Divine Mercy Hospital Nurse Training Policies

DIVINE MERCY HOSPITAL
# 25 High School Drive, San Vicente West, Urdaneta City, Pangasinan

Tel # 075-568-5563 / 075 -656-2103
MEMORANDUM OF UNDERTAKING
OF THE
DIVINE MERCY FOUNDATION OF URDANETA
HOSPITAL CONCERNING NURSE TRAINING ON
BASIC EMERGENCY AND TRAUMA NURSING
MANAGEMENT /CARE
The DIVINE MERCY FOUNDATION OF URDANETA HOSPITAL hereby execute

this Memorandum of Undertaking for the purpose of ensuring that the licensing requirement
as Level 1 Hospital are complied with as follows:
1. The hospital will send four of our Nurses, Ms. Christine Kate Suyat, Ms. Donaliza
Bullan, Ms. Xandy Girl De Guzman-Exiomo, and Ms. Shaira Mae Biendo as our
designated ER Nurses to participate and train at the Ilocos Training Regional
Medical Center (ITRMC) once a schedule for the said training is available. In as
much as we would like to comply with the training of Basic Emergency and
Trauma Nursing.
2. However, the Ilocos Training Regional Medical Center (ITRMC) in San

Fernando, La Union can only accommodate one out of four (1/4) nurses whom we
would like to enroll in their training program, in the person of Ms. Shaira Mae
Biendo. She is currently undergoing the said training from July 18, 2022 to
September 2, 2022.
3. Attached herewith is the communication letter from Ilocos Training Regional

Medical Center (ITRMC).
4. This Memorandum of Undertaking is executed to show our willingness to comply

with the DOH accreditation requirements within 2 years upon signing.
ANITA C. TARECTECAN, MD, FPCS, PFSGS, FPALES

Medical Director
Date: ________
Tel # 075-568-5563 / 075 -656-2103
OF THE
ADVANCED CARDIOVASCULAR LIFE SUPPORT

this Memorandum of Undertaking for the purpose of ensuring that the licensing requirements
1. The hospital will send ten of our Nurses, Ms. Katrina Asumio, Ms. Xandy Girl De
Guzman-Exiomo, Ms. Mae Barrientos, Ms. Mary Ann Agsalud, Mr, Erick Bryan
Taborda, Mr. Nick Russel Domingo, Ms. Phebe Melony Baun-Taa, Mr. Clemente
Duyag Jr., Ms. Marla Gellian Castisimo-Alipio, Mr. Thom John De Guzman, as
our designated OR/DR Nurses and Ambulance Nurses to participate and be
trained by. Dra. Ma. Vanessa Yu an ACLS accredited trainor, once a schedule for
the said training is available.
2. Attached herewith is the communication letter from Dra. Ma. Vanessa Yu and her
credentials


Medical Director
Date: ________
Tel # 075-568-5563 / 075 -656-2103
OF THE
STANDARD FIRST AID TRAINING

this Memorandum of Undertaking for the purpose of ensuring that the licensing requirement
1. The hospital will send two of our Nurse, Ms. Marla Gellian Castisimo-Alipio, and
Mr. Thom John De Guzman as our designated Ambulance Nurses to participate
and train at Philippine National Red Cross Urdaneta Chapter once a schedule for
the said training is available.
2. Attached herewith is the communication letter from Philippine National Red

Cross Urdaneta Chapter


Medical Director
Date: ________
Tel # 075-568-5563 / 075 -656-2103
POLICIES OF MEDICAL, NURSING AND

ADMINISTRATIVE SECTION
MEDICAL SERVICE
1. All Physicians on Duty (POD) undergo 24-hour duty every three (3) days alternately.
2. The 24-hour duty Physicians should attend to all admissions, emergency cases, medico-legal
cases and must refer difficult or serious cases to physicians with training on certain
specialties accordingly.
3. All patient in the ward must be under the responsibility of the 24-hour duty Physicians and
make ward rounds daily and as frequency as necessary.
4. No Physician on Duty should conduct transfer by ambulance. Ambulance Doctors on call are
their off duty.
5. Duty Physician should act as Senior House Officer of the day after office hours or in the
absence of the Chief of Hospital.
6. From duty or out-going Physicians should do the ward rounds and make necessary
endorsement to the incoming duty Physicians should also make his/ her rounds anytime
during his time of duty.
7. Out-going Physician must attend to consultations of OPD cases after the ward rounds.
8. Medical Missions and Out-Reach Programs should be attended by an out-going or from duty
Physicians.
9. All Physicians must compete the charts of patients for discharge charts are brought to the
Philhealth and Billing section, then finally to the Records section.
10. All Physicians going on duty at the hospital general and special staff meetings, scientific
lectures wherever available.
11. All out-going or from duty physician must not leave their post unless properly relived by the
in-coming physician on duty.
12. All in-coming duty physicians must arrive for the duty on or before 9:00 o’clock in the
morning, and make proper endorsements with the out-going duty physicians
13. All physicians on duty must protect themselves with proper PPE’s and observe minimal
precautions especially for Covid-19 cases.
14. Attending physicians are encouraged to do regular daily rounds/ visits and make sure they
can be contacted by our Nurse on Duty (NOD) for referrals and updates concerning their
patients.
Tel # 075-568-5563 / 075 -656-2103
15. Visiting consultants should equip themselves with proper PPE’s when doing rounds,
operations or procedure in the hospital.
NURSING SERVICES
The following are policies and standard Operating Procedures for information and guidelines
of all Nursing personnel:
1. It is the responsibility of all nursing personnel to observe strictly the nursing policies
and adheres to the rules and regulations of the hospital at all times.
2. Good public relation shall be maintained and observed Courtesy and Respect to all
patients, visitors; watchers and the public should be practiced at all times.
3. Professional manner of speaking shall be observed. All conversations must be work-
related and patient-focused. Personal affairs shall not be discussed while on duty.
4. Absolute personal cleanliness and tidiness must be practiced at all times. All nursing
Personnel shall be professionally attired with the official uniform and Hospital ID at
all times. Unnecessary jewelries shall be avoided.
5. Only emergency phone calls shall be entertained during duty hours. Unless urgent and
justifiable, nursing personnel are not allowed to receive and entertain personal visitors
while on duty.
6. All new nursing personnel shall be given orientation before given regular assignment
is given.
7. The 2-weeks weekly schedule of nursing personnel shall be submitted to the Nursing
Office one week before the start of the month.
8. All requests for change/exchange of off duties, leaves, permit to leave office must be
in writing in the prescribed form. It shall be coursed through the Senior
Nurse/Supervising Nurses before submission to the need Director for disposition
(Informed, Approved, Disapproved).
9. All nursing personnel are granted one (1) day off a week. However, an off-duty
maybe postponed during exigency of the service.
10. All nursing personnel are entitled to a fifteen (15) minutes coffee break and a thirty
(30) minutes mealtime. No two (2) personnel assigned in the same ward shall go on
break at the same time. In no time shall a ward be left without a Nurse or a Nursing
Attendant.
11. Going on sixteen (16) hours are not allowed unless approved by the Hospital
Authority (Medical Director or Hospital Administrator). However, in the exigency of
the service, a nursing personnel maybe required to render more than eight (8) hours of
work until the situation is normalized.
12. Absences without previous notification is not allowed. However, if an employee
cannot report for duty because of unavoidable circumstances, he/she should inform
his/her immediate superior at the Nursing Office at least four (4) hours before the
scheduled duty to give time for the Supervising Nurse to look for a reliever. Failure to
inform entails the following:
1st offense - entails an explanation and the employee is considered absent. A
written stern warning is given.
Tel # 075-568-5563 / 075 -656-2103
2nd offense - the employee is considered absent and shall pay the reliever to an
amount equivalent to one (1) day salary / 1 shift salary
3rd offense - the nursing personnel shall be recommended for administrative
sanctions.
13. Vacation leaves should be filed five (5) days before its effectivity. Maximum of 2
consecutive days is allowed.
14. Nursing personnel who wishes to resign from the service shall submit to the Chief
Nurse a resignation letter thirty (30) days before its effectivity. A clearance shall not
be granted unless all the necessary requirements are fulfilled.
15. For change of civil status, a written request addressed to the Personnel Officer
through the Chief Nurse shall be accomplished and four (4) photocopies are to be
submitted. The original copy for authentication of personnel officer.
16. All Nursing Personnel shall be aware of their responsibility. They shall update their:
a. PRC License / PTR
b. PNA Membership (Philippine Nurses Association)
17. Attendance to professional meetings and continuing education program is a must for
all nursing personnel. They are encourage to attend nursing conventions meeting but
at their own expense or if with available expenses.
18. Meetings/Conferences
Attendances to the following nursing service meetings/conferences are
compulsory unless with justifiable reasons:
a. Monthly Nursing Service Meeting that is held every last Friday of each
month.
b. A weekly Supervisor-Senior Nurses meeting every Tuesday.
c. Ward meeting to be conducted monthly by Supervising Nurse/Senior
Nurse and / or Chief Nurse
19. Nursing personnel wishing to undertake Post Graduate Masteral Studies shall request
in writing to the Chief Nurse and discuss the intention before enrolling for the course.
20. Hospital equipment/ facilities are "private owned" and as such, should never be taken
from the units of the hospital for personal use. The personnel concerned shall shoulder
losses or damage to these properties.
21. All Nursing Personnel are required to participate in the different hospital activities
which maybe required or scheduled.
22. All Nursing staff on duty should wear proper PPE’s and universal precautions for
infectious diseases such as Covid-19 disease, Hepatitis B, HIV, etc. should be strictly
observed
23. Proper donning and doffing of PPE’s should be practice and implemented at all times.
24. All personnel with fever and respiratory symptoms such as cough, sore throat. Should
not go on duty and give proper information and make necessary arrangements for
relievers/ stand-in for their duties in order not to compromise the services.
Tel # 075-568-5563 / 075 -656-2103
ADMINISTRATIVE SERVICE:
I- ACCOUNTING
1. Disbursement of funds shall be made only upon certification on the

availability of funds by the Accountant and upon approval of the Hospital
Administration or his authorized representative in his absence.
2. Vouchers for remittances to the SSS, BIR, PAG-IBIG, PHILHEALTH, etc.
and loan repayments shall be made/prepared for remittance within the first ten
days of the month.
3. Financial reports required by hospital management, Accounting Office, and
other government agencies must be prepared immediately and be submitted
within the specified period.
4. Maintains indexing cards to ensure accuracy in all vouchers, payrolls, and all
kinds of payments/transactions of the hospital. Endorsement logbooks of all
cash and checks should be signed by the receiving personnel.
5. Observe the objectives and principles of proper accounting.
6. Official Receipts should be issued and recorded for computation and expenses
II- CASHIER
1. All collections must be issued with the corresponding official receipts and be
deposited with the official depository bank on the following working day.
2. All vouchers paid must have been properly acknowledged and/or receipted by
the payee.
3. Cash advance for salaries, allowances, TEV's and other operating expenses
must be liquidated before another cash advance is withdrawn or allowed.
4. Deposit slips must have file copies and original copies given to the authorized
collection for Trust Fund and Hospital Income must be submitted to the
Accounting, Treasurer's.
5. All salaries, allowances and other remuneration due to employees are paid
accordingly upon signing payrolls within specified period and upon
presentation of updated daily time record of the employee (Biometrics Record)
6. Proper protective barriers should be in place in the Cashier’s Office
7. All office personnel should wear proper PPE’s (Level 1).
Tel # 075-568-5563 / 075 -656-2103
POLICIES ON TIMELY REFERRAL AND CASE

REPORTING OF HIGHLY TRANSMISSIBLE AND
NOTIFIABLE INFECTIOUS DISEASE
I. The following are:
a. Covid-19
b. Monkey pox
c. Cholera
d. Ebola Hemorrhagic Fever
e. Plague
f. Yellow Fever
g. SARS
h. Avian Flu
i. Meningococcemia
j. Other diseases declared by DOH
II. Once the above diseases are diagnosed or suspected, the Community Health Office
(CHO) will be called and notified immediately.
III. The suspected patient will be placed in the Isolation Room / Triage Area while
waiting for assistance to transfer to institution with facilities for such condition.
IV. Nurses assigned to the Isolation Room will be using a N-95 mask, disposable head
cover, disposable gown, disposable gloves, and disposable feet cover (Level 3).
V. Said patient may be referred to Institution with facilities for such conditions via an
Ambulance.
VI. Hospital Staff who were in contact with the patient will be quarantined accordingly to
the most recent guidelines. Monitoring Flu-like fever, rashes, cough, dyspnea and
other signs of illness.
VII. Hospital Staff will be provided by the Hospital with medical support.
Tel # 075-568-5563 / 075 -656-2103
EMERGENCY ROOM
EXAMINATION AND TREATMENT AREA
OBSERVATION AREA
Tel # 075-568-5563 / 075 -656-2103
OR/DR COMPLEX
SUB-STERILIZING AREA
Tel # 075-568-5563 / 075 -656-2103
FEMALE WARD
Tel # 075-568-5563 / 075 -656-2103
RECEIVING LOGBOOK FOR BIRTH/DEATH

CERTIFICATE FROM LCR
Tel # 075-568-5563 / 075 -656-2103
LOGBOOK FOR BORROWING AND RETRIEVAL OF

CHART
LOGBOOK FOR STORAGE, RETENTION AND DISPOSAL

Tel # 075-568-5563 / 075 -656-2103
STERILE BURN SHEETS
HOSPITAL POLICY ON CADAVER DISPOSAL
Immediately upon the death of a person, nurses assisted by the

janitor should be in full P.P.E. wearing double gloves (level 3 or
level 4)
i. The cadaver is immediately placed in a cadaver bag, sealed,
labeled and must not be reopened again. Temporarily placed in the
Cadaver Holding area while waiting for the Funeral Services
provider.
ii. The City Health Office must be informed of the deceased person
who are COVID-19 suspect, probable or confirmed cases.
Information includes patient name, age, sex, contact
persons/relatives.
iii. Funeral Service provider capable of COVID-19 cadaver disposals
are contacted by the relatives immediately.
iv. Non COVID-19 deceased patients are turned over to the funeral
services provider contacted by their relatives.
Tel # 075-568-5563 / 075 -656-2103
HOSPITAL POLICY ON AMBULANCE BREAKDOWN
I. Our institution has a Hospital Ambulance with plate no. AEN229. There are
ambulance drivers on duty and on call.
PLAN A: There are two back up vehicles (Patient Transport

Vehicle) with plate no. AFA538 and another vehicle (EMS) with plate no.
NIS5434, in case the Hospital Ambulance become unserviceable.
PLAN B: The hospital has an existing Memorandum of Agreement

(MOA) with the Dagupan Doctor Villaflor Memorial Hospital (Level 2
Hospital) should there be vehicle/ambulance breakdown or malfunction
during patient transport. Attached herewith is a copy of the MOA with
DDVMH and its LTO (License to Operate).
II. Although the hospital has its ambulance services, patients’ preference is
important and they have the option to get ambulance services from the LGU
or other government hospital’s ambulance.
Tel # 075-568-5563 / 075 -656-2103

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DIVINE MERCY HOSPITAL

# 25 High School Drive, San Vicente West, Urdaneta City, Pangasinan

The DIVINE MERCY FOUNDATION OF URDANETA HOSPITAL hereby execute

2. However, the Ilocos Training Regional Medical Center (ITRMC) in San

3. Attached herewith is the communication letter from Ilocos Training Regional

4. This Memorandum of Undertaking is executed to show our willingness to comply

ANITA C. TARECTECAN, MD, FPCS, PFSGS, FPALES

The DIVINE MERCY FOUNDATION OF URDANETA HOSPITAL hereby execute

3. This Memorandum of Undertaking is executed to show our willingness to comply

ANITA C. TARECTECAN, MD, FPCS, PFSGS, FPALES

The DIVINE MERCY FOUNDATION OF URDANETA HOSPITAL hereby execute

2. Attached herewith is the communication letter from Philippine National Red

3. This Memorandum of Undertaking is executed to show our willingness to comply

ANITA C. TARECTECAN, MD, FPCS, PFSGS, FPALES

POLICIES OF MEDICAL, NURSING AND

1. Disbursement of funds shall be made only upon certification on the

POLICIES ON TIMELY REFERRAL AND CASE

RECEIVING LOGBOOK FOR BIRTH/DEATH

LOGBOOK FOR BORROWING AND RETRIEVAL OF

LOGBOOK FOR STORAGE, RETENTION AND DISPOSAL

STERILE BURN SHEETS

HOSPITAL POLICY ON CADAVER DISPOSAL

Immediately upon the death of a person, nurses assisted by the

HOSPITAL POLICY ON AMBULANCE BREAKDOWN

PLAN A: There are two back up vehicles (Patient Transport

PLAN B: The hospital has an existing Memorandum of Agreement

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