Policies On Continue Interval To Act An Orders For Treatment

DR.
AMADO DIAZ PROVINCIAL FOUNDATION HOSPITAL

Poblacion 4, Midsayap, Cotabato
Title: POLICIES AND PROCEDURES ON TIME INTERVALS FOR TREATMENT

(e.g. doctors orders must be carried out within 30 minutes, time intervals for IV
medications )
Responsible Party: Nursing Department
Regulatory / Standard References: Phic Benchbook
Section: E.R./O.P.D., LR/DR, Ward Nurses, I.V. Therapist Nurses
Policy No.___________
Date Issued:__________
PURPOSE/ INTRODUCTION:
Medication management needs expertise in calculating drug dosages to prevent
medication errors which can have fatal implications to patients. Always remember the 10 rights
in the administration of drugs. Some medications have similar names, but different actions,
classes, that further complicate management process. The use of wrist band system have
potential to store clinical information such as allergies of prescribed meds. Chronic conditions
like asthma and diabetes.
POLIY DESCRIPTION:
The Nursing Service Department policies, procedures and guidelines medication
management for symptomatic, curative, preventive and palliative treatment of patient’s diseases
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and for safe practice. The written policies, procedures and guidelines on medication
management includes but are not limited on the following:
1. Carrying out physician’s medication order.
2. Transcribing and ordering
3. Preparing, Labeling, and Administering (10 Golden Rules in Drug Administration )
4. Documenting
5. Monitoring and Storage
6. Emergency Drugs and Regulated Drugs
7. Medication Recall System (expired or Outdated Drugs)
8. Reporting on:
a. Medication effects and adverse effects
b. Medication errors and near- miss
RIGHTS AND RESPOSIBILITIES:
All Nurses shall be responsible in meeting the criteria of appropriateness, adequacy,

effectiveness, efficiency and safe practice in medication management.
PROCEDURES:
1.Verify doctor’s order before giving or administering the drugs and observe the 10 R’s.
2. Stat orders whether written/T.O/V.O./Txt. Orders, must be carried out immediately
dated & timed by NOD & must be countersigned by the ROD/AP who ordered the
medication/ treatment after examining his/her client.
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3. Standing orders of medications/treatments must be carried out
30 minutes dated & timed by the NOD.
4. Administration of 2 kinds of antibiotics with same timing must be given 1-2 hrs.
intervals to allow time of absorption process and
detection of toxic and prophylactic effects.
5. Administration of corticosteroids and aminoglycosides on the
same timing ( hydrocortisone v.s. gentamycin/ amikacin ) must be given with intervals of
30 minutes allowing time of absorption/prophylactic/ toxic effects and drug potency.
6. Aspirin tablets & other preparations causing gastric disturbance
and possible GI bleeding must be given in full stomach with
precautions.
7. Furosemides preparations must be administered with BP precautions.
8. Vital signs plays a very important role in monitoring clients

receiving drips like KCL,INSULIN,AMINOPHYLLINE,
CLONIDINE/APRESOLINE,DOPAMINE,DOBUTAMINE,
NICARDIPINE, and MAGNESIUM SULFATES etc.
9. Oral medications may not be given if patient prefers not to be
given on their resting periods or night time with doctors
permission.
10.Some medications are given immediately after 30 minutes of reconstitution or as
preferred by the physician.
11. The following information shall be available and accessible to all clinical staff
Involved in the medication management process:( age. sex, current medications,
diagnosis, co-morbidities, and concurrently occurring conditions, past allergies and past
sesitiveness,) For pregnant and lactating status (weight and height is to be considered).
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MONITORING:
Logbook for incident reports

Quality Improvement
Decreases incidence of morbidity/mortality
Decreases sentinel events
DISSEMINATION:
Hospital Order
Orientation
Continuing education
Nursing Policy
REFERENCES:
Existing Nursing Manual Procedures
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PROCEDURES:
A. Carrying out Doctors Orders for Treatment
NURSE:
1. After doctors order, receives and copies medical management from the patient’s chart
to the nurses cardex.
2. Fills up medication or treatment cards.
STAT MEDS should be given immediately.
PRN MEDS should be given as needed
Regular Meds like: OD – Once a Day – White Medicine Ticket (Given at 6 am or as
prescribed)
B I D – Twice a Day – Yellow Ticket (Given at 6am – 6pm)
T I D - Trice a Day - Pink Ticket(Given at 6am - 12 noon – 6pm)
Q I D - 4X a Day – Blue Ticket (Given at 8am-12noon-4pm-8pm)
Irregular/ Treatment Meds –Green Ticket –Given as prescribed.
3. Carries out medication treatment orders.
4. Prepares requests for routine examinations and sends them to the department
concerned ( laboratory, x-ray, etc.).
5. Refers or informs other dept. if patient needs to be seen by other doctors for
management.
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B. Daily Patient Care
OUT-GOING NURSE:
1. Endorses to the in-coming nurse, the shift activities and especial treatment and
medication which is needed to be carried out.
2. Makes rounds with the in-coming shift and introduces the latter to the newly admitted
patients and those needing intensive care.
3. Endorses drugs to the in-coming nurse and signs out.
IN-COMING NURSE:
1. Takes note of patients needing special care.
2. Reads cardex and analyzes reports.
3. Prepares plan of work and determines resources and priorities.
4. Provides nursing care and carries out medical treatment.
5. Records patients care activities and observations made.
NURSING ATTENDANT:
1. Takes vital signs (TPR, BP, CR, FHT if needed)
DR. AMADO DIAZ PROVINCIAL FOUNDATION HOSPITAL

Title: Procedures on Asepsis
Responsible Party: All Members of Hospital Nursing Service Department

Technical Support Services
Regulatory/Standard Reference: PHIC Benchbook, ICC Manual
Section: OPD/ER, LR/DR, Ward, Laboratory Department, Pharmacy, Dental, X-Ray,
Dietary, Housekeeping and Laundry Department
Policy: __________
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Date Issued: __________
PURPOSE / INTRODUCTION:
Sources of infection may comes from exogenous means such as through hands, linens,
air, instruments, IV systems, catheters, transfusion and respiratory equipment. Other sources of
infection comes from endogenous which were present during operations, foreign bodies,
chemotherapy immuno suppression and pre-existing disease. To stop the spread of this
infections, procedures on asepsis, the medical and surgical asepsis were introduced.
POLICY DESCRIPTION:
The hospital shall ensure the practice of medical asepsis (Hand washing) and is routinely
done in ER/OPD, General Ward and OR/DR and other medical areas. Surgical asepsis shall be
strictly implemented in special units (OR/DR ).
GUIDING PRINCIPLES:
There shall be a clear guidelines of procedure on asepsis for the hospital staff to
understand the principles of infection control and practice at all times.
DEFINITION:
Medical Asepsis - is the process of washing/removing bacteria and infectious material on

skin using ordinary plain soap or detergent for at least 10-30 seconds through
Hand washing. Can use alcohol hand rub as alternative.
Surgical Asepsis or Surgical Scrubbing – scrubbing or brushing of hands, nails and arms
with the use of antiseptic soap or detergent in a minimum of 2 minutes. Done
before surgery or invasive procedure.
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RIGHTS AND RESPONSIBILITY:
Prevention of infection is the responsibility of all hospital staff.
PROCEDURE:
Medical Asepsis:
1. Practice good hand hygiene techniques.
2. Carry soiled items including linens, equipment and other used articles away
from the body to prevent them from touching the clothing.
3. Do not place soiled linens or other items on the floor, which is grossly
contaminated. It increases contamination on both surfaces.
4. Avoid having patient’s cough, sneeze, or breath directly on others. Provide
patient with disposable tissues and instruct them as indicated, to cover their
mouth and nose to prevent spread by airborne droplets.
5. Move equipment away from you when brushing, dusting or scrubbing articles.
This helps prevent contaminated particles from settling on your hair, face and
uniform.
6. Avoid raising dust. Use a specially treated or a dampened cloth. Do not shake
linens. Dust and lint particles constitute a vehicle by which organisms may be
transported from one area to another.
7. Clean the least soiled areas first and then move soiled ones. This helps prevent
having the cleaner areas soiled by the dirtier areas.
8. Dispose soiled or used items directly into appropriate container. Wrap items
that are moist from body discharges or drainage in waterproof container such as
plastic bags before discarding into the refuse holder so that handlers will not in
contact with them.
9. Pour liquids that are to be discarded such as bath water, mouth rinse and the
like directly into the drain to avoid splattering in the sink and onto you.
10.Sterilize items that suspected of containing pathogen. After sterilization, they
can be managed as clean items if appropriate.
11. Use personal grooming habits that help prevent spreading microorganisms.
Shampoo your hair regularly, keep your fingernails short and feel of broken
cuticles, any ragged edges; do not wear false nails; and do not wear rings with
grooves and stones that may harbor microorganisms.
12. Follow guidelines conscientiously for infection control or barrier techniques as
prescribed by the agency.
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Surgical Asepsis:
1.Only a sterile object can touch another sterile object. Unsterile touching sterile
means contamination has occurred.
2.Open sterile packages upward so that first edge of the wrapper is directed away
from the worker to avoid the possibility of a sterile surface touching unsterile
clothing. The outside of the sterile package is considered contaminated.
3.Avoid spilling any solution on a cloth or paper used as a field of sterile set-up.
The moisture penetrates the sterile cloth or paper and carries organisms by
capillary actions to contaminate the field. A wet field is considered
contaminated if the surface below it, is not sterile.
4. Hold sterile objects above waist level. This will ensure keeping the object within
sight and preventing accidental contamination.
5. Avoid talking, coughing, sneezing or reaching over a sterile field or object. This
helps to prevent contamination by droplets from the nose and mouth or by
particles dropping from the workers arm.
6. Never walk away from or turn your back on the sterile field. This prevent
possible contamination while the field is out of the worker’s view.
7. All items brought into contact with broken skin, used to penetrate the skin to
inject substances into the body, or used to enter normally sterile body cavities
should be sterile. These items includes dressings used to cover wounds and
incisions, needles for injections and tubes (catheters) used to drain urine from
the bladder.
8. Use dry sterile forceps when necessary. Forceps soaked in disinfectant are not
considered sterile.
9. Consider the outer 1” edge of a sterile field to be contaminated.
10. Consider an object contaminated if you have doubt about its sterility.
DISSEMINATION:
IEC printed materials

Memos
Orientation
Hospital Order
BIBLIOGRAPHY / REFERENCES:
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Center for Disease Control and Prevention (2002), Guidelines for Hand Hygiene in
Health Care Setting, Morbidity and Mortality Weekly Report.
Gordis L. Epidemiology, Philadelphia, W.B. Saunders Company, 1996.
Wet hands under running water with soap

1.palm to palm
2.a. right palm over right dorsum
b. left palm over left dorsum
3.fingers interlace palm to palm
4.back to fingers to opposing palms
5.a. rotational rubbing of right thumb
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b. rotational rubbing of left thumb
6.a. rotational rubbing of left palm
b. rotational rubbing of right palm
1. All hospital staff directly involved in patient care shall practice the wearing of gloves,
mask, goggles, gowns and other personal protective equipment as needed.

3. Proper and correct gloving and scrubbing technique.
BASIC GUIDELINES FOR MAINTAINING SURGICAL ASEPSIS

All practitioners involved in the intra-operative phase have a responsibility to provide and
maintain a safe environment. Adherence to aseptic practice is part of this responsibility. The
eight basic principles of aseptic technique follow.
1. All materials in contact with the surgical wound and used within the sterile field must be
sterile. Sterile surfaces or articles may touch other sterile surfaces or articles and remain
sterile, contact with unsterile objects at any point renders sterile area contaminated.
2. Gowns of the surgical team are considered sterile in front the chest to the level of the
sterile field. The sleeves are also considered sterile from 2 inches above the elbow to the
stockinet cuff.
3. Sterile drapes are used to create sterile field. Only the top surface of a draped table is
considered sterile. During draping of table or patient, the sterile drape is held well above
the surface to be covered and is positioned from front to back.
4. Items should be dispensed to a sterile field by methods that preserve the sterility of the
items and the integrity of the sterile field. After a sterile package is opened, the edges are
considered unsterile. The sterile supplies, including solutions, are delivered the sterile
field or handed to a scrubbed person in such a way that sterility of the object or fluid
remains intact.
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5. The movements of the surgical team are from sterile to sterile areas and from unsterile to
unsterile areas. Scrubbed persons and sterile items contact only sterile areas, circulating
nurses and unsterile items contact only unsterile areas.
6. Movement around a sterile field must not cause contamination of the field. Sterile areas
must be kept in view during movement around the area at least 1 foot distance from the
sterile field must be maintained to prevent inadvertent contamination.
7. Whenever a sterile barrier is breached, the area must be considered contaminated. A tear
or puncture of drape permitting access to an unsterile surface underneath renders the area
unsterile. Such a drape must be replaced.
8. Every sterile field should be constantly monitored and maintained. Items of doubtful
sterility are considered unsterile. Sterile field should be prepared as close as possible to
the time of use.
Disinfectant / Decontaminants
1. sodium Hypochloride ( Zonrox )
2. Povidone 10% ( Disinfectant )

3. Povidone 7.5% ( Cleanser )
4. Deconex 53 plus; 50 FF
5. Solarsept
6. Decosept
7. Isoprophyl Alcohol 70%

8. Soap ( Perla Bar )
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POLICIES ON CLEANING
1.All instruments should be soaked with Sodium Hypochloride
with water 5-10 minutes before cleaning with soap and water.
2. .All soiled linens should be soaked with disinfectant before
washing with soap and water.
3. All instruments should be free from debris blood prior to
disinfection / Sterilization.

POLICIES ON DISINFECTION / STERILIZATION
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1. All instruments should be washed with soap and water
2. Disinfecting container should be cleaned regularly
3. Lumen of instruments or tubing must be completely filled up
with disinfectant solutions ( Zonrox ) 900 cc top water + 100
cc zonrox.
4. Disinfectant solution ( Deconex 53 plus ) is changed every 14 days.
5. Thermometer ( Digital ) should be cleaned with 70% alcohol.

POLICIES ON STERILIZATION
1. All instrument should be wash with soap / water before sterilization.
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2. All instruments, OR supplies, specimen bottle shall be sterilized by steam under
pressure ( Autoclaving )
3. Instruments shall be sterilized every after use.
NEEDLESTICK AND SHARP INJURY
Needle stick injuries are wounds made by a sudden prick from sharp pointed objects such
as needles. These injuries make a small puncture (hole) on the skin. They usually happen on the
hand, arm or foot. They may cause bleeding, pain, and swelling on the wound site. Needle stick
injuries usually happen to healthcare workers in hospitals, clinics, and labs. They may also
happen at home or in the community, where needles not properly disposed of.
Needles are used to draw blood and other body fluids, or are used to give medicines.
Used needles may be clean or maybe dirty. A dirty needle may contain blood that carries germs
which may cause disease or infection. It may have been used on people with hepatitis (swelling
of the liver) or HIV infection. These diseases may be spread to anyone who gets pricked by the
dirty needle.
What may cause needle stick injuries?

Needle stick injuries almost always happen by accident. Not property discarding (throwing
away) used needles may cause injury to you or to someone else. Not using gloves to protect the
hands while working may also cause injury when pricked by sharp objects. Used or unused
needles and other pointed sharp objects must be kept safely away from children at home. Most
of their injuries happen when they step on or play with used needles or sharp pointed objects.
Who are at risk of having needle stick injuries?

Anyone is at risk for needle injuries. They may especially happen to:
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Children with relatives or neighbors using needles
Cleaners of public toilets, parks trains, and cinema seats.
Health caregivers who use needles most of the time while working
People who shares needles for use with illegal drugs.
Police and security officers especially while searching suspects or their property.
How is needle stick injuries diagnosed?

Your caregiver may ask several questions regarding the injury. It would be important to give the
date and time the injury happened. He may ask the type and amount of fluid or material the
needle was exposed to. Your care giver want to know who used the needle and if the user has
infection. He may ask if you have had a vaccine against certain infection before.
Blood Test:
You may need to have blood taken for test. The blood can be taken from a blood vessel in your
hand, arm, or the bend in your elbow. It can give your care givers more information about your
health condition. You may need to have blood drawn more than once,
How is needle stick injuries treated?
Treatment includes washing the wounds with soap and water. You may be given any of the
following medicines.
Antibiotics:
Antibiotics may be given to help treat or prevent an infection caused by germs called bacteria.
Antiviral Medicines:
Antiviral medicine may be given to fight the infection caused by a germ called a virus. One or
more antiviral medicines may be given to prevent Hepatitis or HIV infection. These medicines
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may have unpleasant effects. If you are a woman, tell your care giver if you know or think you
might be pregnant.
Immune Globulins:
Immune globulins can be used to treat many different problems. It may be given to help your
immune system fight infection. It may also help if your body does not produce enough of
certain kinds of blood cells. This medicine may have if your system fights something in your
blood or body that it should not. Ask your care giver for more information about how immune
globulin medicine may help you.
Over the- counter pain medicine:

You may use over the counter ( OTC ) pain medicines, such as Ibuprofen or Acetaminophen,
for pain or swelling. These medicines maybe bought without a caregivers order. These
medicines are safe for most people to use. However, they can cause serious problems when they
are not used correctly. People with certain medical conditions ,or using certain other medicines
are at a higher risk for problems. Using too much, or using this medicines for longer than the
label says can also cause problems. Follow directions on the label carefully. If you have
question talk to your caregiver.
Tetanus Shot:
This is medicine to keep you from getting tetanus. It is given as a shot. You should have a
tetanus shot if you have not have had one in the past 5-10 years. Your arm can get red, swollen,
and sore after given the shot.
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How can needle stick injuries be prevented?
The following may prevent needle stick injuries and possible complications in the future:
At work:
Always use gloves when handling needles that are exposed to blood or other body fluids.
Do not put the cap back on a needle, bend or break a needle by hand, or use a cutting device.
Get a vaccination against certain diseases, such as hepatitis, for protection.
Learn the right way to handle and allow throw away needles, scalpels, and other sharps objects.
Put all sharps objects in a holder marked just for sharp objects. A puncture-proof, closed
container with a lid may be used to contain needles. The containers are placed in areas where
needles are used. It should be replaced before it becomes overfilled.
In the home and community:

Frequent cleaning of parks and schoolyards.
Educate young children about the dangers of handling or playing with needles and syringes.
Teach them not to touch needles and to report found needles to an adult for disposal.
Having community programs about addiction treatment and needle exchange programs for
injection drugs users may be of help.
Prevent the spread of HIV infection and hepatitis by giving vaccines. Ask caregivers or visit
them for the vaccines that you may need.
Where can I get support and more information?
Having a needle stick injury may cause only a small wound in the skin but its long term effect
may be worse. You may get hepatitis or HIV infection later on. Having these infections may
make it hard for you and your family. Contact any of the following for more information:
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Needle stick and sharp injuries can account for transmission of more than 20 blood borne
diseases due to exposure to blood of the health care providers. Inadequate waste disposal
system can extend the problem even beyond health care workers.
To prevent staff acquiring illness due to needle stick and sharp injury, the following
policies shall be imposed.
1. Waste receptacles of sharps and needles shall be provided in all units providing care.
2. Proper disposal of sharps and needles.
Hospital staff ( Nurses, etc.) prone to this injury .
The hospital shall provide training for all hospital staff involved in patients care.
The hospital management shall provide assistance, financial support to victims of this injury.
The hospital management shall provide Hepatitis Vaccine free in complete doses to all staff in
health care. Proper recapping of needle after use and before disposal.

POLICIES FOR PREVENTION & TREATMENT OF NEEDLE

STICK / SHARP INJURY
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PURPOSE:
13.To reduce the risk of NSI to all concerned health workers.
14.To upgrade safe injection guides in accordance with the guidelines of WHO.
POLICIES:
1. There shall be a proper waste management involving the disposal of used
needles and sharps.

2. Always use individual gloves or any new invented protective devices, ex.
ampoule breaker.
3. Quality assurance indicators must be intensified.
4. There must be seminars, conferences, trainings, or websites provided in order to
promote awareness and to educate health personnel.

5. All nursing personnel must follow the standardized practices.
6. The hospital must provide IEC materials regarding NSI
standard practices and disseminate manuals.
7. There must be a corrective measures consisting of clear
instructions and documentations of accidents. These may contribute to the
collective delineation of a hopefully risk- free hospital environment.
Title: Policies and Procedures on Proper Handling and Safe Disposal of

Sharps and Needle Sticks
Responsible Party: Nursing Service Department, X-ray Department,

Laboratory Department, Maintenance and Utility Dept.
Regulatory / Standard Reference: PHIC Benchbook, ICC Manual
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Section: OPD/ER, LR/DR, General Ward, Laboratory, Maintenance and Utility
Policy No. ___________
Date Issued: ___________
Health care waste is a potential reservoir of pathogenic microorganisms,

and requires appropriate handling. The only waste which is clearly a risk for
transmission of infection however, is sharps contaminated with blood.
Recommendations for classification and handling of different types of waste
should be followed.
POLICY DESCRIPTION:
The hospital shall have health care waste management program that will
enable the health care personnel and other hospital workers informed about
hazards related to health care waste trained in appropriate waste management
practices.
All hospital Nursing Staff and health care personnel concerned, are
responsible on the right and appropriate practices in handling and disposing
sharps and needle sticks.
GUIDING PRINCIPLE:
For safety and economic reasons, health care institutions shall organize a
selective collection of hospital waste, general waste and some specific waste
(sharp instruments, highly infectious waste).
Adopt the World Health Organization standards.
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DEFINITION:
1.Health Care Waste- includes all waste generated by health care

establishments, research facilities and laboratories.
2. Infectious Waste- is suspected to contain pathogens (bacteria, viruses,
parasites, or fungi) in sufficient concentrations or quantities to
cause disease in susceptible hosts.
3. Sharps Waste- e.g. used needles, infusion sets, scalpel, knives, blades,
Broken glass.
PROCEDURE:
1. Sharps/needle sticks should be collected and placed in a puncture-proof

containers (usually made of metal or high density plastic) with fitted
covers. Containers should be rigid, impermeable, and puncture-proof
(difficult to open or break). Where plastic or metal containers are
unavailable or too costly, containers made of dense cardboard are
recommended – these fold for ease of transport and disposal and may
be supplied with a plastic lining.
2. Recapped all used needles separating from syringes thrown into half-filled non-
prickable gallon with antiseptic.(including sharps broken ampoules) using
gloves.
3. All receptacles filled with needles and sharps must be properly disposed at
septic vault provided by the institution.
MONITORING:
1. Occupational Health Care provider evaluation and Safety Program

2. Solicitation of Inputs from frontline patient care employees about selection,
identification and evaluation of effective engineering & work practice
control.
DESSIMINATION:
Hospital Order
Memos
Orientation
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Continuing education on personal protection and training issues.
REFERENCES:
ICC Manual
PJN Volume 76 no. 1, Jan. – June 2006 Needle Stick Injury; Phil.
`Perspective
Ruth R. Padilla
Ma. Isabelita C. Rogado
Eularito Tagalog
Evangelita America
Title: Policies for Prevention and Treatment of Needle Stick / Sharp

Injury
Responsible Party: Nursing Service Department, Laboratory Department,

X-ray Department, Housekeeping & Laundry Dept.
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Regulatory / Standard Reference: PHIC Benchbook, WHO Guidelines,
ICC Manual
Section: OPD/ER, LR/DR, General Ward, Laboratory, X-ray, Housekeeping
And Laundry Services
Policy no. ________
Date Issued: ________
1. To reduce the risk of NSI to all concerned health workers.

2. To upgrade safe injection guides in accordance with the guidelines of
WHO.
POLICY DESCRIPTION:
The hospital shall have a clear policy guidelines on prevention and

treatment of NSI cases for the benefit of the Health Care Provider and the
recipient of the Health Care Services.
DEFINITION:
NSI- Needle Sick Injury

- are wounds made by a sudden prick from sharp
pointed objects such as needles.
- Usually happen to health care workers in hospitals,
clinics and laboratories.
- Needles are used to draw blood and other body fluids,
or are used to give medicines. Used needles may be
clean or may be dirty. A dirty needle may contain blood
that carries germs which may cause disease or
infection. It may have been used on people with
hepatitis or HIV infection. These diseases may spread
to anyone who gets pricked by the contaminated
needle.
Sharps – may be defined as any object or instrument, which may cause a

puncture or incisional wound in the skin. The term includes glass ampoules
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hypodermic and suture needles, blades and sharp edges of human tissue,
e.g. bone, nail and teeth.
PREVENTION OF NSI:
1. Have a complete dose of Hepa-B vaccine for protection.

2. Dispose used needles in puncture-proof container.
3. Don’t recap needles (unless using the hand technique).
4. Use gloves when handling needles (won’t prevent injuries but may lessen
chance of transmitting disease).
TREATMENT OF NSI:
1. Washing of wounds with soap and water.

2. Use of antibiotics and anti-viral medicines – may prevent infection.
3. Used of Immunoglobulin – boosting immune system to fight the spread of
infection.
4. Tetanus shots – keeping the health care provider from getting tetanus.
5. Hepa-B vaccination.
POST EXPOSURE MANAGEMENT OF NSI:
1. Wash wounds / flush mucous membrane immediately. Do not use caustic

agents. Don’t squeeze wounds.
2. Asses the risks by characterizing the exposure. Evaluate the source person by
doing medical history, risk behavior, and testing for Hepa B/C and HIV, then
evaluate exposed person by testing for Hepa B/C.
3. Determine Hepa C antibody status of both exposed and source person.
4. If source is Anti Hep.C Virus positive and exposed person is Anti Hep.C Virus
(-) negative, follow up antibody testing for exposed person, prophylactic
immunoglobulin is not effective, no recommended prophylaxis regimen.
5. Inform your superior and the ICN immediately and see HIV specialist ASAP
after injury.
MONITORING:
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Logbooks for reporting cases
Less incidence of NSI infected HCP
Quality Improvement
HCP Safe practice and Environment
DISSEMINATION:
Hospital Order
Memos
Orientation
Continuing Education
REFERENCE:
ICC Manual
Philippine Journal of Nursing Vol. 1 2006
Capitol Medical Center Policy Manual
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Title: Policies and Procedures on Reporting of Infections to Personnel and Public

Health Agencies
Responsible Party: ICC, Disease Surveillance Officer

Regulatory / Standard Reference: PHIC Benchbook, PIDSR
Section: ER/OPD, LR/DR, General Ward, Disease Surveillance Coordinator &
Infection Control Nurse
Policy No.:___________
Date Issued:___________
Early identification of an outbreak is important to limit transmission among

patients by health care workers or through contaminated materials. A potential problem
may be initially identified by nurses, physicians, microbiologists, or any other health
care workers, through surveillance program. Appropriate investigations are required to
identify the source of the outbreak, and to implement control measures. The control
measures will vary depending on the agent and mode of transmission, but may include
isolation procedures or improvements in patient care and environmental cleaning.
POLICY DESCRIPTION:
1.The hospital Medical & Nursing Administration shall established and formulate
policies and guidelines on Surveillance program.
2.The hospital shall designate Dis. Surveillance Coordinator as overseer in the
systematic planning, implementation and reporting of an outbreak
investigation. Case Definition shall be developed.
3.There shall a proof of weekly submission of Notifiable Diseases using the Case
Report Form (CRS) to the nearest Dis. Reporting Unit (DRU) like RHU,PESU
or RESU.
DEFINITION:
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Outbreak- is defined as an unusual or unexpected increase of cases of a known
disease or the emergence of cases of new infection in a particular place or
area.
Case Definition- includes a unit of time, place and specific biological and/or
clinical criteria.
RHU- Rural Health Unit
PESU- Provincial Epidemiological Surveillance Unit
RESU- Regional Epidemiological Surveillance Unit
CIF- Case Investigation Form
DSC- Disease Surveillance Coordinator
ICN- Infection Control Nurse
DRU- Disease Reporting Unit
NDRR- Notifiable Disease Report Registry
The trained designated DSC and the ICN has the responsibility in notifying the
appropriate individual and departments in the institution. This includes the
development of an outbreak team and clear delineation of authority.
PROCEDURES:
1. The OPD/ER nurses are being oriented and alerted to report to the Head
Nurse/Chief Nurse and/or members on the ICN for any patient/client
Suspected or confirmed cases immediately upon client’s entry.
2. Infectious diseases or any outbreaks or clusters of disease in a community
under Category1 in CIF, shall be reported within 24 hrs to the nearest DRU.
3. Report all case of notifiable diseases/syndromes under Category II in CIF
every Friday of the week to nearest DRU.
MONITORING:
28
24/7 Monitoring of reportable disease
Endorsement
Outbreaks tracing
Decrease Incidence of mortality/morbidity cases
Evaluation
Weekly NDRR
DESSIMINATION:
Hospital Order
Memos
Orientation
Continuing education, training & seminar
REFERENCE:
Philippine Integrated Disease Surveillance and Response under R.A. 3573

(Law of Reporting Communicable Diseases to local and national public
health authorities)
29
Title: INFECTION- CONTROL PROCEDURES ON ISOLATION AND UNIVERSAL

PRECAUTION
Responsible Party: Infection Control Committee
Regulatory / Standard Reference: PHIC Benchbook
Section: All Department Heads and Members
Policy no. ________
PURPOSE:
The DADPFH shall employ strategies designed to reduce risk for and/or prevent
health care associated infections to patients, employees and visitors. The head of the
units is responsible for assuring their personnel to follow appropriate policies and
procedures.
POLICY DESCRIPTION:
All department heads in the hospital, staffs and management are required to
work together in the control of infection, research and study the main source of
infection.
- Source of infecting microorganisms or other infectious agents in a
sufficient dose to cause infection.
- Susceptible host.
- Path of transmission ( route and place of entry, exit) to the susceptible host.
Prevention of infection is the responsibility of all hospital staff. It is a must for all
hospital staff to understand the principles of Infection Control and practice it at all
times.
30
GUIDING PRINCIPLE / ETHICAL PRINCIPLE:
Standard precautions require all health care workers to assume, all body
substances of all patients be considered potential sources of infection regardless of
diagnosis or perceived risk.
The aim of this policy is to minimize the risk of nosocomial transmission of
infection agents:
. from patient to patient
. from patient to health care worker
. from health care worker to patient
Standard precautions includes:
1. Hand washing – observe at all times

2. Gloves
-Wear gloves (Clean, non-sterile gloves and adequate ) when touching
blood, body fluids, Secretions and contaminated items.
-Change between tasks and procedures on the same patient.
-Remove promptly after use, before touching contaminated items and
environmental surfaces and before going to another patient.
3. Mask, Eye protection, Face shield
-Use to protect membranes of the eyes, nose, and mouth during
procedures and patient care activities that are likely to generate splashes
or sprays of blood, body fluids, secretions and excretions.
-Wear masks when entering the room of patient with known or suspected
infectious PTB.
4. Gown
-Wear to protect skin and to prevent soiling of clothing during procedures
and patient care activities.
5. Patient Care Equipment
- Handle used equipment with blood, body fluids, secretions and excretions
in a manner that prevents skin and mucous membranes exposures,
contamination of clothing and transfer of microorganisms to other patients
and environments.
• Reusable equipment should be cleaned and reprocessed
appropriately before
• Using to another patient.
- Single use items should be discarded properly.
6. Environmental Control
31
- Routine care ,cleaning and disinfection of environmental surfaces, beds,
bedrails bedside equipments and other frequently touch surfaces.
7. Linens
- Handle, transport and process used soiled linens with blood, body fluids,
secretions and excretions in a manner that prevent exposures,
contamination and transfer of microorganisms.
8. Occupational Health and Blood borne Pathogens
- Needles, scalpels, test tubes, ampoules and other sharp instruments
should be thrown in punctured proof containers ( sharp containers)
9. Patient Placement
-Admit patient with infectious and communicable disease in a private room
or CD ward/ Isolation cubicle.
- Doors should be closed at all times.
- Aircon should be turned off and windows open for patients with PTB,
measles and varicella.
Additional precaution – are to be used for patients known or suspected to

be infected or colonized with highly transmissible pathogens that can cause
infection. Additional precautions are to used in addition to standard
precautions when transmission of infection might not be contained by
standard precaution alone. Additional precautions are not required for
patients with blood borne viruses such as HIV, Hepa B or Hepa C unless
blood/body fluids cannot be contained. Additional precautions should be
tailored to the particular infectious agent involved and the mode of
transmission, and may include any of the following:
. single room
. dedicated toilet
. room sharing by people with same infection, if single rooms are not
available
. special ventilation requirement (e.g. negative pressure room)
. additional use of PPE (e.g. high filtration mask)
. Roostering of immune health care workers to care for infectious
patients (e.g. chicken pox)
. dedicated pt. equipment
. restricted movement of both pts. and health care workers
DEFINITION:
32
1. Infection- is the status or condition in which the body or part of the
Body is invaded by pathogenic agents (bacteria, virus,
parasites) which under favorable conditions multiplies and
produces effects which are injurious.
2. Nosocomial infection- means hospital acquired or hospital associated
Infection that are caused by microorganisms and acquired
within the hospital.
- an infevtion acquired within 48 hrs. after admission to
hospital.
- May be present on admission or acquired while in the
hospital or developed after discharged.
3. Exogenous- hands, linens, air, instruments, IV system, catheters,
transfusion, respiratory equipment.
4. Endogenous- operations, FB, chemotherapy, immunosuppression,
pre-existing disease.
PROCEDURES:
1. All infected patients and highly infectious or suspected infectious cases must be
isolated with proper precautionary measures with doctor’s order.
2. Routine hand washing should be done before and after any nursing
procedures.
3.Nursing rounds should start from clean cases to the dirty or infected cases, to
avoid crossing infection.
4. If possible, assign a health care provider that is equipped, skilled and well trained
on handling the infected cases.
5.The following tips of prevention of infection from invasive services and
procedures such as:
1. shaving
2. antibiotic prophylaxis
3. daily wound dressing.
4. No urinary catheterization unless absolutely necessary.
5. daily cleansing of tracheostomy.
6. suctioning must be done aseptically,catheters and gloves used are
routinely changed every shift and as necessary.
7. Respiratory tubing should be change every 48 hours.
33
8. IV site/IV cannulas are routinely changed or re-sited every
48- 72 hours or 3 days or when necessary.
9. daily cleansing/daily dressing of IV/IV solutions and tubings
should be changed every 24 hours.
10.daily changing of linens as necessary
11.Weekly cleaning of bed pan/bed pan operation
12.daily changing of hospital scrub suit, smock gown, hospital
gown as necessary.
DISSEMINATION:
Hospital Order
Memos
Meetings
IEC Materials
Orientation
Continuing Education / seminars / trainings
REFERENCES:
Infection Control Guidelines for the Prevention of Transmission of Infectious Disease

In the Health Care Setting.
Communicable Disease Network Australia, DOH & Ageing, January, 2004
Care for Disease Control & Prevention “Guidelines for Hand Hygiene & in Health
Care Settings
34
STANDARD PRECAUTIONS
1 Hand washing – observe at all times

2. Gloves
* Wear gloves (Clean, non-sterile gloves and adequate ) when touching blood, body
FLUIDS, SECRETIONS AND CONTAMINATED ITEMS.
* Change between tasks and procedures on the same patient.
* Remove promptly after use, before touching contaminated items and environmental
Surfaces and before going to another patient.
3. MASK, EYE PROTECTION, FACE SHIELD
* Use to protect membranes of the eyes, nose, and mouth during procedures and patient
Care activities that are likely to generate splashes or sprays of blood, body fluids,
Secretions and excretions.
* Wear masks when entering the room of patient with known or suspected infectious
PTB.
4. GOWN
* Wear to protect skin and to prevent soiling of clothing during procedures and patient
care activities.
5. PATIENT CARE EQUIPMENT
* Handle used equipment with blood, body fluids, secretions and excretions in a manner
That prevents skin and mucous membranes exposures, contamination of clothing and
And transfer of microorganisms to other patients and environments.
* Reusable equipment should be cleaned and reprocessed appropriately before using
To another patient.
* Single use items should be discarded properly.
35
6. ENVIRONMENTAL CONTROL
* Routine care ,cleaning and disinfection of environmental surfaces, beds, bedrails
bedside equipments and other frequently touch surfaces.
7. LINENS
* Handle, transport and process used soiled linens with blood, body fluids, secretions
and excretions in a manner that prevent exposures, contamination and transfer of
microorganisms.
8. OCCUPATIONAL HEALTH AND BLOODBORNE PATHOGENS
* Needles, scalpels, test tubes, ampoules and other sharp instruments should be
Thrown in punctured proof containers ( sharp containers)
9. PATIENT PLACEMENT
* Admit patient with infectious and communicable disease in a private room
or CD ward/ Isolation cubicle.
* Doors should be closed at all times.
* Aircon should be turned off and windows open for patients with PTB, measles
and varicella.

Title: POLICIES ON RATIONAL ANTIMICROBIAL USE BASED ON THE

ANTIBIOGRAM IN COORDINATION WITH MICROBIOLIOGY
LABORATORY AND PHARMACY THERAPEUTICS COMMITTEE
36
Responsible Party: ICC, Microbiology Laboratory, Pharmacy and Therapeutic Committee
Regulatory/Standard Reference: PHIC Benchbook/ICC Manual
Section: Medical Staff, ICN, Medical Technician, Pharmacist
Policy no. __________
Date issued __________
PURPOSE/INTRODUCTION:
To reduce the incidence of misuse of antimicrobial agents leading not only to increase of
morbidity but also to the colonization of the areas where misuse occur by highly resistant strain
of microorganisms.
POLICY DESCRIPTION:
1. There shall be a series of appropriate guidelines developed and approved by medical

staff for antimicrobial use or the “Antibiotic Policy” shall be established and agreed
upon by all concerned medical staff.
2. There shall be a creation of Antimicrobial Use Committee and Medical Advisory
Committee to monitor antimicrobial use and shall be reported in a timely manner.
Monitoring usually performed by the pharmacy department.
3. Antimicrobial use in specific patient areas such as the ICU/Hematology/Oncology
Units should be analyzed.
4. Intermittent audits on monitoring of antimicrobial use shall be undertaken to explore
the appropriate of antimicrobial use.
5. The antimicrobial use to be audited will based on changes observed in antimicrobial
use, antimicrobial resistance of organism, or concerns about poor patient outcomes.
6. Physician who are caring for patient shall participate in planning the audit and
analysis of data.
7. If the criteria have not been met, the reasons for inappropriate use shall be identified.
Existing Policy Statement:
One of the most important functions of the microbiology laboratory is to determine

the antibiotic susceptibility of organisms isolated from infected patients in order to
assist the physician in choice of treatment.
37
MONITORING:
Pharmacy Therapeutic Committee

Medical Advisory Committee
Logbook for reporting cases
Evaluation of Treatment
Antimicrobial use Committee
DISSEMINATION:
Hospital Order
Memo
REFERRENCE:
ICC Manual
WHO, WHO Global Strategy for Containment of Antimicrobial Resistance
WHO/CDS/CSR/DRS/2001.2
DR. AMADO DIAZ PROVINCIAL FOUNDATIONHOSPITAL

Title: Policies and Procedures on Routine Collection and Aggregation of Data

from Patient Charts for Use in Quality Improvement, Administrative
Purposes and for Mandatory Reporting to the Department of Health and
Phil Health
38
Responsible Party: Medical/ Nursing Department, Medical Records Section
Regulatory/Standard Reference: PHIC Benchbook
Section: ER/OPD, Admitting Officer, Medical Record Officer, LR/DR, Ward Nurses
Every client/patient seeking for medical attention shall have a permanent health
record. OPD and in-patient will be recorded in their respective logbooks for their case
number. This is to facilitate easy access on the record for collection and aggregation of
data for future references by authorized personnel (DOH and Philhealth).
POLICY DESCRIPTION:
1.The hospital shall have the coordinated policy guidelines for Philhealth
regulatory mandate and a system flow chart in each department, starting
from admission to discharging of patient to ensure the correct entries on
the admission logbooks provided by the Philhealth.
2.Admission logbook shall be placed and available anytime at admission
office.
DEFINITION:
Routine Collection- is a process of daily data gathering from patient’s chart.

Aggregation of data- gathering information from given demographic data of
patient.
PROCEDURE:
1. OPD clients/patients card are entered at OPD logbook with OPD case
number.
2. In-patients charts are entered at admission logbook provided by pre-
numbered Philhealth logbook.
3. Capture all patient admission data in real time at admission logbook.
39
4. Names of all patients whether Philhealth or non- Philhealth member or
dependent shall be entered in the manual admission logbook in chronological
order within 24 hrs. from consultation or admission.
5. The manual shall contain the following data fields as prescribed by the
corporation for uniformity (case number, data and time of admission, name of
patient, date of birth, sex, address, membership, admitting diagnosis and
attending physician).
6. Patients who stayed in the ER for less than 24hrs. but whose condition are
emergency in nature shall recorded in the emergency logbook for purposes of
claims reimbursement with Philhealth.
MONITORING:
Philhealth Inspector/DOH Personnel

Daily Census Report
Admission Logbook
ER Logbook
DESSIMINATION:
Hospital Order
Memos
Orientation
REFERENCES:
PHIC Bench book

Philhealth Admission Loigbook
DR. AMADO B. DIAZ PROVINCIAL FOUNDATION HOSPITAL

Title: Policies and procedures on Routine Reporting of Data for use in Quality
improvement, Administration purposes and for Mandatory Reporting to DOH &
Philhealth
40
Responsible Party: Medical/ Nursing Department/ Medical Records Section
Regulatory/Statutory Reference : Phic Bench book
Section: ER/OPD/Admitting Officer,/ Medical Officer, ICD Coder, LR/DR, Ward
Nurses, Medical Staff
To ensure the reporting of data in the patients charts are properly coded &
indexed for timely production of quality patient care information for use in quality
improvement activities, administrative purposes & for mandatory reporting to DOH &
Phil health.
POLICY DESCRIPTION:
The hospital staff shall have a coordinated system wide policies an procedures in
reporting data collected from patient’s charts. As mandated by Philhealth, accredited
primary hospital shall use only one logbook in book bound form with pre-numbered
pages to be printed published and distributed solely by Philhealth.
RIGHTS AND RESPONSIBILTIES:
All concerned staff shall be responsible in proper recording, documenting,

reporting, indexing, coding & safekeeping to safeguard & to prevent record or charts
loss.
DEFINITION:
ICD-International Code of Diseases
41
PROCEDURES:
1. Total patient’s charts logged on admission logbook for 24 hrs. will tally
on each entry on the daily master list census.
2. Discharged charts for the day less the total admission for 24 hrs. will be
forwarded as total remaining patient for the day.
3. Discharged charts shall be checked for completeness before sending to
MRS for coding, indexing and safekeeping.
4. List all discharged charts in logbook to be endorsed & received by MRS
for safeguarding, safekeeping & preventing losses.
5. For statistical purposes, the Monthly Summary of hospital activities shall
be accomplished after the last entry for the month in the manual
admission logbook to be signed by the medical director/chief of hospital
or his/her authorized representative.
6. Philhealth patients not entered in the manual logbook as the case
maybe, shall be held in abeyance pending outcome of an investigation
within the period prescribed by the corporation.
MONITORING:
Statistical Report
MMHR
Daily Master list Census
Philhealth Admission logbook
DISSEMINATION:
Orientation
ICD Coding Seminar
42
REFERENCE:
PHIC Benchbook
Hospital Records Manual

Incidental Report / Sentinel Event Form
43
Patient’s name: Case No.
Address: Age/Sex:
Admitting Diagnosis: Civil Status:
Name of Complainant:
Relationship to patient:
Nature of Incidence:
Date of Incidence:
Time of Incidence:
Attending Physician:
Summary of Incidental Report/Sentinel Event Report
Date: Time:
Action/Resolution:
_____________________________________
Signature of Responsible Party Involved/NOD
Noted by:
JULIE FE D. SUMAGIT
Chief Nurse ROSARIO ISABEL P. PADER, MD
Chief of Hospital

Title: PROCEDURES ON ISOLATION OF NOSOCOMIAL INFECTIONS
44
Responsible Party: Infection Control Committee
Regulatory / Standards Reference: PHIC Benchbook
Section: Nursing Department
Policy No.:______________
Date Issued:______________
Acquisition of nosocomial infection is determined by both patient factors, such as
degree of immuno-compromise and interventions performed which increase risk. The
level of patient care may differ for patients groups at different risk of acquisition of
infection. A risk assessment will be helpful to categorize patient and plan infection
control interventions for safe practice.
GUIDING PRINCIPLE:
Preventing nosocomial infection requires an integrated, monitored program which
the hospital will continuously evaluate.

The hospital medical and nursing staff shall be responsible in monitoring,
reporting and evaluating all cases of nosocomial infections within the institution.
Infection control is the responsibility of all health care professionals.
PROCEDURES:
2. Limiting transmission of organism between patients in direct patient care
through adequate hand washing and use of gloves, appropriate aseptic
45
practices, isolation strategies, sterilization and disinfection practices and
laundry.
3. Isolate all suspected clients.
4. Detection of early developing hospital acquired infection within 48-72
hrs. upon admission.
5. Use of PPE in caring nosocomial infected patients.
6. Reporting
MONITORING:
Logbook for Nosocomial reports and cases
Decrease incidence of Morbidity / Mortality Cases
DESSEMINATION:
ICC Guidelines
Memos
Orientation
REFERENCE:
ICC Manual

46
POLICY OF SAFE REUSE OF ITEMS
ITEMS
Vials and bottles

A. Vials Reuse for:
1. Urine specimen
2. Stool specimen
3. medicines
B. Bottles Reuse for:

1. Thoracostomy
2. Container for Osteorize feeding
3. For output purposes

4. Suction bottles
5. Container for sterile water
POLICY
1. Identify and gather items for re-use
2. All vials and bottles should be cleaned with soap and water
3. Dry all vials and bottles
4. Pack and label reuse items
5. Sterilize items through autoclave or oven
47
Title: POLICIES AND PROCEDURES FOR ROUTINELY DETERMINING THE

LEVEL OF PATIENT SATISFACTION
Routinely determining the level of patient satisfaction helps to identify gaps

between the health care provider and patients or clients, thus improving the level of
patient satisfaction.
POLICY DESCRIPTION:
1. All OPD/ER clients and in-patients shall accomplished a feedback survey

questionnaires.
2. Evaluation form given to clients/patients shall be explained by the nurse.
3. The evaluation form consists of the whole Health Care Process from OPD/ER
admissions; Ward; General Services; Physicians and Nurses.
4. Analysis and evaluation shall be submitted to the management team/CQI
Committee.
5. Corrective action shall be taken immediately as problem arises.
6. Monthly summary report shall be accomplished and the results be presented
to the top management.
7. Provision of a suggestion box at the lobby and act upon feedback from
patients, families, visitors and communities.
48
PROCEDURES:
1.OPD nurse will provides/gives survey forms to clients at the area while waiting
for their schedule of check-up.
2.The head nurse will distribute survey questionnaires to patients/watchers for
them to accomplished prior to patient’s discharge.
3. Monthly consolidation of surveyed results and being and being presented
during staff meeting.
4. Corrective actions and recommendations will be taken immediately at
appropriate time.

Title: POLICIES AND PROCEDURES ON CODES OF PROFESSIONAL

CONDUCT
Responsible Party: Nursing Service Department
Regulatory/ Standard Reference: PHIC Benchbook
49
Policy no. _________
INTRODUCTION:
The Nursing Service Department has grievance committee that resolve

issues related to professional practice or to conflicts of interest.
POLICY DESCRIPTION:
The Nursing Service Department Grievance Committee shall compose of:

a. 5 Nursing Personnel
b. Have written incident report/complaints addressed to Chief
Nurse office.
c. Have written incident report/complaint and is submitted
through for proper assessment, evaluation and
recommendation.
d. Submit to grievance committee for
recommendation/appropriate action and forward to the
Chief Nurse for final approval.
PROCEDURES:
1. There shall be a written complaint.

2. The complaint must be noted by the Head Nurse &
Supervisor of the area.
3. The head nurse will issue memo to the involved person and
to answer the memo within 24 hrs.
4. The complained shall be tackled, first in the unit by the head
nurse and supervisor of concerned area.
5. Conference with the involved person as initial action done by
head nurse.
6. If the same complaint repeated by the same person,
elevation to Grievance Committee will follow.
7. Evaluate and analyze the complaints
50
8. Inform nursing personnel regarding the complaints against
him/her and advice to make a written explanation or incident
report.
9. Invite the complainant and the personnel to sit down and
discuss the problem/complaint.
10. Give disciplinary action appropriately.
11. Documentation is a merit and keep confidentially.
MONITORING:
Logbook / Written Complaints
DESSIMINATION:
Monthly meetings / Conferences
REFERENCE:
Nursing Manual
Hospital Manual of Operations
your care, their families and carers and the wider community.
c. Provide a high standard of practice and care at all times.
d. Be open and honest, act with integrity and uphold the reputation of your
profession.. As a professional, you are personally accountable for actions and
omissions in your practice and must always be able to justify your decisions. You
must always act lawfully, whether those laws relate to your professional practice or
51
personal life. Failure to comply with this code may bring your fitness to practice
into question and endanger your Registration.
*You shall not discriminate in any way against those in your care.
*You shall treat people kindly and considerately.
*You shall act as an advocate for those in your care, helping them to access relevant
health and social care, information and support.
*You shall respect people’s right to confidentiality.
*You shall ensure people are informed about how and why information is shared by those
who will be providing their care.
* You shall disclose information if you believe someone may be at risk of harm, in line
with the law.
You shall listen to the people in your care and respond to their concerns and preferences.
* You shall support people in caring for themselves to improve and maintain their health.
*You should respect and recognize the contribution that people make to their own care
and wellbeing.
* You should make arrangements to meet people‘s language and communication needs.
* You should share with people, in a way they can understand, the information they want
or need to know about their health.
*Ensure you gain consent before you begin any treatment or care.
* You shall uphold people to be fully involved in decisions about their care.
* You should be aware in the legislation regarding mental capacity, ensuring that people
who lack capacity remain at the center of decision making and are fully safeguarded.
* You should be able to demonstrate that you have acted in someone’s best interests if
you have provided care in an emergency.
* Maintain clear professional boundaries
52
* You should refuse any gifts, favors or hospitality that might be interpreted as an attempt
to gain preferential treatment.
* You should establish and actively maintain clear sexual boundaries at all times with
people in your care, their families and careers.
* You should work cooperatively within teams and respect the skills, expertise and
contributions of your colleagues. Work effective as part of a team.
* You should facilitate students and others to develop their competence.
* Delegate effectively. You should establish that anyone you delegate able to carry out
your instructions. You shall make sure that everyone you are responsible for is supervised
and supported.
* You should have the knowledge and skills for safe and effective practice when working
without direct supervision.
* You should recognize and work within the limits of your competence.
* You should keep clear and accurate records of the discussions you have, the
assessments you make, the treatment and medicines you give and how effective these
have been. You shall not tamper with original record in a way. Any entries you make
must clearly and legibly signed, dated and timed.
* You should give a constructive and honest response to anyone who complains about the
care they have received.
* You shall act immediately to put matters right if someone in your care has suffered
harm for any reason.
*You shall not abuse your privileged position for your own ends.
*You should ensure that your professional judgment is not influenced by any commercial
considerations; uphold the reputation of your profession.
53
POLICIES AND PROCEDURES ON CODES OF PROFESSIONAL

STANDARD
A.THE NURSE SHALL:

a. Perform functions and activities based on written job description within the scope of
nursing practice (RA 7164 Sec 27) and the Professional Code of Ethics.
b. Administer nursing care that must meet the criteria of appropriateness.
c. Use judgment and decision making skills in the selection of appropriate nursing
intervention that are patient-focused and goal oriented. They are based on scientific
principles and are implemented with compassion, confidence, and a willingness to
accept and understand the patient’s responses.
d. Assess critically or question if necessary all orders from other health care team
members and not simply follow blindly.
B. REPORTING AND ENDORSEMENT
a. All Nursing staff should report to duty 15minutes before time to receive endorsement.
b. Proper endorsement must be made before going off duty to be attended by both
incoming and outgoing shift.
c. No one should leave the area without a reliever.
54
C. COURTESY/DEPORTMENT
a. All Nursing Staff, regardless of position held must experience utmost courtesy, tact and
conduct required of a person of good public relation at all times.
b. Everyone is expected to be respectful to his/her supervisor, courteous to their equal
and considerate to their subordinates. They must be courteous and helpful to the
patients and their watchers and the general public.
c. Everyone should possess a spirit of cooperation and mutual assistance to promote
effective and efficient hospital operations.
d. Silence must be observed EVERYWHERE in the hospital most especially
during nighttime.
e. Conversation should be done in low voices.
f. Nobody should argue and/or discuss, compare, or criticize any diagnosis, condition of
the patient, treatment, prescription or other similar matters in front of the patient
and / or relatives.
g. Staff nurses should clarify doctor’s order properly and not in a dictating manner.
h. Complaints from patients and watchers should be referred to the immediate supervisor.
i. Everyone should refrain from gossiping or engaging in rumor mongering while on duty
and within the hospital premises.
D. ATTENDANCE:
a. All staff must report to duty 15 minutes before the time for endorsement.
b. Bundy cards should be placed on the rack provided for and should not be
brought outside.
c. All staff must inform the supervisor in case of emergency absences.
d. Absences must be reported immediately so that proper adjustment of assignment will
be done promptly and properly.
55
e. When circumstances cannot be avoided, ALL STAFF shall be required to go on duty
or extend duty hours or to extend duty hours depending upon the exigency of
services.
f. ALL STAFF are required to go on duty 8 hours per shift, 40 hours a week as per
civil service order. This also includes 15 minutes for break and 30 minutes for
meals.
g. Shifting hours: AM shift--- 7:00AM-3:00PM
PM shift--- 3:00PM-11:00AM
Night shift--- 11:00AM-7:00AM
h. Special request for off duty should be made one week before the planning of schedule
and granting of such will be based on a first come first serve requests.
E. UNIFORM:
a. ALL STAFF must report to duty with the prescribed uniform with identification card.
b. For Nurses, white uniform with white duty shoes: For Nursing Attendants, white
blouse, dark blue pants or skirts with black shoes.
c. Nurses must wear caps if in white uniform.
d. During Fridays and holidays and Night duty scrub suits may be allowed provided it is
prescribed scrub suit uniform. Printed scrub suits as blouse with white pants for
nurses and blue pants for nursing Attendants.
For Male Nurses, dark blue scrub suit with white pants.
e. Shoes must be clean and tidy. High-heeled shoes, step-in, sandals and slippers
are not allowed.
F. LOITERING-ALL STAFF, whether on or off duty, must refrain from making
socialization to other departments except when responding
to calls related to the nature of his/ her work or securing wages from the cashier.
56
G. INTOXICATING DRINKS
No hospital personnel is allowed to bring intoxicating drinks during tour
of duty nor stay inside the hospital premises under the influence of or smell of liquor.
H. SMOKING
Cigarette smoking is strictly prohibited inside and outside hospital premises.
I. FIREARMS/EXPLOSIVES
Nobody is allowed to bring firearms/explosives inside the hospital.
PROFESSIONAL PERFORMANCE:
a. PROFESSIONAL ACCOUNTABILITY
a.1. Nursing is primarily concerned with helping people to
respond adequately to health and illness situations in a manner
that would enable them to assume responsibility for health care.
a.2. It requires the application of knowledge and skills from ins-
titution to experience derived from the science and art of nursing
and related fields.
57
POLICIES AND PROCEDURES IN DETERMINING AND PRIORITIZING

PATIENT’S CLINICAL NEEDS
The Admission Care Services Unit is responsible for admitting

and providing initial care and treatment to all patients when
appropriate.
A. Elective patients seeking admission shall be seen and evaluated by the

physician on duty prior to issuance of admitting orders.
B. Emergency cases or cases requiring confinement are assessed and referred
to the Emergency Room or admitting section.
C .All elective minor surgery cases are scheduled except for brief
58
procedures like incision and drainage.
D. All emergency admissions and non-ambulatory patients shall be done at the Emergency Room after
prior and proper evaluation and examination by the ER Staff.
E. All OB cases in active labor; severe vaginal bleeding and other post partum complications shall be
admitted directly to DR.
F. All admitted patients presenting some deteriorating manifestations of illness or critically ill patients
must be given priority care.

Poblacion 4, Midsayap,Cotabato
Title: Policies and Procedures on Patients’ Rights -Rights to Consent
59
Responsible Party: All Doctors and Nurses and Health Care Providers
Regulatory/Standard Reference: PHIC Bench Book
Section: Medical and Nursing Department; Laboratory; X-ray
Part of communication in medicine involves informed consent for treatment and
procedures.
POLICY DESCRIPTION:
A patient must be competent in order to give voluntary and informed consent. Thus,
competent consent involves the ability to make and stand by an informed, freely made
decision. In clinical practice, competence is often equated with capacity. Decision-
making capacity refers to a patient’s ability to make decisions about accepting health
care recommendations. To have adequate decision-making capacity, a patient must
understand the options, the consequences associated with the various options, and the
cost and benefits of these consequences by relating them to personal values and priorities.
PROCEDURES:
 Adult patient and /or, when appropriate, patients’
families or designated surrogates, receive from their

physician information necessary to give in formed
consent prior to start of any care, treatment or service.
 Informed consent allows the patient to fully participate in
care, treatment or service decisions.
 Needed to obtained informed consent includes, but not
limited to the following:
. the patient’s diagnosis
60
. the general nature of the specific procedure and/or
treatment-its \purpose, whether it is experimental ,and they
name of the person performing the procedure or administering
the treatment.
. the benefits, risks, discomforts, side effects,
complications, and potential problems related to recuperation
associated with the procedure or treatment.
. the likelihood success
. the patient’s prognosis
if the procedure is not performed

. the reasonable alternative medical treatments.
DISSEMINATION:
Hospital order
Memos
Issuances
Meeting
BIBLIOGRAPHY/REFERENCES:
Hospital Administration Manual 2nd Edition
Nursing Outlook 1999
Copyright at 1999 by Mosby Inc.
162 Tilden, Virginia P.
Standard of Nursing Services
61
POLICY ON INFORMING PATIeNTS THE CAUSE OF ANY DELAY OF SERVICES
62
Purposes:
To inform clients a prompt and timely attention by qualified professionals upon
entry.
POLICY:
1. There shall be a time schedule posted visible on the departments concerned that includes the
following:
> ROD/ Scheduled officer of the day
> Consultant schedules
2. Requested laboratory examination/ Diagnostic procedures results shall be with the clients
upon entry on consultation date.
3. Clients should be informed of power interruptions that can cause delay in the electrical
operated machines.
4. Priority numbers given shall be explained to clients as “First come first serve’ basis.
5. There shall be an interpreter with clients during consultation (illiterate Christians, Lumads,
Muslims and other minorities, mentally ill, hearing impaired, deaf/mute) to avoid
communication problem.
6. Avoid over crowding/or unpredicted number of OPD patient census
that may cause the delay of services.
7. Unprepared patients for any requested special procedures ( like FBS,
and other blood chemistries,/ UTZ etc.) hampers the delivery of services.
8. The “LAW OF SUPPLY & DEMAND” ( health care provider v.s.
no. of patients, availability of meds., supplies, serviceable equipments versus no. of
patients, skilled and trained HCP to attend patients with special needs etc. ) will cause
also the delay of services.
63
9. Narrow passage ways/ obstruction of passage ways causes the delay of services.

POLICIES AND PROCEDURES ON HAMA/DAMA
1. Any request for DAMA/HAMA from clients/patients shall be referred to AP/ROD.

2. Advice patients/ relatives/ SOs on implications and consequences of DAMA/HAMA.
64
3. Always indicate DAMA/HAMA on patient’s chart.
4. DAMA/HAMA form request shall be accomplished and signed by patient/ relative and return
request to ward nurse on duty.
5. Patient’s chart should be checked for completeness before sending to the B.O.
6. DAMA/HAMA clients should be given with discharge instructions, health education/ health
counseling together with family members and inform follow-up check-up dates.
7. Clearance certificate of discharge/ discharge slip indicates settled bill duly accomplished
shall be presented to the ward nurse on duty and security guard.
8. See to it that all equipments/items previously issued to the patient are returned before the
discharge.

POLICIES AND PROCEDURES THAT ADDRESS PATIENT’S NEEDS FOR

RELIGIOUS COUNSELLING
POLICIES:
1.The Health worker shall coordinates with the chaplin
65
/priest/or other religious sectarian heads, other persons in the hospital, the relatives of the
patient to do his duties with Christ-like concern and willingness.
2. The HCP shall cooperate by extending the assistance needed to meet the spiritual
needs of the patient.
3. The HCP shall facilitates the services for the patient to fulfill
their spiritual needs.
4. The health worker shall also respect the religious beliefs and convictions of the patient.
5. The health worker shall not impose his own religious beliefs
and conflictions on the patient, let alone indulge in discussing
religious matters with the patient, especially if the patient is not psychologically and
physically disposed.
PROCEDURES:
1. The health worker should make himself/herself available to help the patient. His/Her
very presence can be a source of consolation and comfort, especially in his loneliness and
pain or in his depressed moments.
2. PRAYERS. The health worker should pray even privately and silently before he/she
undertakes his/her duty. He/She should also pray privately for his patient especially
when the patient is in serious or critical condition. he should take time out to pray with
the patient. The prayer should be simple, short, and meaningful.
3. VISITATION. The health worker can pay a visit to his patient
outside his duty hours, if possible. A short visit can be of help.
4. Sacraments. Christ by his life sufferings and death has gained for us the graces and
merits for our salvation. But the graces must be applied to us with our cooperation so that
they can be effective.
God channels His graces and merits to us thru the sacraments. For the sick, aged &
disabled, we concentrate on 4 Sacraments:
a. Baptism. Is indispensable for heaven. Ordinary baptism is
66
performed by the priest in the church for a healthy child.
Emergency baptism is done when an unbaptized child is
seriously or critically ill in danger of death. Anyone who
knows the procedure can administer it. The person can
administer it by taking a container and place water (clean
water) in it. Then pour water on the forehead of the
client to be baptized. While pouring the water pronounce
the words; “ I BAPTIZED YOU IN THE NAME OF THE
FATHER AND OF THE SON AND OF THE HOLY
SPIRIT. IT is a grave responsibility of the Health worker
to administer emergency baptism when situation calls for it/
or when no priest is available and the baby is dying.
a. Confession. Christ give the power to forgive sins. Fruits
of confession is, the sins are forgiven, soul is purified, peace of conscience is
restored, and we receive the grace to strengthen us in temptations.
c. Holy Eucharist/ Holy Communion. The person must be in
state of grace.( He is not conscious of having committed a
mortal sin).He must receive our Lord with the proper inten-
tion ( Love of Christ ). One hour fasting from solid food and drinks ( the sick are
exempted from this).
d. Anointing of the Sick for the seriously ill and critical. The fruit of the sacrament
is for forgiveness of venial sins and the temporal punishment due to sin, spiritual
comfort and consolation, spiritual strength we need to overcome temptations in
those critical moments of our life, and strengthening of supernatural life of grace.
67
Policies ON REFUSAL OF TEST OR TREATMENT
1.Mentally competent adults have the right to refuse treatment or

withdraw from treatment at anytime.
68
2. Health care provider shall not provide care to those clients
not giving consent or against their will to avoid being accused of battery.
2. Never leave the client alone, you are prone to risk of being
accused of negligence, or abandonment.

3. Make sure that the client understands, or is informed about the potential risks,
benefits, treatments and alternatives to treatment.

4. Patients/ Clients shall be informed about the consequences of refusing treatment and
encourage them to ask questions.

5. Patients/ Clients shall be assessed whether mental condition
is impaired.
6. There shall be signature of waiver for refusal of treatment.

CUSTOMER FEEDBACK SURVEY
OUT- PATIENT
Para sa kaayusan at ikabubuti ng serbisyo ng ating ospital, humihingi po kami ng kaunting panahon
upang masagot itong ilang katanungan.bilugan ang numerong nararapat na sagot sa mga
69
katanungan. Ang inyong sagot ay aming bibigyan ng malaking halaga upang magamit para sa
ikakaunlad at kagandahan ng serbisyo ng ospital.
Poor Fair Good Very Good Exellent

1.Malinis ang kapaligiran. 1. 2 3 4 5
2.Maayos ang pagtanggap at
pagasikaso sa mga pasyente 1. 2 3 4 5
3.Magalang ang pakikitungo
ng mga emplyado. 1 2 3 4 5
4.Mabilis ang paglabas ng resulta
sa laboratoryo 1 2 3 4 5
5.Nasiyahan ako sa paglilingkod ng
mga tauhan sa ospital 1 2 3 4 5
6.Malinaw ang pagpapaliwanag sa
nararapat gawin ng pasyente. 1 2 3 4 5
7.Malinaw bang pagpapatupad ng seguridad
ng ospital? 1 2 3 4 5
Mungkahi para sa kaayusan at katiwasayan ng ating ospital:

___________________________________________________________________
___________________________________________________________________
Pangalan:______________________________
Petsa ng pagpacheck-up:_____________________

CUSTOMER FEEDBACK SURVEY

Para sa kaayusan at serbisyo ng ating ospital,humihingi po kami ng kaunting panahon upang
masagot itong ilang katanungan. Bilugan ang numerong nararapat na sagot sa mga katanungan.
ang inyong sagot ay aming bibigyan ng halaga upang magamit para sa ikakaunlad at kaganda
han ng serbisyo ng ospital.
70
IN-PATIENT’S Total customers=
1 2 3 4 5
Poor Fair Good V.Good Excellent
1.Nakita ba kayo ng doctor pagpsok ninyo sa ospital? 1 2 3 4 5
2. Malinis na higaan at kapaligiran 1 2 3 4 5

Maasikaso, magalang,ang mga tauhan ng ospital 1 2 3 4 5
3. Malinis at masustansya ba ang ibinibigay na pagkain sa
ospital.? 1 2 3 4 5
4. Mabilis ang paglabas ng rasulta sa laboratoryo. 1 2 3 4 5
5. Naibibigay bas a tamang oras ang tamang gamut sa
tamang pasyente? 1 2 3 4 5
6. Malinaw ba ang pagpapaliwanag sa nararapat 1 2 3 4 5
gawin ng pasyente?( take home meds.,philhealth ,chip,
billing, pharmacy)
7. Malinaw ba ang pagpapatupad ng seguridad 1 2 3 4 5
ng ospital?
Mungkahi para sa kaayusan at katiwasayan ng ating ospital

__________________________________________________________________________________________
__________________________________________________________________________________________
Pangalan ng pasyente/relative:____________________________________________
Petsa ng pagkaospital:_________________________________
Kuarto(room)____________________________________

SUMMARY OF CUSTOMER FEEDACK SURVEY PART II
B. Out – patients Total _____ customers.

1 2 3 4 5
Poor Fair Good V.Good Excellent
71
1. Malinis na kapaligiran. 1 2 3 4 5
2. Maayos ang pagtanggap at
pag-aasikaso sa mga pasyente. 1 2 3 4 5
3. Magalang ang pakikitungo sa
mga empleyado. 1 2 3 4 5
4. Mabilis ang paglabas ng resulta
sa laboratoryo. 1 2 3 4 5
5. Nasiyahan ako sa paglilingkod ng
mga tauhan sa ospital. 1 2 3 4
5
6. Malinaw ang pagpapaliwanag sa
nararapat gawin ng pasyente. 1 2 3 4 5
7. Ano ang inaasahang bagay na hindi
pa naibigay ng ating ospital. 1 2 3 4 5
8. Karagdagang mungkahi para sa kaayusan
at katiwasayan n gating ospital. 1 2 3 4 5

Customer Survey OPD/In- Patients
1. Nakita ba kayo ng doctor pagpasok nyo sa hospital? N=

Poor Fair Good Very Excellent
Number
Percent
72
2. Maayos ang pagtanggap at pag – asikaso sa mga pasyante. N=
Number
Percent
3. Magalang ang pakikitungo ng mga empleyado. N =

Number
Percent
4. Mabilis ang paglabas ng resulta sa laboratoryo. N =

Number
Percent
5. Nasiyahan ako sa paglilingkod ng mga tauhan sa ospital. N=

Number
Percent
6. Malinaw ang pagpapaliwanag sa nararapat gawin ng pasyente.

Number
Percent
73
POLICIES AND PROCEDURES INDICATING EXTENT OFDUPLICATE
ASSESSMENT AND TREATMENTS PERFORMED BY TRAINEES
POLICIES:
1.All trainees shall undergo orientation on Hospital Policies/ Nursing Policies
and procedures.
2. All nursing staff shall carry doctor’s orders indicating done or undone
to all ordered labs. procedures and / medications and treatments bearing
their names and signatures to avoid duplication of work by the trainees.
74
3. The nurse should countersigned the charting of a trainee to attest that
the information is accurate and authentic.
PROCEDURES:
12. Assign the trainee to 1-2 patients/shift.
13.Let the trainee perform simple procedures with supervision.

14.Increase the number of patients/shifts to a trainee who has
the potential skills & knowledge in the performance of
procedures.
4. Trainees with case of medication errors and “ near miss”
may not be given an assignment of more than 2 patients/shift.

POLICIES ON PATIENT’S EDUCATION
1. The nurse shall assessed the educational needs of each client/patient

and document these in his/her patient’s record which includes but are
limited on the following:
a .patient’s/client’s beliefs and values
b. patient’s/client’s literacy
c. patient’s/client’s educational level
75
d. patient’s/client’s language
e. patient’s/client’s motivations and emotional barriers
f. patient’s/client’s physical and cognitive limitation
g. patient’s/client’s willingness to receive information.
POLICIES ON FAMILY EDUCATION

1. There shall be a written evidence that the nurse assesses the educational needs of the family
which include but are not limited on the following:
a. Family’s beliefs and values
b. family’s literacy
c. family’s educational level
d. family’s language
e. family’s motivation and emotional barriers
Title: POLICIES AND PROCEDURES THAT ADDRESS PATIENT’S
NEEDS CONFIDENTIALITY
Section: Medical Staff / OPD/ER / Ward / OR/DR / Laboratory / Medical Record

Section
Responsible Party: All department concerned
Regulatory /Standard Reference:PHIC Benchbook
Date Approved: December 12, 2009
Effectivity Date: January 16, 2010
1.PURPOSE:
To ensure privacy and protection of personal records and data and to assure
that the basic rights of human beings for independence of expression,
decision and action and human relationships are preserved for all patients.
11.POLICY:
Confidentiality is the right of an individual to have personal, identifiable medical information kept private
. Patient confidentiality means that personal and medical information given to a health care provider will not
be disclosed to others unless the individual has given specific permission for such release.
It is the policy of DADPFH to respect the individual rights of all persons that come to this facility for
care. The patient has the right, within the law, to personal privacy, as manifested by the right to:
1. Refuse to talk with or see anyone not officially connected with the
76
hospital, including visitors, persons officially connected with the hospital but who are not
directly involved in his care.
2. Wear appropriate personal clothing and religious or other symbolic
items, as long as they do not jeopardize safety or interfere with diagnostic procedures or
treatment.
3. To be interviewed and examined in surroundings designed to assure
reasonable audiovisual privacy. This includes the right to have a person of one’s own
gender present during certain parts of a physical examination, treatment, or procedure
performed by a health professional of the opposite sex; and the right not to remain
disrobed any longer than is required for accomplishing the medical purpose for which the
patient was asked to disrobe.
4. Expect that any discussion or consultation involving his/her case will be
conducted discreetly and that individuals, not involved in direct care, will not be present
without permission of the patient.
5. Have his/her medical record read only by individuals directly involved in
treatment or monitoring of quality, and by other individuals only on written authorization by
the patient or that of his/her legally authorized representative.
6. Expect that all communications and other records pertaining to his
care, including the source of payment for treatment, be treated as confidential.
7. Expect that information given to concerned family members or significant other legally
qualified person, be delivered in privacy and with due consideration of confidentiality.
8. Request transfer to another available room if another patient or visitors in that room are
unreasonably disturbing to said patient.
9. Be placed in protective privacy and/or be assigned an alias name when considered necessary
for personal safety.
111.PROCEDURES:
1. The privacy & rights of an individual can be severely compromised by information

from overhead conversation.
2. Patient’s documents (chart, diagnostic results ) must be kept in secured location
to prevent access by unauthorized individual.
3. It is not allowed that results and patient’s diagnosis be relayed via telephone
so that confidentiality is not compromised
4. Never allow watchers and patients to read the chart.
5. The nurse is not in position to reveal any information regarding the patient’s
condition.
1V. MONITORING
Logbook
V. Dissemination
Meetings
Conferences
77
VI. References
Standard of Nursing Practice

Title: POLICIES ON PATIENT INVOLVEMENT IN CARE DECISION MAKING
Responsible Party: Medical/Nursing Service

Section: OPD/ER, General Ward, OR/DR
78
Patient’s involvement in care decision making concerning his/her care is very important
aside from respecting the patient’s rights, but uplifting as well the morale and values of a
certain person.
It is the responsibility of the health care provider to discuss any treatment/procedure
planned and encourage patient involvement in decisions especially to a competent patient.
POLICY DESCRIPTION:
There shall be an advance directive or the so called living will, that specifies medical
treatment for a competent patient, should he or she becomes unable to make decisions.
Ex. DNR orders give you permission not to attempt resuscitation.
Note: Competent patient is able to make rational decisions about his or her well being.

Title: POLICIES ON FAMILY INVOLVEMENT IN CARE DECISION MAKING
Responsible Party: Physicians / Nurses / Family Members / Social Services
PURPOSE:
To establish policy and procedure concerning family involvement in care decision

making and withholding or withdrawal of life-sustaining treatment at
DADPFH.
POLICY DESCRIPTION:
1. The family has the right to determine which treatment options the patient will
accept or decline, including withholding or withdrawal of life-sustaining
79
treatments to an incompetent patient.
2. Life-sustaining treatments my be withheld or withdrawn:
a. upon verbal oral or written request of a competent patient. Verbal
directives from the family and written requests require a notary.
b. As specified by a valid advance directive when a patient lacks decision-
making capability.
c. At the request of the Surrogate Decision Maker on behalf of an
incompetent patient who has a previous advance directive.
DEFINITION:
1. Life-sustaining Treatment- medical care procedures, or interventions, which

when applied to patient with a terminal illness, would have little or no
effect on the underlying disease, injury or condition in which would
serve only to delay the timing of death. This may include, but is not
limited to, resuscitation, artificial nutrition and hydration, mechanical
ventilation, and dialysis.
2. Advance directive- an oral or written statement made by a competent patient,
which states his/her preferences regarding medical treatments,
including but not limited to, life-sustaining treatments or which
designates a surrogate decision maker who will make decision
regarding medical care in the event the patient is unable to do so.
3. Surrogate Decision Maker- refers to a person who is authorized by this policy,

consents to withholding or withdrawal of life-sustaining procedures on
behalf of a patient who lacks decision-making capacity.
RESPONSIBILITIES:
1. Nursing Services will:

a. ensure copy of the advance directive is placed in the medical report;
b. notify the attending 0physician if patient has executed an advance
directive;
c. consult social services if the patient wishes to execute an advance
directive or change an existing directive or wishes to obtain additional
information;
d. d. enter appropriate activities or discussion on advance directives as a
condition to receiving care.
80
2. Social Services will:
a. upon notification from nursing, meet with the patient to provide
information regarding advanced directives and or answer questions.
b. If the patient wishes to execute or change an advanced directive, the
social worker shall assist the patient in completing the directive, and
c. Notify the patient’s nurse that the patient has executed a directive.
3. Attending Physician:
a. assists patients in making decisions about advance directives by
providing information necessary to make an informed decision
b. review advance directive with patient upon admission or at significant
change in patient’s condition, or at patient’s request.
c. Documents reviews of advance directives in the medical record.
1.The nurse shall respect patient’s /family values, religion and cultural
preferences and practices is evident.
1.1. Pastoral services are provided based on the spiritual
beliefs of the patient and family.
1.2. The patient’s rights to self-determination and choice are
respected and accommodated.
1.3. Advance directives, do not RESUSCITATE, waiver,
Living Will if any are respected.
1.4. Patient and family choices to donate organs and other
tissues are supported through provision of relevant
information in accordance to statutory laws, rules and
regulations.
2. There should be a written assessment of appropriate intervention to alleviate
the patient’s pain and discomfort according to wishes of patient and family
and re-assessment are evident.
81
2.1.pain assessment, intervention and evaluation are monitored
and recorded.
2.2. Personal hygiene is rendered based on patient’s need.
2.3. Nutritional assessment and risks are identified and nutritional
needs are provided such as feeding and hydration.
2.4. Interventions address patient and family’s psychosocial,
Emotional, spiritual and cultural concerns.
3. There should be a place designated for patient’s family to stay.
4. The patient and the family are involved in care management and decision in order
to have knowledge and able to continue the care in their home.
Title: Policies and Procedures on Involvement of Patients and Families in Making Care Decisions on
Ethical Issues
Section: Medical / Nursing Department
Responsible Party: All Doctors and Nurses
I. PURPOSE:
To define the involvement of patients and families in making care decisions on ethical issues
based on the code of ethics and patients rights.
II. POLICIES:
A. Right of Unconscious Patients:

1. Must have always companion/watcher.
2. The immediate family of unconscious /retarded/incapacitated will have the
right to decide over the fate of this patients. In case immediate family is not available, the
Resident on Duty will have the right to decide over the fate of the unconscious/
comatose patient.
3.If the legally incompetent patient can make rational decisions, his/her decisions must be
respected and he/she has the right to forbid the disclosure of information to his/her legally
82
entitled representative.
B. Right to Dignity:
1. The patient dignity and the right to privacy shall be respected at all times in medical care and
teaching as shall his/ her culture and values.
2. The patient is entitled to relief of his/her suffering according to the current state of knowledge.
3. The patient is entitled to human terminal care and to be provided with all available with all
available assistance in making dying as dignified and comfortable as possible.
C. Right to appropriate care based on religious and personal beliefs etc.

1. The patient has the right to receive or to decline spiritual land moral comfort including the
help of a minister of his/her chosen religion.
2.The hospital has established policies, processes that respect and support patient and family in
participating in the care decision and care process through adequate information on
refusal or discontinuance of treatment or withholding life sustaining of treatments as
discussed by the physician.
111. PROCEDURES:
1. Physicians or nurses will first identify and organize accurately the patient’s data, including the
assessment , laboratories, treatment to be done and the medications needed; then the
physician and nurse will explain to the patient the treatment or care that will be rendered
during his/her hospitalization.
2. Assess patient condition, if needs referral to other health facilities, prepare documents.
3. Explain the procedures to be done at the level of their understanding the benefits, risk, and
potential consequence.
5. Secure consent/waiver for any major or minor surgery or any procedure.
6. For unconscious the nearest kin will be the one give consent.
7. Document on the patients chart.
IV. MONITORING:
Nursing Audit
V. DISSEMINATION:
Meetings and Conferences
VI. BIBLIOGRAPHY:
World Medical Association Declaration on the Rights of the Patient.
83
POLICIES AND PROCEDURES THAT ADDRESS PATIENT’S NEEDS FOR COMMUNICATION
POLICIES:
1. Always ascertain the level of understanding of patient needing
communication.
2. Records all subjective reactions, & objective observations, attitudes,
moods and mental status of the patient.
PROCEDURES:
84
1. Make & keep eye contact when communicating with patient.
2. Use the patient’s proper name.
3. Tell the patient the truth during the time or on during the stage of bargaining
and acceptance.
4. Use language that patient can understand.
5. Be careful of what you say.
6. Be aware of your body language.
7. Always speak slowly.
8. Always speak clearly & face the patient.
9. Allow time for the patient to answer.
10. Act & speak in a calm, confident manner.

POLICIES AND PROCEDURES ON PRE-OPERATIVE ASSESSMENT

e.g. CP CLEARANCE AND PRE-ANESTHETIC ASSESSMENT
POLICIES:
1. All clients/patients scheduled for surgery whether emergency or elective

must have a properly signed informed consent for surgery and anesthesia.
85
2. High risk patients like aged clients, clients with some medical complications
must be referred to medical internist for cardiopulmonary clearance okayed for O.R.
3. Clients must be prepared psychologically.
Procedures:
1.All headings of patient’s chart shall be filled in prints accurately

complete and legibly written.
2. Pre-operative checklist should be properly and completely accomplished.
3. Any sensitivity to the drugs and foods should be clearly specified in the patient’s chart.
4. Initiates teaching appropriate to patient’s needs.
5. Involves the family during interview.
6. Verifies understanding of surgeon specific pre-operative orders (e.g. bowel prep’n
pre-operative showers, attached prosthesis, etc.)
7. Explains phases in peri-operative period and expectations.

8. Answers patient’s and family’s questions.
9. Develops plan of care.
10. Identification wrist band must be placed to patient’s wrist.
86
Title: Policies and Procedures on Conducting Initial Assessment in

Efficient and Systematic Manner
Responsible Party: Medical / Nursing Service Department
Section: OPD/ER, LR/DR
Policy No. _________
Nursing assessment must be done in a systematic manner based on

nursing model. Initially it starts from the nursing process which starts from
nursing assessment in which the nurse shall carryout complete and holistic
nursing assessment of every patient’s needs, regardless of the reason they
encounter. Assessment includes physical examination, nursing history,
psychological and social examination.
POLICY DESCRIPTION:
The hospital nursing administrator shall be responsible in assigning
87
appropriate professionals to perform and coordinate sequence patient
assessment to client to reduce waste and unnecessary repetition.
Medical and nursing assessment shall be responsible in documentation in
the patient’s medical or nursing records, which can be accessed by all members
of the health care team.
DEFINITION:
Nursing assessment- is the gathering of information about patient’s

physiological, psychological and spiritual status.
Nursing process – chronologically composed in order the assessment,
planning, intervention and lastly the evaluation.
All Nursing Staff are responsible in gathering the patient history, physically,
psychologically, sociologically and spiritually.
The responsibility encompasses promotion of health, prevention of illness,
alleviation of suffering and restoration of health.
ETHICAL PRINCIPLE:
All nurses recognize the primary responsibility to preserve health at all

cost.
PROCEDURES:
1. Record the observations and measurement of signs and symptoms observed.

2. Document assessment using nursing assessment tools.
3. Identify the patient’s nursing problems thru taking a nursing history.
4. Taking psychological and social examination that includes:
1. client’s perception
2. emotional health
3. social health
4. physical health
5. spiritual health
6. intellectual health
88
5. Some technique used may include inspection, palpation, auscultation and
percussion in addition to the v/s of temp., BP, PR, RR, further examination of
body system such as cardiovascular or musculoskeletal system.
6. Taking a nursing history prior to PE, allows a nurse to establish rapport with
the patient and family.
Elements of history includes:
. health status
. course of present illness including symptoms
. current mgt. of illness
. past medical history including family’s medical history
. social history
. perception of illness
MONITORING:
Decrease incidence of unnecessary repetition

Decrease incidence of morbidity/ mortality case
Increase quality work productivity
DISSEMINATION:
Orientation
Meetings
Memos
REFERENCE:
Nursing Outlook July-August, 1999 by Mosby Inc.
89
Title: Policies and procedures that address patient’s needs for security
Section: Admin. Department / Medical and Nursing Department
Responsible Party: All Hospital Staff
I. INTRODUCTION:
To provide safe and quality service.
II. POLICIES DESCRIPTION:
Protection of patients possessions from theft or loss.
Protection of patient from physical assault (e.g. vulnerable patients are infants, children and elderly)
1. Nurses and HCP shall be responsible for providing patient’s care and security.
2. HCP within the patient’s care unit should likewise provide an environment conducive to
recovery.
3. Restraints should not be applied to clients/ patients without the doctors order. Note: confining a
client/patient in bed is a form of imprisonment.
90
4. Nursing service plays a vital role in ensuring the safety, confidentiality and Restraints
completeness of nursing records of the in-patient clinical records.
5. There shall be a security guards designated at entry points of the hospital.
III. PROCEDURES:
1. Regular inspection for defects and cleanliness of equipments, such as stretchers, wheelchairs and beds
and other instruments can prevent accidents.
2. Fire exits & other exit points are being installed and keep the patient oriented and informed for any
safety and precautionary measures.
3. In cases where a patient is in danger of hurting himself or others, the nurse can apply the necessary
restraint with doctors permission.
4. Clients admitted as medico-legal cases are being logged in at security logbook for security purposes.
5. Patient’s clinical records are kept in place that ensures safety, confidentiality and completeness.
IV. MONITORING:
Logbook
V. DISSEMINATION:
Meetings/Conferences
VI. REFERENCE:
Standard of Nursing Practice
91

Title: POLICIES ON FAMILY INVOLVEMENT IN CARE DECISION

MAKING, RIGHTS OF UNCONSCIOUS PATIENTS, RIGHT TO DIGNITY,
RIGHT TO APPROPRIATE CARE BASED ON RELIGIOUS AND RIGHT
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TO APPROPRIATE CARE BASED ON RELIGIOUS AND PERSONAL
BELIEFS ETC.
Responsible party: All Doctors and Nurses and other Health Care Providers
Regulatory/Standard Reference: PHIC Bench Book
Section: Medical and Nursing Department, Laboratory, X-ray, Dietary
POLICIES:
1. The nurse shall treat the patient and the members of the family with respect
and dignity. Studies shows that social value placed upon a upon a person
determines how he/she is treated when in times of critical condition (uncons-
ciousness).
2. The HCP should not only make the family physically comfortable but also is
in a privileged position to help the patient and the family with one of the
most difficult and painful parts of life.
3. The HCP should offer spiritual services based on their religious and personal
beliefs.
PROCEDURES:
1. Nurse-family interactions is important to win their confidence.

2. Educate the members of the family regarding the use of side rails, restraints,
etc., which are instituted to the unconscious or sedated patients.
3. Inform the family members if they wish an spiritual/religious services based on
religious and personal beliefs.
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POLICIES AND PROCEDURES FOR SAFE AND EFFICIENT

DIRECTION OF PATIENTS, THEIR FAMILIES, VISITORS AND
STAFF TRAFFIC
POLICIES:
For Patients/Families
1. There shall be a printed IEC materials, hospital policies & house rules,
given to patients/families upon admission as a part of their orientation.
For Visitors
1. Printed reading materials or IEC shall be provided at security guard or
entrance for information dissemination.
2. Signages must be visible at designated areas.
Staff traffic
1. All HCP involved in the case of clients/ patients shall undergo orientation/
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seminar regarding policies and procedures for safe and efficient direction.
2. IEC, printed materials regarding hospital policies and procedures shall
be distributed in every department.
3. Shall review and re-evaluate the effectiveness of the policies and procedures
for the safe and efficient direction of families & visitors.
PROCEDURES:
1.SIGNAGES are being placed visible in all directed areas.
2.Readable, understandable IEC & reading materials regarding hospital policies/

house rules are being distributed to all clients/patients.
3. Any revision and additional approved hospital policies/house rules
are to be distributed in all department for updates of information.
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POLICIES AND PROCEDURES REGARDING TELEPHONE ORDERS
POLICIES:
1. Only in case of extreme emergency and when no other ROD or medical interns
is present should a nurse receive a telephone orders.
2. The orders should be read back to the doctor to ensure that it has been correctly
received.
3. The nurse should write the name of physician together with her own name and
note the time the order has been given.
4. The ordering physician should sign the order as soon as he arrives.
5. Clear hospital policies with regards in receiving of telephone orders should be
established to avoid misunderstanding and legal risks.
PROCEDURES:
1. Verify patient’s chart for the ROD or nurse to write the orders thru telephone.
2. Read it back to the ordering physician what has been written on the order sheet.
3. Indicate date , time, and signature of the ROD/Nurse receiving the order.
4. Proceed to carrying out of orders process.
5. Let the ordering physician sign his/her telephone orders upon his/her next visit.
96
6. Remember that receiving telephone orders are based on established hospital policies.
Title: Policies and Procedures On Drug Administration

Responsible Party: Medical /Nursing Service Department/ I.V. Therapist nurse,/
Pharmacy Therapeutic Committee, X-ray Department
Regulatory / Standard References: Phic Benchbook
Section: Medical Staff/ Nursing Staff, IV Therapist, Pharmacist, X-ray Technicians
Policy No.__________
Date Issued:_________
The (10) Golden Rule in administration of drugs has been practiced in the field of nursing
profession. This reduces the incidence of medication errors thereby quality services and safe
practice will be delivered, thus making our clients feel comfortable, safe and confident to our
care.
POLICY DESCRIPTION:
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Medication shall be administered only by persons authorized by and within the guidelines
of Hospital Policy Manual .Registered Nurses may administer medications as established by
Nursing Policies and institutional protocols.
The (10) Golden Rule in Administration of Drugs shall be carried by all staff concerned
in a timely, safe, appropriate and controlled manner as follows:
1. Administer the right drug.
2. Administer the right drug to the right patient.
3. Administer the right dose.
4. Administer the drug to the right route.
5. Administer the right drug to the right time
6. Document each drug you administer.
7. Teach the patient about the drug he is receiving.
8. Take the complete patient drug history. There is risk of adverse reaction when
a number of drugs are taken or when a patient is taking alcoholic drinks.
9. Find out if the patient has any drug allergies.
10. Be aware of potential drug-drug and food interactions to protect your patient
and your license & following these guidance for avoiding for avoiding
medication errors.
RIGHTS AND RESPONSIBILITIES:
All hospital medical/ nursing including concerned staff shall be responsible in all
parameters in the administration of drugs as further defined in nursing policies, Pharmacy and
Therapeutic Committee policies and other department policies.
GUIDING PRINCIPLE:
Safety and quality of care given are reflected in the chart. It is imperative that the nurses
notes must be clear and up to date. What is not charted, has not been observed nor done.
“Anything that was not documented was not done”
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PROCEDURES:
1. Verify doctor’s orders that is not clear to you or not legibly written.
2. Read the chart, re checked pt’s name on kardex and medication ticket
properly transcribed from doctor’s orders to medication sheets.
3. Double check or review the chart what was the ordered medications before
administering the drugs.
4. Call the patient’s name and explain that the drug you are about to administer
was the one ordered by his/her AP or ROD.
5. At least you stay 5-15 minutes after administration of drugs to observe the
immediate reactions, adverse effects, and toxic effects of drugs.
6. Any drug reactions will be reported immediately to supervisors or senior NOD
then to ROD/AP.
7. Color coded medication tickets will help to minimize medication errors
on drug administration.
8. Pediatric cases differ their dosage, rates of IVF, and amount of blood to be
infused from adult cases in drug administration, IVF, and blood components.
9. In case of medical errors, an incidental report is being required to be
submitted within 24 hours to immediate supervisor/chief nurse, administrator
and chief of hospital.
10. Verify the drugs ordered whether in tablets, vials, ampoules, syrups, jelly-like
form, stick drugs, additives on IVF, and other forms of drugs.
11.Never leave oral medications, and other treatments at patients bedside.
12. Document everything that everyone should know.
DEFINITION:
Sentinel Event- refers to injuries caused by medical management ( and not necessarily the
disease process)that either caused death, prolonged hospitalization or produced a
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disability during time of confinement or the time of discharge.
MONITORING:
Incidental Reports
Logbooks for ADE’s and sentinel event
DISSEMINATION:
Hospital Order
Memos
Nursing Policies and Protocols
Hospital Protocols
Orientation Continuing Education
REFERENCES:
Nursing Manual
Hospital Manual of Operations
100
101
Title: POLICIES AND PROCEDURE FOR RESOLVING ETHICAL ISSUES

ARISING FROM PATIENT CARE OR REPORTS OR RECORDS OR
RESOLUTION OF ETHICAL DELIMA ARISING IN THE COURSE OF
PROVIDING CARE
POLICY DESCRIPTION:
Ethical dilemma occurs when there are conflicting moral claims. A situation that
requires an individual to make a choice between two equally unfavorable
alternatives.
2.The decision made often has often to be defended against those who disagree with
it.
3. Documentation help in resolving ethical issues thereby meeting the professional
& legal standards.
4. Documentation provides a clear picture of the status of the client, the actions of
the nurse, and the client’s outcomes.
5. Nursing documentation clearly describes an assessment of the client’s health
status, nursing interventions on client’s outcomes, a care plan or health plan
reflecting the needs and goals of the client; needed changes to the care plan,
information reported to a physician and advocacy undertaken by the nurse on
behalf of the client.
6.Within the nurse-client relationship, the nurse must apply nursing knowledge,
skills and judgment according to professional standards.
7. The nurse documentation may be used as evidence in legal proceedings such as
law suits, coroners, inquests, and disciplinary hearings trough professional
regulatory bodies. In court law, the client’s health record serves as legal record of
the case or service provider. Nursing care and the documentation of that care will
be measured according to the standard of a reasonable and prudent nurse with
similar education and experience in a similar situation.
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8. The chief nurse may investigate or collect data from the chart and to the
concerned staff. The chief nurse may also ask questions from clients satisfaction
of care provided by the concerned staff to resolved the issues.
PROCEDURE:
1. There shall be a written complaint.

2. The complaint must be noted by the head nurse and supervisor of the area.
3. The head nurse will issue memo within 24hrs.
4. Incident report by the person concern ( student, CI, Staff nurse) to be submitted to
the department head.
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POLICIES AND PROCEDURES ON AccESSING &REFERRING
PATIENTS TO APPROVED EXTERNAL PROVIDERS. (OUTSDE
LABORATORIES, IMAGING,ETC.)
POLICIES:
1. There shall be an accomplished referral slip by the physician and give it to the
accompanying nurse/or ambulance nurse the duplicate copy.
OPTIONS: The physician may coordinate with the other health facilities for
referral purposes.
2. The nurse shall arranged the necessary requirements for ambulance conduction
of the patient.
3. Bring the patient’s chart to the billing section/ cashier.
4. If the patient is unable to pay part or full his bill, refer patient to the DSWD.
5. There shall be an accompanying health care provider during ambulance
conduction with a copy of referral slip, laboratory results or requests for
Laboratories and diagnostic procedures for endorsement.
PROCEDURES:
1.Verify doctor’s order at the chart.

2. Assessed the client/patient level of consciousness (includes the stability of v/s)
3. Prepare emergency kits and other special needs for emergency procedures.
4. Check the chart discharge instructions and signed clearances from billing/
cashier.
5. Get the copy of referral slip/laboratory requests, & diagnostic procedures
accomplished by the ROD/AP.
6. Review and rechecked all documents ready for the transfer.
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Title: PROCEDURES ON CASE CONTAINMENT OF NOSOCOMIAL INFECTION

Responsible Party: All Members of Infection Control Committee
Section: OPD/ER, LR/DR, Ward, X-Ray, Dental, Laboratory
PURPOSE:
To prevent the spread of nosocomial infection during client’s/patient’s confinement in the

hospital, and the risk of hospital workers in acquiring infections through occupational
exposures.
DEFINITION:
1. Case Containment- means prevention of spread of infections.( e.g. reverse isolation,

prophylaxis of exposed personnel, vaccination, immunization ).
2. Nosocomial Infection- means hospital acquired or hospital associated
- infection that are caused by microorganisms and acquired within the hospital.
- may be present on admission or acquired while in the hospital or developed after
discharged.
PROCEDURES:
1. Once the patient/client develops hospital acquired infection ( nosocomial infection)

all items used and contaminated items, surfaces must be properly cleaned and
disinfected with antiseptics preferred by the infection control nurse or ICC guidelines
of disinfection.
2. Specified single room or isolation rooms are used exclusive only for cases of noso
comial infected client.
105
3. Discharges of confined clients are to be sent to laboratory for Culture and sensitivity
for future references.
4. Always use proper protective devices / equipment supplied by the institution and
discard those disposable items properly.
5. All contaminated surfaces shall be damped-dusted with antiseptic solution preferred

by the ICC.
6. Fumigation/or Terminal disinfection is being done to rooms occupied by patient

or client with nosocomial infection after their discharge.
7. The room is closed/sealed for 2-3 days exposure after disinfection.
8. Doors and windows will be opened for 1 day aeration exposure.
9. Used room is highly recommended for room culture to ensures cleanliness and
zero microbes ready for the next occupant.
10. Proper transport care on used items/ contaminated items properly labelled
coded red properly endorsed to department concerned for precautionary
measures in cleaning, washing, and disinfecting procedures.
11. There shall be a program for immunization, vaccination for staff who are at risk of
acquiring infections through occupational exposures to prevent and manage infections in
hospital staff.
MONITORING:
Logbook for Reporting cases
Decrease the Incidence of Spreading Nosocomial Infection
Decrease Incidence of Morbidity/Mortality Cases
DESSEMINATION:
Hospital Order
Memo
Orientation
106
REFERENCES:
World Health Organization Global Strategy for Containment of Antimicrobial

Resistance. WHO/CDS/CSR/DRS/2001.2
ICC Manual

POBLACION 4, MIDSAYAP ,COTABATO
POLICIES AND PROCEDURES FOR HIRING OF STAFF
RECRUITMENT, SELECTION FOR APPOINTMENT AND PROMOTION

> Is the process of guiding an interested Registered Nurses an available opening
in nursing position.( Article VI. Sec. 23 Civil Service Rules & Laws ) on
recruitment and selection of employees. “ Opportunity for government shall
be open to all qualified citizens and positive efforts shall be exerted to attract
the qualified to enter the service”
POLICIES:
1. An applicant must be:

a. a Filipino citizen.
107
b. a graduate from an accredited school or college of nursing.
c. have passed the Nurse’s Board Examination
d. have current PRC License I.D. to practice nursing in the Phil.
e. a Civil Service Eligible by 1080
f. in good physical and mental condition.
PROCEDURES:
1. Advertise the proposed items to be opened soon to all R.N’s and potential
applicants for screening.
2. Post the list of requirements on the magazine or in the public bulletin in 1-2
months per institutional policy.
3. Reviews and accepts applicants requirements.
4. Post the screening date.
5. Only qualified applicants will be accepted for screening after they have
received appointment for examination.
6. After the exam, inform the examinees to wait for the appointment scheduled
date for personal interview / and screening with confirmation letter.
7. Successful applicants will be informed by IPHO-HR for other requirements
made in acceptance with the provision of CSC Laws & Rules and the
compensation & position Classification by Bureau of Appointments
should be prepared in the prescribed form duly signed by the
recommending officer, the Chief of the Hospital, the appointing officer
IPHO and/or the DOH.This shall be submitted to the Civil Service
Commission for approval.
Reference:
Hospital Nursing Administration Manual
Second edition
108
POBLACION 4, MIDSAYAP, COTABATO
Title: POLICIES AND PROCEDURES FOR CREDENTIALING AND PRIVILEDGING

OF STAFF
Responsible Party: Human Resource Management /Screening Committee

Regulatory / Standards Reference: PHIC Benchbook
Section: Nursing Department
Policy No.___________
Date Issued: ____________
PURPOSE:
109
To establish system and processes in the Nursing Service Department for the
recruitment, hiring, selection, appointment, and promotion of human resources in
accordance with the statutory laws and regulations and institutional policies and
procedures.
POLICY DESCRIPTION:
The Nursing Services Department shall have an effective process for gathering,
verifying and evaluating the nursing staff credentials. The Nursing Services Department
has defined criteria and processes to ensure that the clinical staff knowledge and skills are
consistent with the patient’s needs.
GUIDING PRINCIPLES:
1. There shall be a written policies and practices provided by the employee:

a. A job description which makes it possible to determine the satisfaction
offered thru a particular position.
b. A scale weighing his qualification for a position in light of the
written specifications.
c. A bases for study of conditions of employment which following verbal by
employing officer is a safeguard against the possibility of
misinterpretation.
d. A means of judging the opportunities which the instruction may offer for
the future.
POLICIES:
1. All nursing staffs shall be given a priority or privilege for any ranking position
opened after the results of the quarterly evaluations.
2. Certificates of employment indicating their field of expertise may count as a
factor in credentialing/ privileging of staff.
3. Upgrading of staff thru gathering, verifying evaluating the nursing staff
credentials.
4. The licensure ,education, training, and work experiences of nursing personnel
shall be documented and updated.
5. There shall be an evidence of standardized procedure to gather the credentials
110
of all nursing staff.
PROCEDURES:
1. Inform all interested and potential nursing staff the opened item.
2. Accepts all applications for screening.
3. Verify all updated licensure, education, training, and work experience
and other pertinent requirements.
4. Evaluate the gathered nursing credentials.
5. Recommend those potential nursing staff to the head of the nursing
department thru continuing education and training.
6. The chief nurse is responsible in informing that the said staff is
recommended after screening and evaluation.
6. Appointment from the appointing body will follow.
DISSEMINATION:
• Hospital Order
• Memos
BIBLIOGRAPHY/ REFERENCES:
1.Standard of Nursing Services
(ANSAP Inc.) 2008 Edition
2.Hospital Administration Manual
2nd Edition
111
Title: POLICIES ON PATIENT’S RIGHTS
Responsible Party: Nursing Service Department

Regulatory/Standard Reference : PHIC Benchbook
Section: ER/OPD,OR/DR, General Ward Nurses and Nursing Attendants
Policy No._______
Date Issued:__________
PURPOSE:
To provide the right information in obtaining consent to care, treatment,
112
Treatment plans, respect to care, patient and family’s involvement in decision making,
Options of choices , rehabilitation procedures, its effects & risk & possible complication.
To provide available resources in the delivery of quality care services with respect
to safe practice and safety of the clients/ stakeholders.
POLICY DESCRIPTION
Nursing Department shall be responsible in attaining the desired level of

performance improvement and in achieving the highest level quality of care &
services based on the standard of nursing practices for patient’s safety and the
institution.
RIGHTS AND RESPONSIBILITY
The Nursing Service Department shall establish policies and guidelines that
respect and support patient and family rights which include but are not limited to
the following:
* 1.1. Prerogative to determine what information regarding health and care

is provided to family and under what circumstances
* 1.2. Respect for patient’s personal values and beliefs
* 1.3. Respect the confidentiality of patient health information
* 1.4. Respect for patient’s need for privacy ( e.g. during treatment, procedure,
Physical examination, clinical interview, transport )
1.5. Protection of patient’s possessions from theft or loss
1.6. Protection patient from physical assault ( e.g. vulnerable patients are infants,
and elderly)
1.7. Support patient and family rights by participating in the care decision and
care process
DEFINITIONS
Ethics- declaration of what is right or wrong & what ought to be.

- a formal process for making logical & consistent decision based upon
moral beliefs.
Ethics of Care- an approach to ethical decision making grounded in relationship
113
& mutual responsibility in which choices are contextually bound and
Strategies are focused on maintaining connections & not hurting anyone.
Ethics of Justice- an approach to ethical decision making based on objective rules
& principles in which choices are made from a stance of separateness.
Code of Ethics
-written list of a profession’s values & standards of conduct.
- framework for decision making
- general statements
- offer guidance
- periodically revised
- not legally enforceable as laws but consistent violation indicate an
unwillingness by the person to act in a professional manner & license
can be suspended or revoked.
Documentation- is any written or electronically generated information about

client that describes the care or service provided to that client.
Standard of Practice:
Standard- is a desired and achievable level of performance against which
actual performance can be compared.
Standard 1. Responsibility & Accountability

- Maintains standard of nursing practice & professional conduct determined
by the state policies and the practice setting.
Standard 2. Specialized Body of Knowledge
- Bases practice on the best evidence & other Science and humanities.
Standard 3. Competent Application of Knowledge
- Makes decision about actual and potential health problems and strengths,
plans, and performs interventions, & evaluates outcomes.
Standard 4. Code of Ethics
- Adheres to the ethical standard of the nursing profession
Standard 5. Provision of Service in the Public Interest
- provides nursing services & collaborates with other members of the
health care team in providing health care services.
Standard 6. Self Regulation
- Assumes primary responsibility for maintaining competence & fitness to
114
practice.
Policies and Procedures on Patient’s Rights To Care,

Consent, Freedom of Choice and Rights of Incompetent
Patients ( Minors )
A. Right’s to Care
1. The patient including the family members has the right to know any information
regarding his health condition and care provided.
2. The patient has the right to respect his personal values and beliefs.
3. The patient has the right to respect regarding confidentiality of his health
information.
4. The right to respect for patient’s need for privacy.
5. The right of protection of patients possessions from theft or loss
6. The right of protection patient from physical assault.
7. The right to support family right by participating in the care process through
Information of the following:
• medical condition and confirmed diagnosis and the informant
• planned care, treatment, outcome of care, unanticipated outcome and
participation in care decision according to wishes.
• informed consent
• refusal or discontinuance of treatment
• assessment and management of pain

• compassionate care at the end of life
• process on complaints and differences of opinion about patient care
• participation in clinical research.
• Disclosure of information
B. Rights to consent
• Consent is required from every conscious patient, mentally competent
Adult before you can start the care.
• A person receiving care must give permission or consent for treatment.
115
• If a person is in control of his or her actions, even though injured and refuses
care, you may not assist. ( in fact doing so may be grounds for both criminal
and civil action such as unlawful battery)
• Expressed consent:
Implied consent – when a person is unconscious and unable to give consent
or when a serious threat to life exists, the law assumes that the patient would
consent to care and transport to medical facility. It is limited to true emergency
situation is appropriate when the patient is unconscious, delusional,
unresponsive as a result of drug or alcohol use. However, a serious threat to
life legal action would revolve around that question, it becomes medico-
legal judgment.
Medico legal- is a term that relates to medical jurisprudence ( law) or

forensic medicine. In most instances, the law allows the spouse, a close
relative, or next of kin to give consent for an injured person who is unable
to give consent. Refusal of your intention to render emergency care is also
implied. Ex. A patient action in pulling his or her arm from your splint may
be an indication of refusal or treatment.
C. Freedom of Choice
• The client may choose to accept or reject the treatment offered to him and must
understand the consequences of choosing to do nothing.
• The client have the right to choose his or her attending physician if needing for
further management.
• The client has the right to choose health facility if needed to be referred to other
Institution.
D. Rights of Incompetent Patients ( Minors)

• Minors and Consent – A minor can’t give the wisdom, maturity or judgment
to give consent, the law requires that a parent or legal guardian give consent for
Treatment or transport.
• Mentally Incompetent Adults
116
The same as in minors protocol. Consent for emergency care should be obtained
from someone who is legally responsible such as guardian or conservator when
true emergency exists, you can assume that implied consent applies.
DISSEMINATION
Hospital Order
Memos
Issuances
Meetings
BIBLIOGRAGPHY/ REFERENCES
1. Standard of Nursing Services

ANSAP Inc. 2008 Edition
2. Hospital Administration Manual
2nd Edition
3. Nursing Outlook 1999, 47 162-7
Copyright @ 1999 by Mosby Inc.
162 Tilden, Virginia P.
4. Existing Manual of Procedures
117
Title: POLICIES AND PROCEDURES THAT ADDRESS PATIENTS’ NEEDS FOR CONFIDENTIALITY
Section: Medical Staff / OPD/ ER/ WARD/ OR/OR/ Laboratory/ Medical Record
Responsibility Party: All Department concerned
Date Approved : December 8, 2009
1. PURPOSE:
To assure that the basic rights of human beings for independence of expression,
decision and action and human relationships are preserved for all patients.
11. POLICY DESCRIPTION:

The privacy and rights of an individual can be severely compromised by information from
overhead conversation.. It is the policy of DADPFH to respect the individual rights of all persons that
come to this facility for care.
111.PROCEDURE:
1. Patient’s. document (Chart, diagnostic results) must be kept in secured location to prevent
access by unauthorized individual.
2. It is not allowed that results and patient’s diagnosis be relayed via telephone so that
confidentiality is not compromised.
3. Never allow watchers and patients to read the chart.
4. The nurse is not in position to reveal any information regarding the patient’s condition.
5. Expect that any discussion or consultation involving the case of the patient will be conducted
discreetly and that individuals, not involved in direct care, will not be present without
permission of the patient.
6. Expect that information given to concerned family members or significant other legally
qualified person, be delivered in privacy and with due consideration of confidentially.
7. Expect that all communications and other records pertaining to patients care, including the
source of payment, be treated as confidential.
1V. MONOTORING:
LOGBOOK
V. DISSEMINATION:
Meetings
Conferences
V1. REFERENCE
World Medical Association Declaration on the Rights of the Patient
118
Adopted By the 34th World Medical Assembly Libson, Portugal, Sept./Oct., 1991 and
Amended by the 47th General Assembly Bali, Indonesia, September, 1995

Title: Policies and Procedures on Waiting Time(OPD)

Responsible Party: OPD Department
Regulatory/ Standard Reference: Phic Benchbook
Section: ROD/AP, OPD Nurse, OPD Nursing Attendants, OPD Clerks
Policy: ___________
Date issued:________
To developed a systematized, timely, prompt attention and appropriate actions

to clients needs within the planned waiting period.
DEFINITION:
Waiting time- is a given period set by the hospital to finished every

procedures.
POLICY DESCRIPTION:
The hospital shall have a coordinated system wide to achieve its goal
to meet patient’s/client’s needs upon entry and provide effective system and
conducive, and safe environment.
119
PROCEDURES:
1. Correct sequential procedures shall be written in bold letters using the

common used vernaculars within the community and to be understood for
every client.
2. All opd clients shall be instructed to get their priority numbers and request
form from the OPD clerk/OPD Nurse for them to fill up.
3. Accomplished request form by the OPD clients shall be returned to the

OPD clerk/ OPD Nurse for the correct entry of client’s data registry.
4. OPD clients/ patients shall wait for her/his number to be called by the
OPD nurse for the next instruction.
5. OPD clients/ patients shall be directed to enter the consultation room when
his/her number is called.
6. Indigent clients maybe referred to DSWD for assessment and clients with
special needs may be referred to other health care facility with properly
filled referral form by the ROD/AP for any further evaluations.
7. Clients with laboratory request, x-rays, and other diagnostic procedures

shall be instructed to settle payments of the requested procedures at B.O.
8. Clients shall be instructed where they are supposed to go next.
9. OPD clients with requested laboratory exams ,and diagnostic procedures

shall present their results to the doctor before they will be given medications
and further instructions.
120
Paraan sa pagpakonsulta
(Opd)
PARAAN PAANO MAGPROCESO ORAS TAONG LALAPITAN
1. Kumuha ng priority no.at porma.Sulatan ang -1minute -OPD clerk/OPD nurse

Lahat ng linya sa porma.
2. Ibigay sa Nurse ang napil apan ninyong porma -1-5minutes -OPD clerk/OPD Nurse
3.Hintayin na matawag ang hawak ninyong -5-15 minutes -OPD clerk/OPD Nurse
Numero para sa sunod na instruksyon.
4. Kung kailangan na magpalaboratoryo, -1-3 minutes Cashier/Laboratory/x-ray

X-ray.Lapitan ang Nurse kung saan technicians
Magbayad at ipakita ang request form.
Para sa mga special na kliyente na irefer

sa accredited Labs., /diagnostic procedures,
dalahin ang referral note ng doctor -1 minute - Outside health care
Provider
5. Puntahan ang social worker kung kailangan -25 minutes - DSWD/Social worker
6. Kung may resulta na ng narequest na labs. -10-15 minutes -Doctor/Nurse

Exams nyo,Hintayin na matawag ang inyong
numero o pangalan bago pumasok sa Consultation
room.Doon nyo Makita ang doctor na titingin sa
inyo.
121
MONITORING:
Logbooks for monitoring

Evaluation/ feedback Survey
DISSEMINATION:
Hospital Order
Memos
Orientation
REFERENCES:
Adopted from Vicente Sotto Memorial Medical Center, Cebu City
122
DR. AMADO DIAZ PROVINCIAL FPOUNDATION HOSPITAL
Title: Policies and Procedures on Waiting Time (E.R)

Responsible Party: Resident on Duty, E.R. Nurse, Nursing Attendant, Utility worker
Admitting Officer, B.O./Cashier, P Pharmacy, Transport Services.
Regulatory/Standard References:Phic Benchbook
Section: ROD, E.R.nurse,N.A., Utility, Admitting Officer, B.O./Cashier, Pharmacist, &
Transport Services
Policy No.__________
To attend to acute & critical patients 24 hrs. a day and to provide immediate care &
treatment to patients with life threatening conditions in timely & appropriate manner.
To developed a systematized, timely, prompt attention and appropriate actions to clients
within the panned waiting period.
POLICY DESCRIPTION:
 There shall be a policies and SOP’s to initiate treatment immediately

for life threatening emergencies without delay.
 Patient for observation in E.R. shall stay not more than 6 hours.
 The hospital shall have a coordinated system wide to achieve its goal to
meet patient’s/client’s needs upon entry and provide effective system
and conducive and safe environment.
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The hospital staff shall not transfer the patient unless the patient has been stabilized or the
legally authorized representative signed a waiver after being informed of the risk of transfer.
PROCEDURES:
1. Welcomes patient/watchers/SO/relatives, and place patient in a comfortable position.

2. Assess the patient including history taking, v/s, demographic data, chief complaints.
3. Prepare patient’s medical record/patient’s chart & call the doctor/ROD/AP if patient
requested to be admitted as private case and obtain consent.
4. After medical assessment, evaluation, and disposition by the medical staff, patient will be
provided with medical treatment as necessary to assure that the condition has been
stabilized.
5. Patient’s for observation shall be placed at holding area.
6. All patients coming in E.R. shall be entered in the admission logbook (Phic admission
Logbook) with respective case number same as the patient chart.
7. E.R. shall conform to hospital policies and for complying with applicable protocols,
violence against women and children (VAWC) specified communicable diseases, rabies,
poisoning & unattended or suspicious death.
8. DOA/E.R. death shall be registered in the logbook and observe the ff;
 The cadaver of DOA or E.R. death whether medico-legal or not, should
be transported the morgue with proper identification. Cadaver will be
released only to properly identified nearest relative.
 In cases of DOA, the issuance of death certificate shall be the
responsibility of the last physician who pronounced the patient dead on
arrival.
9. Unconscious & unidentified patients for admission, the accompanying person must be
Identified & must sign the patient chart.
For vehicular accident- the driver must present his license or plate number of the vehicle
to the guard on duty & must be recorded properly in the security logbook.
10. Stat diagnostic examination:
> All labs. Request must be ordered and signed by ROD and send to lab.
personnel.
> Specimen bottles must be provided by the E.R staff.
> Urine specimen of patient’s with urinary catheter shall be collected at the
E.R.
> Stat lab result must be seen by ROD prior to transport.
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Protocol on Patient endorsement/transport
1. E.R. shall properly endorse the patient to the ward.

2. Admitted patients shall be transported to the ward not more than 30 minutes to
prevent congestion in E.R. and admitting section.
3. Ward personnel should be informed ahead of time about the coming admission to
enable them to prepare the bed & necessary equipment.
4. Patient must received promptly by the ward personnel from the E.R. & ushered to the
patient’s room & bed.
5. If the patient is for operation, the charge slip must be attached to the chart.
MONITORING:
Logbook for Monitoring
DISSEMINATION:
Hospital memo
Nursing Policy
Meetings
REFERENCES:
Hospital Manual of Procedures
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List of Services / Facilities Available:

1. Emergency Room (24 hrs.)
2. Private Rooms- Aircon / Non- aircon
3. Wards for Medical, Surgical, Pediatric, OB-Gyne cases
4. Out- patient Consultation
( Mon – Fri 8am - 4pm / Sat 8am – 12pm)
5. Delivery Room
6. Operating Room ( on process )
7. Radiology Services
8. Dental Services
9. Pharmacy Services (24 hrs.)
10. Clinical Laboratory Services (24 hrs.)
- CBC, Blood Typing
- Urine Exam
- Stool Exam
- Blood Chemistry
- ECG
- Newborn Screening
11. Dog Bite Center
12. Records Services
13. Administrative Services
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DR AMADO DIAZ PROVINCIAL FOUNDATION HOSPITAL
PROCEDURES ON ASEPSIS
PROCEDURES BASED ON PRINCIPLES OF MEDICAL ASEPSIS IN

PATIENT CARE
- Practice good hand hygiene techniques.

- Carry soiled items including linens, equipment &other used articles away from the body
to prevent them from touching the clothing.
- Do not place soiled bed linen or any other items on the floor, which is grossly
contaminated. It increases contamination on both surfaces.
- Avoid having patient’s cough, sneeze, or breath directly on others. Provide patient with
disposable tissues and instruct them as indicated, to cover their mouth & nose to
prevent spread by airborne droplets.
- Move equipment away from you when brushing, dusting or scrubbing articles. This
helps prevent contaminated particles from settling on your hair, face and uniform.
- Avoid raising dust. Use a specially treated or a dampened cloth. Do not shake linens.
Dust and lint particles constitute a vehicle by which organisms may be transported
from one area to another.
- Clean the least soiled areas first and then move to the more soiled ones. This helps
Prevent having the cleaner areas soiled by the dirtier areas.
- Dispose soiled or used items directly into appropriate container. Wrap items that are
moist from body discharges or drainage in waterproof container such as plastic
bags before discarding into the refuse holder so that handlers will not in contact
with them
- Pour liquids that are to be discarded such as bath water, mouth rinse and the like
directly into the drain to avoid splattering in the sink and onto you.
- Sterilize items that suspected of containing pathogen. After sterilization, they can be
managed as clean items if appropriate.
-Use personal grooming habits that help prevent spreading microorganisms. Shampoo
your hair regularly, keep your fingernails short & feel of broken cuticles, any
ragged edges; do not wear false nails; and do not wear rings with grooves &
stones that may harbor microorganisms.
- Follow guidelines conscientiously for infection control or barrier techniques as
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prescribed by the agency.
PROCEDURES BASED ON PRINCIPLES OF SURGICAL ASEPSIS

`
- Only a sterile object can touch another sterile object. Unsterile touching sterile means
contamination has occurred.
- Open sterile packages upward so that first edge of the wrapper is directed away from the
worker to avoid the possibility of a sterile surface touching unsterile clothing. The
outside of the sterile package is considered contaminated.
- Avoid spilling any solution on a cloth or paper used as a field for sterile set-up. The
moisture penetrates the sterile cloth or paper and carries organisms by capillary
actions to contaminate the field. A wet field is considered contaminated if the
surface below it, is not sterile.
- Hold sterile objects above waist level. This will ensure keeping the object within sight
and preventing accidental contamination.
- Avoid talking, coughing, sneezing or reaching over a sterile field or object. This helps
to prevent contamination by droplets from the nose and mouth or by particles
dropping from the workers arm.
- Never walk away from or turn your back on the sterile field. This prevent possible
contamination while the field is out of the worker’s view.
- All items brought into contact with broken skin, used to penetrate the skin to inject
substances into the body, or used to enter normally sterile body cavities should
be sterile. These items includes dressings used to cover wounds and incisions,
needles for injections& tubes (catheters) used to drain urine from the bladder.
- Use dry sterile forceps when necessary. Forceps soaked in disinfectant are not
considered sterile.
- Consider the outer 1” edge of a sterile field to be contaminated.
- Consider an object contaminated, if you have any doubt about its sterility.
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TRANSMISSION- BASED PRECAUTIONS
Transmission Based Precautions are used in addition to

standard precautions for patients in hospitals with suspected
infection with pathogens can be transmitted by airborne droplet
or contact routes. Any of these types can be used in combination
with the others.
Airborne Precautions:
-Use these for patients who have infections that are spread through
the air, such as TB, varicella (chicken pox) & rubeola(measles).
- Patient place in private room that has monitored negative air pressure in
relation to surrounding areas 6-12 air changes per hour, and appropriate
discharges of air outside or monitored filtration of air is recirculated. Keep
door close and patient in room.
- Use respiratory protection when entering room of patient with known or
suspected TB. If patient has known or suspected rubeola or varicella; Respiratory
protection should be worn unless person entering room is immuned to these
diseases.
- Transport patient out of room only when necessary and place a surgidal mask on
the patient if possible.
- Consult CDC guidelines for additional prevention strategies for TB.
Droplet Precautions:
- Use these for patients with an infection that is spread by large particle droplets,
such as rubella, mumps, diphtheria, & the adenovirus infection in infants &
young children.
- Use private room if available, Door may remain open.
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- Wear a mask when working within 3 feet from the patient.
- Transport patient out of room only when necessary and place a surgical
Mask on the patient.
- Keep visitors 3 feet from the infected patient/ client.
Contact Precautions:
- Use these for patients who are infected or colonized by a microorganism
that spreads by direct or indirect contact such as MRSA, VRE,VISA.
- Place patient in private room if available.
- Wear gloves whenever you enter the room. Change gloves after having
Contact with infective material. Remove gloves before leaving the patient’s
environment and wash hands with an antimicrobial or waterless antiseptic agent.
- Wear a gown if you have a contact with infectious agents is likely or patient has
diarrhea, an ileostomy, colostomy, or wound drainage not contained by a
dressing.
- Limit movement of the patient out of the room. Avoid sharing patient care
Equipment (Adopted from CDC & Prevention -1996) available at http/www.
CDC.gov/NCIdod/hip/SOLAT/ISOpart2.htm)
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Poblacion 4, Midsayap, Coatato
Title: HAND HYGIENE PROCEDURES

Responsible Person: ALL STAFF
Regulatory/Standard Reference: PHIC Bench book
Section: ALL Section
PROCEDURES:
Hand Hygiene procedures shall be done:

a. Before and after contact with each patient.
b. Before putting on sterile gloves.
c. Before performing any invasive procedures such as placement of a
peripheral vascular catheter.
d. After accidental contact with body fluids or excretion, mucous
membranes, non intact skin, and wound dressing even if hands not
visibly soiled.
e. When moving from contaminated body site to a clean body site during
patient care.
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f. After contact with inanimate objects near the patient.
g. After removal of gloves.
Additional Guidelines:
a. The use of gloves does not eliminate the need for hand hygiene.
b. The use of hand hygiene does not eliminate the need for gloves.
c. Natural fingernails should be kept less than ¼ inches long.
d. Artificial fingernails or extenders should not be worn when having direct
contact with patient at high risk.
e. Gloves should be worn when in contact with blood, infectious
materials, mucous membranes, and non intact skin could occur.
f. Hand lotions and creams are recommended to moisturize and protect skin
related to the occurrence irritant dermatitis associated with hand
hygiene.
REFERENCE:
Modified from Center for Disease Control & Prevention (2002).Guidelines for
hand hygiene in Health Care setting, Morbidity & Mortality Weekly Report.
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DR AMADO DIAZ PROVINCIALFOUNDATION HOSPITAL
HOUSEKEEPING PROCEDURES IN SPECIFIC PATIENT

AREAS
Policy Guidelines:
i. All housekeeping services in the entire premises of the hospital are
rendered by utility/laundry worker assigned.
ii. Housekeeping services includes the following:
1. Cleaning of all areas of the hospital
2. Disposal of garbage
3. Collection of recyclable materials
4. Request for pest control
5. Exposure of contaminated or potentially contaminated rooms
to disinfectants/fumigating agents.
VIZ:
a. CD/Infectious Disease Room – one (1) hour
b. Death and prolonged confinement – 30 minutes
Procedure:
1. Call the utility to notify him/her about the room discharge.
2. Remove all the soiled linen and place it in the hamper and bring
it directly to the laundry room.
3. Instruct utility to inform the HN when he/she finishes cleaning
the room.
4. After exposure requirement, the rooms are usually opened for
airing.
5. Directs Nurse Attendant/Laundry Staff to make the bed ready
for admission.
6. Inspect the room for cleanliness and completeness before
locking it.
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POLICIES AND PROCEDURES ON REPORTING OF
INFECTIONS TO PERSONNEL AND PUBLIC HEALTH
AGENCIES
Policy:
1. There shall be a designated Disease Surveillance Coordinator in an
institution.
2. The DSC nurse may be Infection Control Nurse (ICN) or Chief
Nurse and he/she undergone seminar and training on Philippine
Integrated Disease Surveillance Reporting Program (PIDSR) of DOH.
3. There must be a proof of weekly Notifiable Disease Report Registry
(NDRR) properly accomplished and submitted to the nearest Disease
Reporting Unit (RHU , PESU or RESU).
4. For any infectious disease or any outbreaks or clusters of disease in a
community, shall be reported to RHU upon entry of patient/client be
reported within 24 hrs.
Procedures:
1. The OPD/ER nurses are being oriented and alerted to report to the
head nurse/chief nurse and members of the ICN for any patient/client
suspected or confirmed cases immediately upon client’s entry.
2. Notify simultaneously the PHO, CHD and NEC within 24 hours of
Detection and send advance copy of the Case Investigation Form
(CIF) as soon as possible.
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3. Report all cases of notifiable diseases/syndromes every FRIDAY of
the week to the next higher level using the Case Report Form (CRF).
GENERAL STAFFING PATTERN

NURSING SERVICE
EMERGENCY ROOM
STAFF PLAN ACTUAL SHIFT RELEIVER

AM PM NOC
Nurse II I -
Nurse I 4 5 2 1 1 1
Nsg. Attendant 3 2 1 1
_____________________________________________________________________________________
OUT – PATIENT DEPARTMENT
STAFF PLAN ACTUAL SHIFT RELIEVER

AM PM NOC
Nurse II 1 -
Nurse 1 1 1 1
Nsg. Attendant 1 1 1
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Note:
Monday – Friday (8am-4pm)
Saturday (8am-12noon)
Holidays – optional
GENERAL WARD – STATION I (Private Rm./Philhealth)

AM PM NOC
Nurse II 1 -
Nurse I 4 1 1
COS ( Nurse) 4 1 1 1 1
Nsg. Attendant 4 4 1 1 1 1
STATION II (OB-Gyne/Male & Female Ward/Isolation)
136
AM PM NOC
Nurse II 1 -
Nurse I 8 1 1
COS (Nurse) 8 2 2 2 2
Nsg. Attendant 7 4 1 1 1 1
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Title: POLICIES AND PROCEDURES IN DETERMINING AND PRIORITIZING
NEED FOR REFERRAL TO OTHER ORGANIZATIONS.
Responsible Party: ROD / NOD / Transport Service

Section: Medical and Nursing Department
Policy No. __________
Health referral is a set of activities undertaken by a health care provider or facility

response to an inability to provide the necessary intervention to a patient’s need, whether
it is a real or perceived need. Referral involves not only direct patient care but support
services as well (e.g. transport to move patient from one facility to another ).
A good referral system will therefore ensure that patients are seen and managed
effectively by the right health worker at the right health facility.
Generally, the purpose of referral may be for one or several of the following:
. For second opinion
. For co-management or further management
. For transfer of service
. For continuity and monitoring of care
. For support
POLICY DESCRIPTION:
1. Each hospital shall have a written policy on health referral.

2. The referral system shall take into consideration the general welfare of the
patients and the capabilities of the health facilities within the system.
3. The hospital shall have a referral form to fill-up by the physician before
referring the patient to other facility
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1. The hospital makes referral to higher levels when a patient needs expert advice.
2. When a patient needs a technical examination that is not available at the
hospital.
3. When the patient requires a technical intervention that is beyond the capabilities
of the hospital.
GENERAL PRINCIPLES / ETHICAL PRINCIPLES:
It is a two-way relationship that requires cooperation, coordination, and exchange

of information between doctor to doctor; triage referral ( w/in the hospital ); hospital to
hospital; and diagnostic referral.
DEFINITION:
Referral- refers to the process of linking a consumer with a health service resource,
which is participating health agency.
PROCEDURES:
I. Referral to other Health Facilities:

1.The physician-on-duty prepares clinical summary, accomplishes referral
slip an gives it to the Nurse-on-duty. He may coordinates with other health
facilities for referral purposes, i.e. networking
2.The Nurse-on-duty arranges for the use of ambulance.
3.The Nursing Attendant / Utility worker brings the patient’s chart to the
Billing Section.
4.The Billing Section prepares bill of patients.
5. Cashier collects and issues corresponding official receipt and necessary
Discharged slip.
II. Referral to other Department / Sections / Units within the Hospital

1.The physician-on-duty accomplishes interdepartmental slip within the
hospital.
2.Nurse-on-duty attaches laboratory and x-ray result and provisional
diagnosis and informs the physician to whom the patient is being referred
to.
139
3. In case of referrals to visiting physician, a written consent shall be signed
by the patient or the watcher.
4. The referral physician examines patient and evaluates together with the
referring physician.
DISSEMINATION:
Orientation
Hospital Order
Meetings
REFERENCES:
Manual of Operation Province of Cotabato

Health Referral System Manual of Eastern Visayan, 2008
Title: POLICIES AND PROCEDURES IN DETERMINING AND

PRIORITIZING ADMISSIBILITY OF PATIENTS OR THE NEED
FOR REFERRAL TO OTHER ORGANIZATIONS
Responsible Party: ROD / NOD

Section: ER / Admitting Section
Policy No.:__________
140
. To provide consistent, immediate and effective medical care to all patients.
. To ensure effective implementation and monitoring of Standard Operating
Procedures of the ER / Admitting Section.
. To perform medical and nursing assessment to patients, the type of
illnesses and injuries that require hospitalization, and / or depending on
the discretion of the admitting physician.
POLICY DESCRIPTION:
1. Needs of patients are prioritized based on assessment results.

2. A triage / ER Nurse prioritizes patients for assessment that needs
immediate care.
3. The physician shall determine if admission is required, if this is the case,
admission is arranged.
4. The Hospital Staff identifies the needs of each patients being admitted /
examined based on the established assessment process and within the
prescribed timeframe.
The initial and completion of assessment of the health care needs
of each patient is within first 24 hrs of admission as in-patient or
earlier as indicated by the patients condition. However, the hospital
makes referral to higher level for those patients need expertise and
requires technical intervention beyond the capabilities of the
hospital.
RIGHTS AND RESPONSIBILITIES
. The hospital shall provide the highest level of quality health care services to all
clients needing immediate medical attention according to appropriate actions and
needs upon admission.
The hospital health care professionals shall follow the SOAP format, admitting
notes, doctor’s progress notes, pertaining to clinical pathways/ CPG’s in
assessment of clients admissibility.
GENERAL PRINCIPLE / ETHICAL PRINCIPLE:
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Provision of quality emergency care to all patients.
PROCEDURE:
1. Place the patient in comfortable position and take the pertinent data.
2. Tell the client and watchers what to expect and what is happening.
3. Obtain Client’s initial vital signs: BP, TPR, CR, Weight, FHT for OB patients.
4. Notify the Physician-on-duty.
5. Provide privacy, prepare the client for physical examination and assist the
physician on duty.
6. Prepare admission chart.
7. Carry out doctor’s order and give stat meds.
8. Assist watcher for procurement of medicines to social worker for indigent and
to Pharmacy Department.
9. Complete the chart, do proper recording.
10. Re-check the chart before forwarding to the ward.
11. See to it that patient is properly endorsed to the ward.
12.Endorsed to ward either by wheelchair or stretcher with watcher. In case patient
Do not have any watcher, refer to Social Worker.
MONITORING:
1. Decrease incidence of morbidity and mortality

2. Evaluation of Health Care Providers.
DISSEMINATION:
1. Memorandum
2. Hospital Order
3. Administrative Order
4. Continuing Education
REFERENCES
142
Existing Manual of Nursing Procedures
Standards of Nursing Services

Title: POLICIES AND PROCEDURES ON ADDRESSING AND RESOLVING

PATIENT’S COMPLAINTS
Responsible Party: Grievance Committee (CO, AO, CN)

Section: Hospital Administrators
Policy No. ______________
Date Issued: _____________
143
1.To provide a mechanism which identifies and addresses patient/visitor complaints in a

timely and efficient manner.
2. To improve the delivery of quality healthcare services and protect patient health and
safety by ensuring complaint is reviewed/investigated, tracked and trended.
3. To provide a mechanism through which every patient complaint is reviewed by the
Hospital Administrators, responding on an individual basis, and that a feedback is
available to the complainant.
4. To promote quality patient care, these procedures have been established for
documenting, reporting and responding to patient/client grievances/complaints about
the quality of medical services or patient care.
POLICY DESCRIPTION
The Hospital shall establish policies and procedures in documenting, reporting, &
responding to patient/client grievances regarding quality medical services and
patient care.
The hospital shall create chairman of the Grievance Committee and its members as
overseer of the whole operational complaints expressed by the patients / clients.
Patients have a right to voice out questions, concerns and complaints regarding
his/her care without fear of reprisal.
Patients have a right to make comment, file complaints or make suggestions.
DEFINITION:
Patient Complaint- a formal, written or verbal grievance that is filed by a patient,

or on behalf of a patient who is incapable of doing so themselves, when a patient
144
can not be resolved promptly by present staff.
PIC- Patients Issues Committee
HPO- Hospital Privacy Officer
PRO – Patient Relation Officer
PROCEDURES:
1. All patient complaints, written or verbal (including telephone complaints), and

regardless of point or origin, are recorded on a patient complaint logbook. Complaints
are immediately logged into a logbook, for letters are filed in a folder.
2. Once logged, the Grievance Committee shall review each complaint and route. The
date and time of the review and routing (to whom and when) will be documented.
3. Within three (3) days of receipt of the complaint, the Hospital Administrator shall
generate a letter to the complainant stating that their complaint has been received and
is being investigated, providing a follow- up contact name.
4. In any case, where the individual filling of the complaint is offensive or agitated, the
Grievance Committee is contacted immediately and meets with the patient/client.
5. If the complaint presents apparent issues of legal liability or media involvement, the
appointed Chairman of the Grievance Committee shall immediately notify the
responsible Administrator and/or the Hospital Administrator on call.
6. All complaints alleging the release of protected information will be forwarded to
Hospital Privacy Officer for review and follow-up.
7. In all routine cases, complaints once logged, assigned a tracking number and reviewed
by the appointed Chairman on Patient Relations ,will be routed as follows:
a. Billing Complaints- Compliance officer or Billing/ Cashier
b. Clinical Complaints- Chief Nurse or Administrator
c. Operational Complaints- Hospital Administrator to whom the involved
department reports.
8. Billing complaints shall be immediately reviewed by the Hospital administrator for
the purpose of compliance risk identification and trending, and then referred as
appropriate for investigation, following up and decision.
9. Clinical complaints shall be immediately reviewed for the purpose of risk assessment,
145
need for urgent intervention, and awareness of complaint issues pending investigation
for appropriate routing and follow up oversight.
10.Upon resolution, and in no case later than 30 days, the individual filing the complaint
be sent a follow up letter from the responsible Administrator. The letter shall outline
the resolution of the situation, and advise the complaining individual of their right to
hearing if they are not satisfied with the outcome of the review, and the mechanism by
which that hearing may be obtained.
11.Upon receipt of the resolution letter , the complainant has 30 days to request a
Grievance hearing with the PIC (Patient Issues Committee) . This request must be
made in writing and received within 30 days of the follow up letter.
11.Follow up letters in matters involving an alleged adverse patient outcome shall be
Reviewed and approved by the Hospital administrator responsible for patient relations
and legal affairs if necessary.
12.A Patient Issues Committee (PIC), appointed by the Chief of the Hospital, shall meet
meet monthly to review complaints, appropriateness of action taken and delinquent
responses. The committee shall hear any grievances brought forward by
patient/visitors in regard to action taken in response to their complaint.
13.Patient Relations shall generate a report monthly of all unresolved complaints. Said
shall be by tracking number only and patient identity shall not be disclosed.
14.Upon receiving notification of a request for a grievance hearing, the appointed
Chairman of Patient Relations shall coordinate the hearing.
REFERENCE:
Adopted from The Hospital Policy Manual Louisiana State University Health Sciences
Center: Policy Number: 2.23; July 1, 2007
CREATED GRIEVANCE COMMITTEE OF THE HOSPITAL
Overall Chairman: Dra. Rosario Isabel P. Pader -

Chief of Hospital
Chairman: Arlene B. Albay
AO
Vice- Chairman: Julie Fe D. Sumagit
Chief Nurse
146
Members:
Carmencita R. Refuerzo - HPO
Med.Tech.
Dra. Myra Liza C. Parcon- PRO
Title: POLICIES AND PROCEDURES IN IDENTIFYING CLINICAL SERVICES

THAT WILL BEST ADDRESS PATIENT’S CLINICAL NEEDS
Responsible Party: All Clinical Department Heads

Regulatory /Standards References: PHIC Benchbook
Section: ER/OPD, General Ward, DR/OR, Laboratory, Pharmacy, Transport
Services
Policy No.:___________
INTRODUCTION:
To provide quality health services in every client the available clinical

services with respect to appropriate patients/clients clinical needs.
To determine and prioritize the clients needs upon entry and identifying the
appropriate clinical services that will best address to patient/ clients needs.
POLICY:
The hospital shall provide the highest level of care to ensure patient’s
triaging in determining and prioritizing patients clinical needs.
The hospital shall provide the immediate quality output of requested

diagnostic and laboratory results for quality health care services. These includes
147
the presence of skilled and well trained health care professionals, the presence of
transport services ( ambulance) and the referral system.
The hospital shall have a system wide approach in dissemination of IEC

materials for the clinical services available.
All staff shall follow policies and procedures in determining and prioritizing
patients clinical needs and in identifying the clinical services that will best
address to patient’s clinical needs.
GUIDING PRINCIPLE/ ETHICAL PRINCIPLE:
There shall be a system wide coordinated program to orient every staff the
availability of clinical services.
PROCEDURES:
The hospital staff shall undergo orientation and knowledgeable of

patient triaging as to what clinical services/facilities available in
the hospital that will best address to patients’ needs. ( e.g.
Obstetrician - for OB cases; Internal Medicine - for Medical cases;
Surgeon – for Surgery cases, etc.).
Brochures, IEC printed materials shall be available and posted at the
entry point of the hospital and to other areas like
OPD/ER/Admitting Section.
Individual client or group of clients maybe instructed for any
scheduled laboratory screening , healthy lifestyle seminar, health
education and counseling especially DM clients, HPN, Family
Planning, etc.
Monitoring logbook shall be used for recording and evaluating the
progress of the status of the client on her/his next session or visit.
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MONITORING:
1. Logbook
2. Direct feedback
DESSIMINATION:
1. Continuing education, trainings / seminars
2. Meetings
3. Hospital orders / Administrative orders
4. Orientation
REFERENCE:
Adopted from Manual of Operation Capitol Medical Center
Existing MANOP of Cotabato Province
149
Title: POLICIES AND PROCEDURES FOR CORRECTLY IDENTIFYING PATIENTS

BY THEIR CHART
Responsible Party: Nursing Service / Medical Record Section

Section: OPD/ER, DR, General Ward
Policy Number: _________
To provide easy, safe and correct identification of patients using the color coded
patients’ chart.
To provide a mechanism which identifies patient according to the clinical needs,

manifestations being presented.
POLICY:
1. All charts shall have a corresponding color coding either by doctor’s specialty or by
case / room services as per institutional policy and that is readily accessible to
authorized personnel.
2. All health care providers / newly hired personals shall be informed of the approved
color coded identification of patients by their charts.
PROCEDURES:
1. DADPFH color coding in identifying by their patients’ charts were as follows:
Surgical – Blue
OB/Gyne - Green
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Medicine – White
Pedia / NB – Pink
Isolation –Red
2. Color coded in-patients charts were sorted out at Medical Record Section before
safekeeping to easier access of retrieval.
MONITORING:
1. Decreases the incidence of medication error.

2. Increases the work productivity of the staff.
DISSEMINATION:
1. Memos
2. Hospital Order
REFERENCE:
Existing Hospital Operational Protocol
151
Title: POLICIES AND PROCEDURES THAT IDENTIFY THE SPECIFIC TYPE
ASSESSMENT APPROPRIATE TO THE NEEDS OF PATIENTS WITH

SPECIAL NEEDS.
Responsible Party: Medical and Nursing Services / Technical Support Services

Section: OPD/ER, General Ward, OR/DR, General Services
Policy Number: __________
Assessment of patients with special needs are determined by policies and

procedures that are consistent with legal and ethical requirements.
To delineate every policies, guidelines and procedures to every health care

professionals in discharging the appropriate needs of patients with special needs.
POLICY DESCRIPTION:
1. The Nursing Department shall ensure that patients’ records shall be

available only if they are to be issued to those who are professionals and
directly involved in their care and when they are required by law.
2. Shall practice quality nursing care to meet the standard of safe nursing
practice.
3. To ensure that modification of practice shall consider the principle of safe
nursing practice.
4. Development of referral system to appropriate health care facility if the
institution has no capacity to provide the specific needs of the client.
ETHICAL PRINCIPLES:
Values, customs, and spiritual beliefs held by individuals/clients shall be respected.
152
Individual freedom to make rational and unconstrained decisions shall be
respected.
Personal information acquired in the process of giving nursing care shall be held in
strict confidence.
DEFINITION:
Nursing Assessment- is gathering information about a patient’s physiological,

psychological, sociological and spiritual status. It is the first stage in Nursing
Process. It includes a physical examination, the observation or measurement of
signs which can be observed or measured, or symptoms which ca be felt by the
patient. The assessment is documented in the patient’s medical and nursing
records, which can be on paper as part of the medical record that is accessible by
all members of the health care team.
PROCEDURE:
For Infants:
1. Abandoned infants shall be traced the location where she/he was left and record
all possible information for future references.
2. Abandoned infants shall be examined by Resident on Duty (ROD) or Attending
Physician before referral to Social Welfare Officer (DSWD).
3. If DSWD is not capable of meeting the infant needs, keep the infant in the
hospital for one year and turn over to DSWD depending on hospital policy.
For School Age / Adolescence (Minors):

1. Police blotter / police report shall be presented for medical examination.
2. School Age/ Adolescents shall be turn over to DSWD after proper taking the
history, demographic data, complaints and medical examinations of the
Attending Physician.
3. Provide privacy during medical examinations.
4. Frequent reports and notices of bruises, hematomas, burns observed to school
age and adolescents may be assessed as risk for directed violence (child abuse)
due to deficient parenting skills. Refer to Bantay Bata 163.
For Sexually abused:

1. Police blotter / or police report shall be presented for medical examination.
153
2. Proper taking of history and demographic data of clients after establishing
rapport.
3. Provide privacy during medical examinations.
For Elderly and Disabled:

1. Assistance upon entry to get on and off on the examination table and
transporting to the unit or services appropriate according to their needs.
2. Wheelchair is placed accessible near the ramp for easy passage upon entry of
disabled client.
3. Elderly and disabled clients are being assisted, transported to their respective
units or placement rooms for their access of appropriate needs.
4. Abandoned elderly and disabled client shall be referred to DSWD or Nursing
homes and hospices.
MONITORING:
4. IEC Materials
5. Evaluation
6. Logbook for monitoring
7. Census
DISSEMINATION:
1. Hospital Order
2. Memos
3. Issuances
4. Meetings
BIBLIOGRAPHY / REFERENCES:
Philippine Nursing Act 2002 (Annotated)

Deborah S. Boroughs, MSN, RN
Email address- debbyboroughs@erols.com.
University of Pennsylvania School of Nursing
3. Journal on Nursing Assessment (JONA) vol. 29, no. 12, December,1999
154
Title: POLICIES AND PROCEDURES IN DETERMINING AND PRIORITIZING
PATIENTS CLINICAL NEEDS.
Responsible Party: Medical Service / Nursing Service / Pharmacy / Laboratory

Services/ Technical Support Services
Section: All Nursing Departments, Medical Department, Pharmacy, Laboratory,
Transport Services, Utility and Maintenance, Dietary Department
155
Components of quick assessment is always determined by qualified health
professionals. Proper and timely attention that includes the nature of illness, mechanism
of injury and multiple patients (needs triaging). The initial assessment goal, is to identify
and initiate treatment of immediately and potentially life-threatening condition of the
patient.
POLICY DESCRIPTION:
1. Policies and Procedures in determining and prioritizing patients clinical needs

shall be available in ER/OPD, OR/DR, and General Ward. Clinical services
shall be in a designated primary service area.
2. 24/7 services availability of qualified health care professionals.
3. Early provision of pre-hospital care before transporting the sick to the next level
of health care facility.
4. Extrication shall always be implemented during triaging.
The hospital shall employ qualified health care professionals to provide essential
immediate intervention, rapidly assessing the patient’s gross neurologic;
respiratory; and circulatory status, performing a thorough, accurate patient
assessment, and obtaining an expanded sample history.
The nursing staff shall communicate effectively with the patient and advising
him/her of any procedure to be performed; identifying patients who requires
rapid packaging and initiating transport without delay; safe lifting and moving
to the ambulance including unloading.
Proper documentation and safeguarding patients rights.
Ensuring your own safety and safety of your fellow responders and the institution.
ETHICAL PRINCIPLES:
1. Human life is inviolable (unbroken, that can not be performed or injured ).

2. Quality and excellence in the care of patients are the goals of nursing practice.
3. Accurate documentation of actions and outcomes of delivered care is the
hallmark of nursing accountability.
156
DEFINITIONS:
Triage – a French word to “sort” or to “choose”. Sorting and classifying of patients

into priority levels depending on the illness or injury severity.
-The act of assigning degrees of urgency wounds or illnesses to decide the
order of treatment of a large number of patients.
Extrication – free from difficulties
Mass Casualty- is the event when there are a number of victims that can not be
managed by an ordinary routine. In an ordinary hospital set up, this may be
so when there are six or more casualties at the same time and still
anticipating the arrival of more victims.
Medical Screening Examination- an examination and evaluation within the
capability f the hospital’s emergency department, including ancillary
services routinely available to the emergency department, performed by
qualified personnel ( as defined thereof by hospital by-laws or policies and
procedures ) to determine whether or not an emergency medical condition
exists.
PROCEDURES:
1. Assess mental status (in adult and in children)

2. Assess airways for responsive patients; clear talking or crying.
Partially obstructed maybe observed:
 Retraction
 Nasal flaring
 Labored breathing
Be prepared to open airway; administer supplemental O2; assist ventilation

and initiate transport.
Open airway using head tilt- chin lift or jaw thrust maneuver.
3. Established ABC
*Unresponsive patients
 Any obvious trauma
 Noisy breathing
157
 Shallow / absent breathing
Assess circulation; assess the pulse; identify any external bleeding; evaluate
skin temp., color and moisture; check capillary refill.
4. Identify priority patients for immediate care and transport.
Consider the following:
 Poor general impression
Unresponsive with no gag/cough reflex
Difficulty of breathing
 Pale skin / poor perfusion
 Complicated childbirth
 Uncontrolled bleeding
 Severe chest pain with systolic BP < 100mmHg
 Steadily decreasing level of consciousness
Triage Classification:
A. Emergent
.Category which implies that condition exists that poses an immediate
threat to life or limb.
B. Urgent
.Clients should be treated quickly but as immediate threat to life does
not exist at the moment.
.May still be upgraded to emergent once clinical deterioration
manifest.
C. Non-urgent
. Can generally tolerate several hour for health care service without
a significant risk for clinical deterioration.
Care of Emergency Room Client / Critically Ill Client in the Ward and Other
Departments:
1. Disposition
2. Decision on what will be done
3. Case Mgt.
4. Case manager screen clients and arrange for appropriate referral
and follow-up.
5. Client / Family health teachings
6. Mass casualty principle (for ER only)
158
Triage Tagging
.Red Tag – level I “ Emergency Cases”

. Yellow Tag –level II “ Urgent Cases” needs care within 30 minutes- 2 hr.
. Green Tag- level III Non urgent cases within 2 hours.
. Black Tag – level IV – expected to die or dead.
MONITORING:
Monitoring logbooks on referrals

Patient’s Flow Charts
Referral system
Evaluation of Health Care Professionals
Decreases Morbidity/mortality Cases
DISSEMINATION:
Administrative Orders
Hospital Orders
Memos
Meetings
Continuing Education through Trainings/Seminars
PHILIPPINE NURSING ACT 2002 Annotated, Lily Ann R. Baldago

Anvil Publishing Inc.
Existing Hospital Manual of Procedures
Nursing Outlook vol., no. 4. july/aug. 1999
CPR 3rd Edition Revised 1991.
159
Title: POLICIES AND PROCEDURES INDICATING EXTENT OF DUPLICATE

ASSESSMENTS AND TREATMENTS PERFORMED BY TRAINEES RESPECT
PATIENTS RIGHTS
Responsible Party: Nursing Service Department Heads, Nurse Volunteers, Trainees
Regulatory/ Statutory References: Phic Benchbook
Section: Nurse Supervisor/Senior Nurse, Nurse volunteers, Trainees.
Policy: ________________
160
Clinical Staff Development starts from training of new R.N’s to enhance the skills and
knowledge in the field of clinical experience. According to Bennet’s framework of staff
development, the stages follows from the novice, advance beginner, leading to competent then
to an expert .Bridging program is important to honed the skills and knowledge of the new
professionals. It’s purpose and goals is to developed these young professionals their skills, work
attitudes values and knowledge in the current trends of nursing management in the clinical area
leading them to become a well rounded nurse in the future.
The purpose is to avoid the possibility of duplication of work and miscommunication of

patients/clients rights and privileges during the practice.
POLICY DESCRIPTION:
The hospital shall have a clear policy guidelines in the acceptance and bridging program
of trainees/volunteers, newly hired employees, novices, advance beginners before giving an
assignments and tasks in their assigned units.
The hospital staff administration shall obtain signed voluntary agreement contract to all
nursing volunteers, & trainees prior to exposure in the clinical area.
The regular hospital staff or senior nurses shall be responsible in the orientation and
direct supervision of these trainees in their unit of assignment.
Nursing Service Administration shall have the policy of 6 months period of bridging
program for trainees.
DEFINITION:
Nurse Volunteers/ Trainees- are health care providers who are RN’s willing to render
161
services without expecting any reward or cost.
Bridging Program – a designed program in the clinical area addressed to all accepted
volunteers & trainees within a specified period of time (e.g. 4-6 months).
PROCEDURES:
1. Submission of requirements; pertinent documents including comprehensive resume

And personal data sheet (CSC form 212).
2. Signed contract of volunteer ship/trainees agreement
3. Attends orientation on hospital policies and procedures.
4. Education or in- service seminars/trainings
5. Performance evaluation of trainees before the bridging program ends.
MONITORING:
. Bridging Program
. Performance Evaluation for Trainees
. Patient’s Evaluation Survey Questionnaires
DISSEMINATION:
. Hospital Order
. Memos
. Meetings
. Orientation
. Continuing education training/ seminar
BIBLIOGRAPHY/ REFERENCES:
. Clinical Instructions and Evaluations & Teaching Resource, O’ connor, A.B.(1986)
162
Nursing Staff Development and continuing education.Boston; Little Brown pp.39-44
. NARS manual source Book. A joint project of the DOLE, PRC, BON, DOH. 2009

Title: Policies And Procedures Promoting Interactive, Appropriate, And Relevant

Programs For Patients
Responsible Party: Medical/ Nursing Service Department/ Nutritional Services/Clinical
Laboratory/ Radiology Services/ Pharmacy Department
Regulatory/Statutory References: Phic Benchbook
163
Section: Medical officers/In patient/out patient nursing services/ Dieticians/ x-ray
Technicians/pharmacist
Policy_____________
To promptly identify patient/family educational needs in order to facilitate understanding

of the patient’s health status and care options, increase their potentials to follow therapeutic
health care plan and promote a healthy patient lifestyle.
POLICY DESCRIPTION:
The hospital shall provide the development of educational programs including in-services
by the Hospital Education and Standards Department to qualified Health Educators, the
presence of LCD, Venues, Posters, IEC printed materials.
The Hospital Education and Standards Department shall determine educational goals and
set priorities based on learning needs of the clients.
Specialized Nursing Health Educators shall be responsible in modifying resources to

provide interactive, appropriate and relevant educational programs for patients.
164
GENERAL PRINCIPLES/ETHICAL PRINCIPLES:
This is in line with the DOH and Philhealth standards of accredited hospitals.
DEFINITION:
Patient’s Educational Program – are formed set of activities which consists of

objectives/goals and program content of informative issues concerning patient’s health
education, counseling and healthy lifestyle in understandable manner.
PROCEDURE:
1. All patients shall be assessed for identification of educational learning needs.

2. Patient assessment shall include the identification of literacy problems, learning
abilities, readiness to learn, financial implication of care choices, cultural and
religious practices, emotional barriers, motivation to learn, physical and/or cognitive
limitation and language barriers.
3. Once educational needs are identified, the health care workers shall determine what
department/disciplines will be required to meet those needs.
4. Specialized instructions regarding medications, treatments, diets, activities, exercises
and other pertinent educational needs shall be documented in the medical records. The
patient level of understanding should also be noted.
MONITORING:
Staff Training/Seminars
Patient/Client/customer Feedback Survey
Logbook for Health teachings/counseling
Continuing patient/client education
165
DISSEMINATION:
EIC Printed Materials

Memos
Schedule of Activities (e.g. viewing, demos & return demos to participating clients)
Meetings
Adopted from Louisiana State University Health Medical Sciences Center-Shreveport-

Louisiana, U.S.A.
Brailer,D: The decade of Health Information-rich Health Care: Framework for Strategies
Action. Department of Health and Human Services, Washington, D.C. 2004
w.w.w.nursing management. Con.
Title: Policies and Procedures on Implementation /Compliance to Clinical Pathways

Responsible Party: Medical/Nursing Service Department
Regulatory/Statutory References: Phic Benchbook
Section: Medical Officers, OPD, E.R. D.R. Ward Nurses
Policy___________
166
Quality Services rendered to patients/clients emanates from a well prepared quality
inputs to produce quality outputs in compliance to safe medical and nursing practice. Thus care
maps and clinical pathways outlines what care will be done and what outcomes are expected
over a specified time frame for a usual client within a case type or grouping. This is to update
the health status or health condition of the client from time to time and to ensure that care is
delivered timely and safe and appropriate according to care plans.
Clinical Pathways derived from clinical practice guidelines and other types of
clinical evidence should be developed or implemented for the top 10 cases of admissions and
consultations.
POLICY DESCRIPTION:
The nursing service shall ensure the use of worksheets to organize the care they
provide and to manage their time and multiple priorities. Kardexes are also used to
communicate current orders, upcoming tests or surgeries, special diets or the use of aids for
independent living to an individual client. Flow sheets and checklists are used to document
routine care and observation that are recorded on a regular basis so that care is delivered in an
appropriate and coordinated manner according to care plans.
The hospital shall provide copies of clinical practice guidelines (CPG’s Phichealth
Protocol) to nursing department for references to follow in the management of clinical
pathways-covered conditions ,the order and the timing of treatments following the pathways as
regulated and mandated on Phic benchbook.
RIGTHS AND RESPONSIBILITIES:
Nursing Staff shall individualize care maps & clinical pathways to met client’s
specific needs (e.g. by making changes to items that are not appropriate)
167
GENERALPRINCIPLES/ETHICAL PRICIPLES
Accurate documentation of actions and outcomes of delivered care is the hallmark

of nursing accountability. The hospital nursing staff maintains collegial & collaborative
working relationship with colleagues & other health care providers to ensure safe practice and
quality in the delivery of care.
PROCEDURES:
Upon entry of patient/client, care plans & clinical pathways are clearly outlined
individually or groupings that is written in ink, up dated and clearly identify the needs and
wishes of the client. This serves a permanent health record. (e.g. results of requested labs. &
diagnostic procedures to be attached at the patient’s chart.)
If the status of the clients varies from that of outlined on the care maps or clinical
pathways at a particular time/period, the variance is documented including the reasons and
action plan to address it.
Proper documentation of care plan in patient’s chart such as the ff:
1. detailed clinical history
2.SOAP format
3. admitting orders
4. doctors orders
5. nurses notes
6. medication sheets
168
7. TPR Sheets
8. Laboratories
Inform the physician for any unusual observations, response, reactions, results to
specific treatments and care, for him/her to adjust or change his/her management plans based on
their CPG’s PhicHealth Protocol.
Referral system is needed in cases treatment and primary level management is not
possible.
DEFINITION:
Care plans-are outline of care for individual clients and make up part of the
permanent health record.
Care maps/clinical pathways- are written outline what care will be done and what
outcomes are expected over specified time frame for a usual client within a case type.
Kardex- is the only documentation of the client’s care plans used to communicate
Current orders, upcoming tests & surgeries, special diets, or the use of aids for independent
living specific to an individual client.
MONITORING:
Care maps/clinical pathways
Patient’s Flow charts
Increases quality outputs
Decreases morbidity/mortality cases
DISSEMINATION:
Hospital order
Nursing memo/policy
Orientation
Meetings
169
REFERENCES:
Lorenzi N. and Riley “Managing Change: An Overview, Journal of the American
Informative Association 7(2): 116-124, 2000
BIBLIOGRAPHY:
Derbyshire, P.: User Friendliness of computerized Information Systems; Computer
in Nursing.18(2): 93-93,2000
Lily Ann R. Baldago; Phil. Nursing Act 2002, Annotated

Title: Policies and Procedures for Evaluation of Professionals who Administer Drugs
Regulatory/Standard Reference: Phic Bench book
Section: E.R./O.P.D.,L.R./D.R., and Ward Nurses
Policy No.________
Date Issued_______
170
Evaluation of professionals who administer drugs is always done at the end of

training and supervision during hands on procedures. This is to gauge the knowledge, skills,
values of professional during enhancement program as the framework for providing safe
practice.
POLICY DECRIPTION:
The Nursing service shall employ mechanisms for measuring & correcting
performance of activities in order to assure that organizational objectives and plans are
accomplished.
The Nursing Service administration shall be responsible in evaluating personnel

performance appraisal and evaluation of professionals who administer drugs
DEFINITION:
Evaluation- it is the process of gauging the performed procedures after series of

written exams, deductive reasoning, and practicum.
PROCEDURES:
1. Pre & Post test

2. Demo and return demo based from cognitive, affective, psychomotor domain
3. Practicum after satisfactory passing the 1-3 procedures.
4. Professional nurses with potential skills and got the passing rate will be
recommended by the nursing service and permitted to administer medications.
171
5. Evaluation tool
Performance – 30%
Character/attitude-70%
Total- 100%
MONITORING:
Evaluation
Updates of Training (IV Therapy ) & certificates
DISSEMINATION:
Nursing Policy
Memos
Orientation
REFERENCES:
Nursing Manual DOH

Standard of Safe Practices
ANSAP Inc. 1999
172
Title: DR. AMADO DIAZ PROVINCIAL FOUNDATION HOSPITAL PREPAREDNESS
PLAN
I. RATIONALE:
The prevalence of disasters in Cotabato Province has been reported to be high. The
Province susceptibility to various natural and man made hazards and the vulnerability of many
local communities due to conflicts, poverty, and growing populations could easily cause major
social and economic disaster. Moreover, in disaster prevention and relief, as any aspect of
development, health remains the primary objective and measure of needs and success.
173
This plan is called for, when there is mass casualty. Mass casualty is the event
when there are number of victims that cannot be managed by an ordinary routine. In ordinary
hospital set up, this may be so when there are six or more casualties at the same time and still
anticipating the arrival of more victims.
This plans provides the following:

1. On-site triage and Emergency Team that renders adequate first aid.
2. System for transport, treatment and disposition of patients.
3. Coordination with other hospital that will be involved in handling
casualties, emphasis on proper distribution of cases to prevent over
burdening the capabilities of any single hospital.
II. NATURE OF DISASTER:
1. Natural Calamities
a. typhoons
b. floods
c. earthquakes
d. volcanic eruption
e. tornado
f. landslide / erosion
g. drought
h. epidemic
i. infestation
2. Man-made Calamities
a. terrorism
b. fires/arson
c. bombings
d. armed conflicts
e. gas explosion
f. chemical spills
g. pollution
h. civil disturbances (strikes, rallies, mass actions)
3. Other Calamities
a. plane crash
b. banca wreck
c. vehicular accidents
174
d. stampede
e. riots
III. ROLE OF THE HOSPITAL DURING EMERGENCIES AND DISASTERS:
A. Pre-Disaster Phase:
1. Continuously update the Hospital Preparedness Plan and disseminate to
all employees.
2. Formulate policies, standards, procedures and guidelines on hospital
emergency preparedness and response.
3. Organize Hospital Disaster Teams for in hospital and outside hospital
scene.
4. Continuously train all personnel in BLS (Basic Life Support);
ER/OR/ICU personnel in ACLS (Advance Cardiac Life Support);
response team in EMT (Emergency Management Team); and disaster
coordinators in emergency management.
5. Continuously upgrade the Emergency Room and ambulance.
6. Ensure that necessary equipment , supplies and medicines are properly
stocked and made available for emergencies and disasters.
7. Do advocacy activities on disaster consciousness month, health
emergency week by means of seminars, drills, exercises, etc.
8. Develop and institutionalize networking activities with the communities,
health sector especially with other hospitals.
9. Upgrade and equip the hospital operation center and regularly report all
requirements to PDCC (Provincial Disaster Coordinating Council) and
DOH Central Operation Center.
10. Undertake some disaster related research activities.
B. Disaster Phase:
1. Activate the Hospital Emergency Incident Command System (HEICS) as
needed observing the code alert system.
2. Activate the Hospital Operation Center.
3. Continuously coordinate with the PDCC and DOH-CHD.
4. Provide initial reports.
5. Dispatch assessment / response teams in cases of trauma.
6. Set-up medical triage area for mass casualty in coordination with the
other members of the health sector.
7. Together with the PDCC, CHD, LGU decide and help in the management
of a field hospital if needed.
175
8. Ensure that all medicines and supplies are continuously replenished.
9. Network with other hospitals for transfer of patients in cases of MCI.
C. Post Disaster Phase:

1. Postmortem analysis of the disaster.
2. Psychosocial debriefing of all response teams.
3. Document all activities to include among others the following:
a. Background of the incident
b. Actions taken:
1. response team sent
2. supplies , medicines used
3. coordination with other agencies
c. Pertinent statistics such as patients treated, admitted, transferred,
etc… to include names, conditions, operations, status.
d. Financial cost of the disaster to the hospital.
e. Problems, issues, recommendations and suggestions.
f. Pictures, clippings, etc.
4. Based on lessons learned, review plan and incorporate possible changes
if needed.
IV. HOSPITAL DISASTER COORDINATING COMMITTEE:
A. Composition:
Chairman: Chief of Hospital – Dr. Rosario Isabel P. Pader
Members:
1. Chief Nurse – Julie Fe D. Sumagit, RN
2. Administrative Officer – Arlene B. Albay
3. Medical Officer – Dr. Crispin V. Pombuena
4. HEMS Coordinator – Shirley C. Valenzuela
5. Members of In-House Response Team
B. Duties and Functions:
Chairman – defines the scope of practice as developing protocols standing

orders. He has legal authority to provide directions for patient care
176
through telephone or radio communication (on-line) or standing orders and
protocols (off-line).
- directs Medical Personnel to perform appropriate emergency care and
treatment.
Members:
Chief Nurse
- shall be responsible to immediately contact all
members of the team and other hospital workers to report immediately to the
hospital.
- shall coordinate with the watchers on the surgical ward to
evacuate or transfer their patients to other rooms which shall be used or
converted to surgery intensive care unit or recovery room.
Administrative Officer
- Responsible for documentation and listing of patients.
- Responsible to assign security guards for crowd control.
- Procurement of needs and medical supplies.
- Responsible for assignment of drivers and ambulance operators.
Medical Officer
- Take over the place of emergency room.
- Responsible for the communication and coordination of personnel in the
information section.
HEMS Coordinator
- Maintains an operation center to serve as an alert system to monitor
health and health – related emergencies.
- Provides mobilization and deployment of health teams in anticipation of
or in response to health emergencies.
- Coordinates and integrates other sector in response to health
emergencies.
Composition:
Chair – Dr. Rosario Isabel P. Pader
Vice Chair – Dr. Crispin V. Pombuena
Membetrs:
Chief Nurse
Medical Officers
Nurse Supervisors / Head Nurses / Staff Nurses
177
Nursing Attendants
Laboratory Department
Pharmacy Department
Utility Worker
Ambulance Driver
A. On Site Triage / Emergency Team:
- undertake lifesaving first aid measures such as restoration of
airway, control of hemorrhage, splinting of fractures,
threatening situations such as cardiac arrest, shock, etc.
- to relieve pain
- to look into the proper transportation of the injured for
possible evacuation / referral to other facilities and indicating
in the tag that the medications are already given.
Composition:
Physician on Duty
ER Nurse on Duty
Nursing Attendant on Duty
Utility Workers on Duty
(Augmentation of Staff from other stations)
B. In-Hospital Response Team
- provides immediate emergency medical assistance to victims
brought to the hospital for proper medical care.
- the team shall rush to the hospital premises if they are outside
the hospital when a medical emergency is declared.
Composition:
Chief of Hospital
Physician on Duty
Chief Nurse
ER Nurse – Shirley C. Valenzuela
All ER Nurses, Nursing Attendants
Utility Workers
Medtech on Duty
Security Guard on Duty
Ambulance Driver
(Augmentation of Staff from other stations)
V. HOSPITAL EMERGENCY INCIDENT COMMAND SYSTEM (HEICS)
178
Code of Level of Alertness:
1. CODE WHITE – strong possibility of military operations, forecast

typhoons, national or local holidays that the Chief of Hospital may declare.
2. CODE BLUE – 20-50 casualties are expected (RED tags).
3. CODE RED- when 50 or more RED tags are expected and are already at
the hospital, and the hospital may also respond by sending on-site team.
VI. TRIAGE
It is a classification of patients according to type and seriousness of injury in order

to provide the most orderly, timely and efficient use of medical resources while providing
maximal care in time of disaster.
Triage Categories:
a. Immediate – all patients whose respiration, pulse or mental status
(RPM) is altered.
b. Delayed – most victims falls in this category. RPM intact, but
significant mechanism of injury.
c. Minor – RPM intact, walking and talking.
d. Dead / Dying – RPM not anymore present.
Tagging Patients:
1. RED TAG- PRIORITY 1
First priority for evacuation, needs immediate care, requires
immediate attention and transport.
2. YELLOW TAG – PRIORITY2
Second priority for evacuation, needs care but injuries are not life
threatening, severe burns, complicated by major soft tissue trauma,
hospital admission is required.
3. GREEN TAG - PRIORITY 3
Third priority for evacuation / minor injuries with low probability of
survival under the most ideal situation.
4. BLACK TAG – PRIORITY 4
Last priority, patient is clinically dead.
179
VII. STANDARD OPERATING PROCEDURES IN THE EMERGENCY ROOM AND
WARDS
1. Triage officer or the Physician on duty will categorize the patient and will
assign Coded tags for prioritization of care.
2. The Medtech takes Hct and BT, print in a piece of plaster and place at the wrist
of the patient.
3. The Administrative Officer is tasked to clear the ER from relatives, press,
volunteers and bystanders; likewise she will be the one to answer the press
during interview.
4. SOP medicines are D5LR, mannitol, ATS, TT, HTIG, Hydrocortisone,
Oxygen, Epinephrine, Dopamine, Dextran, Dexamethasone, Sodium
Bicarbonate and Citicolin must be available at the Pharmacy / ECart.
5. Supply Officer base on his inventory and assessment of the situation shall make
arrangements with the local drugstores or suppliers for availability of supplies
at all times during the presence of disaster.
6. Dietary department shall prepare necessary food for the employees and patient.
VIII. PROTOCOLS FOR RESPONDING TEAM
1. Team leader shall assemble his team.

2. All equipment, supplies and packs should be in place.
3. Members of the responding team must have communication gadget for proper
communication and immediate response.
4. Team 1 will be on STANDBY once code white is declared.
5. One’s personal safety shall be the one’s first and foremost responsibility.
6. All Responding Teams must be within the locality for accessibility.
7. All Responding Teams must be in complete uniform / blazers for identification.
8. First on-site responder shall be a team from the Emergency Room.
9. A written after- report must follow.
10. Assignments of stations/personnel:
Red Station – ER Minor Room- All ER personnel, Physician on duty.
Yellow Station – Emergency Room Staff
Green Station – Lobby Nursing Station I and ER
Black Station – Morgue (assigned / Utility Worker)
Prepared by:
180
JULIE FE D. SUMAGIT
SHIRLEY C. VALENZUELA
DR. CRISPIN V. POMBUENA
Approved by:
ROSARIO ISABEL P. PADER, MD

Chief of Hospital

Title: Policy and Procedures on Cleaning, Drying, Disinfecting, Packaging and Sterilizing
Of Equipment, Instruments and Supplies
Responsible Party: All Personnel in Clinical Division and Special Area, ICC, TWG
Section: OPD/ER, OR/DR, Clinical Ward, CSR, Laboratory, Dietary, Dental, Xray Dept.
Policy: ____________
181
Hospitals are conducive to the development and spread of infection. Major
reservoirs of pathogens include the patient’s own bacteria and microorganisms in the hospital
and community environments. Infection can be introduced through people, equipment or
contaminated products.
For a person to be infected, there has to be a source, bacteria, virus or other
organism that can cause the infection, and there has to be a means of transmission of that
infection. Control measures are designed to eliminate the source, or break the chain of
transmission to halt the spread of the disease.
Decontamination, be it of hands, environment, equipment or medical devices is
crucial to preventing source of infection.
POLICY DESCRIPTION:
 Departments responsible for cleaning, disinfection or sterilization shall

establish policies and procedures and a quality control program.
 Ensure that staffs are adequately trained and supervised.
 Ensure that equipment and devices used for cleaning, disinfection, and
sterilization are appropriately maintained.
 The hospital has the responsibility to ensure that standards for the
decontamination of medical equipment, supplies and instruments are met.
 The hospital has the responsibility to procure needed equipments for
decontamination.
 Staff who are expected to use decontamination equipment receive the
appropriate training.
 The area managers and department heads shall work closely together to
ensure strict compliance.
 The Infection Control Committee shall evaluate hospital compliance to the
program.
182
GENERAL PROCEDURES/ETHICAL PRINCIPLES:
This is in line with the DOH and Philhealth standards required for accredited
hospitals.
DEFINITION:
ICC – Infection Control Committee

TWG – Technical Working Group
PROCEDURE:
1. Establishment of Procedure and a Quality Control Program

1.1 All departments responsible for the cleaning, disinfection, or sterilization
equipment and devices shall establish specific procedures to guide these
processes. Departments shall review their procedures at least every two (2)
years. All staff responsible for cleaning, disinfecting, or sterilizing
equipment or devices shall have access to this policy and procedure.
1.2. Departments responsible for cleaning, disinfection, or sterilization shall
establish a quality control program. In order to verify compliance with
established policies and procedures, the program shall include process
monitoring and recording systems in accordance with published standards
and a mechanism to address additions. The program shall also support the
ongoing supervision of staff performance and work practices.
2. Staff Training
Departments will provide comprehensive training for all staff who perform
sterilization and disinfection functions to ensure that published standards are met.
To achieve and maintain competency, as per department procedures and the quality
control program, Staff shall:
 Receive hands on training based on departmental procedures.
 Be supervised until competency is demonstrated and documented.
3. Cleaning
All equipment and devices are cleaned according to the manufacturers’
instructions prior to disinfection or sterilization.
183
4. Semi-critical and Critical Medical Devices that are labeled single use
Semi- critical and critical medical devices that are labeled single use shall be
used once and discarded.
5. Consultation with Infection Prevention and Control

5.1. Departments will consult with ICC to assess and improve disinfection
and sterilization procedures and monitoring reporting processes in the hospital.
6. Maintenance of Equipment
Departments shall ensure that equipments used for cleaning, disinfection, or
sterilization is maintained and serviced by qualified personnel in accordance with
the manufacturers’ instructions. The department shall maintain copies of
maintenance records.
MONITORING:
ICC Surveillance Team
DISSEMINATION:
Hospital Order
Orientation
BIBLIOGRAPHY:
1. Hospital Infection Control Program

2. Manual on Hospital Management, DOH
3. Guidelines for Procedures in Operating Rooms
4. Equipment Operating Manuals
5. Policies and Procedures on Infection Control
6. Guidelines for Disinfection and Decontamination of Medical Equipment
184
Title: Policies and Procedures for Training of Professionals Who Administer Drugs
Responsible Party: All Registered Nurses

Section: Nursing Service Department
Date Issued: _________
185
Training of professionals who administer drugs reduces the incidence of morbidity

and mortality cases in the work area. Therefore, drug administration shall be practiced
only by a professional nurses after they have satisfactory completed a training program
and performance evaluation of nursing staff in the institution (e.g. IV Therapy Training).
To administer drug is a timely, safe, appropriate and controlled manner.
POLICY DESCRIPTION:
1. The Nursing Service Administrator shall have a policies and guidelines on

drugs administered in a standardized and systematic manner.
2. Professional nurses who are directed to administer medications and perform
complicated health care procedure shall follow standard and systematic manner
based on drug administration policies and procedures.
3. The Nursing Service Administrator shall establish a continuing education
through seminars, training updates on new trends on enhancement of skills and
knowledge.
1. The hospital nursing staff shall be responsible and see to it that quality nursing
care and practice meets the optimum standard of safe nursing practice.
2. Nursing staff shall be aware of their duties and responsibilities in the practice
of their profession as defined in the “Philippine Nursing Act of 2002.
7. All nurses are deemed necessary to undergo special training on IV therapy and
be responsible for quality, utilizing the IV nursing process of assessment,
planning, implementation, evaluation and monitoring desired outcome
according to protocol established by ANSAP; PNA; DOH.
GENERAL PRINCIPLE / ETHICAL PRINCIPLE:
Registered nurses are aware that their actions have professional, ethical, moral and
legal dimensions. They strive to perform their work in the best interest of all concerned.
ETHICO- LEGAL IMPLICATIONS:
186
The IV nurses in compliance of PRC, BON Res. No. 08 series of 1994, shall
uphold the Phil. Nursing Act of 1991 (R.A. 7164). The Nurses Code of Ethics established
Intravenous Nursing Standard of Practice by the ANSAP.
PROCEDURES:
1. Orientation of nurses on 10 R’s.

2. Attend IV training to Health Facility accredited by ANSAP.
3. Demos/ Return demos
4. Practicum
5. Evaluation
DEFINITION:
Intravenous (IV) Therapy- is the insertion of a needle or catheter cannula

into a vein based on physician’s written prescription. The needle or
catheter/ cannula is attached to a sterile tubing and a fluid container to
provide medication and fluids.
MONITORING:
Training Updates Schedules

Certificates of Training ( IV Therapy Training )
Evaluation of Performance
DISSEMINATION:
Hospital Order
IPHO- Telefax Order/ Radio Message
Memos
187
Orientation
In-Service Trainings
REFERENCES:
Philippine Nursing Act 2002 Annotated

Lily Ann R. Baldago
Intravenous Nursing Standard of Practice

Revised Edition
Adopted from Hospital Policy Manual Policy Number: 8.6

Effective Date: 4/01/09. Louisiana State University Health &
Sciences Center- Sheveport, Lousiana, U.S.A.
DR. AMDO B. DIAZ PROVINCIAL FOUNDATION HOSPITAL

Title: Policies and procedures for Supervision of Professionals who Administer Drugs
Regulatory/Standard Reference: Phic Benchbook

Section: E.R. /O.P.D. Nurses, Ward Nurses, L.R./ D.R. Nurses
Policy: ____________
Date issued: ________
188
The Nursing Intravenous Standards was established as a guide for those who are
to be supervised in the administration of drugs and will be practicing intravenous nursing. based
on the experience of the trainers and coordinators, it was noted that Intravenous (IV) Therapy is
fast becoming a nursing specialty. The practice is constantly changing and developing. It is not
intended to dictate or limit new concepts and technological advances. Its objectives includes the
three behavioral domains; cognitive, affective and psychomotor.
POLICY DESCRIPTION:
The hospital Nursing Service Administration shall establish Standard Operating

policies and procedures to ensure safe I.V. therapy practice, and drug administration, to protect
the patients by maximizing benefits and to protect the practice Registered professional I.V.
Nurses. The I.V. policies and procedures shall be written and continiously updated and
reviewed as necessary.
All nurses are responsible to ensure the safety of all clients/patients receiving
drugs, parenterals and I.V therapy.
Nursing Service Administration shall be responsible for the governance develop
and implement policies and procedures based on the standards of nursing administration nursing
practice on patient care. It shall also provide updated policies and procedures and clear directive
for nursing personnel at different levels of their functions and responsibilities to patient care.
ETHICO-MORAL & LEGAL ACCOUNTABILITIES:
189
The Nursing Services Department has an established framework for ethico-moral
& legal decision making in the clinical areas, and conforms with the applicable statutory laws,
rules and regulations.
DEFINITION:
Cognitive Domain- intellectual discussions.
Affective Domain- attitudes, attendance and active participation.
Psychomotor Domain- skills as validated by training instructors/supervisors
PROCEDURES:
The basis of safe nursing practice covers legally the carrying out of orders
prescribed a duly registered physician; proficiency in all aspects of I.V. therapy
administration/drug administration validated in clinical judgment & practice; Ten(10) R’s
and observation of aseptic techniques and hospital waste management.
MONITORING:
One on One supervision of preceptors to professional administering drugs.

Monitoring Logbooks for Evaluation
DISSEMINATION:
Memos
Nursing Policy
Orientation
190
REFERENCES:
Standard of Nursing Services

(ANSAP) 2001
Title: Policies on Decontamination, Disinfection, Sterilization, Disinfectants for Specific

Medical Equipment/Items and Area
Responsible Party: All Personnel in Clinical Division and Special Areas

Section: OPD/E.R., L.R./D.R., Ward Nurses, and CSR Personnel
Regulatory / Standard References: Phic Bench book/ ICC Manual
Policy No.___________
Date issued__________
Everyday there is an enormous amount of equipment used throughout trust which

needs to be handled safely and decontaminated prior to re-use. DADPFH has the duty to ensure
that all re-usable equipment are cleaned and sterilized to make it safe for re-use, storage, repair
and maintenance or inspection.
POLICY DESCRIPTION:
The policy provides guidelines for the recognition of clean and soiled equipment
and guidelines for storage or treatment after use including the area.
The policy states that all instruments, medical equipments and soiled linens shall
be free from debris blood by soaking with Sodium Hypochloride with water for 5-10 minutes
prior to cleaning, disinfection/sterilization.
All personnel in Clinical Division and special areas has a responsibility to carry
191
out decontamination on any piece of equipment they have used.
DEFINITION:
Cleaning-is the removal organic and inorganic material from objects and surfaces.
This is normally accomplished by using detergents or enzymatic products.
Thorough cleaning is necessary before disinfection and
sterilization because inorganic and organic materials that remain on the
surface of the instruments interfere with the effectiveness of these processes.
Decontamination-is the use of physical or chemical means to remove, inactive,

or destroy microorganisms on a surface or item so that there are no
infections and the surface or item is rendered safe for handling use or
disposal. The selection and use of cleaning equipment, chemicals and
exposure times suggested by the device manufacturer should generally
followed to prevent damage to the items.
Disinfection- is a process that reduces the number of microorganism ( with the

exception of bacterial spores) on inanimate objects. This is done most often
by use of an approved hospital detergent/disinfectant or chemical sterilant.
a.) High level disinfection- includes pasteurization or use of Denonex 53
plus. All microbial life ( except spores) is destroyed. Items that touch
mucous membranes should receive high level disinfection. i.e. flexible
endoscopes, laryngoscopes and other similar instruments.( semi- critical
items).
b.) Intermediate level disinfection –utilizes hospital grade disinfectant, an
EPA- approved tuberculocidal cleaner/ disinfectant. Items that touch
mucous membranes or skin that is not intact should receive intermediate
level disinfection. i.e. thermometer, hydrotherapy tanks.
c.) Low level disinfection-process that will inactivate most vegetative
bacteria, some fungi, some viruses, but can not be relied upon to
inactivate resistant microorganisms.(e.g. mycobacteria or bacterial
spores) and is used for items that touch intact skin i.e. stethoscopes, beds,
whirlpools, & equipment that is non-invasive to patients.( non- critical
items).
Antisepsis- inhibits the growth of microorganism on living tissue (e.g. skin

preparation before vascular line insertion or other invasive procedure).
192
Alcohol, chlorhexidine gluconate and iodophors, i.e. betadine are the most
frequently used solution for antiseptics. Germicidal chemicals used for
antiseptics are not generally adequate for decontaminating environmental
surfaces.
Sterilization- is the complete destruction of all microbial life. It is accomplished by

either physical or chemical process such as steam under pressure, dry heat,
ETO gas, and liquid chemicals. All items that enter sterile tissue or the
vascular system must be sterile i.e. implants, scalpels , needles, surgical
instruments etc.
MONITORING:
Twice a year ICC Monitoring & Surveillance Team
DISSEMINATION:
Meeting
Bulletin
Ward Manual
Hospital Memo
Orientation
REFERENCE:
ICC Manual
Existing Hospital Policy
193
Title: Policies on Patient Admissions/Referrals, Isolation and Timely Case Reporting of

Highly Transmissible and Notifiable Infectious Disease e.g. Miningococcemia,
SARS, Avian Flu, ect.
Responsible Party: Nursing Department
Section: OPD/ER, Ward
Policy no.________
Patient care is provided in facilities which ranges from highly equipped clinics and
technologically advanced hospitals to frontline with only basic facilities. Despite progress in
public health and hospital care, infections continue to develop in hospitalized patients, newly
admitted patients and may affect also hospital staff.
POLICY DESCRIPTION:
In case a patient shall diagnosed to have communicable disease or highly

transmissible and notifiable infectious disease, every effort must be made by the attending
physician or Health Coordinator to make arrangement to transfer out the patient to a single
private room for the sake of other patient. Notifiable infectious disease like meningococcemia,
SARS, avian flu, etc. may be transferred to other health care facility that are capable of
providing care and other services.
All hospital staff nurses, doctors, and designated personnel are responsible in
monitoring patients who are admissible, referring, isolating and timely case reporting of highly
transmissible and notifiable infectious disease.
194
PROCEDURES:
1.Verify doctor’s written order

2. Attending physician explains the procedure
3. Secure consent. Prepare patient physically and psychologically.
4. Document
5. Provide safe and medical transport services.
MONITORING:
Report Logbook
DISSEMINATION:
Meetings
Endorsement
Duplicate copies of reported Notifiable Disease Report
ICC Manual
REFERRENCE:
ICC Manual
195
Poblacion 4, Midsayap ,Cotabato
Title: Policies and Procedures on Reporting Adverse Effects

Responsible Party: Medical/Nursing Service Department; Pharmacy; Therapeutic
Committee; X-ray Department.
Section: Medical Staff, Nursing Staff, Pharmacist, X-ray Technician
Reporting of any observed unusualities manifested by clients (esp.

hypersensitive clients) who are receiving irritating medications is essential on the
part of monitoring team. This decrease incidence of morbidity and mortality
cases. Therapeutic committee may require to cancel procurement of such
medicine from supplier.
POLICY DESCRIPTION:
The hospital pharmacy and therapeutic committee shall develop policy and
guidelines in proper reporting on adverse drug effects and disseminate information to
all concerned departments.
RIGHTS AND RESPIONSIBILITIES:
All nursing staff are responsible in reporting to Pharmacy Therapeutic

Committee any unusualties observed from their patients after receiving such
medication.
PROCEDURE:
1.Verify ordered meds at patient’s chart.
196
2. Observe client/patient receiving medication.
3. Inform ordering AP/ROD about the observation/manifestation of the
client.
4. Fill-up the ADE form
197

Policies On Continue Interval To Act An Orders For Treatment

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DR.

AMADO DIAZ PROVINCIAL FOUNDATION HOSPITAL

Title: POLICIES AND PROCEDURES ON TIME INTERVALS FOR TREATMENT

RIGHTS AND RESPOSIBILITIES:

All Nurses shall be responsible in meeting the criteria of appropriateness, adequacy,

8. Vital signs plays a very important role in monitoring clients

Logbook for incident reports

DR. AMADO DIAZ PROVINCIAL FOUNDATION HOSPITAL

Title: Procedures on Asepsis

Responsible Party: All Members of Hospital Nursing Service Department

Medical Asepsis - is the process of washing/removing bacteria and infectious material on

Prevention of infection is the responsibility of all hospital staff.

IEC printed materials

Wet hands under running water with soap

mask, goggles, gowns and other personal protective equipment as needed.

BASIC GUIDELINES FOR MAINTAINING SURGICAL ASEPSIS

2. Povidone 10% ( Disinfectant )

7. Isoprophyl Alcohol 70%

1.All instruments should be soaked with Sodium Hypochloride

2. .All soiled linens should be soaked with disinfectant before

washing with soap and water.

3. All instruments should be free from debris blood prior to

DR. AMADO DIAZ PROVINCIAL FOUNDATION HOSPITAL

POLICIES ON DISINFECTION / STERILIZATION

2. Disinfecting container should be cleaned regularly

3. Lumen of instruments or tubing must be completely filled up

with disinfectant solutions ( Zonrox ) 900 cc top water + 100

4. Disinfectant solution ( Deconex 53 plus ) is changed every 14 days.

5. Thermometer ( Digital ) should be cleaned with 70% alcohol.

DR. AMADO DIAZ PROVINCIAL FOUNDATION HOSPITAL

1. All instrument should be wash with soap / water before sterilization.

3. Instruments shall be sterilized every after use.

NEEDLESTICK AND SHARP INJURY

What may cause needle stick injuries?

Who are at risk of having needle stick injuries?

How is needle stick injuries diagnosed?

Over the- counter pain medicine:

In the home and community:

DR. AMADO DIAZ PROVINCIAL FOUNDATION HOSPITAL

POLICIES FOR PREVENTION & TREATMENT OF NEEDLE

needles and sharps.

promote awareness and to educate health personnel.

Title: Policies and Procedures on Proper Handling and Safe Disposal of

Responsible Party: Nursing Service Department, X-ray Department,

Health care waste is a potential reservoir of pathogenic microorganisms,

RIGHTS AND RESPONSIBILITY:

1.Health Care Waste- includes all waste generated by health care

1. Sharps/needle sticks should be collected and placed in a puncture-proof

1. Occupational Health Care provider evaluation and Safety Program

Title: Policies for Prevention and Treatment of Needle Stick / Sharp

Responsible Party: Nursing Service Department, Laboratory Department,

1. To reduce the risk of NSI to all concerned health workers.

The hospital shall have a clear policy guidelines on prevention and

NSI- Needle Sick Injury

Sharps – may be defined as any object or instrument, which may cause a

1. Have a complete dose of Hepa-B vaccine for protection.

1. Washing of wounds with soap and water.

POST EXPOSURE MANAGEMENT OF NSI:

1. Wash wounds / flush mucous membrane immediately. Do not use caustic

DR. AMADO DIAZ PROVINCIAL FOUNDATION HOSPITAL

Title: Policies and Procedures on Reporting of Infections to Personnel and Public

Responsible Party: ICC, Disease Surveillance Officer