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6.1 OPD SERVICES (Clause 4.4.1)

SAN LAZARO HOSPITAL Medical Services caters the following clinical areas in the OPD

1. Animal bite
2. Pediatric consults:
a.well baby – follow up
b.sick baby
3. Adult consults:
a.well adult – for physical examination medical certificate
4. EMS:
a.annual physical exam
b.medical consults/sick leaves/absences

These services are interfacing in the Emergency Department, Clinical Wards, Delivery
Room, and Operating Room.

6.2 OPD PROCESS MAP (Clause 4.4.1)

These processes are usually integrated with the nursing services as doctors and nurses
work hand in hand in patient care. Patient’s initial diagnosis usually starts in the Triage where
the doctor determines whether the patient will be admitted, or be treated in the Emergency
Department. Out-Patient services include patient consultation, diagnosis and management.

6.3 Operational Planning and Control in OPD Services (Clause 8.1)

To ensure quality services provided in the Out Patient Departent, services shall be planned,
implemented and controlled to meet quality requirements. Operational Planning shall include
but not limited to the following:
a. Determining requirements of patient’s need for care in the OPD through conduct of
patient history, physical exam, diagnosis and management, as applicable;
b. Criteria for processes under OPD are indicated in the Quality Objectives and Plans while
the acceptance criteria for the services are specified in the Service Specifications.
c. Determining resources needed such as
 Vaccines, antibiotics and maintenance meds
 Alcohol, syringes, cotton balls, sharps’ container
 Designated waiting area both for the patients and relatives
 suitable process environment by maintaining the sanitation of the OPD
 adequate manpower to patient ratio
d. Implementation of monitoring and measurements to ensure that out patient department’s
ability to meet the requirements for its services. This shall include the following:
 Monitoring completeness and availability of vaccines
 Monitoring the infection control and patient safety practices in the OPD
 Monitoring and maintaining bioref and room temperature.
 Monitoring and maintaining the cleanliness of the comfort/rest rooms
e. Establishing documented information in the form of policies, procedures, guidelines and
other internal documents. In addition, external documents such as Clinical Practice
Guidelines and the same documents shall be maintained.


The OPD Staff shall determine and review the requirements of its clients. In general,
client requirements are determined as they come to the Out Patient Department after the
Triage. Statutory and regulatory requirements shall be determined and be strictly complied with
in the performance of the processes. These requirements shall also be defined in the
established procedures for the process.

To ensure the successful treatment of our clients, evidence based clinical practice
guidelines shall be used as the standard references.

Client feedback, whether verbally or on paper, shall be dealt with utmost importance,
being inputs to planning, program implementation and as basis for providing appropriate actions
by management.

Effective communication arrangements with clients shall be implemented and shall be

specified in the Procedures to be established. Effective communication arrangement includes,
but not limited to the following:
1. Schedule of Services
2. Citizen’s Charter (posting of services and steps in the office)
3. Quad – media (Television, radio, prints, internet, tarpaulins, posters, flyers)
4. Client Feedback
5. Patient Education


In order to ensure that processes within SAN LAZARO HOSPITAL are carried out
consistently and will produce quality outputs or services that meet client requirements,
organizational requirements and legal requirements, the following operational controls shall be
applied to each process, as applicable:

Operational Application / Evidences Controls Responsibility

a. Availability of 1. Strict adherence to statutory and regulatory Make sure that this Medical and
Documented requirements pertaining to the process. documented Nursing
Information 2. The use of Clinical Practice Guidelines, information is
Standard Operating Procedures (SOP) and available and
Work Instructions (WI) to ensure effective suitable for use when
control of the processes and to provide a and where needed.
clear step by step instruction on how a
specific activity in the process will be carried
out. See complete list of SOPs and WIs in
the Masterlist of Documents.
3. The use of external documents as
references enumerated as follows:
a. Clinical Practice Guidelines
b. Textbooks
c. Manuals
d. Journals

b. Availability 1. BP apparatus Ensure fitness for Medical and

and Use of 2. Weighing Scales purpose by Nursing
Monitoring and 3. Thermometers monitoring its
Measuring 4. Pulse oximeter calibration and
Resources 5.Stethoscope verification status.

c. 1. Strict monitoring of vital signs of patients in Check if these are Medical and
Implementation the OPD. carried out as Nursing
of Monitoring 2. Monitoring of patients’ condition planned.
and Measuring 3. Monitoring of availability and completeness
Activities of vaccines
4. Inventory of Medical Supplies including their
expirations dates.
5. Monitor Implementation of Infection Control
and Patient Safety Practices.
d. Use of 1. ECG, pulse oximeter Ensure that these Medical and
Suitable 2. Oxygen tank are available, Nursing
Infrastructure 3. Surgical equipment like minor surgical set maintained and
suitable for use.
Check the preventive
maintenance status
of this equipment
and report to
e. Use of 1. Implementation of Infection Control in the Regularly check the Medical and
suitable process OPD such as regular cleaning and sanitation. suitability of the work Nursing
Environment 2. Implementation of Patient Safety practices environment in the
3. Establishment of policies to make OPD OPD to ensure that
services nondiscriminatory, calm, non- patients are being
confrontational, stress reducing, burn-out managed in a safe
prevention, and an environment emotionally and infection-free
protective. environment.

f. Appointment of 1. Ensuring competency of doctors and Ensure that persons Medical and
competent nurses. assigned in the OPD Nursing
persons 2. Regular updates on medical and nursing have the proper
thru continuing professional development education, training,
3. Conduct of training and mentoring sessions skills and experience
4. Mortality and Morbidity conferences among to be assigned in the
doctors OPD.
g. Validation of 1. Medical services to validate effectiveness of Treatment is on time Medical and
processes treatment in the OPD is to ensure good quality and patients’ Nursing
and effective care that is of utmost highest satisfaction
standards with patients’ satisfaction
h. Actions to Meetings/conferences can be done for Regular evaluation of Medical and
Prevent Human feedback personnel Nursing


For each process, coding system shall be applied to provide identification of services
offered and delivered. A unique identification code shall be applied to each type of case. These
codes shall include hospital number, patient tag and color codes for type of patient and
medicine administration.


Personal data and client information are the primary client property under the care of the
SAN LAZARO HOSPITAL shall identify, verify, protect and safeguard clients’ properties
that are entrusted to it as it provides the services. These include client information and
documents, drugs and medical supplies and other medical paraphernalia submitted, among
others, which should be treated with due diligence.

Personal client information shall be treated with utmost confidentiality. Appropriate

controls of these properties shall be adopted such as restrictions in the release or access to
these by unauthorized party. Unauthorized release or access to any party shall be dealt with in
accordance with existing rules and regulations.

Preservation of medical services is generally carried out by maintaining appropriate

records for each process. These shall also be carried out under the records control procedure.

6.5 Control of Changes

Medical services shall ensure that when there are changes in diagnosis or changes in
treatment plans, the patient or their immediate family members are informed of these changes.
Documented information regarding the description of the changes made, the