
#+. 'nterprets hospital policies and procedures.
#,. 3aintains good relationships with other hospital personnel.
#/. %ttends meetings and conferences.
POSI#ION #I#LE: NURSING A##ENDAN#
!!
.efinition % nursing attendant is one who operates at a level of a wor$er trained on the
Bob to assist the professional nursing staff by performing routine duties in ta$ing care of
hospitali*ed patients.
Kualification 6equirements
)ducation Preferably 3idwifery8Nursing under board8 Nursing %ide8Practical Nursing
%ssistant81aregiver 1ourse graduate or those with comprehensive training as nursing
assistant.
Training and )-perience 7ith comprehensive training as nursing assistant.
SP)1'F'1 8%1TC%( FCN1T'2NS %N. %1T';'T')S
. Aob .escription
!. Performs direct care
a. %ssist in admission "prepares bed, participate in the orientation of
patients8relatives.
b. Provide 8assist patient in personal hygiene and comfort
Provide bed bath, hair shampoo, oral hygiene, and perineal care to patients
when necessary.
#. 3aintains cleanliness and orderliness of the area.
+. Prepares and sterili*es diagnostic and therapeutic pac$s, sets and linens.
,. 'ssue supplies and equipment needed in the wards and special departments.
/. 3a$es and pac$s medical supplies such as cotton balls, 2S, dressing pac$s, eye
pac$s, gau*e, sil$ sutures and cotton pledgets.
F. 5rings soiled linens to the linen section for replacement.
G. Prepares solution for disinfections for use of the wards.
H. 'nform staff nurse on equipments, facilities that needs maintenance chec$ up.
I. Participates in the orientation of new nursing staff.
!@. 1hec$s and receives endorsements from outgoing aide.
!!. %ttends rounds with the ward nurse.
!#. Performs simple procedures li$e perineal care, SS enema, etc.
!+. 3easures and records inta$e and output.
!,. 3onitors and records vital signs.
!/. Provides specimen vials, collects urine and stool specimen and send them to the
laboratory.
!F. Provides clean linen and ma$es bed.
!G. Shaves patient for surgery.
!H. 3aintains cleanliness and orderliness of the patient4s unit at all times.
!I. 6emoves8cleans8arranged all unused equipment from patient areas and returns them
to designated area.
#@. 2rgani*es beds and bedside tables, counters, cabinets and chair.
#!. %nswers patient calls and deliver messages.
##. Submits all charges to billing section at the end of every shift.
#+. Prepares diet list of patients.
!#
POSI#ION #I#LE: 9ARD CLERK
.efinition 7ard 1ler$ are trained on the Bob to assist the professional nursing staff
by performing routine duties in the review of records and required documents of
hospitali*ed patients, inventory of drugs and supplies, facilitate admission, billing and
discharge.
Kualification 6equirements
)ducation Preferably 3idwifery8Nursing %ide8Practical Nursing
%ssistant81aregiver 1ourse graduate or those with comprehensive
training8understanding of medical and nursing terms.
Training and )-perience 1omputer literate, with comprehensive training as 1ler$,
$nowledge in preparation of reports and communication letters.
SP)1'F'1 8%1TC%( FCN1T'2NS %N. %1T';'T')S
Aob .escription
!. 6eviews patient4s chart for accuracy, completeness and proper arrangements.
#. Gather patient4s personal data to complete needed information. Submits the
completed charts to record section every morning.
+. 6eceives labels and stoc$s incoming deliveries and supplies from the supply
and property section for use of the wards and other special sections.
,. Submits required report of supplies inventory and updates stoc$ level to the 1S6.
/. Submits patient4s census to medical records section everyday at H@@am.
F. Facilitate 8follow up required documents of P&'(&)%(T& and Pay patients.
G. Gives information8education to patients and families regarding hospital rules and
regulations.
H. %ssist in the preparation of death certificate, and birth certificate.
I. Prepare reports and perform other functions as ordered.
ORGANI:A#IONAL S#RUC#URE O$ #HE DR0NRMH
NURSING SERVICE
Chief Nurse
!+
1hief Nurse
T6%'N'NG
? 6esearch

1hief of &ospital
Arti'le IV& CODE O$ CONDUC#:
!. )veryone should be aware of her8his Bob description.
#. There should be strict adherences to hospital rules and regulation.
+. No visitors should be allowed during tour of duty.
,. Silence within hospital premises should be observed.
/. %rguments with co<wor$ers should be $ept in private.
F. Personal phone calls should be minimi*ed.
G. 1onfidential information should not be divulged e-cept to proper authorities.
H. %ll employees should wear and display appropriately the official employee4s
'. of .AN63&.
!,
Nurse Supervisors
&ead Nurse in 1linical %reas

%sst. 1hief Nurse
&ead Nurse in Special %reas
1S6
2P.
26866
)6

3'1C8S'1C

N'1C8P'1C

Surgery
3edicine


25<Gyne


Pediatric

P&'(&)%(T&8
Pay 7ard
1ustodial
Public &ealth
Cnit

.6
Nurse Supervisors
I. %ll employees should be aware of and fully understand the &ospital policies0
ignorance of the policies e-cuses no one.
!@. New employees should be properly oriented on &ospital Policies by the head
of the Personnel Section and by the Nurse Supervisor in their respective areas
of assignment.
!!. %ll employees shall show courtesy, respect and compassion to all patients,
visitors and co<employees at all times.
!#. %void use of cell phone in front of the patient.
!+. Secure consent from proper authority when ta$ing pictures 9for documentation
purposes:.
!,. )ating while on duty should be done one at a time, and not in front of the
patient.
!/. &ead Nurses are responsible for the safe $eeping of the $eys in the areas.
!F. %dministrative %ide8Nursing aide assigned at the 268668.68'1C
8Nursery8N'1C is responsible for the cleanliness of the area.
Arti'le V& CODE O$ E#HICS $OR #HE NURSES
!. The nurse in all professional relationship, practices with compassion and
respect for the inherent dignity, worth and uniqueness of every individual,
unrestricted by considerations of social or economic status, personal attributes
or the nature of health problems.
#. The nurse4s primary commitment is to the patient, whether an individual,
family, group, or community.
+. The nurse promotes, advocates for, and strives to protect the health, safety, and
rights of the patient.
,. The nurse is responsible and accountable for individual nursing practice and
determines the appropriate delegation of tas$s consistent with the nurse4s
obligation to provide optimum patient care. The nurse owes the same duties to
self as to others, including the responsibility to preserve integrity and safety, to
maintain competence, and to continue personal and professional growth.
/. The nurse participates in establishing, maintaining and improving health care
environments and condition of employment conducive to the provision of
quality health care and consistent with the values of the profession through
individual and collective action.
F. The nurse participates in the advancement of the profession through
contributions to practice, education, administration and $nowledge
development.
G. The nurse collaborates with other health professionals and the public in
promoting community, national, and international efforts to meet the health
needs.
!/
H. The profession of nursing, as represented by associations and their members, is
responsible for articulating nursing values, for maintaining the integrity of the
profession and its practice and for shaping social policy.
Arti'le VI& GENERAL POLICIES
!. There are +<shifts, F@@ %3<#@@ P3, #@@ P3<!@@@ P3 and !@@@ P3
<F@@ %3 for a total of eight 9H: hours per shift and a total of forty hour a
wee$. &owever, upon the discretion and approval of the management a
twelve " hour 9!#: shifts can be an option for scheduling pattern as long as
the systems implemented will ensure the quality of nursing care provided
and that the total number of hours required will be served. Four 9,:
consecutive days of !# hours tour of duty is being discouraged0 ma-imum
of + consecutive days only will be implemented to ensure efficiency and
maintenance of health and well < being of the staff.
#. 6otation of shift2ti,e of duty (/3' P3' &ight shift$ is every one month <
+ months. 6equest of staff especially for training needs8schooling is given
consideration as long as it will not affect quality of service and other staff.
+. )ndorsement should be done !/ minutes before shifting.
,. Schedule is subBect to change when e-igency of service arises.
/. 't is the responsibility of the nursing personnel to $now her schedule of
duties and off<duties.
F. )-change of off<duties should be based on valid reasons which should be
determined by the recommending supervisors, a properly filled up form
should be submitted at least + days before the scheduled e-change of
duties.
G. There should be a senior nurse8plantilla staff nurse on duty for every shift.
H. Nursing personnel should go on straight duty if the incoming is absent,
however, he8she can only go on straight duty up to !F hours0 a reliever
should be provided beyond this period. 'f the administration opted to
implement the !# hours shift, head nurses8 supervisors must do all the
possible remedies to relieve the outgoing staff and avoid #, hours
continuous duty. There should be an on<call staff to augment the service in
case of absences.
I. 2ff during holidays and e-tra<off should be scheduled without hampering
the quality of service.
!@. % directory of nursing division personnel should be available especially at
the nursing office. This could also be utili*ed as part of disaster
preparedness. 9See attached directory of Nursing Service Staff :
!!. %ll newly hired nurses8nursing attendant should be oriented with the
nursing policy before e-posure to the assigned area.
!F
!#. %ll nurses and nursing attendants reporting for duty should wear the
official uniform. For NC6S)S white uniform with collar and white rubber
shoes, e-cept )68'1C8.68268P).'%8Nursery, must wear the prescribed
uniform. For NC6S'NG %TT)N.%NTS Green blouse and pants, and
blac$ shoes.
!+. %ll nurses must be informed on JN2 3).'1%( %556);'%T'2N
P2('1DJ. 't should be spelled out on patient4s chart.
!,. .on4t leave space in the chart. 'f with space, underline it, and then write
the initial8signature of the nurse on duty.
!/. Professional ethics should be strictly observed. )very personnel should be
addressed with respect. Nurses, nursing attendants and other hospital staff
must practice courtesy to patient, relatives, and co<employee as well as to
the general public.
!F. No personnel should entertain personal visitors while on duty unless
necessary.
!G. The telephone is for official use only. Personal calls should be avoided
e-cept when necessary. No long distance call shall be allowed e-cept in
cases of emergency but with permission from the higher authority.
!H. Nursing personnel must read updates8notices every time he8she reports for
duty.
!I. Nursing .ivision Staff meeting is scheduled every first Tuesday of the
month, while the Supervisor4s meeting is every 3onday. %n emergency
meeting can be called anytime when the need arises. )-cept when there are
Bustifiable reasons, failure to attend the meeting will mean forfeiture +*
s+8e +**5s'he,ule 7rivilees plus a written e-planation. Staffs that are on
their official duty will be considered as present during the meeting.
20. *ncident .eport)
%ll unusual incident and administrative problem should be reported to the
nursing office immediately 9during the shift the incident too$ place: to be
forwarded to the proper authority, i.e., absconded patient, carelessness in
applying hot water bags, fall incident, wrong medication, loss or damage to
the patient4s and hospital property, reporting under the influence of liquors,
quarrelling, negligence , etc. % 4ritten incident report must be
accomplished and submitted to the 1hief Nurse within ,H hours, failure to
submit the needed report will be dealt accordingly, the 1hief Nurse may
issue memos to the involved staff.
#!. %ll nursing service personnel are responsible for the losses and brea$age of
hospital supplies and equipment that are under their care. 'f the losses or
brea$age are due to negligence or failure to observe safety measures, the
concerned staff maybe as$ed to replace it. &ospital properties are for
!G
hospital use, equipments8supplies should not be brought home for personal
consumption. 1+rr+;in +* +<=en tan!( ne)uli>er( +ther 8e,i'al
e/ui78ents to be brought home for continuous use is not allowed but for
humanitarian reason, the employee may as$ the approval of the
director8representative 9property department: for #<+ days use only.
##. Staff Nurse must see to it that all equipment8machines are functional at all
times. %ll defective machines should be sent to the 1entral Supply
6oom8Property and 3aintenance Cnit for repair8replacement and should be
reported to the Nurse Supervisor. 3a$e sure that it will be logged in the
instrument and equipment logboo$.
#+. %ll nursing division personnel must help the hospital to save supplies and
energy. (ights must be switched off when not needed. &ospital supplies
should not be used for personal purposes. 1onservation of water supply
should be observed.
#,. .esignated Senior Nurse is the manager of the unit and shall be responsible
in preparing the monthly schedule of their staff, overseeing that stoc$s,
equipment and other supplies are adequate, functional and properly
recorded. %ll other issues and problem related to nurses can be relayed to
them through the supervisor. They may also be called as representative of
their unit during Supervisor4s meeting. %s part of performance evaluation,
their recommendations8observations on the staff will be given consideration
but final evaluation remains to the authority 1hief Nurse.
#F. 6otation is being done to enhance the staff4s $nowledge in all areas and to
promote camaraderie among all nursing division employees. The process
shall be done gradually and at phase. 6otation in area of assignment shall
be every si- months and as necessary. 'f possible nurses assigned in special
areas that will require special training shall not be included in the rotation
unless a properly trained personnel is available to relieve the area 9i.e., 26,
'1C:. &ead Nurses shall be rotated every two 9#: years. The acting Senior
Nurse and those who will be retained in their area shall be responsible for
orienting the newly rotated co<employees. There should be proper
endorsement of equipment and supplies on or before the rotation.
#G. .T6 should be accomplished accurately and honestly and must be
submitted to the nursing office on the first<second day of the succeeding
month, chec$ed and initialed by the Nurse Supervisor.
#H. %ll Supervisors must prepare the schedule in advance and should be posted
at least four 9,: days before the succeeding month, approved and signed by
the 1hief Nurse. .raft of monthly schedule can be chec$ed by N2.8N%
!H
prior to Printing to chec$ if the request were granted or not and to clarify
other issues.
#I. 2fficial receipts for Professional Fee must be provided by the attending
private physician especially for reimbursement of P&'(&)%(T& patients.
Nursing .ivision staff is not allowed to receive professional fee of private
attending physician.
+@. Problems, suggestions, and complain with co<employee must always be in
writing.
Arti'le VII& 9ORKING HOURS
S)1T'2N !. %ll nursing personnel shall wor$ H hours per duty, for a total of !F@
hours for #!<## wor$ing days in a month. This may be changed for the e-igency of the
service. The 1hief Nurse, %ssistant 1hief Nurse, Training 2fficer and Supervisor will
report H hours a day for a total of ,@ hours a wee$.
Shifting hours are as follows
3orning shift F@@ am to #@@ pm
%fternoon shift #@@ pm to !@@@ pm
Night Shift !@@@ pm to F@@ am
6egular Shift H@@ am to ,@@ pm
2PT'2N 9!# &2C6S .CTD:
3orning shift F@@ am to F@@ pm
Night Shift F@@ pm to F@@ am
6egular Shift H@@ am to ,@@ pm
S)1T'2N #. 5rea$ time of !/ minutes shall be provided. Nobody is allowed to eat at
the Nurses4 Station. Staff should eat one at a time at the designated area.
Arti'le VIII& 0O1 A##ENDANCE
The hospital has hired each employee because it needs his8her services.
)very time an employee fails to attend to his wor$, the quality of service is affected0
consequently, the Nursing 2ffice has to implement the following policies
S)1T'2N !. REPOR#ING #IME
%ll nursing personnel must report at least !/ minutes before the scheduled
duty, to chec$ supplies, facilities, and medicines as well as to endorse patient properly.
They must time<in and time<out at the 5undy cloc$. Nobody is allowed to leave
his8her post without a reliever. Nobody is allowed to loiter in the hospital especially
!I
during their tour of duty. % locator slip must be accomplished each time an employee
leaves the hospital while on duty.
S)1T'2N #. O$$ DU#IES
Nursing personnel who will render H hours per duty for #!<## days a month
will be given H<I days off in a month. Special request for off duties is filed one wee$
before the preparation of the schedule 9#+
rd
of the month:. The approval will depend on
area8 ward situation.
S)1T'2N +. E6CHANGE O$ DU#% SCHEDULE
6equest for e-change of duties is made in writing and shall be approved by
the supervisor if Bustifiable. %ll parties involve must sign the request letter. Failure to
fulfill their agreement will be dealt with accordingly. Cnapproved request for
e-change of duties shall be considered null and void. The supervisor who approved the
request shall be responsible for arranging the schedule8staffing pattern.
S)1T'2N ,.ON CALL
Schedules are subBect to change for the e-igency of the service. %nybody
can be called to render e-tra service when the need arises. 6efusal to render service
without valid reasons is subBect to disciplinary action. %nybody who renders e-tra
service shall be granted e-tra day off as compensation.
S)1T'2N /. O$$ICIAL SCHEDULE
Staffs are not allowed to ma$e changes or erasure in the official schedule
sheet. %nybody who will be caught doing such act will be dealt with accordingly.
S)1T'2N F. A1SENCES5#ARDINESS
F.! 'n cases of absences, the nursing personnel must notify the NS2 at least ,
hours prior to scheduled duty. %fter being absent, she must also notify the
NS2 before reporting for duty. 2nly the 1hief Nurse, %ssistant 1hief
Nurse, Supervisors and the Senior Nurse can accept the notice of
absence.
F.# %ny employee who is absent without proper notice will be subBected to
appropriate disciplinary action such as deduction in off duties or stiffer
penalties for repeated offense.
F.+ 'n cases of absences the day prior to the scheduled off duty, the following
day which is his8her official off duty will also be considered absence if
she failed to report. 'f he8she reported on the said date, her official off
duty will be rescheduled.
F., Tardiness e-ceeding +@ minutes !@ times a month without valid reason
will mean forfeiture of one off duty. &abitual tardiness will be dealt with
accordingly.
F./ %pplication for sic$ leave for more than five 9/: days shall be submitted
together with medical certificate. %pplication for vacation leave shall be
#@
filed in advance, as much as possible / days before and not later than the
preparation of duties for the ne-t shifting.
%5S)N1)S
!. Filling of sic$ leave, maternity leave, vacation leave and privileged leave
should be in accordance with the civil service rules and regulations subBect to
the recommendation of the 1hief Nurse of the hospital.
#. 'n case of sic$ness he8she should notify his8her supervisors immediately and
should see$ consultation preferably in .6AN63&.
Arti'le I6& UNI$ORM 5GROOMING
%ll nursing personnel must report to duty in proper prescribed uniform.
Scrub suit should be worn only at the )6, .6, 26866, '1C and Nursery. Good
grooming should always be maintained. 2nly light ma$e<up is allowed. &air should
always be properly fi-ed.
UNI$ORMS
7ard Nurse
Female 7hite blouse and white pants, Nurse4s cap, &ospital '., white shoes and
white stoc$ings8soc$s.
3ale 7hite polo, short sleeves, white pants. 7hite soc$s and white shoes, &ospital
'..
'1C, 26866, N'1C, Nursery, and .6 Nurse Scrub suit with embroidered name and
position, white shoes with soc$s, &ospital '.. 5la*er8Smoc$ Gown when going
outside of the comple-. 7hite uniforms must be worn at all times when reporting to
duty0 and will change to scrub suit for sterility purposes. Slippers to be used
e-clusively at the comple-.
)6 Nurse Scrub suit with embroidered name and position, &ospital '., rubber8white
shoes.
Nursing %ttendant uniform Green blouse and pants with embroidered name, 5lac$
shoes with soc$s, &ospital '..
Arti'le 6& PER$ORMANCE EVALUA#ION
Performance evaluation shall be conducted every si- months. The 1hief
Nurse is held responsible for the rating of employees under his8her department. The
immediate Nurse Supervisor ma$es the initial rating. The 1hief Nurse shall then
review the given rating before final submission to the P)61. 6ecommendation for
promotion shall be granted based on merit and performance evaluation and other
credentials.
#!
Arti'le 6I& POLIC% ON VOLUN#AR% SERVICE 2See ?MOA *+r V+luntar=
Servi'e3
S)1T'2N !. % professional nurse, midwife, nurse aide who is willing to render
voluntary service must submit an application letter and meet the following
requirements
a. Passed the board e-amination and licensed by the P61 to practice her
profession0 and
b. 5e in good physical and mental condition.
S)1T'2N #. 2nly those who passed the Nursing .ivision Screening 1ommittee of
this hospital will be accepted as volunteer of the Nursing .ivision .The Screening
1ommittee will be responsible in processing the records and certificate on voluntary
service. The Training 1ommittee will be the one in<charge of giving the necessary
training, orientation and e-posure to accepted volunteer.
S)1T'2N +. ;olunteers once accepted must sign a waiver, ;oluntary 7or$ %greement
9;7%: that his8her services and e-pertise offered to .AN63& is without any
remuneration or obligation from the management. Furthermore, being a volunteer will
not be an assurance that he8she will be hired in any vacant position in this hospital.
2Please see A77en,i< -@AV+luntar= 9+r! Aree8ent3&
S)1T'2N ,. ;olunteers will wor$ under direct supervision of the permanent staff on
duty and the supervisor where they will be assigned. They should follow rotation and
official schedule of duties.
S)1T'2N /. ;olunteer nurses will not be allowed to accompany patients for transfer
or referral to other health facilities or to carry out doctor4s order without the
supervision of the permanent staff on duty.
S)1T'2N F. ;olunteers will be allowed to write on the patient4s chart 9e-cept for
3edico<legal: however, the permanent nurse8midwife on duty must countersign
his8her charting.
S)1T'2N G. ;olunteers must abide to all the rules and regulations of the hospital0 any
violation could result to termination of his8her voluntary service. )-amples are
a. 7earing of proper uniforms ? '.
b. Signing on the attendance logboo$
c. No smo$ing policy within hospital compound
S)1T'2N H. ;olunteers are allowed to render services for si- 9F: months only.
Services could be terminated anytime or be renewed depending upon the
recommendation of the Screening 1ommittee and the approval of the 1hief Nurse. %
##
certificate for voluntary service will be issued only upon presentation of .aily Time
6ecord.
Arti'le 6II& ORIEN#A#ION PROGRAM $OR #HE NE9 NURSING
DIVISION S#A$$
2rientation should cover the overall physical setting and organi*ational
structure, overview of the mission, vision, philosophy, policies and standards of the
hospital and nursing service, Bob description, and the relationship with the community
and other agency. 't also includes 1S1 (aw, 1ode of )thics, 7aste Segregation,
Performance )valuation Policies, Patient Service Policies, Safety, 'nfection 1ontrol
and other important updates.
Arti'le 6III&RESPONSI1ILI#% AND ACCOUN#A1ILI#% O$ SENIOR NURSE
!. Senior Nurses shall be accountable for the action and inactions of their
subordinates. They shall be responsible in ensuring that their staffs perform
their respective tas$s and responsibilities.
#. 'ssues and concerns shall be settled first within the section. 'f unsettled, the
matter should be raised to the Supervisor81hief Nurse.
+. 1hief Nurse shall be accountable and responsible for the action and inaction of
the Supervisors, Senior Nurse and the entire Nursing .ivision.
,. %ll communications and tas$s that need action shall be acted upon within !/
days. Tas$s and communications that need action as soon as possible shall be
acted upon within + days.
/. .ifferent committees must be responsible for their designated tas$s and
responsibilities.
Arti'le 6IV& NURSING DIVISION S#ANDING COMMI##EES
The utili*ation of standing committees whose main purpose is to
establish standards for safe and effective nursing care is one of the many tools
contributing to the performance of the Nursing .ivision. (Membership with the
committees will have a term of 2 years for the chairman and 1 year for the
members, except for committees that requires special training for their
members
The different standing committees within the Nursing .ivision are the
following
!. Policies and Procedures 1ommittee.
#. Screening and Performance )valuation 1ommittee.
+. Staff .evelopment 1ommittee.
,. Nursing %udit 1ommittee.
#+
/. 1omplaints and Grievances 1ommittee.
F. 6esearch 1ommittee.
G. 6eligious 1oncern 1ommittee
H. &ealth , Safety, and 1ontinuing Kuality 'mprovement 91K': 1ommittee
I. 'nfection 1ontrol 1ommittee
!@. &ospital 7aste 1ommittee
!!. Non<communicable .isease 1ommittee
!#. 1ommunicable .isease 1ommittee
!+. 1ommittee on Programs and 2ther &ospital %ctivities
!,. 1ommittee on 5idding and Procurement
3embership 9Please see updated (ist of 3embers " A77en,i< B:
The 1hief Nurse appoints the chairman of the different committees. The
chairman, in turn, selects his8her members from different levels of the nursing
staff for ma-imum participation.
The different committees shall formulate the guidelines including their regular
schedule of meeting.
6oles8 Functions of each 1ommittee
!. Policy and Procedures 1ommittee
The Policy 1ommittee establishes guidelines or policies for the Nursing
.ivision personnel which delineates responsibilities and prescribes the
action to be ta$en under a given set of circumstances.
The Procedure 1ommittee identifies ways of improving the quality of
patient care by reviewing nursing procedures and updating them according
to current standards in care.
't periodically appraises and revises policies, and if indicated, develops
new policies to meet present and future needs, submits recommendations to
the 1hief Nurse regarding the development, revision, or modification of
policies8procedures.
#. Screening and Performance )valuation 1ommittee
This committee participates in the recruitment and selection of
personnel. The committee screen, interviews, evaluates and
recommends candidates for admission or for promotion to positions in
the Nursing .ivision.
+. Staff .evelopment 1ommittee
#,
This committee plans for short<and long range training programs whole
year round to upgrade performance of the Nursing .ivision personnel
through the introduction of new concepts, increased $nowledge in
problem analysis and development of good wor$ing relations and
positive attitude towards wor$s. These include orientation, leadership,
s$ills training or on the Bob training programs.
,. 1omplaints and Grievances 1ommittee
This committee receives and reviews complaints and grievances within
the Nursing .ivision to e-pedite fair Budgment in accordance with the
policies provided by the agency and the 1ivil Service 1ommission. The
committee should address the complaints0 ma$e reports on their
findings and recommendations to be forwarded to the 1hief Nurse.
/. 6esearch 1ommittee
This committee initiates researches in nursing and participates in
hospital related researches8studies. 't shares research findings to staff
and encourages development of research related activities.
F. Nursing %udit 1ommittee
This committee evaluates nursing care to patients through interview,
observation or review of patient4s charts.
Nursing Service %udit is an official e-amination of nursing records,
physical facilities and personnel involved in patient care for the purpose
of evaluation, verification and improvement. 't is a tool in analy*ing
and evaluating nurses, bedside records and physical facilities. 't serves
as a means of improving nursing care by revealing e-isting
deficiencies.
% Nursing audit committee is created and composed of a representative
from all levels of the nursing staff a member of a Training Staff,
Supervising Nurse, Senior Nurse and a Staff Nurse. 1omposition may
vary in other hospitals. 'n smaller hospitals, the 1hief Nurse or his8her
%ssistant may be a member of this committee.
G. 6eligious 1oncern 1ommittee
This committee initiates religious activities for patients and employees
to meet their spiritual needs and will be in<charge of mass, blessings,
request of religious organi*ations and the last sacrament for dying
patients.
H. 1ontinuing Kuality 'mprovement 91K': 1ommittee
#/
This committee enhances patient care through systematic assessment
and improvement of the quality of care rendered by the Nursing Service
staff.
I. 'nfection 1ontrol 1ommittee
This committee initiates development, implementation, evaluation,
review and updating of written guidelines, policies, and procedures that
addresses infection prevention, detection and control of health care
facilities 9refer to .2& 'nfection 1ontrol 3anual:
!@. &ealth and Safety 1ommittee
This committee assures that condition in the wor$ environment is
conducive for the health and safety of personnel.
!!. 1ommittee on Programs and 2ther &ospital %ctivities
This committee will be in<charge of .2& Program monthly activities,
&ospital 7ee$ 1elebration, (eprosy 7ee$ and other activities of the
hospital.
!#. 1ommittee on 5idding and Procurement
This committee ensures quality of medical supplies and prepares
specifications of needed item to be included in the annual procurement
plan. The committee can represent the Nursing 2ffice during public
bidding conferences when needed as member of the Technical 7or$ing
Group.
!+. Non<communicable .isease 1ommittee
This committee is responsible for monitoring and reporting non<
communicable cases to 6egional )pidemiology and Surveillance Cnit
96)SC: of 1enter for &ealth .evelopment "3etro 3anila 91&.<33:,
and to coordinate8attend 8advocate activities related to the Non<
communicable program of the .2&. 3embers are e-pected to monitor
8ensure that the following new cases are entered in the registry form and
submitted on time as scheduled.
a. 1ancer
b. 1hronic 2bstructive Pulmonary .isease 912P.:
c. .iabetes
d. Stro$e
!,. 1ommunicable .isease 1ommittee
This committee is responsible for monitoring and reporting communicable
cases to the management, 6egional )pidemiology and Surveillance Cnit
96)SC: of 1enter for &ealth .evelopment "3etro 3anila 91&.<33:,
#F
and to coordinate with (GC for follow<up8surveillance in the
community8area affected by the disease. 3embers also
coordinate8attend8advocate activities and ensure that standard protocols
related to the .2& Program on disease surveillance are implemented.
Arti'le 6V& RN HEALS GUIDELINES 21ase, *r+8 DOH De7art8ent Or,er N+&
-CDDAC-.B ,ate, Se7te8)er E( -CDD3
General O)Fe'tive: To create a pool of registered health professionals with enhanced
clinical and public health competencies towards the improvement of health care
service delivery.
S7e'i*i' O)Fe'tives:
e. 'mprove access to quality healthcare services.
f. 'ncrease nurses and midwives employability through the provision
of learning and development opportunities.
g. Foster independence in the community4s health care delivery
system0
h. %ddress the inequitable distribution and augment the nursing and
midwifery wor$force in the .2& hospitals and health facilities
specially rural, underserved, hardship communities0
i. 'mprove the current nurse to patient ratio in accordance to .2&
standard staffing pattern.
B. 'mproved local health systems that will support the country4s
attainment of universal health care or JEalusugan Pang$alahatan.M
'mplementing guidelines in hospital setting
a. The nurses and midwives shall undergo learning and development in
clinical and public health during their one 9!: year of deployment.
b. Nurses assigned in hospitals shall be provided with competencies
through rotations in different specialty department of the hospital.
c. Nurses and midwives with 1ertificate of 1ompletion shall be
considered for priority employment in government health facilities
where vacant post e-ists.
d. Nurses and midwives shall be evaluated on a regular basis during the
one 9!: year period.
e. %bsences, tardiness or under time shall be deducted from their monthly
allowance.
6ecruitment and Selection
a.%pplicants shall apply directly to the recipient .2& hospitals or
through the 1&.4s. The registry of nurse applicants from .2()
shall be a source of candidates to the proBect.
b. 2nly nurses with valid P61 license are eligible to apply.
#G
c.Preference shall be given to nurses and midwives residing in the
localities where the recipient .2& hospitals or health facilities are
sited.
d. Nurse and midwife volunteers, trainees, or those e-posed in
.6AN63& shall be given priority.
e. Nurses and midwives must be physically and mentally fit. % medical
certificate from a government hospital is required.
f. To enhance and provide focus for the clinical and public health
rotations, competences shall be anchored on courses geared towards
specialty modules with continuing professional units as required by
P61.
g. 6eplacements shall be allowed in case of drop<outs but will only
complete the remaining period of the proBect.
DOH Me8+ ,ate, O't&DE( -CDD( 5rientation prior to assumption of duty0
monitoring and evaluation of performance are the responsibilities of the
hospital where they will be assigned.
Arti'le 6VI& NURSING DIVISION ADMINIS#RA#IVE PENAL#IES
a. .iscipline is imposed to train, correct, strengthen, or mold wor$
attitudes and behavior. 5y instilling discipline, order and control are
gained among the employees.
b. .isciplinary actions become necessary when an employee violates rule
or is consequently deficient in meeting standards of quality, quantity
and8or attendance. %ll disciplinary actions must be clearly documented
and the employee must be given every opportunity to e-plain his8her
side. 't is only after due process has been observed that the disciplinary
action will be ta$en.
c. The Nursing 2ffice maintains the right to enforce disciplinary actions
where the employee4s conduct, behavior or attitude is detrimental to the
well being of the patient, the other employee4s and8or the hospital itself.
d. The intent of any disciplinary action is to motivate the employee to
change his conduct, behavior or attitude, N2T T2 PCN'S&.
e. 7hen the initial appropriate disciplinary actions fail to bring about the
necessary change in behavior, the ne-t series of steps 9stiffer
impositions: are applied which may eventually lead to termination of
employee4s services. &owever, there are some infractions that are so
serious such that stiff disciplinary measures may be immediately
applied, including recommending immediate suspension or dismissal.
#H
f. Penalties for all administrative offenses shall be based on the guidelines
provided for under the 1ivil Service (aws 931 No. +@4s !IHI: P. No.
H@G and 1ode of 1onduct 6% No. FG!+, classified into grave, less
grave, and light and their corresponding penalties.
g. ;iolation of the other Nursing .ivision policies stated above of this
3anual shall have corresponding penalties.
Ste7s +* Pr+ressive
Dis'i7line
DE$INI#ION O$ #ERMS
.epri,and means warning in oral or written form. &owever, for the purpose of proper
administration of employee offenses, official reprimand must always be in writing,
with a copy furnished by the Personnel 6elations Section for the employee4s #@! file.
Suspension means that laying<off of an employee without pay for a prescribed number
of days without the loss of continuity of service on account of administrative charges
for the violation of established &ospital 6ules and 6egulations.
Habitual %ardiness means that the employee has reported late for wor$ for a total of
!@ days and beyond in one month or more for three consecutive months regardless of
the number of minute.
#I
*nfractions are grouped into three categories8classes based on their relative
seriousness. )ach class is to be treated separately based on guidelines specified in the
policy on the 6ules and 1onduct and .isciplinary %ction.
a. 1lass '8(ight 2ffense
These are relatively minor offenses and generally call for a series of
progressive disciplinary measures. They are classified lighter generally
easy to correct.
b. 1lass ''8(ess Grave
These are generally light offenses but slightly more serious that a
documented action is immediately necessary on the first commission.
c. 1lass '''8Grave
These are very serious in nature and call for, generally, immediate
discharge upon commission. .isciplinary action ta$en for 1lass '''
infractions should be given particular attention and must be
administered swiftly without preBudice to observance of due process. 'n
certain circumstances based on meritorious grounds, the penalty may be
changed or reduced after a meeting of all concerned parties.
Arti'le 6VII& COMMUNICA#ION $LO9 IN #HE NURSING SERVICE
1ommunication flows between, in and out of the organi*ation including
patients, visitors, families, friends and the community, that nurses are e-pected to
understand and be able to answer queries as they proBect the image of .AN63&.
Formal and official channels of communication between individuals in the
Nursing Service, between heads of the different services will be based on the
organi*ational charts. D+;n;ar, '+88uni'ati+n flow comes from higher to lower
authority, the 1hief Nurse and his8her %ssistant communicate with all supervising
nurses. 'n their absence, the person ne-t in ran$ ta$es their place. 7ritten
communication from the 1hief Nurse to nursing personnel is coursed across the line
through the Supervising Nurses and the Senior Nurse.
7hen a Supervisor or &ead Nurse gives bac$ written reports or information
u7;ar, '+88uni'ati+n is applied. )-change of ideas usually ta$es place during
meetings, rounds and conferences. 5oo$lets, memos, brochures, and periodicals are
also effective in disseminating information and will be utili*ed as needed.
%ll information regarding the patient should be regarded as confidential unless it is a
policy matter. 'n which case, the hospital administrator may release the information
+@
required. The patient himself8herself may also request through the %dministrative
2ffice, information he8she may need for Philhealth, insurance and retirement.
PAR# II& PA#IEN# SERVICE POLICIES
Arti'le I& Ea'h ;ar, +r unit 8ust have ;ritten Stan,ar,s +* Pr+'e,ure an,
P+li'ies 2Cust+,ial 9ar,( ER( Me,i'al 9ar,( OPD( OR5DR( Nurser=( CSR( O1A
G=ne( Pe,iatri's( NICU( ICU( Surer=( an, #rainin Servi'e *+r Nursin an,
Other A**iliates&3
In eneral the *+ll+;in 8ust )e +)serve,:
S)1T'2N !. % '+nsent form must be sign by the patient8relatives before initiation of
care and before admission and special procedures. The patient8relatives must sign the
1onsent Form for %dmission( 2A77en,i< G D3 and 1onsent for 2peration ? Special
Procedures, 9A77en,i< G -:.
Patient8relatives must be properly informed of the hospital policies, rates, and given a
copy of the J'nstruction Guidelines or Paunawa FormM 9A77en,i< G .:.
a. Pananagutan ng Pasyente o (egal na Nangangalaga
b. 3ga Earapatan at Pananagutan ng Pasyente
S)1T'2N #. Proper en,+rse8ent of patient must be done at bedside by the outgoing
Nurse to the incoming Nurse and shall endorse using the updated $arde- 8)ndorsement
Sheet8Patient4s 1hart.
S)1T'2N +. Me,i'ati+ns an, treat8ent must be charted only after the nurse
concerned has administered the drugs. Standard 2perating Procedures on
.ocumentation of medications on therapeutic sheets must be observed. 2A,a7te,
*r+8 the Manual +n Nursin Stan,ar,s +n Intraven+us Pra'ti'e B
th
E,iti+n(
ANSAP GUIDELINES $OR DRUG ADMINIS#RA#ION3

1ounterchec$ the medication card against the doctor4s written order.
!. 2bserve !@ 6s when preparing and administering medication.
#. )-plain procedure to patient 9the name of medicine and action8interaction of
medication: before administration.
+. 7ash hand before and after the procedure 9use gloves especially for
chemotherapeutic drugs:.
,. %ll nurses must possess a valid P61 license and preferably have attended
training on '; therapy.
/. Proper identification of patient should be observed. The Nurse will as$ the
competent patient to state his8her name.
F. For patient with altered mental status, the nurse should chec$ the bracelet or
name tag on patient4s wrist or verify to the watcher the name of the patient.
+!
G. Golden 6ules should be observed at all times.
Riht Or,er& D+'t+rHs +r,er is al;a=s ;ritten( ,ate, an, sine, )=
the +r,erin 7h=si'ian&
Riht Me,i'ine& Me,i'ines 8a= have si8ilar na8es& 1e 'are*ul in
e<a8inin the la)el&
Riht D+se& 9hen in ,+u)t( ,+u)le 'he'! ;ith the 7h=si'ian& It is
)etter t+ )e sa*e than s+rr=&
Riht Patient& #here are ti8es that 7atients have the sa8e na8e an,
surna8e& Veri*= the 8i,,le initial& As! the 7atient t+ state hisIher
na8e&
Riht R+ute an, $re/uen'=& S+8e 7r+'e,ures are iven +rall= +r
7arenterall=& Che'! several ti8es t+ 7revent err+rs&
Riht Assess8ent& Assess ;hether 7atient has an= alleries +n
7revi+usl= a,8inistere, ,rus an, )l++, trans*usi+n&
Riht A77r+a'h& Patients ;h+ are havin 7r+)le8s ;ith ,ru
a,8inistrati+n es7e'iall= 'hil,ren ;ill )e 8+re '++7erative i*
a77r+a'he, in entle 7ersuasive 8anner that )uil,s trust an,
'+n*i,en'e in the 7atient&
Riht $ee,)a'!& #+ the +r,erin 7h=si'ian( is i87+rtant s+ he ;ill
!n+; the 7atientHs 7r+ress&
Riht O)servati+n& Patient sh+ul, )e reularl= visite,( i* there are
an= s=87t+8s +* rea'ti+ns&
Riht D+'u8entati+n& #his is leal re/uire8ent& 9hat is n+t
,+'u8ente, has n+t )een +)serve, +r iven&
H. 6eport immediately to the attending physician in case of medication error8near
miss incident. %ccomplish %dverse .rug 6eaction Form 9%6F: then submit it
to the pharmacy. 2A77en,i< G --3
I. %ny drug administered should be recorded on the patient4s chart, at the
medication sheet and nurse4s notes.
!@. Cnavailable drug should also be noted. 'ndicate the time the drug should have
been administered then encircle.
+#
12(26 12.'NG


OD 4 J

1ID 4 K


#ID 4 @

4 D- PRN
DRUG NAME
%mpicillin /@@ mg
%mpicillin !gram
1lo-acillin /@@mg8 !gram
1efuro-ime G/@ mg
Pen G Na ! million 'C
&ydrocortisone !@@mg
1eftria-one /@@mg
1eftria-one ! gram
1hloramphenicol ! gram
++
S/3P6+ 3+7*#/%*5& #/.7


DELA CRUZ, JUAN R.
Amoxicillin 500mg PO TID
Ham " ! pm " F pm


DELA CRU:( 0UAN R&
1efuro-ime G/@mg T'; qH 9<: %NST
!# am " H am " , pm



DELA CRU:( 0UAN R&
Salbutamol ! neb q,
H am " !# pm " , pm " Hpm

Eindly fill<up the ff.
1omplete name surname, given name, middle initial
Generic name, dosage, route, frequency and %NST, if done. .on4t use the brand
name
e.g. Paracetamol ! amp T'; q,
%t the bac$, $indly signed by the nurse who carried out the order with signature over
trodat.
Facilitate color coding of medication card. %lso include oral, '; and nebuli*ation.
POLICIES $OR #RAINING PRO$ESSIONALS 9HO ADMINIS#ER DRUGS
!. %ll trainees must possess a valid P61 license and if possible should have
attended training on '; therapy.
#. Nurse trainees must be informed on JNO MEDICAL A11REVIA#ION
POLIC%M. 't should be spelled out in the patient4s chart.
+. 2ral medications are $ept at hand of the patient4s relative0 the trainee nurse
together with a senior nurse should follow up patient4s proper inta$e.
+,
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,. Nurse trainees are allowed to administer parenteral medications, properly
chec$ed and supervised by a senior nurse observing patient4s rights in giving
medications.
/. Trainees will be assigned wor$ing schedules 9errands, medication, or
documentation: to prevent overlapping of functions and duties.
F. Trainees should be evaluated after training.
S)1T'2N ,. Nurses and nursing attendants are not allowed to do the following
s7e'ial 7r+'e,ures e<'e7t th+se ;h+ are 7r+7erl= traine, an, 'erti*ie,. 'f in
e-treme emergency, the doctor delegated these responsibilities, the doctor will be held
liable for the wrong act done by nurses.
a. Suturing
b. )pisiotomy and episiorraphy
c. NGT insertion
S)1T'2N /. 2nly nurses with certificate of IV thera7= trainin are allowed to do ';
insertion. 9Philippine Nursing (aw of !II! Section #!, %rticle v of 6% G!F,:
S)1T'2N F. 6eading of s!in test should be done and signed by the doctor.
S)1T'2N G. Nurses must go with the ,+'t+rHs r+un,.
S)1T'2N H. 2nce a doctor or a nurse ,eleate, her function to other e.g. nursing
attendants and the latter committed a mista$e, the former should be held liable for the
mista$e following the principle of command responsibility.
S)1T'2N I. 2nly in case of e-treme emergency and when no other doctor is present
should a nurse refer and receive tele7h+ne +r,ers( ;hi'h sh+ul, )e ;ritten +n the
D+'t+rHs Or,er Sheet ;ith ,ate( an, sinature +* the nurse ;h+ re'eive, the
+r,er( an, sh+ul, )e '+untersine, )= the ,+'t+r as s++n as 7+ssi)le& D+'t+rHs
+r,er thru te<t 8essain is n+t all+;e,&
S)1T'2N !@. %ll nursing personnel are responsible for the requisition, maintenance
and proper utili*ation of e/ui78ent an, su77lies. The end user 9Senior Nurse: should
prepare the 6equest in ;oucher, chec$ed and signed by the supervisor. Out +* +r,er
8a'hines an, e/ui78ents must be forwarded to Property for repair.N2. must
ensure that forwarded equipments8machine are properly recorded in the logboo$ and
signed as received.
S)1T'2N !!. C+8*+rt( 7riva'= an, sa*et= 8easures to prevent inBury should
always be provided to the patient. Proper room ventilation must be observed.
'f possible, adult male and female patients must be confined separately& 2Please see
List +* Sa*et= Measures an, Manual +n Sa*e H+s7ital Pra'ti'es&3
+/
S)1T'2N !#. Unuse, 8e,i'ines an, su77lies brought by the patient should be given
bac$ to them or their relatives 8 pharmacy. D+nate, unused drugs must be recorded
properly. 6ecipient of donated drugs must sign once they received8used the drugs.
9Please see inter,e7art8ental 7+li'= ;ith the Phar8a'=3&
S)1T'2N !+. % request, properly signed by the doctor, must accompany all laboratory
and radiology e-amination. Nurses are not allowed to sign in the 7res'ri7ti+n(
la)+rat+r= and ra,i+l+= re/uest e-cept during emergency, which later on must be
countersigned by doctor on duty. .octors will be accountable for pre<signed
prescription and laboratory request0 these matters should be clarified by Nurse on .uty
8Senior Nurse during their shift before accepting the responsibility.
S)1T'2N !,. Patient86elatives should see$ approval from the %dministrative 2ffice
before using a,,iti+nal ele'tri'al a77lian'es inside the hospital premises. )-tra
charges for additional appliances should be e-plained to the patient8families but as
much as possible we refuse for additional electrical appliance that may result to
electrical overload which is one of the common causes of fire.
S)1T'2N !/. The nurse on duty must issue the 9at'herHs Pass to patient4s relatives
upon admission. 2nly one watcher is allowed per patient at the ward e-cept for critical
patient needing e-tra support.
SEC#ION DK& 2bserve proper en,+rse8ent +* su77lies an, e/ui78ent ever= shi*t
in ea'h area5unit& % log boo$ of inventory of equipment must be signed every shift by
nurse on duty. .o not accept bro$en8damaged equipment without the incident report
accomplished during the end of the shift. 3issing article must also be immediately
reported to Senior Nurse8Supervising Nurse. 1entral Supply 6oom has standing
procedures related to this incident. Please see guidelines on distribution and collection
of linen.
S)1T'2N !G. % nurse8nursing attendant must accompany all patients who will be
transferred from one ward to any hospital unit within .AN63&. % nurse must
accompany patients for transfer to other hospital, preferably with a physician. The
nurse must chec$ the doctor4s order for referral 9referral letter:.
PA#IEN# #RANS$ER
!. For trans<in and trans<out from one ward to another, there should be a written
order from the doctor. 'nform the ward8admitting section where the patient is to
be transferred.
#. The nurse on duty should accompany patients who are not critically ill for
transport to other hospital per ambulance. 'f critically ill, a medical officer
should accompany the patient. She8he should secure the signed
ac$nowledgement slip and submit to the Senior &ouse 2fficer upon her return.
+F
+. The nurse should accompany the patient for special diagnostic procedures
outside the hospital.
,. %ssess, informs the resident physician, record patient4s condition in the chart
and a ;aiver 2A77en,i< -L3 must be signed by the relative prior to transport.
/. 6ecord in the logboo$ all patients being referred out for diagnostic procedures
or being transferred to other hospital.
F. Patients who will be transferred via self "conduction are not allowed to bring
the .AN63& hospital equipments such as o-ygen tan$. 'f 2# will be badly
needed, patient8relatives are required to deposit amount equivalent to /@> of
the total cost of the item, to submit valid '., a promissory note countersigned
by baranggay official to guarantee return of the borrowed equipment.
S)1T'2N !H. %bandoned patients brought in by police or Non<Government
2rgani*ation without the accompanying relatives, i.e., beggars, street children,
victims, and insane persons should be treated fairly. Should be referred to the 3edical
Social Service Cnit. Personal belongings, if there is any, should be properly recorded
by the Nurse on .uty and Supervisors, attested by the security guard and submitted to
the Nursing 2ffice. %ll items should be properly labeled.
S)1T'2N !I. Nurses should hold stri't '+n*i,ential 7ers+nal in*+r8ati+n acquired
in the process of providing care. 2nly authori*ed person should enter 8read restricted
area8information. e.g. Patient4s chart
S)1T'2N #@. ;alues, customs and beliefs held by an individual are to be respected
including the JPatient4s 5ill of 6ights.M7hich, state that the patient has the right to
$now his conditions, right for informed consent, right to refused care, right to refused
on human researches, right to maintain privacy 8 confidentiality of information
gathered during the delivery of care, and the right to practice his8her religion&
2A77en,i< J3
S)1T'2N #!& Un7ai, )ills including professional fee of private consultants cannot be
a reason to delay discharge of patients. %ll indigent patient must be classified and refer
to social service for assistance.
S)1T'2N ##. Patients8relatives have the riht t+ ,e'i,e to discontinue 8withheld
resuscitation, forgo life<sustaining treatment, or end life care devices upon signing a
waiver8.o Not 6esuscitate Form& 2A77en,i< J M L3
S)1T'2N #+. $ee,)a'! Surve=5E<it intervie; will be conducted regularly to all
patients8families to assess level of satisfaction on the quality of care given during
his8her stay in this hospital. 6esult will be discussed during quality circles8meetings of
the 1ontinuing Kuality 'mprovement Team. %ppropriate recommendations must be
+G
forwarded as soon as possible to the 1hief of &ospital and .ivision &ead for
immediate action 2A77en,i< -D3
S)1T'2N #,. The patient 8a= re/uest 7rivate 7h=si'ian to handle his8 her care but,
the consultants must be duly recogni*ed by this hospital, have written 32% with
.6AN63&. %dmitting doctor must e-plain clearly regarding professional fee, hospital
bills and other charges if they choose to have private doctor.
S)1T'2N #/. RELEASE O$ CADAVER 2A77en,i< D-A$l+; Chart3
!. 7ard8Cnit
Nurse8Nursing %ttendant on duty verifies the following in the chart of the deceased
and writes down this information in the ward8unit logboo$.
a. 1omplete name, age, se-, diagnosis, address
b. Pronouncement of death
c. Time of death
d. Name of the attending physician
Nurse on duty interviews patient4s relatives and accomplish the pertinent data on the first page of the death
certificate. She sees to it that all parties concerned have signed the four pages
of the death certificate 9nearest relative of legal age and the attending
physician:. #he nurse ;h+ 7re7ares the 'erti*i'ate sh+ul, als+ sin( )ut
the *inal t=7in ;ill )e the res7+nsi)ilit= +* the Me,i'al Re'+r, Se'ti+n&

Nurse on duty is required to properly filled up two 9#: cadaver information tag which
include the following
a. Name
b. %ge
c. Se-
d. .ate ? time of death
e. &ospital number
f. Cnit8ward
g. .iagnosis
Note 2ne tag is tied in the right wrist. The body is then wrapped with
linen while the other tag is attached to the chest area.
#. Nurse on .uty notifies the following departments8personnel
%dmitting8'nformation Section
%dmitting Section processes the papers prior to the release of
the cadaver. 1ler$ as$s the nearest of $in to get clearance bill from the
cashier.
+H
1ashiers sign the clearance form upon payment of charges. 'ndigent patients will be
referred to the Social Service for assistance.
+. Nurse inquires whether a funeral parlor or the parents8relatives
themselves will attend to the processing of the cadaver4s release.
For a funeral parlor
a. % calling card and proper identification form must be
submitted.
b. The funeral representative and the nearest $in sign
authori*ation form.
c. The funeral parlor then ta$es the responsibility of registering
the death certificate.
d. Three copies of the 6elease of 1adaver forms are signed by
the funeral parlor and relative witnessed by the
nurse8security guard assigned in the area.
7ithout a funeral parlor
The nearest $in secures the cadaver release form and register the
death certificate. 6elatives must also be properly identified and
signed the release form, witnessed by the nurse8security on duty.
,. Cpon presenting the above forms 9clearance and the cadaver release
form: the Security 2fficer releases the body to the patient4s nearest of $in
together with the authori*ed funeral parlor representative, both of them
must sign in the logboo$.
/. 2ther matters
Storage of unclaimed cadavers
The nurse see$s the assistance of the Social Service to loo$ for
the relatives of unclaimed bodies. 1adavers unclaimed after F hours
from the time of death shall be referred to accredited mortuaries for
safe$eeping8proper storage.
6equest for autopsy should be prepared by the attending physician with consent duly signed by the nearest
of $in who are of legal age.
%ll medico<legal cases are referred to the proper police authorities by the guard on
duty.
a. .eath on %rrival cases and )mergency 6oom .eath 9vehicular
accident, trauma cases: are considered medico<legal cases and should
also be relayed to the police authorities by the security guard on duty.
+I
b. 6equest for viewing of the body by media, etc. should be coursed to the
1hief of &ospital81hief of 1linic during the office hours and Senior
&ouse 2fficer after office hours.
c. Cnpaid bills cannot be a reason to delay the release of the cadaver.
6elatives are then requested to arrange with the Social Service for
assistance.
d. .eath 1ertificate of .2% patients are signed by authori*ed 3unicipal
&ealth 2fficer. Funeral parlor representative duly authori*ed by the
relatives may facilitate the processing of papers. % 1linical %bstract
must be prepared and be given to patient4s relatives.
e. 6elease of cadaver is done by the authori*ed officer 9Nurse on
.uty8Security 2fficer on duty: after completion of cadaver release
form, clearance, clinical discharge summary and consent from the
nearest of $in or guardian of patient.
f. Temporary storage of unclaimed personal belongings, such as clothing,
electrical appliances, pillows, linens, thermos, plates8glasses and other
materials used during patient4s stay is being discouraged, however, if
unavoidable , relatives are given only #, hours 9! day : to retrieve their
belongings or else , it will considered as waste for garbage disposal.
6elatives should be properly informed regarding this policy.
S)1T'2N #F. 1IR#H CER#I$ICA#E
!. The nurse who assisted the doctor during delivery will be the one
responsible for writing the following data
3other4s maiden name and the father4s name
.ate and time of delivery
Se-, type of birth, birth weight
Name of the doctor who attended the delivery
#. %ll other information needed in the birth certificate will be the
responsibility of the ward nurse who will receive the patient from the
delivery room. 7ard 1ler$ can be utili*ed for chec$ing8reviewing and
ensuring that all pages of the birth certificate have been completed, with
accurate information properly signed by the attending physician and the
informant. %lways as$ the mother to sign as informant especially if they
are not married.
+. Cpon completion of data, the ward nurse who received and interviewed
the patient will be the one to sign in the P6)P%6). 5D portion of the
birth certificate. The responsibility of interviewing patient can be
,@
delegated to the nursing attendant8ward cler$ but the ward nurse will still
be held responsible for the accuracy of the data and the signatures.
,. The draft form should be properly accomplished and validated8signed by
the informant. The draft form and official form should be forwarded to
3edical 6ecord Section.
S)1T'2N #G& #HE -JAHOUR CENSUS $ORM
a. The nurse on duty in each area must accomplish the #,<hour census form
at e-actly !# midnight during the !@@@ pm " F@@ am shift. The four
copies consolidated #, hour census will be accomplished by the assigned
head for the night. Failure to accomplish the form will be dealt
accordingly. The 1hief Nurse or her designate must chec$ the census
before final submission to the 1hief of &ospital ? the 3edical 6ecord
Section. 2ne copy will be retained at the office of the 1hief Nurse for
reference purposes.
b. The nurse attendant8ward cler$ will be the one to submit the #,<hour
census to the record section immediately the following morning e-cept
on Saturday and Sunday.
S)1T'2N #H. PA#IEN#HS CHAR#
!. %fter interview of the relatives in the admitting section, the )682P.
Nurse who attended the patient will be the one responsible in chec$ing
the completeness of all the data needed in the cover sheet including the
name of informant, attending physician, admitting diagnosis. 7ard 1ler$
if available can do this function She8he must ensure that patient consent
for admission is properly signed and that all pages of the chart have the
following data. 1omplete name of patient 9last name, first name, middle
name:.
!.! %ge, se-, ward, hospital number
#. The first ward nurse who will write in the additional sheet must complete
Patient4s personal data8 info during the patient4s stay in the hospital 9can be
delegated toward cler$:.
+. %ll medical procedures and interventions should be recorded in the
patient4s chart, including the date and time of interventions0 li$ewise
,. %ll<important observations, untoward signs and symptoms should be
properly documented.
/. 6ecords of patients for admission and discharge must pass the admitting
section for proper processing of papers.
F. 1onsent slip should be properly signed before operation or any special
diagnostic procedures.
,!
G. 1harting must be in Focus .ata %ction 6esponse 9F.%6: Style at all
times. 1harts must be accomplished before the end of the shift. N2. is
not allowed to leave without completing the charts. Proper chart
arrangement must be observed. Failure to complete the chart on time will
be dealt with accordingly. %ll charts must be audited and signed by head
nurse 8supervisor of the area prior to final submission to the Nursing
2ffice8 Statistic 2ffice8 3edical 6ecord Section. 1harts of discharges and
deaths are e-pected to be submitted every I@@ %3 daily after reviewing
its entry in the #, hours census report and nursing audit of the
supervisors.
H. % medical record 8chart are a collection of information about the person
you are caring for. 't is a legal and confidential record with pertinent
information of the care provided. 'f it is not recorded, it did not happen. 'f
it is recorded incorrectly, it happened incorrectly. This is why it is so
important to be accurate when documenting.
S)1T'2N #IA RE$ERRALS O$ PA#IEN#S
a. The decision to send a referral is made by the senior house0
b. %ll patient must have chart and e-amined first by Physician "in<charge
before referring to higher authority8consultant and to other health
facilities
c. The attending resident shall sign all referrals0 and
d. The referral slip, accomplished in duplicate should include the reasons
for referral and the nature of such.
e. ;ital signs of patient must be stabili*ed prior to transfer.
f. Physician 8 Nurse on duty must accompany patient for transfer to other
hospital.
S)1T'2N +@. A SECURI#% IN #HE EMERGENC% ROOM
POLIC%:
The Security Force of the &ospital 9including the e-isting contractual services
of agency hired security guards: is responsible for all security problems within the
)mergency .epartment86oom. The local police department is normally contacted for
bac$ up, when necessary8needed, by the security. Security is responsible for and
should be notified for all cases of unruly patients and visitors, all problems with the
crowd control, and8or any problem regarding stolen property and8or patient valuables.
Security is often preventive in nature0 that is, if it is contemplated that the security
force may be necessary, it is probably wise to call Security at that point. 2ften, the
arrival of Security prevents a situation from getting out of control.
S)1T'2N +!A SPIRI#UAL CARE
,#
POLIC%:
The spiritual and religious care of the patient is to be considered an integral
part of the overall care of every patient. 6espect for religious belief and practices must
be observed as long as it will not affect, harm other patients8personnel of this hospital.
1AP#ISM: EMERGENC% POLIC%
Nurses of all faiths may bapti*e according to the philosophy of the hospital
baptism should be administered when in doubt of life or whether tissue is embryo or
fetus.
LAS# SACRAMEN#S
POLIC%:
The last sacrament for any patient who dies in the )6, for any patient who is
dead on arrival, and for critically ill patients may be given by the patient4s family
regardless of religious orientation.
CLERG% SERVICE:
1atechists of any religion are allowed to conduct religious services.
6eligious services of the sic$ and dying should be referred to Social 7or$er.
&oly mass is scheduled at the 1hapel every first Friday of the month at !!@@ am.
S)1T'2N +#& R+utine Vainal Internal E<a8inati+n *+r all O1AG%NE cases prior
to discharge in the ward must be done by Physician in 1harge. .octor4s may delegate
their function to N2. but will apply the principle of command responsibility.
S)1T'2N ++. %ll patients must be referred first to Physician in 1harge who in turn
will refer patient to the attending consultant8private physician. Give the latest vital
signs, laboratory results, and observation during referral.
S)1T'2N +,.%ll admitted newborn delivered at .6AN63& must be referred to the
%dmitting Sections for the hospital number and up date of census.
S)1T'2N +/ACARE O$ SLUGS( DAR# AND O#HER $OREIGN O10EC#S
POLIC%:
3edico<(egal evidence that is e-tracted from patients li$e slugs, darts, etc.
shall be endorsed to the medical records for safe$eeping after the resident ma$es some
mar$ings and will only be released to police authorities upon proper identification.
PROCEDURES S#EPS
,+
Me,i'al
O**i'er
!. )-tract slugs, bullets, or any foreign
obBect from the patient. Place mar$ing
li$e initial of the resident physician.
#. 6eceive and label the slugs, darts, etc.
and logs it in the )6 logboo$.
+. Forwards and endorses slugs, dart, etc.
in the morning to the medical records
officer.
,. 6eceives the endorsed bullets, darts,
for safe$eeping until properly claimed
by police authorities.
S)1T'2N +F<PRESS5MEDIA
POLIC%:
Tri<media representatives must as$ permission from the 1hief of &ospital
during office hours and Senior &ouse 2fficer 9S&2: after office hours prior to
interview and gathering of information about the patient.
Giving out information about the patient must be done through authori*ed
personnel only. Treatment must be given priority to avoid unnecessary delay. Picture
ta$ing8 videos must be with the consent of the patient.
S)1T'2N +G. Ne;)+rn S'reenin < all babies delivered at .6AN63& must undergo
the screening test. % request with complete information signed by Physician "in<
1harge must be sent to laboratory few hours after delivery. 1ollection of blood is done
#, hours after delivery and preferably up to G# hours. &owever, the pediatrician may
request the test even after G# hours upon her8his discretion. The parents will pay
charges for test $it. &owever, indigent patient may see$ financial assistance from the
Social Service. Parents must sign the dissent form if they refused the procedure to be
done. 2A77en,i< DK3
,,
NURSE
NURSING
A##ENDAN#
MEDICAL
RECORDS
S)1T'2N +H. Patients ;ith s7e'ial nee,s must be treated accordingly, a referral for
special assistance could be done after initial assessment .7e don4t do internal vaginal
e-amination for suspected rape victims.
S)1T'2N +I. 1l++, re/uest must be fully accomplished by doctor prior to
submission to laboratory department. Please refer to 7ard S2P4S in 5lood
Transfusion for more information& 2A77en,i< D@3
S)1T'2N ,@. Inta!e an, Out7ut should be strictly done by ml as unit of measure.
S)1T'2N ,!& In*e'ti+n '+ntr+l 7r+t+'+ls should be strictly implemented to
minimi*e the ris$ of disease transmission. Standard precautions shall be practiced
during care of ALL patients regardless of diagnosis. The Manual +* 1asi' In*e'ti+n
C+ntr+l P+li'ies an, Pr+'e,ures -CDC E,iti+n 7re7are, )= Phili77ine H+s7ital
In*e'ti+n C+ntr+l S+'iet= 2PHICS3( 'nc. can be used as reference materials and when
applicable can be adapted. 'n general, the following should be observed
a.'solation Precaution< warned8informed staff directly involved in the care of
patients with highly transmissible infectious diseases about the infection
status of patients so that appropriate precautions, isolation measures are
observed.
1odes can be used as
A<%irborne Precaution
C<1ontact Precaution
D<.roplet Precaution
PE< Protective )nvironment
Please see attached anne- recommended Flow 1hart on 'solation
Precaution Policies and Procedures 9%ppendi- G:
b. &and &ygiene
7ash hand after touching blood, body fluids, secretions, e-cretions, and
contaminated items, whether or not gloves are worn. 7ash hands
immediately after gloves are removed, between patients contact, and
when otherwise indicated to avoid transfer of microorganisms to other
patient or environments. 't may be necessary to wash hands between
tas$ and procedures on the same patient to prevent cross<contamination
of different body sites.
c. 7ear gloves for touching body fluids, secretions, e-cretions,
contaminated items, for touching mucous membranes and non intact
s$in.
,/
d. Face mas$ and eye shield during procedures and patient<care that are
li$ely to generate splashes or sprays of blood, secretions, especially
during suctioning, and endotracheal intubation.
e. Gown 9 non<sterile is adequate : during procedure and patient " care
activities when contact of clothing8e-posed s$in with blood 8body
fluids, secretions, e-cretions is anticipated.
f. (inen
&andle, transport, and process used linen soiled with blood, body
fluids, secretions and e-cretions in a manner that prevents s$in and
mucous e-posure and contamination of clothing and that avoid transfer
of microorganisms.
S)1T'2N ,#. 1reast*ee,in P+li'=A all infants delivered in this hospital should be
initiated to e-clusive breastfeeding as soon as possible after birth. No
pre<lacteal feed should be given unless directed by a doctor. Please see
S2P for the 5reast Feeding Program. 9%ppendi- !/< Flow 1hart in .6:
S#ANDARD OPERA#ING PROCEDURES M GUIDELINES A# #HE
EMERGENC% ROOM 9%ppendi- !!< Flow 1hart in )6 Procedures
? %dmission:
!. 'nitial assessment of patient immediately upon arrival. 1hec$ the following
then prioriti*ed according to their condition
a& %irway " clogged secretions, foreign bodies
)& 5reathing " respiratory rate
'& 1irculation " cardiac rate, 5P, pulse rate
,& (evel of consciousness, pupillary reaction, etc.
#. )-ecute the doctor4s stat order depending on patient4s condition but let the
patient8relative sign the consent before any medical or surgical interventions.
)-amples are the following
a& .rugs, o-ygen, '; fluids as ordered
)& )1G, defibrillator, 1P6, suction as ordered
'& (aboratory test requested
,& Sutures, dressing if necessary
e& Strap, splint as ordered
+. %ccomplish patient4s data sheet and record all interventions and treatment done
,. Further assessment of Physician<in<1harge, monitoring of N2.8N% for final
disposition
/. 'f patient is for admission, accomplish the following
,F
a& %dmitting form with complete data, diagnosis and signature of the
admitting physician
)& Face sheet8cover sheet signed by the admitting physician and with
admitting diagnosis0
'& 1onsent for admission signed by patient8relative0
,& 1omplete set of patient chart including the hospital number, &ospital
'.8registration and inde- card0 and
e& Two 9#: copies of admission and discharge sheet 9one copy for the
%dmitting Section, and another copy for the 7ard Nurse: signed by the
admitting physician.
F. 6efer patient or relative to the 3edical Social Service wor$er for classification
and assistance.
G. Prepare charges8order of payment for all the drugs, supplies and other bills
consumed at the )6. Payment86eplacement of used supplies will be depending
on the patient4s classifications c8o Social Service
H. Notify ward of new admission 97ard Nurse8N% prepares the bed and other
necessities:.
I. .irect patient to the designated ward together with the chart and endorse to the
7ard Nurse including unfinished doctor4s order.
!@. %ccount all the drugs and supplies consumed at the )6, and record them in the
monitoring logboo$.
!!. 6ecord at the )6 logboo$ the name of patient, disposition date and time of
admission, address, age, admitting diagnosis and the physician<in<charge.
!#. .2% patients should be properly documented especially date and time of
arrival 9see details on the care of cadaver:.
)6 Cnit 3anagement
!. )nsure accurate endorsement of supplies, equipment and instruments at the
beginning and end of every shift.
#. 1hange soa$ing tray as necessary, use acceptable soa$ing solutions.
+. 3aintain cleanliness of the area and ensure that all equipment, instruments are
functional and that emergency drugs and supplies are available.
,. %s much as possible control overcrowding in the area. Prioriti*e 8triage patient
according to their conditions. 6equest the patient4s relative to stay outside.
/. 3aintain proper recording, update logboo$s.
F. Never leave the unit without somebody to relieve the staff on duty.
G. 3a$e a daily census of the number of patients treated for #, hours every !#
midnight.
H. 'f patient requested for medical certificate, attached the request form at the
chart and endorse to medical record section especially medico<legal cases.
DRUGS AND MEDICINES A# #HE EMERGENC% ROOM
,G
%ll medicines within the )mergency 6oom are $ept in the designated medicine
cabinet. The staff nurse is responsible for safe$eeping the stoc$ or any losses of
medicines within his8her area of assignment. Safe$eeping of narcotic drugs is the
responsibility of the head8charge nurse.
%ll prescribed medicines must be in generic. %dministering of '; meds must
be done by an '; trained nurse, or by the physician. 'f the prescribed drugs8medicines
are not available at the pharmacy, the nurse will notify the attending physicians of any
substitute medicine. 'f drugs8medicines are still not available, prescription will be
given to the relatives.
PROCEDURES S#EPS
!. %ccomplishes the prescription, with
complete data including doctor4s name ?
license number 9trodat with signature:.
#. 6eceives8chec$s the prescription.
Patients8relatives signed at the bac$ of the
prescription. Nurse will countersign,
prepare and administer the drug.
,H
Me,i'al
O**i'er5
Ph=si'ian
NURSE
NURSING
A##ENDAN#
+. Get the drug8medicine from the
pharmacy as replacement to maintain the
stoc$.
,. 6eceives8chec$s medicines ta$en from
the pharmacy, $eeps a correct list of
available medicine.
ADMISSION POLICIES
!. 'f the patient is for admission, doctor4s JstatM orders should be immediately
carried out.
#. Patient8relative should be given an admitting slip by the Nurse on .uty which
should be presented to the admitting cler$.
+. S$in testing and other procedure should be done at the )mergency 6oom.
,. 7ard should be notified of admission by the %dmitting 1ler$ and )6 Nurse.
/. %ttach patient4s tag.
F. Proper endorsement including patient chart and available medicines should be
done by the Nurse on .uty to Staff Nurse at the ward8 268.6.
G. %ll admitting consent and waiver should be signed by the patient or patient4s
relative. 9See %nne- :
9ARD POLICIES AND PROCEDURES
I& ADMISSION #O 9ARD
A& U7+n n+ti'e +* a,8issi+n
!. 5ased on the information from the admitting unit and )682P. nurse
endorsement, ward nurse prepares bed assignment, supplies, and materials
needed.
#. Nursing %ttendant 9N%: prepare patient4s unit 9bed and hospital linen, bed
tag, wristband, bedside table, '; stand, o-ygen etc.:
+. 6223 %SS'GN3)NTS<Ta$e note that communicable cases are isolated
in a designated room .Please see ward procedures regarding room
assignments.

,I
NURSE
1& U7+n arrival +* 7atient in the ;ar,
9ARD NURSE
!. Cpon notice of admission the ward nurse and or nursing attendant
prepares assigned bed, medical supplies, and materials needed according to
patient4s condition and information from the admitting unit, and the
)682P. nurse endorsement. Nurse accompanies the patient to designated
unit, assesses his8her condition and record finding in the chart using
5(C)85(%1E ball pen during %3 " P3 shift and 6). during night
shift. 2rient patient ? relatives on hospital policies, physical set up and
ward staff.
REMINDER:ON LINEN POLICIES
a& L+ss linen ;ill )e 'hare t+ the sta** +n ,ut= in the area i* the 'ause
+* l+ss is ,ue t+ nelien'e&
)& Chanin +* linen ;ill )e ,+ne ,ail= +r as nee,e,&
'& Seni+r Nurse ;ill )e res7+nsi)le *+r 8+nit+rin the invent+r=
re7+rt ,+ne )= Nursin Atten,ant&
,& Nursin Atten,ant ;ill )e the +ne t+ as! 7atient5relatives t+ sin
the Linen 1+rr+;erHs M Chare Sli7" an, t+ u7,ate the linen
invent+r= l+)++! ever= )einnin an, en, +* shi*t& Patient 8
relatives must sign the 1harge85orrower4s slip for linen 9PH@@.@@8per
linen: upon admission in the ward ,should the patient8relatives failed to
return the linen due to losses, then the PH@@.@@ will be added to the
patient4s hospital bill.

SAMPLE 1ORRO9ERHS5CHARGE SLIP
/@
.6AN63&
('N)N 526627)64S81&%6G) S('P
Pangalan ng Pasyente PPPPPPPPPPPPPP
PetsaPPPPPPPPPPSilid87ardPPPPPPPPP
%$o po ay nanghiram ng PPPP bilang ng
$umot8linen mula sa ospital upang ito ay
a$ing gamitin habang nasa pagamutan.
Tung$ulin $o na ito ay ingatan at ibali$
bago umuwi.%ng bawat isang 9!: linen ay
nag$a$ahalaga ng PH@@.@@ na a$ing
babayaran 9isasama sa hospital bill:
$apag ito ay nawala o nasira.
%ng a$ing paglagda ay $atunayan ng
a$ing pagpayag at a$ing naunawaan ang
lahat.
PPPPPPPPPPPPPPPPPPPPPPPPPPPP
Pangalan ng Pasyente8Eamag<ana$
F(27 1&%6T 2F ('N)N .'ST6'5CT'2N %N. 12(()1T'2N
#. 2rient patient8companion to the hospital unit and policies.
+. Perform admission care, carries out orders, plans nursing care and initiates
medical management li$e request for e-aminations, etc. 3a$e sure that the
patient and family were informed regarding the management. 3aintain
privacy of the patient during procedure.
,. 'nform others units such as the laboratory, dietary, pharmacy, social service,
etc. of the needs and requirements of the patient.
/. .iscusses with patient or companion the medical8nursing care plan, and the
e-tent or his8her participation.
F. Fills<up medication or treatment cards. )ach medication card should
contain the following information
a. Patient4s room, bed number and name
b. The drug to be administered, dosage, route of administration, frequency
and time intervals.
c. The date it was originally ordered and the signature of the nurse
transcribing the order.
G. 1olor coding of medication card will be as follow
G6))N < 5'. H%3 ? FP3
7&'T) < 2. F%38FP3, H%38HP3
/!
'ssuance of
linen from
&ouse$eeping
&ead8Staff
Nurse
received ?
signed 6'S
? issue
linen to
Nursing
%ttendant
Nursing
%ttendant
provides
linens to
patient ?
as$ed them
to sign the
borrower4s
slip
1ollection
of soiled
c8o
Nursing
%ttendant
(aundry
Cpdate of
inventory
logboo$
D)((27 < qF F%3, !#NN, FP3, !#3idnight
P'NE < qH F%38#P38!@P3
6). < P6N
5(C) < T'. H%3, !P3, FP3
26%NG) < q!#, round the cloc$ F%3, FP3
Note &GT monitoring " +@ minutes pre meals.

H. 1harts observations, measures, and medications administered to the patient.
I. )nter patient4s name in the daily ward census, E%6.)O and diet list.
!@. Cpdate4s ward directory.
!!. Nursing attendant forwards diet list to the dietary unit.

C& Dail= 7atient nursin 'are 8ust )e ,+ne a''+r,in t+ the *+'us nee,s +*
the 7atient& Pr+7er ,+'u8entati+n ;ill )e i87le8ente, usin the $+'us
Data A'ti+n Res7+nse 2$DAR3 re'+88en,e, )= the De7art8ent +*
Health& 2I87le8entati+n +* $DAR ;ill start Ma= D( -CD- a*ter th+r+uh
+rientati+n +* sta** )ase, *r+8 the ne; DOH Manual t+ stan,ar,i>e,
*+r8s5*+r8at that ;ill )e utili>e,&3
DAIL% PA#IEN# CARE:
!. 'f the patient is ambulatory, morning care and evening care should be done by
the patient. 'f not, he8she will be assisted by the nursing attendant.
#. (inens should be change daily by the house$eeping section.
+. 1hart observations, vital signs and medications administered to the patient
chronologically. %ll entries are accomplished accurately, legibly with date, time
and properly signed& 9HA# IS NO# 9RI##EN( CONSIDERED NO#
DONE&
,. 'f there are changes or additional entry, write the word Jaddendum to careM put
the date and time the entry was made then signature8initial of the nurse on duty.
/. 6efer patient to Physician<in 1harge if needed.
F. )ndorse to the incoming nurse the shift activities, special procedures and
medications which needed to be carried out.
G. The incoming nurse should ta$e note of patients needing special care.
H. )ndorsement of patients should be done at the bed side.
I. .iscuss management of patient with physician.
!@. %ll laboratory results must be attached to the laboratory result sheet and report
to the Physician<in 1harge.
!!. 'n cases of error in charting, underline the word and put on the top of the word
J8ista!en entr=" the initial of the nurse including date and time.
/#
!#. The supervisor8 senior nurse should ma$e rounds of the patient.
a. Supervises nursing care provided by ward nurse.
b. 2bserve staff nurses to determine their level of competency.
c. 2versee the utili*ation of supplies and equipments.
d. %ssists ward nurse when needed.
#HE 9ARD NURSE
!. See to it that all emergency drugs8medicine8supplies are available at all
times and equipments are well maintained.
#. %ssesses and records patient4s condition in the chart. .on4t leave space in
the chart. 'f with space, underline it then write the initialQsignature of the
nurse on duty.
+. Plan nursing care and should include health education activities with respect
to patient rights. ')1 materials should be available in the wards for
distribution. .iscusses with patient or companion the nursing care plan and
e-tent of his8her participation including the $eeping of cleanliness in the
ward.
,. 7atchers are not allowed for uncomplicated8non<pathologic cases. 6elatives
are requested to stay in the waiting area of the hospital.
/. 2nly one watcher is allowed for pathologic cases and post<op patient.
F. No food will be given to patients #, hours after the discharge order of the
doctor.
G. %ll babies delivered should be given 51G and &epatitis 5 vaccine.
Newborn Screening test must be done #, hours after birth. )-clusive breast
feeding must be practiced at all times. Please see 5reast Feeding Program
Policy.
H. Patients name must be recorded on daily ward census logboo$8form.
Earde- should be updated including name of patient, age, date of admission,
diagnosis, attending physician, ';F, diet, and special endorsement.
I. 2nly authori*ed hospital personnel are allowed to read the documents
pertaining to patients.
!@. Submit diet list to dietary section before /+@ am and notify for any diet
change of the patients.
!!. Panel screen should be provided to patients that needs privacy.
!#. Notify admitting section in case of bed changes, Trans<in, trans<out, and
discharges of patients. Patients requesting transfer from charity to pay or
/+
from pay to charity shall be referred to Physician<in 1harge and admitting
section.
!+. 1arries out medication and treatment orders. 't is imperative that the nurses4
notes be clear, accurate and up<to date. .octor4s order must be carried out
within +@ minutes. 8hat is not 4ritten considered not done. Cnmet
schedule of drug administration due to its unavailability must be encircled.
!,. %ll procedures to be done should have proper consent signed by
patient8relative.
!/. 'nterdepartmental referral of patients for 1ardio<Pulmonary clearance or co<
management should be from doctor to doctor.
!F. Sends request for routine e-amination to the department concerned.
Specimen for stool, urine and sputum e-amination should be brought by the
relative of patient to the laboratory together with the request. %ll laboratory
requests must be recorded into the logboo$ and to be received by the
laboratory staff.
!G. 'ndigent patient will be referred to the Social 7or$er for approval of
request of drugs and medicine, laboratory and other procedures.
OU#AGOING NURSE
!. )ndorses to the incoming nurse the shift activities and special treatment
and the medication, which need to be carried out.
#. 3a$e rounds with the incoming nurse and introduces the latter to newly
admitted patients and those needing intensive care.
INCOMING NURSE
!. 6ead E%6.)O and analy*e reports.
#. Prepares plan of wor$ and determines resources and priorities.
+. Provides nursing care and carries needed medical treatment. 6ecords
patient care activities and observation made.
,. 6efers patient to Physician<in 1harge when necessary.
/,
CUS#ODIAL 9ARD: COLOR CODING O$ PA#IEN#HS CHAR#S AND
SPECIAL NURSING CARE POLICIES5GUIDELINES $OR LEPROS%
PA#IEN#S 2A,a7te, *r+8 DR0NRMH Re*eren'e Manual V+lu8e II3
Person 4ith leprosy change a lot' often' per,anently' the change is usually
instantaneous' it usually occurs at the point of diagnosis) %he co,bined factors of
the age old stig,a and the ,ind pictures of stereotype leprosy patient causes the
person diagnosed to feel different and ,arginalized and at the 4orst inferior and
ostracized) /s a result' person diagnoses 4ith leprosy hide the fact until it can no
longer be denied)
PREVEN#ION O$ IMPAIRMEN#S AND DISA1ILI#IES 2POID3 IN
LEPROS%
Disa)ilities in le7r+s= are in,ire'tl= )r+uht a)+ut )= the ,e*+r8ities resultin
*r+8 7eri7heral nerve inv+lve8ent +r ,a8ae +* e=es( han,s an, *++t nerves an,
7la'e the 7atient at a li*el+n ris! +* ,evel+7in se'+n,ar= i87air8ents su'h as
s!in 'ra'!s( inFuries( sti**ness an, )lin,ness& #he *+ll+;in are iven e87hasis:
!. preservation of nerve function
#. preservation of vision
+. the daily practice of self<care and
,. use of protective footwear
DANGER SIGNS:
!. %cute nerve pain or tenderness
#. 6ecent decrease in sensation 9R!# mos.:
+. 6ecent decrease in muscle strength 9R!# mos.:
,. 6ed eye, recent decrease in vision and8or pain
/. )ye with a lid pap 9lagopthalmos:
ELEMEN#S O$ 1ASIC NURSING CARE $OR LEPROS% PA#IEN#S
Care +* the A8)ulat+r= +r OutA7atient
< General personal hygiene
< 3edical treatment
< %ncillary treatments< emphasis on Prevention of 'mpairment and
.isabilities 9P2'.:
< &ealth education
Care +* the A'utel= Ill
//
(eprosy patients usually do not ta$e to their beds e-cept when they
have developed inter current disease or leprosy reactions.
Care *+r the 7atient ;ith interA'urrent ,isease
< Personal hygiene and daily care of patient
< Positioning with special focus on maintaining the functional position
< Prevention of bedsores
< %ttention to the e-cretory functions
< Seeing to it that ancillary procedures needed for the therapy are done
adequately, correctly and regularly
< 2bservation and recording8reporting of symptoms which are li$ely to
affect the care and treatment of the patient
Care +* the Patient ;ith Rea'ti+ns
< 3edical treatment is focused on continuing 3.T and the
Budicious regimen of steroids to suppress the reactive process
< %ll the foregoing elements for the acutely ill patient with inter<
current disease should be followed
< ;igilant observation and prompt administration of preventive
measures against
development of complication from the neuritis
positioning
care of hands, feet and eyes
referral to the appropriate physician for the development of
progressive symptoms.
Re*er t+ NS=8)+ls *+r 'hartin s!in lesi+ns an, ,e*+r8ities"&
DR0NRMH Re*eren'e Manual V+lu8e II
HEAL#H EDUCA#IONA It ,+es n+t 8ean si87l= tellin 7atients ;hat t+ ,+"
#here*+re( 7atient e,u'ati+n 2'+88+nl= re*erre, t+ as Health E,u'ati+n3
is:
Transactional ,N2T prescriptive
Persuasive, N2T coercive
'nformed, N2T simply informing
%dherence8concordance N2T compliance
Proper color coding of patient4s chart represents every ward of custodial
patients. This promotes classification and organi*ed retrieval of patient4s
records. %ssigned color coding as follows
/F
PINK < 5uilding % < Female 1ustodial
7ard
%ELLO9 < 5uilding 5 "3ale 1ustodial
7ard
ORANGE < 5uilding 1"3ale 1ustodial
7ard
GREEN < 5uilding . "3ale 1ustodial
7ard
MOS# COMMONL% O1SERVED PS%CHOLOGICAL RESPONSE O$
PERSONS DIAGNOSED 9I#H LEPROS%
6egression " loneliness, fear, insecurity
'nferiority ,shame, unworthiness of respect of others
.epression< due to loss of parts of the body or loss of function
.ependency<refusing to recogni*e that due to loss of function, he must
depend on others, at least for a period of time.
Drus *+r Ps='hiatri' Patients iven M+nthl= )= Me,i'al Re7resentatives
*r+8 Nati+nal Center *+r Mental Health 2NCMH3
&aloperidol /mg.8ampule 8tablet
Fluphena*ine .eoconate 93ode*ine: #@ mg.8ml
Patients are re*erre, t+ O''u7ati+nal an, Reha)ilitati+n Unit *+r *urther
8anae8ent& S+8e suesti+ns t+ han,le 7s='h+l+i'al res7+nse:
,istur)e, 5,e7ressi+n +* ,ian+se, le7r+s= 7atients&
Physical activities<e-ercises if not contraindicated to patients condition
Stress 3anagement activities< share or tal$ to friends, fun activities
(istening
(ivelihood activities8programs
D& All sta** +n ,ut= 8ust a''+87lish their 'hartin ,urin the shi*t& All
7atient +)servati+ns an, treat8ent 8ust )e ,+'u8ente, usin $DAR
$+r8at& Chart arrane8ent 8ust )e as *+ll+;s:
MEDICAL an, PEDIA#RIC CASES
!. 1linical Face Sheet
#. 1onsent for admission
+. &istory
,. Physical )-amination
/. Progress Note ,.octor4s 2rder8Nurse4s 1ompliance Sheet
/G
F. ;ital Sign 3onitoring Sheet
G. 3edication 6ecord Sheet
H. 'ntravenous Fluid Sheet
I. .ischarge 1hec$list
!@. Nurse4s Progress Notes86emar$s Sheet
!!. .ischarge Summary
!#. )-it 'nterview 8Patient Satisfaction Form
D.& La)+rat+r= Re7+rt5Result
DJ& Gra7hi's
O1ADeliver= CASES
In a,,iti+n the *+ll+;in are in'lu,e, in the 'hart +* La)+r an, Deliver=
'ases
a. 25 &istory 9Summary of Parturition:
b. (abor 6ecord
c. Newborn 6ecord
d. ;ital Sign 6ecord Sheet 93other ? 5aby:
e. Graphic 1hart 93other ? 5aby:
f. 3edication 6ecord 93other ? 5aby:
g. '; Fluid Sheet 93other ? 5aby:
h. Nurse4s Progress Notes 93other ? 5aby:
E& 1l++, #rans*usi+n SOPHS 2A77en,i< D@3
!. Properly identify patient for blood transfusion. 1hec$ the doctor4s order.
3a$e sure that request form are properly filled<up by the requesting physician
and coordinated with the laboratory staff. 1hec$ if the consent was signed by
the patient8relative. 3a$e sure that the transfusion papers8consent is for the
patient. The laboratory staff coordinates the request to blood ban$ to ensure
availability of blood. 3edtech inform N2. once blood is available.
#. The nurse gets baseline vital signs of the patient before transfusion. 'f the
patient is febrile, do not proceed with the blood transfusion0 refer the patient
to the doctor for further assessment.
+. 1hec$ twice the blood type, e-piration date, color 8appearance. 1hec$ if
properly cross<match.
,. Thaw blood for transfusion at room temperature according to standard time.
/. 'nform the doctor before starting the blood transfusion0 clarify if there is
any further instruction.
/H
F. Give antihistamine at least !/<+@ minutes before the transfusion 9as per
doctor4s order:.
G. 3a$e sure that you are using the right intravenous fluid as side drip 9Plain
NSS: to avoid any reaction such as agglutination8clotting.
H. 3onitor patient4s vital signs. Stay with the patient on the first !/ minutes
of 5lood Transfusion. 2bserve for any signs and symptoms of untoward
reaction. 'f so, stop the transfusion, assess patient then refer immediately
to the attending physician.
I. For every type of blood there is specific standard time to consume the
content of blood bag, please refer to the manual of blood transfusion for
further information.9See Primer for 5lood Transfusion:
!@. 1hec$ vital signs after blood transfusion and record.
$& DISCHARGE PLAN:
!. %ll patients4 bill8charge slip must be attached to patient4s chart and
forwarded to the billing section, discharge processing starts upon doctor4s
order that the patient may go home, transfer, and discharge against medical
advice or died.
#. Cpon payment and clearance by the admitting, billing, cashier,
professional fee of doctor4s and other charges, the nurse will sign last
before final discharge. 3a$e sure that the patient8relative was given
instruction about 2P. follow<up, home medications, home care and other
important health instructions. 9Please see attached .ischarge 'nstruction
Form:. %ll indigent will be sociali*ed, in the absence of social wor$er, the
Senior &ouse 2fficer, and any member of the )O)123 may sign the
charge slip.
G& MANAGEMEN# O$ COMMUNICA1LE5REPOR#A1LE
DISEASESA
As 8u'h as 7+ssi)le( '+88uni'a)le 'ases sh+ul, )e re*erre, t+
+ther h+s7ital *+r *urther 8anae8ent( h+;ever( i* this is n+t 7+ssi)le( the
*+ll+;in 7r+'e,ures sh+ul, )e *+ll+;e,:

a. 'solate patient in a designated room8ward
b. Practice standard barriers8 nursing precautions such as wearing of
gloves, mas$, cap and gowns.
/I
c. 6eport the case to 6)SC of 1&.<33, coordinate with (GC for
follow<up8surveillance in the community8area affected by the
disease
NURSING A##ENDAN#:
!. Prepares patient4s unit 9bed, linens, bed tag, wristband, bedside table, ';
stand, o-ygen, bedpan, etc:.
#. %ssist the nurse on duty on functions that can be delegated to her. Ta$e
vital signs and inform nurse on observations on the physical conditions of
the patients.
+. Provide comfort and personal hygiene.
,. Forward diet list to the dietary unit.
/. 3aintains cleanliness and orderliness of the wor$ing area.
F. 1leans8disinfect medical equipments and monitor other supplies such as
linens.
G. Provide health teaching, training, learning e-perience to student affiliates,
new staff, and other interested sta$eholder.
POLIC% ON ROOM AND 1ED ASSIGNMEN#S
!. 'n cases of infectious diseases, patient should be isolated in isolation room.
#. 'n case there is no available bed at the time of admission the patient will be
placed on folding bed with the permission of the attending physician and
waiver from the patient8relatives.
+. Sharing of beds is allowed during cases of outbrea$s, disasters and e-igency
of needs. % waiver from patient8relatives should be obtained.
,. For private patients, the admitting section is the one responsible for room
assignment. 'n case there is no available private or semi<private room at the
time of admission, the patient will be placed at available bed in the ward until
there is vacancy in private rooms. % waiver will be signed by the patient.
SU10EC#: ROOM ASSIGNMEN#S O$ PA#IEN#S IN #HE 9ARD
1ED DIS#RI1U#ION( E4UIPMEN#( PROCEDURE CHARGES:
P%D 7%6.S
P&'(&)%(T& 7ard N #/ 5eds 9!H 5eds S , 1ribs S+5assinets:
P,@@8day
Female 7ard N H beds
3ale 7ard N !@ beds
Pedia 7ard N , crib
N + bassinets
F@
P6';%T) 6223S N !! 5eds w8 air condition /@@8day
6oom ! N + beds
6oom # N + beds
6oom + N + beds
6oom , N # beds
'ntensive 1are Cnit 9'1C: N # 5eds w8 air condition P H@@8day

Pediatric 'ntensive 1are Cnit 9P'1C: N !crib Samenities w8air con PG@@8day
1&%6'TD 7%6.S
Pediatric 7ard N #I 5).S 9#+ cribs S+ beds S+bassinet: without air condition

3iscellaneous N , cribs
Gastro 7ard N H cribs
6espiratory 7ard N H cribs
'solation N # beds S !crib
&allway N ! bed S ! crib
N'1C N # bassinet
.engue 7ard N !, 9I cribsS / beds:
3other<5aby Friendly 7ard N #+9!I beds S , cribs:
Gynecology 7ard N !@ beds
25 7ard N G beds
(6 N # beds w8 air condition
N'1C N , cribs w8 air condition
Female 3edical 7ard N !F beds
3iscellaneous N F beds
Gastro N F beds
6espiratory N F beds
3ale 3edical 7ard N #H beds
3iscellaneous N F beds
Gastro N F beds
6espiratory N F beds
&ansens4 6oom N F beds
'solation N ! bed
)mergency 6oom N !/ beds
3ini 26 N ! bed w8 air condition
Surgery N + beds
2bservation N !@ beds
' ) 6oom N ! bed
GENERAL POLICIES O$ #HE OPERA#ING ROOM

6egular operating hours shall be between G@@ am 9earliest cutting time: and +@@ pm
9latest cutting time:.
F!
a. )mergency operations can be done and scheduled anytime. 5ut in case of
two or more emergency operations, the Surgeon will decide which will
be given priority based on the patient4s severity 8 urgency of condition.
b. % proposal slip approved by 1hief of 1linic, should be personally
submitted to the 26 supervisor or her designate not later than +@@ pm
for elective surgeries, the day prior to the date of the proposed operations.
c. %ll cases for elective operations and to whom anesthesia is to be
administered should have a complete wor$ up and a consent for operation
.%s a standard, for patient ++ years old and above<1P 1learance is needed
.For patients +# years old and below 151, Crinalysis and 1hest O<6ay
may be enough, however, the final decision will depend on the doctor4s
who will do the procedure.
d. Sterility of the 26 is the responsibility of everyone involved and should
be enforced strictly by the 26 Nurse8her designate.
e. 7ard N2. must endorse to 268.6 Staff new order for patients in the
nursery.
f. 7ard N2. must write her8 his nurse4s notes on the patient chart prior to
transfer of the patients to 26.
Note 26N%P has recommended policies and S2P that is being applied to .AN63&.
Please see the reference manual of 26N%P.
POLICIES AND PROCEDURES< OPERA#ING ROOM
D& GENERAL POLICIES REGARDING #HE USE O$ OPERA#ING
ROOMS:
a: 6egular operating hours shall be between G@@ a.m. 9earliest cutting
time:, and +@@ p.m. 9latest cutting time: .%'(D )O1)PT Saturdays,
Sundays, and (egal &olidays.
b: )lective Surgeries are scheduled as follows
3onday <Surgery 1ase
Tuesday <)NT, &ead ? Nec$ Surgery
7ednesday <25<Gynecological 1ase
Thursday <2phthalmology 1ase
Friday <Surgery 1ase
Saturday <)mergency 1ase only8Gen. 1leaning8disinfections
Sunday <)mergency 1ase only
II& POLICIES5PROCEDURE IN SCHEDULLING CASES $OR SURGER%
!. The following may schedule cases for surgery< physician and consultant.
F#
#. The proposal slip approved by 1hief of 1linic should be personally submitted to
the 26 Supervisor or to her designate, and each department should schedule
their cases on their assigned days and rooms.
+. Proposal for elective cases should be submitted to the 26 Supervisor or to her
designated not later than +@@ p.m. the day prior to the date of the proposed
operations. % first come first serve in time and room assignments must be
strictly observed.
,. Proposal submitted after +@@ P3 on the day prior to the date proposed
operations may be accepted by the 26 Supervisor in meritorious instances.
/. Patients who are scheduled for operation should be admitted in the hospital
before F@@ p.m. if they are schedule for Surgery the ne-t day. For outpatient
surgery, the patient should be at the operating room ! hour before cutting time.
F. The 2perating 6oom can only accommodate a ma-imum of + elective 26
1ases per day.
G. 1ontaminated or dirty cases are to be scheduled last.
H. %ll cases for elective operations and to whom anesthesia is to be administered
should have a complete wor$<up and a consent for operation duly signed by the
responsible party must be accomplished.
I. PreA+7erative 'he'!list *+r8 8ust )e a''+87lishe, 7ri+r t+ an= +7erati+n&
Please re*er t+ the stan,ar, IHOMP 'he'!list *+r8&2See PreAO7erative
Che'!list $+r8 AA77en,i< @3
The following preparations and wor$<up are necessary for a patient where
anesthesia is to be administered.
a. (aboratory e-amination such as
151 9hemoglobin and hematocrit determination:
Crinalysis
2ther e-aminations 9depending on the type of operation to be
performed:.
b. 3edical clearance which includes
1hest O<ray
)1G for patients above ,@ years of age.
c. %dequate amount of blood should be in the hospital laboratory.
d. Patients scheduled for elective surgery will be automatically cancelled at
/@@ p.m. a day prior to surgery if patient4s wor$<up and necessary
preparations are incomplete.
e. The anesthesiologist may cancel the operation not complying with the
requirements at the soonest possible time with the information and
reason submitted to the surgeon.
!@. Scheduled time for an operation should refer to the Jcutting timeM.
!!. No elective operation should be scheduled on Saturdays, Sundays and (egal
&olidays, only JstatM cases will be accepted
F+
!#. %ll elective cases required a pre<operative conference before the scheduled date
of operation.
!+. %ll elective cases should be done 3onday to Friday between H@@%3 " /@@
P3 only.
T&) F2((27'NG S&2C(. 5) 25S)6;).
a. %dmitted patients should be at the 2perating 6oom +@ minutes before
the scheduled time.
b. The surgeon should indicate and notify the 26 on the estimated duration
of the operation in order to assure a more definite schedule of operation
for the day.
c. % notification of delay from the surgeon and the anesthesiologist is
necessary in order for the 26 Supervisor to re<program other 26 cases
scheduled on that day and are able to notify the doctor4s of the new time
arrangement.
d. The surgeon is given !<hour delay, or otherwise the operation will be
cancelled.
e. Notice of cancellation of cases should be conveyed without delay to the
26 supervisor or to the designate.
''' P2('1')S %N. P621).C6)S 12N1)6N'NG 2P)6%T'NG 6223
P6';'().G) 2F T&) &2CS) ST%FF
!. The surgeon who actively performed the operation must sign the surgical
3emorandum required for every case and his name must be stated as the
surgeon.
#. Foreign and visiting surgeons8 anesthesiologist with no affiliation with the
hospital shall be required to obtain a written permission from the 1hief of
&ospital to perform surgery or to give anesthesia 9li$e in medical mission:
through the recommendation of the &ead Surgery, 2bstetrics and Gynecology,
2phthalmology, ))NT, and &ead of the %nesthesia .epartment.
+. 't is the surgeon4s prerogative to decide who will be his8her anesthesiologist.
For JstatM cases, the anesthesiologist on duty shall be called, #nd call shall be
the anesthesiologist schedule on the ne-t day, and +rd call will be the one
scheduled on the +
rd
day.
';.ST)6'('TD %N. %S)PS'S 'N T&) 2P)6%T'NG 6223

!. Sterility of the 2perating 6oom is the responsibility of everyone involved in the
surgery, this is to be enforced strictly by the 2perating 6oom Supervisor8 26
Senior Nurse.
#. 26 %ttire
a. %ll 2perating 6oom personnel should wear the prescribed 26 attire at all
times within the 26 comple-.
b. 7earing of street clothes underneath the scrub suit is not allowed.
F,
c. 26 personnel should change out of their prescribed 26 attire before going
out of the 2perating 6oom.
d. 26 attire soiled during the performance of the procedure should be discarded
and change with new sets
+. %vailability of materials and supplies at all times in the 2perating 6oom is the
responsibility of the supervisor.
,. Procedures not routinely or unusual cases requiring special supplies or
materials should be coordinated with the surgeon the day prior to surgery.
/. 6eference cards shall be available wherein Surgeon4s preferences are inde-ed.
Supplies and materials that cannot be procured on time shall be relay to the
surgeon as early as possible, for disposition or personal procurement.
;.6)12;)6D 6223
!. The operation of the 6ecovery 6oom and its subsequent policies are under the
supervision and responsibility of the %nesthesia .epartment and its chairman.
#. .ischarge of patients from the 6ecovery 6oom shall require the order of the
responsible anesthesiologist.
+. The presence of a 1linical Nurse in the 6ecovery 6oom is mandatory.
!ote" #ll policies will be sub$ect to change and revision as per discretion of
the %perating &oom 'ommittee to facilitate better implementation and
organi(ation, as the need arises.
;'. P2('1')S 2N &%N.('NG SP)1'3)N
!. %ll tissues removed during routine surgical procedure should be sent to the
Pathology Section for e-amination.
#. Proper handling of specimen is essential to maintain tissue in good condition
for pathological e-amination.
+. Tissues are to be preserved in !@> formalin solution in a wide mouth bottle
container, which is properly labeled with the following information
o name, age, se- ? case number of patient
o $ind of specimen
o date specimen was ta$en
,. 3edico<legal specimen such as pellet8slug or any other foreign body should
be properly labeled by circulating nurse who endorses it to the 26 Supervisor
for safe $eeping. The information contained in the label includes the
following
name, age, se- ? case number of patient
date of operation
type of specimen and area where specimen was ta$en. The
specimen is then ta$en to the medico<legal officer of the
hospital.
F/
Note Forceps should not be employed on removing a pellet from body as it
produces false striae. % pellet covered with blood should not be washed or wiped.
't should be placed on a piece of gau*e on its original condition.
;'' 'NT6%CT)6'N) F)T%( .)%T&<N)2N%T%( .)%T&

%s soon as the fetus is delivered, it is bapti*ed by a layperson. %n aborted fetus
whose weight is less than /@@ gm. are given to the member of the family. % death
certificate is not required. % fetus whose weight is more than /@@ gm is either
brought home or sent to the morgue. % death certificate is issued in such cases.
Note The 26N%P<P1S develop a manual on the 2perating 6oom Standards that
serves as ready reference.
POLICIES A# #HE OU#APA#IEN# DEPAR#MEN#
!. The 2ut " Patient .epartment is open 3onday to Friday H@@ %3 " !#@@ P3
? !@@ P3 " /@@ P3 on F'6ST 123) F'6ST S)6;) 5%S'S. 1ut off time
for registration " !@@@ %3 and +@@ P3 with special schedule for pay patient
during Saturday and Sunday.
#. %ll new patients must pass the registration unit where patient4s '. card with
hospital number was being issued after paying the registration fee at the
cashier. J2ne number for a lifetime policy.MThe patient then proceeds to the
staff on duty at the 2P. to sign consent for treatment ? for initial assessment
of the nurse. ;ital signs and the chief complaint were ta$en including patient4s
pertinent data. Then the patient proceeds to the doctor for final chec$ up. 'f the
patient is for admission, the protocol for admission will be followed as such.
Patient4s flow chart of admission was posted at the 2P. lobby for ready
reference. 'f the patient is not for admission, advice is being given together
with the medicines to be ta$en at home.
+. 2ld patients will submit his '. card to the registration staff for retrieval of old
chart then proceed directly to the nurse on duty at the 2P.. The same
procedure is being followed if patient is for admission.
,. SP)1'%(TD 1('N'1 ? 2T&)6 S)6;'1)S<Schedule depends on the
prerogative and availability of the 1onsultant
2phthalmology < 7ed. 8Sat. #@@P3 " /@@ P3
25<Gynecology, Family Planning < 3on.8Friday H@@ %3<!!@@ %3
7ed.<1harity, Thursday<Cltrasound
Sat. 8Sun. H@@ %3<!!@@ %3
.ental 1linic < 3onday<Friday
Pediatrics < Sat.8Sun. I@@ %3<!#@@ %3
FF
!@@ P3< !@@ P3
))NT < 3onday !@@ P3<#@@ P3,
< Tuesday8Thursday I@@ %3<!!@@ %3
< Sat. I@@ %3 <!#@@ %3

Gastro )nterologist < Tues.8Thursday !@@ P3<,@@
P3
Crologist < Tuesday /@@ pm<F@@ P3
3edicine < Sat. I@@ %3 <!#@@ %3
'nternal 3edicine < Sun. H@@ %3 <!@@@ %3
Surgery < Friday. I@@ %3 <!#@@ %3
General Surgery < Sat. I@@ %3 <!#@@ %3
The )6 Physician on .uty must see 3edico<legal cases within #, hours of
incidence or beyond at the emergency 6oom. The 6esident on .uty at the 2P.
sees cases more than #, hours from incidence.
/. P2('1D 2N 'SSC%N1) 2F 3).'1%( 1)6T'F'1%T) " %ll medical
certificates are issued by the record section after + wor$ing days. Two copies of
request for medical certificate must be accomplished, ! copy will be attached at
the patient4s chart for submission to the record section, while the other copy
will be given to the patient, to be shown on the scheduled day of release of
certificate. 'n the event that a medical certificate is urgently needed, the
attending physician can issue a provisionary medical certificate.
F. P2('1D 2N .'%GN2ST'1 6)KC)ST " %ll diagnostic request 9radiological
? laboratory: form must be accomplished fully by the attending physician to
include pertinent physical findings and initial impression.
G. P6)S16'PT'2N " The &ospital 3anagement emphasi*es adherence to the
Generic (aw of !IHH. %ll prescriptions should therefore be in generic and in
conformity with the National 8 &ospital .rug Formulary.
H. .2& P6'26'TD &)%(T& P62G6%3S %T T&) 2P. ? .2TS JTuto$
GamutanM " The hospital provides free counseling and medications to patients
who are found to be positive for %F5 on sputum e-am and or chest -<ray. 9See
.2TS Protocol, Procedures and Guidelines:.
I. F%3'(D P(%NN'NG " The hospital provides counseling on family planning
methods ? devices including ;oluntary Sterili*ation 95T(:, and Pap4s smear.
!@. )OP%N.). P62G6%3 2N '33CN'T%T'2N< This hospital fully supports
the goal of .2& that aimed to eliminate measles, neonatal tetanus, polio,
diphtheria, pertussis and other communicable disease. 'n line with this, all
FG
babies born at .AN63& will be immuni*ed every 7ednesday after well baby
chec$ "up of a physician.
!!. .'S)%S) SC6;)'((%N1)< 6eports of cases encountered during
consultation must be forwarded to 6)SC of 1&.<33 and (GC.
1ommunicable cases such as measles, .PT, and PT5 will be transferred
8referred to the appropriate health facilities such as San (a*aro and other
hospital for further management. 9Please see %ppendi- #,< Flowchart in the
3anagement of S%6S, % &!N!.:
LA1OR AND DELIVER% ROOM POLICIES
2A77en,i< DLA$l+; Chart +* DR Pr+'e,ures3
The nurse on duty should immediately inform the doctors for any
admission at the delivery room. %s a policy, physician should be the one to
handle all deliveries especially for primigravida, including suturing of
episiotomy wound. 2nce delegated to nurses or midwives by the physician,
he8she will be legally responsible to the wrong actions of nurses or midwives.
% pediatrician evaluates newborn baby especially complicated cases. Fully
effaced, crowning, uncomplicated cases that are in labor may be handled by
nurses or midwives while waiting for the doctor to arrive.
1REAS# $EEDING POLIC%
!. G)N)6%( 25A)1T';)
.r. Aose N. 6odrigue* 3emorial &ospital is committed to support and promote
breastfeeding, programs which poster good mother<child relationship, and promotes
emotional, physical and mental health.
-& $UNC#IONAL S#RUC#URE
To implement and supervise the program, a lactation management committee
will be created whose functional structure will be as follows

FH
1hief of &ospital
1hief " 3edical
Services
1hief " Nursing
Services
1hief<%dministrative
Services
%ncillary
Services
25 Program
1oordinator
Nursing Service
5F 1oordinator
Non<3edical Service
1oordinator
P62G6%

A& PROGRAM DIREC#OR

The 1hief of &ospital acts as the Program .irector who is responsible for the
overall administrative management and operations of the program.
P62G6%3 1226.'N%T26S
The 25 Program 1oordinator together with the 1hief of Nurse is responsible for
the technical and administrative supervision of all hospital services involved in the
implementation of the 5reastfeeding Program in the hospital.
1. Service coordinators will be designated by the P62G6%3 .'6)1T26 from the
medical and non<medical staff who will be responsible for ensuring the effective and
efficient implementation of the program. They shall be responsible for ensuring
proper documentation and record $eeping of all the activities of the program and its
periodic evaluation. They shall be responsible in conducting lactation management
training courses and shall act as liaison officers between program 1oordinators and
hospital staff involved in the program.
'''.P2('1')S
!. The Ten Steps to Successful 5reastfeeding shall be posted in all concerned areas
of the hospital. %ll staff of the hospital should always observe full
implementation of these steps.
#. (actation management training courses shall be conducted regularly by Program
committee with the primary aim of developing the s$ills on counseling and in
promoting breastfeeding to all mothers.
+. The Program 1ommittee shall see to it that the breastfeeding policies are
enforced.
,. 5reastfeeding policies set up by the committee in consonance with the directive
of the .epartment of &ealth shall be distributed in all sections of the hospital and
shall be made $nown to all staff.
/. %dvantages of breastfeeding shall be discussed by care providers to e-pectant
mothers and encouraged its active implementation.
F. Posters and instructional materials to enhance the $nowledge of the patients,
relatives, and hospital personnel.
G. The medical staff shall regularly conduct 3other4s classes.
H. %ll well babies shall be roomed< in and practice e-clusive breastfeeding unless
contraindicated.
';. P621).C6)S
FI
3edical Staff Nursing Staff
!. 5reastfeeding shall be started soon after delivery as the condition of the mother and
the infant permits.
#. 5abies with complicated cases shall be placed in their corresponding units.
+. The following newborn babies are roomed<in within +@ minutes and are started on
5reast feeding immediately and fed on demand basis.
a. 7ell babies
b. 'nfants with low birth weight 9#,/@@ gems or less: but with good suc$.
,. Physican in 1harge should be on rounds to chec$ roomed<in babies as the case
maybe.
;.P62&'5'T26S
!. No mil$ formula shall be $ept on stoc$ in the hospital .%ny necessary formula
must be purchased by the patients8relatives outside the hospital.
#. %ll mil$ formula shall be by prescription only. No formula prescription shall be
made without the approval of the attending physician on her designate based
on the medical conditions of the neonates.
+. No feeding bottles, artificial teats, and pacifiers shall be allowed in the hospital
e-cept when necessary.
,. No medical mil$ representatives shall be permitted to promote their products
within the hospital compound.
/. Posters, gifts, samples from mil$ companies, donations or supplies of infant
formula, technical or financial assistance shall be monitored and
documented.
F. %dministrative sanctions shall be imposed upon violations of the 3il$ 1ode after
due process.
;'. P2('1')S 2N .'S1&%6G) 2F 6223).<'N 5%5')S
!. .ischarge instructions will be provided to all mothers of roomed<in and
non< roomed "in babies.
#. Follow<up of discharged babies is scheduled after one wee$ at the 2P.
or as ordered by the physician<in<charge.
+. %ll roomed<in babies will be recorded on separate logboo$.
;''.6)126.'NG %N. 6)P26T'NG
c. .ata ban$ on breastfeeding program activities shall be set up to ensure
adequacy of information that may help in improving the program.
d. 6oomed< in babies who develop sepsis after discharge shall also be
recorded to determine the incidence among roomed< in babies.
CEN#RAL SUPPL% ROOM
SOP AND 0O1 DESCRIP#ION O$ #HE
CEN#RAL ROOM SUPERVISORADR0NRMH
G@
ST%N.%6. 2P)6%T'NG P621).C6)S 9%ppendi- !I:
1)NT6%( SCPP(D 6223
The 1entral Supply 6oom is an allied service of the 2perating 6oom. 't is a part
of the hospital where supplies, equipment and articles for ready use to patients are
stored, prepared and dispensed.
'. 25A)1T';)S
General
To provide adequate equipment, surgical supplies and other professional
supplies and materials to all clinical areas of the hospital, necessary for better patient
care.
Specific
!. To provide proper storage, prepare and control the use of supplies, materials
and equipment in order that these will be immediately and constantly available
for routine and emergency use.
#. To standardi*e techniques in order to ensure economy of time, effort and
materials for efficiency of service.
+. To maintain proper aseptic technique.
''. 5orrowing of %rticles and 6equisitioning of Supplies
!. 6equisitions of supplies for use in all clinical areas are made every morning
between H@@ and !@@@ %3. )nough supplies are requisitioned for the whole
twenty four hours and are done by nursing attendant.
#. &ospital personnel with permanent appointment, medical and nursing affiliates
and trainees in the hospital are allowed to requisition supplies and borrow
articles necessary for patient care. Patients, visitors and all others not
concerned with the hospital are not entitled to this privilege. 1asual employees
may be allowed to requisition supplies, but they are not allowed to borrow
equipments and apparatus e-cept when they present a written permission from
the Senior Nurse or permanently employed Staff Nurse. Nursing %ttendant
9N%: prepares requisition slip and forwards it to 1S6 &ead.
+. Cnder no circumstances should supplies, materials and equipment issued from
the 1entral Supply be brought outside the hospital premises e-cept upon
previous approval by the 1hief of &ospital or in his absence by any of his
authori*ed representatives " the %dministrative 2fficer, 1hief of 1linic, or
1hief Nurse, in the order of their availability.
,. To avoid confusion in the endorsement, no borrowing of dressing trays and
other articles is allowed 9e-cept in urgent cases: fifteen 9!/: minutes before
and fifteen 9!/: minutes after change of shifts.
/. 5orrowers must sign their full names legibly on the borrower4s boo$ to enable
the 1entral Supply 6oom staff to readily trace delayed return of articles.
G!
F. %ll borrowed articles must be returned immediately after use on or before the
end of the shift. Non<e-pandable materials not returned within his shift and8or
within twenty four hours shall be the responsibility of the original borrower.
G. )conomy in the use of supplies must always be practiced. For purposes of
economy and minimi*ing infections0 $idney basins, dressing instrument with
infectious substances, etc., must be invariably rinsed before returning to the
1entral Supply 6oom where thorough cleansing, scrubbing and re<sterili*ation
are done. 5rea$ages and brea$down of supplies, materials and equipment
should be reported to the 1entral Supply 6oom personnel and the bro$en
articles must be returned together with the borrower4s brief but clear
e-planation of the circumstances surrounding the incident. 7ith comments and
recommendations of the Nurse Supervisor involved, the same is forwarded to
the %dministrative 2fficer who finally decides whether to change or condone
the amount involved. 5rea$ages without e-planation or with an unsatisfactory
e-planation must be replaced in $ind by the person involved.
H. (osses do not require e-planation but should be treated and acted upon in the
same manner as provided in the immediately preceding paragraph.
'''. Procurement of )quipment, Supplies and 3aterials
)quipment, supplies and materials needed in the 1entral Supply 6oom are
procured through the usual standard processing procedure of the hospital. The 6';
form is prepared on 3onday to give time for its approval by offices concerned, the
Property 2ffice, %dministrative 2ffice and 1hief of &ospital. The needs of these
articles as seen by the one in charge of the 1entral Supply 6oom or as suggested or
requested by those in charge of the different departments are evaluated and determined
by the requisitioning Nurse Supervisor who prepares the list of articles with the proper
prescription, specification and Bustification on the processing. Supplies stoc$ed in the
Property Section are requisitioned monthly.
';. Preparation of Supplies and 3aterials
%rticles li$e dressing instruments and others, especially those used in
infectious cases upon returning to the 1entral Supply 6oom are first soa$ed in
disinfectant solutions. 't is the responsibility of the 1entral Supply 6oom staff on duty
to
!. 1lean, pac$ and sterili*ed all articles that need sterili*ation returned during her
shift.
#. Pac$ and have 2.6. and 2.5. linens autoclaved as soon as possible after
delivery of clean linens.
+. See to it that there is a continuous supply of hot water. %utoclaving must be
done at least once during each shift and as often as necessary.
G#
;. Storage and 3aintenance of Facilities
!. Sterile articles should be $ept in cabinet inside the sterile storage room and all
others in cabinet provided for them. The 1entral Supply 6oom staff should
$now the source of all supplies, materials and equipment for circulation to
avoid confusion in locating them and to ensure an adequate supply of all
articles all the time. This is accomplished with inventory control and
systematic storage.
#. 't is the responsibility of the 1entral Supply 6oom staff on duty to follow up
all borrowed articles not returned before the end of her shift. %ll articles
including those not returned at the change of the shifts must be properly
endorsed to the succeeding staff on duty.
+. The 1entral Supply 6oom staff must notify the supervisor of destroyed
equipment and facilities for repair and of supplies for requisitioning.
,. 't is the responsibility of the Nurse Supervisor to determine and maintain the
adequacy of the equipment and stoc$ supplies and see to it that all destroyed
equipment and facilities are repaired or replaced. For supplies below /@>
instruct or prepare 6'; and forward it to supply officer for timely action.
;'. 6ecording and 6eporting
!. %ll articles borrowed are recorded in a record boo$ provided for the purpose. %
separate borrower4s boo$ is provided for each of the following sterile articles,
non<sterile articles, brea$ages and losses, o-ygen gauges and articles not
returned in eight 9H: hours.
#. Supplies requisitioned for use in all clinical areas are written by the
requisitioner on slips of paper that are spindled during the day. The night staff
records all of these in a record boo$ for daily supplies issued.
+. Stoc$ supplies and articles are provided with cards and supplies ledger cards.
,. 5rea$ages and losses, especially equipment and other non<e-pendable
materials should be reported as soon as possible after the brea$age or loss is
discovered to the %dministration 2ffice through channel for appropriate action
and a copy thereof be furnished to the 1hief of &ospital.
$LO9 CHAR# O$ CEN#RAL SUPPL% ROOM ON DIS#RI1U#ION O$
SUPPL%
G+
SUPPL% SEC#ION5
PROCUREMEN#
UNI# 9Procure and
release supplies to 1S6
POLICIES AND PROCEDURES IN #HE IN#ENSIVE CARE UNI# 2ICU3
CONCEP# O$ IN#ENSIVE CARE UNI#
(21%T'2N 7ithin the P&'(&)%(T& 5uilding< %dBacent to Pay 7ard
5). 1%P%1'TD Four 9,: beds
12N1)PT The 'ntensive 1are Cnit 9'1C: is a hospital facility for care
of critically< ill clients at a more intensive level, staffed by speciali*ed health care
providers which contain a comple- assortment of monitors and life support equipment
that can sustain life in once<fatal situation. The critically < ill patients are so close to
dying so the outcome of the intervention is difficult to predict.
't is described as J1(2S).M CN'T wherein the system is more
coordinated management of the client based on the team who wor$ e-clusively.
Physicians and nurses here are called J'NT)NS';'STSM with special training in
critical care medicine and nursing and paramedic certified to levels of )3TS.
Generally, it is the most e-pensive, technologically advanced and resource intensive
area of medical care.
25A)1T';)S
G,
CEN#RAL SUPPL%
ROOM 9Prepares 6';,
pac$, sterili*e received
supplies, distribute and
monitor use of
instruments ? supplies
)nd Cser "
utili*e and
charge
supplies to
patient
6eturn
borrowed
instruments
for
sterili*ation
)nd Cser 9 )6,2P.,
7ard, 26,.6
Submit 6equest for
supplies8instruments
To provide a concentration of specially trained staff that has the education,
training, and personality to render services and give attention to processes necessary to
life.
3aintain consolidation of all maBor life support devices essential for meeting
the needs of the acutely and critically ill clients.
To provide a sympathetic understanding of the apprehension and tension which
a clients family undergoes during critical period.
Provide opportunities for professional development of both the medical and
nursing staff.
P2('1')S
The Section 1hief of the '1C shall be responsible for the
management of the unit.
For Private 1lients, the %ttending Physician shall be primarily
responsible for the management of his8her client at all times.
For Service 1lients, the '1C Physician<in<1harge8 Physician "on<
.ec$ shall be responsible for the management of the clients.
KC%('T')S 2F %N '1C NC6S)
The nurses within this area must undergo in<service training in
critical care nursing management, certified 116N. 116N
should be caring, sympathetic, responsible, and detailed oriented.
&e8she must be able to direct or supervise others, correctly assess
clients4 conditions, and determined when consultation is required.
&e8she needs emotional stability to cope with human suffering
emergencies and other stresses. Social maturity is an asset which
made them different from other area nurses because of their
unusual status and responsibilities.
%ge and health is also vital for better performance and ma$e best adBustment to the
demand of this Bob.
12.) T)%3
%s an integral part of the unit, a 12.) T)%381%6.'%1 %66)ST T)%3, shall be
organi*ed as to be able to provide an immediate emergency care for clients both within
the '1C or in any section of the hospital. The team shall be composed of
Physician " on< .uty, as the team leader
%ttending Physician for private cases
&ead Nurse8 Staff Nurses of '1C
3edical Technologist8 )1G Technician
%.3'N'ST6%T';)
G/
The coordination of the unit, training of personnel, and
general responsibility for level of care will be under the direct
supervision of the '1C Section &ead.
&ouse staff coverage, consisting of attending physician and
physician<on<duty at the '1C, will be responsible during the
day and the physician "on< duty at night shift shall,
li$ewise, be responsible during the night.
%ll nurses assigned to the '1C will undergo training in
critical care management, and also a periodic in<service training
every si- 9F: months8 year.
'NT)NS';) 1%6) CN'T 6C()S %N. 6)GC(%T'2NS
A& %.3'SS'2N P621).C6)S %N. 16'T)6'%
%ll '1C admissions are classified as private cases. The unit manager8SN
reserves the right to assign the room and notifies the %dmitting Section.
6equest for admission to the '1C is made by %ttending Physician8 )6
.octor.
Nurse in the unit where the patient is coming from notifies the '1C.
The '1C nurses must e-plain the rules and regulation, S2Ps, infection control
measures of the unit and the corresponding charges of the supplies and
equipments used by the patients to the relatives.
)6 nurse8 Floor nurse informs the '1C of the wor$ing diagnosis of the patient,
contraptions attached to the patient, the preparation needed. The )6 nurse must
accompany and endorse the patient properly to the '1C staff.
% ! 1lient needing cardiac monitoring
(ife<threatening arrhythmias, hypo$alemia 8 hyper$alemia, to-ic
syndromes,
Poisoning cases
1ardiac arrest8 post arrest with salvageable pr,ognosis
%cute myocardial infarction8CNST%5() %NG'N%
Shoc$ States Septic, 1ardiogenic, hypovolemic.
1ongestive &eart Failure 91&F: Pulmonary )dema
%cute 6espiratory Failure8 ;entilator Support
%cute renal failure with metabolic acidosis
%cute neurologic conditions8neurosurgical conditions
Cnstable post operative clients needing monitoring
&ypertensive )mergencies
1ritical )ndocrine condition
NO#E: CON#AGIOUS DISEASES an, #ERMINAL CASES MA%
NO# 1E ADMI##ED5 E6EMP#ED IN #HE CRI#ERIA:
GF
Gangrenous wounds )nd stage malignancy
3illiary T5 )S6.
%F5 9S: SPCTC3 )nd stage liver disease
3eningococcemia Prolonged 16%. !/
minutes
Septic shoc$ clients 1omatose
5urn client4s Poor prognosis
'n private cases, the %ttending Physician retains control of his client,
and ma$es all the necessary decisions unless he requests transfer of
client to the '1C.
The client8 any responsible, legal and related member of the family will
sign the J12NS)NT F263M, and then the Nurse<on< duty will sign as
witness.
Private "duty nurses 9P.N: are not assigned to '1C. The Nurse<in<
1harge and the attending physician will convince the client and the
relatives about the value of S2P.
%dmission from within the hospital8 transfer<in from other facility 8area
will require a complete endorsement on medication, treatment, etc. by
the transferring nurse.
1& #rans*erA in:
% written order by the attending physician is necessary to transfer a client to
the '1C.
The attending physician chec$s with the Nurse<in 1harge 8 %dmitting section
for bed availability.
The transferring unit will notify the %dmitting section about the transfer of
client to '1C.
O<=en: %ll patients will receive o-ygen by cannula at #(P3 from admission
until modified by Physicians order or if the patient is intubated prescribed Fi2# is
administered.
Vital Sin:
1P record every +@ minutes till stable then every hour.
P6, 66 shall be recorded as well as 5P.
Temperature be chec$ed every , hours and or P6N.
Neuro logical status of the patient is monitored every hour for
by using the Glasgow coma scale
ECG M+nit+rin:
GG
%ll patients must be connected to cardiac monitor.
$lui,s:
% dependable ';F line is ./w unless changed by the physician.
Fluid inta$e shall be determined by 'nta$e and 2utput recording.
Urine an, 1+;el:
%ll patients are placed on complete bed rest unless ordered by the physician.
Ph=si'al Care:
'1C nurse 6outine physical hygiene including daily sponge bath, oral care,
dressing of wound, and linen changes are done by the Night
duty nurse.
The may be allowed to change or maintain dressing aseptically.
)g. 1;P, 1ut down, Tracheotomy care
C& #rans*er ?+ut: The prescribed length of stay in the '1C will be set at five 9/:
days as average unless maBor cardiac arrhythmias, shoc$, severe pain and pulmonary
edema are present
paro-ysmal atria 8 tachycardia Nodal rhythm
uncontrolled atrial flutter8 atrial fibrillation #
nd
+
rd
degree %; 5loc$
atrial standstill Frequent P;14s
%; .issociation 3ultifocal P;1
Nodal tachycardia ;entricular tachycardia
'n case of private client, the '1C &ead with the consent of the attending
physician will determine when the client has to be transferred out.
1lient who may no longer need intensive care management, a transfer slip
signed by the nurse<on<duty is accomplished. The '1C nurse accompanies the
patient during transfer and ma$es a complete endorsement to the floor nurse.
D& Dis'hare:
%ll discharges require the attending physicians4 order.
.ischarges without physicians4 order will necessitate signing by the
client8relatives of the 6elease from 6esponsibility Form 9.%3%8&%3%:.
Facilitate the discharge order 9please follow the discharge flow chart:.
E& Visitin Privilees:
Due t+ the seri+us '+n,iti+n +* the 'lient in the ICU( the *+ll+;in
7r+'e,ures ;ill )e stri'tl= +)serve,O
;isiting privileges will be determined by the attending physician8nurse<on<duty
depending on the client4s condition.
%bsolutely JN2 ;'S'T26SM for unconscious clients.
JN2 ;'S'T26SM allowed for conscious clients during the first #, hours.
2nly two 9#: visitors are allowed per visiting time.
;isit will be limited to not more than !/ minutes only.
GH
2nly immediate family members, wife, husband, legal guardian, ne-t of $in
shall be allowed to enter the '1C one or two at a time within the specified
visiting hour.
1hildren under !# years of age are not allowed to visit unless e-ceptions are
made by the attending physician.
'nformation about the clients4 condition will be given to the immediate family
2N(D.
Taped 3usic maybe allowed for the patient provided that it is battery operated.
Visitin H+urs:
!@@@ %3 < !#@@ NN
/@@ P3 < G@@ P3
Newspapers, maga*ines, televisions, flowers, and foods for the client are
S#RIC#L% P62&'5'T). inside the '1C.
Get well soon messages maybe posted with permission from the Senior Nurse.
#O PREVEN# CROSSA IN$EC#ION ,the visitors must wash hands with
soap and water or dispense %lcohol G@> into the hands, rub together until dry
before entering and e-iting the unit.
ICU LOUNGE5GALLER% ? Serves as ;aitin area *+r 7atientHs relative
l+'ate, )esi,e the 'ha7el5'+rner +* PHILHEAL#H ;ar,&
T72 9#: relative are not allowed to sleep at the gallery
6elatives are requested to maintain S'()N1)S, 1()%N('N)SS %N.
26.)6('N)SS%T %(( T'3)S.
6)1&%6G'NG 2F )()1T6'1%( G%.G)TS 91)((P&2N)S, 6%.'2S,
)T1: %T T&) G%(()6D 2CT()T 'S P62&'5'T).. 2verloading can affect
the function of cardiac monitors and respirator attached to the patient.
1ommunication to the '1C is made through 1%(( from the staff nurses.
DO NO# $ORGE# HAND9ASHING" Han, ;ashin )e*+re an, a*ter atten,in
'lients& Han, ;ashin )e*+re an, a*ter enterin 7atientHs unit&
$& ORDERLINESS:
Strictly JN2 S32E'NGM.
S'()N1) is strictly enforced.
;isitors and &ealth 1are Providers 3CST 7)%6 '1C G27NS 8 %P62N and
S('PP)6S before entering the unit.
GI
NO#E: NO S#REE# SHOES( SLIPPERS( AND CLO#HES ARE ALLO9ED
INSIDE #HE UNI#
Foods are not allowed inside the unit.
General cleaning is done when the room is vacated
No sweeping use wet mop 2N(D.
)-haust fan will be open once in a shift
1lients4 room must be closed always.
Sufficient space is provided for each client4s equipments, and personnel.
No overcrowding of clients, health care personnel, and student nurses to
prevent infection transmission by direct contact.
%dequate ventilation is provided.
G& CLIEN#S 1ELONGINGS:
1lothing, valuables, and other personal belongings of the client to be admitted
in the unit are sent home through relatives for safe$eeping. The '1C Staffs are
not held responsible for the losses within the premises.
2nly the necessary articles are permitted at the clients4 bedside
H& RECORDS
% G6%P&'1 1&%6T S&))T for vital signs 9temp., pulse rate, cardiac rate,
resp. rate, weight, urine and stool, inta$e and output: is used and be placed at the
clients4 bedside. 2ther pertinent records should be attached to the clients4 chart.
I&DIE#AR%:
No food from outside is to be brought to the '1C e-cept when dietary
cannot provide for the special dietary needs of the client. 'n this case,
diet shall be screened always by the Nurse "on "duty.
Follow clients4 diet as ordered.
0& LA1ORA#OR%
!. (aboratory requests shall be written on the (ogboo$ to before submitting to
the laboratory unit by the nursing aide.
#. 6esults of all laboratory wor$<ups must be forwarded to the '1C
immediately by the laboratory personnel. 'n case of emergencies, requests and results
must be called via intercom8telephone %S%P.
+. 'n cases of N2 6)%G)NT, the laboratory personnel will advise clients4
relative to facilitate it outside.
K& CARDIAC 1OARD :2 Placed at the bac$ of the )<1art:
1ardiac 5oard shall always be available to provide $IRM SUPPOR# during
cardiac compression.
(& EMERGENC% CODE CAR# 2EACAR#: This should always be chec$ed for
complete stoc$ of drugs and supplies every shift&
H@
DRUGS an, SUPPLIES used after the emergency should be identified and
listed for immediate replacement by the N2. in the %3 shift.
LIS# O$ ICU DRUGS
Generi'5 1ran, Na8e 4uantit= E<7irati+n Date Nurse Sin& Date
2 Please see atta'he, 5 anne< 3
LIS# O$ E4UIPMEN#S AND SUPPLIES
S#ANDARD E4UIPMEN#: SUPPLIES:
%ir< conditioned room 5P apparatus with stethoscope
3echanical bed with side rails 5ed linen and pillows
5edside cardiac monitor Syringes, needles
5edside tables and cabinet '; catheter, suction catheter, )T tubes
2-ygen tan$ filled with suction %irway adBuncts
'; hoo$s and '; stand cotton balls, gau*e, feeding tubes
Nebuli*er gowns for &1P, G@> alcohol
Patient, visitors, slipper
.efibrillator measuring cup, basin,
3edicine glass
!# " (ead )1G 3achine urinals, bedpan, and urine bag
Syringe pump penlight, flash light, etc.
Portable suction apparatus
3echanical ventilator
1entral 3onitor in the Nurses4 Station
$OR MONI#ORING:
Me'hani'al Ventilat+r
To provide ventilator support and monitoring for infant, pediatric, and
adult clients with respiratory failure 8 insufficiency.
To assist breathing through an )T tube 8 tracheotomy.
Car,ia' M+nit+r
#o monitor electrocardiography, heart rate, pulse rate, blood pressure
9systolic, diastolic, and mean arterial pressure<3%P:, arterial o-ygen
saturation, respiratory rate, temperature, and carnographD 9))12#,
'n12#:.
ECG D-ALea, Ma'hine 2Aut+8ati' an, Manual:
a machine that records the activity of the heart.
Pulse O<i8eter
For continuous monitoring of o-ygen saturation and to detect
alternating intensity of o-ygenation.
V+lu8etri' In*usi+n Pu87
H!
Cse in the administration of total protein nutrition and drug therapy
such as those used in chemotherapy, anti<tumor drugs, o-ytocin,
and where precise powered infusion is required.
S=rine In*usi+n Pu87
's designed to meet the fluid and drug delivery requirements of
today changing clinical environment. 't is indicated for infusion via
intravenous 9';:, intra arterial, epidural, and subcutaneous routes
of administration. 't accepts wide range single " use syringes with
volumes from !@<!@@ml, /ml is optional.
Ne)uli>er A77aratus
7or$s to convert the medication to a high<quality mist of fine
particles that penetrates deep into the lungs
De*i)rillat+r 2Res7+n,er ;5 AED PRO3
'S % S)(F "T)ST'NG 5%TT)6D 2P)6%T).U %CT23%T).
)OT)6N%( .)F'56'((%T26 indicated for emergency treatment
of victims e-hibiting symptoms of sudden cardiac arrest that are
unresponsive and not breathing. %fter applying the %).s pad to the
client chest, the %). automatically analy*es the clients4 )1G and
advises the operator to push the button and deliver a S&21E if
needed. 't guides the operator using a combination of voice
prompts, audible alerts, and visible indicators.
Manual Resus'itat+r
's made of silicone, rubber8P;1 materials, late- free used to
ventilate patients with apnea or used for spontaneously breathing
clients to augment ventilation or o-ygen delivery. 't is also use as
advice for artificial ventilation and cardiopulmonary resuscitation.
1l++, Pressure 21P3 A77aratus
Is designed as a non< invasive method of measuring blood pressure
on healthy s$in of the upper arm or thigh region only.
Su'ti+n A77aratus
The aspiration of secretions often through a rubber or polyethylene
catheter connected to a suction machine.
Or+7har=neal 5 Nas+7har=neal Su'ti+n
% method of aspirating mucus or other secretions or fluids from the
nose, mouth, and pharyn- using a suction catheter attached to the
suction apparatus.
#ra'he+t+8= tu)e su'ti+nin
H#
'nsertion of a double tracheotomy tube in the opening or incision
made in the trachea to remove the secretions unable to e-pel8cough,
to provide air for clients to breathe.
En,+ tra'heal su'ti+nin
% deep suctioning by the use of catheter which is inserted farther
into the trachea usually #@cm8Hin. of the catheter to maintain patent
airway by stimulating cough refle-.
Lines( #u)es( Drains
P6'26 to treatment0 chec$ all these connections to prevent
dislodging during treatment and mobility. )G Feeding Tubes, 1hest
Tubes, 'F1s, pacema$er, 1;P, arterial lines and '; lines.
$+r E8eren'= Use,:
.efibrillator 1ut down 8 1;P set
6espiratory 6esuscitative )quipment '; Solutions
2-ygen supply with gauge '; catheter, 3acro set, Syringes, plaster
1ardiac 5oard 5andages, gloves, sutures, blades
(aryngoscope 5P %pparatus w8 Stethoscope
Suction apparatus Tourniquet
9HA# IS CRI#ICAL CARE NURSINGP
7hen people hear critical health care patient, most of the time, these
are patients that have life<threatening conditions and are confined in the 'ntensive 1are
Cnit of the hospital. Those nurses who can render duty wor$s in the '1Cs are called
1ritical 1are Nurses. 1ritical 1are Nursing is a speciali*ation in the nursing field that
ensures the delivery of optimum health care to critically " ill patients. Patients who are
considered critically " ill are highly at ris$, have unstable condition, and are
considered to have comple- and sensitive health care needs, thus, these patients need
cautious and intensive nursing care&
1ritical 1are nursing field is considered a new specialty. '1C was alien to the
7estern world until !I/@s. The 'ntensive 1are Cnit was created in order to care for
gravely ill patients. They require more attention compared to patients who are
confined in regular hospital wards. 3ostly hospitals are required to have '1Cs, thus it
needs for trained nurses and doctors.
1ritical 1are Nurses are essentially s$illed in the area of diagnosis because
they have to accurately diagnosed and recogni*e the immediate needs of their patients.
't is also vital to spell the difference between life and death. 1ritical 1are Nurses are
tas$ed to deal with the family of the patient. They wor$ as a counselor to help the
family deal with the crisis at hand. They will answer the questions and concerns that
will be raised by the member of the family.
H+

NURSING ROLES IN ADMISSION( PA#IEN# CARE MANAGEMEN#(
AND DISCHARGE O$ #HE PA#IEN#
1ritical care nursing is a specialty within the nursing field. The number of lives saved
with this speciali*ed care can be directly related to the competence of the nurses in the
intensive care unit.
To clearly define nursing role it is important first to consider the total duties and
responsibilities of the 1ritical 1are Nurse followed by the nursing procedures on
admission to discharge.
DU#IES AND RESPONSI1ILI#IES:
D& 1ontinuous assessment of the patients4 condition and cardiac status.
Cse of monitoring equipment.
The nurse responds with confidence and adapts to rapidly changing patient
condition. &e 8She must be aware of the heart rhythm and be able to identify
significant arrhythmias, tachycardia at their onset. 't also requires the use of sound
clinical Budgment 9$nowledge, s$ills, logic, and common sense: and understanding
the principles and operation of the monitoring devices.
6epeated direct observation of the patient.
The nurse must closely monitor the activity of the heart thru the parameters
appearing on the screen of the device. Ta$ing and recording of the vital signs hourly
then refer the patient accordingly.
#. 6outine nursing care must be observed.
Generally routine nursing activities must be done at night shift such
as bed bathe, sponge bath, and oral care, changing dressings,
diapers and feedings at her own scheduled time or discretion.
The nurse manages comprehensive care of the patient.
+. Nursing measures of patient with cardiac problems.
The nurse must be able to perform the therapeutic measures such as
< %dministration of 2# T&)6%PD
< begin access line
< prepare and anticipate drugs and supplies for emergency situation
< 'n case of v< tachycardia8fibrillation, prepare defibrillator for a shoc$
or begin compression if fatal arrhythmia is present before the
physician arrives.
< ta$e !#<lead )1G
,. )motional support for the patient and the family with a caring practice.
The nurse responds to the unique needs of patient and families
coping with unanticipated treatment, quality of life, and end<of<
life decisions. %llaying the patients4 fear and apprehensions
with a caring attitude.
H,
/. 1ommunication< being an advocate.
The nurse e-plains the gadgets attached to the patient, its uses
and rationale, the medications Laction why it is prescribed, the
nursing procedures to be done to gain cooperation.
The nurse collaborates with other multidisciplinary team for
referrals, diagnostics, etc.
/. 6ecords $eeping and provides patient and family teaching.
NURSING ROLE IN #HE ADMISSION O$ PA#IEN#S IN #HE IN#ENSIVE
CARE UNI#
S$illed nursing management of a critically "ill patient operates on many levels.
The critical care nurses4 s$ill level is dependent upon their $nowledge, e-perience of,
and e-posure to critically "ill patients.
!. Notify '1C physicians as soon as the patient arrives.
3edical treatment must be started promptly because the earlier the therapy, the
better the survival rate.
#. Start o-ygen administration via nasal catheter.
% routine procedure done to all acutely ill patients. This must be ready at all
times to save time.
+. Perform a !#< lead )1G and obtain the rhythm strips.
%n incidence of fatal arrhythmias is very high.
,. %ttach the patient cardiac monitor to the patient4
3ost death occurs within the first +@ minutes after admission due to
arrhythmia.
/. 1hec$ and record vital signs. 1areful recording of the parameters 5P, 16, 66,
Temperature, P6 are essential and serve as the baseline data for evaluating patients4
course situation.
F. 1ontinuous assessment and observation " an important function.
6educe patients4 ris$ of precipitous deterioration.
Prevent their confusion8 agitation leading to harm.
G. %ssist the 3. during physical e-amination.
H. Start the drug therapy as ordered&
%dministration of medication must be timely and the availability of drugs
saves life.
B& H+listi' '+88uni'ati+n&
The nurse often is the $ey provider of information to patients4 relative
and other members of the team.
The nurse must orient the relative on the policy, rules and regulation of
the unit especially visiting hour schedule, infection control measures
H/
9use of gown, no street slippers8shoes inside the unit, &%N.
&DG')N) before and after entering the patients4 room:.
Give emotional support to the patient and the family.
NURSING ROLES IN PA#IEN# CARE MANAGEMEN#
1e,si,e nursin 'are is *le<i)le an, vital as ++, 'are&
The nurse plans and implements care based on the needs of the
individual patient.
The presence of cardiac monitors, equipments may not relieve the
nurses4 basic responsibilities rather they only supplement other nursing
care or measures.
DIREC# PA#IEN# CARE:
3aintain good hygiene and physical comfort.
%dministration of medication on time.
3onitor and record inta$e and output.
3aintain and observe body positioning by turning the
patient.
Feed and maintain patients4 diet for fast recovery.
Facilitate proper elimination and record8document.
)-plain to the patient and to the family the concept and
function of the machines attached.
%llow the patient to e-press his fears and apprehensions.
NURSING ROLES IN #HE DISCHARGE O$ #HE PA#IEN#
Pre7are the 7atient *+r ,is'hare:
Pur7+se:
'ncrease the patients and family understanding of the health
problems and possible complications and restriction.
.evelop the patient and family ability to care for the patients4
needs and provide a safe environment.
3a$e sure that any referrals needed for further care are
properly made.
DISCHARGE PLANNING SHOULD INVOLVE 1O#H #HE PA#IEN# AND
#HE $AMIL% MEM1ER 9HO 9ILL 1E #AKING CARE O$ #HE PA#IEN#"&
Pre7are t+ + h+8e:
%s$ the patient to have the primary caregiver at home for the '1C
NC6S) to give proper instruction on ta$ing medication, proper diet,
e-ercise, activity to perform at home and return chec$<up of the patient.
Teach the patient and the family member about how to handle the care at
home.
Tell them what is li$ely to happen and when they can e-pect full
recovery, to recogni*e possible problems and what to do.
HF
Tell the patient and family member what patient can and cannot do0
< 5ed rest
<wal$ only for few steps for ! wee$
<personal hygiene
<e-ercises li$e rising of legs and arms for a period of time.
<soft food diets.
1asi' 7rin'i7les +* ++, 7atient tea'hinO
<schedule the teaching when the patient is already alert and interested in
learning.
<start with the thing that the patient is most concerned.
<use clear, ordinary words not medical words
<encourage the patient to comment and as$ questions.
<as$ for the return demonstration of procedures.
<use pictures in teaching and give handouts.
E4UIPMEN# CHARGES:
Pa= 9ar, Me'hani'al Vent5Res7irat+r D
S#
Da=
P.( JCC5,a= then PLCC5,a=
therea*ter
Patient Car,ia' M+nit+r D
st
,a= PJLC5,a= then
P.LC5,a=
therea*ter
De*i)rillat+r -CC5sh+'!
Pulse O<i8eter -CC5,a=
V+lu8etri' In*usi+n Pu87 .CC5,a=
S=rine Pu87 -LC5 use,
1ell liht DCC5shi*t
Dr+7liht -L5use,
2-3 Dis7+sa)le 1a'terial $ilter D(@CC5use,
Dis7+sa)le 1reathin Cir'uit D(DCC5use,
Su'ti+n Ma'hine DCC5use,
D-ALea, ECG ;5 Stri7s JCC D
st
,a=s use,
#hen .CC5use,
a*ter
CHARI#% 9ARD:
Me'hani'al Vent5Res7irat+r P-L5shi*tQ EL5,a=
Patient Car,ia' M+nit+r -L5shi*tQ EL5,a=
De*i)rillat+r -L5sh+'!
Pulse O<i8eter -L5shi*t Q EL5,a=
V+lu8etri' In*usi+n Pu87 -L5shi*t Q EL5,a=
S=rine Pu87 -L5use,
2-3 1a'terial $ilter D(@CC5use,
Dis7+sa)le 1reathin Cir'uit D(DCC5use,
1ell liht -L5shi*tQ EL5,a=
HG
Dr+7liht RNICU PICU -L5shi*tQ EL5 ,a=
Is+lette 2Pe,ia( NICU( PICU3 -L5shi*tQ EL 5 ,a=
Ra,iant 9ar8er -L5shi*tQ EL 5 ,a=
In'u)at+r LC5,a=
Su'ti+n Ma'hine -L5use,
PROCEDURES PER$ORMED:
C P R ;5 A8)u)ain P ECC57r+'e,ure
E# inserti+n *ee -LC57r+'e,ure
NG# Inserti+n $ee DLC57r+'e,ure
Gastri' Lavae -CC57r+'e,ure
In,;ellin $+le= Catheter Inserti+n DCC57r+'e,ure
Su'ti+nin $ee DCC57r+'e,ure
IV$ Inserti+n -C5 7r+'e,ure
Ne)uli>ati+n *ee -L57r+'e,ure
9+un, Dressin EL5,ressin
O<=en Inhalati+n LC5 h+ur
NO#E: O- '+nsu87ti+n *+r 7atient ;ith 8e'hani'al ventilat+r Q D $ull #an!
ever= -A. H+urs
PAR# DD: S#ORAGE( OPERA#ION( AND CARE O$ #HE
E4UIPMEN#S
CLEANING AND DISIN$EC#ION O$ #HE UNI#
S#ORAGE O$ MACHINES5E4UIPMEN#S
MACHINE:
C+ver the 8a'hine5e/ui78ent ;ith 'lean 'l+th +r 7lasti' ,ust '+ver&
St+re the 8a'hine5e/ui78ent in a '++l ,r= 7la'e&
Av+i, sta'!in +ne 2D3 8a'hine5e/ui78ent +n the t+7 +* the +ther 8a'hine&
A77l= PO9ER t+ the 8a'hine5e/ui78ent *+r at least +neAhal* t+ +neAhal* t+ +ne
h+ur 7er ,a=&
St+re 8a'hine5e/ui78ent a;a= *r+8 '+rr+sive 'he8i'als&
A77l= s8all a8+unt +* +il +n the ;heels an, )earins +* the e/ui78ent 5
8a'hines&
Re8+ve )atteries ever= a*ter use an, st+rae i* 8a'hines5e/ui78ents are )atter=
+7erate,&
9i7e +r 'lean 8a'hines5e/ui78ents ;ith ,a87 'l+th t+ re8+ve the e<'ess ,irt
+''asi+nall=&
9hen trans7+rtin the 8a'hines5e/ui78ents *r+8 +ne 7la'e t+ an+ther( av+i,
)u87in( *alls( et'&
CA1LES:
Ma'hine 'a)les( r+un, ;ires( 7+;er '+r,( ele'tr+,e ;ires sh+ul, )e st+re an,
'+il l++sel= an, 7r+7erl= 7la'e +n *lat sur*a'e&
HH
Ca)les sh+ul, never )e t;iste,( )rai,e,( stret'he,( 7inne, +r hane,&
Al;a=s han,le 'a)les )= their '+nne'ti+ns&
Av+i, usin a,hesive ta7e( 7laster t+ )un,le '+nne'ti+ns&
Av+i, ste77in +n the ;ires +r 'a)les&
Ins7e't 'a)les reularl= *+r sins +* 'ra'!&
ELEC#RODES:
Ele'tr+,es sh+ul, )e ;ashe, ;ith ;ater an, s+a7 )e*+re st+rin&
Kee7 the ele'tr+,e sur*a'e 'lean an, )riht&
Never 'lean the ele'tr+,e sur*a'e ;ith san, 7a7er&
S#RAPS:
Al;a=s ,is'+nne't stra7 *r+8 ele'tr+,es )e*+re st+rae&
Av+i, stret'hin stra7s&
Av+i, st+rin the8 in a h+t envir+n8ent
PLUGS:
Ins7e't 7lu s're; an, tihten it i* ne'essar=&
Never ,eta'h r+un, 7r+n *r+8 the ;ire 7lus&
Av+i, t;istin an, )en,in the 7lus&
ADAP#ORS:
Ins7e't a,a7t+r '+nne'ti+n t+ the 7lu an, tihten it i* ne'essar=&
Never ,eta'h the a,a7t+r *r+8 the 7lu '+nne'ti+n&
Av+i, ,r+77in the a,a7t+rs +n har, sur*a'es
OPERA#ION O$ #HE MACHINE5 E4UIPMEN#:
PS%CHOLOGICAL PREPARA#ION:
E<7lain the 7r+'e,ure t+ the 'lient an, +r t+ the relative( e<'e7t ;hen the
7atient is in the state +* e8eren'=&
Reassuran'e t+ the 'lient an, *a8il= that n+ ,aner ;ill +''ur ,urin the
7r+'e,ure&
PH%SICAL PREPARA#ION :
Pla'e hi8 in a '+8*+rta)le an, rela<e, 7+siti+n 2l=in 7+siti+n3&
A,vise hi8 t+ re8+ve all Fe;elries&
L++sen tiht 'l+thin&
A77l= ele'tr+,e Fell= +r al'+h+l s+luti+n (in a '+tt+n )alls( +n the
ele'tr+,e sites 2RA M LA( L le an, R le an, Chest area3 )e*+re atta'hin
t+
the 'lientsH s!in
PREPARA#ION O$ #HE MACHINE:
HI
Che'! the 8a'hine i* it is *un'ti+nal an, ;ell r+un,e,&
Che'! PO9ER an, all+; 8a'hine t+ ;ar8 a)+ut .AL se'+n,s&
C+nne't 'a)le( ele'tr+,es t+ the 'lient at the 7r+7er sites as in,i'ate,
D+nHt +7erate the 8a'hine near a hih v+ltae ,evi'e&
Av+i, +7eratin 8a'hine *r+8 +ne 2D3 e<tensi+n 'a)le&
Che'! 7lus an, '+nne't+rs i* the= are 7r+7erl= seate, in their res7e'tive
re'e7ta'les&
A v+i, 8a!in a,Fust8ent ;ithin the 8a'hine( an, han,le it 7r+7erl=
CLEANING AND DISIN$EC#ION O$ #HE IN#ENSIVE CARE UNI#
$LOORS: 9E# MOPPING Ausin the '+l+r ?'+,e, 8+7s
1LUE 8+7A
9HI#E 8+7A
%ELLO9 8+7A
1LACK 8+7A
Materials: General 'leanin usin s+a7 an, ;ater
Deterent ,isin*e'tant 2L=s+l -S3
All 8+7s sh+ul, )e laun,ere, ever= ,a=( i88erse, in ,isin*e'tant
*+r at least +ne 2D3 h+ur an, rinse in ;ater an, let it ,r= un,er the
sun&
9ALLS AND CEILINGS:
9ash it ;ith s+a7 an, ;ater u7+n ,is'hare +* 'lients&
9ash the8 ;henever it is ne'essar=&
SINKS( COM$OR# ROOMS:
$re/uent 'leanin +* lavat+r= sin!s an, '+8*+rt r++8s an,
,e'+nta8inate therea*ter& Use, +* s+a7 ,is7ensers a*ter usin CR&
CLIEN#HS ROOM:
R+utine ,ail= 'leanin 7r+'e,ures 8ust )e +)serve, an, ,+ne&
H+use!ee7in 7ers+nnel 8ust ta!e 7r+7er 7re'auti+ns es7e'iall= in
an is+lati+n r++8s& 9ear =+ur PPE&
NO#E: All 8aterials use, in 'leanin r++8s 8ust )e ,is'ar,e,&
E/ui78ents use, 8ust )e ,isin*e'te,& M+7 hea,s 8ust )e laun,ere, an,
let it ,r= un,er the sun& Dirt= ;ater 8ust )e ,is'hare,&
A$#ER CARE:
C+nta8inate, arti'les( su77lies 8ust )e ,isin*e'te, +r sterili>e, +r
;ra77e, the8 *+r aut+'lave 7r+'ess&
All linens( 7ill+;s( +;ns( et' 8ust )e re8+ve, an, sen, t+ the laun,r=
in a se7arate laun,r= )a&
I@
All in*e'te, s+ile, linens 8ust )e ;ashe, ;ith er8i'i,al ,eterent
s+luti+n&
DISIN$EC#ION: #his a77lies t+ all ,iseases an, is in,i'ate, ;hen 'lient is
alrea,= ,is'hare, +r trans*erre, t+ +ther unit:
AIR #HE ROOM $OR -J HOURS
CLEAN ALL SOILED E4UIPMEN#S( LINENS( O#HER MA#ERIALS USED
1% #HE CLIEN# 9I#H GERMICIDAL DE#ERGEN# SOAP OR SOLU#ION&
POLIC% ON REPLACEMEN# O$ EMERGENC% DRUGS(
MEDICINES AND SUPPLIES
!. )mergency drugs, medicines, and supplies should be available at all times.
Proper endorsement by the nurse on duty should be done after each shift.
#. %ll emergency drugs, medicines and supplies used by the patient should be
accounted for and replaced accordingly.
+. The nurse on duty is accountable for any lost or damage of emergency drugs,
medicines and supplies.MF'6ST 'N, F'6ST 2CTM policy shall be observed.
,. 1onsumption report must be submitted to the pharmacy the following day for
replacement.
/. )-cess medicines donated by patients should be turned over the pharmacy.
F. Nearly e-piry medicine should be returned to the pharmacy three months
before the e-piration date.
POLICIES AND PROCEDURES ON IN$ORMING PA#IEN#S ON
AVAILA1ILI#% O$ DOC#ORS OR AN% CAUSE O$ DELA% O$
SERVICES
!. The Physician< in 1harge should do daily bedside rounds in the morning but if
any case a question about patients4 condition arises after the doctor4s rounds, it
should be clearly e-plained by the nurses to the patient8relatives that it would
be entertained once the doctor is available.
#. For patients on cardiac or respiratory arrest, if the Physician "in 1harge is not
visibly around, the nurse on duty will air J12.)M so that whoever 3edical
2fficer is available will attend the patient.
+. 6eferral of patients should be from doctor to doctor.
I!
ON ISOLA#ION ROOM
!. 1ommunicable diseases if confirmed or suspected should be admitted in
isolation room. 'n the event that no isolation room is available, the nurse
should inform the admitting section who in turn will inform the Physician<in
1harge. % divider8screen should be placed to the patient.
#. Personnel e-posed to communicable diseases should be given prophyla-is by
the hospital if needed.
+. %ccidental needle pric$s should be referred to the laboratory for e-amination
and then report to 'nfection 1ontrol 1ommittee for evaluation.
,. %lways observe precautionary measures in attending patient with
communicable diseases.
/. Proper hand washing before and after each procedure should be observed.
F. 'f the patient is postpartum, her baby should stay in the N'1C as transient
patient.
POLIC% ON $AMIL% INVOLVEMEN# IN PA#IEN#S CARE AND
DECISIONAMAKING
This institution allows patient8immediate relative to actively participate in
securing consent for admission and procedures.
'n case of dying or critically ill patient, the immediate relatives of legal age
should be involved in the care and decision<ma$ing regarding patient4s care
and management.
1onsent or waiver should be obtained from relatives of legal age regarding
patient4s end<of<life care or withholding from procedures li$e 1P6, intubation,
and giving of emergency medicines. This should be updated by the relative
every day provided that the relative was fully informed of the patients4 status
and prognosis by the physician. 9See %ppendi- F:
%bandoned patients will be referred to the medical social service for location
of relatives and for coordination with the proper agency or institution.
The care, decision<ma$ing and management of an abandoned patient are under
the discretion of the physician or senior house officer on duty until the arrival
of relative8s.
PAR# IIIA ENVIRONMEN#AL POLICIES
I#
ENVIRONMEN#AL CARE
)nsure that standard procedures for routine care, cleaning and disinfection of
environmental surfaces, especially frequent touched surfaces in patient<care areas are
being followed.
MANUAL CLEANING
a. %ll items requiring disinfection or sterili*ation should be dismantled before
cleaning.
b. 1old water is preferred for cleaning as it will remove most of the protein
materials 9blood, sputum, etc.: that would be coagulated by heat or
disinfectants and would subsequently be difficult to remove.
c. The most simple, cost effective method is to thoroughly brush the item,
$eep the brush below the surface of the water to prevent the release
of aerosols. The brush should be decontaminated after use and
dried.
d. 6inse items finally in clean, warm water and dry. 'tems are then ready for
use or disinfection or sterili*ation.
e. Personnel handling contaminated items should wear good quality globes
for personal protection.
ENVIRONMEN#AL CLEANING
a. Floors, surfaces, sin$s and drains should be cleaned with water and
detergent. 6outine use of disinfectants is unnecessary.
b. 'f there is spillage, e.g. blood, sputum, although cleaning is
preferred, disinfection before cleaning is sometimes recommended.
c. 1lean8wipe wearing gloves, using @./<!> sodium hypochlorite
9household bleach: or a disinfectant with appropriate activity.
d. Gloves should be worn. 6elease of chlorine gas from disinfection of
large spillage can be ha*ardous to staff.
e. 'f spillage is immediately removed, general disinfection of the room
is not necessary0 thorough cleaning will do.
f. 7alls do not accumulate dust and associated contaminants and do
not need to be cleaned frequently.
g. &ori*ontal surfaces such as floors, and simple devices such as ';
poles and bed frames, can be maintained by cleaning with water and a
detergent.
h. Some devices or areas that are repeatedly touched may need more
frequent and intensive cleaning, including disinfection. )-amples are
bedrails, door handles, and areas li$ely to receive spatter.
DISIN$EC#ION O$ SUR$ACES
Soiled surfaces may be cleaned of visible spillage and disinfected with a
chemical agent suitable for the tas$. 2n a clean surface alcohol is rapidly
bactericidal and rinsing is not required
I+

Pr+'e,ures +n Re'='lin an, ReAuse +* E/ui78ent

The central processing areas should consist of decontamination, pac$aging,
sterili*ation and storage areas.
De'+nta8inati+n
6eceive materials, sort, clean and preferably disinfect. 7ear appropriate glove
and plastic aprons. Gown sleeves that are fluid<resistant are desirable as are
surgical face mas$s and eye protection.
Pa'!ain
%ssembling. i.e oiling 9mil$ing: and pac$aging clean but unsterile materials
prior to sterili*ation. (abel accurately with contents, date of processing and
e-pire date.
Sterili>ati+n Pr+'ess
%utoclaving is preferred.
%ny sterili*ation procedure should be monitored routinely by physical
9mechanical:, chemical and biological techniques. 3echanical techniques
include the daily assessment of cycle time, temperature and pressure gauge.
% log boo$ should be $ept.

P+li'ies an, 7r+'e,ures +n 'ase *in,in an, 8anae8ent +* n+s+'+8ial in*e'ti+ns
a. 6eporting of cases by the '1N or the staff nurse in charge or the
area supervisor.
b. Preparation of nosocomial case report form using the S&'P form.
c. 6eview by the infection control team.
d. 'solation precautions to be applied for the case.
e. 1linical and laboratory review by the infection control physician.
f. Prescription of antibiotic treatment for the patient.
g. 6e< evaluation of case by the infection control physician.
S#ANDARD PRECAU#IONS

Standard precautions synthesi*es the maBor feature of Cniversal Precautions 9!IHH:

and 5ody Substance 'solation 9!II@: and includes infection control practices and use
of PP) recommended for healthcare personnel when having contact with %(( patients
wherever healthcare is delivered, regardless of patient diagnoses or presumed
infection status
Standard precaution is designed to protect &17s and patients from contact with
infectious agents in re'+ni>e, an, unre'+ni>e, s+ur'es +* in*e'ti+n&
I,
Standard precautions are intended to be applied to the care of all 7atients in all
healthcare settings, regardless of the suspected or confirmed presence of an infectious
agent.
'mplementation of Standard Precautions constitutes the 7ri8ar= strate= for
successful prevention of healthcare<associated transmission of infectious agents
among patients and healthcare personnel.
o &ealth 1are 7aste 3anagement
)nsure that appropriate handling, transport, storage, treatment and
disposal of healthcare waste are being followed. %ll ha*ardous waste
generated should be properly segregated in color coded bags and
transported in covered carts. 33.% 2rdinance 5lac$ " dry non
infectious, Green< wet non<infectious, Dellow< wet and dry infectious,
2range " radioactive. Please see attach flow chart on 7aste
3anagement.

o 2ccupational &ealth and Safety
)ducate the personnel about the principle of infection and safety
education while stressing individual responsibility for infection control.
3edical evaluation before placement can ensure that personnel are not
placed in Bobs that would pose undue ris$ of infection to them such as
determining immuni*ation status and obtaining histories that may
predispose personnel to acquiring communicable diseases.
POLIC% ON IN$EC#ION CON#ROL
P6);)NT'2N 2F N)).()S ST'1E %N. S&%6P 'NAC6D
O)Fe'tive
To prevent health care associated infection and ensuring safety to handling
manipulation and disposal of sharps.

P+li'=
!. 2rientation of all health care wor$ers for proper handling of sharps and
disposal such as used needles, blades8lancets and other sharp instruments. They
should be disposed to puncture proof container immediately after use.
#. .2 N2T 6)1%P N)).()S. 'f recapping is necessary CS) S'NG() &%N.
T)1&N'KC) or CS) 3)1&%N'1%( .);'1) 9forceps:.
+. Cse forceps in pic$ing sharps debris or any equivalent.
,. .o not overfill sharp containers and seal properly for disposal.
/. %ll needles8sharp inBuries should be reported to 'nfection 1ontrol 1ommittee
for evaluation and management.
I/
NEEDLE S#ICK IN0UR% ? MANAGEMEN# O$ E6POSED PERSON
D& REVIE9 #HE CIRCUMS#ANCES O$ #HE E6POSURE
a. .etermine how long ago the incident occurred.
b. .etermine the nature and degree of e-posure< whether s$in was punctured, bleeding
occurred 9e-amine for s$in perforation: " depth of needle penetration< whether the
needle or syringe was visibly blood contaminated.
c. .etermine First %id response " was the site washed immediately, howU " wash,
disinfect and consider surgical treatment if the wound is tetanus prone.
-& ASSESS RISK( COUNSEL AND EDUCA#E PA#IEN#
a. %ssess the degree of e-posure.
b. 6eassure the patient that the ris$ of disease transmission is small.
c. %dvice that consideration should be given to the following < no need to
avoid donating blood, organs or semen < possibility of ris$s
associated with breast feeding, pregnancy.
d. )-plain precautions to avert disease transmission to close contacts, e.g.
safe se-, no sharing of toothbrushes or any item which may be
blood contaminated.
.& PROVIDE POS# E6POSURE PROPH%LA6IS
a. &epatitis 5 immune globulin 9&5'G: '3 if less than G# hours from
time of e-posure inBury.
b. &epatitis 5 vaccination, '3 9separate site from &5'G:
c. Tetanus vaccination " use of 1.T 9children R H: or %.T 9persons
over H years:, with or without tetanus immunoglobulin will be based on
tetanus immuni*ation history and the type of wound.
J& COLLEC# 1LOOD $OR 1ASELINE #ES#ING
%fter counseling and obtaining informed consent
a. 6equest &'; %b, %nti<&1;, and &5c%b if the patient is not
vaccinated, or &5s%b if already vaccinated.
b. Provide history on &'; testing form and on routine serology request
forms eg Needle stic$ inBury " e-posed person, not hepatitis 5
vaccinated. Forms are ideally coded.
L& $OLLO9 UP
a.%rrangements should be made to 1omplete the full course of hepatitis 5
vaccination followed by antibody testing at #<,months after
completion of the vaccine course.
b. 6etest for &'; %b 9at + months:, hepatitis 5 and hepatitis 1 9at + and F
months:.
K& DOCUMEN#A#ION
a. .ate and time of e-posure8inBury 1ircumstances of the inBury First
aid applied.
IF
b. 6is$ assessment and e-planations given to the patient.
c. Tests ordered.
d. Prophylactic antimicrobial medications administered.
e. Follow up arrangements for receiving test results and continuing
vaccinations. Precautions advised during follow up period.
f. N2T) confidentiality must be maintained at all times.
P+li'ies an, Gui,elines +n A,8issi+n an, Use +* Private R++8s
a. This hospital is licensed to operate as a #@@ bed capacity hospital.
b. 5ed sharing is strictly prohibited specially for clients with highly
communicable diseases.
c. 5ed sharing is also not allowed for clients deemed to be at ris$ of
contacting infectious diseases li$e clients who had Bust undergone surgery or
transplantation and clients who have &'; %'.S infection.
d. 1ohorting is allowed if the client9s: admitted in the room has the
same disease entity.
e. 1lients can cohort or share a room if they are infected with same
microorganism.
f. 'n cases of respiratory infection both in adult and pedia patients,
adherence to the bed capacity of the room or ward must be observed in order
to facilitate fast recovery of patients and to avoid overcrowding.
g. Private rooms are useful as an isolation precaution by reducing the
possibility of transmission of infectious agents in two ways
h. Separates infected or coloni*ed patients from susceptible patients
i. %ct as a reminder for health care wor$ers and visitors to hand wash before
leaving the room.
a. Patients admitted with a communicable disease will be the priority
admission in private rooms.
B. %s much as possible patients who are suspected to have a
communicable disease should be transferred to a facility that is capable to
handle such diseases 9e-. San (a*aro &ospital:.
$. %dmission of PT5 patients is discouraged. &owever, in the
presence of life threatening conditions, they must be admitted in the
'solation 6oom.
l. Sharing of beds can be allowed in cases of outbrea$s and calamities
where availability of beds is scarce.
P+li'ies an, Pr+'e,ures +n Preventi+n +* N+s+'+8ial In*e'ti+ns

The hospital hereby adopts the following activities to prevent hospital acquired
infections.
a. Practice of good aseptic technique in performing medical and surgical
procedures.
b. Practice the use of proper personal protective equipments in performing
medical and surgical procedures.
IG
c. Practice strict hand washing procedures before and after preparing
medications, ta$ing vital signs, assessing patients, and toughing
patients.
d. Strict segregation of wastes according to classification.
e. 1lient4s relatives shall be included in health teaching on the prevention of
nosocomial infections.

SURVEILLANCE
1omprise collecting relevant data on all infection sites and recogni*e
outbrea$s. .ocument nosocomial infection trends from patient<based
information temperature records, wound dressing changes, and laboratory
results bacteriology, then report to proper authority.
SA$E#%( VISI#ING HOURS( VISI#ORS AND S#A$$ #RA$$IC
!. The following conditions should not be allowed inside the hospital premises
;isitors under the influence of alcohol or any prohibited drug.
Patient4s relative who demonstrate aggressive behavior such as
shouting, threatening or creating any unBust commotion. They will
be referred to proper authorities.
.eadly firearms or weapons even toy resemblance.
1hildren below !# years old.
6elatives of patients who are in labor. They should stay in the
waiting area unless called by the .elivery 6oom Staff.
;isitors wearing sando.
7atchers of patients who delivered by Normal Spontaneous
.elivery8status post 1urettage unless ordered in writing by the 25
Physician.
#. The following conditions are allowed inside the hospital premises
;isitors coming from far places or province who arrived beyond the
visiting hours will be allowed upon permission by the P'1 and S&2
provided that they will observe silence in order not to disturb other
patients and will only come in one or by #4s at a time or pairs 9if
many:.
2ne watcher to patients who have undergone surgical procedures
925, Surgery, Pediatrics:
3a-imum of two 9#: watchers to patients who are severely ill or
with maBor complications.
+. ;isiting hours shall be strictly observed.
IH
.:CC PMAL:CC PM ;ee!,a=sA Charit= Patients
.:CC PMA@:CC PM ;ee!en,s an, h+li,a=sA Charit= Patients
AM M PM ? Phil Health M Pa= Patients
#HE PA#IEN# SA$E#% #EAM
Functions
2versee the development of strategies and plans for the delivery of high
quality and safe services
3aintain strategic direction, strong leadership and transparent lines of
accountability
See to it that the hospital put patents4 safety and well<being above other
considerations
3onitor that patient care plans are developed and applied based on evidence,
effectiveness, and standards
)nsure that the right systems and processes are in place to deliver efficient,
effective, and safe services
)nsure that personnel are trained, supported, and responsive to the needs of the
patients
)nsure that professional standard requirements are maintained
II
!@@
#HE PA#IEN#SH SA$E#% IMPLEMEN#ING POLICIES
!. 5edside rails and8or restraints should be used routinely for children, restless
patients, the aged, those under sedation and unconscious patients as per order of
the attending physician.
#. Suicidal patients should always be provided with a #, hour watcher. %lert other
caregivers of patients4 suicidal tendencies.
+. Strictly JNo Smo$ingM within hospital premises is enforced.
,. Floors should be free of debris that might cause patients to slip and fall. Spilled
liquids should be wiped immediately. )ncourage Banitors to use dry mops for
slippery8wet areas.
/.Patient4s unit, hallway and fire e-it should be neat and free from ha*ardous
equipment, footstools, electrical cord, shoes, '; stand etc.
F. Nurses should ta$e turns in ma$ing rounds, chec$ing patients4 condition at
least every hour and more frequently to high<ris$ patients.
G. Stretchers, wheelchairs and beds4 wheels should be loc$ed when not in use.
H. Security guard on duty should notify of any suspicious strangers loitering in the
patient4s unit8ward.
I. Cnsafe and defective equipment and devices should be reported or turned in to the
3aintenance8)ngineering .epartment for repair or condemnation.
!@. Fire e-tinguishers available in the unit should be changed annually with the
maintenance personnel. Fire e-it signages must be luminous.
!!. Nurses need to be $nowledgeable about their healthcare facility4s policies and
procedures and always follow them.
!#. Nurses should have open communication with one another as well as other
healthcare professionals. They should not be afraid to question orders or
medications.
!@!
!+. Nurses must %(7%DS review the medication rights before giving medications.
!,. Nurses need to be involved in creating and updating and reporting systems that
avoid blaming individuals but rather encourage learning from the error, so that it
can be prevented in the future.
!/. Nurses should $eep abreast with the current issues and trends that affect their area
of practice so that they can be involved in evidenced<based decision ma$ing when
ta$ing care of patients.
!F. Nurses ought to be part of hospital committees that focus on ma$ing the
healthcare system safe, effective, patient<centered and timely.
!G. Nurses must submit incident report, all errors and Jnear missM to the nurse
supervisors for proper action to prevent it from happening again.
!H. Patients are given identification bracelets showing their names and allergies.
!I. )nsure proper lighting, less clutter, minimum distraction in medication area.
#@. 3edications with dangerous effect are being mar$ as Jhigh alertM and preparation
should be handled with precaution.
IMPLEMEN#ING POLICIES ON ACCIDEN#S
Stan,ar, O7eratin Pr+'e,ure Person
Responsible
When a patient had an accident e.g. fall!
a. Do ph"sical assessment and ta#e $ital signs. Chec# for an" in%ur"
and extent of in%ur".
&. Notif" the nurse super$isor on dut"' ph"sician in charge regarding
the accident.
c. (ring the patient &ac# to &ed if the condition permits.
d. )ender emergenc" care and carr" out doctors orders such as cold
compress application I* +uids insertion O, inhalation etc.
e. Accomplish an accident' medical examination report of the doctor
-ho examined the patient in triplicate cop".
f. .u&mit copies of the report to the Chief of /ospital0s o1ce Nursing
O1ce and Administration O1ce -ithin ,2 hours after the accident.

.ta3 nurse on
dut"
and Ph"sician in
Charge
Assigned Nurse

.enior nurse'
Charge Nurse
!@#
When the $isitor or -atcher had an accident!
a. )ender emergenc" care on the spot.
&. Inform super$isor on dut"
c. .end the $isitor or -atcher to 4) for treatment if condition permits.
d. )eport to .ecurit" 5uard for medico6legal purposes.

Nurse on dut"
and Ph"sician in
Charge
.enior Nurse'
Charge Nurse
.enior Nurse'
Charge Nurse
Nurse on Dut"
When nursing personnel had an accident during his'her tour of dut"!
a. )ender emergenc" care on the spot.
&. Notif" Ph"sician in Charge
c. Notif" super$isor on dut"
d. .end the personnel to 4) for treatment if condition permits.
e. Accomplish an incident'medical examination report in triplicate cop".
f. .u&mit copies of the accident report -ithin ,2 hours after accident.
7Chief of /ospital0s O1ce Nursing O1ce Administrati$e O1ce8
g. 5i$e cop" of the accident report and the medical examination report
to the personnel concerned for future reference 74mplo"ment
Compensation Disa&ilit" Claims8
Nurse on dut"
and Ph"sician in
Charge

.enior Nurse'
Charge Nurse
.enior Nurse'
Charge Nurse
.enior Nurse'
Charge Nurse
.enior Nurse'
Charge Nurse
4) Ph"sician
.enior Nurse'
Charge Nurse
.enior Nurse'
Charge Nurse
PERSONNEL SA$E#% IMPLEMEN#ING POLICIES
!. %lways observe necessary safety measures when using wheelchairs, stretchers, beds
and
other equipments.
#. Never operate electrical equipments with wet hands.
+. .o not attempt to use equipment unless you are familiar with its operation.
,. 5e sure that the electrical equipment is plugged into the proper type of outlet.
/. No smo$ing within the hospital premises.
F. 6eport any unsafe conditions such as the following to the Banitorial supervisor or
nurse
supervisor
7et and slippery floors
.efective equipment
'nadequate lightning
G. 1oordinate with the maintenance department of the hospital in the preventive
maintenance or repair of any equipment.
H. Fire drills8)arthqua$e drills are conducted so that employees $now how to act
during
emergencies.
!@+
I. 2-ygen tan$ should have o-ygen guard.
!@. 6ecommend staff for immuni*ation of the following
Flu ;accine
&epatitis 5
Pneumonia
!!. Gradual phase out of mercury should be observed. Fluorescent light should be
discarded once busted. 3ercurial thermometer and mercurial 5P apparatus must be
submitted to the 3aintenance department for safe $eeping.

PAR# IVA IN#ERADEPA#MEN#AL COORDINA#ION POLIC%
RADIOLOG%
!. The nurse on duty will forward to the -<ray department the request for
e-amination for proper scheduling and specific instructions.
#. For patients who will undergo -<ray inside the room, necessary precautions
should be observed as follows
a. Nurse, ambulatory patients and relatives should go out of the room during
the procedure to protect him8her from the radiation.
b. 'f the patient is bedridden, the bed should be F feet away from the source of
radiation.
c. 'nform pregnant patients in their first trimester of pregnancy not to undergo
radiologic e-amination unless in emergency cases and must have a written
approval from the resident on duty. Pregnant women in the #
nd
and +
rd

trimester should be given or provided with a lead shield and clearance from
the 25 department.
LA1ORA#OR%
!@,
!. %ll laboratory requests must be properly filled up by the attending
physician.
#. JStatM orders should immediately be carried out.
+. Specimen for stool, urine and sputum e-amination should be brought by
patients relative to the laboratory together with the request. %ll laboratory
requests must be recorded into the logboo$ and to be received by the
(aboratory staff.
,. 'f the procedure is not available in the laboratory, the 3ed<Tech on duty
will inform the relative.
/. Preparation for diagnostic procedures should be posted on the patient4s
chart.
F. %ll laboratory results must have hospital number for easy reference.
RECORDS SEC#ION
D& 1harts of all discharged patients shall be forwarded to 6ecords Section
within #, hours after patient discharge.
-& .aily floor census must be submitted to the 6ecords Section everyday at
H@@am.
.& Patients86elatives are not allowed to have access on their charts.
MEDICAL SOCIAL SERVICE
$+r ER an, OPD 7atients:
!. The N2. issued charge slips and as$s patient to pay at the cashier.
#. 'f the patient has no capacity to pay, cashier shall refer patient to the
3SS for interview and tapping of resources. 'n its absence, the patient
will be referred to the Senior &ouse 2fficer.
$+r INAPatients:
!. The following shall be referred to 3SS
Pay patients who are to be transferred to the service ward.
2verstaying patients without capacity to pay.
.eceased foreigners.
'ndigent patients in need of medicine, blood, or have to undergo
diagnostic procedures.
%bsconded patients.
%bandoned patients.
Cnidentified patients or those without relative8watcher.
&%3% patients.
;ictims of abuse, incest or maltreatment.
PHARMAC%
ON E6PIRING DRUGS
!@/
%ll purchased drugs and medicines shall have a minimum of eighteen
months e-piration date upon delivery.
Purchased drugs and medicines with remaining three months shelf life shall
be returned to Pharmacy.
6eceived donated drugs and medicines shall have a minimum of one year
shelf life. &owever drugs and medicines having a shelf life with less than
si- months can be receive provided it can be consumed prior to the
e-piration date.
ON INDIGEN# PA#IEN#S
'f the patient4s companion cannot pay, the pharmacist will refer them to the
3edical Social Service section.
'n the absence of 3SS, the pharmacist will refer them to the 3edical
Social Service section.
'f the Senior &ouse 2fficer or the 3edical Social Service signed the
prescription for approval, the pharmacist will require the companion of the
patient to present the green card, records the hospital number, confirms the
name of the patient and writes their name with signature on the bac$ of the
prescription.
'f the patient is admitted, charge slip will be forwarded to the 5illing
Section.
For indigent patients in the observation area, charge slip will be retained at
the pharmacy Section as basis for monthly report for indigent patients.
ON EMERGENC% CASES
.rugs and medicines needed shall be given immediately.
The pharmacist will issue corresponding charge slip.
'f the patient is admitted, charge slip will be forwarded to the billing section.
'f the patient is for transfer and cannot pay, the charge slip shall be recorded as
basis for monthly report for indigent patients.
ON EMERGENC% PURCHASE
%ll drugs and medicines prescribed must be served by the pharmacist
whenever the drug is available at the Pharmacy.
)mergency drugs and medicines of indigent patients that are not available at
the hospital pharmacy shall be endorsed by the social wor$er for emergency
purchase.
'f there is no social wor$er on duty, the prescription must be noted by the
Senior &ouse 2fficer.
.rugs and medicines for emergency purchase must be included in the PN.F.
The 6'; for emergency purchase must be signed by the physician on duty
before the Pharmacist as$s a utility wor$er on duty to buy a medicine.
!@F
The pharmacist will inform the nurse on duty to instruct the patient4s
companion to get the medicine at the pharmacy.
POLICIES ON REGULAR REVIE9 O$ PRESCRIP#ION ORDERS
%ll prescription should be properly filled up by the physician and must contain
the following information4s
Name of patient
.ate of prescription
%ge and address of patient
G)N)6'1 name of drug must be written in full
Signature and license number of prescribing physician
'ncomplete prescriptions should be return to the physician for completion before the
issuances of medicines.
%ll prescription should pass the hospital pharmacy and if not available it should be
stamped JNO# AVAILA1LEM before it could be bought outside.
)mergency drugs in the ).6., wards and 2.6. shall be replaced if
corresponding prescription is presented.
Prohibited drugs such as .ia*epam, Eetamine, 3ida*olam, Phenobarbital and
others should be filled up only if yellow prescription is presented.
6egulated drugs such as 3ethylergometrine, Nalbuphine, Tramadol and others
should be filled up only if S# license of the prescribing physician is listed.
6equisition for drugs and medicines shall be prepared by the hospital
pharmacist with complete specifications, indicating the quantity, the cost and
must be included in the %nnual Procurement Plan of the hospital.
%dmitted personnel in the hospital and8or confined from other hospital can
avail of free drugs and medicines at the discretion of the 1hief of &ospital.
.iscount on drugs and medicines for the immediate relatives of hospital
personnel who are admitted shall be at the discretion of the 1hief of &ospital,
%dmitted patients who were classified as indigent by the 3edical Social
Service of the &ospital shall be given free drugs and medicines available at the
hospital pharmacy.
(ist of available drugs and medicines should be posted on ).6. 2.6, 2P. and
wards.
Service patient shall pay to the cashier before filling of prescription but those
who cannot afford to pay the medicines should be referred to Social Service.
Personnel 8Senior 1iti*en can avail of #@> discount on drugs and medicines
available at the pharmacy.
ON E6CESS DRUGS AND MEDICINES
!@G
)-cess drugs and medicines of admitted patients bought from pharmacy shall
be coordinated with the billing section and to be deducted from their hospital
bill provided an official receipt is presented.
)-cess drugs and medicines bought outside and donated by patient shall be
turned over to the pharmacy to be classified as donation.
.onated drugs and medicines shall be given to indigent patients.
DIE#AR%
!. The nurse on duty is responsible for submitting the complete diet list of
patients including height and weight for pediatric patients.
#. Patients with special diet must be referred to the nutritionist for counseling.
+. Prescribed therapeutic diet 9i.e. osteori*ed feeding: should indicate the
following name of patient, caloric requirement, amount per feeding, date
and time prepared, and e-piry period.
,. The .ietary Section should give special instruction sheets to patient prior
to discharge.
/. 6equest for hot water is available at the nurse4s station. Schedule of
distribution of hot water must be posted in every ward to inform patients
accordingly. The nursing attendant shall be in charge of the distribution.
Time of distribution /@@am<F@@am
/@@pm<F@@pm
F. 2verstaying patients are not entitled to regular meals. Twenty four hours
after discharge order, patients will no longer receive food from the dietary
section. .ate of discharge should be reflected on the diet list
G. 3eal tray will not be given to )mergency 6oom patients. Food will be
served only to patients admitted in the ward or private rooms.
H. Food bought outside intended for patients should be discouraged.
DIE# LIS#:
!. The dietary staff pic$s up diet list at /+@%3 in the ward.
#. %ny new diet orders for the day must be sent to the .ietary Section using the
diet order forms or thru the phone.
+. The dietary section must be informed of any diet changes, admission ?
discharge at least ! hour before serving time. %ny changes made after serving
time will ta$e effect the ne-t mealtime.
,. )ndorsement of properly labeled blenderi*ed food shall be recorded in the
logboo$ for .ietary4s record purposes.
/. No food tray will be given if the patient is on NP2 9Nothing by mouth:. )-cept
if the patient is in Private and Semi<Private 6ooms and Pediatric patients in the
ward.
!@H
F. .ischarges and transfer of room and bed should be reported immediately by
the nurse on duty to the dietary section in order to avoid confusion in serving
of food trays.
G. 1omplaints of the patients will be forwarded to the nurse on duty if they are
not given meal tray because they are not included in the diet lists.
H. The nurse on duty shall responsible for ma$ing the correct diet list. 't should be
legibly and clearly written to prevent mista$es in names and diet of the
patients.
NE9 DIE# ORDERS:
New diet orders for the day should be forwarded to the dietary section using
proper diet order forms. ;erbal and telephone orders will also be accepted. New diet
orders include
!. .iet change
#. .iet order for admission
+. 1hange of bed number 9if there is any:
Notification for diet changes and admission should be submitted to the .ietary Section
at !@@@%3 and +@@P3. .iet changes after the specified time will be addressed on
the ne-t meal.
NO#E: )atients or watchers can put their remaining soiled trays on the tray cart or
food conveyors stationed outside the ward.
POLIC% ON LINEN:
!. (inen should be changed daily by house$eeping staff.
#. 1ollection of soiled linens should be done by house$eeping staff.
+. )-tra linen should be charged by the nurse.
,. Soiled linen should be placed on the hamper to be collected by the house$eeping
staff.
/. The nurse on duty should inspect the soiled linen for the presence of instrument and
needles.
F. The nursing attendant is responsible for monitoring of linen collected and delivered.

POLIC% ON #RANSPOR# SERVICES $OR #HE NURSING SERVICE5HEMS
'. 7&2 can avail of transport servicesU
The following personnel8patients are allowed to avail of .6AN63& 2fficial
3otor ;ehicles
Personnel who are on official business and who are not receiving
regular *ransportation #llowances (*# , Cnder Section +F! " 1hapter
, " G%%3
!@I
LNo official who has been granted transportation allowance by any
government office shall be allowed to use government service
transportation. 'f a government vehicle has to be used, a proportionate
amount shall be deducted from the transportation allowance of the
official concernedM.
Post operative patients from 2P. minor operating room that being
transferred to ward.
Patient4s for referral outside of .6AN63& with proper coordination.
II& 9HEN t+ use trans7+rt servi'eP

%nytime during regular wor+ing days for personnel. ,hould be available
2-./ for emergency cases.
6equest for vehicle beyond official time should be supported by an
approved hospital order.
.uring Saturdays, Sundays and Non<wor$ing &olidays with an approved
hospital order.
III& 9HERE t+ use trans7+rt servi'eP
2n official trips within the region or 3etro 3anila
2n official trips outside the region or 3etro 3anila with an approved hospital
order.
Se'ti+n D.( P&D& E..& %ll government motor vehicles shall be $ept in the
garage when not in use provided therefore by the agency e-cept when in use
for strictly official business outside office hours.
COA Cir'ular @LALL( Se7t& DB@L. &owever, bringing home of a government
motor vehicle after office hours by the official to whom it is assigned maybe
allowed if the agency does not have a garage that could ensure the safety of the
vehicle OR when in terms of mileage8time, it is more economical for the official to
par$ the vehicle in the residence of the official to whom the vehicle is assigned ?
the official assumes complete responsibility or in a .2& hospital nearest the
residence of the official.
IV& HO9 t+ avail +* +**i'ial 8+t+r vehi'leP
Pri+riti>ati+n ? s'he,ulin +* tri7s& Cpon approval of the Vehi'le Re/uest
Sli7 2VRS3 form by the .ivision &ead or authori*ed official concern, it will be
forwarded to the T3S for preparation of official trip<tic$et. Trips are scheduled
according to priority of e-pected result8effect of travel.
CANCELLA#ION O$ #RIP5S
!!@
Trips may be cancelled before and during the trips upon request of the following
officials0
!. 1hief of Sanitarium
#. .ivision &ead
+. %dministrative 2fficer
,. .esignated Transport83aintenance 2fficer


The above 2fficers may cancel reservations and use of official vehicle8s for the
SA$E#% of both vehicles and passengers. To avoid accident that may cause damage
to the vehicle and inBury to the passengers, vehicle must be brought immediately to the
motor pool for proper diagnosis repair and maintenance. Proper notice shall be given
to the .ivision concerned in case of scheduled trip cancellation.
A& USE O$ #RANSPOR# SERVICE
2fficial trip<tic$et shall be prepared in the T3S based on the approved Vehi'le
Re/uest Sli7 9all information stated on the ;6S shall be strictly followed:.
%ll prepared trip<tic$ets shall be forwarded to the Hea, +* Manae8ent Su77+rt
Divisi+n 5A,8inistrative O**i'e for approval.
9.uring emergencies, Disaster #ea8 Lea,ers are allowed to approve official trip
"tic$ets:.
No vehicle shall be allowed to leave the hospital compound without an approved
trip<tic$et.
ALL PASSENGERS including the driver8s are required to sign on the spaces
provided on the official trip<tic$et.
Cpon completion of the daily trip, the driver shall submit the accomplished official
trip<tic$et to the Transport 2ffice.
O7erati+n e<7enses of official motor vehicles such as fuel 90io1diesoline and
2nleaded 3asoline:, toll fees ? par$ing fees shall be charged to the Special #ash
/dvance of the 1ashier Section.
Min+r re7air e<7enses an, 8aintenan'e of all official motor vehicles shall be
charged to the Special #ash /dvance issued to the Transport 3anagement Section.
DURING HEAL#H EMERGENCIES
!!!
Priority shall always be given to the use of any official motor vehicle during
emergencies. The &ead of the &ealth )mergency 3anagement 9&)3: shall
have full authority on the utili*ation of transport services upon
declaration8activation of health emergency. &e or She is authori*ed to approve
or disapprove official travels of any official motor vehicle of .AN63&.
%n official motor vehicle shall be permanently assigned to the &ealth
)mergency 3anagement 9&)3: and must be $ept in good running condition at
all times with its fuel tan$ maintained at safe level. 2fficial drivers shall report
to &)3 on a #,<hour shift during emergency.
For immediate response to any health emergencies that may occur during non<
wor$ing holidays or wee$ends, an official motor vehicle shall be par$ed at the
3otor pool par$ing garage. %ll official drivers residing near the hospital
compound shall be considered 2n<1all. .river8s residing near the
emergency8disaster area shall be considered on<call.
PROVISION $OR AMENDMEN#S5E$$EC#IVI#%
The Nursing Service policies and guidelines amended and revised year #@!#
have provision for further amendment should the need arise and shall ta$e effect
immediately upon approval of the 3anagement 1ommittee.
Submitted by .ate
PPPPPPPPPPPPPPPPPP
Nursin Servi'e C+88ittee +n P+li'ies M Gui,elines
%pproved by
D0NRMHAMANAGEMEN# COMMI##EE
S/39+6 #) S93*6/&0' .&' +3%--' 3/&
Chie* Nurse
!!#
:96*%/ #) -/;/0/' 3P3
Su7ervisin A,8inistrative O**i'er
7/<+ /6<*& 0) S/&#H+=' 37' 3PH
Chie* +* Clini'
+70/.75 S/) :/<*665&/.' 3)7)' 3)H)/)
Chie* +* Sanitariu8
APPENDI6 D

Dr& 0+se N& R+,riue> Me8+rial H+s7ital
PAHIN#ULO# NG MA%SAKI# O NG SINUMANG MA% PANANAGU#AN
A!+ si TTTTTTTTTTTTTTTTTTTTTT( TTTTTTta+n ulan na naninirahan
sa TTTTTTTTTTTTTTTTTTTTTTa= !usan l++) at ;alan sin+8an 7u8ilit +
tu8a!+t ( a= na)i)ia= n 7ahintul+t na a!+ + an a!in
TTTTTTTTTTTTTTTTTTa= la7atan n lunas + tistisin n sin+8an 8anaa8+t sa
Dr& 0+se N& R+,riue> Me8+rial H+s7ital !un it+ an !ina!ailanan sa
a!in5!an=an !ara8,a8an& Na)a)ati, !+ rin na an+ 8an an !ahihinatnan sa
nasa)in 7aa8+t + 7atistis a= hin,i a!+ 8ahaha)+l + 8asasa!,al sa
sinu8an !inauu!ulan&
Sa !atuna=an n lahat n it+ a= nila,aan !+ an 7ahintul+t na it+ sa
hara7 n 8a sa!si na=+n i!aATTTTTTTn )u;an n
TTTTTTTTTTTTTTTTTTta+nTTTTTTTTTTTTTTTT&
TTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTT
La,a + tata! n hinlala!i n 8a=sa!it + 8a= 7ananautan
MGA SAKSI:
D& TTTTTTTTTTTTTTTTTTTTTTT
-& TTTTTTTTTTTTTTTTTTTTTTT
CONSEN# O$ PA#IEN# OR RESPONSI1LE PAR#%
I( TTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTT( TTTTTTTTTTTTTTT=ears +*
ae( resi,in atTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTT( un,er
!!+
8= +;n v+liti+n an, ;ith+ut *+r'e +r inti8i,ati+n here)= '+nsent t+ su)8it 8=
TTTTTTTTTTTTTTTTTT
t+ an= +7erati+n +r treat8ent +r )+th )= an= 8e8)er +* the Me,i'al Sta** +* Dr&
0+se N& R+,riue> Me8+rial H+s7ital sh+ul, it )e'+8e ne'essar= in the '+urse +*
his5her illness& I un,erstan, that I shall n+t h+l, 5suit an=+ne ;hatever the result
+* treat8ent5+7erati+n 8a=)e&
IN 9I#NESS( I HEREUN#O SE# M% HAND this TTTTTTTTTTTTTTT,a=
+*TTTTTTTTTTTTTTTTTTTTTTTTTTTTTTT=earTTTTTTTTTTTTTTTT&
TTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTT
Sinature +r thu8) 8ar! +* 7atient +r res7+nsi)le 7art=
9I#NESSES:
D& TTTTTTTTTTTTTTTTTTTTTT
-& TTTTTTTTTTTTTTTTTTTTTT
APPENDI6 -
Dr& 0+se N& R+,riue> Me8+rial H+s7ital
IN$ORMED CONSEN# $OR SURGER%( ANES#HESIA OR O#HER
PROCEDURES
#+ 9h+8 It Ma= C+n'ern:
I( TTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTT( TTTTTTTTT=ears
+l,(
2Given Na8e3 2Surna8e3
8arrie, 5sinle5;i,+;e,( here)= '+nsent t+ the 7er*+r8an'e
u7+nTTTTTTTTTTTTTTTT
2M=sel*5Na8e +*
Patient3
;h+ is 8= TTTTTTTTTTTTTTTTTTTTTT( the 7r+'e,ure5+7erati+n5anesthesia
hereun,er
2Relati+n3
state, a*ter have )een *ull= e<7laine, t+ 8e )= the ,+'t+rs '+n'erne, in'lu,in
the ris! inv+lve, an, their alternative 7r+'e,ures:
Pr+'e,ures5+7erati+n5anesthesia E<7laine, )=:
TTTTTTTTTTTTTTTTTTTTTTTTTTTT TTTTTTTTTTTTTTTTTTTTTTTTTTT
TTTTTTTTTTTTTTTTTTTTTTTTTTTT TTTTTTTTTTTTTTTTTTTTTTTTTTT
I als+ '+nsent t+ the 7r+7er ,is7+sal )= auth+rities +* the Dr& 0+se N&
R+,riue> Me8+rial H+s7ital +* ;hatever tissue 8a= )e re8+ve, *r+8
8=sel*5the 7atient&
I als+ '+nsent t+ the ta!in +* 7h+t+ra7hs in the '+urse +* this
treat8ent +r +7erati+n *+r the 7ur7+se +* a,van'in 8e,i'al !n+;le,e&
!!,
IN 9I#NESS HEREO$( I hereunt+ set 8= han, this TTTTT,a= +*
TTTTTTTT
-CTTTTat TTTTTTTTTTTTTTTTTTTT&
TTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTT
PatientHs sinature +r thu8) 8ar! +r 7ers+n
ivin *ree '+nsent
IN #HE PRESENCE O$:
TTTTTTTTTTTTTTTTTTTTTTTTTTTTT TTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTT
9itness A,,ress
TTTTTTTTTTTTTTTTTTTTTTTTTTTTT TTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTT
Inter7reter A,,ress
APPENDI6 .
PAUNA9A SA LAHA# NG MGA PAS%EN#E
2PA#IEN#HS IN#RUC#ION GUIDELINES3
!. 'ngatan ang iyong '.8registration card. .alhin ito tuwing babali$ sa ospital ang pasyente.
#. Eayo po ay may $arapatan na magdesisyon, 5asahin and JPatients 5ill of 6ightsM.
+. 'sang bantay na may !H taon ang edad pataas sa bawat pasyente.Eumuha sa guardia
ng watcher4spass ang bantay.'sauli ito $apag lalabas na ang pasyente.
,. Eailangan humingi ng pahintulot $ung nais magdala ng additional electrical
appliances sa ospital
/. 'laga$ sa guard and deadly weapons pagpaso$ ng ospital tulad ng baril at iba pa.
F. %ng $ama ay para sa pasyente lamang. Palagian ilagay ang side rails.
G. 3ahigpit na ipinagbabawal ang mga sumusunod
a.Paninigarilyo sa loob ng compound ng ospital.
b.Pag<alis ng pasyente na walang pahintulot
c.Pagpapadede sa bote, lalo na sa mga bagong pangana$.
d.Paglalaba ng iyong mga damit at pagsasampay sa bintana ng hospital.
H. (ahat po ng sanggol na bagong pangana$ dapat ay may JNewborn
ScreeningMPipirma ang magulang sa J.'SS)NTM form $ung hindi pumapayag.
I. .apat ay magawa ang birth certificate ng maagap upang maiwasan ang multa at
abala Eailangan dalhin ang marriage contract ng magulang. Siyasating mabuti ang
birth certificate bago pirmahan at $unin ito sa 6ecord Section ma$alipas ang isang
lingo pag$alabas ng ospital.
!@. .apat ang Philhealth member ay maagap na magsubmit ng requirements.
%lamin agad sa Philhealth Section ng hospital ang mga $ailangan upang
maiwaswan ang abala sa paglabas.
!!/
!#. %ng oras po ng dalaw ay +@@P3< /@@ P3. $apag araw ng (unes<5ierness,
+@@P3< H@@ P3. $apag araw ng Sabado<(inggo at &olidays para sa mga
1harity.
!+.&indi po pinapayagan ang mga bata anim9F: na taon pababa ang edad na
dumalaw sa maysa$it upang maiwasan silang mahawa sa sa$it.
!,.Tumulong po tayo sa $alinisan ng hospital.'lagay sa tamang lalagyan ang
basura at tray ng pag$ain.
!/. %ng follow<up consultation po ay tuwing !@@ P3 sa 2ut patient department, mula
(une hanggan 5iernes lamang. Para sa pay patients ang 2P. $apag araw ng
Sabado at (inggo.
!F. %ng issuance po ng medical certificate ay pag$alipas ng + araw ng pag gawa
matapos na magrequest. 5u$as po mula (unes hanggang 5iernes, H@@ %3</@@P3
lamang ang 3edical 6ecord Section.
!G. %numan ang iyong re$lamo ay maaring sabihin o isulat sa pamunuan ng ospital.
PPPPPPPPPPPPPPPPPPPPPPPPPPP PPPPPPPPPPPPPPPPPPP
(agda ng Pasyente8Eamag<ana$ (agda ng Nagpaliwanag
Petsa PPPPPPPPPPPPPPPPPPPPP
&ospital VPPPPPPPPPPPPPPPPPP
APPENDI6 J
PA#IEN#HS 1ILL O$ RIGH#S 2KARAPA#AN NG MGA PAS%EN#E3
An )a;at 7as=ente 7+ a= 8a= !ara7atan sa 8a su8usun+,:
!. 1onsiderate, equal and respectful care. 9Na$auunawa, pantay, at magalang na pangangalaga:
#. Cpon request, has the right to review medical records and have them e-plain. 9 Eung inyong hilingin
$ayo ay ma$a$abasa at mabibigyan ng paliwanag tung$ol sa inyong talaan pang$alusugan.:
+. 2btain from your physician complete current information concerning your diagnosis andprognosis
in terms you can understand. 7hen it is not medically advisable to give you such information, it shall be
made available to an appropriate person in your behalf. 93abigyan ng impormasyon tung$ol sa inyong
sa$it sa pamamaraan na madaling maunawaan, at $ung hindi ma$abubuti sa inyong $alagayan ay
ipaliwanag sa taong inyong mapagtitiwalaan.
,. 6eceived from your physician necessary information to give informed consent prior to start of any
procedure, e-cept for an emergency situation not requiring an informed consent, shall include the
procedure, ris$ involved probable duration of incapacitation if any. 93abigyan ng sapat na paliwanag at
$aalaman bago hingin ang pahintulot at gawin ang anuman procedure, pati na ang epe$to at ang tagal na
maaring $ailangan upang lubos na ma$apagpahinga
/. 6efusal of treatment to the e-tent permitted by law and be informed of the medical consequences of
your action. 9Tumangggi sa gamutan o anuman gagawin ng naayon sa batas at bigyan ng impormasyon
sa maaring idulot ng pagtanggi.:
F. Privacy and confidentiality of all records pertaining to your treatment, e-cept as otherwise require
by law. 9Panatiliin ang pribadong records ng pasyente, liban na lang $ung $ailanganin.:
G. 6equest for services customarily rendered by hospital consistent with your treatment.
9&ilingin ang serbisyong $ina$ailangan na may $inalaman sa iyong $aramdaman:.
!!F
H. 5e given information as to your continuing health care requirements following discharge or transfer
to other health facilities. 93abigyan ng inpormasyon tung$ol sa pangangalaga at gamutang $ailangan
paglabas ng ospital o bago mailipat sa ibang pasilidad gamutan:
I. Cpon request, an e-planation of your bill or charges regardless of source of payment.
93abigyan paliwanag sa mga bayarin sa anuman paraan ito mababayaran:
!@. 5e advised of the hospital rules and regulation. 95igyan ng payo at $aalaman tung$ol sa mga
regulasyon ipinatutupad sa ospital:
!!. The right to ma$e statement such as the living will, or to withhold health care.
9 Earapatan magpahayag ng sariling $agustuhan tulad ng huling habilin at pagpapatigil sa gamot:
!#. 6ight to choose 8preference for private attending physician. 9Earapatang pumili ng pribadong
doctor:
PPPPPPPPPPPPPPPPPPPPPPPPPP PPPPPPPPPPPPPPPPPPPPPPPPPPPPPPP
(%G.% NG P%SD)NT)85%NT%D (%G.% NG N%P%('7%N%G
Petsa PPPPPPPPPPPPPPPPPPPPPPPP
&ospital VPPPPPPPPPPPPPPPPPPP
APPENDI6 L
DISCHARGE AGAINS# MEDICAL ADVICE59AIVER
', PPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPP, hereby certify that ' am leaving8that
' am causing the discharge of PPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPfrom
.r. Aose N. 6odrigue* 3emorial &ospital, against medical advice. ' have been
informed of the dangers involved, and ' release the hospital and its staff from all
liability for any ill effects, which may result from this action.
PPPPPPPPPPPPPPPPPPPPPPPPPP PPPPPPPPPPPPPPPPPPPPPPPP
Signature of 7itness Signature of Patient
PPPPPPPPPPPPPPPPPPPPPPPPP
.ate
The patientPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPP left the hospital
Notwithstanding medical advice that he8she was not ready for discharge and
that leaving hospital at this time was dangerous and might result in
serious complications .The patient refused to sign the above consent.
PPPPPPPPPPPPPPPPPPPPPPPPPPPP PPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPP
Signature of .isinterested 7itness Signature of Nurse
!!G
PPPPPPPPPPPPPPPPPPPPPPPPPPPPPP PPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPP
Time and .ate Time and .ate
APPENDI6 K
9AIVER $ORMA DNR RE4UES#
', PPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPP, hereby certify that it is our decision to
remove, discharge, and stop all life sustaining devices of PPPPPPPPPPPPPPPPPPPPPPP
9Name of Patient: against medical
advice. ' have been informed of the dangers involved, and ' release the hospital and its
staff from all liability for any ill effects, which may result from this action.
PPPPPPPPPPPPPPPPPPPPPPPPPP PPPPPPPPPPPPPPPPPPPPPPPP
Signature of 7itness Signature of Patient86elatives
APPENDI6 E
POLICIES ON ISOLA#ION PRECAU#IONS
a. 6egard all patient blood, e-cretions and secretions as potentially
infectious and institute appropriate precautions to minimi*e ris$s of
transmission.
b. 7ear gloves that are clean at the time of use for contact with
mucous membranes and non< intact s$in of all patients.
c. .econtaminate hands between each patient contact.
d. .econtaminate hands promptly after touching infective material
9e.g., blood, body fluids, secretions, or e-cretions:, infected patients or
their immediate environment, and contaminated articles used for patient
care. 7aterless hand antiseptics are efficient unless the hands are visibly
soiled in which case they should be washed first. Cse no touch technique
when possible to avoid touching infective material.
e. 7ear gloves when in contact with blood, body fluids, secretions,
e-cretions and contaminated items. 7ash hands immediately after
removing gloves. 'f gloves are not readily available, wash hands
thoroughly as soon as patient safety permits.
f. .ispose of feces, urine, and other patient secretions via designated
sin$s. 1lean and disinfect bedpans, urinals and other containers
appropriately.
g. 1lean up spills of infective material promptly. General disinfections
of floors and walls are then not necessary.
!!H
h. )nsure that patient< care equipment, supplies, and linen
contaminated with infective material are disinfected or sterili*ed between
each patient use. 'f no washing machine is available for linen soiled with
infective material the linen can be boiled.
i. Csed dressings and other medical waste should be disposed of in
sealed, labeled plastic bags and preferably incinerated or deeply buried.
APPENDI6 @
Republic of the Philippines
Department of Health
Center for Health Development Metro Manila
Dr. Jose N. Rodriguez Memorial Hospital
PREAOPERA#IVE CHECKLIS#
SurnamePPPPPPPPPPPPPPPPPPPPPPPPPPPPPP %ge PPPP &ospital No.
PPPPPPPPPPPP
Given NamePPPPPPPPPPPPPPPPPPPPPPPPPP 3.'.PPPPP Se-PPPPP 7ard
PPPPPPPPPPPPPP
Procedure A
9
P
9
Nig
ht
)emar#s
:. Informed consent for the operation
signed.
,. 9edical Clearance updated.
;. /ospital supplies materials and
medicines completed.
2. A$aila&le &lood properl" cross6
matched.
!!I
5. Operati$e area of the &od"
prepared.
<. (o-el preparation done.
=. With pre6op orders.
>. NPO post midnight maintained
?. @ull &od" &ath done.
:0./air prepared com&ed if necessar".
::.Oral h"giene done.
:,.Nail polish ma#e6up contact lens
remo$ed.
:;.Ae-elries remo$ed.
:2.Dentures remo$ed.
:5.Dressed in go-n'camisa.
:<.Bnder-ear remo$ed
:=.With -rist identiCcation tag.
:>.*ital signs ta#en &efore and after
pre6op medications.
(P P) ))
Temp.
:?.Pre6op medications administered.
,0.O) notiCed.
PPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPP
Nurse Signature 2ver Printed Name

1onfirmed byPPPPPPPPPPPPPPPPPPPPP
26 Personnel
NURSING SERVICE S#ANDING COMMI##EES 2A77en,i< B 3
D&C+88ittee +n P+li'ies an, Pr+'e,ures
Aacinta 1.Garcia,6N
(elia %.dela 1ru*, 6N
Gloria ...omingo, 6N
-&C+88ittee +n S'reenin an, Per*+r8an'e Evaluati+n
)lisea %. 6eniedo, 6N
Slyvia 6.3esina, 6N
%lma P.Gamboa, 6N
.&C+88ittee +n In*e'ti+n C+ntr+l
6osalinda 3. 1aliwatan, 6N
(eila %..ela 1ru*, 6N
)velyn T. ;eraque, 6N
1harito T. .e Gu*man, 6N
!#@
J&C+88ittee +n Relii+us A'tivit=
)velyn 5. %vena, 6N
1harlotte ).)spayos,6N
Dolanda S.Sales,6N
L&C+88ittee +n Pr+ra8s an, Other H+s7ital A'tivities
1oncepcion 3. 1astro,6N
&arvey 1. 1auba , 6N
3ichelle 1. Fernando, 6N
K&C+88ittee +n Nursin Au,it
6uth 2. 1ando, 6N
3arilyn 1. Soriano, 6N
Aosefina S.Padigus, 6N
E&C+88ittee +n Resear'h
)li*abeth S. Flores, 6N
1resencia ..G. 1apiral, 6N
Paola Eatrina G. 1hing, 6N
@&C+88ittee +n C+87laints an, Grievan'e
(u*viminda S. Tapang, 6N
Procerfina G. (adera, 6N
.*ry P. 5ungayong, 6N
B&C+88ittee +n 1i,,in an, Pr+'ure8ent
Procerfina G.(adera,6N
%lma P. Gamboa,6N
'nfection 1ontrol 3embers
DC&C+88ittee +n Health M Sa*et= an, C+88ittee +n
C+ntinu+us 4ualit= I87r+ve8ent 2C4I3
&elen T. Nitafan, 6N
6osalinda 3. 1aliwatan, 6N
)ric Aohn P. 1apito, 6N
DD&C+88ittee +n Sta** Devel+78ent
(etecia G.Francisco, 6N
Gloria ...omingo, 6N
(i*a 5. Policarpio, 6N
D-&N+nA'+88uni'a)le Disease C+88ittee
)thel G. Franco,6N
3arBorie Eaye P. 1ustodio, 6N
3aria %nna S. (agana,6N
!#!
3ylene S. Supnet,6N
3ary 1ris 3. Gon*ales, 6N
.oris .. 2ran*a, 6N
D.&C+88uni'a)le Disease C+88ittee
)ric Aohn P.1apito, 6N
6ogelio G. 5anico,6N
%lbert G. 1apuli, 6N
3ario ). 1antillo,6N
3ary 1laire 3. 1astro,6N
Paola Eatrina G. 1hing,6N
Leen, *+r S=8)+ls:
!##
DOCUMEN#
DOCUMEN# PROCESS
PROCESS
MUL#IDOCUMEN#S
MUL#IDOCUMEN#S
AL#ERNA#E
PROCESS
AL#ERNA#E
PROCESS
DECISIO
N
DECISIO
N
PREPARA#ION
PREPARA#ION
MANUAL
OPERA#IO
N
MANUAL
OPERA#IO
N

COLLA#E
DA#A
DA#A
DIREC#ION OR $LO9 O$ PROCESS
$LO9 CHAR# A ER PROCEDURES M ADMISSION
2A77en,i< DD3






!#+
SOR
#
SOR
#
1EGINNIN
G AND END
1EGINNIN
G AND END
REPOR#
COMPLE#E
D OR $ILED
REPOR#
COMPLE#E
D OR $ILED
Patient arrives at the )6
2ld
patientU
Assessment!
7CA(DOC8
7Nurse! 9edical8
Assessment!
7CA(DOC8
7Nurse! 9edical8
%ssessment ? .isposition
)mergency 1are Treatment
91%5:
.iagnostics
'ssuance of &osp. '.
?1hart Preparation
1hart 6etrieval
No

Des
$LO9 CHAR# A RELEASE O$ CADAVER 2A77en,i< D-3
!#,
1onfinement
Necessary
Payment8 replacement of
)6 charges ? referral to
%dmission unit
)ntry in the (ogboo$
Patient pronounced dead
9by .octor:
Patient pronounced dead
9by .octor:
1ashier Sign4s 1learance
Notify %dmitting, 'nformation,
.ietary, 5illing, 1ashier
Social Service if
relative cannot pay
'n " patient
91ertificate prepared
by &ospital:
'n " patient
91ertificate prepared
by &ospital:
.2% 8 )6 .eath
91ertificate signed by
1ity &ealth 2fficer:
.2% 8 )6 .eath
91ertificate signed by
1ity &ealth 2fficer:
Payment of
charges, &ome
care instructions
? 2P. follow
up if needed
&ome
instructions
2P. Follow up
9if needed:
Payment of
charges, &ome
care instructions
? 2P. follow
up if needed
&ome
instructions
2P. Follow up
9if needed:
Status of
death
1adaver forwarded
to morgue 9, hrs
ma-imum storage:
$LO9 CHAR# A OU# PA#IEN# DEPAR#MEN#2A77en,i< D.3

!#/
'n charge of
processing
cadaverU
Nearest $in sign4s
%uthori*ation Form
Funeral Parlor
6elative
6egistration of
.eath 1ertificate
c8o relatives
6elease of dead body upon
presentation of clearance
6elease of dead body upon
presentation of clearance
6egistration of .eath
1ertificate c8o
Funeral Parlor
6egistration of .eath
1ertificate c8o
Funeral Parlor
%rrival of Patient
%rrival of Patient
2ld
Patient
2ld
Patient
Submit &ospital
'. and prepare
2P. chart
Submit &ospital
'. and prepare
2P. chart
Fill " up form 9patient4s
data + copies:
Fill " up form 9patient4s
data + copies:
Payment of charges
Payment of charges
%ssessment
;ital signs, 3edical chec$ "
up (aboratory e-am if needed
%ssessment
;ital signs, 3edical chec$ "
up (aboratory e-am if needed
'ssuance of &ospital '.
'ssuance of &ospital '.
Needs
1onfinement
Needs
1onfinement
$LO9 CHAR# A OPERA#ING ROOM 2A77en,i< DJ3

Des

No


!#F
Sent &ome
with care
instructions
Sent &ome
with care
instructions
%dmitting Section
%dmitting Section
%dmitted to 7ard
%dmitted to 7ard
Patient arrives at the )682P.
2P
2ld patient
Assessment! if operation
needed
7Nurse! 9edical8
Assessment! if operation
needed
7Nurse! 9edical8
)mergency
2peration
)mergency care treatment if needed
.iagnostics
'ssuance of &osp. '.
?1hart Preparation
1hart 6etrieval
Schedule for
elective surgery
upon approval of
1218&ead,
clearance ?
consent signed
2P
No


Des
$LO9 CHAR# A DELIVER% ROOM PROCEDURES
2A77en,i< DL 3
Des


No


No
!#G
%dmitted for 26 upon
approval of
1218.ivision &ead,
consent signed, ? 1P
clearance if needed
Schedule for
elective surgery
upon approval of
1218&ead,
clearance ?
consent signed
2P
Perform
pre,
during
and post
operation
care
2P
Pregnant mother arrives at the
)682P.
2P
2ld patient
Assessment!
7Nurse! 9edical 8
Assessment!
7Nurse! 9edical 8
Full tern nor,al
pregnancy 9in labor:
.iagnostics
'ssuance of &osp. '.
?1hart Preparation
1hart 6etrieval
6eferral 8
)mergency
1S
Des
$LO9 CHAR# ? NE9 1ORN CARE PROCEDURES
2A77en,i< DK3




No


Des
!#H
%dmitted to ward8.6 for
monitoring and delivery
upon order of 3. and
consent of
patient8relatives
%dmitting Cnit
Perform pre,
during and
post delivery
care to
mother ?
newborn
2P
%ssess newborn immediately upon delivery.
)nsure patent airway and warmth, provide
emergency care if needed. 9%pgar score:.1ord
care, eye care , ;it. E ? carry out other doctor4s
order
2P
Assessment!
7Nurse! 9edical8
%pgar score within
normal
'nitiate early latching
8breastfeeding
'nitiate early latching
8breastfeeding
N'1C upon 3.4s order
initiate 5reast feeding if
not contraindicated



$LO9 CHAR#?DISCHARGE PROCEDURES
2A77en,i< DE3







!#I
.ocument care given, prepare
birth certificate, request for N5S,
and inform admitting section
p
)ndorse to ward with mother
e
.octor4s 3G&
order
Payment of charges 8 bill.
1ashier signs clearance
Payment of charges 8 bill.
1ashier signs clearance
Forward all charge slips to
billing section, and inform
dietary section
7aiver signed by
patient8relatives
witnessed by nurse
&%3%
requested by
patient8relatives
6eferral to Social
Service if assistance is
needed
6eferral to Social
Service if assistance is
needed




$LO9 CHAR#A1LOOD #RANS$USION 2A77en,i< D@ 3
!+@
)ndorse to ward with mother
e
.ischarge of
patient with home
care instructions
e
6eleased patient
as requested with
advice on hospital
policies
e
6equest forwarded to
(aboratory Section
6equest forwarded to
(aboratory Section
Proper blood typing and cross
matching done, thaw
Proper blood typing and cross
matching done, thaw
6equest forwarded to Phil
5lood8PN61
6equest forwarded to Phil
5lood8PN61
Ta$e vital signs and record, inform
3. before transfusion
Ta$e vital signs and record, inform
3. before transfusion
.octor4s 2rder for 5lood
Transfusion with signed
patient4s consent
e
.octor4s 2rder for 5lood
Transfusion with signed
patient4s consent
e
$LO9 CHAR# O$ CEN#RAL SUPPL% ROOM
DIS#RI1U#ION O$ SUPPL% 2A77en,i< DB 3
!+!
.ischarge of
patient with home
care instructions
e
6eleased patient
as requested with
advice on hospital
policies
e
.ocument care given, provide comfort
e
Administration of antihistamines as ordered
E I*@ 7PN..8 change I*@ tu&ing and needle
Administration of antihistamines as ordered
E I*@ 7PN..8 change I*@ tu&ing and needle
Transfuse blood according to standard time. 2bserve patient for
any untoward reaction. Stop transfusion if any reaction was
noted ? report to 3.
Transfuse blood according to standard time. 2bserve patient for
any untoward reaction. Stop transfusion if any reaction was
noted ? report to 3.
.octor4s 2rder for 5lood
Transfusion with signed
patient4s consent
e
.octor4s 2rder for 5lood
Transfusion with signed
patient4s consent
e
CEN#RAL SUPPL%
ROOM 9Prepares 6';,
pac$, sterili*es received
supplies, distributes and
monitors use of instruments
? supplies
)nd Cser 9)6, 2P.,
7ard, 26, .6:
Submits request for
supplies8instruments
SUPPL%
SEC#ION5PROPER#%
UNI# 9Procure and release
supplies to 1S6:
e
SUPPL%
SEC#ION5PROPER#%
UNI# 9Procure and release
supplies to 1S6:
e
SKIN( SO$# #ISSUE AND MUSCLE CARE $OR
LEPROS% PA#IEN# 2A77en,i< -C 3
!+#
.ocument care given, provide comfort
e
.octor4s 2rder for 5lood
Transfusion with signed
patient4s consent
e
.octor4s 2rder for 5lood
Transfusion with signed
patient4s consent
e
)nd Cser " utili*es
and charges
supplies8machine to
patient
SUPPL%
SEC#ION5PROPER#%
UNI# 9Procure and release
supplies to 1S6:
e
SUPPL%
SEC#ION5PROPER#%
UNI# 9Procure and release
supplies to 1S6:
e
6eturn borrowed
instruments to 1S6 for
sterili*ation
e
6eturn borrowed
instruments to 1S6 for
sterili*ation
e
'NSP)1T
'NSP)1T
1()%N %N. S2%E
9<: 1allus
9S: 7ound
9S: 'nfection 9<: 'nfection
Soa$ in
water with Soap ? water
vinegar ?
apply
antibiotic
9S: 1allus
2'('NG
2'('NG
9S:
)O)61'S)
9S:
)O)61'S)
%PP)N.'O #!
4uesti+nnaire +n 4ualit= +* Care as Per'eive, )= the Patient
Dr& 0+se N& R+,riue> Me8+rial H+s7ital

Res7+n,ent N+& TTTTTTTTTDate:TTTTTTTTTTTTTTTTTT
Instru'ti+n: Please ans;er the *+ll+;in /uesti+ns& 9here a77li'a)le( 7ut a 'he'! +77+site
=+ur '+rres7+n,in ans;er&
Part ' < P)6S2N%( .%T%
Ae last )irth,a=TTTTTTTTTTTT
Gen,er TTTTTTTTTTMale TTTTTTTTTT$e8ale
Civil Status : TTTTTTSinleTTTTTTMarrie,TTTTTSe7arate,59i,+;TTTTTTLiveAin
Lenth +* sta= +r '+n*ine8ent in DR0NRMH
TTTTT-AL ,a=sTTTTTKAD. ,a=sTTTTTT- ;ee!sA D 8+nth
TTTTT- 8+nthsA D =earPPPPP- ? L =earsTTTTT 8+re than L =ears
!++
SUPPL%
SEC#ION5PROPER#%
UNI# 9Procure and release
supplies to 1S6:
e
SUPPL%
SEC#ION5PROPER#%
UNI# 9Procure and release
supplies to 1S6:
e
6eturn borrowed
instruments to 1S6 for
sterili*ation
e
6eturn borrowed
instruments to 1S6 for
sterili*ation
e
9<: )O)61'S)
9<: )O)61'S)
Area +* '+n*ine8ent
TTTTTTPe,ia 9ar, TTTTTTSuri'al 9ar, TTTTTTTO1AG=ne TTTTTTMe,i'al 9ar,
TTTTTTCust+,ial 9ar, TTTT PHILHEAL#H TTTTTTTT Pa=;ar,
M+nthl= In'+8e
TTTTTTTTTTTT0+)less
TTTTTTTTTTTTJ(CCC&CCAK(CCC&CC 8+nthl= in'+8e
TTTTTTTTTTTTE&CCC&CCAB(CCC&CC 8+nthl= in'+8e
TTTTTTTTTTTTDC(CCC&CC an, a)+ve
Level +* e,u'ati+n
TTTTn+neTTTTele8entar=TTTTThih s'h++lTTTT'+lleeTTTTT7+st ra,uate
Previ+us '+n*ine8ent in +ther h+s7italP TTTTN+ TTTTT%es I* =es( Pu)li'
h+s7italTTTTPrivate h+s7italTTTT
SURVE% PERCEP#ION O$ PA#IEN#HS ON #HE 4UALI#% O$ NURSING CARE"
2Enlish Versi+n3
Instru'ti+n: 1ase, +n =+ur 7er'e7ti+n +* /ualit= +* 'are( 7lease rate the nurses a''+r,in t+
the *+ll+;in ite8& Please 'he'! 253 +77+site the nu8)er that '+rres7+n,s )est t+ =+ur
ans;er&
6 Q n+t a77li'a)le D Q ,+ne ina,e/uatel=
C Q n+t ,+ne - Q ,+ne a,e/uatel=5'+rre'tl=
A& Sta**in Ca7a'it= an, $a'ilities C D - <
!. %dequacy of nursing staff attending patient4s need
!+,
9responding within / min. when called: PPPPP PPPPP PPPPP PPPPP
#. Preparation of facilities, utilities, and supplies
to facilitate service 9chec$ed within the shifts: PPPPP PPPPP PPPPP PPPPP
+. %bility to manage the cleanliness of her8his unit
97aste disposal according. to color code
and standard: PPPPP PPPPP PPPPP PPPPP
,. Frequency linens are fi-ed and changed 9at least
once a day 8 as per necessary: PPPPP PPPPP PPPPP PPPPP
/. 6oom temperature or ventilation management
91onducive for rest and sleep: PPPPP PPPPP PPPPP PPPPP
F. Frequency nurses made their rounds 9at least ,<F -
a shift8 as per necessary: PPPPP PPPPP PPPPP PPPPP
2ver all score PPPPP PPPPP PPPPP PPPPP
1& #e'hni'al S!ills C D - <
!. %wareness of patient4s problems and needs PPPPP PPPPP PPPPP PPPPP
#. %bility in providing health teaching8instruction PPPPP PPPPP PPPPP PPPPP
+. Provision of proper nutrition and electrolyte
5alance PPPPP PPPPP PPPPP PPPPP
,. Provision of privacy, comfort and rest PPPPP PPPPP PPPPP PPPPP
/. Provision of spiritual and social support PPPPP PPPPP PPPPP PPPPP
F. Provision of personal hygiene PPPPP PPPPP PPPPP PPPPP
G. )fficiency in the admission and discharge
!+/
processes TTTTT TTTTT TTTTT TTTTT
Over all s'+re TTTTT TTTTT TTTTT TTTTT
C& Inter7ers+nal relati+nshi7
D& Friendly and approachable in dealing with
patient 8relatives PPPPP PPPPP PPPPP PPPPP
#. 6esponding immediately when called PPPPP PPPPP PPPPP PPPPP
+. Staying with the patient when needed PPPPP PPPPP PPPPP PPPPP
,. Gives understandable e-planation to clients PPPPP PPPPP PPPPP PPPPP

Over all s'+re TTTTT TTTTT TTTTT TTTTT
III& Satis*a'ti+n +n the /ualit= +* 'are
Instru'ti+n: %+ur ans;ers in the *+ll+;in /uesti+ns ;ill ,eter8ine =+ur satis*a'ti+n +n
the /ualit= +* 'are in Dr& 0+se N& R+,riue> Me8+rial H+s7ital& Please 'he'! 253 the nu8)er
that '+rres7+n,s )est t+ =+ur ans;er&
J Q hihl= satis*ie,5;illin . Q 8+,erate
- Q l+; D Q n+t ;illin5 n+t satis*ie,
D - . J
!. 7illingness of the patient and family to comply
with the prescribed treatment ? procedure PPPPP PPPPP PPPP PPPPP
#. 7illingness to provide the needed
information PPPPP PPPPP PPPPP PPPPP
+. Satisfaction on the quality of care rendered. PPPPP PPPPP PPPPP PPPPP
,. 7illingness to recommend utili*ation
!+F
of .6AN63& should the need for hospitali*ation
arise in any member of their familyU TTTTT TTTTT TTTTT TTTTT
Over all s'+re TTTTT TTTTT TTTTT TTTTT

APPENDI6
#aal+ #ranslati+n
Kali,a, n Pananalaa n Narses sa Panana; n 8a Pas=ente n
Dr& 0+se N& R+,riue> Me8+rial H+s7ital
Gin++ 5 Ginan:
An 8a su8usun+, 7+ a= !atanunan tun!+l sa ilan 7ansarilin in7+r8as=+n( at sa
in=+n 7anana; sa uri + !ali,a, n 7ananalaan in=+n tinatana7 ha)an naririt+
sa Dr& 0+se N& R+,riue> Me8+rial H+s7ital& An 8a !asautan in=+n i)i)ia= a=
8aaarin 8ain )asehan n a8in 7a)a)a+ u7an 8a7a)uti an a8in ser)is=+&
Ma!aaasa 7+ !a=+ na anu8an in7+r8as=+n in=+n i7a!a!al++) a= 8ananatilin lihi8&
Sala8at 7+ n 8ara8i sa in=+n 7a!i!iisa&
!+G
Gu8aalan(
SAMUEL C&SUMILANG( RN&MAN
Chie* Nurse
1ilan: TTTTTTTTTT
Petsa : TTTTTTTTTT
#au)ilin: Sautin an 8a su8usun+, na !atanunan& La=an n tse! 253 !un
!ina!ailanan&
I A Unan 1ahai ? Pansarilin #ala
E,a, n++n hulin !aara;anTTTTTTTTTT
Katauhan: TTTTTTTTTTTLala!eTTTTTTTT1a)ae
Esta,+ sa 1uha=: TTTTTTT;alan asa;aTTTTTTT8a= asa;a
TTTTTTThi;ala=TTTTTTTnasasa8a n hin,i !asal
1ilan n ara; n 7ananatili sa Dr& 0+se N& R+,riue> Me8+rial H+s7ital&
TTTTTTT-AL ara;TTTTTTTKADC ara; TTTTTTT - lin+ ? D )u;an
TTTTTTT - )u;anA D ta+nTTTTTTT- ? L ta+nPPPPPP hiit L ta+n 7ataas
!+H
!+I
Sili, na tiniilan TTTTPe,iatri' TTTTMe,i'al 9ar, TTTTTSuri'al 9ar, TTTTICU
TTTTO1AG=ne 9ar, TTTTTCust+,ial 9ar, TTTT PHILHEAL#H TTTTT Pa= 9ar,
1u;anan !ita: TTTTTT;alan hana7)uha=
TTTTTT8aliit na 7ina!a!a!itaan 2J(CCCAK(CCC !ita5)u;an 3
TTTTTT!ata8Ata8an !ita 2E(CCCAB(CCC !ita5)u;an 3
TTTTTT8ataas na !ita 2DC(CCCA hiit 5 )u;an3
E& Antas n PaAaaral: TTTTTT;alan 7inaAaralan TTTTTT ele8entar=a
TTTTTT hihAs'h++l TTTTTT !+lehi=+
TTTTTT ta7+s n !urs+ TTTTTT 7+stAra,uate
Datin 7a!a!asa!it at 7atiil sa isan 7aa8utan&TTT9alaTTTMer+n( saanP
Pu)li!+n Os7italTTTTTTPri)a,+n Os7italTTTTTT
II A Kaala8an at 7anana; tun!+l sa uri5!ali,a, n 7aAaalaa&
#au)ilin: La=an n tse! 253 an 7ina!aAan!+7 na !asautan sanAa=+n sa in=+n
sarilin 7anana;&
< Q Hin,i !ina!ailanan
- Q Gina;a n ta8a at sa7at sa 7ananailanan
D Q Gina;a 7er+ hin,i sa7at
C Q Hin,i ina;a
A&Ka!a=ahan 2Sta**in 'a7a'it= M *a'ilities3 C D - <
!. 5ilang ng narses na nangangalaga sa mga
pangangailangan ng pasyente.9Tugon sa PPPPP PPPPP PPPPP PPPPP
loob ng / minuto :
#. Pag$a$aayos ng pasilidad at $agamitan PPPPP PPPPP PPPPP PPPPP
!,@
9may magagamit sa shift:
+. Ealinisan ng buong paligid PPPPP PPPPP PPPPP PPPPP
9Pagtatapon sa tamang lalagyan:
,. .alas ng pagpapalit ng linen o $umot. PPPPP PPPPP PPPPP PPPPP
9 ! beses sa ! araw at $ung $ailangan na:
/. Temperatura ng $apaligiran8$uarto PPPPP PPPPP PPPPP PPPPP
9sapat upang matulog o magpahinga:
F. .alas ng pagdalaw ng narses. 96ounds: PPPPP PPPPP PPPPP PPPPP
9,<F - bawat shift o higit pa:
Over all s'+re TTTTT TTTTT TTTTT TTTTT
1& Kaala8an at alin n narses
!. Sapat na $aalaman ng narses sa sa$it at
pangangailangan ng pasyente PPPPP PPPPP PPPPP PPPPP
#. Eahusayan sa pagtuturo o pagbibigay ng
paliwanag sa pasyente at pamilya PPPPP PPPPP PPPPP PPPPP.
+. Pagbibigay ng sapat na nutrisyon at
';F J .e-trose J PPPPP PPPPP PPPPP PPPPP.
,. 6espeto sa pribadong $arapatan at pamamahinga. PPPPP PPPPP PPPPP PPPPP
/. Spiritual at social na pangangailangan PPPPP PPPPP PPPPP PPPPP
F. Pagtulong sa personal hygiene. PPPPP PPPPP PPPPP PPPPP
G. Eahusayan ng proseso sa pagtanggap at
pagpapalabas ng pasyente & TTTTT TTTTT TTTTT TTTTT
Over all s'+re TTTTT TTTTT TTTTT TTTTT
!,!
C& Pa!i!itun+ sa !a7;a
D& 3abait na pa$i$itungo8madaling lapitan. PPPPP PPPPP PPPPP PPPPP
#. 3adaling tawagin $ung $ina$ailangan PPPPP PPPPP PPPPP PPPPP.
+. Pananatili sa pasyente $ung $ailangan. PPPPP PPPPP PPPPP PPPPP
,. Pagbibigay ng madaling maunawaang
paliwanag. TTTTT TTTTT TTTTT TTTTT
III& Kasi=ahan sa i)inia= na 7ananalaa&
Pali;ana:An in=+n !asautan a= susu!at sa in=+n !asi=ahan sa uri n
7ananalaan i7ina!al++) sa in=+ ha)an naririt+ sa DR0NRMH& La=an n tse! 253
an nu8er+n naaan!+7 sa in=+n !asautan&
J Q Pina!a8ataas - Q Kata8Ata8an
. Q Mataas D Q Pina!a8a)a)a
! # + ,
!. Eagustuhang sumunod sa mga isasagawang
pag<gamot, dahil sa maayos na pag alaga PPPPP PPPPP PPPPP PPPPP
#. Eagustuhang magbigay ng $ina$ailangan
mahalagang impormasyon at tiwala sa PPPPP PPPPP PPPPP PPPPP.
nangangalaga.
+. Eagustuhang tumulong sa gamotan PPPPP PPPPP PPPPP PPPPP.
,. Eagustuhang bumali$ sa .AN63& $ung sa$ali at muling mangailangan ng gamutan sa ospital
ang alinman sa miembro ng pamilya. PPPPP PPPPP PPPPP PPPPP
!,#
NURSIN S!R"I#! M$N%H&' R!P$R% ($RM )*ppendi+ ,- .
Region/ Province:
______________________________________________________________________
Name of Hospital:
______________________________________________________________________
Date of Accomplished:
______________________________________________________________________
Address:
______________________________________________________________________
ed Capacit!: ______________________ ed "cc#panc! $%&:____________________
N'R()N* P+R("NN+,
CA-+*"R. A'-H"R)/+D AC-'A,
Chief N#rse ____________ ____________
Asst0 Chief N#rse ____________ ____________
(#pervisor ____________ ____________
(enior N#rse ____________ ____________
"R N#rse ____________ ____________
(taff N#rse ____________ ____________
N#rsing Attendant ____________ ____________
1ard Cler2 ____________ ____________
"thers3 (pecif! ____________ ____________
!,+
____________ ____________
____________ ____________
-"-A, ____________ ____________
P+R("NA, R+C"RD: $ 4or last month&
" Attendance N#m5er of N#m5er of
606 A5sence 7itho#t leave ___________ ____________
608 vacation leave ___________ ____________
609 (ic2 leave ___________ ____________
60: Maternit! leave ___________ ____________
-"-A, ___________ ____________
" Resignation and Hiring of N#rses ____________
806 N#m5er of N#rses 7ho resigned last month _____________
808 N#m5er of N#rses 7ho 7ere hired last month ___________
" Resignation and Hiring of N#rsing Attendants
906 N#m5er of N#rsing Attendants 7ho resigned last month _____________
908 N#m5er of N#rsing Attendants 7ho 7ere hired last month ___________
" N#m5er of N#rsing Personnel 7ho attended contin#ing ed#cation programs $in;service or
o#tside& ______________
-"P)C( DA-+ N"0 "4 H"'R(
____________________________________________________________ _____________
____________________________________________________________ _____________
____________________________________________________________ _____________
____________________________________________________________ _____________
____________________________________________________________ _____________
+<')PM+N- AND ('PP,)+(
60 Are there ne7 e=#ipment #sed 5! n#rsing personnel> __________
.+( ____________ N" _______________
606 1hat are these> _______________________________________________________
608 Date of Ac=#isition: _____________________________________________________
609 Do the! 2no7 ho7 to operate these>
80 Do !o# have ade=#ate 5#dget for the follo7ing s#pplies per month:
.+( N"
Medical ___ ___
Ho#se2eeping ___ ___
"ffice ___ ___
"thers3 please specif! ___________________________
R+P"R-(
60 1hat 7ere the reports 5! the n#rses last month>
Name of Report 1ho prepared the Report 4re=#enc! (#5mitted to
!,,
____________________ ____________________ ________ ___________
____________________ ____________________ ________ ___________
____________________ ____________________ ________ ___________
____________________ ____________________ ________ ___________
____________________ ____________________ ________ ___________
)NC)D+N- R+P"R-( $4or the past ? months3 s#mmari@e the n#m5er and nat#re of pro5lems/
incidents 7ritten a5o#t& and actions ta2en0
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
ACC"MP,)(HM+N-(
A0 Patient Care
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
0 -raining/ Contin#ing +d#cation Program/ Activities
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
C0 Research
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
D0 +Atension (ervices
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
!,/
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
+0 N#m5er of (t#dents affiliating in the hospital $last month&
" N#rsing _________________
" Mid7ifer! ________________
" N#rsing Aide ______________
%PP)N.'O V <7%';)6 F26 T6%NSF)6
APPENDI6 -@
VOLUN#AR% 9ORK AGREEMEN#
EN27 %(( 3)N 5D T&)S) P6)S)NTS
This %greement made and entered into this PPPPPP day of PPPPPPPPPPPPPPP#@!PPP by
and between
.6. A2S) N. 62.6'GC)T 3)326'%( &2SP'T%(, a government owned hospital
with principal address at Tala, 1aloocan 1ity represented by ).G%6.2 S%.
A%;'((2N%6, 3.., 3.&.%., of legal age, married, Filipino and with office address at
Tala, 1aloocan 1ity, 'n his capacity as 1hief of Sanitarium ''' of the said hospital,
hereinafter referred to as the institution0
< a n d <
PPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPP, of legal age, PPPPPPPP, and a resident
ofPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPP
PPPPPPPPPPPPPPPPPPPPPPPPP1ity hereinafter referred to as the ;olunteer8Trainee0
7 ' T N ) S S ) T &
!,F
7&)6)%S, the institution is a Secondary Special &ospital that engages in both custodial
and general care of patients0
7&)6)%S, the institution, being equipped with basic hospital facilities can provide
comprehensive training as may be needed by the ;olunteer8Trainee0
7&)6)%S, the ;olunteer8Trainee presents, his8herself voluntarily to the institution to
render his8her free services0
7&)6)%S, the institution in its intent to promote enhancement of $nowledge and s$ills
in the medical8paramedical8administrative field accepts the request of the ;olunteer8Trainee0
7&)6)%S, both the institution and the ;olunteer8Trainee agree on the following terms
and conditions of this %greement, to wit
!. That this %greement shall be for a period of PPPPPPPPPPPPPPP and shall be effective
PPPPPPPPPPPPPPPPPPPPPP to PPPPPPPPPPPPPPPPPPPPPPP.
#. 'n the event that the ;olunteer8Trainee is desirable to renew or e-tend the period of this
%greement, he8she shall propose such desire to the 'nstitution and it shall be subBect to
the conformity and consent of the latter. % new %greement shall thereby be e-ecuted by
the 'nstitution and the ;olunteer8Trainee to embody similar terms stated herein and such
others as may thereafter be agreed to by both parties0
+. That the ;olunteer8Trainee understands and agrees that permission by the 'nstitution for
his8her to perform voluntary wor$ is only for the purposes stated above, which is thus,
made subBect to conditions as may hereinafter stated0
,. That the ;olunteer8Trainee shall in no case be considered as an employee of this
'nstitution, thus, he8she shall not be entitled to any form of salary, compensation,
remuneration or benefit which includes but is not limited to food8meal allowance and
others of similar nature, that may accrue to an employee of the 'nstitution, for any service
or such others as consequence of his8her voluntary wor$0
/. That the ;olunteer8Trainee shall be allowed to participate and perform wor$ only at the
PPPPPPPPPPPPPPPPPPPPPPPPPPPPPP. &e8She shall, therefore, be under the supervision
and control of the personnel who may be designated by the supervision and control of the
personnel who may be designated by the PPPPPPPPPPPPPPPPPPPPPPPPPPPPP.
F. That the ;olunteer8Trainee shall be issued a 1ertificate of Training or 1ertificate of
%ttendance as may be appropriate to be signed by the .ivision &ead concerned with the
conformity of the 1hief of 1linics and 1hief of Sanitarium if only, so requested by the
;olunteer8Trainee0
G. That the ;olunteer8Trainee understands and agrees that his8her voluntary services in favor
of the 'nstitution shall not afford his8her any accommodation or preference to any vacant
position in the latter0
!,G
H. That the ;olunteer8Trainee shall e-ercise due care and diligence in handling and in using
all the instruments, equipment and facilities of the hospital. 'n case of destruction, loss or
any damage to the same by reason of his8her own act, omission or negligence, he8she
shall be liable to pay and indemnify the 'nstitution for such destruction, loss or damage0
I. That the ;olunteer8Trainee shall be held free from any form of liability and other
damages for death of the ;olunteer8Trainee or third persons or any inBury that may be
caused to his8her or third persons especially when the same is by his8her own act,
omission or negligence or by reason of acts, omissions or negligence of third persons,
while he8she is in the 'nstitution e-cept only in instances for which e-isting laws may
regard the letter to be negligent and thus, liable0
!@. That the ;olunteer8Trainee shall abide by all the policies, rules and
regulations being implemented by the 'nstitution. Failure or omission on his8her part to
conform and abide by the same shall be a valid ground for the termination of this
%greement without any prior notice to his8her by the 'nstitution0
!!. The 'nstitution li$ewise reserves the sole discretion to terminate this %greement before
its e-piration without prior notice to the ;olunteer8Trainee in the event that the institution
finds some other reasonable and valid grounds for terminating the same, without those
being necessarily stated herein.
'N 7'TN)SS 7&)6)2F, we have hereunto set our hand this PPPPPPPPPPPPPPPPPPPPPPP
#@!PPP at Tala, 1aloocan 1ity.
PPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPP PPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPP
.6. A2S) N. 62.6'GC)T 3)326'%( &2SP'T%(
PPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPP
5y 453#&5% ,#. 6#7899%!#&, 3... 1T1 No. <
1T1 No. < Place of 'ssue <
.ate of 'ssue < .ate of 'ssue <
Place of 'ssue <
Signed in the presence of
PPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPP PPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPP
%1EN27().G)3)NT
6)PC5('1 2F T&) P&'('PP'N)S
1%(221%N 1'TD
-<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<-
5)F26) 3), a N2T%6D PC5('1 for and in PPPPPPPPPPPPPPPPPPPPPPPPPPPPP1ity, this
PPPPPPPP
!,H
day of PPPPPPPPPPPPPPPPPPPPPPPPPPP #@!PPP, personally appeared ).G%6.2 S%. A%;'((2N%6,
3..., 3.&.%. and PPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPwith their 1T14s 'ndicated below their
respective names, $nown to me and to the $nown to be the same persons who e-ecuted the foregoing
instrument and they ac$nowledged to me that the name is their true act and deed.
This instrument relates to a 3emorandum of %greement and consists of three 9+: pages, including
the page on which this ac$nowledgement is written, each and every page whereon the left margin, have
been signed by the parties and their witnesses and sealed with my notarial seal.
'N 7'TN)SS, 7&)6)2F, ' have hereunto set my hand and seal this PPPPPPP day
of PPPPPPPPPPPPPPPPPPPPPPPP #@!PPP at PPPPPPPPPPPPPPPPPPPPP 1ity.
!,I
PREPARA#ION O$ #HE LA1OR ROOM AND DELIVER% ROOM
!. The .6 Nurse receives patient. Notifies (abor 6oom Physicians.
#. %ssesses, monitor and records patient4s condition including vital signs 95P, 66,
7eight, Fetal &eart Tone:
+. Prepares patient for e-amination.
,. Provides necessary nursing care for patient in labor up to complete delivery process.
/. 'nform Pediatrician8Physician to catch for the newborn and for immediate newborn
assessment.
F. 1arries out doctor4s order.
G. Prepare and attaches '. tags for the baby and perform routine newborn care.
7ithin the !
st
+@ minutes after birth
.ry and provide warm to avoid hypothermia
Facilitate bonding with the mother through s$in to s$in contact.
1lamp and cut the cord once pulsation has stopped.
.o not mil$ the cord towards the newborn.
7ithin I@ minutes of age
Facilitate the newborn early initiation to breastfeeding and transfer of
colostrums.
Provide proper eye care.
%dminister )rythromycin or Tetracycline ointment for both eyes.
'nBect @.!ml of ;itamin E intramuscular.
PREAOPERA#IVE PROCEDURES
% day before the operation
9ARD NURSE:
.ay before 2peration
!. 6eceives request for surgery prepared by the surgeon.
#. 1onsent for operation should be signed by patient or relative. 9 See %ppendi- #:
+. Forwards 26 notification for surgery to the 26. 9See %ppendi- #+:
,. 'nspects chart and sees to it that consent for surgical intervention has been signed by
patient or her8his nearest $in.
!/@
/. 'nforms anesthesiologist of the operation schedule.
F. Prepares patient psychologically and spiritually.
G. Gives dietary instruction to patient.
H. 1ardio<pulmonary evaluation is mandatory to all patients aged ,@ years old and above
and pediatric patients.
I. Prepare patient.
a. Performs procedure 9e.g. enema: as needed.
b. 6emove nail polish.
c. .enture and other valuables should be given to relatives for safe $eeping.
d. 6eassure patient.
!@. 1hec$s availability of need supplies, pre<operative medicines and anesthetics.
!!. Fills up and signs chec$list of pre<operative preparation. 9See %ppendi- H :
!#. Put Pre<2perative )valuation form in the patient4s chart.
!+. .ay of 2perations
a. 3onitor and record vital signs
b. Give pre<operative medicines as ordered then record and sign.
c. Properly endorse patient to 26 nurse +@ minutes before the scheduled operation.
SKIN( SO$# #ISSUE AND MUSCLE CARE 2A77en,i< -C3
!/!
'NSP)1T
1()%N %N. S2%E
9<: 1allus 9S: 7ound
9S: 'nfection 9<: 'nfection
Soa$ in
7ater with Soap ? water
vinegar ?
apply
antibiotic
9S: 1allus
6emove 1allus
Soa$ing
2'('NG
2'('NG 9S: )O)61'S)
9<: )O)61'S)
Dressin 8aterials5e/ui78ent in ,+in ul'er ,ressinO
!. Scissors /. NSS8E3n2,
#. Forceps F. 5etadine solution
+. Gau*e pads8rolls G. Sand paper VH@
,. %dhesive plaster H. 2intment 9*inc:
CARE O$ #HE E%ES 9I#H POOR 1LINK OR CLOSURE:
9%dapted from .6AN63& 6eference 3anual ;olume '':
!. %void eye dryness and inBury
Thin$<5lin$
Protect eyes against dryness ? dust 9sun glass, caps ,umbrella:
Eeep eyes clean
1over eyes at night, especially if they seem sore or red in the morning.
#. 2nce or twice each day inspect for eye problems, care for any findings and, refer
to a doctor for more serious symptoms.
'nspect for dirt or redness, ma$ing sure that hands are clean first. 9Cse a mirror, or
as$ relatives to inspect it for you.:
6emove any specs using a piece of cloth.
1lean eyes
%pply any eye drops or eye ointment that the doctor has given.
CARE O$ HANDS( AND $EE# 9I#H LOSS O$ $EELINGS
96efer to .6AN63& 6eference 3anual ;olume '':
ALL DA% AVOIDANCE O$ HAND M $EE# IN0UR%
!. (earn which parts of hands8feet have lost feeling.
#. 7atch for anything that may be hot and P62T)1T hands8feet from heat. Eeep
hands8feet distant from the heat source. 'nsulate against heat, using a layer that does
not let heat through. %void washing in hot water.
+. 7atch for and avoid rough or sharp obBects.
,. 5eware of long periods of one type of hand activity that might cause hand8feet
blisters.
!/#