Pcs Manual 2014 Revised4

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FIRST CABUYAO HOSPITAL Revision Date:
AND MEDICAL CENTER, INC. Page 1 of 304
QUALITY PROCEDURE
PATIENT CARE SERVICES
GENERAL NURSING UNIT
POLICIES ON PATIENT'S RIGHTS TO CARE

PURPOSE
Each patient is unique with his or her own needs, strengths, values and Beliefs. UPar-HMC works to
establish trust and open communication with patients and to understand and protect each patient's
cultural, psychological and spiritual values. Patient care outcomes are improved when patients has
appropriate their families or those who make decisions on their behalf, are involved in care
decisions and processes.
POLICIES
1. Patients and personnel of UPar-HMC shall be educated with the Patient’s Rights.
2. Patients shall be informed of their rights and how to act on them.
3. The personnel of UPar-HMC shall be taught to understand and respect patient's belief and
values and shall provide considerate and respectful care; these protect the patient's dignity.
4. Patients and their families need complete information on the case and services offered by
UPar-HMC. This information shall have an open and trusting communication between
patients, their families and UPar-HMC.
5. The right to receive medical care shall respect the patient's race, religious beliefs, sexual
orientation, social status, cultural background.
6. Patients in emergency shall be extended immediate medical care and treatment without any
deposit, pledge, mortgagee, or any form of advancement for the treatment.
7. The patient has the right to continuity of health care. The physician has an obligation to
cooperate in the coordination of medically indicated care with other care providers treating
the patient. The physician may not discontinue treatment of a patient as long as further
treatment is medically indicated without giving the patient reasonable assistance and
sufficient opportunity to make alternative arrangements for care.
Description of Revision Originated by: Checked by: Approved by:
Dept. Head Hospital Admin./Medical Director Chairman/President

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QUALITY PROCEDURE
POLICIES ON PATIENT‘S RIGHTS TO CONSENT

PURPOSE
The patients are involved in their care decisions by granting informed consent.
POLICIES
1. The patient shall be provided with all information relating to the planned care to enable him/
her to make decisions.
2. The consent process shall be clearly defined by UPar-HMC.
3. Informed consent for care requires the people other than the patient be involved in Decisions
about the patients care. This is true when the patient does not have the mental or physical
capacity to make their decisions. When patient cannot make Decisions regarding his care, a
legal representative shall be identified. This shall be noted in the patient's record book.

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QUALITY PROCEDURE
POLICIES ON THE PATIENT'S RIGHTS FREEDOM OF CHOICE

PURPOSE
To implement the patient’s right to choose freely and change his/ her physician and hospital
regardless of whether they are in the private or public sector.
POLICIES
1. Upon admission a patient is given the right to choose his attending physician. For patients
who do not have their own physician the hospital shall assign an attending physician from its
roster of physicians.
2. The patient shall have the right to ask for the opinion of another physician at any stage or
facility.
3. The patient shall have the right to ask the medical staff to help limit visitors to certain people.
4. The patient shall have the right to leave the hospital regardless of his physical condition
provided that:
a. He/she is informed of the medical consequences of his/her decision.
b. He/she releases those evolved in his/her care from any obligation relative to the
consequence of his decision.
c. His/her decision will not prejudice public safety
d. No patient shall be detained against his/her will on the sole failure to fully settle his
financial obligation.

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POLICIES ON PATIENT'S RIGHTS OF INCOMPETENT PATIENTS

PURPOSE
To ensure minor patients and their parents or guardian and to assure that the rights of a legally
incompetent patient are respected and to guarantee that this medical needs are addressed.
POLICIES
1. The minor patient shall have the right to a considerate and a respectful care.
2. They shall have the right to obtain complete current information concerning their diagnosis,
treatment and progress from their physicians through their parents or immediate legal
guardian.
3. The minor patient shall have the right to review information from their physician necessary to
give informed consent through their parents/ legal guardian prior to the start of any
procedure and/ or treatment where medically significant alternatives for care or treatment
exist, or when the patient legal guardian request an information concerning medical
alternatives, the patient shall have the right to such information and to know the name of the
person responsible for the procedure and/ or treatment.
4. The patient through their parents/ legal guardian shall have the right to refuse treatment to
the extent permitted by law or belief religion and shall be informed of the medical
consequences of their action, a written consent shall be secured from the legal guardians.
5. The patient shall have the right to every consideration of his privacy concerning his own
medical care progress.
6. The patient shall have the right to expect the communication and record pertaining to his
care shall be treated confidentially.
7. The patient shall have the right to expect within its capacity, the hospital shall take
reasonable response to the request of their patient for service.
8. The patient shall have the right to obtain information as to any professional relationship
among individual, by name, which are treating them.
9. The patient and the legal guardian shall have the right to be advised if the hospital proposes
to engage in or perform human experimentation affecting his care/ treatment. Patient shall
have the right to refuse to participate.
10. The patient shall have the right to expect reasonable continuity of care.
11. The patient shall have the right to examine and receive an explanation including his/ her
parents or guardians of his/ her right regardless of source of payment.
12. The patient and the legal guardian shall have the right to know what hospital rules and
regulations apply to his/ her conduct.

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13. If the patient’s legally entitled representative, or a person authorized by the patient forbids
treatment which is, in opinion of the physician not in the patient’s best interest, the physician
shall challenge this decision in the relevant legal or other institution. In the case of
emergency, the physician shall act to the patient’s best interest.
14. In the event a third party consent is required, the following persons in order of priority stated
hereunder, shall give consent:
a. Spouse
b. Son or daughter of legal age
c. Either parent
d. Guardian
15. If a legally entitled representative is not available, but a medical intervention is urgently
needed, consent of the patient shall be presumed unless it is obvious and beyond any doubt
on the basis of the patient’s previous firm expression that he/she would refuse consent to the
intervention in that situation.
16. Physician shall always try to save the life of a patient unconscious due to suicide attempt.

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POLICIES ON PATIENT/FAMILY EDUCATION

PURPOSE
To involve patients and families in the goal of increasing comprehension and participation in the
self-management of health care needs thru patient education.
POLICIES
1. Patient/family education shall be an interdisciplinary and collaborative process designed to

meet the needs of the individual patient throughout the continuum of care.
2. Educational material shall be provided to patients as a reinforcement or resource for
teaching and should be provided in their primary language or with the assistance of an
interpreter whenever possible.
3. The heath care team shall be responsible for:
 Assessing the patient’s need for information, understanding and/or skills inclusive of
special communication needs, interpreters, etc.
 Identifying, planning, and coordinating the teaching interventions necessary to meet
the ongoing healthcare goals of the patient/family initiating interventions designed to
address specific learning needs.
 Evaluating the learner’s response and documenting/communicating, the outcome
and need for the follow up teaching.
NEEDS ASSESSMENT FACTORS

 Assessment of patient/family learning needs shall include:
o Identification of designated learnings to be involved in the educational process,
primary language or mode of communication a patient’s ability to read written
materials prior to knowledge of identified topics, readiness to learn identified barriers
to learning physical, cognitive, or emotional limitations, cultural, spiritual or religious
factors, desire and motivation to learn age/developmental factors and individual
learning preferences.
o Patient education’s individualization according to the identified learning needs of
each patient. Topics/teaching interventions may include but are not limited to subject
such as:
 Patient’s rights and responsibilities, medical condition, medication, use of
specialty equipment, nutrition/potential food drug interactions, personal care
and hygiene, discharge planning, pain management, coping, development

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issues, health maintenance and disease prevention, and available hospital or

community resources.
 Teaching interventions are planned and communicated as needed in
collaboration with other interdisciplinary care providers.
PATIENT TEACHING INTERVENTION, EVALUATION, AND RESOURCES
1. Health care providers shall be responsible for providing educational content to patients by
methods that foster understanding of the material. These methods shall include oral
instruction, provision of written material, audio/video material, formal classes,
demonstration/return demonstration, or others.
2. Each team member shall be responsible for evaluating the effectiveness of the education
based upon the patient’s learning outcomes.
3. Specialty services and personnel shall serve as resources for the development and selection
of materials supporting patient education activities. Examples of available resources include
printed and audio/visual material, online resources, vendor-supplied patient education
materials, and Closed Circuit Television (CCTV).
4. The health care provider distributing materials to the patient/family shall be responsible to
evaluate and assure that the material provided from any source is accurate and appropriate
to reinforce education. Materials provided to one patient may not be appropriate for
distribution to another. The abilities and needs of each patient shall be independently
assessed.
REQUIRED DOCUMENTATION
1. Routinely distributed patient education materials shall be periodically submitted to content

experts for review, revision, and approval.
2. Content experts shall include physicians, nurses, therapists, pharmacists, nutritionists, and
other health care professionals with expertise in the content area.
3. The Patient Health Education Office shall be a resource for the internal review and approval
process, including evaluation of material for demonstrated need, visual effectiveness,
potential duplication or replacement of existing materials format, graphics, cost, length,
readability, and translation.

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QUALITY PROCEDURE
POLICIES ON PATIENT AND FAMILY INVOLVEMENT IN CARE DECISION

MAKING
PURPOSE
To define the involvement of patients and families in making care decisions on ethical issues based
on the code of ethics and patients right.
POLICIES
1. Hospital employees shall identify and organize accurately the patient's data, including the
assessment, laboratories and treatment to be done and the medications needed.
2. The physician and the nurse shall explain to the patient the treatment of care that will be
rendered during his/ her hospitalization.
3. Patient shall decide to which service he/ she may be admitted and before the treatment the
patient will decide if she/ he will accept or refuse it
4. During the treatment, the nurse or the Physician shall give the patient an option on how the
treatment should be done depending upon the situation or the procedure.
5. If the patient is unconscious or otherwise unable to express his/ her will, an informed
consent shall be obtained whenever possible.
6. All hospital employees shall respect every patient whatever status, condition or illness/ he
she may have. If an UPar-HMC employee would commit a mistake from this policy, he/she
shall report to his/her senior and be accountable for his or her actions.
7. Patients have different beliefs or religious organization. All employees of UPar-HMC shall
respect each patient if spiritual needs will be provided for the patient especially for those who
are unconscious and dying.

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POLICIES ON INVOLVEMENT OF PATIENTS AND FAMILIES IN MAKING

CARE DECISIONS ON ETHICAL ISSUES TO INCLUDE THE FOLLOWING:
I. RIGHT OF THE UNCONSCIOUS PATIENTS
1. If the patient is unconscious or otherwise unable to express his / her will, informed
consent shall be obtained whenever possible, from a legally entitled representative.
2. If the legally entitled representative is not available but a medical intervention is
urgently needed, consent of the patient shall presume unless it is obvious and
beyond any doubt on the basis of the patient’s previous firm expression or conviction
that he/she shall refuse consent to the intervention in the situation.
II. RIGHT TO DIGNITY
1. The patient’s dignity and right to privacy shall be respected in all times in medical
care and teaching. As shall his / her culture and values.
2. The patient shall be entitled to relieve his / her suffering. They are also entitled to
humane terminal care and to be provided with all available assistance in making
dying as dignified and comfortable as possible.

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POLICIES ON RIGHT TO APPROPRIATE CARE BASED ON RELIGIOUS

BELIEFS AND PERSONAL BELIEFS
PURPOSE
To provide patients and families pastoral care services. The pastoral care services focuses on the
patients’ and families’ spiritual well-being and provides support to the staff. Unihealth Parañaque
Hospital and Medical Center respects regardless of the religious and personal beliefs of patients
and families.
POLICIES
1. The hospital shall be made aware of the different religious affiliations of its patients. As such
these beliefs are taken into consideration in giving care to our patients.
2. Relatives requesting their patients of pastoral/spiritual blessings:
a. The nurses of the nursing unit shall inform the Nursing Supervisor about the request
of the patient or relative
b. The staff nurse in the unit Nursing Supervisor shall contact the chaplain of the
hospital.
c. If the chaplain of the hospital is not available, the nursing Supervisor shall inform the
nurse of the particular nursing unit. In return the nurse will inform the relatives of the
non-availability of the chaplain.
d. The relatives can bring their own priest/minister due to the non-availability of the
chaplain. The nurse in the nursing unit shall inform the nursing Supervisor.
3. The chaplain of the hospital shall hold _____________and _______________masses in the
chapel located at 10th floor beside the functional hall.
4. Patients who request for a particular diet as part of his religion shall be accommodated e.g.
Muslim patients request for meat- free diet.
5. Patients shall have the right to refuse medical treatments or procedures which maybe
contrary to his religious beliefs. Patients who refuse blood transfusion (e.g. Jehovah’s
Witness) shall not be given blood except in instances when withholding transfusion of blood
or blood products may endanger the patient’s life.
6. The patient shall have the right to receive or to decline spiritual and moral comfort including
the help of a minister of his/her chosen religion.

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QUALITY PROCEDURE
POLICIES THAT ADDRESS PATIENT’S NEEDS FOR CONFIDENTIALITY

PURPOSE:
To assure that the medical records of the patient shall be kept confidential at all stages of his/her
treatment.
POLICIES:
1. All UPar-HMC employees shall be responsible for maintaining the confidentiality of all patient
information about their health status, medical conditions, diagnosis, prognosis and treatment
and all other information.
2. New employee orientation shall include education on the importance of patient’s right and
Confidentiality.
3. All UPar-HMC Employees and Non-Employees shall not share valuable information within or
outside the vicinity.
4. Information shared within UPar-HMC employees shall be on a need to know basis only.
5. All patient inquiries shall be channelled through Medical Records.
6. All UPar-HMC employees shall not discuss hospital and patients issues with news media.
7. All inquiries shall be channelled to the Boardroom through the Nursing Supervisor/ Senior
House Officer.
8. If the patient will transfer to other Hospital, copies of the following information shall be
furnished:
a. The patient’s Clinical Abstract written by the ROD
b. Duplicate copies of all diagnostic results
c. Films of the ultrasound
d. Ct-Scan
e. X-ray (secure LOA from the ROD in order to obtain this films from the Radiology
department)
9. All information about the patient shall be considered confidential.
10. The hospital or its medical staff and all those who have legitimate access to the patient’s
record shall not be authorized to divulge any information to a third party who has no concern
with the care and welfare of the patient without his consent except:
a. When such disclosure will benefit public health and safety
b. When it is in the interest of justice and upon order of the court
c. When the patient waives his right in writing.
d. When it is needed for continuing medical education or advancement of science.

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11. Informing the spouse or the family of the patient’s condition shall be allowed provided that
the patient is of legal age and shall have the right to choose on whom to inform. In case the
patient is minor or is mentally incapacitated, such information shall be given to parents, legal
guardian or next of kin.
12. All identifiable patients’ data shall be protected appropriate to the manner of its storage.
13. All identifiable information about a patient’s health status, medical condition, diagnosis,
prognosis & treatment and all other information of a personal kind shall be kept confidential
even after death.
14. Expect that all communications and other records pertaining to his care, including the source
of payment for treatment, all else shall be treated as confidential.

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POLICIES THAT ADDRESS PATIENT’S NEEDS FOR PRIVACY

PURPOSE
To assure that the privacy of patients shall be respected at all stages of his/her treatment.
POLICIES
1. Patients shall have their personal privacy respected; case discussion, consultation,
examination and treatment shall be confidential and shall be conducted discreetly.
2. Patients shall have the right to be told the reason for the presence of an individual.
3. Patients shall have the right to have visitors leave prior to an examination and when
treatment issues are being discussed.
4. Privacy curtains shall be used in the wards and semi-private rooms.
5. The patient shall have the right to be free from unwarranted public exposure except in the
following cases:
a. When his mental or physical condition is in controversy and the appropriate court
orders him to submit to a physical or mental examination by a physician
b. When the public health and safety so demands
c. When the patient waives his right.
6. The patient shall have the right to be interviewed and examined in surroundings designed to
assure reasonable audio-visual privacy. This includes the right to have 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.
7. Expect that information given to concerned family members or significant other legally
qualified person, information shall be delivered in privacy and with due consideration of
confidentiality.
8. The patient shall have the right to be placed in a protective privacy and/or shall be assigned
an alias name when considered necessary for personal safety.

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POLICIES THAT ADDRESS PATIENT’S NEED FOR SAFETY & SECURITY

PURPOSE
To maintain a safe and secured environment for patients.
POLICIES
1. The environment at the Unihealth Parañaque Hospital and Medical Center shall be kept safe
for patients, employees, and visitors through several mechanisms that include but are not
limited to Maintenance Department and Infection Control Committee.
2. The patient shall have the right to expect reasonable safety in so far as the hospital practices
and environment are concerned. To address the needs of the patient, visitor and staff
regarding safety and security, security guards are posted in and around the hospital round
the clock.
3. Other safety and security measures shall include limited access to the facility through the
issue of visitors’ identification cards on major entrances and the use of employee
identification cards that are to be conspicuously displayed at all times.
4. Maintenance personnel shall make routine inspections of all area of the hospital to assess
for any unsafe areas. When items or areas are found to be out of compliance in their
respective units, the Head Nurse/Department Head shall channel the information to the
correct Department for correction or repair.
5. Infection Control Committee shall monitor all areas of the hospital and hold in services to
correct the deficiency found during the surveillance.
6. Emergency fire alarms/exit plans shall be scattered in strategic areas of the hospital. These
shall be used to alarm everyone for the need to evacuate the hospital because of a fire. Fire
extinguishers shall also be found in strategic locations.
7. All patient-owned cord and plug-connected electrical appliances and equipments used in
patient rooms shall be inspected for electrical hazards by maintenance personnel prior to
use. All equipment shall be labelled as UL approved and in safe working condition (no frayed
cords, etc.) No electrical appliances shall be permitted within six feet of a patient’s bed. Heat
generating appliances such as hot plates and coffee makers shall not be used in a patient’s
room. The use of other electrical appliances may be restricted. UParHMC shall not be
responsible for incidents related to personal electrical equipment.
8. Smoking shall be prohibited on the Hospital Grounds and Facilities.
9. All medications taken while in the hospital shall only be those prescribed by a doctor,

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dispensed by the hospital pharmacy and administered by a nurse. Patients shall not be
permitted to administer their own drugs or keep personal medications at their bedsides,
unless specifically ordered by the physician.
10. Wheel chairs shall be available on all nursing units, but getting in and out of them without
assistance may be hazardous. Patients shall be advised to ask for help from a member of
the hospital staff.
11. Patients shall be advised not to bring items of value to the hospital. If valuable items are
brought, they shall have the option to notify the admissions or nursing staff immediately so
the items can be inventoried and deposited in the hospital safe. The hospital shall not be
responsible for valuables unless they are deposited in the safe. If a patient loses something,
they shall notify the nurses immediately for them to help patients find the lost item. Items
found shall be turned in to Security.
PROCEDURES
1. When an injury occurs with a patient, these are the following steps:
a. The Nurse in charge informs the Head Nurse if present. If Head Nurse is not present
he/she informs the supervisor about the incident.
b. The Head Nurse/Charge Nurse informs the ROD.
c. The ROD assesses the patient and identifies the problem that must be corrected then
informs the AP and asks the treatment and management.
d. The Head Nurse /Charge Nurse informs the supervisor about the recommendation
treatment and management of the AP.
e. The Supervisor informs the Hospital Administrator about the said recommendation.
f. The Hospital Administrator decides for approval.
g. The Supervisor requires the Nurse in charge to make an incident report within 24 hours
for documentation.
2. When an employee is injured these are the following steps:
a. The Head Nurse/Charge Nurse/Health Care Attendant brings the injured employee to the
ER for injury assessment and treatment by ER consultant.
b. The Head Nurse/Charge Nurse then informs the Supervisor about the incident,
c. The Supervisors go to the ER to check the injured employee and ask the ER consultant
about his/her recommendation.
d. The supervisor informs the administrator about the incident, treatment to be administered
and the recommendation of the ER consultant for approval.
e. The injured employee then submits an IR to the Supervisor within 24 hours for
documentation.
3. When a visitor is injured these are the following steps:

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a. The Head Nurse/Charge Nurse/ Health Care Attendant/any UPar-HMC employee who
saw the incident brings the injured visitor to the ER for injury assessment and treatment
by the ROD/ER Consultant.
b. The UPar-HMC employee who saw the incident and who brought the injured visitor to the
ER then informs the Supervisor about the incident.
c. The Supervisor goes to the ER to check the injured visitor and asks the ROD/ER
Consultant about his/her recommendation and then waits for approval.
d. The UPar-HMC employee who saw the incident submits an incident report to the
Supervisor within 24 hours for documentation.

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POLICIES ON INFORMED CONSENT

PURPOSE
To ensure that informed consent is obtained from the patients in UPar-HMC.
POLICIES
1. Informed consent shall be obtained and placed on the patient’s medical record for
admission, surgical procedures, special diagnostic x-ray procedure, for emergency
treatment, administration of blood and blood components, ambulatory care treatment,
treatment of minors, mentally disabled, anaesthesia and deep sedation.
2. General consent shall be obtained during:
 Full registration
 ER registration
 In-patient admission
3. Specific informed consent shall be obtained for these procedures:
 Surgical and Invasive procedures
 Surgical and X-ray procedures
4. Blood consent shall be obtained for the administration of blood and blood products.
5. Chemotherapy consent shall be obtained for the administration of chemotherapy drugs.
6. In emergency situations, consent for treatment shall be implied, allowing treatment to
process without obtaining written patient consent. Emergency situation could reasonably be
expected to result in:
 Placing the health of individual in serious jeopardy.
 Serious impairment of bodily functions
 Serious dysfunction of bodily organ.
7. The attending physician shall be legally responsible for informing the patient of the nature
and purpose of the procedure whether diagnostic or therapeutic and the rest involved in the
proposed procedure.
8. The physician shall be responsible for the completion of the informed consent. If the nurse
will be the one to fill-up the consent, it shall be checked by the Physician.
9. No abbreviations shall be written on the consent form.
10. Consent forms shall be documented.
11. Witness in the consent shall be: a Physician (other than the one performing the procedure),
Nurse or any legal adult. The witness signature only verifies the patient’s identification and
does not indicate or imply responsibility on the informed consent.

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12. The patient shall be free of destruction and not under the effect of sedation when signing. In
an Emergency situation, it shall be the responsibility of the physician who will be performing
the procedure/ treatment to determine if the patient is capable in making informed decision.
13. The patient shall at any time revoke the signed informed consent prior to the procedure
being performed.
14. No elective surgery/ procedure shall be executed without any informed consent from the
relatives or patients themselves otherwise subject to cancellation of the procedure or
surgery.
15. UPar-HMC, shall specifically delineate the person authorized to give the consent:
 An adult patient
 Patient's legal wife/ husband
 Any parent, whether adult or minor for his child
 The patient's siblings(of legal age)
 Any person/ guardian who is responsible for the patient ( of legal age )
16. Consent for individual with a developmental disability and incompetent minor, the following
shall give the consent:
 Any parent of the child.
 Guardian of the child.
17. For incompetent adults or temporarily not capable of giving consent patients, the following
shall sign the consent form:
 The patient's Husband/ wife
 The patient's siblings ( of legal age)
 Guardian/ representative of the patient (legal age)
18. If other than the patient, when the person granting the consent is not available or present, a
witnessed telephone consent shall be obtained by the Attending Physician/ Resident on
duty with a second staff person (RN) participating, regarding the next to kin permission to
perform the procedures. The conversation shall require:
 That the next of kin identify him/herself
 The next of kin affirming his/her relationship with the patient
 The next of kin granting his/her approval of the procedure
 The Attending Physician stating any restrictions which are to be met.
19. Informed consent must be documented at the Medical Records of the patient (nurses
notes)

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POLICIES ON PATIENT’S RIGHTS TO REFUSE TREATMENT

PURPOSE
To guarantee the rights of a patient to refuse treatment.
POLICIES
1. A patient shall have the right to refuse treatment/ life-giving measures to the extent permitted
by the law.
2. A patient shall have the right to be informed of the medical consequences of his act of
refusing treatment or life-giving measures.
3. A patient who refuses treatment shall release those involved in his/her care from any
obligations relative to the consequences of his decision.
4. A patient shall have the right to refuse treatment provided that his/ her decision will not
prejudice public health and safety.
5. If a patient is unconscious or is legally incompetent and his or her legally entitled
representative or a person authorized by the patient forbid treatment which is, in the opinion
of the attending physician not in the patient's best interest, the physician shall challenge this
decision in the relevant legal or other institutions. In case of emergency, the physician shall
act in the patient's best interest.
6. The patient's refusal to undergo any treatment procedure shall not be considered applicable
for all procedures ordered by his or her attending physician and his refusal shall be revoked
by the patient anytime.
PROCEDURES
1. When a patient refuses any medication or treatment procedure ordered by his or her
Attending physician, the Nurse, the Resident on duty, or the attending physician informs him
of the consequences of his decision.
1. If the patient still refuses the said treatment procedure, the patient is then asked to sign a
document releasing the hospital for any responsibility relative to the consequences of their
decision.
2. In the case of an unconscious or legally incompetent patient, the legally entitled
representative signs the release from responsibility in accordance with the policies of the
hospital on the Rights of the Incompetent.
3. The document signed by the patient or relatives refusing medical treatments or procedures

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are documented in the patient’s chart for legal purposes.

PATIENT’S RIGHT AND RESPONSIBILITIES
(Mga karapatan at tungkulin ng Pasyente)
As patient at Unihealth Parañaque Hospital & Medical Center, you receive the best care possible.
You also have responsibilities that help both you and your clinical team make informed decisions
about your treatment while you are in our care. Please review your rights and responsibilities
carefully, and be free to ask your attending physician or nurse if you have any questions.
Bilang pasyente ng Unihealth Parañaque Hospital & Medical Center nais naming malaman at
maunawaan mo na mayroon kang mga karapatan at tungkulin na naaayon sa batas upang
siguraduhin na ikaw ay makatanggap ng mahusay na gamutan habang ikaw ay nasa aming
pangangalaga. Kung mayroon kang katanungan maaaring ipagbigay alam sa iyong doctor o nars.

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PATIENT’S RIGHT
(Mga Karapatan ng Pasyente)
The right to appropriate medical care and humane treatment.

Karapatang gamutin ng maayos at mabigyan ng sapat at makataong pag-aalaga anuman ang katayuan sa
buhay.
The right to informed consent.

Karapatang mabigyan ng malinaw at makatotohanang paliwanag sa pamamaraang kanyang mauunawaan
ang lahat ng impormasyon tungkol sa mga pagsusuri, eksamen, gamutan o operasyon na gagawin sa
pasyente at karapatang hingin ang kanyang pahintulot bago ito isagawa. Maipaliwanag ang mga posibleng
peligro o komplikasyon. Kung ang pasyente ay “minor” ang pahintulot ay dapat ibigay sa kanyang nga
magulang o legal guardian.
The right to privacy and confidentiality.

Karapatang maging pribado ang usapin tungkol sa kanyang sakit.
The right to be informed.

Karapatang malaman ang tunay nyang sakit at lahat ng resulta ng kanyang eksaminasyon. Malaman ang
lahat ng bagay tungkol kanyang karandaman pati na ang mga bayaring kanyang haharapin.
The right to refuse and self-determination.

Karapatang tumanggi sa gamutan o mabigyan ng pangunahing lunas matapos maipaliwanag ang magiging
kahihinatnan nito. Karapatang tumanggi sa anumang uri ng eksperimento/pagsusuri o pag-aaral.
The right to choose to other health care provider and facility.

Karapatang mamili ng kanyang doctor o pagamutan, humingi ng pangalawang opinion at malaman kung may
alternatibong paraan ng gamutan sa kanyang sakit.
The right to religious belief.

Karapatang tumanggi sa gamutan kung hindi sang-ayon sa kanyang paniniwala matapos maipaliwanag sa
kanya ang benepisyo at peligro nito.
The right to leave.

Karapatang umuwi o umalis ng ospital matapos maipaliwanag ang magiging kahihinatnan ng kanyang
desisyon.
The right to express grievances.

Karapatang maghain ng hinaing kung may pagkukulang ang ospital. Maaring magtungo sa tanggapan ng
chief Administrative Officer.

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PATIENT’S RESPONSIBILITIES
(Mga Tungkulin ng Pasyente)
The responsibility to provide information.

(Tungkulin sabihin ng tama at kompleto ang impormasyon tungkol sa kaniyang sakit.)
The responsibility to comply with instruction and to be involve in the decision regarding your
healthcare.
(Tungkulin sumunod sa mga pinag-uutos at pinapayo ng kanyang doctor at makibahagi sa pagpapasya ukol
sa iyong kalusugan.)
The responsibility to comply with instructions and to be in the decisions regarding your health care.
(Tungkulin sumunod sa mga ipinag-uutos at pinapayo ng kanyang doctor at makibahagi sa pagpapasya ukol
sa iyong kalusugan.)
The responsibility to ask questions regarding the nature of your illness and its management including
options, likely outcomes, benefits, risks and costs.
(Tungkulin magtanong ukol sa tunay na kalagayan ng iyong karamdaman, mga posibleng lunas,
komplikasyon, benepisyo at kabayaran.)
The responsibility to inform the physician of refusal to treatment or problems adhering to the plan of
care agreed upon.
(Tungkulin sabihin sa knayang doctor kung hindi makakasunod sa gamutan o problema sa pagsunod sa
npagkasunduan na plano ng gamutan.)
The responsibility to pay hospital charges.

(Tungkulin bayaran ang hospital bills.)
The responsibility to comply with hospital rules and regulations.

(Tungkulin sumunod sa mga alituntunin ng Ospital.)
The responsibility for being considerate of the needs of other patients and hospital staff.
(Tungkulin isaalang-alang at igalang ang mga karapatan ng ibang pasyente at mga kawani ng ospital.
Magbigay ng konsiderasyon sa kapwa pasyente sa pagtanggap ng panauhin, pag iingay at paninigarilyo.)

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THE PATIENT CARE SERVICES DEPARTMENT

VISION
The Patient Care Services Department will be a highly respected, responsible group of caring
professionals in Nursing Practice and Quality support services at the point of care delivery and
evaluating nursing care as firm and as direct as possible.
MISSION
The Patient Care Services Department will be providing excellent patient centered care in all
aspects by compassionate nurses.
PHILOSOPHY
 Nursing care for each patient and family is individualized, compassionate and culturally
appropriate.
 A patient’s care is delivered via collaborative efforts of the entire health care team, including
the patient and his/her family wherein realistic goals are set and patient teaching is
emphasized.
 Excellence in quality nursing practice includes the art of “Nursing as Caring” and the science
of critical thinking and clinical competence
 Commitment in continued advancement in technology enhances nursing practice which
allows nurse to spend more time on direct patient care activity.
 Believes that information & collaboration is essential to care coordination thru inter-hospital
personnel partnership to best facilitate patient care process.
OBJECTIVES
 Engage nurses to develop interpersonal skills that allow collaborative relationship with
patient, families, co-workers, physicians, and ancillary department members.
 Develop skills in the principles of nursing leadership.
 Improve patient outcomes.
 Expanding professional competencies within acceptable standards of nursing care.
 Provide education and clinical training that helps promote progression from academics to the
acute care setting.

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CORE VALUES
The Patient Care Services Department implements its mission guided by the dynamic and integrated
core values that promulgate the organization, provides direction and purpose which is reflected in its
work:
Unity – believes in teamwork and is highly emphasized on a daily basis, works with different
departments and healthcare professionals in order to achieving goals such as meeting patients’
needs, and improving patient outcomes.
Professionalism – is the essence of the Patient Care Services department as it upholds the
standards qualities such as:
1. Accountability
2. Responsibility
3. Commitment
4. Reliability
These degree of qualities are mainly supported and achieved thru the staff by continuous mentoring,
collaboration and cooperation in the organization.
Advocate – supports the interest of their patient, mainly can both listen and speak to you in times of
need. By the word itself advocacy it seeks to ensure that patients and relatives are able to express
their views and defend their rights and can organize a wide variety of health care related support and
educational services to maintain, improve, and manage health of a patient or a client.
Diversity - embraces acceptance and understands that every individual is unique and recognizes
individual differences. Appreciates a workforce whose diversity mirrors the population they serve.
The institution believes that it is our responsibility to promote a climate of diversity among its staff,
other departments and its customers because it is vital to our service.
Veracity – the institution believes in acting in pure honesty, ethical and professional manner is a
must and in its endeavours, wherein it will create an environment that promotes trust among its
patients, healthcare professionals and other professionals for a benefit of good patient care which
will promote a positive image to the institution.

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Compassion - a fundamental part in the nursing profession which motivates the organization to
promote care towards the best interest to their patients and other stakeholders. Characterizes our
concern and consideration for the whole person, commitment to the common good and act as an
outreach to the ones who are vulnerable. This is a critical link towards the common bond that
supports the holistic culture and healing of an individual which is practiced in a participative and
person-centered way.
Excellence – is reflected on the continuous commitment for growth, development, and

understanding in the improvement of their professional knowledge and skills as well as exploring
new opportunities in learning. Believes on the importance of having a transformation is highly
welcomed and embraced and the status quo or mediocrity is not tolerated and prominence is
acknowledged.
SIX DIMENSIONS OF CARE
1. Safe: Avoiding injuries to patients from the care that is intended to help them.
2. Effective: Providing services based on scientific knowledge to all who could benefit and refraining
from providing services to those not likely to benefit (avoiding underuse and overuse). Doing the
right thing for the right person at the right time.
3. Family-centered: Providing care that is respectful of and responsive to individual patient
preferences, needs and values, and ensuring that patient values guide all clinical decisions.
4. Timely: Reducing waits and sometimes unfavorable delays for both those who receive and those
who give care.
5. Efficient: Avoiding waste, in particular waste of equipment, supplies, ideas and energy.
6. Equal: Providing care that does not vary in quality because of personal characteristics such as
gender, ethnicity, geographic location and socio-economic status.

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Doc. No. /Rev. No.

Ma. Elena Domingo, MD
QUALITY PROCEDURE DIRECTOR, NURSING CARE
SERVCIES
Ma. Elena Domingo, MD

DIRECTOR,
Ma. Elena NURSING CARE
Domingo, MD
SERVCIES
DIRECTOR, NURSING CARE
SERVCIES

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JOB DESCRIPTION
CHIEF NURSE: The executive head of the nursing service. She is responsible to the
administration for the effective management, integration and direction of all
activities concerned with nursing care and services, and support of medical care
plan.
Job Summary:
1. Carries full administrative responsibility and authority for the entire nursing
service of the institution.
2. Coordinate all activities of the nursing service department with other services.
3. Organizes, directs, coordinates, and evaluates activities of the nursing service
staff which allow for satisfaction and professional growth.
4. Defines job description for each category of nursing personnel.
5. Interviews and screens all applicants for the nursing service and evaluate their
qualifications and experiences.
6. Participates in formulating hospital policies, in developing and evaluating
program and services.
7. Direct planning and implementation of staff development programs for different
categories of nursing personnel and conducts monthly meeting for all nursing
personnel.
8. Promotes and maintain cordial relationship with patients, their families and the
community and provide opportunities for nursing staff to work with other groups
so that the aim of the hospital can be interpreted to mean good interpersonal and
interdepartmental relationship.
9. Participate in the hospital outreach program.
10. Participate in professional meetings as the representative of the nursing service
personnel, and provides for healthful living conditions of nursing personnel.
11. Subjects to call “as the need arises.”
12. Daily ward rounds. To gain an insight to the problems and needs as presented by
the patients and the family, the nurses and other health disciplines.
13. Approved schedule of duties and off duties.

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14. Performs others duties as required.

15. Attend seminars, workshops locally and nationally as need arises.
16. Recruits and recommends personnel for appointment, promotion or dismissal
depending on staffing needs of the services.
17. Conducts orientation to the newly hired nursing personnel, clinical instructors of
different college of nursing and nursing students every each new groups of
exposure to the hospital.
18. In-charge of linen department, supervises and evaluates linen clerk to the job
given to her, checked and approved the segregation of condemned linen and
make a purchase order for replacements. Monitor if there is a sufficient stock of
linen and coordinates with Superjack Inc. as regard to laundry.
ASSISTANT CHIEF NURSE FOR TRAINING: Responsible for supporting the operations of the
nursing department.
Job Summary:
1. This role provides leadership and support to the Chief Nursing Officer (CNO) responsible for
all nursing and other designated patient care functions/services within the hospital
organization.
2. The role will assume responsibility for assisting in assessing, planning, coordinating,
implementing and evaluating nursing practice on a facility level.
3. Role assumes 24/7 responsibility in CNO’s absence.
4. The role is accountable to support CNO to ensure high quality, safe and appropriate nursing
care, competency of clinical staff, and appropriate resource management related to patient
care.
5. Responsible for overseeing and managing the assigned department directors ensuring the
quality of care of patients, including neonates, infants, children, adolescents, and adults.
6. Integrates service into the organization's primary functions.
7. Responsible for coordinating and integrating interdepartmental and intradepartmental
services.
8. Develops and implements policies and procedures that guide and support the provision of
services.
9. Recommends a sufficient number of qualified and competent staff to provide care and
treatment.
10. Ensures that the competence of all directors are assessed, maintained, demonstrated, and
improved on an on-going basis.
11. Continuously assesses and improves the performance of care and services provided.

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12. Enforces quality control programs, as appropriate.

13. Responsible for ensuring director accountability for their assigned departments.
14. Recommends space and other resources needed by the department.
15. Participates in selecting sources for needed services not provided by the department or the
organization.
16. Supports the mission, goals, and objectives of the hospital.
17. Maintains and improves own nursing management knowledge.
NURSE SUPERVISOR: Responsible in the management of nursing care and personnel for the
effective operation of the nursing service.
Job Summary:
1. Supervision of patient care

o Checks the Head nurse’s plan for patient care and sees to it that they are properly executed.
o Keeps herself informed of patient’s needs and problems.
o Reinforces health instructions given to patients and their families as the need arises.
o Verifies implementation of requests of referrals to evaluate continuity of care.
o Serves as consultant and adviser to the Head nurse in developing, devising and adopting
work techniques and methods for the solution of problem related to patient care.
2. Personnel Management
o Interprets standard operating and new procedures and policies, review work performance of
personnel to determine if it conforms to recognized standard.
o Plans the programs and work of all nursing personnel of the unit.
o Directs arrangements of schedule of work hours, off duties, vacation leaves, etc. of all
nursing personnel not assigned in the unit.
o Evaluates work accomplished by each nursing employees in the ward.
o Prepares the plans for counselling of co-workers; this is done individually especially to
personnel with problems.
o Renders harmonious relationships and self-discipline among nursing personnel under her
supervision.

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o Helps in providing an adequate and safe environment by guiding and helping Head nurses in
providing and maintaining a safe, orderly and clean environment for patient and personnel.
o Helps in providing adequate supplies and equipment by:
 Determining the needs for supplies and equipment’s based upon experience and future
plans for programs of patient care:
 Making proper representation to the administrator of the need of the department;
 Coordinating with the specially department (maintenance and property) to meet the
needs for supplies and equipment for the department.
HEAD NURSE: Heads the unit and is directly responsible for the administration and
supervision of a particular units and its overall operation.
Job Summary:
1. Staff Related
o Supervises staff in clinical area.
o Assess clinical competency and performance of staff.
o Adjust staffing to meet individual patient requirement and staff request.
o Provides means of continuing education of staff plan and coordinates and participates
in orientation of new staff.
o Counsel staff regarding personal behaviour and clinical performance as needed.
2. Patient Related
o Possesses a working knowledge of each patient diagnosis, history, goal of treatment
and appropriate nursing care.
o Evaluates nursing care given to patient and
o Make recommendation to staff.
o Collaborates with physicians in area of treatment and patient care to assure quality
care.
o Investigate problem in the units and handles events within the unit scope.
Communicates and refers to the nurse supervisor.
o Ensures proper, safe and economical use of equipment supplies and facilities for
patient care. Establish and maintain unit stocks.
CHARGE NURSE: Supervises and support a nursing staff while also treating a limited
number of patients each responsible for a different shift, department, or

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specialized unit. Charge nurse are responsible for maintaining a high

level patient of care, evaluating other nurses and acting as an
educational resources for nurses.
Job Summary:
1. Managerial Duties and Responsibilities

o Experienced registered nurses who have displayed leadership, management, and
communication skills.
o They are responsible for managing, supervising, and assisting the nursing staff, also
providing administrative support and patient care.
o Regular duties include directing the admission, discharge, and general flow of
patients, and assigning nurses and support staff to patients.
o An effective charge nurse is flexible and is able to prioritize and adapt during
emergencies.
o Provide guidance on administering care to new patients or those with special needs
and answering questions regarding protocol.
o Creates a plan of care that is individualized to a patient’s needs.
o Develops and implements training courses and organize seminars to help educate
and train new nurses and staff.
2. Administrative Duties and Responsibilities
o Performs administrative duties including creating schedules, maintaining adequate
supplies and informing staff of changes to protocol.
o In some settings, charge nurses plan budgets for the nursing staff and may provide
clerical assistance to the hospital staff.
3. Nursing Duties and Responsibilities
o May provide patient care.
o Assess and monitor patients.
o Other duties include monitoring vital signs, conferring with doctors on a patient’s
progress and reporting special circumstances.
STAFF NURSE: Responsible for the direct and indirect nursing care of patients within
an assigned area.
Job Summary:

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1. Gives direct nursing care.

2. Identifies nursing needs of patients.
3. Plans, gives and evaluate nursing care.
4. Admits patient.
5. Performs such nursing activities such as bathing and oral hygiene.
6. Assists patient in moving, maintaining proper alignment of patient’s body and utilizing
good body mechanic.
7. Takes and record vital sign.
8. Observes medical sepsis.
9. Observes signs and symptoms, institutes remedial action when appropriate and record
these in his/her chart.
10. Report observations to the physician.
11. Observes and respond to patients’ emotional & spiritual need.
12. Acts as a liaison between patients and hospital personnel.
13. Interprets to the patient and his family their roles in promoting successful therapy and
rehabilitation.
14. Prepares patients for, and assists physicians with diagnostics and therapeutic
procedure.
15. Carries out doctor’s legal values.
16. Assists physicians when examining patients.
17. Performs irrigations, catheterizations and gives enema.
18. Administers and charts medications and patients reactions to medications.
19. Instructs patients and families.
20. Sees to it that equipment receive proper care maintenance.
21. Discharge patients.
22. Performs post – mortem care.
23. Teaches and direct new professional nursing personnel.
24. Acts as head nurse when so delegated.
25. Receive and endorses ward equipment and supplies.
26. Interpret hospital policies and procedures.
27. Gives health teaching.
28. Maintains good relationship with other hospital personnel.
29. Charts accurately medications given.
30. Attends meetings and conferences.
NURSE TRAINEE:
Job Summary:

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1. Takes vital signs of the patient in the assigned station which includes:
a. Temperature
b. Pulse Rate
c. Cardiac Rate
d. Respiratory Rate
e. Fetal Heart Tone (pregnant patients)
2. Reports on the assigned area 30mins to 1 hour prior to scheduled duty.
3. Reports to Senior Nurse/Charge Nurse/Supervisor any deviation or untoward
signs/symptoms observed to any assigned patient.
4. Performs simple treatment as steam inhalation, compresses, perineal heat, sitz bath,
giving of enemas after proper instructions of the Supervisor or Charge Nurse.
5. Assists the Nurse on duty on performing IV insertion, NGT insertion, foley catheter
insertion and other bed side procedures.
6. Serves as an errand of staff nurses on the assigned station.
7. Helps staff nurses in getting the result from laboratory, radiology and cardiology
department.
8. Helps staff nurses in rendering morning care to patients.
9. Helps in changing linens of patients especially when the healthcare attendant was not
able to do it during their rounds.
10. Undergoes 5 month training period.
11. Rotates to clerical areas such as laboratory, pharmacy, radiology, and medical records
for one month, this is included in their 5 month training period.
12. Handles patient with the supervision of the Charge Nurse upon the discretion of the
Supervisor.
13. Wears white uniform and temporary IDs while inside hospital premises.
MIDWIFE: Assist the nurse or performs simple nursing procedure under the direct
supervision of the nurse. Helps to maintain cleanliness and orderliness of
nurses and patients units.
Job Summary:
1. Checks and receives articles from outgoing aide.
2. Accounts for all linens during her shift and endorses them to the nursing aide of the next
shift.
3. Attends nursing rounds with the ward nurses.

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4. Assists in giving baths to ambulatory patients.

5. Serves drinking water and nourishment.
6. Feeds patients who cannot eat by themselves.
7. Gives performs simple treatments like perineal care, enema, refilling of hot water bags
and ice caps.
8. Measures fluid intake and output.
9. Take and charts vital signs when delegated.
10. Provides specimen vials, collect urine and stool specimen and send them to laboratory.
11. Answers patient’s calls and delivers messages.
12. Provides clean linen and makes bed, serves and empties bedpans.
13. Scrubs bedpans and urinals.
14. Shaves patients for surgery.
15. Maintain cleanliness and orderliness of the patients units at all times.
16. Sees to it that all beds are complete with linens and pillows.
17. Tidy beds and bedside tables, counters cabinets and bedside chairs.
18. Removes all used or discontinued equipment from patient areas and cleans and returns
them to the utility room.
HEALTHCARE ATTENDANT: Assists in the transport of patients, does errands for the unit,
maintain cleanliness of the unit.
Job Summary:
1. Performs proper endorsement of outgoing to incoming duty every shift; never leave the
area without a reliever.
2. Reports on the assigned area 30mins prior to scheduled duty.
3. Assists the nurse on duty on giving bed bath, mouth care, and giving back rub.
4. Changes bed linens and patient’s gown during morning rounds.
5. Makes beds closed, occupied and surgical beds especially for rooms that are for
admission.
6. Cleans and empties bedpans and urinals and secure them in proper storage.
7. Assists patient to move in bed or to wheelchair or stretcher and transport them to
radiology department, ultrasound, cardio, and OR for any procedure to be done.
8. Sends any request or specimen to laboratory, radiology, cardio and to other department
with the corresponding request notebook.
9. Forwards medication requests to Pharmacy Department and receives dispensed
medications and delivers it to designated stations.
10. Helps maintain cleanliness and orderlies of the patient’s unit.

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11. Performs chest compression to patients that needs CPR.

12. Monitors and checks all oxygen tanks and gauges on the assigned station and updates
the Supervisor/Charge Nurse on its status.
13. Brings all empty oxygen tanks together with designated folders to CSR department.
Ensures all oxygen is duly charged by the charge nurse on duty.
14. Assists in providing post mortem care to expired patients.
15. Wears appropriate uniform with ID while inside hospital premises.
ER CLERK:
Job Summary:
1. Assists at the ER in rendering patient care.
2. Receives and delivers supplies for replacements.
3. Updating ER logbooks and file patients record
4. Checks and forwards the professional fee form the Accounting Department.
5. Bill patients for discharge.
6. Responsible for the medico-legal and death certificates of the patient.
7. Notify the Housekeeping department as soon as the patient has a discharge order.
8. Receives all diagnostic (ex. laboratory, X-ray, ECG, Ultrasound) results and file at the
same time in the patient chart.
9. Checks supplies and materials needed in the nurse station.
CSR PERSONNEL:
Job Summary:
1. Prepare and sterilize cotton balls, OS, gloves, rubber, goods, etc.
2. Check and see to it that all equipment are functioning properly.
3. Monitor the whereabouts of equipment and replace if malfunctioning.
4. Replace and replenish solution/supplies of treatment trays.
5. Collect empty dextrose bottles, clean and prepare for use.
6. Autoclave supplies, instrument, etc, including OR-DR use
7. Collect, clean and replenish unit supplies as alcohol sponges, sterile OS, adhesive

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tapes, tongue depressor, medication tray, including medicine glasses, thermometers,

etc.
8. Keeping all treatment trays and equipment free from dust.
METHODS OF ASSIGNMENT OF NURSING CARE
PURPOSE:
Any of the following methods may be adapted with due consideration to time and exigency of
services.
1.1 Case Method – a system whereby the care of each patient is assigned to one member of the
nursing staff.

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1.2 Team Nursing – a system whereby the team takes care of a group of patients, with the leader,
a registered nurse who assigns the duties to the members of her team at the beginning of each
shift: plans and coordinates the care for each patient and serves continuously as a resource
person for the team members. In certain situations, the team leader may perform some nursing
care functions.
1.3 Functional Method – a system whereby the head nurse or charge nurse assigns specific
tasks to each personnel who is responsible only for her assignment.
1.4 Primary Nursing Care – is patient-centered, individualized care that is comprehensive in
scope, coordinated and continuous from patient/client admission to discharge. Primary nurses
are accountable for the outcomes of the nursing care given, not just for the fact care is given.
The primary nurse may provide nursing care services to the patient individually or through
coordination of care with associates. This is accomplished through direct communication (on the job
or by telephone), nursing care plans notes and other records.
The Primary Nurse. Physician and Head Nurse control the quality of care the client receives by
maintaining an effective communication system. The quality of care given depends on the ongoing
nursing care plans, clarity of directions and the ability of the primary nurse.
1. PATIENT CARE AFFAIRS:
In most hospital due to the acute staffing problem it leaves the Patient Care Services no other choice
but to utilize the services of the professional nurse to work on a Total Patient Care level, whereby
he/she finishes his/her work routinely or mechanically. This makes the nurse frustrated and
dissatisfied with his/her job. In Unihealth Paranaque Hospital & Medical Center the nursing services
attempts to do its best by maximizing the utilization of the services of the available personnel
according to their level of preparation.
The nature of nursing service is dynamic and ever-evolving for when one problem is solved, another
comes up. It is one of the sustained services requiring 24 hours close services to the patients and

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such the personnel is exposed to more problems.

In planning the nursing care program, the following guidelines are observed:
1.1 The patient and the family comes first
1.2 A progressive set-up is adapted whereby patients are categorized according to conditions,
comforts, and needs. They are classified as follows:
A. Category I: A convalescent patient who requires supportive care. This is generally when the
patient presents his problems and needs and where health teaching is much needed in
preparation for the patient’s discharge. This type of patient is placed in units accessible to bath
and toilet facilities, to help them gradually do some things for themselves as much as possible
get back to normal state of health.
B. Category II: A patient who requires moderate nursing care; a moderately-ill patient whose
extreme symptoms are subsiding or have not appeared; whose behaviour pattern is moderate;
whose activity is partially controlled but who requires periodic treatment and or observation or
instruction. This type of patient is placed in the unit next room of the acutely-ill patient.
C. Category III: A patient who requires intensive care is acutely ill, and manifests a stage of
extreme symptoms, whose behaviour pattern is very marked; whose activity is completely or
rigidly controlled; who requires continuous treatment and or health instruction. This type of
patient is placed in intensive care unit located at the 2 nd floor which is staffed with registered
nurses prepared to take care of acutely ill patients. The unit is equipped with a pool of
equipment’s and supplies for intensive nursing care.
D. Category IV: an emergency patient who requires extensive nursing knowledge and highly
special skills in the nursing care management aspects. This type of patient is placed in the
intensive care unit.
1.3 Instituted the team nursing care approach which is a departure from the routinely functional
method of assignment.
1.4 The professional nurse in cooperation with the other members of the nursing staff, develops,
implements, and evaluates a written plan of care for each patient, which is kept current with the
patient’s changing needs.
1.5 Nursing care plan supports the medical care plans and reflect the preventive, diagnostic, and
therapeutic, supportive and restorative care needs of the patient.
1.6 The nursing care plan is reflected in the patient’s clinical record which gives evidence of the
nursing care provided and the progress made by the patient.

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1.7 The professional nurse determines nursing care requirements, assumes the responsibilities
requiring professional skill and judgment, assigns and supervises the care performed by the nurse
aides and the activities which can be carried out by other personnel.
The Patient Care Services are guided by the seven areas of professional nursing functions. Six of
these areas are independent area of nursing and one is the dependent.
The six independent areas of nursing care are:
1. The supervisor of a patient involving the whole management of care requiring the application of
principles based upon the biological physical and social sciences.
2. The observation of symptoms and reactions, including symptomatology of physical and mental
conditions and needs requiring evaluation or application of principles based upon the
biological, physical and social sciences.
3. The accurate recording and reporting of facts, including evaluation of the whole care of patient.
4. The supervision of others, except physician, contributing to the care of patient.
5. The applications and the execution of the nursing procedures and techniques.
6. The direction and the education to secure physical and mental care.
The dependent area of nursing function is the seventh area.

7. The application and the execution of legal prescription of physician concerning treatments and
medications with an understanding of cause and effect thereof.
RULES AND REGULATIONS OF THE NURSING SERVICE
HIRING PROCEDURE FOR STAFF NURSE
1. Application to the nursing service department shall be entertained upon the fulfilment of the
following:
a. B.S.N. graduate from accredited college of nursing.
b. Passed the Nursing Licensure Examination.
2. Pre-employment requirements – the following documents must be submitted. Photocopied

requirements are accepted provided the original copy is presented for proper verification:
a. Application letter addressed to the HR Department Head.

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b. Bio data with ID pictures.

a. SSS and TIN.
b. PRC ID card/Board rating & Certificate.
c. Diploma.
d. Transcript of Record.
e. Clinical Experience Record.
f. Police Clearance.
g. Recommendation letter from latest employer.
h. BLS/ IVT License/Certificate
3. Orientation Program
Under the direct supervision of the Chief Nurse, applicant who have submitted al the pre-
employment requirements, passed the entrance exam and personnel interview shall be
allowed to join the formal orientation program consisting of:
a. General classroom orientation
b. Ward orientation in order to qualify for hiring, the applicant must get a passing mark in
the orientation and also pass the medical examination.
PERFORMANCE APPRAISAL
1. Performance appraisal is conducted on a bi-annual basis for all

permanent employees.
2. Employee under 6 months’ probation shall be evaluated with in the
probation period.
a. After the fifth months of employment, the Chief Nurse will decide whether the new
employees shall be recommended for permanent employment or not.
PROMOTION:
1. Recommendation for promotion shall be made after careful deliberation by the Supervisor
and Chief Nurse.
2. Promotion shall be based on qualification, aptitude and performance rather that a seniority or
tenure.
3. The nursing personnel must obtain a very satisfactory performance
rating in the last rating submitted to qualify to his/her respective promotion.
4. Committee on Evaluation for PCS screens and evaluates candidates
for promotion. Basis for promotion are ranking status, competence, qualifications, and
eligibility for the position.

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DISCIPLINARY ACTION:
1. All nursing personnel shall conduct themselves in a courteous and

professional manner at all times.
2. Practices such as loud talking, creating unnecessary case and arguing
which detract a professional atmosphere are to be avoided.
3. A helpful and polite manner should be maintained at all times.
Condition that could lead to potential conflict with other should be referred to the supervisor
on duty.
4. Errors in medication and treatment.
5. Errors in transcribing or carrying out doctor’s order.
6. Errors and failure to carry out standard operating procedure of the unit.
7. Breakage or losses.
8. Failure to participate in the in – service training program and meeting.
ABSENCES:
1. Absences before and after scheduled off – duties, which are not justifiable, shall subject to
disciplinary action.
2. Unauthorized absences during holiday shall also be subjected to disciplinary action.
3. Medical certificate for leave must be authenticated by the hospital medical staff.
4. When an employee is not be able to report to work for any reason, the nursing service office
shall be notified at least 4 hours before the scheduled time of reporting. Failure to do so,
she / he will be charged as absent without leave.
STANDARD DRESS CODE
1. Nursing service department personnel are expected to wear the prescribed standard uniform,
nurse’s cap and ID during hour of duty.
2. Hair, uniform and shoes shall be kept neat, clean and presentable at all times.
3. No decoration, colored pins and hanging accessories shall be allowed in the uniform.
4. Probationary employees are allowed one month to prepare for the standard uniform.
INCIDENT REPORT

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An incident is any happening that is not consistent with the routine operation of the hospital. Incident
report is made to record the occurrence of the incident. Points to consider in making an incident
report:
a. The report or recording of the incident should be made and submitted within 24-48
hours from the time of the incident.
b. The incident is carefully and accurately filled out by the person involved. If these are
two or more persons involved, each should make his own report separately. This
should be brief, clear, concise and complete.
POLICY ON NURSING DRESS CODE
PURPOSE
To guide nursing service personnel regarding the existing policy on wearing uniform.
SCOPE
This policy covers all nursing personnel, and other medical allied personnel under the nursing
service, concerned in the delivery of efficient and effective coordination of services in the hospital.
DEFINITIONS
1.1 Skin head haircut – completely shaven hair cut (bald).
RESPONSIBILITY
REFERENCE DOCUMENT
1.2 Human Resources General Procedure
MATERIAL

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POLICIES
1.3 General Guidelines on Wearing Uniforms
a) All nursing service department personnel shall be expected to wear prescribed
uniform and shoes during their tour of duty.
b) Hair, uniform, and shoes shall be kept clean, neat and presentable at all times.
c) Hair should be kept clean and tied properly with the use of hairnet is advised.
d) No decorations, colored pins or hanging accessories shall be allowed on the uniform.
e) Complete uniform shall be worn when timing in and out, throughout the tour of duty.
f) Stethoscope is a part of the nursing uniform of UParHMC nurses.
g) Shirt and blouses shall be properly buttoned and uniforms with long sleeves should
not be rolled-up
h) Uniforms designed to be tucked in, shall be tucked-in properly at all times.
i) Uniforms shall not be worn before and or after official duty in places like
karaoke/videoke bars, pub house, etc.
j) Uniform shall not be worn when off duty outside of hospital premises especially when
attending socio-political and civic functions not sponsored by hospital.
k) Wearing of accessories and jewellery shall be kept at a minimum.
l) Wearing of backless blouses, spaghetti strap style of blouses, and skimpy shorts
shall not be allowed even if not on duty.
m) During cold months, black, dark blue, and white colored sweater or blazers shall be
allowed to cover the top uniform.
n) Complete and proper wearing of uniform includes the hanging or pinning of ID.
o) Violation of the above guidelines shall be considered serious offense and
corresponding penalties shall be imposed.
Dress Code for Female Nurse
a) Chemise shall be worn under light colored fabric, preferably white.
b) Undergarments without pattern/design of skin tone and in excellent condition shall be
worn at all times.
c) Wearing t-shirt under blazer shall not be allowed.
d) Shoes shall be white or black low heels and closed.
e) Slippers and sandals shall not be allowed.
f) Stockings shall be colored white or in flesh tone.
g) Hair Style shall follow the hospital prescribed cut.
h) Soft and dark colour hair dye shall be acceptable.
Dress Code for Male Nurse
a) Proper undershirt shall be worn with the uniform, preferably white.
b) Socks shall blend well with colour of shoes and uniform.

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c) Shoes shall be closed-type, black or white in colour.

d) Hair shall be kept short, no skinhead haircut, no colourful highlighted hair colour at all
times.
e) Earrings are prohibited.
Dress Code for ICU, OR/DR, NICU, ER and PICU Nurses
a) For ER nurses hospital prescribed uniform shall be allowed to wear in every tour of
duty.
b) In the ICU, smock gown shall be worn over the scrub suit when going out. Hair
bonnet, shoe cover, and mask are a must and should be used at all times when
giving nursing care.
c) Smock gown shall be worn over the uniform when going out of OR, DR, NICU, and
ICU.
d) Scrub suit shall be worn in OR/DR, NICU, PICU, and ICU.
INTRODUCTION TO NURSING TRAINING AND EDUCATION PROGRAM
The Nursing Training and Education Program is designed to provide adequate quality training to
willing applicant in order to equip them with the basic nursing information and skills to enable them to
adapt to the work situation smoothly and safely and to function in accordance with the institution’s
mission-vision.
This program allows the department to have a ready well-trained pool of nurses who can be hired
anytime in case an inadvertent resignation happens abruptly. We should always be prepared
because a rapid turnover of nurses is a normal pattern in all hospitals.
The department’s strategy is to provide a free training for all qualified applicants who in return will
not be paid by the hospital during their exposure and duty hours. The plan is to train them well
through a tough theoretical input, return demonstration and preceptor ship to reduce the possibility of
committing errors.
The entire program will serve as the survival of the fittest scheme where the best of the best will be
selected for possible hiring. Ranking will be made at the end of the program.
Before the previous’ program ends, another batch will be trained in order to provide replenishment in
the manpower as the previous batch terminates their program.
A certificate of training will be given at the end of the program. By this strategy, the department will
have enough number of staff, while the hospital pays less on the other hand the applicant is having a

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tough quality training which they pursue their profession here or in other institutions. Payment will
start in the trainee stage. We recommend that payment be given amounting to 150.00php per day
for 5 months.
This amount will enable us to accommodate more interested applicants who will be screened until
the cream of the crop is left.
The following are the phases of the program:
PHASE 1-APPLICATION Phase
STEP 1. The application phase starts when the HR department calls 10 interested applicants for
initial completion of their application.
Application folder should contain:

1. Requirements:
 Application letter addressed to the Head of the HR department
 Curriculum Vitae
 ID Pictures 2x2 colored (2 pcs)
 SSS and TIN
 Board Rating and Board Certificate
 Collegiate Diploma
 Registration PRC Card Number
 Clinical experience Record
 BLS and IVT License/Certificate
 Transcript of Records
 NBI or Police Clearance
 Recommendation Letter from latest employer (if previously employed)
STEP 2. Upon completion of the requirements, they will be forwarded to the training officer for the
initial screening process. The training officer will decide who will proceed to take the HR examination
and interview.
STEP 3. THE HR PROCESS. They will take both the Psych and personality tests. Then after, the
HR conducts the initial interview. Based on the evaluation and tests results, the HR will now pass the
applicant to the nursing department for further examination and interview.

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STEP 4. Nursing Exam and Panel Interview. The applicant will now take series of examination based
on basic nursing skills and theory. The applicant must have at least 80% equivalent grade before
he/she can proceed to the panel interview. The panel interviewers consist of the Chief Nurse, the
training officer, ICN, Head Nurse and Supervisor. The applicant who passed the entire screening
process will be recommended to the HR Department who will call the applicant confirming his/her
successful process and that he/she will be part of the orientation phase and final NTEP batch.
PHASE 2. HOSPITAL ORIENTATION

A 3-day Hospital Orientation which consists of the following:
2.1 Background
a. History
b. Services
c. Organizational Chart
d. Founders
e. Policies; UParHMC culture
2.2 Hospital Services
a. Human Resources
b. Admitting
c. Cashier
d. Purchasing
e. Pharmacy
f. Laboratory
g. Radiology Department
h. Cardio-Pulmonary Department
i. Rehab
j. CSR
k. House Keeping
l. Dietary
m. Medical Record
n. Billing
2.3 Tour
2.4 Nursing Service

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a. Areas
b. ECCS (Emergency and Critical Care Services)
c. OR/DR
d. NICU/PICU/WELL BABY UNIT
e. General nursing Unit
2.5 Each of the department will have a 10-15 min introduction of their department’s services and
personnel.
PHASE 3. NURSING ORIENTATION

A 3-day orientation regarding the UParHMC institution standards of care.
This consists of the following:
a. Basic Input
b. Theoretical Evaluation
c. UParHMC Standard of Practice
Patient’s chart
Recording and Documentation
Endorsement
Medical Care Plan
Carrying/Transcribing Doctors orders (verbal, telephone, text order)
Medication
Admission and discharge
Ward routine
Introduction to E-cart and its content
d. Return Demonstration
e. Infection Control
PHASE 4. PRECEPTORSHIP PROGRAM (Trainee Stage)

A. 3-week long program to aid the applicant in their designated areas. A senior staff nurse will be
assigned to monitor one preceptor who will be the senior’s teammate. The preceptor will be rotated
in one GNU and one special area to promote area mastery within the 3-week exposure.
The program consists of the following:
A. Exposure to the Area

- Unit orientation
- Familiarization of the personnel, set-up, policies and routines

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PHASE 5. EVALUATION AND ABSORPTION (Volunteer Program)
1.0 A 5-month independent exposure in the designated area. He/she will no longer have a preceptor
during his/her work and will assume the full responsibility of care to the patient. He/she will still be
under the continuous observation/evaluation of the head nurse/supervisor.
Hiring will be based on the following result:

a. Preceptors’ feedback
b. Performance Appraisal
c. Theoretical and Nursing Practice Adherence (Competency Exam written and practical)
1. ER/ICU/PICU
a. Emergency Drugs/E-cart/Cardiac Drugs
b. Basic ECG Rhythm strips analysis and Interpretation
c. Manipulation and control of machine/equipment
d. Dosage and solution, MCP
2. OR/DR
a. Instrumentation
b. OR Phase (Pre, Intra, Post-op)
c. Gowning, Gloving, Hand washing
d. Dosage and Solution
e. New Born Care
3. General Nursing Unit
a. E-Cart
b. Dosage and Solution
c. Basic Pharmacology
d. Basic Nursing Procedure
e. Medical Care Plan
f. Available slots
2.0 After the entire program, all applicants who made up to the last point of the process will be
ranked. The one to be prioritized for hiring will be the top ten of the group. A month before they
terminate a new batch will enter as trainee. The process will proceed until enough pool has been
accumulated.
3.0 A certificate will be given to them as they terminate their program.
4.0 Focusing on the Areas of Concern:

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4.1 Endorsement/Rounds
4.2 We came up with two options meant to be tested for its effectively in the area
4.3 Group endorsement and rounds – HN/CN to HN/CN
4.4 One on one Endorsement and rounds – NOD to NOD includes MCP validation to
Doctor’s order
5.0 Routine Schedule

5.1 This will serve as a guide or pattern which the nurse will follow as they improve their time
management skills and form their own strategy.
5.2 Below is an example daily routine plan
0:00 – 0:30 – Endorsement and rounds

0:30 – 1:00 – Reading of/checking of chart/medication
2:00 – 3:00 – V/S, medication, bedside care
3:00 – 4:00 – Opening charting
4:00 – 6:00 – V/S,- medication
6:00 – 7:00 – Closing charting, I and O
7:00 – 8:00 – Endorsement and rounds
5.3 The following are the goals

a. Be punctual and avoid absenteeism
b. Be systematic and learn to prioritize patient activities
c. Be efficient , able to finish all tasks with minimal resources and time
d. Outgoing staff will not be allowed in the area one hour and beyond
after duty hours.
6.0 Documentation
6.1 Charting of nursing assessment and activities will be based on the FDAR format wherein
F stands for FOCUS; D for DATA; A for ACTION; and R for RESPONSE. For the FOCUS
the nurse on duty will note what is his/her priority problem observed on the patient upon
endorsement. For the DATA the nurse on duty will write all the objective and subjective data
that supports the identified problem of the patient. When it comes to ACTION the nurse on
duty will take note all nursing independent interventions and Consultant’s intervention and
write it on the nurses’ notes together with the time the action was done to the patient. Finally,
RESPONSE the nurse will evaluate the response of the patient to all actions that were taken
by the nurse on duty.
6.2 Carrying out and Transcribing doctor’s order, medication card making

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QUALITY PROCEDURE
6.3 A box method will be used to show that an order has been carried out. Example is shown
below:
Box method:
01/01/14 IVF to follow is PNSS 1 L for 8 hours

8:30am
Dr. Robert Enriquez
100302 Napoleon L. Manaog Jr, RN
0681189
Medication Card Making:
a. Classify PO (color coding is still to be followed)
b. Parenteral (color coding is still to be followed)
Data included: Front view
Lopez, Roberto
5 8am
0 Cefuroxime 500mg/tab 1 tab 4pm
2 PO Q8 12mn
5/9/2014 Napoleon L. Manaog Jr RN
0681189
Date included: Back view

It should contain the name of the charge nurse and date as verification that he/she counter checked
the medication before administration
5/9/2014 Keith/Nap
7.0 Staffing
7.1 Each area will have fixed nurses for 6 months before rotation will occur. We will observe a
same patient assignment rule as much as possible but consideration can be taken by the head
nurses dependent on the variety of cases available.
7.2 Pulling out must be limited as much as possible to same subsection e.g. ICU to ER or vice
versa but in an inadvertent circumstances pulling out of area of the subsection will be done if
options are limited.

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8.0 Job Description/Responsibilities

8.1 in order to provide smoother and specific functions assumption, specific job descriptions have
been identified and as follows:
A. SUPERVISOR
a. 24 hour census summary
b. Schedule verification/checking
c. Problem-solving, IR
d. Information dissemination
e. Performance Evaluation/appraisal summary
f. Volunteer program Monitoring
g. Seminar/Training monitoring
h. Membership updates monitoring
i. Reassuring standards and policies are implemented
B. Head Nurse/Charge Nurse

a. Unit manager
b. Floor stocks
c. Equipment Inventory
d. Requisition of supplies /stocks, replenishes requisition of office supplies
e. E-cart inventory including date of expiration
f. Staff meeting
g. Problem-solving
h. Schedule-making
i. Accomplish 24 hours census
j. Station maintenance
k. Information Dissemination
l. Quality assurance of chart
m. Performance evaluation
n. Bulletin board update
o. Physical plant
C. STAFF NURSE
AM SHIFT PM SHIFT NIGHT SHIFT

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 Bedside nursing  Bedside nursing  Bedside nursing

 Update chart and MCP  Update chart and MCP  Update chart and MCP
 E-cart inventory  E-cart inventory  E-cart inventory
 Carrying out doctors order  Carrying out doctors order  Carrying out doctors order
 Request of medicines  Request of medicines  Request of medicines
 Request of stocks  Request of stocks  Request of stocks
 Changing of due  Filling of Flow sheets and
contraptions accomplishing charts
forms
 24 hours checking of
doctors order (using RED
ball pen)
OTHERS:
9.1 LATES/ABSENCES – notification must be done at least 4 hours prior to duty

9.2 Rotation to other areas: duration – 5 months (with pre-assessment and orientation prior to
rotation)
9.3 Relaying of laboratory and diagnostic results to patients – is done by the ROD as indicate din the
memo. While relaying of results to the Attending Physician is done by the charge nurse on duty as
soon as the result is available.
9.4 Changes in the chart entries will be done as soon as the present chart forms are consumed. A
seminar-orientation will be done to introduce the chart format and entries.
ORIENTATION PROGRAM OF NURSING SERVICE PERSONNEL
PURPOSE
To direct and acquaint newly hire employee/s regarding the policies, set-up, functions of each
department, job description, etc. conducted for a period of two weeks, with the Chief Nurse and the

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Training Nurse Supervisor. Applicants who have submitted all the pre-employment requirements,
passé the Psychological test, nursing proficiency test and personal interview, shall be allowed to join
the formal orientation program.
SCOPE
This policy covers all newly hired personnel (Registered Nurse, ER Clerk, Healthcare Attendant),
concerned in the delivery of efficient and effective coordination of services in the hospital.
DEFINITIONS
 Registered Nurse – a nurse who has passed minimum standard of education and training
established by a state before being licensed to render nursing care, for apply, to persons in need
of such care.
 CSSR Clerk – is a hospital clerk employed and trained in the job at the Central Supply Room.
He/she is responsible for the preparation and issuance of 24 hours supplies of the hospital and in
the maintenance of hospital equipment’s needed in rendering quality care.
 CSSR (Central Supply Room) – integral part of the supply, management system in the hospital.
 ER Clerk – is a hospital clerk employed and trained in the various clerical jobs, receptionist
duties on a nursing unit.
 Nursing Care Plan – is a method for organizing and delivering nursing care.
 Patient’s Profile – a clear picture of the patient, what has been done and what will be done are
reflected on this form and it allows quick reference to the particular needs of the clients for
certain aspect of nursing care.
 Nurse’s Notes – it is a clear and concise written account of patient’s condition, medical history;
care rendered and progress while confined in the hospital.
 Medication Administration Record (MAR) – it is where all routine, stat and pm medication are
written.
 Organizational Chart – usual expression of responsibility and relationship among people and job.
 ISO (International Standard for Organization) – an international accrediting body for hospital
standardization.
 Orientation Program – under the direct supervision of the Chief Nurse.
RESPONSIBILITY
4.1 Chief Nurse – design and developed the nursing division orientation program
4.2 General Duty Nurse (GDN) – comply with division requirements regarding orientation.
4.3 Rules and Regulations of the Nursing Department.
4.3.1 Hiring Procedure for Staff Nurses:
A. Application to the Nursing Service Department shall be entertained upon the

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fulfilment of the following:

 Filipino Citizen
 BSN graduate from College of Nursing
 Passed the Nurse Licensure Exam
B. Pre- Employment requirements – the following documents must be submitted.
Xerox copies are accepted provided the original copy is presented for proper
verification:
 Application letter addressed to the Head of the HR department
 Bio Data
 ID Pictures 2x2 colored ( 2 pcs )
 SSS and TIN
 Board Rating
 College Diploma / Board Certificate
 Registration PRC Card Number
 Clinical experience Record
 Transcript of Records
 NBI or Police Clearance
 Recommendation Letter from latest employer (if previously employed)
 BLS and IVT License/Certificate
c. Orientation Program
 General Ward Orientation
 In order to qualify for hiring, the applicant must get a passing mark in the
orientation, and also passed the medical examination conducted by E.R.
Consultant or Attending Physician.
4.3.2 Performance Appraisal
 Performance Appraisal is conducted every 6 months for all permanent
employees in the Nursing Service Department.
 Employee under 2 months’ probation shall be evaluated within the probation
period.
4.3.3 Personal Affairs
 Evaluation of applicants is done by the Evaluation Committee designated by the
Chief Nurse.
 All applicants will be referred to the personal office for the completion and filing
of application forms.
 Final selection of applications and recommendations resulting from the interview
will be forwarded to the personal office for proper actions.
 The Chief Nurse will notify in writing personal office of all vacancies, promotions

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QUALITY PROCEDURE
and additional staff positions and will interview available applicants.

 Applicants for nursing positions are open to graduate Nurse who are registered
in the Philippines and have the required personal, educational and professional
qualifications.
 Nurses applicants should not be less than 21 years and not more than 35 years
of age, with pleasing personality, are in excellent physical condition, morally
sound, emotionally stable and possess desirable personality traits.
4.3.4 Staff Development
 Orientation – Introduction of a new staff to the Philosophy, objective, policies,
procedures and physical layout of the institution as well to the key personnel to
enable the staff member to adjust herself quickly within the setting of the
hospital.
 Pre- Service Training of personnel before actual appointments or a assumptions
into the position. This helps perspective workers to adjust themselves to their
new situation and to acquaint them to the place and the role they play in the
Organization. This gives both the employer and the application a chance to
determine his fitness to the job.
 In – service – This helps newly appointed employees learn about their
environment more readily, know the people they are working with, as well as to
understand better their tasks and responsibilities.
4.3.5 Training (Nurse Trainee)
 These are the program designated to equate the employee and the job. In-
service training programs usually are planned or all personnel. In hospital nursing
service it is a process in which the nursing service personnel is helped to carry
his/her work functions satisfactorily, to learn or increase competent effective
giving or good patient care.
 The Program provides :
 Orientation- To help the new employee adjust to a new environment and
duties.
 Skill Training – to provide the employee with skills and attitudes required
for the job and to keep the employee abreast of changing methods and
new techniques of patient care.
 Continuation education – to help the employee keep up-to-date with the
new concepts, to increase knowledge, understanding and competency, to
develop ability to analyzed problems to work with others.
 Leadership and Management Development- to equip a selected group of
employee for growing responsibilities and new position.
4.3.6 Professional and Educational Opportunities

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 Professional growth is encouraged for the improvement of the personnel, but not
at the expense of the service. Special permit and arrangement with the nursing
service office should be made if the personnel service to study. She/he shall have
been with for at least (2) years before she will be given a special permit.
 Attendance at professional and cultural meetings in and outside the hospital is
also encouraged.
4.3.7 Evaluation
 The Department of Nursing Service conducts a systematic appraisal program by
which it evaluates its progress towards attainment of established objectives.
Evaluation is a day to day analysis of strengths and weaknesses in order to
provide guidance and counselling; stimulation and challenge for professional
growth. Patient’s satisfaction, improvement of nursing skill, and improvement
interpersonal relationships may be measured objectively and subjectively.
Purpose of Evaluation:
A. To forecast, modify and develop objectives.
B. Analysed results of evaluation are used a method of determining the
effectiveness of the department.
C. Administrative and clinical records and reports are utilized as tools to
evaluate nursing care.
D. Evaluate serves as a minor of the efficiency of nursing supervision.
E. Evaluation assists the administration in achieving optimum use of staff
resources, i.e., proper placement of staff, promotions, reappointments,
separations, etc.
REFERENCE DOCUMENT
Human Resources General Procedure

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MATERIAL
Not Applicable
PROCEDURE
OBJECTIVES
7.1.1 General Objectives
At the end of four weeks the registered nurse is expected to:
a. Explain the organization and administration of the Medical Center
and Nursing Service in particular.
b. Utilize appropriate forms in-patient care management.
c. Demonstrate skills in giving care to selected patient, utilizing the
nursing process.
d. Report administrative problem to appropriate person.
7.1.2 Specific Objectives (First Week)
At the end of the first week the registered nurse is expected to:
1. Know the hospital as a whole in terms of
a. History and organization
b. Philosophy, aims and objectives
c. General patient care policies and administrative policies
d. Job description of the nursing personnel
e. Functions, location, responsibilities, and different department of
the hospital.
2. Identify clinical forms used in patient care including administrative forms.
3. Make nursing care plans.
4. Identify the roles, functions and responsibilities of general duty nurse,
assistant hospital director for nursing, ward clerk, CSSR clerk, and
charge nurse.
5. Nurse legal documentation
6. Functions and responsibilities of different committees like safety, ISO,
Infection Control.
7. Nursing practice standard, and nursing memorandum
8. Nursing In-service Education
ACTIVITIES
DAY 1 - Read nursing procedural manual, and nursing policies manual, study organizational
chart and hospital tours.
DAY 2 - Endorse to nurse preceptor to orient regarding the different forms use in nursing,

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QUALITY PROCEDURE
administrative forms, types of clientele, nursing procedure.

DAY 3 - Review of policies and manuals of different departments within the hospital.
DAY 4 - Plan care of selected patients. Discussion of nursing care plans.
DAY 5 - Continuation of care of assigned patients
DAY 6 - Post-conference
7.1.3 Specific objectives (Second Week)

At the end of the second week the registered nurse is expected to:
a. Study the nursing module for drug administration.
b. Pass the nursing examination for drugs and calculations.
c. Discuss specific drugs of patient under her care.
d. Administer drug accurately and efficiently.
e. Analyse data obtained from observation, interview and records.
f. Anticipate patient’s/doctor’s needs.
g. Demonstrate skills in preparing patient for diagnostic procedures
and/or assisting medical staff in performing procedure.
h. Documents patient observation or interventions.
i. Work effectively with co-workers and other member of the health team.
ACTIVITIES
DAY 1 - Assigned to selected patient with different cases

Update Nursing Care Plan
Drug selected/Drug administration
Charting
Skills applications
DAY 2 - Post-conference
7.1.4 Specific objectives (Third Week)

At the end of third week the registered nurse is expected to:
a. Identify and categorize hospital patients and use respective forms.
b. Know the duties and responsibilities of Morning and Night shift nurses
and other allied medical personnel
c. Supervise ward clerk, chambermaids, housekeeping staff, watchers,
etc.

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ACTIVITIES
DAY 1 - Familiarize self on different forms used for specific client (HMO Corporate Accounts)
DAY 2 - Observe activities during NOC shift.
DAY 3 - Hold short health teachings among watchers and patient.
ORIENTATION PROGRAM
TOPIC CONTENT
I. Welcome UParHMC Explanation of Orientation Program
History of the Hospital
Philosophy and Objectives of the Nursing Service
PNA membership and Code of Ethics
Organizational Chart of Nursing Services
Officers and Members of UParHMC
Nursing 12hrs duty schedule pattern
Nursing Services and other Departments
Components of the Nursing Service
II. Job Description Hospital Director
Chief Nurse
Training Officer
Nurse Supervisor
Charge Nurse
General Ward Nurse, OR/DR, NICU, ER, ICU, PICU
ER Clerk
Midwife
Healthcare Attendant
Nurse Trainee
III. Personnel Policies Nursing Tour of Duty
Service Rotation plan
Work assignment
Personnel Information
Legal Documentation
Hospital Patient House Rule
Rules and Regulation of the Nursing Service
General Patient Care Policies
IV. Policies on Leaves Vacation Leave – VL
Sick Leave – SL
Emergency Leave – EL
Maternity Leave – ML

Doc. No. /Rev. No.
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Vacation Leave w/o pay

Resignation
Breach of Contract
Dismissal/Termination/Punishment
V. Employment Status Classification
Regular
Contractual
Probationary Status
Regular or Permanent
Definition of Professional Employee
VI. Benefits Vacation Leave
Sick Leave
Maternity Leave
Emergency Leave
Uniform/Nursing supplies
Overtime
Holidays
VII. Organization Philippine Nurses Association
Association of Nursing Service Administrators of the
Philippines, Inc.
Operating Room Nurses Association of the Philippines
Maternal and Child Nurse Association of the Philippines
VIII. Other Policies and Review of Organizational Chart of Nursing Dept.
Documentation Patient Chart
Nursing Care Plan/Patient’s Profile
Forms
Accepted Abbreviations
Codes
Service and medication
Admitting Admission from ER and OPD
HVC Client and other Agency
Admission Forms and Procedures
Transferee from other Hospital
Direct Admission to OR and DR, Ward
Executive Check up
Transporting of Patient to Nursing Units
In-patient transferred to ICU
Room Reservation & Policies of Admission

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Transfer Private Room to Ward

From other unit of the hospital
To other hospital
Discharge Cleared with promissory notes
Transfer to other Hospital
Expired (Funeral Parlour)
Against Medical Advice
Absconded Patient
Out on Pass
Valuables Safety –forms use
Safekeeping – Cashier
Visiting Hours Ward and Private Room
Number of Visitors allowed
Cut-off children below 7 years old
Nursing Communication Communication Logbook
Informal Correspondence Form
Nursing Memorandum
Nurses Monthly Meeting
Accident and Incident Forms and Procedures
Case Investigation
Dietary Policies Admission, Transfer, Discharge, Expired
Extra tray
Diet changes/Special Diet
Patient for Procedure
Dietary Prescription Form
OR and DR Policies of OR/DR/RR
Pharmacy Requisition of Drug
Generic Drug Act Law
Handling/Storage/Prescription of Narcotics
Procurement of STAT Requisition
Crediting of Drug and Exchange
Employees Prescription and sales
Unit Stock Procurement
CSSR Equipment and Supplies
Charging and Requisitions
Borrowing and Returning of Articles
Care of Apparatus and Instruments

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ATTACHMENTS
 Narrative Report
 Performance Rating Sheet
 Hospital Daily Census
 Daily Assignment Sheet
 Patient’s Profile
 Nurse’s Notes
 Medication Administration Record (MAR)
 Nursing Care Plan (NCP)

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STAFFING
The Nursing Service, regardless of the size of the institution or the scope of its functions, provides
for direct care patient services and administration of the department auxiliary services necessary for
the care of patients. UParHMC has _____ nurses, ___ midwives, and ____ orderlies performing
direct beside care. The rest are assigned in special areas performing direct bedside care to
“transient” patients like the ER, OR, DR, and ancillary areas performing indirect care like the CSR
and Linen services.
a. In determining the number of nursing service personnel required to adequately staff unit and the
whole nursing service consideration, is given to the number of nursing personnel required on a
yearly basis.
b. And existing hospital policies on leaves and the 48 hour’s working law wherein the monthly
master plan is then made for each unit to insure enough staffing coverage for 24 hours.
 Classification and Job Description of Nursing personnel

o Working Hour
The legal working hours per week is 48 hours and this is reflected in the monthly and weekly
schedule of duties prepared for the units by their respective head nurses duly approved by
the unit supervisor and the nursing office.
o Split assignment
In view of minimum staffing of the nursing services it therefore mobilizes its manpower
resources to the maximum and re-assigned personnel’s in other units as exigencies of
service demands.
The nursing personnel in each unit except the special services are divided into three shifts of
eight hours to provide a continuous patient care in 24 hours. The schedule of duties of the
majority of the nursing personnel is as follows:
 Morning Shift: 6:00AM TO 2:00PM
 Afternoon Shift: 2:00PM TO 10:00PM
 Night Shift: 10:00PM TO 6:00AM
o Off Duties
Off duties or non-working days are schedule in the respective units by the HN through the
Nursing supervisor. The following guidelines will be observed:
1. Off duties should not be substituted for absences.
2. Special requests for off duties are submitted one week before making the weekly
schedule.
3. Request for change in duties will be filled at least a day before (a form is provided for this
purpose) and is duly approved by the PCS.

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4. 3 to 4 consecutive non-working days are given as only a privilege and on special

occasion for a reasonable cause provided service is not disrupted.
5. All nursing personnel enjoy holidays on a rotation basis provided service is not
jeopardized and with the approval of the nursing office.
o Absenteeism
Absences from duty are to be reported to the nursing office. Notification must be done either
by written note, telephone or by courier 4-6 hours before the start of the shift. Failure to do so
shall necessitate a written explanation to be submitted to the PCS upon coming back to work.
After and absence, the nursing personnel reports personally to his/her immediate superior on
the first day of her assumption of duty.
Unauthorized absences during holidays shall be subject to disciplinary action. In case

personnel absent himself/herself without notification, he/she will be met by the following:
First Offense Counselling

Second Written warning
Offense
Third Offense. Written explanation and last warning to be submitted to Nursing
Office.
Off days proceeded or followed by an absence which are not justifiable will be
considered an absence and will be subjected to disciplinary action.
Medical Certificate for sick leave must be authenticated by the Personnel Medical
Officer or M.D authorized by the Personnel Office or the Hospital Director.
o Leave Privilege:
Vacation leave and Sick leave:
After one year of continuous, loyal and satisfactory service, each employee is entitled to 7
days’ vacation and 7 days sick leave with pay for every year of service rendered.
Sick Leave is granted on account of sickness on the part of the employee.
Maternity leave:
Whether permanent or temporary appointment, a married woman may enjoy, in addition to
the vacation and sick leave, a maternity leave of 60 days.
Birthday leave: An employee may enjoy his/her 1 day birthday leave as rendered.
o Application for leave
Application for vacation, sick or maternity leave is coursed through the PCS department. The
following should be observed when the employee files an application leave through a

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QUALITY PROCEDURE
properly-filled application form.

Application for vacation leave shall be filled at least a week before the desired date. In case
of absence due to sudden illness or unforeseen and unavoidable circumstances, notice of the
absence must be sent immediately to the PCS and the application for leave submitted
immediately upon his/her return of duty.
o Miscellaneous
A. Meetings: Regularly monthly meetings for the nursing service personnel are as follows:
1. General staff meeting (all nursing personnel) – every first Wednesday of the month.
2. Supervisor’s and head nurses meeting done every 3rd week of the month.
3. Nursing Aides, orderlies and OR, DR staff Midwives, every 1st Monday of the month.
Attendance to staff meeting must be observed by every nursing personnel
Unjustified absence from meetings should be explained in writing within 72 hours.
B. Change of status:
The nursing personnel contemplating to get married should notify the nursing service
department at least 15 days before weddings takes place.
Female personnel should apply for a change of name within two weeks after the wedding
for record purpose, change of address, and additional data, et.c
Any changed in the information originally given on the information sheet, personnel
records, e.g., change of address.

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COMPUTATION OF NURSING CARE HOURS:
 Add the total hours of patient care rendered by the different categories of nursing personnel.
Example:
Station I, II, III, IV is staffed with 24 staff nurses each one rendering 48 working hours a
week.
 Get the total of the daily patient census for a given period.
Example:
Station I, II, III, IV has an average daily census of 70 patients per day.
70 x 7 = 490 (total number of patients for one week)
 Divide the number of hours given by each category of works by patient total to indicate the
average amount of time provided for each patient during 24 hours.
Example:
1,152/490 = 2.35(nursing care hours given by each staff nurse)
Step 1. Find the total number of general nursing hours needed in one year.
o Average patient census x Average nursing hours per patient in 24 hours x days in
week in a year.
Step 2. Find the number of general nursing hours needed in one year which should be given
by professional nursing personnel and the number which should be given by non-
professionals:
o Number of general nursing hours per year x percent to be given by professional
nursing personnel.
o Number of general hours per year x percent to be given by non-professional nursing
personnel.
Step 3. Find the number of professional nursing personnel and non-professional nursing
personnel required on a yearly basis
o Professional nursing hours needed per year hours given per year by one professional
nurse (hours on duty weekly per nurse x weeks on duty during one year per nurse)
o Non-professional nursing hours needed per year – hours given per year by one
nursing aide (hours on duty weekly per nursing aide x week on duty during year per
nursing aide.

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PROFESSIONAL DECORUM
Every personnel can be agreeable and kind, A cordial greeting will last a long time; a friendly smile
will linger for days; and a spirit of helpfulness will last forever. These three ideas are very necessary;
nobody needs them more than the people who are sick.
When on duty, every personnel should be addressed professionally, Too much familiarity should be
avoided.
All nursing personnel are expected to be well groomed at all times. Hair is worn short and off the
collar. Elaborate hair-dots are out of place in the hospital, as are coloured nail ribbons to hold the
hair in place are not allowed.
SILENCE
Nursing personnel must continually strive to help minimize noise such as banging of doors, talking in
loud voice, jarring of beds and the other likes.

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GENERAL POLICIES OF THE NURSING DEPARTMENT
 Nobody shall be allowed to eat in their respective areas when the canteen is still open. Nurses
may use their lounge during night time when the canteen is already closed.
 All patients for IV insertion shall be done by the licensed nurse IV therapist and ROD, ANST
(After Negative skin test) reading shall be done by the ROD and to be signed to them prior to
giving the drug. The nurse who received the verbal orders shall request the doctor to sign the
orders made by them before these are carried out.
 For telephone orders, the ROD shall receive the Telephone order and will sign after the orders
are taken. In cases of emergency, the NOD shall receive the said orders signed then
immediately notifies the ROD. The ROD shall countersign the orders received by the NOD
before these are carried out. Request the Attending Physician who gave the telephone order to
countersign his/her order during his/her rounds.
 Once the blood bank releases the blood or blood products to the nurses’ station, the blood shall
be checked by the NOD and Supervisor and accomplish the transfusion form. The NOD and
Supervisor shall affix his/her signature at the side of the form. After this, a resident on duty
should re-check the unit of blood and confirm the items in the transfusion form signed by the
nurse; then affix his/her signature in the right side of the form. The ROD shall be the one to order
the nurse that the blood maybe transfused then.
 All nurse trainees shall be required to undergo a five month training period.
 The Nurse on duty in the night shift shall be held responsible in requesting the medicines, and
supplies needed by the patient. The requisition slip must be prepared triplicate signed by the
patient/relatives except in emergency cases that is forwarded to the pharmacy and CSR for
billing purposes. All discontinued and excess medicines and supplies taken from the concerned
department should be returned immediately for credit memo.
 All CSR supplied oxygen gauges should be charged by the NOD after termination of patient use
with corresponding charge ticket and the monitoring sheet as an attachment.
 All hospital equipment and machines shall be properly handled, maintained, monitored and kept

Doc. No. /Rev. No.
QUALITY PROCEDURE
clean in the rightful place.
 Double – checking of items requested and claimed from various departments shall be done
before it is brought back to the unit.
 If our ambulance service is not used, resident physician regardless of whether on duty or not,
shall be discouraged to accompany patient unless the medical director permits them so.
 The personnel shall go in 48 hours of duty once a week, Request for off duty is granted as long
as there is no conflict with other personnel.
 For changing of schedule, Change of Schedule form shall be accomplished 2 days before the
said change of schedule. It shall be signed by the Supervisor and the Chief Nurse to be
forwarded to the HR Department.
 Request to repair or job order form, to be filled out by the requesting nurse and approved by the
Chief Nurse and to be given to the administrative officer for approval. Urgent request shall be
referred directly to the specific service.

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WARD ROUTINES AND PRACTICES
PURPOSE
To establish a documented procedure in admission of patient at the ward.
SCOPE
Starts when the patient is admitted at the room of choice up to the time patient is for discharge.
DEFINITION
 Admitting Orders-written orders or procedures from the Attending Physician or consultants to be
carried out by the nurse and ROD regarding the patient’s admission.
 ER CON – Emergency Room Consultant
 ER NOD- Emergency Room Nurse-on-Duty
 GNU NOD- General Nursing Unit (Ward) Nurse-on-Duty
 ROD- Resident on Duty
 AO – Admitting Office
 HMO-Health maintenance Organization
 IM- GS Unit-Internal Medicine and General Surgery Unit
 ICC- Infectious Control Committee
 ROC-Room of Choice
RESPONSIBILITY
 ER CON- facilitates patient’s admission
 Supervisor on Duty- Assigned the patient to corresponding unit (Pediatric Unit, IM-GS Unit, and
OB-Gyne Unit) and based on ICC policy for infectious cases.
 ROD - Informs Attending Physician and do necessary referrals & complete the Patients’ history
 Charge Nurse – Informs the NOD assigned regarding the admission
 GNU NOD- prepares the room of the patient and carry out the Doctors’ admitting orders; orients
the patient regarding the furniture and equipment’s inside the room and accomplishes the room
checklist
 Healthcare Attendant- accompanies the patient to their respective ROC
 Room Checklist – a list that contains all the furniture and equipment present in the patient’s

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QUALITY PROCEDURE
room. The patient and the NOD will sign on the list aware that all that is listed on the checklist
are complete and are all functioning well.
 Admitting Office Personnel – Informs the roving supervisor regarding the admission coming
from the ER including the patient’s name, doctor, room number and diagnosis.
REFERENCE DOCUMENTS
MATERIALS
 Admitting Orders
 Patient’s Chart
 ID Band
 Room checklist
FLOWCHART (PATIENT FROM ER)

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QUALITY PROCEDURE
FLOWCHART FOR DIRECT ADMISSION(FROM ADMITTING DEPARTMENT)
ATTACHMENT
 Patients Chart
 Patient Consent form
 ID Band
 Admission logbook

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ADMISSION OF PATIENT
All patients coming to the hospital either for confinement or for consultation passes through the
Emergency Room where they are seen by the ER ROD (Resident Physician on Duty) and determine
whether for admission or could be sent home.
1. The patient with an order for admission from the attending physician (AMD) shall go
directly to the Admitting Office where he/she shall be officially registered and admitted by
an admitting clerk.
2. Walk-in patients are those without AMD. Patients with AMD but without admitting orders
shall be directed to the ER to be seen by the ROD.
3. The ward nurse shall receive the patient and check the admitting papers. Any data
clarification or completion is referred to the admitting clerk.
4. Patient may come directly to the nursing unit from the admitting office, delivery room or
operating room. The ward nurse shall receive the patient from the ER then carries out the
routine admission procedures:
a. Place patient comfortably in bed
b. Greet patient and introduce self by name and function.
c. Accomplishes room chart checklist
d. Orient to the ward specific routine, and hospital rules and regulations, patients’ rights
and responsibilities
e. Advice the patient of the availability of safety deposit box at the Accounting
Department for the valuables. The hospital will not be responsible for any losses.
f. Follow hospital policies on visiting hours and watchers.
g. Provide with an admission kit which includes the following:
- Kidney basin - Straw
-Toilet tissue - Hand towel
-Spoon and Fork - Medicine cup
-Calibrated glass
-Mineral bottled water
-Toothbrush

Doc. No. /Rev. No.
QUALITY PROCEDURE
ADMISSION PROCEDURES
Regular/Direct Admission: Refers to patients (regardless of the service) who come to the hospital
for confinement though not in need of any urgent or emergency
medical and nursing attention.
1. The patient with an order for admission from the attending physician goes directly to the ER to be
seen by the Resident-on-duty and to the admitting office where she/he is officially registered and
admitted by an admitting clerk.
2. Walk – in patients are those without attending physicians. Patients with attending physician but
without admitting order are directed to the emergency room to be seen by resident on duty. All
admission with their complete admission papers are conveyed to the nursing unit by the nurse.
3. The ward nurse receives the patient and checks the admitting papers. Any data that need
clarification or completion is referred to the patient/relatives.
4. Patients may come directly to the admitting room, OR/DR. The nurse at the receiving unit then
carries out the routine admission procedures.
5. Patient admitted direct to OR/DR, the admitting clerk should provide a data chart and to be
returned to the latter before the patient is endorsed to the ward.
Emergency Admission: Refers to patient requiring immediate or urgent medical and nursing
attention.
1. The patient is brought immediately to the ER for the needed medical and nursing attention. The
resident on duty is called to attend to the patient while the attending physician is being contacted.
A responsible relative is requested to register the patient at the admitting office.
2. The ward nurse should receive the patient coming from ER, OR/DR from the endorsing nurse of
the units where patients came from: accompany them to the room to see the general condition of
the patient and receive endorsements.
3. For admissions coming from the ER, OR/DR the nurse at nursing units continues to carry out
whatever medical orders have been started in any of the said department.
POLICIES AND PROCEDURES FOR SAFE AND EFFICIENT DIRECTION

OF PATIENT/FAMILY

Doc. No. /Rev. No.
QUALITY PROCEDURE
PURPOSE
 To document policies and procedures for the safe and efficient direction of patients, their families
and visitors
 To document policies and procedures for staff traffic.
 To guide the security officers and the ER staff in the safe and efficient direction of patients, their
families and visitors.
SCOPE
This policy starts from the patient entering the emergency room until the patient is seen by an ER
consultant or until the patient is discharged from the hospital.
POLICY
It shall be the responsibility of the nursing staff, the security guards, the admitting staff and the
physicians of UParHMC to provide safe access and assistance to all customers of Unihealth
Parañaque Hospital and Medical Center. Part of the responsibility includes greeting of patients and
visitors and also the responsibility of the said employees to direct and assist patient for safe and
efficient transport from one section of the hospital to another.
PROCEDURES
1. Family waiting areas are provided outside the ER. Patients who are brought to the ER are
wheeled in with one companion only. This is done to decongest the ER and prevent the spread
of infection.
2. From the ER, a patient may be brought to the different diagnostic sections by stretcher or
wheelchair depending on the ER physician’s orders. They are brought back to the ER once the
procedures are completed.
3. If the patient does not need admission he/she is sent home passing through the ER exit.
4. If a patient needs admission he/she is brought up to the room by stretcher or wheelchair.
5. Visiting hours for the general nursing care units is from 10:00am to 10:00pm. A visitor’s pass is
issued to the patient’s companion by the security guards; this should be worn by the watchers
while they are inside the hospital premises.
6. The security guards shall monitor all visitors who enter the hospital. Their belongings are
inspected before they enter the premises before they leave.
7. All visitors who enter the hospital premises proceed to the information desk where inquiries on
patient’s room number are entertained. The information clerk provides visitors with the room

Doc. No. /Rev. No.
QUALITY PROCEDURE
number of their patient and directs them to their rooms.

8. The security officers of the hospital also watch the parking lot for parking violators and other
suspicious activities.
9. Employee traffic is also guided by these policies. All employees are required to stay at their
designated work areas. Before and after office hours, employees are not allowed to loiter around
the hospital. Employee’s belongings are inspected for deadly weapons and firearms before they
are permitted into the hospital. After office hours their belongings are likewise inspected.
POLICY ON WAITING TIME

PURPOSE

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QUALITY PROCEDURE
To establish a sorting process shall be carried out at the entrance of the emergency room so that
non-emergency patient can be segregated from those need urgent attention.
Classification of patients:
1. ER case for consultation
2. Private Case
3. House Case
POLICIES
All patients shall be attended by the ER nurse by taking the vital signs, information taken reason why
they seek medical attention; and should be seen by the ER Consultant within 3 minutes.
All admissible patients shall be admitted and must be transferred to their respected room within 30
minutes once relative or patient decides to be admitted.
All critical and unstable patients both private and house case which require intensive care, and
emergency surgical intervention shall be seen by the attending physician within 4 hours. Patients
with emergency surgical intervention shall be seen by the attending physician within one hour.
ABSCONDING PATIENTS
Abscond – to depart secretly and hide oneself from the institution.

Doc. No. /Rev. No.
QUALITY PROCEDURE
I. Classification of Absconding Patients:

 With lead intention
 No intention
 Not informed about the SOAP-ie. Company patients, check-up patients.
II. Condition / Situation which poses the greatest possibility for ascendance:
 Emergency cases
 Elective cases with no deposit or progressive payment the following day.
 Increasing hospitalization bill but failure to arrange for progressive payments by the patient /
relative.
 Professional ascendance.
 Patient discharged by the Attending Physician but unable to settle their bills within the day or
24 hours.-
 Patients with previous unsettled accounts.
III. Observable characteristics and behaviour:

 Ambulatory patient with discharge order but no preparation / intention to go home. Relatives
not eager to settle the hospital bills.
 Patient’s personal belonging begins to disappear.
 Unusual disappearance of watcher.
 Patient always approach the nurse’s station, loiters the corridor, fire exit, stairway and
elevators.
 Patients who would ask permission to buy cigarettes, newspapers or foods – on the pretext
that he need these items only to condition the nurse / security guard, thus the disappearance
and intended abscondence(s).
 Be friend hospital personnel by bribing, i.e. giving foods, cigarettes, etc.
V. Role / Responsibilities
 The nurse / credit and collection or whoever is tasked should inform the security guard or
give notice on the following:
a. Patient discharge given but patient is unable to settle their hospital accounts within 24
hours.
b. Suspected professional abscondence.
c. Patients determined to have and previous unsettled bad debts / accounts or to make for
progressive payments, i.e. emergency cases.
Hospital Policies:

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QUALITY PROCEDURE
 NOD shall coordinate with the guard on duty particularly the roving guard within 24 hours
regarding patients who are possible candidates to abscond. They are referred to as “Close watch
patients”.
 If patient is declared absconded, NOD shall inform the supervisor and guard on duty immediately
and make an incident report form if patient is confirmed to have absconded.
SCHEDULING DIAGNOSTIC PROCEDURE OUTSIDE THE HOSPITAL
It is the responsibility of the nurse on duty to arrange the schedule of procedure to be done outside
the hospital. Nurse on duty notifies the patient or the relative as to the time, amount and preparation
needed. If everything is settled, the intern on duty or the Resident is in charge to accompany patient
when transporting to other hospital.
OUT ON PASS
PURPOSE

Doc. No. /Rev. No.
QUALITY PROCEDURE
To establish a documented procedure in allowing patients to go out on pass from the hospital.
SCOPE
This procedure covers from the time the patient or relatives requested to go out of the hospital for a
period of time not exceeding 48 hours up to the time the patient returns to the hospital.
Patients going out on pass (including those going out for diagnostic procedures or treatments) are
required to settle their accounts and / or get cleared by the credit and collection unit of the business
office.
DEFINITIONS
 Out on Pass (OOP) – permission given to a confined patient by his/her AP/ROD to go out of the
hospital not exceeding 48 hours for a valid reason.
 Out on Pass Notice and Clearance - a form given and signed by the patient or relatives before
leaving the hospital
 NOD – Nurse on Duty
 AP – Attending Physician
 ROD – Resident on Duty
RESPONSIBILITY
 Attending Physician
o Approves the Out on Pass request of the patient, make sure that there is written order
allowing patient to go out on pass.
 Resident on Duty
o Assess the reason and purpose for the out on pass request of the patient
o Informs the patient’s attending physician about the request
o Assess whether patient’s condition will permit him/her to leave the hospital
 Nurse on Duty
o Facilitates the out on pass procedure in coordination with the attending physician / ROD /
Charge Nurse.
o Explains to patient/relative regarding the 48 hour allowable time for out on pass.
 Lobby Guard
o Receives one (1) copy of out on pass notice and clearance.
o Check belonging brought down by the patient’s or relatives
o Check the patient’s ID Band.

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o Log in the time the patient leaves the hospital premises.
REFERENCE DOCUMENT
MATERIAL
 Out on Pass Form
PROCEDURES / GUIDELINES
1. Once the patient requested to go out on pass, the NOD inquires the reason.
2. NOD informs patient’s AP / ROD regarding the request.
3. AP / ROD assesses whether patient’s condition will permit him/her to leave hospital
4. Once the patient is granted to go out on pass, the NOD explains to patient / relatives that
hospital is not liable for any untoward incidents while the patient is out of the hospital.
5. The patient / relative present’s one (1) copy to the guard on duty prior to leaving the hospital
premises.
6. Document the patient’s chart / nurses notes the date / time the patient left the hospital premises
and the time the patient returns.
7. Instruct patient on his medications while out on pass.
OUT-ON PASS PATIENT
 Patients for diagnostic procedures or treatment to be done outside the hospital or patients who
need to go out of the hospital shall accomplish an out-on-pass form in duplicate.

Doc. No. /Rev. No.
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 Patients going out on pass (including those going out for diagnostic procedures or treatment)
shall be required to settle their accounts and / or get cleared by the credit and collection unit of
the business office:
o Make sure that there is written order allowing patient to go out on pass.
o Instruct the patient’s relative to present the duplicate of the out on pass form to the guard
when they leave the hospital.
o Instruct the patient to be back on time.
o Instruct the patient on his medication while on out on pass.
o Make charting on time the patient went out and the expected time of return.
o If the patient fails to come back on time 24 hours from the expected time of return, the
Attending Physician is notified and the patient is considered discharged.
DISCHARGE AGAINST MEDICAL ADVICE

Doc. No. /Rev. No.
QUALITY PROCEDURE
PURPOSE
To establish a documented procedure with regards to going home of patient’s against medical
advice.
SCOPE
Starts from the time the patient asks/requests to be discharged against medical advice until patient is
discharge.
DEFINITIONS
 DAMA – Discharge Against Medical Advice
 DAMA Form – a form signed by the patient or responsible person stating that the hospital is not
liable for any incident that may happen to the patient after leaving the hospital premises.
RESPONSIBILITY
 AP (Attending Physician)
o Gives consent on patient’s request to be discharged against medical advice.
o Writes order in the patient chart or instruct the ROD to write on his/her behalf thru telephone
order.
o Explains the consequences of the request.
 Nurse on duty
o Carry out doctor’s order
o Facilitate release of patient
 Healthcare Attendant
o Brings patient’s chart to the billing department for computation of patient’s hospital bill.
o Assists the nurse in transferring the patient from the bed to the wheelchair/stretcher.
o Assists patient/relatives to bring down the luggage, if any.
o Transfers patient to the private vehicle
REFERENCE DOCUMENTS
MATERIAL

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 Wheelchair/stretcher
 DAMA form
 Billing Clearance Form
PROCEDURES
1. The ROD notifies the attending physician of the patient’s desire/request to be discharged and
accomplish a written order for “discharge against medical advice.
2. AP/ROD explains to the patient or person responsible the implications/complications of “going to
be discharged against medical advice”.
3. NOD accomplishes two (2) copies of DAMA form
a. One copy – attached to the patient chart
b. One copy – given to the patient
4. NOD sees to it that the patient or any responsible person signs the DAMA Form after clearly
explaining its content.
5. NOD ensures the completeness of the data sheet.
6. Ask relative to make arrangement regarding the transportation of their choice. Hospital
ambulance is not allowed to be used by patient who is discharged against medical advice.
7. NOD informs the Charge Nurse of the condition of the patient and the DAMA status.
8. NOD updates the admission and discharge logbook and the DAMA logbook.
9. NOD ensures that all bills are settled.
10. NOD issues and sign a discharge clearance form once bill is settled.
11. NOD informs the lobby guard regarding the status of the patient.
12. The HCA assists the patient to the lobby area via wheelchair or stretcher.
FLOW CHART

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ATTACHMENTS
 DAMA Form
TRANSFER TO HOSPITAL OF CHOICE

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PURPOSE
To establish a documented procedure with concerns to transfer to hospital of choice.
SCOPE
Starts from the time the patient asks/requests to be transferred to their hospital of choice until patient
is discharge.
DEFINITIONS
 THOC – Transfer to Hospital of Choice.
 THOC Form – a form used to to communicate pertinent, accurate clinical patient care information
at the time of an emergency call to a facility or a patient transfer between health care facilities or
programs.
RESPONSIBILITY
 AP (Attending Physician)
o Gives consent on patient’s request to be transferred to hospital of choice
o Writes order in the patient chart or instruct the ROD to write on his/her behalf thru telephone
order.
 Junior Consultant on Duty/Resident on Duty
o Coordinates with Hospital of Choice regarding patient’s transfer.
 Nurse on duty
o Carry out doctor’s order
o Facilitate request for transfer of patient.
 Healthcare Attendant
o Brings patient’s chart to the billing department for computation of patient’s hospital bill.
o Assists the nurse in transferring the patient from the bed to the wheelchair/stretcher.
o Assists patient/relatives to bring down the luggage, if any.
o Transfers patient to the ambulance.
REFERENCE DOCUMENTS
MATERIAL

Doc. No. /Rev. No.
QUALITY PROCEDURE
 THOC/Referral form
 Billing Clearance Form
POLICIES
 Patients who are admitted at the General Nursing Unit shall be transferred to a hospital of choice
upon order of the Attending Physician or JCOD/ROD with a written consent given by the patient
or responsible party.
 All patients for transfer to other institutions shall be provided a clinical abstract accompanied with
diagnostic procedures results done to the patient.
 The patients and the responsible party along with the nurses and JCOD/ROD shall make the
necessary arrangements for the transfer.
 A JCOD/ROD and a GNU shall accompany the patient during transfer at all times.
 In cases when the patient’s condition does not permit transfer but the family insists, the patient
shall be considered as discharge against medical advice and the parents are made to sign the
corresponding form.
PROCEDURES
1. Once the Attending Physician transcribes order for THOC.
2. Nurse carries out order.
3. Nurse accomplishes THOC Form and facilitates arrangements with patients for transfer.
4. ROD/JCOD coordinates with hospital of choice. ‘
5. Nurses facilitate documents needed for transfer such as Clinical Abstract, Diagnostic procedure
results and provide a copy to the patient.
6. Nurses facilitates discharge procedure
7. Nurses shall arrange with the ambulance for arrangements regarding transfer to institution of
choice via ambulance conduction.
8. Once bill is settled, patient will be informed by the nurse on duty or billing department.
9. NOD issues and signs a discharge clearance form once bill is settled.
10. NOD assists patients for transfer via ambulance conduction accompanied by an ROD.
11. Once patient is transferred NOD informs AP of transfer and documents the said transfer at the
Nurses’ notes.
12. NOD informs housekeeping for cleaning of room.

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FLOWCHART
ATTACHMENTS
 THOC Form

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AMBULANCE CONDUCTION
PURPOSE
To establish a documented procedure in insuring prompt ambulance conduction service of patients.
SCOPE
This starts from the time the request of the Ambulance Conduction was received until the Ambulance
Service is actually provided.
DEFINITIONS
 Ambulance Conduction - transporting patient to or from the hospital using the ambulance.
 One (1) Way - patient is to be taken to the hospital for admission or for transfer to other hospital
of choice.
 Two (2) Way - patient is transported to other hospital for special procedures then back to the
hospital.
 Ambulance Conduction Slip - form used to gather data regarding patient’s information which
shall include the patient’s name, age address and assistance needed.
 Ambulance Transport Sheet - form used by ambulance nurse which serves as a patient’s chart
during the ambulance conduction.
 Ambulance Logbook - serves as Emergency Room record for the ambulance conduction.
 AC - Ambulance Conduction
 HOC - Hospital of Choice
 AP - Attending Physician
 ROD - Resident on Duty
 Ambulance Nurse - Nurse on duty at ER
 IR - Internal Receipt
 Code 1 - Normal Ambulance Run
 Code 2 - Ambulance run with the beacon lights on
 Code 3 - Ambulance run with beacon lights and siren
RESPONSIBILITY
 ER NURSE - coordinates and facilitates request for ambulance conduction.
Note: Only the ER Nurses are given the task for any ambulance conduction.
 Charge Nurse - coordinates with the ER-Nurse regarding any changes or requirements needed
prior to AC.

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 Resident On Duty (ROD) - accompanies the patient for ambulance conduction.

Note: ROD accompanies the patient, if he/she is in critical condition; otherwise, the ER Nurse
has the sole obligation to accompany the patient.
 Hospital Director - ER-In-Charge in case ROD assists during the AC.
 Housekeeping - accompanies and assists the ambulance team during ambulance conduction.
 Ambulance Driver - facilitates conduction to destination.
REFERENCE DOCUMENT
 ER General Procedure
 ER General Procedure in Transferring Patient from ER to HOC
 WI in One (1) Way Ambulance Conduction
 WI in Two (2) Way Ambulance Conduction
 WI for Assessing BP
 WI for Measuring Body Temperature
MATERIAL
 Oxygen tank with gauge
 Tuckle box
 Portable suction machine
 Ambu-bag
 BP Apparatus
 Ambulance Transport Sheet
 Ambulance Conduction Slip
 Ambulance Logbook
PROCEDURES
 Receiving the request for Ambulance Conduction.
o The nurse receives request for AC from the patient or relatives.
Note: The nurse fills up (2) copies of Emergency call slip
(1)for billing Department,
(2)ER copy for filing purposes
o Explain the procedure for AC.
o Notifies ambulance driver for ambulance preparation.
o Notifies the Charge Nurse regarding staffing at ER.
Note: ER-NOD is assigned as ambulance nurse. Floor or unit nurse is assigned by the
Charge Nurse to stay at the ER during the AC.
o The nurse coordinates with the ROD for dispatch and instructions. If medically warranted,

Doc. No. /Rev. No.
QUALITY PROCEDURE
the ROD accompanies the ambulance team during the AC. The Hospital Director is notified.
o The nurse identifies and classifies conduction either one (1) way or (2) way. The nurse
coordinates with the cashier for billing purposes.
 Departure/Arrival
o The ambulance nurse notifies the ROD/ER-NOD the time of departure and arrival through the
receiver radio.
o Informs the ROD regarding patient’s status and progress of the patient.
 During the transport
o Instruct the driver regarding type of AC whether Code 1, 2 or 3 respectively.
o The nurse observes and evaluates patient’s condition.
o Informs the ROD for any changes in patient’s condition.
o Coordinates with the ER personnel regarding arrangements and preparations prior to arrival
at the hospital.
o Endorses patient to ROD (refer to General Procedure for ER)
ATTACHMENTS
 Ambulance Conduction Slip
 Ambulance Transport Sheet
 Ambulance Logbook

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POLICY ON MEDICO-LEGAL CASES
PURPOSE
To guide the nursing personnel on the existing policy regarding medico-legal cases.
POLICIES
 Patients who are considered medico-legal cases in emergency or treatment room shall be given
necessary first aid or emergency measures by the resident. As general rule, all medico-legal
cases must be referred to the hospital medico-legal officer immediately or within 24 hours. He is
the hospital representative to the court for any legal matters pertinent to the patient’s injury or
illness.
 Emergency cases shall be referred to a government hospital or any hospital of choice for follow-
up of emergency treatment given. Critically ill-patients are kept in the hospital until the time
transfer is impossible and safe. Patients who choose to be admitted and who have an attending
physician may remain to be treated until accomplish.
 The ER nurse shall check that all ER records area accomplished paying special attention to the
time of arrival, how the patient was brought in and the condition of the patient upon arrival.
Injuries must be accurately reflected in the drawing. All pertinent data/ details of the accident are
to be stated in the medico-legal form.
For all medico-legal cases within the hospital, the primary responsibilities of nurses shall be:
 Immediate reporting to the supervisor and the security guard and medico-legal officers.
 Accurate recording of the incidents/ events surrounding the case.

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INCIDENT REPORT
PURPOSE
An incident is any happening that is inconsistent with the routine operations of the hospital.
Incident report is made record the occurrence of an incident. Points to consider in making an incident
report:
 The report or recording of the incident should be made and submitted within 48 hours from the
time of the incident.
 The incident is carefully and accurately filled out by the person involved. If there are two or more
persons involved, each should make his own report separately.
 A brief summary of the incident is accomplished at the back of the incident report form. This
should be brief, clear, concise and complete.
 The form is accomplished in the copies: (1) copy for the Patient Care services office file, (1) copy
for the individual file of employee involved and (1) copy for the 201 file.
PROCEDURES ON ENDORSEMENT OF PATIENT

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PURPOSE
To establish a documented procedure regarding patient endorsement
SCOPE
This procedure covers the endorsement of all patients to the incoming duty nurse.
DEFINITIONS
 Medical Care Plan – a form used during endorsement wherein all patient information updates are
written including the basic information of the patient and all previous and latest orders the patient
has. It also consists of all laboratory and diagnostic procedures and results done to the patients
 Chart – a compilation of documents and laboratory results related to the patient’s condition for
record purposes.
 Vital Signs – bodily functions that are basic indicators of a person’s physical status which
includes temperature, respiratory rate, pulse rate, and blood pressure.
 Bed rest – confinement to bed prescribed as part of therapy.
 Census – total number of patient in unit/floor.
 IVF – intravenous fluid.
 AP – attending physician.
RESPONSIBILITY
 Charge Nurse – responsible in endorsing patient’s condition and all contraptions/apparatus
connected or attached to the patient and impending or on-going procedures and tests that need
to be done to the incoming charge nurse on duty.
 Staff Nurse – responsible in endorsing patient’s condition and all contraptions/apparatus
connected or attached to the patient and impeding or on-going procedures and tests that need to
be done to the incoming staff nurse on duty.
REFERENCE DOCUMENT
MATERIAL
 Medical care plan
 Chart
 Clipboard/Clear book
 New Medicine cards/tickets

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PROCEDURES
 The outgoing nurse will verbally endorse all that has transpired during his/her tour of duty as
follows:
o Treatments and procedures and other relevant information.
o On-going problems within the area.
 Endorses patient’s
o Name
o Age
o Attending Physician
o Reason for admission
o Diagnostic test
o Special notations/endorsement
o Diet Observation of patient’s general condition and abnormalities noted.
o Latest IV fluid being administered to the patient:
 Name of IVF
 IVF rate
 Amount left in the IVF bottle / IVF level
 Additives / Time started/ Incorporation
 Time due
 IVF to follow
 Dressing for Post-OP patient
 Contraptions attached to the patient such as:
o Nasogastric tube (NGT)
o Thoracostomy tube
o Foley catheters
o Oxygen (O2)
o Pulse oximeter
o Gomco machine
o Jackson-pratt (JP)
o Colostomy bag
o Mechanical Ventilator
o Isolette
o Bili light / phototheraphy
o Cardiac monitor
o Gastrostomy tube
o CVP manometer

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o Blood transfusion (BT)

o Total Parenteral Nutrition (TPN)
 Latest vital signs
 New medicines to be started
 AP to be notified
 AP who made their rounds
NURSING ROUNDS
 Walking-planning round- usually done at the beginning of the shift; nursing team visits each
patient briefly in a systematic manner for the purpose of evaluating the patient for his plan of
care, classifying and revising the plan and directing the personnel regarding specifics of the
patient.
 Introduce self and team member who will give care to the patient.
 Address patient by name, and observer courtesy.
 Mentally update care plans, she talks to and listen to the patient.
 Inform patient of any tests, procedures and check if preparations have been followed.
 Accept expression of complaint and assure patient that she/he will attend to the complaint and

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QUALITY PROCEDURE
return to effect any change necessary as soon as possible.

 Check for proper functioning of contraptions such as IVF, catheter, NGT, wound dressing, etc.
 Check if patient has been fed and if necessary supplies have been provided.
PERIODIC ROUND
PURPOSE
Enables the nurse to assess each patient’s particular needs and problems paying attention to newly
admitted patients, post-operative cases and the critically ill.
 Check vital signs for any significant changes

 Check for proper functioning of contraptions
 Check if necessary nursing care was provided to the patient.
 Check if patient has been fed.
 Check if medicine were given, if treatment and procedure were done.
 Accept any complaint and effect necessary changes or comfort measure as soon as possible.
Teach patient or give instructions concerning his care; carry out preparation for procedures if
necessary.
ROUNDS WITH DOCTORS

 Acknowledge the presence of a doctor who comes to the unit with a greeting.
 Introduce self to the physician if necessary.
 Present the patient’s chart to the doctor.
 Give a brief description of patient’s condition, including most recent vital signs.
 If situation allows, join the doctor in making the rounds.
 When orders are made, read order to clarify.
 Write verbal orders if instructed.
 Request doctor to counter sign verbal orders.
 For telephone orders, request the doctor to countersign his orders as soon as he comes to visit

Doc. No. /Rev. No.
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the patient.
 Write T.O. for Telephone Orders and V.O. for Verbal Orders. Write ordering physician name and
countersign to indicate who received the order.

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REFERRAL SYSTEM
Referral System is a cooperative task between the attending physician and nurses of a unit. The
attending physician issues the request for referral to another consultant and gives
the information relative to the medical diagnosis of a patient. Promptness in
coordinating and channelling referral accurately is strongly encouraged.
1. Consultation
a) When a consult or referral is made, a consultation or referral sheet must be provided on top
of the standing order sheet.
b) Relay recommendation to the attending physician as soon as possible.
c) Make charting and endorse to the receiving nurse if referral has been made or not.
2. A doctor who is called for a consult or referral does not automatically become a co – attending
physician unless specified by the patient’s attending physician. The name of the doctor called for
consult or referral should not appear at the door or patient room.
COMMUNICATION SYSTEM
Use of the Local Phone

 Local telephone units are installed indifferent areas of the hospital.
 These telephones are used for business matters only; except in cases of emergency, hospital,
employees are not allowed to use station telephone for their personal or social calls. Encourage
patient or patient visitor to use public phone.
 Employee, patient and visitor are not allowed to place long distance calls charged to the
UParHMC
 Telephone numbers of doctors and other personnel should not be given to outsiders only when
necessary and with direction.
 Telephone numbers and doctors must be regularly updated.

Doc. No. /Rev. No.
QUALITY PROCEDURE
Telephone Decorum
Telephone Courtesies
1. Answer calls promptly.
2. Greet the caller pleasantly
3. Show courtesy
4. Be ready to take a message. Take special notes of names, figures, dates and other pertinent
details.
5. Be attentive
6. Use the caller’s name
7. Apologize for use or delay. Things may not always turn out alright but you can always be
gracious.
8. Good manners require that the caller hang up first.
Some don’ts in using the telephone
 Never leave the phone unattended.
 Never talk if you have something in your mouth.
 Never prolong the telephone communication longer than it is necessary.
 Never hangs-up the telephone with doubts in mind.
 Never calls unprepared. Write down points you want to make and question to ask.
 Never commit anything to memory.
 Never slack in making or receiving a call.
ROUTINE ACTIVITIES OF THE A.M., P.M., AND NIGHT SHIFT
ACTIVITIES OF THE MORNING SHIFT (6AM-2PM)

1. Planning Assessment
 Receive endorsement from the outgoing shift.
 Make rounds with special attention to critical patients, new admission, pre and post-operative
and patient with contraption.
 Take and records vital signs every four (4) hours on all patients with specific order.
 Join doctor’s rounds.
 Make necessary referrals

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2. Implementation
 Carry out Doctor’s order, transcribe doctor’s order.
 Communicate with other staff members if orders are changed / discontinued.
 Check chart and check previous order.
 Give medications.
 Perform treatment. Change and discard linens.
 Assist Physician in examination, treatment dressing, etc.
 Check completeness of emergency drugs and make replacement as necessary.
 Accomplish discharge form and give necessary instruction to patient.
 Check contraption, intravenous fluids etc., if properly functioning.
 Record intake and output, empty output and clean container.
 Carry out admitting order and notify other services department about admission.
 Transport patient.
 Receive post – op patient and clarify post – op order when necessary.
3. Evaluation
 Review update kardex, evaluate effectively of nursing care.
 Assist patient at meal if unable to feed himself.
 Fill out request form and laboratory and X – ray etc.
 Make final rounds.
 Make accurate and informative charting
ACTIVITIES OF THE AFTERNOON SHIFT (2PM-10PM)
and patient with contraptions.
 Take and records vital signs every (4) four hours on all patients with specific order.
 Assists doctors during rounds.
2. Implementation
 Follow some activities as that of A.M shift.
 Bed side Nursing.
 Changing of due contraptions.

Doc. No. /Rev. No.
QUALITY PROCEDURE
 Make necessary referrals. Carry out doctors’ order.

 Remind visitors on the policy regarding visiting time.
 Give reinforcement in instruction given to the patient by the A.M shift nurse regarding
preparation for procedures that need special preparation(s) for scheduled surgery.
 Check chard and doctor’s order made during the day.
 Check ordered medicine and treatment if carried out.
 Check diagnostic and other procedure for the following day if request have been sent.
 Check preparations of patient for special procedure for the following day (e.g. clear liquid
after dinner, enema at bedtime, etc.)
 Check medicine boxes for completeness of medicine, intravenous follow up for succeeding
shift.
 Do Housekeeping of nurses’ station, tidy up drawers and shelves.
3. Evaluation
 Review and update Medical Care Plan.
 Evaluate nursing care given to the patient.
 Make accurate and informative charting.
ACTIVITIES OF THE NIGHT SHIFT (10PM-6AM)
and patient with contraptions.
 Take and records vital signs every (4) four hours on all patients with specific order.
 Assists doctors during rounds.
2. Implementation
 Follow some activities as that of afternoon shift.
 Bed side Nursing.
 Make rounds and reinforce visiting hours.
 Filling of flow sheets and accomplishing chart forms.
 Check the chart for completeness. Chart should be properly filled-up with patient’s data;
check if history is being done by the ROD and is attached to the patient’s chart.
 Request of needed medicines, stocks or equipment (dressing set) for the next day.
 Check diagnostic and other procedure for the following day if request have been sent.

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 Check preparations of patient for special procedure for the following day is properly
implemented (e.g. NPO post-midnight).
 Accomplish diet list and submit to the dietary department before 5am.
 Carry out doctors’ order, check ordered medicines and treatment if carried out.
 24 hours checking of doctors’ order made during the day (using RED ball pen)
 Computes for 24 hours grand total of intake and output.
3. Evaluation
 Review and update Medical Care Plan.
 Evaluate nursing care given to the patient.
 Make accurate and informative charting.

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QUALITY PROCEDURE
DISCHARGE OF PATIENT
PURPOSE
To standardize procedure of discharging a patient:

 To provide the necessary instructions and health teaching for further care and treatment.
 To discharged the patient without any misunderstanding and unpleasantness or disagreeable
experiences related to his dismissal.
 To see to it that the patient receives all his valuables and belongings if they were given to the
hospital for safekeeping.
SCOPE
From the time the discharge order is made up to the time the patient leaves the hospital.
DEFINITION
The departure of the patients from the hospital to his home.
RESPONSIBILITY
 AP (Attending Physician) - Responsible for final assessment and discharging patient.
The attending physician fills out the final diagnosis in the record of admission and signs
correspondingly.
 Resident on duty - Responsible in doing final assessment of patient in the absence of Attending
Physician and in giving instructions regarding home medications and follow-up of patient.
 Nurse - Responsible for carrying out the discharge order and preparing the home instructions.
As soon as there is written and signed order by the attending physician on the patient’s record,
the nurse should notify the billing office and pharmacy, CSR about the patient’s discharged.
Drugs that are not to be taken home must be returned to the pharmacy for credit to the patient.
Help patient dress up.
Responsible for accompanying patient to the lobby.
REFERENCE DOCUMENTATION

Doc. No. /Rev. No.
QUALITY PROCEDURE
MATERIAL
 Patient’s chart
 Telephone
PROCEDURES
1. The Attending Physician will order in the chart that the patient is for discharge, specified as “MAY
GO HOME”.
2. If no order yet but the patient insist on being discharged, the resident on duty will be the one to
assess or talk to the patient.
3. Resident on duty informs the consultant of the patient’s request to be discharged. The consultant
then decides if the patient may sent home.
4. If the patient’s condition is still unstable and still insist on being sent home they will be released
as HAMA or discharge against medical advice, as ordered by his consultant.
5. Assigned nurse carries out the doctor’s order.
6. Assigned nurse fills-up discharge notification slip and gives it to the HCA.
7. The nurse will check the medication box for any excess medicine.
8. The nurse will follow up from the billing section one hour after the discharge slip has been
forwarded if bills are already computed.
9. Notify the patient if bills are ready to settle.
10. The nurse prepares two copies of home medication if any.
i. original copy- patient’s copy
ii. duplicate copy- to be attached to patient’s chart
11. Health teaching and instructions on take home medications are to be given by the nurse.
Note: Home medications include:
a. medication to be taken at home
b. prescribed diet
c. schedule of follow up with the attending physicians
12. Request the patient/relative to sign the home instruction as a proof that he/she understood the
instructions/health teaching.
13. The assigned nurse signs release form/discharge clearance and instructs patient/relative to
submit it to the lobby guard on duty.
14. The nurse accompanies patient to the lobby.
15. Orderlies’ assists patient in going down the lobby by pushing wheelchair/stretcher and by
bringing patient’s personal belongings.
16. The NOD will remove the patient’s ID band upon exit on the main door and courteously/briefly

Doc. No. /Rev. No.
QUALITY PROCEDURE
explain reason.
17. The nurse removes the name tag at the patient’s door and forwards the chart to the medical
record.
18. NOD instructs the housekeeping to clean and disinfect the room.
FLOWCHART
ATTACHMENTS
 Home Instructions Form.

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QUALITY PROCEDURE
POLICY ON REQUISITION OF SUPPLIES AND MEDICINES

PURPOSE
To ensure that these policies may be a guide to the nursing personnel when requesting supplies and
medications for patients.
POLICIES
 The nurse on duty in the morning and afternoon shall be held responsible in requesting the
medications and supplies needed by the patient. The requisition slip shoud be prepared in
triplicate form signed by the patient/relatives except in emergency cases, is forwarded to the
pharmacy and CSR for billing purposes. All discontinued and excess meds and supplies taken
from the concerned department shall be returned immediately for credit memo.
 All hospital equipment and machines shall be properly handled, maintained, monitored and kept
clean in the rightful place.
 Double-checking of items requested and claimed from various departments shall be done before
it is brought back to the unit.

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QUALITY PROCEDURE
PROCEDURES ON DRUG ADMINISTRATION

PURPOSE
To guide nursing personnel regarding correct/safe administration of medications by different routes,

and to prevent errors in drug administration thereby protecting patient lives.
SCOPE
This procedure covers all nursing, medical personnel concerned in the delivery of efficient, effective
and quality health care services.
DEFINITIONS
o GI – gastro intestinal
o Buccal – oral
o Sublingual – under the tongue
o Semi-fowlers - 45 high back rest position
o Urethral – urinary passage
o Lithotomy position – lying on back with both legs open, raised and flexed
o Intradermal – underneath the skin
o Intracutaneous – underneath the sub-cutaneous tissues
o Conjunctival sal – eye lid
o PH – acidity and alkalinity of a substance
o Parenteral route – thru vein
o Intrasynovial – joint area
o Intracheal – thru throat
o Sub-cutaneous – fat tissues
o Anti-infective – anti-allergy
o Intramuscular – into a muscle body
o Subcutaneous – into tissues just below the dermis of the skin
RESPONSIBILITY
o Consultant/ROD – make medication order and enters on doctor’s order sheet
o Nurse on Duty (NOD) – carry out the written doctor’s order and administer the medication.
o Pharmacist – dispense the medicine to nurse for patient’s use
o Ward Clerk – procure the medicine from the pharmacy

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REFERENCE DOCUMENT
o Handwashing
o WI - Adding Medication to IV fluid container
o WI - Administering Cleansing Enema
o WI - Administering Injection
o WI - Administering Rectal Suppository
o WI - Administering Vaginal Instillations
o WI - Nasogastric Tube Intubation
MATERIAL
o PIMS
o Medication Card
o Nursing Care Plan
o Prescription Pad
o Doctors Order Sheet
o Medication Sheet
PROCEDURES
General Safety Precautions
 The following are general safety precautions that the nurse should observe for the preparation
and storage of medications.
 Double-check all mathematical calculations for preparing and administering medications.
Review calculations and verify dosage of highly toxic drugs with another registered professional
nurse. Verify from ROD/AP who ordered the drug.
 Work with adequate lighting.
 Be very attentive; discourage interruptions.
 Check labels three times: when taking medication from storage; when preparing medication; and
when replacing medication in storage.
 Check expiration date; discard medication if expiration date has passed.
 Do not use discoloured medication or medication with unexpected precipitate unless specifically
directed otherwise (e.g., directions for administration may indicate that for a certain medication a
change in color does not interfere with the safety of the drug).
 Pour oral liquids from the bottle on the opposite side from the label.
 Wipe the bottle after pouring a liquid.
 Hold the medicine cup at eye level to pour medication. The meniscus (the lower curve of the
liquid) should be at the calibration line indicating the proper dosage.

Doc. No. /Rev. No.
QUALITY PROCEDURE
 Pour tablets or capsules into the cap of the bottle and then empty the cap into the medication
cup. Tablets or capsules are not to be poured into the nurse’s hand.
 Administer only those medications that you have prepared personally.
 Once poured, do not return medications to the storage container.
 Use sterile equipment and sterile technique to prepare parenteral medications.
 Use recommended diluents for parenteral medications; follow directions for proper concentration
and rate of administration of the medication.
 Discard needles and syringes in appropriate containers; follow appropriate institutional
guidelines for disposal.
 Aspirate unused portions of medications from ampules and refrigerate it for the next dose, if the
potency is not affected during refrigeration.
 Store drugs as recommended (e.g., tablets should be kept dry and protected from light).
Solutions should be stored at temperatures recommended.
 Return bottles with damaged labels to pharmacy.
 Never leave medicine cabinets unlocked or medications unattended.
 Complete a count of the controlled substances at the end of every shift with a professional
registered nurse who is starting a tour of duty on the ward.
 THE TWELVE RIGHTS OF MEDICATIONS ADMINISTRATION

o Right Patient
o Right Drug
o Right Route
o Right Reason
o Right Dosage
o Right Time
o Right Response
o Right Assessment & Evaluation
o Right Documentation
o Right Expiry Date
o Right Refuse to Medication
o Right Client Education
 ADMINISTRATION BY ORAL ROUTE

o Administer gastric irritating drugs with meals or snacks to minimize their effect on the gastric
mucosa, unless contradicted.
o If food interferes with the absorption of the drug, or if digestive enzymes destroy a significant

Doc. No. /Rev. No.
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portion of the medication, administer between meals or on an empty stomach.

o Do not administer oral medication to a comatose patient.
o If patient is vomiting, withhold medication and refer to physician.
 TABLETS/ CAPSULES
o Unless a tablet is scored, it should never be broken to adjust dosage. Breaking may cause
incorrect dosage, GI irritation, or destruction of drug in an incompatible pH. Scored tablets
may be broken with a file.
o Time-release capsules and enteric-coated tablets should not be tampered with in any way.
Instruct the patient to swallow whole and not to chew, crush, or break open.
o Sublingual tablets are to be placed underneath the tongue. Instruct the patient not to
swallow or chew such tablets and not to drink water, all of which will interfere with the
effectiveness of the medication. The medication should be left in place until completely
dissolved.
o Buccal tablets should be placed between gum and check (next to upper molar). Instruct the
patient to avoid disturbing tablet until completely dissolved to ensure absorption. Avoid food
and liquids until medication is completely dissolved.
 LIQUIDS
o Emulsions. May be diluted with water.
o Suspensions. Shake well until there is no apparent solid material.
o Elixirs. Do not dilute. Diluent may cause precipitation of drug.
o Salty solutions. Unless contraindicated because of patient’s diet, mix with water or fruit juice
to make it palatable.
 ADMINISTRATION BY GASTROSTOMY TUBE

See also administration guidelines for nasogastric tube.
o Place patient in semi-Fowler’s position.
o Determine tube patency by injecting 10 cc of air and auscultating abdomen for swooshing
sound. Also, aspirate for gastric contents.
o Assess site around tube for evidence of leakage of fluids, erythema and/or skin breakdown
and document appropriately.
o Administer medications following nasogastric tube instructions.
GENERAL NURSING IMPLICATIONS

 A Fowler’s or semi-Fowler’s position should be assumed for nasogastric and gastrostomy tube
feedings and maintained for at least 30 minutes to aid digestion. This position also facilitates
absorption of medications.
 If the patient seems unable to tolerate this position, then place the patient on his/her right side

Doc. No. /Rev. No.
QUALITY PROCEDURE
with the head of the bed above stomach level. This will help prevent regurgitation yet will
facilitate gastric emptying.
 Position the patient on the left side with the head of the bed elevated above stomach level for
medications such as antacids that should remain in the stomach as long as possible. This
position will delay gastric emptying.
 When teaching patients self-administration of medication or feedings by nasogastric or
gastrostomy tube, utilize a return demonstration teaching format.
 Assist the patient to assume a comfortable position with his altered body image. His/her
understanding and acceptance may enhance this process.
 A mirror may be helpful as the patient initially attempts nasogastric medication administration.
 ADMINISTRATION BY INHALATION
NURSING IMPLICATIONS FOR ALL METHODS OF DRUG ADMINISTRATION BY INHALATION
o Administer only one medication at a time through nebulizer. Unless specifically ordered to
the contrary. Several drugs, used together may cause undesirable reactions or they may
inactivate each other.
o Measure medication precisely with a syringe. Dilute medication as ordered and place in
nebulizer. For home administration, ascertain that the patient has equipment necessary for
preparation of medication and is able to measure accurately. Single dose premixed
nebule(s) may be most useful available and economically feasible.
o Teach patient to assemble, disassemble and clean equipment, including nebulizing kit.
o Emphasize the importance of cleaning the mouthpiece and nebulizer from the previous
treatment should be discarded. (Other tubing is to be cleaned each day as directed).
o Seat patient comfortably or place in semi-Fowler’s position to permit greater diaphragmatic
expansion.
o Provide written instruction for medication treatment and the appropriate steps and method
for cleaning and care of all equipment
 ADMINISTRATION BY NASOGASTRIC TUBE

 Place adult patient in a sitting position for administration.
 Position an unconscious patient or an infant on the left side, with head of bed in semi-
Fowler’s position, for administration of medication.
 Check for correct placement of tube before initiating administration of medication.
o Auscultate for bowel sounds in all four quadrants of the abdomen.
o Listen to distal end of tube. Normally, no noise should be heard. Remember to turn off
or disconnect the gomco or suction apparatus. Place distal end of tube in a glass of
water. A few bubbles may occur as the gas in the stomach is released. Do not

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administer medication if bubbles occur with respirations, as this may indicate placement
of the tube inside the lung.
o Attempt to withdraw a few ml of fluid with a catheter tip syringe from the distal end. Do
not administer if there is an absence of fluid, because this may indicate displacement.
o Inject 5-10 ml of air or sterile water for an adult (0.5 ml for an infant) into the distal end,
and listen over the epigastric area with a stethoscope for a swooshing or popping sound,
indicating placement in the stomach.
 Administration: Prevent excessive air from entering the stomach by maintaining a flow of fluid
from initiation to completion of administration.
o Hold or position the tube at a level slightly above the patient’s nose to prevent reflux.
o Pour 10-20 ml of water into the catheter tip syringe at the distal end of the tubing and
permit the fluid to flow in by gravity.
o Before the syringe is empties, pinch off the tubing and add the medication via the
syringe.
o As the medication is about to flow completely out of the syringe, pinch off the tubing and
add 10-20 ml of water to ensure that all the medication has reached the stomach;
maintain patency.
 After completing administration of medication:
o Clamp nasogastric tube and remove the attached syringe.
o Assess for gastric distress demonstrated particularly by abdominal distention and
regurgitation.
o Record fluid administered via nasogastric tube.
o Do not administer enteric-coated or sustained-release tablets through a nasogastric tube
as crushing these tablets destroys their intended therapeutic effect.
 Cold solutions cause abdominal cramping.
 Oily medications may adhere to the tubing and not mix adequately with the irrigating solution.
 Small-bore feeding tubes do not accommodate crushed medications well. They obstruct
easily and should be reserved only for elixirs or solutions. Some of the newer small-bore
feeding tubes now have auxiliary medication ports and larger-end exit ports and should
facilitate the administration of medications. A syringe smaller than 30 cc should not be used
to attempt to dislodge plugs in small-bore feeding tubes. The increased pressure (psi)
exerted by small syringes may rupture these tubes.
 ADMINISTRATION OF EYE MEDICATIONS

 ADMNISTRATION OF EYE DROPS
o Instruct patient to lie down or sit with head tilted back.
o Have a separate tissue available for each eye.

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QUALITY PROCEDURE
o If excessive exudate is present, wipe the lids and eyelashes clean before instillation.
o Use an individual, squeezable plastic container or dropper for each patient. If a dropper is
used, draw up only the amount of solution needed for administration.
o Instruct the patient to look up towards the ceiling.
o Hold the applicator close to the eye, but do not touch eyelids or lashes.
o Expose the lower conjunctival sac by drawing down the skin below the eye with a gauze
pad.
o With the same hand, use a sterile cotton ball and gently press against the lacrimal duct
during and for 1-2 min after instillation, to prevent excessive systemic absorption of the
medication as a result of draining down the lacrimal duct.
o Place the heel of the hand administering the drops on the hand holding the gauze pad,
and instil the number of dropping medication on the cornea, as this may cause tissue
damage and discomfort.
o Instruct patient to keep eye closed for 1-2 min after application to allow for absorption of
medication.
 ADMINISTRATION OF EYE OINTMENT

o Instruct patient to lie down or sit down with head tilted back.
o Have a separate tissue available for each eye.
o Expose the lower conjunctival sac as indicated above in administration of eyedrops.
o Squeeze a strip of ointment into the conjunctival pouch (inner edge of lower lid) – usually
1 cm (approximately 1/3 inch), unless otherwise ordered.
o Instruct patient to close eyes for 1-2 min after application to permit the warmth of the
body to melt the medication and spread medication over area to be treated.
o A cotton ball may be used (with eyes closed) to lightly rub the lids in a circular motion, to
enhance distribution of the medication.
o Warn patient that vision will probably be blurred for a few minutes after application of
ointment.
 ADMINISTRATION OF EAR DROPS

o Warm drops to body temperature by holding bottle in hand for a few minutes before
applying.
o Have the patient lie on his/her side with the ear to be treated facing up.
o For instillation in adults, pull the cartilaginous part of the pinna (the external part of the ear)
back and up; this straightens the ear canal. Point the dropper in the direction of the
eardrum, and allow the drops to fall in the direction of the external canal.
o For instillation of drops in children less than 3 years of age, pull the pinna back and down;

Doc. No. /Rev. No.
QUALITY PROCEDURE
this straightens the ear canal. Point the dropper in the direction of the eardrum and allow the
drops to fall on the external canal.
o Have the patient remain on his/her side for a few minutes after instillation to allow medication
to reach eardrum and be absorbed.
o Gently massaging the area directly anterior to the ear may facilitate entry of the medication
into the canal.
o Never pack cotton or a wick tightly into the ear. On occasion, a loose cotton wick is inserted
into the ear by the physician so that the medication will bathe the eardrum continuously. The
wick should be changed when it appears non-absorbent or soiled.
 ADMINISTRATION OF DERMATOLOGIC PREPARATIONS

o Medications can be applied to the skin by rubbing, patting, spraying, painting, or by
iontophoresis (medication is driven into skin by means of an electric current).
o Use sterile technique if there is a break in the skin.
o Cleanse skin before medication is applied. The cleansing agent should be specified by the
physician.
o Do not apply medications with bare hands; use gloves, tongue depressors, gauze, cotton or
special applicators.
o Remove ointment from a jar with tongue depressor, applicator or gauze – not with fingers.
o If medication is to be rubbed in, apply using firm strokes that follow the direction of hair
growth.
o Apply only a thin layer of medication unless specified otherwise.
o Solutions should be painted on with an applicator.
o Powders should be administered to clean, dry skin. Instruct patient to turn head, or offer
gauze to cover mouth, to prevent inhalation of powder particles.
o If medication stains, cover with sterile gauze and instruct patient to take adequate
precautions (use old sheets or plastic cloth) to protect clothing and bed linens.
o Moist dressings or compresses are prepared by soaking sterile towels or dressings in a
solution as ordered. Squeeze out excess solution and apply them to the area to be treated.
The area is then wrapped with a covering such as towels or blue pads for a specified amount
of time. Sterile gloves should be worn if sterile solution is to be applied.
 RECTAL ADMINISTRATION
 RETENTION ENEMAS
o In order to avoid peristalsis, administer retention enemas slowly, at low pressure, using
small amount of solution (no more than 120 ml) at body temperature, through a small
rectal tube or small applicator of a pre-packed enema.

Doc. No. /Rev. No.
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o Instruct the patient to lie on his/her left side and to breathe through mouth to relax the
rectal sphincter.
o Apply gloves and gently insert the lubricated tip of the rectal tube (or applicator tip of pre-
packed enema) approximately 7 cm – 10 cm (3-4 inches) directed towards the umbilicus.
o Retention enemas containing medication should be administered after a bowel
movement to promote maximum absorption of medication in the empty rectum.
o When removing the rectal tube or applicator tip, apply finger pressure to the anus for a
few seconds until the urge to evacuate passes.
o Have patient remain flat for 30 minutes after administration of enema.
o Ensure patient privacy throughout the procedure.
o If patient is immobile have a bedpan readily available and within easy reach.
 SUPPOSITORIES
o As a rule, suppositories should be refrigerated, since they tend to soften at room
temperature.
o Remove the wrapper and coat the suppository with a water-soluble lubricant.
o Use examination glove or finger cot to protect the finger used for insertion (index finger
for adults, fourth finger or smallest finger for infants).
o Instruct patient to lie on left side and to breathe slowly through the mouth to relax the
sphincter.
o Spread the buttocks and gently insert the lubricated suppository beyond the internal
sphincter (usually about 2 inches)
o As the suppository enters the rectum, use gentle sideways pressure to direct the
medication towards the lateral wall of the mucosa.
o Have the patient remain on his/her side for 20 minutes after insertion, to prevent
expulsion. For the pediatric patient, hold or tape together the buttocks until impulse to
defecate passes.
o If indicated, teach the patient how to self-administer enema or suppository. Observe
self-administration technique to ensure that procedure is being done correctly.
 VAGINAL ADMINISTRATION
o Arrange douche-containing medication so that container hangs just above the patient’s
hip. In this manner the force of the liquid does not drive the solution through the cervical
os. Irrigating solution temperatures should be between 105-110F(40.6-43.3C) unless
otherwise indicated.
o Vaginal suppositories, creams, gels, and ointments may be administered using an
applicator or gloved hand.

Doc. No. /Rev. No.
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o Instruct patient to lie down. A lithotomy position may facilitate medication administration.
o The medication should be administered high in the vaginal vault.
o If indicated, instruct the patient on how to self –administer vaginal medication. Observe
self-administration technique to ensure that administration is done properly.
o Instruct patient to remain with hips elevated for 5 minutes and then to remain in bed for
at least 20 minutes longer; to promote absorption of medication and prevent drainage of
medication after suppository has melted.
o Instruct patient to wear a sanitary pad to prevent staining and to absorb excess drainage
from the medication.
o Reusable applicators should be washed with warm soapy water, dried, labelled with
patient’s name, and stored for later use.
o Instruct patient not to use tampons after inserting medication, as this may absorb
medication and alter intended dosage.
 URETHRAL ADMINISTRATION
o Cleanse area around urinary meatus as for a catheterization.
o Gently insert lubricated urethral suppository using sterile technique. These suppositories
are extremely small and may be compared to the size of lead in a pencil.
 ADMINISTRATION BY PARENTERAL ROUTES

 INTRADERMAL OR INTRACUTANEOUS INJECTIONS
o These injections are made into the dermis and produce local effects. The techniques are
used mainly for local anesthesia and sensitivity tests, such as allergy panels and
tuberculin tests.
o The inner aspect (volar) of the forearm is the most common site for intradermal injections
as it gives good visualization of the response to test media. The upper aspect of the
chest or the back of the patient may be used.
o Use a tuberculin-type syringe with a 26-27-gauge needle ½ - 5/8 inch long.
o Cleanse the site selected for injection with alcohol, using a circular motion moving
outward from the projected site of insertion. A dry sterile sponge may be used to dry the
area.
o Stretch the skin and insert the needle with the bevel upward at a 10-15 degree angle
until the bevel of the needle is just under the outer layer of skin. Inject the fluid slowly,
usually 0.5 ml or less. Withdraw the needle quickly after injection. A small blister or
wheal should have been formed by the solution just below the surface. Do not rub the
site.
o After injection, observe the patient for local reactions, such as redness and swelling.

Doc. No. /Rev. No.
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Observe also for systemic hypersensitivity reactions like difficulty in breathing and fever.
o If a blister or wheal is not present or the site bleeds after the needle is removed, then the
needle may have been below the skin layers and the test results will be invalid.
o Circle and mark test sites to facilitate interpretation of results.
o Instruct patient to report backing 24-48 hours (or as indicated) to evaluate response.
 SUBCUTANEOUS AND INTRAMUSCULAR INJECTIONS

o Use sterile technique.
o Assist patient into a comfortable position to prevent strain on the muscle.
o In selecting the proper gauge and length of needle for injection, consider age, weight,
condition of patient, and physical properties of medication.
o In order to promote absorption of medication and minimize pain after IM injection,
palpate potential site. Choose a site that is not tender to patient and where tissue does
not become firm on palpation. Alternate the sites of injection, and chart the sites used –
for example, RD for right deltoid, RGM or right gluteus medius; or according to
institutional guidelines for charting injections.
o Cleanse the site selected for injection with alcohol, using a circular motion, moving
outward- from site of insertion.
o Generally, for a SC injection, pick up tissue in selected area and hold firmly until needle
has been inserted at a 45-degree angle. The SC route is appropriate for small dose (0.5
– 1 ml) of water-soluble drugs.
o For IM injection, stretch the skin if patient is in a normal site of nutrition. If the patient is
emaciated, pinch the tissue to form a muscle bundle to ensure that the medication is
injected into the muscle. Insert needle at a 90-degree angle. The IM route permits
larger volumes (1-5 ml) of more irritating drugs to be administered and produces a more
rapid system response than the SC route.
o Leave a margin of needle at least ¼ - ½ inch from hub to prevent its complete
disappearance in case of breakage.
o When preparing for SC and IM injections, include a small bubble of air in syringe (0.2-0.3
ml) in addition to medication. The air bubble will help expel all solution from the needle
so that irritating solutions will not leak into the tissues as the needle is withdrawn, or leak
out of the injection site.
o Insert the needle quickly to minimize pain. After insertion, aspirate to be sure that the
needle is not in a blood vessel. If blood returns into the syringe, withdraw the needle and
discard the medication. Prepare another dose using new sterile equipment, select
another site, and start the injection procedure again.
o Administer the medication slowly to allow for absorption, and remove the needle quickly

Doc. No. /Rev. No.
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while pressing down at the point of insertion with a sterile sponge to prevent bleeding.
Apply an adhesive bandage if necessary.
o Massage the area after injection to increase circulation and promote absorption of
medicine.
o Some irritating drugs may be ordered and administered by the Z-track injection method.
This involves placing a clean needle on the syringe after drawing up the medication.
Displace laterally the skin, subcutaneous tissues while withdrawing the needle.
o Evaluate patient shortly after medication administration and chart effects and/or
effectiveness of administered drug.
NURSING IMPLICATIONS - GENERAL NURSING IMPLICATIONS FOR ALL ANTI-INFECTIVES

 Ask if patient has experienced any unusual reaction or problem with the anti-infective such as
hives, rashes, or difficulty in breathing. Such reactions indicate an allergy or hypersensitivity
and are an indication to discontinue the drug immediately. Epinephrine, oxygen antihistamines,
and corticosteroids must be immediately available.
 Report history of allergy to any to physician. Conspicuously mark patient’s chart, medication
record, and bed. Inform patient not to take that drug again unless the physician gives approval
after reviewing the history of past allergic reactions to this medications.
 Ascertain, if indicated, that diagnostic cultures and sensitivity tests have been done before
administering first dose of anti-infective. Use correct procedure for obtaining, storing, and/or
transporting specimen to the laboratory.
 If the anti-infective is mainly excreted by the kidneys, anticipate reduced dosage inpatients with
renal dysfunction. Nephrotoxic drugs are usually contraindicated in patients with renal
dysfunction, because toxic levels of the drug are rapidly attained when renal function is
impaired.
 Notify physician when two or more anti-infective are ordered for the same patient, especially if
the drugs have similar untoward effects, such as nephrotoxicity and/or neurotoxicity.
 Assess patient for therapeutic response, such as reduction of fever, increased appetite, and
increased sense of well-being.
 Assess patient for superinfections, particularly of fungal origin, characterized by black furred
tongue, nausea, and diarrhoea.
 Prevent superinfections by
o limiting patient’s exposure to persons suffering from an active infectious process
o rotating site of IV administration and by changing site of IV tubing every 24-48 hour
o providing and emphasizing need for good hygiene
o instructing care provider to wash own hands carefully before contact with the patient

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 Have the order for an anti-infective administered in the hospital reviewed at least every 5-7 days
for renewal or cancellation.
 Schedule drug administration throughout 24 hr period to maintain appropriate drugs levels. A
drug administration schedule is determined by the half-life (½) of the drug, the severity of the
infection, and the patient’s need for sleep.
 Obtain and monitor serum drug levels throughout therapy to ensure that patient is receiving the
appropriate dose.
 Teach patient and/or family
o To use anti-invective’s only under medical supervision
o The method for taking and time intervals at which to take the anti-infective
o To report signs and symptoms of allergic reactions and superinfections
o To prevent recurrence by completing recommended course of therapy; even though the
patient may feel well.
o To discard any drug remaining after course of therapy is completed
o (for diabetic) to perform finger-sticks as opposed to urine testing for the most reliable blood
sugar results
GENERAL NURSING IMPLICATIONS FOR PENICILLINS

 Assess rigorously for allergic reactions, as incidence is higher with penicillin therapy than with
other antibiotics. If a reaction occurs, the drug must be discontinued immediately. Epinephrine,
oxygen, antihistamines and corticosteroids must be immediately available.
 Anticipate that allergic reactions are more likely to occur in patients with a history of asthma, hay
fever, urticaria, or allergy to cephalosporins.
 Detain patient in an ambulatory care site for at least 20 min after administering a penicillin.
Injection to assess for the onset of anaphylaxis. Be prepared for prompt treatment of
anaphylactic reaction.
 Do not administer long-acting types of penicillin V, because these types are only for IM use.
They may cause emboli, or CNS or cardiac pathology if administered IV.
 Do not massage repository (long-acting) penicillin products after injection, because rate of
absorption should not be increased.
 Prevent rapid administration of IV penicillin, because this method may cause local irritation and
may precipitate convulsions.
 Teach patient and/or family
o The signs and symptoms of allergic reaction, instructing the patient to stop medication when
noted and to check with medical supervision as soon as possible
o To take oral penicillin with a glass of water 1 hour before or 2-3 hour after meals
o To return for repository penicillin injections to complete treatment; if physician orders.

Doc. No. /Rev. No.
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o To complete entire prescribed course of therapy, even though patient may feel well; a patient
with alpha-hemolytic streptococcus infection must continue with penicillin for a minimum of
10 days, and preferably 14 days to prevent development of rheumatic fever or
glomerulonephritis.
 Most penicillins are excreted in breast milk and should be prescribed cautiously to nursing
mothers.
ATTACHMENTS
 Nurse Medication Sheet
 Medication Card
 Medication Sheet
POLICY ON TIME INTERVAL TO ACT IN ORDER FOR TREATMENT
PURPOSE
To establish a guideline for the nursing personnel that they may be guided in the time intervals
needed to act in order for treatment.
POLICY
 The NOD shall request the medicines orders by the Attending Physicians with the use of
Pharmacy requisition through NETWEB. The request form shall be forwarded by the HCA of
NOD to the pharmacy department. NOD or HCA shall get the medicines as soon as possible or
upon the availability of the medicines.
o A maximum of 1 hour shall be allowed from the time the order was made to the time initial
dose is started unless specified to be started right away.
o STAT medications shall be given within 30 minutes the medicines were ordered.
 All medications for skin testing shall be started from the time ANST has been read by the
Resident on duty.
 Emergency purchased medicines will be given within 30 minutes upon the pharmacy
department informs the NOD that medicines becomes available.
 Standing medicated shall be given within 30 minutes before and after the standard time.
 Medication Standard time to be followed:
o OD (once a day) – 8am
o BID (twice a day) – 8am - 6pm
o TID (three times a day) – 8am – 1pm – 6pm

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o QID (four times a day) – 8am – 12pm- 4pm- 8pm

o Q 8 (every 8 hours) – 8am- 4pm- 12am
o Q6 (every 6 hours) – 12am-6pm-12pm-6am
o Q12 (every 12 hours) – 8am -8pm
o Q4 (every 4 hours) – 8am-12pm-4pm-8pm-12am-4am
 Sliding or adjusting of the medicines must be according to the standard time. The time interval
ordered will be followed as closely as possible.
 Multiple antibiotics may not follow the standard time but 2 hours interval between antibiotics is
allowed unless specified.
POLICIES ON VERIFICATION OF PRESCRIPTION AND ORDERS
PURPOSE
To guide the nursing personnel in correctly verifying prescription and doctors’ orders thus
minimizing risk for errors.
POLICY
 The medication sheet and the Doctor’s order sheet shall be checked by the NOD prior to
administering the medications. The NOD administering a medication will be aware of the
following information concerning each medication before administration.(See also 12 rights of
medication administration)
o Therapeutic action
o Untoward actions or side effects
o Antidote (if applicable and its location)
o Route and frequency of administration
o Normal dosage and maximum safe dosage
o Precautions example: BP and pulse precaution
o Contraindications
 The NOD shall notify the Attending Physician of the review of medications every time the
attending Physician revised their orders.
 Prior to the administration of all medicine, the amount ordered and two licensed nurse (NOD
and/or Head Nurse/Supervisor) must check the amount, drug computation and medications

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prepared. The two licensed nurse will check the original doctor’s order.
 During life threatening situations (e.g. Cardiac arrest) the verbal order supersedes the written
orders. The NOD will restate before accepting the order. The ordering physician will document
all orders as soon as the patient is stable.
POLICY ON SAFE MEDICATION ADMINISTRATION
PURPOSE
To guide nursing personnel regarding correct/safe administration of medications by different routes,

and to prevent errors in drug administration thereby protecting patient lives
POLICIES
Medication will be administered only upon the order of physicians who are members of the medical
staff, are authorized members of the hospital or have been granted clinical privileges to write such
orders and render the guidelines of their respective scopes of practice. Administration will be by a
Physician, registered Nurse, Respiratory Therapist, Physical Therapist and/or their respective
supervised students. The ordering Physician should include their licensed number when ordering
Medication.
 The administration of the following Rescue drugs thru infusion drip shall be done only at the ICU
or in an ICU set up:
o Nitrates
o Adrenaline/Epinephrine
o Dopamine
o Dobutamine
o Aminophylinne
o NaHCo3

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o Hypnotics
o Anticonvulsant Agents
o Insulin
o Anti-hypertensive drugs
 An automatic stop order shall apply to instances when the physician did not specify the exact
number of doses or duration of medication (open-ended medication orders). It will serve as a
protection against the indefinite open-ended medication orders that can be harmful to the patient
and at the same time ensures continuous therapy if so desired by the physician. Open-ended
drug orders shall automatically be discontinued unless to follow is ordered or renewed in writing.
 Medications reorder procedure:
o Albumin every 24 hours
o All controlled drugs every 72 hours
o Oxytoxics and IV solutions every 72 hours
o TPN every 48 hours
o Antibiotics every 7 days
o All other medications every 10 days
 Orders written to “HOLD” medications with no specific time frame shall be considered to be
orders to discontinue the medications. These orders must be re written in their entirety when it is
desired to resume the medication. When a hold medication order with a specified time frame is
written, the administration of the medication will resume at the end of the specified time. No
medications will be left at the patient’s bedside except for the following: respiratory inhaler
and throat lozenges.
 Dose preparation will be performed in a well-lighted medication area.
 The NOD will ascertain positive identification of the patient by asking their name and by reading
the identification wristband prior to administration of all medications.
 NOD will check for medications allergies prior to administration of all medications.
 Questions regarding medication compatibility will be referred to the pharmacist or researched
in available compatibility references. All mixed solutions will be observed for signs of
incompatibility or precipitation prior to patient administration.
 Incompatible injectable (IM, subcutaneous) medications will be administered at different
injection sites.
 Medications will be prepared immediately prior to administrations, particularly medications
prepared for parenteral administration, according to unit dose protocol. To the maximum extent
possible, drugs are to be administered by the person preparing the dose (except when unit dose
system is used and intravenous admixtures are prepared by the pharmacy.
 The NOD administering the medications will stay with the patient until the patient swallows the
medications and a notation in the patient’s medication record is made. This also applies to

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medication held because of the nurse’s discretion. (If a medication is held or refused a notation
is made on the patient’s medication sheet)
 “PRN” medications administered will be qualified by designating the time of administration and
parameters, i.e. patient’s blood sugar, blood pressure. If pain, there must be a space for pain
scale pre-post administration of medications
 Maximum amounts of solution to be administered intramuscularly in one site include:
o adults, three (3) ml
o children, one (1) ml
o infants, one half (1/2) ml
o newborn, one half (1/2) ml
 Subcutaneous injections will be administered in one of the following sites, unless otherwise
ordered by the physician.
o Outer aspect of the arm over the triceps
o Outer portion of the thigh over the quadriceps muscles
o Any area of the abdomen
 All medications ordered should contain one specific dosage, never a dosage range, with the
exception of those orders using a sliding scale where the physician specifies the parameters.
Orders for medications that are not specific to strength (and or dosage must be cleared with the
physician)
 The apical pulse will be taken prior to administration of any digitalis preparation. If the pulse is
below 60 the medication will be held and the physician will be consulted.
 Medication from home that the patient brings to the hospital will be sent back to immediate
relative.
 Use IVF Tag; note in the tag the room number of patient, date, patient’s name and number of
the IVF bottle also; the time the Fluid was started. Include admixtures if there are any. Indicate
in the card the duration of the fluid and desired flow rate, the nurse who transcribed the order on
the card signs his/her name legibly.
 SYRINGE AND NEEDLES FOR IVF PUSH AND IM INJECTIONS SHOULD BE DISCARDED
AFTER USE; COLLECT ALL USED DISPOSABLE SYRINGE AND NEEDLES IN ONE BOX
FOR PROPER DISPOSAL.
 ALL ORDERED MEDICATIONS ARE ENTERED IN THE KARDEX, THIS IS UPDATED AS
NECESSARY.
 If the patient expires, all unused medications must be returned and deducted to patient
account.
 Unavailable medications will be obtained from pharmacy not from another patient’s medication
box.
 Drug reactions will be reported immediately to the attending Physician and Pharmacy

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department by completing the Adverse Drug Reaction Reporting Form). A notification form will
be sent to nursing administration. Such reactions will be documented on the medical record;
management of the adverse reaction of medicines will be initiated by the attending Physician.
 Medications given thru “IV Piggyback” should be properly LABELLED in the proximal and distal
end of its tubing’s.
 Errors in administration of medication will be reported immediately to the attending physician
and a medication variance form (Incident Report) will be sent to supervisor, the actual
medication administered will be documented on the medical record proper sanctions will be
implemented according to a thorough investigation.
 Reference materials containing monographs on all drugs are available on each nursing unit.
The MIMS annual contain information such as generic names and brand names, available
strength and dosage forms and pharmacologic data including indications, side effects and drug
reactions. A copy of latest MIMS annual will be available at each nursing station.
 Emergency Carts will be locked when left unattended.
 Outgoing or incoming NOD may prepare medications that have to be administered during the
end of shift that have to be administered during the end shift report as long as NOD who
prepares the meds also administers and charts it.
 Pain reliever ordered in a series like “every four hours, for six doses” shall be given as ordered
even if not in pain unless contraindicated.
 INVOKE THE TWELVE RIGHTS IN DRUG ADMINISTRATION.
 Usage of JCI “Do not list” of Abbreviations is a must, and a copy of this list is attached in the
manual.
 DRUGS OF TREATMENT GIVEN ROUND THE CLOCK TO SUSTAIN A MAINTENANCE
DOSE LEVEL OR FOR OTHER SPECIFIC REASONS CAN BE ADMINISTERED OUTSIDE
THE ROUTINE STANDARD TIME
 ALL DIURETICS ARE USUALLY GIVEN IN THE EARLY MORNING BEFORE BREAKFAST
EXCEPT IF HOUR ADMINISTRATION IS SPECIFIED BY THE MD.
 ALL MEDICATIONS ARE STARTED AS SOON AS POSSIBLE AND THE SUCCEEDING
DOSES ARE ADJUSTED ACCORDING TO THE STANDARD TIME INDICATED. ADJUSMENT
SHOULD BE MADE SUCH THAT THE TIME INTERVAL AS ORDERED SHOULD BE
FOLLOWED AS CLOSELY AS POSSIBLE.
 ALL MEMBERS OF THE NURSING STAFF (NURSE, MIDWIFE, CLERK, OPERATING ROOM
NURSE, HEALTHCARE ATTENDANT) ARE STRICTLY PROHIBITED FROM SELLING
DRUGS UPON REQUEST OF PATIENT, PATIENT’S RELATIVES, OR EVEN STAFF
MEMBERS OWN RELATIVES OR OF ANY PARTY.

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POLICY ON PROPER DOCUMENTATION OF DRUG ADMINISTRATION
PURPOSE
To guide the nursing personnel on the correct and proper way of documenting on the medication
sheet for drug administration.
POLICY
 Each dose of medication administered shall be properly recorded in the patient’s medical
record (medication sheet); time and date ordered must be written on medication sheet.
POLICY ON DURATION OF DRUG ADMINISTRATION
PURPOSE
To guide the nursing personnel on how the drug administration or order should last.
POLICIES:
The hospital shall establish a policy regarding the duration of drug administration
 It is advisable, but not mandatory the drug orders shall indicate the number of doses and/or
days to be administered.
 Orders for narcotic analgesia shall be rewritten every 72 hours. The patient’s nurse is
responsible for notifying the prescribing physician of an order which is about to expire. This may

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be done verbally or in writing.

 Orders for adult total parenteral nutrition solutions and pediatric parenteral nutrition solutions
shall be rewritten daily.
 A Physician shall indicate any medications to be administered orally after a patient has been
placed on a “NPO” status.
 All drug orders are cancelled when patients go to surgery or the delivery room, when a general
anesthetic is administered, or when the patient is transferred to another service or an intensive
care unit. All orders will be re-written as part of new admission orders, dated and timed.
 Outpatient standing orders shall be limited to six (6) months in duration.
 The following medications have specific automatic stop orders:
o 5HT3 receptor antagonists (Zofran, Anzemet, KYtril, etc.) – five (5) days
o THC (Marinol) – Ten (10) days.
o Fentanyl (Duragesic) patches, benzodiazepines and Zolpidem (Ambien) – fourteen (14) days
o Ketorolac therapy – five (5) days
 All other inpatient drugs shall be stopped after thirty (30) days. Continuation of the medication
shall require a new physician order.
REDUCING MEDICATION ERRORS
PURPOSE
Reducing medication errors many hospitals now use a computerized medication ordering system to
better manage medications and to significantly reduce medication errors.
To help reduce the potential problems:
 Ask your doctor or nurse about any new medications, what they are, what they do, when they
are given and their side effects.
 Tell your doctor and nurse if you have any allergies or have had previous reactions to drugs,
food, latex, etc.
 Bring a list of all the medications you are taking, DO NOT bring the actual medications from
home, unless directed by your doctor or hospital staff. Tell your doctor and nurse about all drugs
you are taking (even vitamins, herbal remedies or over-the-counter medicine).
 Make sure the nurses and doctors check the wrist identification band provided by the hospital
before giving your medicine.
 If you have an IV and the site is red or, painful tell your nurse. Tell the nurse if the IV doesn’t
seem to be dripping properly (if it is too fast or too slow or empty).

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POLICY ON VERBAL, TELEPHONE AND TEXT PHYSICIAN’S ORDERS

PURPOSE
To establish guidelines for accepting, transcribing and confirming verbal, telephone and text
physician’s orders.
DEFINITION
 Verbal Orders – are orders that are dictated in person by an Attending Physician to Registered
Nurses.
 Telephone Orders – are orders that are dictated over the telephone by an Attending Physician.
 Text Orders – are made by a physician using the SMS capabilities of his/her cellular phone.
POLICY
 Physician verbal, telephone and text orders shall be utilized only in situations where the ordering
doctor is not available to write the order and delay will result in a compromise in patient care.
 Physician verbal, telephone and text orders shall only be accepted by the following healthcare
professionals. Orders shall be appropriate and within the processional’s scope of practice.
o Registered Nurses
o Registered Pharmacists

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o Licensed Respiratory therapists

o Certified/Registered EEG technologists
o Physical and Occupational Therapists
o Licensed Dieticians
o Licensed Medical Technologists
o Licensed Medical Technicians (Clinical Lab)
o Licensed Radiologic Technologists
o Licensed Radiation Therapists
o Physician Assistants
 Verbal orders for anti-neoplastic agents shall not be accepted.
 The verbal, telephone and text order shall be documented by the professional who accepts the
order and shall include:
o Name of the patient
o Date
o Time
o Instruction/order, including name of the medication, strength, dose increment, frequency,
route, quantity or duration and age and/or weight of the patient when appropriate. PRN
orders must include specific time interval and indication.
o Notation that order was a verbal or phone order.
o First and the last name physician issuing the order.
o Legal signature of healthcare professional receiving the order.
 All orders shall include physician cell phone number
 Prohibited abbreviation shall not be used in documenting verbal orders.
 The individual accepting the verbal order shall record and then read back the order in its entirety
to the prescribing physician at the time the order was given, documenting that the order was
given, documenting that the order was “read back”.
 Verbal, telephone and text orders shall be transcribed by any staff member authorized to
transcribe other physician orders. When the orders are transcribed by unlicensed staff, they
shall be countersigned by a licensed staff member prior to implementation.
 Nursing staff shall tag all verbal orders with a “sign here and date” tag to alert the physician of
the need to sign the verbal order upon return to the unit.
 Nursing staff and other healthcare professionals shall be permitted to act upon verbal, telephone
and text orders provided the orders contain the appropriate information and are within the scope
of practice for said healthcare professional.
 Verbal, telephone, and text orders shall be signed or initiated by the prescribing practitioner as
soon as possible, but not later than five (5) days after being given. When the physician who

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made the order is unavailable, it is acceptable the team member or the attending staff to
authenticate the verbal order(s).
 Physician extenders (physician assistants, advance practice nurses, etc.) shall may accept
verbal orders from their supervising physician; the supervising physician shall countersign these
verbal orders within 24 hours for inpatients and hospital emergency departments and 72 hours
in all other cases.
 Medical staff members, house officers and other practitioners who fail shall authenticate a verbal
order is in non-compliance with the rules and regulations of the medical staff and shall be
subject to corrective action.
PROCEDURES ON SETTING UP, INSERTION, CHANGING AND

DISCONTINUING IV INFUSION
Procedure on Setting up an IV Infusion

Steps to be followed by all PCS staff nurses:
1. Verify written prescription and make IV label
2. Observe 12 Rights when preparing and administering IVF
3. Explain procedure to reassure patient and/or significant others, and secure consent.
4. Assess patient’s vein; choose appropriate site location, size/condition
5. Do hand hygiene before and after the procedure
6. Prepare the necessary materials for procedure(IV tray with IV solution, administration set, IV
cannula, forceps soaked in antiseptic solution, alcohol with cover (this should be exclusively
used for IV), plaster, tourniquet, gloves, splint, and IV hook), sterile 2x2 gauze or transparent
dressing.
7. Check the sterility and integrity of the IV solution, IV set and other devices.
8. Place label on IVF bottle duly signed by RN who prepared it. Include patient’s name, room no.,
solution, and drug incorporation, bottle sequence, duration, time, and date.
9. Open seal of the infusion aseptically following the Infection Control measures.

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10. Open IV administration set aseptically and close the roller clamp and spike the infusate
container aseptically.
11. Expel air bubbles if any and put back the cover to the distal end of the IV set.
Procedure on Insertion of IV Cannula to Patient

Steps to be followed by all PCS staff nurses:
1. Verify the written prescription for IV therapy and check prepared IVF.
2. Explain procedure to the patient and relatives always observed the 12 Rights for administering
drugs.
3. Do hand hygiene before and after procedure
4. Choose site for IV insertion.
5. Apply tourniquet 5 to 12cm (2-6 inches) above injection site depending on condition of patient.
6. Check on radial pulse below tourniquet.
7. Prepare site with effective topical antiseptic or cotton with alcohol in circular motion and allow 30
seconds to dry, avoid touching the area.
8. Using the appropriate IV cannula, pierce skin with the correct technique.
9. Upon backflow visualization, continue inserting the catheter into the vein.
10. Position the IV catheter until the hub is 1mm to the puncture site.
11. Slip sterile gauze under the hub. Release the tourniquet; remove the stylet while applying digital
pressure over the catheter with one finger about 1-2inches from the tip of the inserted catheter.
12. Connect the infusion tubing to the prepared IVF aseptically.
13. Open the clamp and regulate the flow rate. Reassure patient.
14. Anchor needle firmly in place with the use of:
a. Transparent tape/dressing directly on the puncture site.
b. Tape (using any appropriate anchoring style)
c. Band aid
NOTE: Do not place unsterile tape directly on IV insertion site. Instead, place a small piece of
OS and then secure it with adhesive tape.
15. Tape a small loop of IV tubing for additional anchoring. Apply splint, if needed.
16. Calibrate the IVF bottle and regulate flow of infusion according to prescribed duration.
17. Label on IV tape near the IV site to indicate the date of insertion, type and gauge of IV catheter
and countersign.
18. Label with plaster on the IV tubing to indicate the date when to change the IV tubing.
19. Observe patient and report any untoward effect.
20. Document in the patient’s chart and endorse to incoming shift.
21. Discard sharps and waste according to Health Care Waste Management (DOH/DENR)
Procedure on Changing IV Infusion

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Steps to be followed by PCS staff Nurses:

1. Verify doctor’s order; countercheck IV label, IV card, infusate sequence, type, amount, additives
(if any), and duration of infusion.
2. Observe 12 Rights for administering drugs
3. Explain procedure to reassure the patient and significant others and assess IV site for redness,
swelling, pain, etc.
4. Change IV tubing and cannula if 48-72 hours has lapsed after IV insertion for adult patients
while 7 days for pediatric patients.
5. Prepare necessary materials; place on an IV tray.
6. Wash hands before the procedure.
7. Calibrate new IV bottle according to duration of infusion as per prescription.
8. Close the roller clamp.
9. Open and connect the IV tubing into the solution bottle.
10. Regulate the flow rate according to the prescribed infusion rate. Expel air bubbles, if evident.
11. Reiterate assurance to patient and significant others.
12. Discard all waste materials according to Health Care Waste Management (DOH/DENR)
13. Document and endorse accordingly.
Procedures on Discontinuing IV Infusion

Steps to be followed by the PCS staff Nurses:
1. Verify written doctor’s order to discontinue IV including IV medications.
2. Observe 12 Rights
3. Assess and inform the patient of the discontinuation of IV infusion.
4. Prepare the necessary materials; IV tray or injection tray with sterile cotton balls with alcohol,
plaster, pick-up forceps in antiseptic solution, kidney basin and band aid.
5. Wash hands before and after procedure.
6. Close the roller clamp of the IV administration set.
7. Moisten adhesive tapes around the IV catheter with cotton ball with alcohol; remove plaster
gently.
8. Use pick-up forceps to get cotton ball with alcohol and without applying pressure, remove
needle or IV catheter then immediately apply pressure over the venipuncture site
9. Inspect IV catheter for completeness.
10. Discard all waste materials including the IV cannula according to Health Care Waste
Management (DOH/DENR)
11. Reassure patient
12. Document time of discontinuance, status of insertion site and integrity of IV catheter and
endorse accordingly.

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POLICY AND PROCEDURE ON MEDICATION MANAGEMENT

POLICY
The UPARHMC shall maintain supplies of concentrated electrolytes in the Pharmacy Department;
Concentrated electrolytes will not be routinely stocked on patient care areas except in the sealed
emergency trays to avoid inadvertent use in undiluted form.
The number of drug concentrations available at UPARHMC shall be standardized where possible
and limited to the minimum required to meet patient care needs.
The following concentrated electrolyte solutions shall be stored by and mixed in the Pharmacy
Department except in emergency situations:
 Magnesium sulphate.
 Potassium Chloride.
 Potassium phosphate.
 Potassium acetate.
 Sodium acetate.
 Sodium chloride 3%.
 Sodium chloride 2.5 mEq/mL.

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 Sodium phosphate.
DEFINITION
High-Alert drugs are drugs that have an increased risk of causing significant client harm when they
are administered in error.
GUIDING PRINCIPLES & VALUES

There shall be standardized process for the storage of concentrated intravenous electrolyte
solutions and intravenous potassium chloride containing infusion solutions. Concentrated
electrolytes are high-alert drugs.
All pharmacy staff, central stores staff and nursing staff shall be asked to comply with this policy in
order to ensure the proper storage of concentrated electrolytes.
PROCEDURE
 Concentrated electrolyte solutions for intravenous use will be available in the Pharmacy
Department only, with the exception of the following items stocked in the Pediatric Intensive
Care Unit (PICU), Neonatal Intensive Care Unit (NICU), and Emergency Department Trauma
Room.
o PICU: Sodium Chloride 3% inj – 250 mL, Sodium Chloride 2.5 mEq/mL – 40 mL.
o NICU: Sodium Acetate 4mmol/mL.
o Emergency Trauma Room: Sodium Chloride 3% inj – 250 ml.
 All concentrated electrolytes in PICU, NICU, and ER will follow narcotic scheduled medication
controls and include appropriate high alert labelling precautions to avoid them being mistaken
for other similarly packaged medications.
 Concentrated electrolyte solutions shall not be provided as regular floor stock medication.
Receipt and Storage of Product into Pharmacy and Central Stores.

 Product shall be received into Pharmacy by the Pharmacy Technician and into Stores by
Receiver.
 Products shall be stocked into designated storage areas.
 Potassium Chloride containing infusion solutions shall be clearly identified to differentiate them
from other IV solutions.

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 Potassium chloride and potassium phosphate concentrated solutions shall be stored separately
in a clearly defined storage area in the sterile products area.
 Potassium chloride concentrate in 250 mL bottles (Baxter) shall be immediately removed from
their cases when received and labelled appropriately and taken to Sterile Products Area.
 Hypertonic saline (NaCl 3%) shall be received and stocked in Pharmacy.
Caution: HYPERTONIC SALINE Administer into a large vein.
If UNUSED, discard the bag in sharps bucket, do not leave unattended and
STOP SIGN LABEL HIGH ALERT DOUBLE CHECK
 Labels shall be applied to the FRONT of each bag upon receipt into the Pharmacy, Note:
overwrap removed labels applied and overwrap reapplied and sealed.
Storage of Product in Patient Care Areas.

 Potassium Chloride for infusion shall be supplied to all patient care areas as premixed bags of
standardized concentrations either as supplied by the manufacturer or as prepared by
Pharmacy. These premixed bags shall be stored separately from non-potassium containing
solutions and storage areas, where possible labels will be further differentiated with red bins or
red tape.
 Other potassium solutions stocked in PICU:
o Potassium Chloride 1 mEq/mL – 10 mL syringes in SWI.
o Potassium Chloride 1 mEq/mL – 50 mL syringes in SWI.
 Potassium Chloride 1 mEq/mL prefilled syringes (4 mL) for dialysis shall be stored in the
Pharmacy Night Cupboard.
 Potassium Chloride 1 mEq/mL prefilled syringes (10 mL) shall be stored in the Pharmacy Night
cupboard and used only if a premixed solution cannot be used. Nurses may call on-call
pharmacist to verify calculations if desired.
 Potassium Chloride 1 mEq/mL prefilled syringes (4 mL) shall be stored in the Pharmacy Night
Cupboard for dialysis requirements after hours.
 Sodium acetate shall be maintained as stock on NICU as stability is not sufficient to permit
supply of stock bags. Sodium acetate is managed as a controlled substance in NICU.
 *Sodium Chloride 2.5 mEq/mL (40 mL) remains temporarily as stock on PICU while the unit
assesses the appropriateness of an additional premixed Dextrose/NaCl solutions prepared by
Pharmacy.

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POLICIES AND PROCEDURE FOR MONITORING ADVERSE DRUG

EFFECTS
PURPOSE
To establish a uniform and consisted method of review, evaluation, and documentation of physician
occurrences and peer review for the purpose of performance improvement, risk reduction, patient
safety, appropriate utilization, and reduction of morbidity and mortality. Behaviour issues will follow a
separate review process according to the medical staff code of conduct policy and will also be
protected under peer review.
POLICY
It shall be the policy of UParHMC to conduct review of medical staff indicators, appropriateness of
care, complication and/or mortality rate, and resource utilization in a consistent and timely manner.
DEFINITIONS

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 Occurrence – an incident that is inconsistent with the UParHMC procedures or routine patient
care or results in serious physical or psychological injury or death.
 Peer review component definitions – definitions of circumstances requiring peer review are listed
below. Clinical operations improvement or the credentials committee may suggest revision to
the lists, with final; approval granted by the medical executive committee. Circumstances
requiring peer review include:
o Medical staff indicators
o Appropriate use of blood and components, medications, tests, procedures, level of care, etc.
o Deviation from external benchmarks identified for comparisons in screening for opportunities
for improvement in management and outcomes.
o Risk occurrence
 Peer review participants -
o A peer reviewer shall be defined as a member of the medical staff in good standing. In
instances for occurrences involving clinical decision-making the opinions of a physician
licensed in the same medical specialty as the individuals whose care is under review should
be obtained.
o A peer committee is either the medical staff department to which the physician is assigned or
the physician components of an integrated performance improvement committee where the
members are considered experts in the function are being monitored.
o An individual functioning as a peer reviewer will not have performed any medical
management on the patient whose case is under review. However, opinions and information
may be obtained from participants involved in the patient’s care.
o A practitioner-focused review is defined as when a process becomes more practitioner
specific and requires more in-depth review involving monitoring, analysing and
understanding individual practitioner performance.
LEVEL OF SIGNIFICANCE
 Level 1 – Occurrence that did not directly put patient care at risk. The case is managed and
documented appropriately.
 Level 2 – Occurrence that may impact patient safety or well-being or hospital operations. The
case is managed appropriately, but documentation is not adequate.
 Level 3 – Occurrence or medical/surgical case management is questionable with no potential
for significant adverse effect on the patient or hospital operations.
 Level 4 – Occurrence or medical/surgical case management is questionable with high potential
for significant adverse effect on the patient or hospital operations.
 Level 5 – Occurrence or medical/surgical case management with significant, adverse effects on
the patient and or is direct violation of any legal/medical staff by laws/rules requirements.

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PROCEDURE
 Physician Performance Reviews – Chart review and/or verbal notification.
o Members include:
 Chief Medical Officer
 Clinical Risk Manager, Clinical Operation Improvement
 Clinical Operations Improvement
 Medical Staff Services
o Issues include:
 Quality – Review the summary of quality indicators identified and analyse for trends.
 Risk – Review the summary of risk indicators identified and analyse for trends.
 By laws/Rules and Regulations/Medical Staff Policies – Review the summary of
bylaws/rules and regulations/medical staff policies violations identified and analyse for
trends.
 Utilizations – Review the summary of utilization issues and analyse for trends.
 Reports and/or data collected shall be maintained in a confidential manner in accordance with
UParHMC law. All occurrences are summarized by occurrence type and physician for review at
the monthly Physician Performance Review meeting. From there, cases or trends can be
referred to Department chairs and integrated performance improvement committee, and/or
directly to Credentials or the Medical Executive Committee.
 Participants in the review process by the practitioner whose performance is under review:
o The individual whose case or trend is under review shall have the opportunity to present his
or her information regarding case management to the committee performing review. The
individual whose case is under review has the right to sit on the review committee during the
time case reviewed and discussed, to provide additional.
 All the individuals whose cases are referred for committee for review shall be notified of the
medical record number and ate of the admission case to be reviewed, in addition to the reason
for review, at least two weeks prior to the schedule for review meeting date. In case of
immediate referral to committee, as determined by the Department Chair, the Department chair
shall notify the individual, whose case is under review, regarding the reason for review and the
schedule date of review, as soon as the Department Chair makes the determination that the
case must be referred for formal review.
 Peer review activity time frames:
o Cases forward to the medical staff departments or peer review committees from the weekly
physician review meeting are to be reviewed within one month of the referral or the next
meeting.
o Issues believed to be such severity or urgency that immediate actions is warranted, the

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Director, Clinical Outcomes Improvement and/or the Manager, Medical Staff Affairs shall,
upon the receipt of report, immediately notify the Medical Staff President and/or Officers and
the involved physician.
o Time frames are adhered to in a reasonable fashion. All cases refereed for peer review shall
be reviewed within the time frames listed above. In those instances where peer review falls
out of the required time frames (medical record incomplete, practitioner under review is
unavailable, reviewing committee rescheduling, etc.) the reasons for the delay will be
documented. All efforts will be made to complete the peer view process as soon as
practicable within the confines of the delay.
 Actions
o Level 1 issuances will not require actions. Recurrence or a pattern shall constitute a higher
level of significance, thus requiring handling in a manner consistent with the level 2 or 3.
o Level 2-5 issues require contact with the physician by the Department Chair or Vice Chair,
with a written plan of action as applicable.
 File Access
o Access by the physician will occur only during an investigation and with the appropriate
approval and access granted by the person or committee involved in the investigation.
(Indiana Code, Sec. 34-50-15-4) These are retained in the Medical Staff Office.
Arrangements will be made for a review location on a case-by-case basis.
o A Department Chair, Service Medical Director, and section chief may access the files of its
member only for the performance of the responsibilities of the position.
o The President of the Medical Staff may have access to all Medical Staff Members’ files in the
performance of the responsibilities of the position.
o The Chief Executive Officer, President of the Hospital, the Director of Outcomes
Management or the Chief Medical Officer, Manager of Medical Staff Affairs.
o The Clinical Operations Improvement Clinical Risk Manager or Peer Review Coordinators
may access all professionals’ staff members’ in the performance of their responsibilities.
 Performance Improvement
o All cases undergoing peer review beyond the weekly physician review meeting will have a
worksheet completed that lists the rationale for conclusion made by the peer reviewer(s)
o All opinions regarding medical management, including minority opinions, will be considered
in the ultimate determination of a case. This includes information and opinions from the
individual whose case is under review.
o Results of peer reviewer are utilized at time of medical staff reappointment send to improve
the organization’s performance in individual situations, and, as a whole.
o Results of peer review activities are aggregated and reported ongoing and at time of medical
staff reappointment to provide for practitioner specific appraisal of competency and renewal

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QUALITY PROCEDURE
of clinical privileges.
o Aggregated and trended results of peer review activities are utilized in the hospital-wide
performance improvement program, via quarterly reporting to the Credentials Committee, to
allow for organizational improvement as necessary
o Peer review conclusions, outcomes and actions resulting from peer are monitored for the
effectiveness; results of follow-up effectiveness monitoring are reported to the Medical
Executive Committee.
INDICATORS
Quality Indicators – Medical Executive Committee

Quality concern (reviewed)
DVT/PE acquired after admission (trended)
Readmission for complication within 30 days (trended)
Unexpected death (see criteria below) (reviewed)
Iatrogenic disorder (adverse condition induced by effects of treatment) or Iatrogenic
complication (reviewed)
Sentinel events (reviewed)
Pathology Review:
Appropriateness Protocol deviation
Risk Indicators
Behaviour

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QUALITY PROCEDURE
Confidentiality
Privacy/Dignity
Verbal Communication
Documentation/Documentation not meeting Bylaws/inappropriate documentation
Failure to diagnose, missed diagnosis or misdiagnosis
Utilization indicators
Timeliness
Discharge Issues
Bylaws Violations
No response to page
Failure to provide adequate coverage
Failure to see patient in a 24 hour period
Bylaws Issue
Unexpected Death Criteria

Unexplained patient in the hospital
Deaths in outpatient setting, excluding the ED
Deaths during the elective surgery/invasive procedures
Death within 72 hours of elective surgery/ invasive procedures
All pediatric deaths
Deaths thought secondary to:
 Medication reaction
 Blood transfusion (haemolytic reaction)
 Potential nosocomial infection as cause of death
 Inpatient accident (e.g fall)

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REVIEW PROCESS

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Reviewer screens that occurrence type selected is
FIRST CABUYAO HOSPITAL
correct, Change is indicated
Revision Date:
QUALITY PROCEDURE
TREND
No further review
Summary of all occurrences are reviewed weekly for
Needed by case. No
analysis of trends or need for Peer Review
Trends ID (Stop)
Questioned case(s) or trend(s) ID’d
Peer Review Committee. May request additional

information from involved practitioner Acceptable (Stop)
Questioned
Action(s): letter, review of additional similar cases,

Resolved (Stop)
monitor of the following admissions for a define time
frame etc.
Not Resolved
Resolved (Report
MEC AND/ OR BOARD resolution to MEC)
Not Resolved
Credentials Committee
May request a peer review panel
OR
External Peer Review
Report MEC AND/OR BOARD

National Resolved
Practitioner FINAL DECISION
Data Bank if indicated

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QUALITY PROCEDURE
PATIENT’S RECORD AND STANDARD CHARTING
The standard content of the patient’s chart:
 Basic contents include forms that are used by all patients.

o Professional Fee
o Patient Data
o Consent Form
o TPR
o Standing Order
o Doctor Order Sheet
o History
o Progress Notes
o Medication Sheet
o Nurses Notes
o Laboratory/Diagnostic Sheet
o P.E. and History
o Consent for Admission
o Diabetic Sheet
o Consultation Record
o Progress Notes
o Discharge Summary
o Clinical Abstract
o Blood Transfusion Record
o Blood Transfusion Consent
o Consent for Operation
o Consent for Surgical Treatment/Procedure
o Pre-operative Checklist
o Pre-anaesthetic Checklist
o Discharge Instruction
o Neuro-Vital Signs Monitoring Sheet
o Discharge Against Medical Advise Form
o Transfer to Hospital of Choice
o Serial Laboratory Monitoring Sheet

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o Nebulization Sheet
o Room Checklist
 For referral and unanswered consult the consultation form is initially placed in the first page of
the chart, put back at its designated place after the order has been relayed to attending
physician or transcribed and carried out.
 The pre- operative checklist is placed on the first page of the chart before the patient goes to
OR.
 The patient’s data sheet is placed on the top of the sheet once discharge order is given to
remind the attending physician to fill out the final diagnosis.
 All chart form shall be put together and submitted to the record section.
PATIENT’S DATA
Purpose: Provide basic information about the patient:

 Personal Information
 Patient Category (private or house case)
 Date and time of admission
 Plan of Hospitalization
 Admitting impression with chief complaint
 Admitting ROD
 Procedures/surgery performed
 Final Diagnosis
 Main attending physician
 Note the AP must write the diagnosis and affix their signature prior to discharge of the patient
PF FORM
Purpose: a form wherein the doctor/s may write their professional fee prior to discharge of patient.
VITAL SIGNS FLOWSHEET & TPR GRAPHIC SHEET
Purpose: To provide record of vital signs, weight, bowel habit, urination, and number of hospital
days the patient is admitted.
Guidelines:
 To record temperature use BLUE ink and dot on the designated column.

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 To record pulse use RED ink and dot on the designated column
 To start the graph encircle the normal values and connect it with the initial temperature and
pulse recording.
 Chart the RR and BP in the designated space under correct time using the shift color code (AM-
Blue, PM-Black, and NIGHT-red)
 Record weight as ordered. This is usually done before breakfast.
 Chart frequency of stool and urine.
Abbreviations used for charting urine and stools are as follows:

FC – Foley catheter
CE – cleansing enema
SSE – soap suds enema
FE - fleet enema
CC – condom catheter
Indicate the diet as ordered:

NPO – nothing per orem
OF – osteurized feeding
FULL – regular diet
STANDING ORDER SHEET

Purpose: To provide updated information regarding patient diet, medication, treatment, and
activities.
Note: It must be updated all the time by the nurse who carries out the doctors’ order.
Guidelines:
 Fill out the patient’s data including name and room number and hospital number
 Use black ink only. Place double bar (//) to discontinued orders. Write the date when the order
was made.
 The date of the order and date started should always be indicated.
 Write medicines, doses, route, and frequency on the designated column. Write results of
sensitivity tests.
 Other treatments and activities are written on the lower half of the sheet.
 Always check succeeding pages for the orders, if there are any.

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PHYSICIAN’S ORDER SHEET

Purpose: The physician order sheet contains the written, verbal or telephone medical orders.
Guidelines:
 All orders must be signed by the physician
 A registered nurse may take verbal or telephone orders but must be signed by the physician
within 24 hours.
 New orders must be written to defer or change a previously written order. Do not cross out
previously written orders which have to be discontinued or changed.
 The nurse complete the data required at the top portion of the sheet.
 The doctor’s order sheet should be finally checked to see that all orders have been transcribed
correctly to appropriate forms and carried out to make sure that no order is missed out.
 For orders which are not written in the official physician order sheet such as admission orders
and consultation orders do the following:
o Copy drug orders and label accordingly, then write doctor’s name per (sign your name)
o Transcribe the drug orders to appropriate sheets
 The physician’s order sheet may be used for other purposes like consent forms, release of
hospital from responsibility, progress notes or communication between consultants regarding
management of patient.
 Draw a box-like line from the start of the doctor’s order up to the last order and sign on the right
side including date and time orders was carried out.
MEDICATION SHEET
Purpose: To provide information regarding all medication and treatment with medicines.
Guidelines:
 Medication column: write the Generic and Brand name including the dosage, frequency and
route of administration.
 Treatment such as irrigations, nebulization and steam inhalation should be written in
nebulization sheet.
 Write standard time the drug has to be given. Specify whether it is AM or PM Ex. BID – 8am-

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QUALITY PROCEDURE
6pm
 Write the date on the left upper corner of the box with the time ordered adjacent to the right
upper corner of the box.
 To record medications which were administered, write nurses initials on the appropriate space
according to date and time.
 To record withheld medications or medications not administered, the nurse’s initials are
encircled. The reason for not administering the medication is recorded in the nurses’ notes.
 Change of route or dose. Write “changed” after the double bar (//) and indicate the date and time
that the order was made including the complete name of NOD with license number and
signature.
 Discontinued medication. Write “D/C” after the final dose and indicate the date and time the
order was made, affix complete name of NOD with license number and signature.
 When patient goes to the OR all previous orders must be discontinued automatically and noted
in the corresponding sheet.
 For post-operative medication orders write the word post-op then write in new medication order.
 All initials entered should be identified by the nurse through a sample of her signature in the
space provided.
 Note drug allergies on the standing order sheet
 Record each dose of medication after it is administered.
 Record only those mediations which only the nurse administered. IV medications should also be
recorded.
 Make an accurate recording of the medication including the name, dosage, route of
administration and time.
 Make universally accepted standard abbreviation only.
 Make an accurate observation regarding reaction of patient to drug.
 Implementation of JCI “Do Not Use” List of Abbreviation is a must; a copy of this list is attached
in this manual.
INTRAVENOUS FLUID SHEET

Purpose: To provide complete information about patient’s intravenous therapy and blood
therapy.
Guidelines:
 All fluid bottles/bags are numbered consecutively from the time of start up to the time
discontinued.
 IVF started in the Delivery Room or Operating Room is numbered as IVF # 1 or IVF # 2 and so
on.

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QUALITY PROCEDURE
 All IVF infused post-operatively are labelled as post-op and a new numbering is assigned. Ex.
post-op # 1
 For blood transfusion, the numbering is done consecutively from the first unit to the last unit as
BT # 1 and so on. NSS used for flushing purposes should be noted in the nurses’ notes.
 Side drip bottles are recorded separately from the main IVF and renumbered. Ex SD # 1, SD # 2
 Name of solution column:
o Indicate the name of solution, amount of fluid and any medicines and dose of medicine
incorporated in the bottle if there is any.
o For blood, albumin and other blood components indicate the type of blood, kind, amount,
donor or serial number (use the blood transfusion record sheet)
 Date and Time signature column:
o Started: write the date and time the IVF was started or infused as follow-up. Write nurses full
name license number and signature.
o Discontinued or consumed: write date and time the IVF is discontinued or consumed. Write
nurses full name license number and signature.
o Amount infused column: write the exact amount of solution infused or transfused during the
shift. Amount received column: write the exact amount of solution received from the outgoing
NOD from the start of the shift the duration of infusion and the desired flow rate.
 The following should be written at nurses’ notes:
o The name of the Physician/NOD who inserted the IVF including the type of cannula, gauge,
IVF rate, site and due changing of contraption.
o Any reactions observed during and after the therapy.
o Any interruptions, incurred, reasons for such interruptions, time restarted.
INTAKE & OUTPUT

Purpose: To maintain an accurate and current record of the fluid intake and output balance.
Guidelines:
 Intake – includes IVF, blood products, side drips, albumin, oral intake (water, all kinds of
beverages, juices), feeding through NGT or gastrostomy tubes.
 Output – urine voided or through catheter, ureterostomy, cystostomy, vomitus, BM, secretions-
includes drainage from NGT, colostomy output, wound drainage, thoracostomy, T-tubes etc.
 Record of intake and output should be entered correctly in the proper columns
 Recording of intake and output is done at the end of each shift.
 Intake and output is measured and recorded in cc or ml.
 Summation is done at the end of each shift and 24 hour total is done at 6am.

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NURSES’ NOTES
Purpose: This form is used by the nurses to chart a record the significant evaluation on the
condition of a patient under her / his care during each tour of duty.
Note: Write the date, time the Nurse’s full name with signature and license number. Use FDAR
method of charting.
Guidelines:
 Charting is done every shift 6am-2pm, 2pm-10pm, and 10pm-6am. No nurse should go on duty
without making the necessary notation on each patient’s chart.
 The nurse signs her name legibly and affixes RN, license number and signature on all her
charting at the end of her shift. There should be no blank space left in between charting or
between shifts.
 Erasures are not permitted. A straight line is drawn across a statement and the nurse must sign
it. This is resorted to when there is no possibility of changing the whole form or sheet to correct
an error.
 Long and or print method is used in recording. Use BLUE for AM, BLACK for PM, and RED for
night shift.
 All charting are entered in chronological order. Statements remarks and other data are written
as they occur, observed or accomplished.
 Some specific situations:
o Dressing: chart appearance of wound, type of dressing applied and patient’s response.
o Decubitus care: chart size and appearance, drainage if there is any and patient’s response
and special instructions.
o Diagnostic test: indicate the type of the test, side effects, outcome, patient’s response and
special instructions.
o Admission: write the chief complaint. Describe condition of the patient upon admission,
method and time of admission and patient’s general appearance.
o Discharge note: chart method and time of discharge note special instructions given.
o Referrals: note the time the referral was answered
o Diet: includes type and patient’s response to food

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o Contraptions: indicate the contraption, note whether it is properly applied and functioning.
o The time the Consultant made rounds should be indicated.
o Medications: all medication started should be written; including the time skin test is done and
read by the ROD.
o Any untoward signs and symptoms that happened to the patient should also be written on
the sheet.
LABORATORY REPORT SHEET
Purpose: Used for chronological posting of laboratory reports.
Guidelines:
 All reports must have the patient’s name, ward/ room number, hospital number, name of
attending physician.
 The nurse attaches the laboratory report sheet. Report with abnormal findings is clipped on top
of the chart until the AP or ROD is notified via SMS. This may then be attached to the laboratory
report sheet.
 The nurse makes sure that the right report is attached to the right chart. The nurse should check
the patient’s name on the report and match it against the patient’s chart.
 Attach reports starting from the first bottom line going to the top line.
 Notation whether AP or ROD has been notified or not shall be entered in the nurses notes.
CONSENT FORMS
Purpose: Necessary before a surgical procedure or operation. The consent is signed by the
patient or responsible representative to ensure that the patient has been given the
necessary information about the procedure, to protect patient’s rights as well as the
physician and the health care facility.
PRE-OPERATIVE CHECKLIST
Purpose: This checklist is to ensure that the patient is completely prepared for surgery before
leaving the nursing unit.
Guidelines:
 Fill-out the data – name, room number, date and surgeon, anesthesiologist.
 The nurse puts the checklist on top of all the hospital forms in the evening prior to surgery.

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QUALITY PROCEDURE
 The nurse checks the items which are accomplished in her shift
 On the day of surgery, the nurse makes a final check on all items and prepares the patient
accordingly.
 The vital signs are taken and recorded and the pre-op medications are given and charted
accordingly.
 Sensitivity tests are recorded using “negative” ( - ) or “positive” ( + ) accordingly.
 All contraptions are also indicated such as IV’s, tubes, etc.
 The type of enema administered in also indicated.
 The time when the patient started NPO
 A final check is accomplished with the OR nurse before the patient is brought to the OR.

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POLICY AND PROCEDURE FOR CORRECTLY IDENTIFYING PATIENT BY

THE CHART
PURPOSE
To provide an identification system to insure that all hospital patients are properly identified prior to
any care, treatment or services provided. To be able to uniquely identify all patients and create
specific patient chart that is readily available.
POLICY
The patient chart shall contain identifiers unique to each patient.

 Identifying procedures:
 The patient’s chart shall have a complete name, address, birthday, demographic data (sex, age,
civil status) and hospital number.
 Colour coding of the patient’s chart shall be attached in the front area of the chart
o Yellow – Pedia
o Blue – Adult (IM)
o Green – Surgery
o Pink –Obstetrics
 A tamper-proof, non-transferable identification band shall be prepared and affixed to the patient.
Personnel responsible for preparing the ID bands are as follows:
o Emergency Department – Patient registration
o In-patient Admissions and Observation Admits – Admitting Department.
o Labour and Delivery – Labour and Delivery Unit Staff
o Ambulatory Care Clinics (OPD)- Registration Staff (Secretary)
 Identification bands shall be sent with admission paperwork to the patient location and affixed at
the point by the receiving personnel.

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o Color coding of the wristband:

 Blue – IM
 Yellow – pedia
 Green – Surgery
 Pink - OB
 If an admission through the Emergency Room, the Admitting Office shall prepare identification
band, deliver to the Emergency Room and place it on the patient.
 The identification band shall show the Medical Record number, patient patient’s name, date of
birth, sex.
 Initially, the identification band shall be checked by the appropriate hospital staff to ensure that it
is legible and contains the correct information when the patient is registered.
 Prior to the administration of tests, treatments, medications, or procedure the healthcare
professional providing the care shall be responsible for verifying the patient identity by utilizing
two identifiers: patient name and patient medical record number or DOB. Staff shall verbally
assess the patient to assure proper identification, the patient’s name and DOB, and match the
verbal confirmation to the written information on the identification.
 If the identification band is illegible, missing, or contains incorrect information, the test,
treatment, medication, or procedures shall not be done until the patient is properly identified.
 Nursing department shall be responsible for obtainin a new band in the event that an
identification band is illegible, missing, or contains incorrect information, obtaining a new band is
from Patient Registration and Admissions. Labor and Delivery and Outpatient Surgery shall
generate a new band if needed for their patients.
 The patient shall remove the identification band after discharge. In the event of death, the
identification band shall remain on the patient’s body.

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POLICIES AND PROCEDURES ON PROGRESS NOTES
PURPOSE
 To improve services and all patients of Unihealth Paranaque Hospital & Medical Center.
 To provide a daily account of a patient and his/her illness and of the development in his/her
diagnosis, and treatment, for all of those who share in his care.
POLICIES
 Progress notes shall serve as a record of events during a patient’s care. It allows clinicians to
compare the past status to the current status, serves to communicate findings, opinions and
plans between physicians and other members of the medical care team. It shall also allow
retrospective review of the details of the case for all interested parties.
 Progress notes shall be done by all Residents, Junior Consultants, and Attending Physicians for
all patients of Unihealth Paranaque Hospital & Medical Center.
 Nurses shall also write a separate progress notes to be written on the Nurses Notes
 The Progress notes shall be in the following form:
o Written in a separate sheet following the problem-oriented SOAP format. S for subjective
complaints, O for objective complaints, A for Assessment, and P for plan.
o As side notes in the Doctor’s Orders sheet. This is usually written in the space allotted at the
side of the sheet.
 Whenever possible the progress notes shall be done at least once a day or for each patient
encounter. Nurses’ notes may be written more often depending on the level of care of the
patient.

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QUALITY PROCEDURE
BASIC RULES OF DOCUMENTATION FOR PROGRESS NOTES
 The date and time of all notes shall be indicated.

 The person who wrote the notes shall be properly identified with his/her role in the care of the
patient properly as indicated, e.g. ROD, IMJOD, etc.
 The Progress notes shall be signed over the printed name and PRC license number as
indicated.
 Use blue or black ink; for errors it shall be done by drawing a line through the erroneous entry
and signed with your initials.
 Abbreviations, misspelling and punctuation errors shall be avoided.

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SPECIAL DEPARTMENT ROUTINES AND PRACTICES
EMERGENCY ROOM
Policies and Procedures:
1. Admission
 Upon arrival of the patient, the nursing aide shall provide physical assistance while
the nurse assesses patient condition.
 Patient information sheet shall be presented to be filled up.
 The resident on duty (ROD) shall attend to the patient and takes the medical history.
Initial appropriate medical treatment is given is necessary and is referred to attending
physician.
 All medical records in the emergency room shall be duly accomplished before a
patient is brought to the ward.
 All “stat” order of medication and procedure shall be administered and charted by the
ER nurse.
 Intravenous fluid shall be started at the ER except in cases when the patient request
that they be started in his room.
 The ER nurse shall inform the unit of necessary room preparation according to the
needs of the patient.
 The ER nurse shall see to it that after a procedure is completed, charges are done
accordingly.
2. Consultation
 The ER nurse shall gather the patient data and nurse aide taking the vital sign.
 History and examination shall be taken by the ROD.
 Health teaching and instruction regarding take home medicine shall be properly given
to the patient by the nurse.
 Medical certificate form if requested shall be issued by the resident on duty (ROD)
 Non – emergency patient seeking consultation shall be referred to the outpatient
department (OPD).

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3. Treatment
 The ER nurse shall assist the Consultant or ROD in all kinds of procedures and
treatment.
 Intramuscular injection may be given by the ER nurse to the patient present a written
note or prescription from the attending physician. Sensitivity test shall be done in all
drugs requiring ST, if to be given to the first time. At the back of the prescription form
indicate the time and result of ST, and the date and time of administration of the first
dose.
4. Transport of patient
 All patients for admission shall be accompanied by the ER nurse or aide. They may
be transferred to the ward to either by wheelchair or stretcher depending upon the
health condition of the patient.
5. Referrals
 Patient requiring admission but cannot afford service shall be referred to hospital of
choice, no official record is forwarded: only a referral slip with the list of treatment /
medication is given to the patient.
6. Charting and Recording

 The ER nurses shall start the initial charting of the following vital signs, IV fluids,
treatment, medication, laboratory examinations and other procedures done.
 All patients seen at the ER admitted or OPD shall be recorded in the ER logbook.
E.R. HEADNURSE
 A nurse who shall be responsible for the organization, management and direction of the ER
with regards nursing. Being responsible for the explanation and implementation of
philosophy, objectives, policies and standards.
 She/he shall interpret the organizational structure of the nursing services to her / his co-
workers in the unit.
 She/he shall provide patient care and performing nursing procedures for the good of the
patient.
 She/he shall keep a record of all emergency drugs and making sure it is complete at all
times.
 She/he shall assume the responsibility for the orientation of new personnel and participating

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in the orientation of new personnel and participating in the new orientation program as part
of the hospital, job development program hopefully in the near future.
 She/he shall understand the legal aspect of nursing and demonstrating knowledge of the
same in the performance of her / his duties.
 She/he shall evaluate nursing staff in the ER.
E.R.STAFF NURSE
 A nurse under the immediate supervision of the head nurse, responsible for nursing care of
patients assigned to her / his.
 She/he shall acquire knowledge of the philosophy, objectives, policies and standards of the
hospital and the nursing service.
 She/he shall keep himself / herself up to date in medical and nursing procedures
 She/he shall give instructions to patients and patient’s relatives.
 She/he shall maintain a complete, accurate and intelligent record of nursing care and
observation of patient.
 She/he shall provide patient care in conformity with the established hospital standards and
policies.
 She/he shall relieve the head nurse in her / his absence.
 She/he shall keep the head nurse informed of all nursing care problem.
 She/he shall prepare patients physically, psychologically for treatment operation and
diagnostic studies.
 She/he shall administer medications and observing patient reactions and reports them
immediately.
NTENSIVE CARE UNIT
Cases eligible for admission:

 All suspected and / or definite cases of acute myocardial infarction
 Shock of whatever etiology.
 CHF – Pulmonary Edema.
 Acute Respiratory Failure
 Severe Electrolyte Imbalance
 Unconsciousness of undetermined cause

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 Severe trauma accident

 Severe Burns
 Poisoning with unstable vital signs
 Post – operative patient with unstable vital signs
Admission Procedure:
 The ICU staff shall be notified in advance regarding all possible admissions. Admissions will
be accepted depending upon the availability of the beds and medical problems presented by
the patients.
 All admissions shall be accompanied by a nurse and ROD.
Visitors:
Visiting hours is limited to 11 AM to 12 NN\ 7 PM to 8 PM and only one (1) member of the
immediate family shall be allowed to enter the patient’s room during visiting hours. Seven years old
and below are not allowed inside the ICU.
Transfer / Discharge:
 Patients shall be transferred as soon as the need or criteria for admission in the unit are no
longer present. Transfer or discharge order shall be written by attending physician or ROD.
 The ICU nurse shall notify the ward before transferring the patient.
 The ICU nurse shall accompany the patient to the ward and endorsed to the ward nurse.
When a patient admitted to the ward and needs ICU care, the doctor has been given order
for transfer. The ward nurse makes arrangements with ICU if a bed is available.
OPERATING ROOM
Objective:
 To render comprehensive and efficient service to patients who will undergo surgery.
 To be able to anticipate the needs of the surgeon during surgery.
 To create a wholesome working atmosphere in the operating room.
 To uphold the moral values, the ethical code of the medical profession and to recognize and
respect the legitimate right and dignity of man in the course of the practice of the surgery.
Policies and Procedure:

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1. Scheduling of operation:
 Regular operating hours shall begin at 6AM to 5PM.
 Operation shall be arranged with the operating room nurse.
 A telephone or verbal notification is accepted from the surgeon and shall be followed
by a written notification.
 The nurse shall prepare the OR notification form in duplicate.
 The accomplished OR notification form shall be brought to the OR to confirm the
schedule and to be signed as accepted by the OR nurse.
 The original copy is left in the OR and the duplicate shall be brought back to the ward
and kept in the patient chart.
 In cases of emergency surgery other cases shall inevitably be packed beyond their
scheduled hour.
 Cases that cannot be started with in 45 min. and whereby it overlaps the scheduled
next cases. The cases on deck shall be given the priority.
 Notification of postponement of scheduled operations shall be made in writing.
2. Pre-Operative preparation of patient: follow pre-op guidelines:

 A written informed consent shall be obtained from the patient or next of kin.
 Shaving of all elective cases shall be done in the nursing unit.
 For emergency cases, skin preparation shall be done in the nursing unit or in the
operating room depending upon the general condition of the patient and discretion of
the surgeon.
 Cardio-Pulmonary clearance shall be accomplished and recorded in the chart for
patient 35 years and above.
3. Case of patient on the day of surgery

 The patient shall be taken to the OR by an OR nurse and an HCA 30 min. before the
scheduled time of surgery.
 All patients shall be in a hospital gown and ID name tag before entering in the
operating room.
 The “pre-operative care checklist” shall be carefully accomplished by the ward nurse
and reviewed by the OR nurse before taking the patient. This checklist should signed
by both. The OR nurse and the nurse of the unit.
 X-ray films shall be brought with the patient to the OR if needed.
4. Care of the patient after surgery

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 The ward nurse shall be notified in advance before the patient is transported back to
the ward. She shall be advised to the equipment or gadget that the patient will need.
 Operating room staffs with an Healthcare Attendant transport the patient from the
recovery room (RR) or to the unit. The patient chart shall contain a complete and
accurate recording of what has been done during. Post-operative orders shall be
accurately endorsed to the ward nurse by the OR/RR nurse.
5. Care and Disposal of Specimen

 All specimen removed at surgery shall be the responsibility of the OR staff.
6. Post-Mortem Care
 The patient who expires in the OR is transported to the morgue after rendering post
mortem care shall be done by the OR staff.
7. Borrowing and Lending Instruments

 No instrument, supplies or articles shall be borrowed from OR, these things can be
borrowed or procured from the CSR.
 All borrowed instrument shall be returned immediately after used.
8. Policies related to other Department

 The X-ray department shall be notified in advance by the ward nurse for any Portable
X-ray procedure that will be done in the OR.
GUIDELINES FOR PREPARATION OF PATIENT FOR SURGERY
Preparation of the patient the day before surgery when an order for surgery shall be made:
1. Notify specific anaesthesiologist indicated and refer accordingly.
2. Accomplish and send OR notification for patient under special equipment needed, indicate
this in the request.
3. Place the pre- operative checklist on the top of the standard order sheet.
4. Explain the procedure to the patient and relatives in understandable terms.
5. Secure written consent for surgery signed by the patient or responsible relative. Patient who
signs the consent should be of legal age.

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6. Check the results of indicated laboratory and x-ray examination and check that cardiac
clearance report is on the chart if clearance requested.
7. Render complete physical preparation as indicated.
a. Complete bath in the evening before surgery
b. Prepare pre- operative area
c. Instruct observances of NPO
d. Do bowel enema as ordered
e. Check and removed nail polish
f. Prepare clean hospital gown
8. Administered sensitivity test to drug / solution if indicated and record the result.
On the day of surgery:
1. In cases there have been some changes / delay in the carrying out of patient at the OR for
operation, please advise / notify the concerned surgeon / anaesthesiologist about the
changes.
2. Complete physical preparation needed:
a. Remove dentures, jewellery and endorse to watchers.
b. Change patient clothing into a surgical gown.
3. Take and record the vital signs before administration of pre – operative medication and
before sending the patient to OR.
4. Administer and chart pre – operative medications.
5. Make a final check and accomplish all items in the pre – operative checklist and affix
signature.
6. Endorse the patient to Operating Room / Delivery Room.
7. Prepare post – operative unit:
8. Prepare post – operative bed
If indicated, prepare suction apparatus, oxygen regulator & cannula, IV stand and other equipment
that will be needed by the patient after surgery
POLICY ON ASSURING SAFETY AND READINESS OF PATIENT PRIOR TO
SURGERY
PURPOSE
To establish a standard procedure and policy on assuring safety and readiness of patient prior to
surgery.
POLICY
 PRE-OPERATIVE CHECKLIST

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o Cardiopulmonary clearance shall be required to all patients above 35 years of age who will
undergo major or medium procedures except for uncomplicated obstetrical cases where a
cardiopulmonary clearance is required for patients 40 years of age and above.
o Cardiopulmonary clearance shall only be done by an internist/cardiologist who is an active
member of a medical staff. A CP clearance issued shall be acceptable for a period of one
month for normal cases and 2 weeks only for patients with co-morbid conditions.
o A Pediatric clearance done by the pediatrican shall be done for all patients three (3) months
to twelve (12) years of age. Patients below three (3) months, the clearance shall be issued
by a Neonatologist. Pediatric clearances for patients above 12 years shall depend on the
discretion of the surgeon or the Anesthesiologist. This applies to all cases whether elective
or emergency. The clearance shall be given by Pediatrican/Neonatologist who is an active
staff of Unihealth Parañaque Hospital and Medical Center. A Pediatric clearance issued is
acceptable for 2-3 days only.
o Properly accomplished informed consent shall be signed prior to transfer to the operating
room. This shall be obtained by the Attending Physician assisted by the nurse.
o No cases shall be scheduled without appropriate Accounting, Industrial, & CP clearance. All
clearances shall be settled at least two hours before the operation. In the absence of such
clearance 2 hours prior to the operation, the Attending Physician should be informed of the
postponement or cancellation.
o Patients wheeled to the OR shall have proper ID band or bracelets.
o NPO for eight hours shall be observed for patients undergoing general/regional anaesthesia.
o All pre-operative shaving for elective cases shall be done inside the OR not earlier than 30
minutes before the scheduled time or upon prepping the patient.
o Removal of dentures, jewelleries, clothing (including underwear) nail polishes, contact
lenses, shall be done before a patient is transferred to OR/DR.
o Cleansing Enema shall be done at the wards or at the patient’s room. Only fleet enemas will
be permitted at the labour room.
o Patients shall be transported to the OR, 45 minutes before the scheduled time of procedure.
o A pre-operative checklist shall be filled up which will consist of the following information:
 Accounting Clearance
 Doctor for referrals and CP clearance
 Time of last meal
 Last time of urination
 Latest Vital signs
 Patient’s weight
 Pre-meds if given
 Other pre-operative preparations done

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 Name of the ward and OR nurse assigned

 Time and date of OR procedure
POLICIES AND PROCEDURE ON THE IMPLEMENTATION OF THE

SURGICAL CHECKLIST
“Sign Out” refers to the period during or immediately after wound closure but before removing the
patient from the operating room.
POLICIES:
 The WHO Surgical Safety Checklist is made part of the chart of all patients who will undergo
surgery at the Operating Room of Unihealth Parañaque Hospital & Medical Center.

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 During surgery a single person shall be made responsible for checking the boxes on the list of
all the phases of the procedure. This person will often be a circulating nurse, but it can be
clinician or healthcare professional participating in the operation. Designating a single person to
confirm completion of each step of the Checklist shall ensure that safety steps are not omitted in
the rush to move forward with the next phase of the operation.
 The operation is divided into three phases each corresponding to a specific time period in the
normal flow of the procedure – the period before the induction of anaesthesia (sign in), after
induction and before incision (time out), during or immediately after wound closure but before
removing patient from the OR. In phase the coordinator shall be permitted to confirm that the
team has completed its task before it proceeds further.
 During “sign in” the coordinator shall verbally review with the patient if possible, that his or her
identity has been confirmed, that the procedure and site are correct and consent for surgery has
been given. The coordinator will visually confirm that the operative site is marked (if appropriate)
and that the pulse oximeter is on the patient and functioning. The coordinator shall also verbally
review with the anaesthesiologist the patient’s risk of blood loss, airway difficulty
 And allergic reaction and whether a full anaesthesia checks shall been completed. The
surgeon’s presence is not essential for completing this part of the Checklist.
 For “time out” each team member shall introduce him or herself by name and role. The team
shall pause immediately prior to the skin incision to confirm out loud that they are performing the
correct operation on the correct patient and site and verbally review with one another the critical
elements of their plans for the operation using the checklist questions for guidance. They shall
confirm that prophylactic antibiotics have been administered and that essential imaging is
displayed.
 For the “sign out” the team shall review together the operation that was performed, completion
of sponge and instrument counts and the labelling of any surgical specimens obtained. It shall
also review any equipment malfunctions or issues that need to be addressed. Finally, the team
shall review plans and concerns regarding post-operative management and recovery before
removing the patient put of the operating room.
 A detailed description of each of the steps in the checklist can be found in the “Implementation
Manual WHO Surgical Safety Checklist (First Edition)”, a copy of which is attached to this policy.
The contents of the manual shall be discussed with the medical and nursing staff assigned in
the OR.
 The Head of the Operating Room shall monitor compliance to this Checklist and will conduct a
review of all the problems and concerns encountered in the implementation of this Checklist as
well as the problems involving safety in the operating room that were unearthed as a result of
the Checklist.
 The Head of the Operating Room shall also make recommendations that will modify the
checklist to adapt to the need of the OR UParHMC.

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POLICIES AND PROCEDURES FOR THE IMPLEMENTATION OF THE

PRE-ANAESTHESIA CHECKLIST
PURPOSE
To identify policies and procedures for the implementation of the pre-anaesthetic assessment
checklist that should be accomplished for all the patients of Unihealth-Parañaque Hospital and
Medical Center who will undergo surgery under anaesthesia.
POLICIES

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The safety of the patients of Unihealth Parañaque Hospital & Medical Center shall be the primary
concern of the hospital as well as the members of its staff. In recognition of the risk involved during
surgery, the hospital introduced a Pre-anaesthetic checklist that shall be accomplished by all
anaesthesiologist prior to surgery. In addition to confirming that the patient is fit for the surgery, the
checklist shall remind anaesthesiologist to do a formal inspection of the anaesthetic equipment,
medications, and a patient’s anaesthetic risk before each case.
PROCEDURES
1. Once a patient is proposed for surgery, the anaesthesiologist is notified by the ward nurse or
resident-on-duty. If the patient is already on the operating room as in direct to OR admission,
the operating room nurse notifies the anaesthesiologist.
2. The anaesthesiologist sees the patient the day before the surgery for the elective cases and
before the scheduled surgery for emergency cases.
3. Other that getting the patient’s vital signs, during the pre-anaesthetic assessment the
anaesthesiologist determines patient’s anaesthetic risk. He checks for pre-existing medical
conditions and takes note of laboratory procedures done. If the patient underwent
cardiopulmonary clearance, NOD takes note of the recommendation of the cardiologist or
internist. During the pre-anaesthetic assessment does an objective evaluation of the airway
using a valid method. If the airway evaluation indicates a high risk for a difficulty air way, the
anaesthesiologist takes note of this and he prepares against an airway difficulty. The risk of
aspiration should also be evaluated as part of the airway assessment. These findings are written
in the Pre-anaesthetic form.
4. During the pre-anaesthetic assessment the anaesthesiologist consults the surgical team
whether the patient risks losing blood of more than 500ml. He/she then makes sure that the
blood has been prepared for OR use.
5. If the anaesthesiologist thinks that additional laboratory procedures are necessary for the safety
of the patient, then he requests for those and results are relayed to him prior to the surgery.
6. If during the pre-anaesthetic assessment the anesthesiologist thinks that it is the best interest of
the patient that the procedure be delayed, he will discuss this with the surgeon or the
cardiologist.

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DELIVERY ROOM
1. Admission
 Patients shall come from the Emergency Room or nursing unit.
 Patient from the unit brought to the delivery room shall be in a hospital gown, with all
jewellery and valuables are removed.
2. Kinds of Delivery and Care of the Patients

 Normal Delivery- refer to all deliveries through the birth canal either spontaneous or by
extraction.

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 The internal examination shall be done only by the Attending Physician or ROD
 Once the patient has been examined perennial shave is done.
 Consent for the delivery and anesthesia shall be obtained.
 Caesarean Section- refers to all deliveries through surgical incision made in the
abdominal wall and uterine wall.
3. Post-Partum/Post-Operative Care
 The patient shall be given sufficient time to stay in the delivery room and NOD shall
check the condition of the patient before transporting her to the ward.
 The unit nurse shall be notified in advance before a patient is transported back to the
respective ward and should be carefully endorsed to the unit nurse by the DR Nurse.
4. Care of the New Born

 The DR Nurse shall notify the NICU nurse of the coming delivery and in turn the NICU
nurse notifies the Pedia-ROD and AP.
 Initial resuscitation and proper identification and launched on the mother’s breasts shall
be done before the baby is transferred to the NICU.
5. Care of Still Birth and other Fetal Death

 Conditional lay baptism shall be administered to the fetus.
 Post-Mortem care shall be rendered and the body is brought to the morgue
 An aborted fetus (1-4 months gestation) is also given conditional baptism. An aborties is
either packed or place in a container with proper identification. Parents shall claim the
fetus if they wish, otherwise it is sent to the pathology laboratory for studies with signed
consent from the parents.
6. Certificate Birth and Delivery

 Birth certificate data form shall be filled out by the parent for all babies born alive inside
the DR or with in the hospital premises. The parents and AP signature affixed as
informants on all the copies of all birth certificate. It shall be prepared and completed by
the medical clerk assigned for such records.
 Fetal Death Certificate forms shall be prepared by the medical clerk in charge.
7. Disposal of Placenta
 All normal placentas shall be deposited in the freezer provided by the purpose if not be
discarded in the proper waste disposal.

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 Pathological Placenta shall be brought to the pathology department for histopathological

studies.
8. Deliveries outside the Delivery room

 For all deliveries outside the OR, the patient shall be brought to the DR for expulsion of
placenta. Care of the newborn shall be done at ER and the baby and the Mothers are
admitted in the same room.
RECOVERY ROOM
Objective:
 To render optimum care to patient during the immediate post-operative and anaesthesia
period.
 To serve as a place where the patients can be effectively and constantly observed during
the crucial period of recovery from surgery and an aesthesia.
 To prevent, detect and manage as early as possible any problem or complications that
may arise during the critical period.
Procedure and policies:
1. Admission
 The RR shall be open 24 hours if the condition necessitates intensive care, the patient
may be brought to the ICU depending upon the discretion of attending physician or ROD.
 All patients undergoing surgical procedures shall stay for a minimum of two hours and
until vital signs are stable and upon the discretion of the anaesthesiologist.
2. Nursing Responsibilities
 The RR nurse shall be responsible to the head nurse of the OR
 She/he shall be responsible for carrying out all post-operative orders of all patients
admitted to the RR.
 She/he shall be responsible for the maintenance of cleanliness and orderliness in the
unit.
 She/he shall be able to start cardio – pulmonary resuscitation in cases of emergency.
 Only medication ordered by the concerned doctors shall be carried out.
 She/he shall notify the concerned doctor of any untoward signs and symptoms
manifested by the patient.

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 She/he shall notify the ward nurse when the patient is ready for transfer to the ward.
 She/he shall be responsible for the accurate and detailed charting in each patients in the
RR.
 She/he shall be responsible for the replacement of all medicines and supplies used by
the patient from stock during the shift.
 She/he shall not leave the RR unless another RR nurse is present to watch over the
patient.
3. Patient Transport
 The RR stretcher shall be used to transport patient from OR.
 The patient shall be accompanied by the OR nurse when transporting the patient to the
RR.
 The OR nurse shall make an endorsement to the RR nurse with the following:
o type of surgery done
o type of anesthesia
o overall evaluation of vital sign
o drugs and IV’s being administered
o types and number of drain and tubes in patient
o complication during surgery
o condition immediately after surgery
o post – operative orders
 Order for transport and discharge from the RR shal come either from the attending
physician, anesthesiologist or the resident physician concerned before the patient is
transferred or discharged from the unit.
 The ward nurse shall be informed and notified of necessary equipment or contraption
prior to transfer of patient to the unit.
 The RR nurse shall accompany the patient at all time during the transfer.
4. Endorsement
 The RR nurse shall give a complete report of the patient status to the ward nurse the
same item endorsed by the OR nurse are also endorsed by the RR nurse to the ward
nurse. The ward nurse shall receive the patient from the RR nurse; she should
accompany the patient to the room and help place the patient in a comfortable position
5. Record
 The RR nurse shall do her own charting and sign it before endorsing the patient, the
chart and medicine to the ward nurse.
 The RR nurse shall record the patient’s vital sign every 15 minutes and other parameters

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as ordered by the attending physician.

 The RR nurse shall record all post – operative orders carried out.
 The post – operative vital signs sheet shall be included in the endorsement. Including the
following forms that should be properly and completely signed:
o PACU form
o WHO Surgical Safety Checklist
o Anesthesia Form
o Circulating Record
o Operative Technique (2 copies)
o NSD Form
JOB SUMMARY
OR / DR Nurse Supervisor
1. Direct and supervise nursing and related activities of the hospital:

 Plans assignment of staff: instrument set – ups and lay – outs of the table for various
operation considering surgeon’s preference and supplies available.
 Prepares general procedure and list requirements of each surgeon for each type of
operation performed.
 Standardizes pack and draping of patients for each operation performed.
 Inform staff of new procedure and administrative changes.
 Discuss monthly with staff surgical procedure and major problems.
2. Conduct orientation program to new staff in OR and to the rest of OR personnel regarding
efficiency in assisting surgeon and strict aseptic technique observance during operative and
post-operative procedure.
3. Ensures that operating room is kept scrupulously clean
4. Coordinates operating activities with other department.
5. Cooperates with surgeon in selecting new instruments and equipment’s, See to it that
supplies and equipment’s used is charged accordingly, See to it that there is enough supply
of linen and drapes.
6. Direct maintenance of the required records and reports including work performance of
his/her department.
7. Supervise preparation packing and sterilization of supplies.

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DUTIES AND RESPONSIBILITIES
Scrub Nurse
1. Arrange sterile instruments and supplies needed in the operation.

2. Offers sterile gown and gloves to the surgeons.
3. Stand beside the surgeon throughout the operation and handed him all the needed sterile
instrument. Sponges and equipment’s with in the sterile area.
4. Anticipate surgeon needs.
5. Ensure completeness of counting before and after the procedure.
6. Coordinate well within the circulating nurse and helps in keeping the sterility of the area.
Circulating Nurse
1. Prepare patient for the procedure

2. Ensure proper conditioning of the equipment’s and completeness of the surgical set – up.
3. Accomplish accurate records of patient’s condition and development.
4. Identifies and send specimen for examination to proper department.
5. Ensure proper counting and reporting of instrument, needles sponges and syringes.
6. Alert the surgical teams of any break of sterility.
7. Coordinates with different department as needed in the operation.
NEONATAL CARE UNIT
Policy
The hospital shall provide a NICU, which shall be, give intensive care necessary during the critical
neonatal period. It shall constantly aim to provide the highest standard in newborn care and
safeguard the total well-being of each child.

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Admission
 The new born shall be transferred in from the OR/DR with properly filled out
identification card and ID band placed securely around the right ankle by the NICU nurse.
 Babies born outside the hospital shall not be admitted in NICU.
 New born care shall be rendered according to the baby’s need and condition.
 Babies who are sick shall be admitted in the isolation room of the NICU.
Rooming – In
 Only normal new born shall be roomed – in upon the recommendation of the pediatrician-in
charge.
 The EINC NICU staff(s) transfers the new born to the mother’s room after the initial new born
care.
 The mother or her companion gives direct nursing care.
PEDIATRIC INTENSIVE CARE UNIT
Policy:
The Pediatric Intensive Care Unit shall be composed of highly qualified staff using team approach to
provide specialized services to critically ill patients in a carefully controlled environment, and UPar-
HMC shall be committed to provide service, training and research on critically ill children.
Objective:
 To improve child health care delivery to critically ill infants and children.
 To train residents, nurses and other paramedical services in pediatric critical care.
Cases that are eligible for admission:

 Children requiring assisted ventilation.
 Children requiring continuous cardio-respiratory monitoring due to metabolic/serum electrolyte
disturbances.
 Post-Cardiac arrest in other place but still in reversible condition.
 Severe hypovolemia requiring transfusion or hydration.
 CNS depression with signs of increased intracranial pressure with threat to cardiopulmonary

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function.
 Renal failure needing close intake and output monitoring like peritoneal or Hemodialysis.
 Post-surgical cases which need close monitoring of fluids, electrolytes and acid-base balance.
 Metabolic diseases needing at least hourly evaluation monitoring ex. Juvenile Diabetes Mellitus
in ketoacidosis
 Tumors and hematologic conditions which have reasonable chances of remission and
improvement.
 Any other potentially reversible life-threatening disease.
Visitors:
Parents shall be allowed to visit their children as soon as admission procedures are completed and
the child has achieved stability. PICU shall not accommodate a guardian/parent at the child’s
bedside. They shall be provided with a comfortable physical environment to make them aware that
their presence is important and that their physical and emotional needs have been considered as a
part of the total care of their child. Visitation hours are from 12pm-1pm and 5pm-6pm only.
Admission Procedure:
1. Patient in the ward that needs PICU care should be referred immediately to the PICU-ROD or
PICU Resident-on-Referral.
2. This patient shall be examined and assessed by the PICU-ROD immediately.
3. Regardless of service (pay or charity), the patient shall be immediately referred to the pediatric
intensivist upon recommendation of the consultant-in-charge or service consultant-on-duty
respectively. PICU-ROD must be actively involved in the management of this patient while in the
ward.
4. Immediate coordination with the PICU nurses shall be made for proper preparation of bed and
monitoring devices.
5. If there is no available be or ventilator, the patient may stay in the ward while awaiting vacancy.
6. PICU-ROD must try to create vacancy and to admit the patient immediately to PICU. He shall be
actively involved in the management of the patient while in the ward.
7. If ventilator is the only problem, the relatives shall take the responsibility of renting ventilator
from outside source.
8. If there is available bed and ventilator, the patient’s relatives will be asked to see and coordinate
with the admitting clerk in the admitting section.
Criteria for Discharge or Transfer:

Children recovering in the PICU shall be generally transferred to the ward prior to home discharge
or sending back to referring hospital.
Guidelines:

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1. Assisted ventilation discontinued (may be humidified oxygen 60% or less).

2. Electronic C-R monitoring discontinued.
3. Stable vital signs with establishment of spontaneous, adequate circulation.
4. The frequent intake and output, fluids and electrolytes, acid-base monitoring is no longer
required.
5. Improved or improving level of consciousness.
6. When the feared complications that necessitated the PICU admission have elapsed according to
the pathophysiology of the primary illness.
7. When resources in the ward at time of transfer are available time of day, staffing (whatever is
best for the patient).
OTHER DEPARTMENT
BUSINESS SECTION
Billing section of the business office is open daily from 8 A.M. to 5 P.M.

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Admission
On admission, the charge ticket of the patient admitted shall be forwarded to the billing section
which is to be noted on his progress bill.
Transfer
For transfer of room, the patient or relative shall inform the nurse of his desire to transfer and the
nurse notifies the admitting section.
Discharge
 As a general rule, the discharge of the patient shall be noted in his chart will be made only upon
the order of the attending physician.
 Immediately after the discharge order is written in the chart, ask the professional fee of the
attending physician and final diagnosis, shall be brought to the billing for the final assessment.
 After the settlement of hospital account, the cashier signs the clearance slip. The clearance slip
together with the receipt shall be given to the patient.
 The nurse affixes her signature in the clearance slip after checking the room for completeness
and indicating the time patient left the unit. Patient shall leave the clearance slips signed by the
nurse with the security guard on duty when he leaves the hospital.
PHARMACY DEPARTMENT
The department shall be responsible for the safe and proper distribution of drugs to all patients and
unit of the hospital. Pharmacy services for outpatients and inpatients are available 24 hours a day.
The pharmacists are responsible for updating drugs.
Ward routines in relation to the pharmacy:

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 Every shift shall be held responsible requesting drugs and supplies needed by the patient.
 Requisition slip in triplicate shall be signed by patient and relatives shall be forwarded to the
pharmacy and total cost of all drugs, procedure and supplies received by the patient is entered
to the charge ticket as basis for billing purposes.
MEDICAL RECORD DEPARTMENT

The medical record department shall be open daily except Sunday and holiday. It is where all chart
or record of discharge patient are kept and maintained.
DIETARY DEPARTMENT
A modified centralized method of dietary service is adopted in our set – up. The diets shall be
planned, prepared, cooked and made ready for distribution or serving by the dietary personnel.
The nurse prepares the diet list containing the prescribed diet for the entire patient in the unit.
SECURITY SERVICES
Ensure the protection of patient, hospital personnel and property.
Nursing responsibilities in relation to security service
 Nurses shall report to the security guard any doubtful, unusual activity or quarrels in the ward or
with in the hospital premises.
 Security guard shall also be aware of absconding and absconded patients and likewise justify
any loss of articles and equipment’s
 All incoming and outgoing person shall be subject to inspection. Bringing appliances inside the
hospital shall register in the logbook before bringing such in the room.
 The security personnel as well as the nurse shall ensure that policies in visitor and visiting hours
are properly implemented.
 Security guard shall demand discharge slip or out on pass slip from all patient leaving the
premises.
 The security guard shall do the trafficking of all vehicles.

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LINEN DEPARTMENT
Job Description: LINEN CLERK

 She shall be responsible for the distribution and inventory of all linens in the hospital.
 She shall be responsible for the segregation of condemned linen and its replacement.
 She shall repair and sewed torn linens.
 She shall receive and log delivered linens and responsible in sorting out of soiled linen to be
sent to laundry agency.
 She shall endorse and dispense linens to nursing units in case of changes and admission plus
extra linen to anticipate admission when linen clerk is not available
 She shall reconcile and tally the daily inventory and do the physical inventory once a month.
 She shall responsible in the appropriate channelling of problem concerning the linen department
to the department head.
 She shall mark grounds to gain insight to the problem.
MAINTENANCE DEPARTMENT
The Maintenance Department services the needs of the hospital in terms of repair, maintenance
and replacements of all that refers to its physical plant. It has sections of carpentry, electrical,
upholstery, painting, plumbing and masonry. It handles the hospital’s water supply system,
refrigeration, air-conditioning and ventilation system, patient’s signal and calling system, fire alarm
warning system and other sections that services maintenance.
The head and the coordinator of services shall be responsible to the Administrator for the
supervision, inspection of the quality, quantity and method of work in the department as well as the
efficiency of the staff.
Gardeners and janitors doing the housekeeping work shall be included in the department staff but
they can be under another’s supervision.
 Request Slips: Use requisition and Issue Slip
o All requests slips for the Maintenance Coordinator. These requests shall be listed in a log
book at the Maintenance office, reviewed and prioritized by the one in charge, according to
the needs of the patients and the hospital. Urgent requests shall be attended to immediately.
Damages on electrical devices and lighting system, defective plumbing fixtures are some of
the urgent requests.
o All requests for supplies shall be brought to the Maintenance on Mondays, but supplies are

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given out only on Wednesday afternoons. Powdered soaps shall be placed in plastic pails
with cover not in plastic bags. Used bulbs, mop handles and used brooms are brought for
exchange. Toilet duck solution destroys enamel; it should not be used every day.
o Furniture and equipment’s for repair shall be brought down together with the requests
indicating what is to be done. The floor supervisor shall be notified when the repair work is
finished. Used request for Minor Job Repairs.
 Oxygen Tanks: Use Requisition and Issue Slip
o Date all oxygen tanks received and use the first ones first. Request enough oxygen tanks
that will meet the need of the Unit for 24 hours. If necessary, additional tanks can be
requested in the afternoon to meet the night needs. However in an emergency, one can
request tanks from the oxygen storage room.
o Do not continue to use tanks found with leakage, return them immediately for exchange.
Empty tanks shall be brought down for exchange every day. Refrain from keeping many
empty tanks in the unit. Handle oxygen caps carefully to prevent breakage.
o Oxygen tanks when being used in rooms shall be anchored with oxygen stand to prevent
falls and further injuries to the patient.
 Miscellaneous
o Motor-driven machines and equipments shall be brought down periodically for servicing,
oiling or replacement of worn-out parts. Floor polishers shall be brought down every 2
weeks; electric fans are brought down once a month. Floor polishers when not in use are
laid down on the floor and not left standing on its brushes. Equipments with rated voltage
(220 or 110) must be checked against the line voltage before plugging into the outlet.
o Loose spare parts of machines, door or cabinet knobs, outlet covers, and screws of other
electrical gadgets shall be returned to the maintenance.
o Empty dextrose bottles shall be brought to the parking are neat the canteen in the enclosure
prepared for these bottles. Do not place these near the incinerator.
o Garbage is bagged. Cans, bottles, and what cannot be burned shall not be mixed inside the
plastic bag. Remind the staff, personnel, patients and relatives not to throw garbage outside
of the windows.
 Preventive Maintenance and problems that shall be avoided with more attention and
carefulness:
o Tripping of electrical cords and connections of Steam inhalators, Suction machines,
ventilators, Aerosol apparatus etc. will cause toppling down of machines and breakages.
o Detachment of patient’s call buttons, breakage of pendant switches because beds are
pushed too near against the wall or trying of dangling cords to post of beds.
o Overheating suction apparatuses because suction is flooded with liquid substance and are
forced to run in operation causing a hard-start-up of monitor.

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o Broken outlets and covers because things are pushed against these carelessly or machines
are unplugged incorrectly by pulling cords at any angle.
o Mismanipulation of the operating controls of the air cons causing damage to switches or
neglecting to shut-off air cons when there is power failure.
o Floor polishers are pushed to move beds or other furniture causing misalignment and
destroying its fender.
o Scratches on painted walls and doors due to careless driving of wheelchairs, food wagons,
stretchers, oxygen rollers, hamper wagons or rollers.
o Wasting of water through carelessly leaving toilet rubber balls floating or faucets dripping
without reporting it for repair.
o Sagging of extra beds because these are used for sitting of three or more persons. Using
force in turning bed screw lifters without properly inserting them first.
o Vinyl flooring is destroyed when indiscriminately pushing heavy equipment or refrigerators
while cleaning.
o Danger of oxygen tanks falling down when not anchored, bumped or shaken, because these
are not carefully anchored to posts or to steel stands.
o Absence or damaging posted instructions on machines for proper operation; people trying to
manipulate machines by trial and error without proper instructions; not reporting to proper
authorities when machines or other gadgets are not working properly.
o If door locks are changed, the old keys shall immediately be replaced in key boards, to avoid
delays and confusion.
o Disposable syringes used by infectious patients shall be bagged and burned; those used by
the other clean patients are rinsed and collected in separate container for give-away.
POLICIES ON THE USE OF TREATMENT ROOM / PROCEDURE ROOM
FUNCTION:
The treatment or procedure room is a special room or place in the pediatric units where minor
procedures such as blood extraction, intravenous line insertion/re-insertion, injections/immunization,

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lavage, lumber tap, and other medical procedure/s as specified by the attending physician are
performed.
General Guidelines:
 Personnel: Only authorized staffs shall be allowed inside the treatment/procedure room.
o Consultant/Junior Consultant
o Phlebotomist/IV Therapist
o Nurse Supervisor
o Nurse In Charge
 Equipment and Supplies:
o All necessary equipment shall be kept inside and properly maintained.
o Supplies shall be kept clean and stored in the designated places. They should be
replenished after every procedure.
o Clean white linens and bed cover shall be readily available or stored in the built-in cabinets.
 Infection Control –
o The Nurse Supervisor and nursing staff shall be the ones responsible in the proper disposal
of sharps and soiled items further in maintaining the cleanliness of the unit. The Infection
control nurse will see to it that all infection control processes are observed.
 Equipment found in the Treatment Room
o Oxygen tank with gauge
o Bed
Other Guidelines:
 The treatment room shall be used by patients who have to undergo medical procedures while in
the ward.
 The treatment room is located from 5th-9th floor.
 The upkeep of the treatment room shall be the responsibility of the nurses and nurse supervisor
of the station where the treatment room is located.
 All supplies in the treatment room shall be replenished by the nurse supervisor. All equipment
should be checked, maintained, and calibrated periodically (in coordination with the
Maintenance Department).
 The treatment room shall be locked when not in use but the key should be available at all times.
 Patient’s one year and below and those difficult to insert regardless of age shall be referred to
the junior consultant on duty.
 All necessary equipment and supplies to be used should be prepared prior to procedure.
 All procedures to be done should be explained to the patient and relatives, informed consent
should be obtained when necessary.

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Treatment / Procedure Room Consent

Dear Parents:
The Treatment Room or Procedure Room is a special place in the Pediatric Units wherein minor
procedures such as: blood test, intravenous insertion, injection or immunization, lumbar tap, lavage,
bandage change and others as specified by the attending physician, are safely done.
Generally, Pediatric patients are very difficult to handle requiring not only skills of the hospital staff
but also cooperation and understanding in the part of the parents or guardian are requested to wait
outside until the procedure is done to avoid unwanted stress or distractions to both the child and the
staff.
By: The Management
Conforme: _________________________________ ___________________

Signature over Printed Name of Relative Date and Time
_________________________________ ___________________
Signature over Printed Name of Witness Date and Time
INFECTION CONTROL NURSE
ROLES AND FUNCTIONS OF INFECTION CONTROL NURSE

 Education
 Liaison and Public Relation

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 Resource
 Surveillance
 Communication
 Research
UNIVERSAL PRECAUTIONS AND ISOLATION POLICIES
Universal Precautions – techniques / procedures that are intended to prevent potential, mucous
membrane, and non-intact skin exposures to blood borne pathogens in health care settings.
Immunization with HIV vaccine is recommended as an adjunct to universal precautions for persons
who have exposures to blood.
COMPONENTS
 Gloves should be worn for touching blood and other specified body fluids requiring universal
precautions (amniotic pericardial fluid, semen, vaginal secretions or any fluid visibly containing
with blood).
o Touching mucous membrane and non-intact skin
o Handling items and surfaces soiled with blood or body fluid
o Performing vascular access on invasive procedures
o Gloves should be changed after contact with each patient.
 Hand washing after gloves is removed. Hands and other skin surfaces should be washed
immediately and thoroughly if contaminated with blood or other body fluids requiring universal
precaution.
 Special care should be taken to prevent injuries caused by needles, scalpel, and other sharp
instruments or devices during procedures/handling/cleaning/disposal.
 Masks and protective eyewear or face shield should be worn to prevent exposure of mucous
membrane of the mouth, nose and eyes during procedures that are likely to generate droplets of
blood and other body fluids.
 Gowns / aprons should be worn during procedures that are likely to generate body fluids.
 Mouthpieces, resuscitation bags, or other ventilation devices should be available for use in
areas in which the need for resuscitation is predictable.
 Healthcare workers who have exudates lesions or weeping, dermatitis should refrain from all
direct patient care and handling equipment.

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 Linens and articles soiled with blood on bloody body fluid should be placed and transported in
bags that prevent leakage.
STANDARD OPERATING PROCEDURES TO CONTROL INFECTION
 Prevention of Catheter Associated Urinary Tract Infection

o Urine bags should not touch the floor; it should not be place higher than the urinary bladder.
o Silicone catheters are changed only when necessary, preferable once a week. Since these
are very expensive, consult the Supervisor before each change.
o Do perineal care before catheterization with meticulous skin antisepsis especially at the
meatus. Change gloves after perineal skin antisepsis immediately before actual
catheterization, use betadine 1:4 as can be requested from the CSSR.
o Perineal care is done 2x daily, thereafter.
o Secure catheter properly to prevent minute abrasions on the mucosa of the meatus. Use clip
hanger for the urine bag to prevent urine stagnation in the tubing.
o When disconnecting catheter from the bag, disinfect first the port with 70% alcohol before
reconnection.
o When aspirating the urine for urine culture and sensitivity, disinfect the catheter area with
alcohol before puncturing catheter. Use needle at 45 degree angle, Adhere to the system of
Sterile Closed drainage.
 Prevention of Surgical Infection
o Clean Operating Room Suite before each surgery, use damp cloth dusting on all horizontal
surfaces before the surgeries start in the morning, Control/Limit people from entering the
Operating Room Suite.
o Wash and dry air condition filters and exhaust fans in the Operating Room daily. In the
private rooms this is done after a patient’s discharge or once a week.
o Cleansing bath and shampoo before any surgery especially before craniotomy.
o Skin prep and shaving should be done 2 hours before the surgery or on the day itself, if
there is no definite surgery time. For Orthopaedic surgery skin prep, in the Operating Room
is done with double gloves.
o Observe no touch technique when dressing wounds, Hand washing and skin antisepsis with
70% Isopropyl alcohol is done before any wound dressing. Charge the alcohol to the patient,
all soiled dressing is placed directly in plastic bags and is discarded accordingly.
 Prevention of Nosocomial Pneumonia
o Proper washing and disinfection of respiratory therapy equipment AMBU bags and
laryngoscope blades should be washed with soap and water, and then brought to the CSSR

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for high level disinfection. (soaked in glutherallhyde “cidex” for 10 minutes after washing)
o Breathing circuits must be changed every 48-72 hours and the changing must be reflected
on the pulmonary sheet placed on the respirator, Pulmonary Unit disinfects these circuits
with Dexan.
o ORAL CARE is a must for all patients especially those with Respiratory treatment.
o Suction tubings, stoppers and suction bottles must be cleaned with soap and water and
soaked in Dexan solution, 300cc/ 1 gallon for 24 hours.
o Suction catheters will be recycled provided these are soaked (10 minutes) in Cidex in CSSR.
ICU does its own soaking, General units bring their suction catheters to CSSR after washing
these soap and water for a 10 minutes soaking in Cidex.
o Suction machines must be wiped cleaned 2x a day and covered when not in use to prevent
accumulation of dirt on the machine and tubing’s.
 Prevention of I.V Therapy Infection
o Each nursing unit is provided with an IV tray containing 70% alcohol, Betadine antiseptic
solution, dry sterile cotton balls in a covered container and mosquito forceps soaked in
Glutheraldehyde solution. These trays are renewed once a week.
o Practice no touch technique in preparing IM or IV site insertion; IV tray should not be placed
on patient’s bed.
o IV tubing’s are changed every 72 hours as well as IV cannulas (Make a Tx card to remind
nurse of the time of changing), however the financial condition and psychological state of
patient should be considered before changing. Cover of air filters should not be removed, but
if removed for incorporation it should be re-capped immediately after.
o IV butterfly needles are changed every time it is clogged. If not dislodged within 72 hours,
change it together with the tubing’s.
o IV tubing’s for hyperalimentation are changed after 24 hours.
o If phlebitis sets in within 24-48 hours change IV site, Change also the complete IV set.
o For KVO use of D5W 250cc/500cc in 24 hours is recommended so that the bottle could be
changed daily.
o All opened ampoule medications not used within 24 hours should be discarded.
o Do not pre-cut plaster for any IV insertion.
o Disposable syringes are not re-autoclaved and not re-used.
o Used needles should not be recapped. These are placed in any empty plaster gallon for
burning. (Ask empty gallons from dietary or from Maintenance)
PREVENTION OF NEEDLE STICK INJURIES

 Needles should not be recapped, purposely vent or broken by hand, removed from disposable

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syringes or manipulated by hand.

 After use, disposable syringes and needles, scalpel, blades and other sharp item should be
placed in puncture resistant container for disposal.
 Large bore reusable needles should not be placed in a puncture resistant container for transport
to the reprocessing area.
ISOLATION – steps / techniques to prevent the spread of an infectious agent from an infected or
colonized person to another person.
Components:
Private room / roommate selection
Protective barrier (masks, gowns, gloves)
Special emphasis on hand washing
Special handling of contaminated articles
Techniques:
 Hand washing – use anti-microbial soap and let it dry after use.
 Hands are washed even after wearing gloves.
PROCEDURES ON ISOLATION OF NOSOCOMIAL INFECTIONS

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PURPOSE
To establish a documented procedure in the Isolation of Nosocomial Infection.
SCOPE
This applies to all admitted patients, all medical personnel and hospital staff.
DEFINITION
 Isolation – the physical separation of an infected or colonized host from the remainder of the at-
risk-population in an attempt to prevent transmission of the specific agent to other
individuals/patients.
 Nosocomial Infection – infection acquired during hospitalization not present or incubating at
the time of admission to hospital, usually occurs 48 hours after admission
 Case Containment is the implementation of additional measures aimed at preventing further
transmission of infection after the initial detection within the UPar-HMC facility.
 Surveillance – a systematic collection, analysis and interpretation of data of specific events
(infection) and disease.
 ICT – Infection Control Team
RESPONSIBILITY
 Administration-should provide adequate isolation rooms and facilities for Hospital Acquired
Infections
 Infection Control Committee
o Advises all departments with Nosocomial Infections.
o Helps in the planning and implementation of training for the prevention and case
containment, and Isolation of Nosocomial Infection.
 Infection Control Team Members
o Admitting Physician/Medical Resident on Duty
 Responsible for detecting and recording of Nosocomial Infections on a systematic and
current basis.
 Responsible for advising others about the hospital’s policy on isolation, infection control
and disposition of patients with infection.
o Head Nurse/Charge Nurse/Staff Nurse

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 Assists the residents on detecting and recording of patients with nosocomial infections
or other infectious conditions.
 Participates in the care of individual patients with nosocomial infections or other
infectious conditions.
o Infection Control Nurse
 Responsible for analysing nosocomial infection data with the help of the infection
control team.
 Prepares a monthly report for the infection control committee.
 Reports to the infection control committee.
 Collects clinical data for the information of the infection control committee.
 Acts as a specialist adviser to all nursing staff and other hospital staff on matters
relevant to infection control.
 Participate with other members of the ICT in the formulation of policies for infection
prevention and control.
MATERIALS
Patient Chart
PROCEDURE
 Alert the ICT once case is confirmed. Fills up a Nosocomial Infection Surveillance Form.
 All measures used in prevention should be continued during containment.
 Isolation procedures should take place depending on the infection’s mode of transmission and
if reverse isolation is needed. See Isolation policies and procedure for further clarification.
o The isolation room in the ER (Emergency Room) can temporally be used for patients with
HAI if having consultation at the ER. Patient can stay in the ER not more than 2 hours.
o The patient should be transferred to a private isolation room in the ward floors once
available. Cohort only if same infectious case and no other co-morbidities present. If no
rooms are available, facilitate transfer depending on hospital of choice by the patient and
only if the patient’s condition is stable.
o Newly detected Hospital Acquired Infected patient in the ICU should be transferred to ICU
Isolation room immediately.
o Newly detected Hospital Acquired Infected patient in the wards should be transferred
immediately to a private isolation room.
o A private room can be used, only if all isolation rooms are occupied. Doors must be closed at
all times.
o All personnel and visitors entering the room should wear proper PPE’s depending on the

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alert status of the color-coding isolation precaution scheme. (e.g. N95 for airborne
transmission; surgical mask for droplet transmission; gowns, gloves, face shield for contact
transmissions)
o Visitors should be limited and monitored. Visitors should be instructed by the ICT.
 Isolation room maintenance should be conducted regularly by the UPARHMC maintenance
department. This is to ensure the proper set-up of an isolation room is still in place.
PROCEDURES ON CASE CONTAINMENT OF NOSOCOMIAL INFECTIONS


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PURPOSE
To establish a documented procedure in the case containment of Nosocomial Infection.
SCOPE
This applies to all admitted patients, all medical personnel and hospital staff.
DEFINITION
 Case Containment is the implementation of additional measures aimed at preventing further

transmission of infection after the initial detection within the UPHMCI facility.
 Nosocomial Infection – infection acquired during hospitalization not present or incubating at
the time of admission to hospital, usually occurs 48 hours after admission.
 Isolation – the physical separation of an infected or colonized host from the remainder of the at-
risk-population in an attempt to prevent transmission of the specific agent to other
individuals/patients.
 Surveillance – a systematic collection, analysis and interpretation of data of specific events
(infection) and disease.
RESPONSIBILITY
 Administration-should provide adequate isolation rooms and facilities for Hospital Acquired
Infections
 Infection Prevention and Control Committee
o Advises all departments with Nosocomial Infections.
o Helps in the planning and implementation of training for the prevention and case
containment, and Isolation of Nosocomial Infection.
 Infection Control Team Members
 Admitting Physician/Medical Resident on Duty
o Responsible for detecting and recording of Nosocomial Infections on a systematic and
current basis.
o Responsible for advising others about the hospital’s policy on isolation, infection control and
disposition of patients with infection.
 Head Nurse/Charge Nurse/Staff Nurse

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o Assists the residents on detecting and recording of patients with nosocomial infections or
other infectious conditions.
o Participates in the care of individual patients with nosocomial infections or other infectious
conditions.
 Infection Control Nurse
o Responsible for analyzing nosocomial infection data with the help of the infection control
team.
o Prepares a monthly report for the infection control committee.
o Reports to the infection control committee.
o Collects clinical data for the information of the infection control committee.
o Acts as a specialist adviser to all nursing staff and other hospital staff on matters relevant to
infection control.
o Participate with other members of the ICT in the formulation of policies for infection
prevention and control.
MATERIALS
Patient Chart
PROCEDURE
 Alert the ICT once case is confirmed with the attending physician and if available, an infectious
disease doctor... Fills up a Nosocomial Infection Surveillance Form.
 All measures used in prevention should be continued during containment. See Prevention
Strategies.
 Isolation procedures should take place depending on the infection’s mode of transmission and
if reverse isolation is needed. See Isolation policies and procedure.
 Placement of Isolation color-coding scheme should take place.
 Continual risk assessment should take place.
 Facilitates containment of the infection:
o Advises proper hand washing, isolation and other related infection control measures.
o Educate patients/relatives/hospital staff regarding the infection, which procedure is of
fundamental importance. If available, written educational information using appropriate
language and educational level should be given to any infected person and/or the caregiver.
The information should be carefully explained.
o Education and communication with healthcare staff and other relevant personnel is essential
in the prevention of further transmission of HAI.

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o Monitor patient’s condition and review chart daily until the day of discharge.
 Other Important Key Factors in Case Containment:
o The assigned Nurse on Duty (NOD) should only handle same confirmed infectious case.
o All used patient care items should be considered contaminated and handled properly. See
Isolation Precaution Procedures, and Disinfection Procedures.
o Proper handling and disposal of sharps should be strictly observed.
o Patient care equipments and supplies used for HAI patients should not be used for other
patients; this is to avoid cross-contamination and further transmission of infection.
o Maximum septic technique in all procedures should be observed.
o During post-mortem care for patients with HAI, all isolation procedures should be observed.
o Wall to wall terminal cleaning should be done right after discharge. The room should not be
occupied for 8-24 hours (depending on the transmission of the disease). Housekeeping
personnel should wear proper PPE’s during the procedure.
o Most HAI patients have a very low immune system. Therefore, Reverse Isolation should be
observed by the patient, visitors, and all healthcare staff. See Reverse isolation procedure.
o Patient transport should be minimized. Proper PPE’s or protective barriers should be used
during transport. Avoid overcrowding in the elevators.
 Prophylaxis for exposed personnel such as vaccination and immunization is for strict
compliance. An infectious disease doctor should be consulted for proper treatment. Work
restriction will also be implemented and clearance on “fit to work” should be issued by physician
or preferably by an Infectious Disease Doctor.
 All healthcare personnel with worsening condition of HAI should be treated as another admitted
patient.
 All relevant observations and information by health care staff should be reported to the ICN and
the attending physician immediately.
 The progress of the patient’s condition should be recorded in the chart and reported to the ICT
on a daily basis.

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POLICIES ON PROPER HANDLING AND SAFE DISPOSAL OF SHARPS /

NEEDLE STICK INJURIES
PURPOSE
 Safe disposal prevents / minimizes accidental needle stick injury.

 To promote safe disposal of used “sharps”.
POLICIES
 All used sharps such as needles, lancets, etc. including empty/broken ampoules shall be placed
on sharp containers provided in every unit for safe disposal.
 All used sharps shall be placed in a puncture-resistant waste container (sharp container)
 Any used injection equipment that falls outside the sharp container shall be placed inside it.
 In the event that a needle is be picked up by the staff for placement in a sharp container, tongs
or pick up forceps shall be used to pick up the needles.
 Staffs shall not be allowed to insert their hands into the sharp container nor forcibly push use
injection equipment into the sharp container.
 Staffs shall ensure that sharp container have sufficient space available to allow used injection
equipment to ran unimpeded into the sharp container.
 Hospital Personnel shall continuously monitor the environment and health workers to avoid,
prevent, or put a stop to situations which could give rise to needle stick injury, such as unsafe
syringe handling practices by staff.

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POLICIES ON ASEPSIS
PURPOSE
The purpose of this policy is to ensure that healthcare staff is provided with the correct information
in relation to Aseptic Technique which is the method used to prevent the contamination of surgical
wounds and other susceptible sites by potentially pathogenic organisms. It can also reduce the
healthcare workers’ risk of exposure to potentially infectious blood and body tissues during clinical
procedures.
Aseptic Technique is vital in reducing the risk of healthcare associated infection. It should be used
during any invasive procedure which breeches the body’s natural defences for example skin,
mucous membranes, or when handling equipment which will enter a normally sterile cavity or area.
Surgical Asepsis – use of techniques designed to exclude all microorganisms.

Medical Asepsis – use of technique designed to exclude agents of communicable diseases but not
necessary all.
POLICIES
 There shall be a safe removal of hazardous waste, i.e., prompt disposal of contaminated
needles or blood-soaked bandages to containers reserved for such purposes.
 There shall be prompt removal of wet or soiled dressings.
 There shall be prevention of accumulation of bodily fluid drainage, i.e., regular checks and
emptying of receptacles such as surgical drains or nasogastric suction containers.
 There shall be avoidance of backward drainage flow toward patient, i.e., keeping drainage
tubing below patient level at all times.
 There shall be immediate clean-up of soiled or moist areas.
 There shall be labelling of all fluid containers with date, time, and timely disposal per institutional
policy.
 There shall be maintaining seals on all fluids when not in use.
 All items in a sterile field shall be sterile.
 Sterile packages or fields shall opened or created as close as possible to time of actual use.
 Moist areas shall not be considered sterile.
 Contaminated items shall be removed immediately from the sterile field.
 Only areas that can be seen by the clinician shall be considered sterile (i.e., the back of the
clinician is not sterile).
 Gowns shall be considered sterile only in the front, from chest to waist and from the hands to

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slightly above the elbow.

 Tables shall be considered sterile only at or above the level of the table.
 Non sterile items shall not cross above a sterile field.
 There shall be no talking, laughing, coughing, or sneezing across a sterile field.
 Personnel with colds shall avoid working while ill or apply a double mask.
 Edges of sterile areas or fields (generally the outer inch) shall not be considered sterile.
 When in doubt about sterility, the personnel shall discard the potentially contaminated item and
begin again.
 A safe space or margin of safety shall be maintained between sterile and non-sterile objects and
areas.
 When pouring fluids, only the lip and inner cap of the pouring container shall be considered
sterile; the pouring container shall not touch the receiving container, and splashing shall be
avoided.
 Tears in barriers and expired sterilization dates shall be considered breaks in sterility.

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POLICIES ON PREVENTION AND TREATMENT OF NEEDLE STICK

INJURIES
PURPOSE
To ensure that any needle stick injury is appropriately treated, monitored and reported in
accordance with Infection Control Policy
POLICIES
 All staff and other hospital personnel who sustain a needle stick injury shall report such injury
immediately to Infection Control Committee thru the Infection Control Nurse, or supervisor and
personnel in charge of the unit upon occurrence of the injury, and the protocol for handling of
such injury must be strictly followed.
 All staff who has any contact with a used or suspected to be used, syringe in such a manner as
to penetrate the skin shall report this needle stick injury immediately to ICN, who has been
designated to assist with needle stick injury. Other personnel who have been designated to be
responsible for assisting with the treatment of such injury shall be:
o Nurse Supervisor
o Personnel in charge of the unit / immediate superior
o Emergency Room Physician or the Resident doctor
 Immediately upon occurrence of needle stick injury, the injured staff shall inform the person in
charge who has been designated to assist the injured staff.
 Person with needle stick injury shall go to the ER for assessment of ER Physician, or any IM at
the ER
 Incident report shall be submitted to ICC thru ICN together with the copy of consultation record
for reporting to the ICC chairman and treatment approval.
 The ICN shall insure that the approved needle stick injury treatment protocol is properly
implemented.

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POLICIES REGARDING RISK IDENTIFICATION, ASSESMENT AND

CONTROL, SECURITY RISK AND USE OF PERSONAL PROTECTIVE
EQUIPMENT
PURPOSE
 To determine the safe way on performing duties and responsibilities in performing daily task.
 To determine the proper way of risk identification, assessment and control with regards to daily
work at the Hospital
 To implement the proper way of using protective equipment, risk assessment and control.
POLICIES
 Obedience to safety regulations while on duty shall be the responsibility of every person
employed. Cooperation to the safety program shall be essential for the performance of any job.
 Supervisors and other management personnel shall be responsible for the enforcement of the
Safety Rules.
 Any person in doubt as to the correct meaning and interpretation of any rule as set forth in this
set of Safety Rules shall secure an explanation from his immediate superior.
 Accidents can happen through inexperience and insufficient training. If a personnel do not know
the correct manner of doing a job, he/she shall ask rather than suffer an injury through
ignorance.
 All personnel shall report immediately all unsafe conditions and unsafe tools or equipment to
their superior, to the Safety Department, or to Security Department, as this will prevent
accidents. Supervisors shall see to it that corrective actions are taken immediately.
 No intoxicating liquor shall be introduced or consumed at working places. Persons found on
duty in an intoxicated condition, or carrying intoxicating liquor on the job shall be subjected to
disciplinary action. A person that comes to work in an intoxicated condition shall not be allowed
to enter job premises.
 All personnel shall always obey safety signs placed throughout the premises, as these have the
purpose of warning personnel of existing hazards.
 All personnel shall be absolutely prohibited to carry weapons on the job.
 All personnel shall pay strict attention to their work. Practical joking or horseplay shall be
prohibited.
 No person shall be permitted to operate hospital equipment or machines without proper

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QUALITY PROCEDURE
authorization. Operator in-charge of such equipment shall be held responsible for the strict
compliance to this rule.
 All personnel shall never use compressed air for cleaning clothing of any part of their body. This
practice is very dangerous, especially around the mouth, eyes, ears, etc.
 When using the ramp for transporting stretchers, hospital beds and machines, personnel shall
always secure the brake and the wheels.
 All personnel shall keep clear of suspended loads at all times.
 All personnel shall never take short cuts in or over critical areas.
 All personnel shall never carry loads or objects that will obstruct vision ahead, especially when
going upstairs or downstairs.
 All personnel shall not carry caustic, gasoline, sodium hypochlorite, acids and other dangerous
chemicals in open containers. All personnel shall wear suitable eye protection and safety
apparel.
 When transporting heavy loads, all personnel shall be required to use a pushcart. All personnel
shall also learn the proper lifting procedure when lifting loads heavier than half of their body
weight.
 Warning signs shall be posted to point out dangerous conditions, they shall be obeyed.
 Supplies kept in emergency first aid boxes shall be used only in the event of injuries and
contents shall not be removed unless properly authorized.
 If the light should fail in unfamiliar areas or elevated places, all personnel shall keep to the wall
or handrail and shall feel their way step by step.
 If sick, all personnel shall report to the clinic. While emergency, first aid on the job is important,
every employee shall be obligated to secure prompt and adequate medical treatment for all
injuries.

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POLICIES ON PROGRAM FOR THE PROTECTION OF HEALTH CARE

WORKERS e.g PERSONAL PROTECTIVE EQUIPMENT (PPE)
PURPOSE
 To introduce Personal Protective Equipment (PPE) that is designed to protect the wearer’s body
from infections.
 To protect Health care workers from hazards in the workplace.
POLICIES
Health care workers are exposed to patients, and they are more likely to get sick or get the disease.
Being exposed, they have legal obligations to take all reasonable precautions to protect them and
these protections should be put into place.
Use of Personal Protective Equipment (PPE)

 Gloves
All personnel shall wear gloves (clean, non-sterile gloves are adequate) when touching
blood, body fluids, secretions, excretions and contaminated items. The same shall change
gloves between tasks and procedures on the same patient after contact with material that
may contain a high concentration of microorganisms. The same shall remove gloves after
use, before touching non-contaminated items and environmental surfaces, and before going
to another patient, and shall wash immediately to void transfer of microorganisms to other
patients or environments.
 Mask, Eye Protection, Face Shield
All personnel shall wear a mask and eye protection or a face shield to protect mucous
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 exertions
 Gown
All personnel shall wear a gown (a clean non-sterile gown is adequate) to protect skin and
prevent soiling of clothing during procedures and patient care activities that are likely to
generate splashes or sprays of blood, body fluids, secretions or excretions. The same shall
select a gown that is appropriate for the activity and amount of fluid likely to be encountered.
The same shall remove a soiled gown as promptly as possible and shall wash hands to
avoid transfer of microorganisms to other patients or environments.

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GUIDELINES FOR EMPLOYEES PERMITTED TO STUDY

 Nursing service personnel shall be granted the privilege to study on a part time basis, after
completion of one year of employment with UParHMC.
 Privilege for those preparing for CGFNS review / exam or local board exam shall be likewise be
given to employees who have completed one year employment with UParHMC.
 To avail such privilege, the personnel shall submit a letter requesting for permission to study or
review in duplicate copies.

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PRIVATE DUTY NURSE ASSOCIATION
DEFINITION
A private duty nurse is a registered nurse who undertakes to give a comprehensive nursing care to
clients on a one to one ratio. She /He is an independent contractor usually selected and approved of
by the Nursing Service Administrator to be included in the hospital roster for special services to
augment their existing manpower. A PDN who work in the hospital is expected to conform and abide
by the rules and regulations governing her/his practice. She is directly under the responsibility of
the Head nurse/Nurse supervisor who supervises the care of all the patients in his/her unit.
Request for PDN must be done through the PCS supervisor who will relay it to the chapter
president, who in turn will inform the available PDNs to communicate with the OIC for patient’s
details. Special nurses provided for hospital duty are those who are in the PCS office roster and
have undergone full orientation related to institutional policies and regulations. If a PDN was patient
provided, the PCS office should be notified and courtesy calls are expected from the outsourced
PDN.
Only the Nurse supervisors can arrange or call PDNs to report on duty upon the referral of the
chapter President to avoid miscommunication and overlapping.
PURPOSE
A PDN is expected to be capable of doing the following, during the course of her/his practice;
 To accurately assess the patient’s physical condition and interpret significance of the findings as
a basis for planning her nursing care.
 To identify emotional and social factors and relate these factors to signs and symptoms
observed in the patient.
CODE OF ETHICS
 The nurse’s primary responsibility is to those people who require nursing care.
 She shall hold in confidence personal information and uses judgment in sharing this information.
 The nurse shall maintain the highest standard of nursing care and carries the responsibility for
nursing practice through continuous education.

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 She shall serve as a professional at all time and maintains a high standard of personal conduct.
 She shall share with other members in the community the responsibility of initiating and
supporting projects to meet health and social needs of the public.
 The nurse shall work in a cooperative relationship with her colleagues and allied health
professionals.
 She shall implement desirable standards of the nursing practice and nursing education and must
be actively involved with a national professional nursing education.
 PDNs shall read memos in the units passed by the PCS office regarding appointments of new
personnel; changes that concerns nursing service.
 Anyone who effuses a case without valid reason shall be subjected to disciplinary actions. Valid
reasons accepted – illness on the part of the PDN or her/his immediate family, approved
vacation leave, sudden death in the family, nature’s wrath (flood, typhoon) etc.
 PDNs shall be expected to report in complete white uniform. Skirts, high heeled shoes are not
allowed. Good grooming shall be must for all PDN. Only stud earrings, black/brown hair
clips/headbands are allowed.
 Professional decorum shall be observed at all times. Dedication and commitment are expected
in the delivery of the PDN’s service. Unnecessary talking or visiting to co PDNs and staff while
on duty is being discouraged. Sleeping, shedding of shoes while on duty merits stern warning
and disciplinary actions.
 PDNs shall confer with the senior ward nurse on duty for any changes or unusual observations
noted on patients. Written endorsement before going on off duty shall be given to the nurse on
duty. Staff nurses shall be updated about the patient’s conditions. PDNs and staff nurses shall
work harmoniously with the end goal of treating clients well.
 PDN rates shall be adhered to all times. Request forms for PDN service shall be accomplished
and explained thoroughly by the PDN who will handle the client.
 Do not keep patient’s chart inside the room nor allow patient’s relatives access to client’s chart.
It is a legal document; therefore authorization shall be secured from proper office.
 PDNs shall never call the AMD for referrals/updates/orders directly from the client’s room nor
from the phone within the hearing distance of the client.
 Place an order of client’s medicines good for 2 days usage. Excess drugs shall be expected to
be returned to the pharmacy unless patient expressed desires to have enough stock as take
home medicines.
 Articles borrowed from the nurse station shall be made known and returned to staff nurse on
duty.
 All articles borrowed from the CSR shall be properly cleaned and returned after use. Report any
breakage or damaged equipment to the CSR personnel. PDNs shall be held liable for any
unreported damages prior to the use of the articles as well as losses of borrowed articles.

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 PDNs shall not file clean linens inside the patient’s room. Keep the patient’s room orderly and
clean. Stained linens are soaked and pre washed before they are discarded in the laundry
hamper.
 Social calls while on duty shall not be allowed for the PDNs both in the hospital and house case
duty.
 PDN shall go on 8 hour duty. Only if there is a shortage 12 hour duty is allowed.
 A PDN who wants to go on duty shall provide her/his own reliever with prior knowledge of the
client, the nurse duty, and her team mate and chapter president. The reliever provided for
should be equally adept and competent to handle the case. Off duties are forfeited unless a
reliever is secured.
 PDN who came in late for duty shall pay the cash or time equivalent to affected nurse.
 Smooth and harmonious working relationship shall be fostered and maintained among PDNs at
all times. Individual differences should be settled amicably among persons concerned with the
help of Chapter officers before forwarding unsettled complaints to the PCS office.
 When accepting a case, the PDN shall know the necessary details of the case to be handled-
name, age, gender, room #, AMD and initial diagnosis.
 PDNs shall do the routine discharge services to clients under their care-hospital equipment
inventory, securing passes and giving discharge instructions to clients/responsible significant
others. Moreover, on the client’s death, PDN renders the post mortem care prior to bringing the
corpse to the morgue; all necessary documents shall be complied with the responsible authority.
All equipment’s used by the patient shall be cleaned and returned by the PDN to its proper
place.
 PDN who have to continue their services at the client’s home shall notify the PCS office and the
chapter for her inability to receive cases until such time that her service at client’s residence has
been terminated.
PRIVATE DUTY NURSES’ RESPONSIBILITIES IN HOUSE CASE PATIENTS

 PDN shall be directly responsible to the attending physician of his/her client.
 She shall carry out only prescribe nursing care and treatment of his/her client.
 She shall be entitled to a minimum adjusted rate with a full meal, snacks, transportation
allowance during her eight or twelve hour’s duty (100/day).
 PDN shall be entitled to the prescribed rate written on the contract based on an eight or twelve
hour’s duty per shift depending on the category or case of the patient.
 She shall secure a written contract, signed by both parties: client and nurse.
 For those on monthly or weekly basis salary, she shall go off duty at least once a week without
pay, She shall look for a reliever to be paid by the client directly before going off duty whether on
an eight or twelve hour basis (applicable to all APDNPP/UParHMC members).

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GENERAL GUIDELINES:
 Punctuality
o In reporting for duty at least 30 minutes before the expected time.
o Attend the scheduled meetings.
o Participate in nurses’ seminars and functions of the association.
o Pay the duty dues and loans, in both the mini chapters and main chapters as prescribed by
the association.
 Observance of Good Grooming while on duty
o She shall wear a complete full white nurses’ uniform.
o She shall have a complete equipment such as blood pressure apparatus, bandage scissors,
penlight, tourniquet, ballpens (red, black, blue), pentel pen and wrist watch.
o Avoid wearing of slippers, dangling earrings, necklaces and colorful hair clips.
o She/he shall observe personal hygiene at all times.
 The following acts of dishonest shall be the cause of disciplinary action:
o Overcharging a patient without referring to the legal rates.
o Getting the patients’ medicines and supplies for one’s personal use.
o Abusing hospital property and supplies.
 Observance of Professional Ethics:
o Putting down, criticizing or insulting a nurse in order to gain credit with the patient or the
patient’s family.
o Being quarrelsome or having a heated argument with the patient, patient’s relatives and/or
colleagues.
o Incurring the following incidents through sheer incidence:
 Leaving a patient without proper endorsement.
 Patient falls from the bed.
 Patient gets burned by a hot water bag or a steam inhalation.
 Patient develops an infection at an injection site.
 Failure to carry out treatment and requests for laboratory and other diagnostic
procedures which will delay diagnosis of patient’s condition.
 Failure to carry out doctors’ orders that will lead to patients’ death.
 Breach of contract
 Non-compliance of hospital rules and regulations as required for a PDN.
 Being intimate with the patient of the opposite sex or with the patient’s companion.
 Getting another job without informing the proper authorities.
 Illegal substance use / selling.

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 Knowingly taking part in abortions and other illegal procedures.

 Adultery, acts of immortality.
GUIDELINES FOR THE PDN MEMBERS:

 Membership –each member must be oriented with the PDN guidelines. He/she will affix his/her
signature at the end of the document as proof of understanding and compliance.
 Renewal –member should be cleared by the NSO and evaluated fit for renewal of practice on
the base hospital. Required documents for annual renewal should be filed in short folder and
submitted to the chapter secretary for evaluation, payment of dues and registration are
submitted to the chapter treasurer. Inform the proper authorities for changes in residence, civil
status and contact numbers.
 Termination -Membership in the association may be terminated upon recommendation of the
Board of Directors if a member is found guilty after previous investigation and due process by
the Board. The concerned member was given the opportunity to defend him/herself.
 Resignation – shall be made in writing addressed to the president of the association and maybe
accepted upon prior clearance of the Board. This is also applicable to those PDN going abroad.
 Meetings –special meeting may be called by the president or upon a request of at least three
members of the chapter.
 Improper use of the nurses’ uniform or the prescribed scrub suit shall merit fine imposition.
 Punctuality –The PDN should always report for duty on time, failure to do so, the PDN
concerned should make necessary arrangement with the outgoing shift nurse.
 Maternity leave –should be made at the sixth month of the gestation.
 Grounds for removal from the roster List:
o Failure to attend monthly meetings without prior notice.
o Approved fine shall be collected by the treasurer.
o Non-payment of APDNPP dues.
o Non – renewal of the membership on or before January of each year.
o Any unlawful or grave misconduct upon recommendation of the chapter authorities.
 Trainings/Orientation –every member of the chapter shall undergo required trainings prior to full
acceptance of the base hospital.
 Scope of Nursing Practice –under R.A. 7164 of the implementing guidelines, Articles V Sec 27.
This nursing law protects all nurse practitioners.
 All complaints whether from the hospital, patient, allied health professional, colleague shall be
made into writing and submitted to the PCS office or PDN chapter President for due process.
 PDN members are encouraged to participate and coordinate with the different activities of the
Association.
 Regarding offenses committed by any member of the Association:

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o First Offense – oral explanation and written report for filing purposes depending on the
severity of the case.
o Second Offense – one month suspension from holding duty and all member hospitals be
duly notified, if found guilty.
o Third Offense – expulsion from the Association, endorsement for blacklisting to all member
hospital.
MONETARY CONTRIBUTIONS/FUNDS
 Every PDN is entitled to his/her professional fee before going off duty or depending upon any or
previous arrangement with the patient or patient’s family.
 Every PDN is obliged to pay his/her daily dues, either hospital or house case to the chapter
treasurer during the monthly meeting.
DUES:
Annual UParHMC chapter membership fee – 400.00
Daily duty dues 8 hours – 50.00
 Every membership fees and dues are collected by the chapter president who in turn will remit it
to the Association treasurer at the earliest time possible. Bank transactions are encouraged for
safety and documentation purposes.
 Voluntary SSS, Philhealth, BIR payments / contributions.
 Mortuary benefits from the APDNPP and PNA. Other benefits are subjects to chapter’s
discretion and funds availability.

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RULES AND REGULATIONS GOVERNING PRACTICE OF PRIVATE DUTY

NURSES
OBJECTIVES
To provide professional nursing care and service to patients who request for individualized patient
care.
To maintain high standard of quality patient care to patients confined at UParHMC in line with
objectives of the institution.
DUTIES AND RESPONSIBILITIES
While the private or special duty nurse contracts individually with the patient for her services, she is
usually contacted by the NSO. The PDN, when on duty in the hospital, is expected to conform to the
rules and regulations of the nursing service department. She / He is directly responsible to the head
nurse who supervises the care of all patients in the nursing unit. She / He is expected to abide by
the job description set by the NSO of UParHMC.
GENERAL RULES AND REGULATIONS
 The NSO shall reserve to itself the prerogative to provide its patients qualified PDN.
 The PDN shall be a member of PNA.
 The PDN shall be subject to the rules and regulations of the UParHMC regarding nursing
procedures, use and requisition of equipment and supplies, system of medication, charting, diet,
precaution technique, decorum, etc. Any violation shall be subjected to disciplinary action
instituted by the NSO.
 She / he shall wear proper uniform while on duty.
 White uniform, white shoes, stocking and nurses cap. No extra jewelleries and extra
decorations are allowed while on duty.
 She/he shall wear his/her ID at all times while on duty.
 She/he shall not leave hospital premises while on duty.
 She/he shall endorse her patient to the head nurse for relief during meals or any other

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QUALITY PROCEDURE
necessities. She is allowed thirty (30) minutes meal break and fifteen (15) minutes coffee break.
 She/he shall not be personal work within duty hours.
 She/he shall not fall asleep while on duty. No PDN is allowed more than twelve (12) hours duty
per day.
 The PDN shall be directly responsible and accountable for all nursing care rendered to her
patients.
 The PDN shall report / coordinate the condition of her patient to the nursing service director
through head nurse/ charge nurse of the unit. Chart of patient under her care shall be left at the
nurse’s station.
PROCEDURES FOR REQUESTING PDN

 All requests for PDN / private nurse aide shall be coursed thru NSO. No arrangement shall be
made among PDN without prior knowledge of the NSO.
 The ward nurse informs the supervisor on duty about the request for private duty nurse / private
nurse aide.
 A member of the nursing staff with at least one (1) year of experience in the hospital maybe
requested to go on private duty nursing after duty hours or on her off duty.
 Outside PDN to work in UParHMC the ff. must be observed:
o She should be properly oriented to the setup, policies and practices of the hospital.
o Nursing care is confined only to the bedside; all other duties in relation to the patient care
are done by the staff of the unit. She is under the direct supervision of the head nurse or
charge nurse of the unit.
o She is advised to see the nursing service directress either before assuming duty or as soon
as possible after her tour of duty.
WORKING HOURS
All are required to report forty eight (48) hours duty per week at 8 hours per day depending on the
time requested indicated on the consent.
Reporting Time
AM Shift 6:00AM to 2:00PM

PM Shift 2:00 PM to 10:00 PM
Night Shift 10:00PM to 6:00AM.

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GUIDELINES FOR STUDENT NURSES

OBJECTIVE.
To enable the students to participates and adapt to the system being implemented by the UParHMC
Nursing Service Department as an affiliating hospital in relation to the assessment and evaluation of
their individual cognitive/ knowledge and skills level.
SPECIFIC OBJECTIVE
At the end of the 8 hours shift, the student nurses will be able to:
 Recognize the importance of an individualized nursing care.
 Explain clearly the chosen nursing interventions in response to the subjective and objective
complaints of the client as gathered in the nursing and patient care audit.
 Translate the nursing interventions implemented into actions as documented.
 Appraise the care being given and be able to recognize the reaction of the patient in response to
the nursing care being rendered.
 Re-modify and redesign the nursing care plans in response to the charging health needs of the
patients.
 Evaluate the nursing care plan as to its affectivity and conciseness.
SPECIFIC ROLE AND RESPONSIBILITIES EXPECTED FOR STUDENT NURSES

 Submit all requirements upon assembly time.
 Prepare for inspection of uniform, paraphernalia etc.
 Report to the assigned unit or ward as accompanied by the Clinical Instructor. Render
appropriate courteous and acknowledgement toward the Nurse – on – Duty.
 Attend nursing endorsements between the outgoing and incoming nurses.
 Go with nursing rounds not only with the assigned patient but also with all the admitted patients.
 Prepare pseudo charting.
 Initiate interaction with the assigned patients.
 Observe the NOD in preparing medications.

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 Go with the Attending Physician and the NOD in case of rounds.

 Attend to errands.
 Render routine patient care as the need arise.
 Assist in giving the medication.
 Report anything significant findings regarding to patients to the NOD or CI.
 Prepare final pseudo-charting, accomplish charting in the nurse’s notes, and have it
countersigned by both CI and NOD.

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MONITORING AND CHARGING OF OXYGEN
OXYGEN RATES COMPUTATION

When using Oxygen tank
Oxygen Rate = Number of pounds (lbs.) used x PHP 1.50
When a full tank is consumed, PHP 2,700 is charged automatically
NOTE: This computation is usually used in the floors where there are no pipe-in oxygen
OXYGEN RATES COMPUTATION

For Centralized Oxygen (Pipe-In)
Oxygen Rate = Number of litres per minute x 60 x Number of hours x PHP 0.50

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QUALITY ASSURANCE NURSING DEPARTMENT
Quality Assurance – is the process of establishing standards of excellence of nursing interventions

and taking steps to ensure that each Patient receives the expected level of care.
Quality Assurance - is a fulfilment of the social contract between society and profession.
Quality Nursing Care – is the presence of all the elements / character specified in the standards
relative to the structure, process, and outcome.
Frame for Evaluation
Quality nursing care is determined by the appropriate combination and interaction of structure and
process.
Structure – refers to the basic support component of nursing which include among Others, physical
facilities, number and quality of personnel, communication system and staff development.
Process - refers to the desired effect as specified clinical manifestations mobility levels, patient’s
knowledge on self-care skills.
Outcome - refers to the desired effect as specified manifestation mobility level, patient’s knowledge
on self-care skills.
Steps in Developing a Quality Assurance Program
1. Formulation or review of the nursing division philosophy and objectives.

2. Formulation or review of standard.
3. Formulation of evaluation tools
4. Data Collection

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QUALITY PROCEDURE
5. Data analysis
6. Taking actions
Based on the analysis of finding, corrective actions should be recommended to the Chief Nurse. In
cases where identified deficiencies require higher level of intervention, recommendations are
submitted by the Chief Nurse to the management.
Quality Assurance Committee
The committee is responsible for establishing the criteria against which the nursing care is
measured. The nursing audit committee should include representative from each clinical unit, should
have experienced nurses concurrently employed in direct nursing care activities. To ensure that
they are thoroughly familiar with contemporary health care theory and practice, the chairperson of
the nursing audit committee hold a staff position in the nursing service and should directly report to
the Chief Nurse.
Nursing Service Audit
It is an official examination of nursing records, physical facilities and personnel involved in patient
care for the purpose of evaluation, verification and improvement. It is a tool in analysing and
evaluating nurses’ bedside records and physical facilities. It serves as a mean of improving nursing
care by revealing existing deficiencies.
Nursing Audit Committee
It should consist of a chairman, co-chairman, and qualified secretary and a number of selected
members. It composed of the following:
Chairman - Nurse Supervisor

Co-Chairman - Nurse Supervisor
Member - Head Nurses / Senior Nurses
Chief Nurse - is an ex – officio member
Objectives of the Nursing Audit Committee

 Review systematically the nursing records of the hospital patients.
 Maintain the record of performance of each professional nurse or staff.
 Provide a biographical index of the quality of nursing care received by every patient.

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 Develop a more valuable and pertinent information for the health care received by every team
and staff.
 Develop a means to reveal areas of strengths and weaknesses in the hospital service.
 Develop and improve the quality of nursing care and nursing notes.
 Develop better cooperation / collaboration among nurses and members of the health team.
 Provide a means for self – evaluation of nursing care.
Functions of the Committee
 Acts as a liaison between the nursing service and the health care team.
 Serve as a means of correcting shortcomings.
 Aid in establishing a cooperative spirit among the nursing personnel
 Keep confidential all information obtained during audit.
Committee Activities
The committee should meet to review the record of discharged patients, equipment and supplies as
well as nurse’s clinical records must be appraised. The appraisal would determine their quantitative
and qualitative values and to make provision for all the needs involved in quality patient care.
Responsibilities of the Committee
 All members must have free access to the evaluated record form.
 The chairman should inform the nurses of his / her deficiencies and suggest ways or means by
which these may be improved, and should be recorded in individual file.
 A regular system and follow up on the concerned nursing personnel’s performance should be
established.

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QUALITY PROCEDURE
Unihealth Parañaque Hospital & Medical Center

NURSING DEPARTMENT
QUALITY ASSURANCE PROGRAM
CONTROL CHECKLIST # 1
Unit _________________ Date____________________ Time_______________
Concurrent Nursing Audit

Patient : _____________________________________________
Diagnosis : _____________________________________________
Directions : Check appropriate column.
COMMENTS YES NO NA
PATIENT’S CHART
A. Formal:
 Correct sequence
 Laboratory results attached according to dates.
 All sheets have appropriate headings and dates
 Intake and output records complete.
 TPR complete and recorded every 24 hrs.
B. Doctor’s Orders
 Doctor’s orders in generic name
 Orders are carried out, transcribed, dated, timed and signed within 1 hr.
 All verbal orders are countersigned by physicians within 30 minutes.
 Standing orders are signed by Resident/consultants.
 STAT orders are carried out, signed, timed, and charted within half an hour.
 Special procedures/referrals noted and accomplished within the shift.

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C. Nurse’s Notes
 Nurse’s admission notes are:
o Complete
o Legible
o Relevant
 Medications are charted in generics
 Patient’s response to medications and treatments noted/charted
 Idiosyncrasies / allergies to food and drugs noted.
 Unusual observations and properly noted.
 Serious / critical patient’s conditions are written in red.
 All entries are timed and signed legibly.
 Pre-op checklists are accomplished.
GRAND TOTAL
Noted:_______________________ _________________________
Nurses On Duty Quality Assurance Program
Committee Members

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QUALITY PROCEDURE
Unihealth Parañaque Hospital & Medical Center

NURSING DEPARTMENT
QUALITY ASSURANCE PROGRAM
CONTROL CHECKLIST # 1
Unit_____________________ Date_________________ Time_____________

Concurrent Nursing Audit: Patient’s Chart
Patient :________________________________________________
Diagnosis:________________________________________________
Directions : Check appropriate column:1 – meets criteria; 2 – variations
COMMENTS ELEMENTS COL.1 COL.2
 Patient’s Care
 Hygiene and Physical Comfort:

o Patient bathed either by NA and watcher and skin – care given.
o Patient’s mouth cleaned.
o Patients well groomed
o Special attention given to pressure or irritated areas.
o Dressings clean / dry.
o Patient’s bed cleaned, straightened and kept dry.
o Bedside tables arranged and cleaned.
 Activities and Body Mechanics:

o Patients activity (dangling, setting up in chair,
o ambulatory executed)
o Exercises given if indicated.

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o Patient’s position conducive to recovery

o Patient turned as indicated.
o Supports (feet board, sandbags, pillows)
o Splints, slings applied correctly
o Patient understands reason for activity
 Rest and Sleep

o Quietness maintained at night and during rest period.
o Lighting controlled at all times.
o Comfort measures (repositioning, listening used to induce sleep at rest.)
 Safety
o Patient assisted during his initial activity after bed rest, 1st post op day.
o Side rails up and in safe working condition.
o Restraints used as needed & applied properly.
o Safety precautions used for patients while in chairs or wheelchairs if needed.
o Flowers dry / safe from hazards.
o patients and / or his family understand the proper isolation techniques and the reason
for it
o Contaminated articles (dressings, bed pans, urinals) are cleaned / disinfected
properly.
o Proper signs displayed for patient’s safety (no smoking , with patient, with O2
Administration)
o Machines or electrical equipment at bedside properly connected and maintained.
o Precautionary measures used such as labelling drainage bottles (T-tube)
o NPO signs posted for patients with such orders.
 Nutrition, Fluid and Electrolyte Balance:

o Oral Fluids given / restricted and recorded as indicated.
o Fluids and foods within patient’s labelling is being administered at the proper reach.
o Correct IV fluid with precise labelling is being administered at the proper rate.
o Patient assisted adequately and promptly in eating if unable.
o Patient receives correct diet, measures taken to obtain change if ordered.
o Patient and his family understood reason for the special diet, fluids restriction and
encouraged to follow prescribed diet.

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 Elimination
Measures instituted for the maintenance of proper bowel function.
o
Urinary elimination properly checked and recorded.
o
Bowel and bladder training initiated or continued.
o
Perineal care given at least once to patients with catheter.
o
Drainage tubes are properly connected and positioned.
o
Ostomy bags properly applied, cleaned and changed as needed.
o
Patient understands plan for elimination care.
o
 Oxygen and Ventilation
o Patient encourage to turn, cough and deep breathe at designated intervals.
o Oxygen therapy properly given (take humidity portion of catheter.
o Suction equipment properly set up (clean outside, completeness)
o Tracheostomy patent and site clean.
o Respirator used correctly.
o Patient and family understood the reason for and the precautions to be used in
respiratory therapy.
 Sensory
o Eyeglasses, hearing aids, dentures etc. are properly cared for.
o Appropriate measures used for effective communications.
 Meeting Emotional Needs

o Patient treated with kindness.
o Patient oriented about the hospital, has been informed of mealtime, communication
system, toilet facilities.
o Nurse listens to the patient, encourages questions and generally makes the patient
feel at ease.
o Nurse stays away from anxious fearful or very ill patients. Patient’s family feels
relatively at ease in the hospital setting and free to ask questions.
o Nurse notifies the patient’s family and/or friends as indicated (request of patient,
serious conditions, dying pt.)
o Dying patient and his family and friends treated with compassion.
 Considering Special on Spiritual Needs

o Patient aware of the availability of religious counsel and services.

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o Priest, minister informed, if patient’s condition is critical.

o Protocol of the patient’s religion observed by the staff.
 Patient and Family Teaching

o Patient teaching initiated.
o Family involved in the teaching as necessary.
o Person from other discipline utilized as indicated.
o Other services of community agencies obtained.
o Family members included in the discharge planning.
o Members of the health team included in the discharged planning.
TOTAL GRAND TOTAL
Noted_____________________ _________________________
Nurses On Duty Quality Assurance Program
Committee Members

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POLICIES ON REPORTING OF SENTINEL EVENTS

PURPOSE
To guide the nursing personnel on the hospital policy regarding sentinel events.
DEFINITION
Sentinel events are rare events that lead to catastrophic patient outcomes.
Reporting of sentinel events is mandatory for all hospital and health service staff.
List of reportable sentinel events is based on categories which include:

 Procedures involving wrong patient or body part.
 Suicide of a patient in an inpatient unit.
 Retained instruments or other material after surgery requiring re-operation or further surgical
procedure.
 Intravascular gas embolism resulting in death or neurological damage.
 Haemolytic blood transfusion reaction resulting from ABO incompatibility.
 Medication error resulting in major permanent loss of function or death of a patient. Reasonably
believed to be due to incorrect administration of drugs.
 Maternal death or serious morbidity associated with labour and delivery.
 Infant discharged to wrong family or infant abduction.
 Other adverse event resulting in serious patient harm or death.
POLICIES

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Reporting Requirements
All hospitals and health services shall be required to report sentinel events to the Director, Office of
Safety and Quality in Healthcare via their Department Heads/Supervisor.
Sentinel events shall be reported using Sentinel Event Notification and include the hospital
identification code, the date on which the event occurred, a brief description of the sentinel event
and whatever the investigation will be conducted under qualified privilege. The name of the contact
person must be included.
Investigation of Sentinel Events

Sentinel events often signal serious breakdowns in health care systems and shall require thorough
investigation and response. The investigation of sentinel events shall involve a comprehensive and
systematic analysis of the facts to identify contributing factors.
Recommendations and strategies shall be developed and implemented to minimize occurrence of

similar events in the future. Hospitals and health services shall be encouraged to follow the standard
for investigating high and extreme risk clinical incidents.
The principles of natural justice shall be followed in every sentinel event investigation.
Natural justice encompasses various rules of procedural fairness to achieve two basic principles:
 Persons involved in an incident must be given adequate opportunity to present their case, and
 Decision-makers hearing the case must be unbiased
Following an investigation, the Sentinel Event Final Report shall be forwarded after 45 working days
of initial notification. If an extension is required, a request shall be forwarded to the Senior Policy
Officer stating the reason and the estimated extra time required.

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POLICY ON PATIENT SAFETY ON HOSPITAL BEDS
PURPOSE
To prevent patient falls from hospital beds
POLICIES
 Side rails shall be used as defined in Restraint Policy (Nursing Policy).

 Upon admission to unit, patient shall be told the purpose and importance of bed rails being in
the up position. The fact should be stressed that this is for their own safety and welfare. If a
patient is not capable of understanding, a family member should be informed of the need for
side rails to be in the up position.
 The bed shall always be in the low position when the patient is unattended. This could lessen
the severity of a fall if one should occur
 Items such as water pitchers, telephone, call buttons etc. shall be in easy reach of patient so he
does not have to over reach and possibly fall if one should occur.
 Beds shall always be lowered before patients attempt to stand.
 When side rails such as water pitchers, telephones, call buttons, etc. shall be in easy reach of
patients attempt to stand.
 Brakes should always be locked when in a position and especially during patient transfer.
Patients shall use the bed for support when getting in and out of the bed and could be injured if
the bed moves. When setting the breaks, push and pull bed to ensure stability.
 The electrical integrity of the bed cord and plugs shall be checked periodically by staff to ensure
that the cord is not broken or frayed and that the third prong in plug is intact.

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 Any defective bed shall be removed from service and repairs requested.
HOSPITAL RESTRAINT POLICY

PURPOSE
The use of restraint is an emotive issue involving challenging and difficult decisions about care and
treatment. If an action fits the definition of restraint it is not necessarily unacceptable or wrong. This
policy seeks to outline the circumstances in which restraint is justified and outlines the procedure for
carrying out restraint as a therapeutic intervention, in order to maintain the balance between
independence and safety and preserving the dignity, rights and well-being of the patient.
RESTRAINT METHOD
 PHYSICAL RESTRAINT
Any manual method physical or mechanical device material or equipment that immobilizes or
reduces the ability of a patient to move his or her arms, legs, body or head freely, or prevent the
patient from voluntarily exiting the bed.
 CHEMICAL RESTRAINT
A drug or medication when it is used as a restriction to manage the patient’s behaviour or restrict
the patient’s freedom of movement and is not a standard treatment or dosage for the patient’s
condition.
 SECLUSION
The involuntarily confinement of a person alone in a room or an area from which the patient is
physically prevented from leaving. May only be used for the management of violent or self-
destructive behaviour.

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EXCEPTIONS TO RESTRAINT USAGE

 Restraint does not include devices, such as orthopedically prescribed devices, surgical
dressings or bandages, protective helmets or other methods that involve the physical holding of
a patient for the purpose of conducting routine physical examinations or tests or to protect the
patient from sliding out of bed, or to permit the patient to participate in activities without the risk
of physical harm.
 Side Rails are not a restraint:
o When used to prevent the patient from sliding out of bed with beds with certain therapeutic
surfaces, and other beds that have slippery surfaces.
o When used for patients on turning beds for respiratory failure or other treatment modes
(critically ill patients in the ICU or PICU).
o When used with gurneys to prevent patients from falling off the gurney.
o When used with patients who are experiencing involuntary movements.
o When used with patients who are not physically capable of getting out of bed regardless of
whether side rails are raised or not.
o When padded and raised for Seizure Precautions.
 “Freedom” splints, when used as a reminder not to bend the arm on a cognitively intact patient,
are not restraints.
 Therapeutic holding is not a restraint.
 Cribs, high chairs, strollers with straps and the like are not restraint but commonly accepted
baby/infant/child safety devices.
 Patients who are recovering from Anaesthesia in the PACU unless the use of restraint extends
beyond normal recovery time.
 Patients may not be restrained to perform a test or procedure a test or procedure that the patient
has refused.
 Forensic and correction restrictions used for security problems, i.e., handcuffs.
POLICY
 It shall be the policy of Unihealth-Parañaque Hospital & Medical Center to ensure the safety and
general well-being of all patients, whose condition necessitates the use of restraints, paying
particular attention to the risk associated with vulnerable patient populations, such as
emergency, paediatric, and cognitively or physically limited patients.
 Restraint shall only be imposed to ensure the immediate physical safety of the patient, staff or
others and must be discontinued as soon as safely possible, regardless of the scheduled
expiration of the order.
 Restraint shall only to be used when alternative or less restrictive interventions are ineffective.
 The Unihealth-Parañaque Hospital & Medical Center staff shall use the least restrictive form of

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restraint that protects the physical safety of the patient, staff, or others.
 The Unihealth-Parañaque Hospital & Medical Center shall not permit restraint use for any other
purpose, such as coercion, discipline, convenience, or retaliation by staff.
 Restraint used on patients because of violent or self-destructive behaviour shall be limited to
emergencies in which there is imminent risk for patient physically harming himself, staff or
others, and non-physical interventions would not be effective.
 The use of restraint shall not be based on a patient’s restraint history or solely on a history of
dangerous behaviour.
 The hospital shall discontinue restraint or seclusion at the earliest possible time, regardless of
the scheduled expiration of the order.
 New RN Staff members who initiate or terminate restraint shall be specifically trained to do so
during orientation and before participating in the application of restraint. Ongoing education of
existing employees shall be done as needs are identified and will emphasize prevention,
alternative measures and protective vulnerable patient populations.
This staff training, education and competency shall focus on:
o Strategies to identify staff and patient behaviours, events, and environmental factors that
may trigger circumstances that require the use of restraint or seclusions.
o Consideration or failure of non-physical interventions.
o Methods for choosing the least restrictive intervention based on an assessment of the
patient’s medical or behavioural status or condition.
o Safe application and use of all types of restraint used in the hospital, including training in
how to recognize and responds to signs of physical and psychological distress.
o Clinical identification of specific behavioural changes that indicate that restraint is no longer
necessary.
o Monitoring the physical and psychological well-being of the patient who is restrained,
including but not limited to respiratory and circulatory status, skin integrity, vital signs, and
any special requirements specified by hospital policy associated with the in-person
evaluation conducted within one hour of initiation of restraint or seclusion.
o Use of first aid techniques and certification in the use of cardiopulmonary resuscitation,
including periodic recertification.
RESTRAINT PROCEDURE
 ASSESSMENT/CRITERIA
o Assessment of the patient considers root cause of behaviour and alternative measures to
restraint use. Alternative measures are to be considered prior to application of restraint
devices. Risks associated with any interventions must be considered in the context of an
ongoing loop of assessment, intervention, evaluation, and re-intervention.

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o Least restrictive methods/interventions should always be attempted first.

o The use of restraints will be determined by the treating physician.
o The criteria for use of restraints are:
 Patient’s behaviour exhibits danger to self or others.
 Alternative measures are ineffective.
 EDUCATION
The risks and benefits will be discussed with the patient, or the patient’s representative. The
patient, or patient’s representative, should be involved in the decision making process when
appropriate. Patient family/significant others request for the use of restraint cannot be a
determining factor in the decision to use a restraint.
 PHYSICIAN ORDER
o Time limited order for Medical/Surgical Restraint.
o The treating physician’s time-limited order, written for a specific episode must be obtained
for use of any type of restraint. Written and verbal orders must be documented on the
Physician’s Order Sheet. The use of PRN or standing restraint orders is prohibited. The
treating physician’s time limited order cannot exceed 24 hours and will specify the reason for
the restraint’s use and the type of restraint.
o If the treating physician is not available to issue and order, physical restraint use may be
initiated by a registered nurse based on assessment of the patient. The treating physician is
notified during or immediately after restraint application and a verbal order or written order,
along with consent from the relatives. A written order, based on an examination of the
patient by the treating physician, must be signed within 24 hours of the initiation of the
restraint.
o Time limited order for patients restrained because of violent or self-destructive behaviour
that jeopardizes the immediate physical safety of the patient, staff, or others.
o Initial orders for adult patients restrained because of violent or self-destructive behaviour will
be for a maximum of four hours, two hours for children/adolescent (age 9-17), and one hour
for children under nine.
o The treating physician must conduct an in person evaluation of the patient and write the
order within one hour of the initiation of restraint. At the time of this in-person evaluation, the
treating physician works with the patient and staff to:
 Evaluate the patient’s physical and psychological condition and immediate situation.
 Evaluate the patient’s reaction to the intervention.
 Determines whether restraint should be continued or terminated.
 Identify ways to help the patient regain control, so that restraint can be discontinued.
 Make any necessary revisions to the patient’s treatment plan.
 Provide a new written order, if restraint is not terminated.

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If the patient’s physician, or designee, is not the treating physician who gives the order,
the patient’s physician will be notified of the patient’s status as soon possible if the
restraint is continued.
 Re-evaluation/assessment of the continuation of the behavioural restraint order must be
done in person as a “face to face” assessment and written by the treating physician or as
a verbal order by the registered nurse every 4 hours for adults over 18 years, every 2
hours for children and adolescents age 9-17, & every hour for children under age 9.
 The treating physician must do a face to face re-evaluation/assessment every 24 hours
for patients, age 18 and older and every 4 hours for patients ages 17 and younger.
 MONITORING
o In most cases use of restraints requires the following observations, assessment, and care
performed as often as needed but at least every two hours. Patients restrained because of
violent or self-destructive behaviour are assessed and monitored through in-person
observation by a registered nurse at least every 15 minutes.
o The frequency of assessment and monitoring of a restrained patient should be
individualized, taking into consideration variables such as patient condition, cognitive status,
and other relevant factors. In some cases the time frames of the policy may not be sufficient
and in others they may be disruptive to patient care.
o Observations/Assessments:
 Placement of restraint.
 Skin condition under restraint.
 Circulation of immobilized limb
 Patient condition, Orientation status and Comfort.
o Provision of Care:
 Active/Passive range of motion
 Change of Position
 Hygiene/Elimination needs are addressed
 Food/fluid intake
o Restraint need assessed
 DOCUMENTATION
o Documentation of the initial restraint assessment and reassessment is completed by the
registered nurse in the nurses’ notes.
o For patients restrained for violent or self-destructive behaviour. The face to face medical and
behavioural evaluation by the treating physician will be documented on the physician’s order
sheet. It will include a description of the patient’s behaviour and condition, the intervention
used, alternatives or least restrictive attempted and the patient’s response.
 TERMINATION

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o Restraint may only be used while the unsafe situation continues. RNs that have had the
education and competency to recognize when the patient is no longer a threat may terminate
restraint use earlier than the order indicates based on assessment of patient condition or
may again attempt alternative measures.
o When the restraint is terminated and the unsafe condition, is still evident and alternatives
remain ineffective, a new order must be obtained to reapply the restraint. Termination of the
restraint should be based on the determination, before the order expires, and that the
patient’s behaviour is no longer a threat to self, staff members or others.
CONSENT POLICY
PURPOSE
A consent form is necessary before any surgical procedure or operation. The consent is signed by
the patient or responsible representative to ensure that the patient has been given the necessary
information about the procedure, to protect his rights as well as the physician and the health care
facility.
Types of Consent:
 Consent for Operation
o Consent by patient
o Consent by patient’s representative
 Consent for procedure
o Consent by patient
o Consent by patient’s representative
WHO CAN GIVE CONSENT?

 Patient- he/she must be conscious of sound mind and 21 years or above. If patient is a minor,
but married, the patient’s status is under the category of “Emancipated Minor” and can sign the
consent for himself. When a surgery involves an organ of reproduction the spouse’s consent is
also necessary.
 Spouse
 Parents

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 Descendants
 Ascendants
 Brothers
 Sisters
 Anybody appointed by the court
In case of emergency and when no relative is around and the patient is unable to give consent, the
surgeon or the attending physician can assume responsibility to sign consent.
PROCEDURE
 It is the physician’s duty to disclose the medical information to the patient in terms of the
operative procedures (diagnostic or treatment), alternative and prognosis if the treatment is
withheld.
 Since the duty of securing the signature of the patient for the consent form is delegated to the
nurse, she gives the patient reassurance about the procedure to be done in simple terms as a
part of her pre-operative teaching.
 The nurse writes the type of operation or procedure to be done, the date and time of operation
and the name of physician and surgeon.
 She/he writes the type of anaesthesia to be administered and the doctor in charge of the
administration of anaesthesia.
 Abbreviation or initials should not be used in the consent form to ensure clarity of the
interpretation of the procedure to be performed.
o Ex. Avoid using O.S. to mean left Eye
o Write the complete word left or right.
 The patient/ representative signs the consent with his/her full name printed below his signature.
 If the nurse secures the signature of patient/ representative for consent, the nurse may sign as
INFORMANT and the other nurse as WITNESS.
 The nurse signs her full signature and affixes R.N
 The form is placed with the pre-operative checklist.

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DO-NOT-RESUSCITATION/
CARDIOPULMONARY RESUSCITATION
PURPOSE
Resuscitation is a medical procedure which seeks to restore cardiac and/ or respiratory function to
individual who have sustained a cardiac and/ or respiratory arrest. A do not resuscitate is a binding
legal document that states resuscitation should be attempted if a person suffers cardiac or
respiratory arrest. Abbreviated DNR, such an order may be instituted on the basis of a advance
directive from a person, or from someone entitled to make decisions on their behalf, such as a
health care proxy. “Do Not Resuscitate “(“DNR”) is a medical order to provide no resuscitate to
individuals for whom resuscitation is not warranted.
Cardiopulmonary resuscitation (“CPR”) is the common term used to refer to resuscitation. However,
the options an available to treat very sick patients is broader than CPR as literally defined. Other
options include intensive care, antibiotic therapy, hydration, and nutritional support. Appropriate
comfort care measures should be employed for all patients, especially terminally ill patients.
CPR may involve simple efforts such as mouth-to-mouth resuscitation and external chest
compression. Advanced CPR may involve electric shock, insertion of a tube to open the patient’s
airway, injection of medication into the heart and in extreme cases, open chest heart massage. This
means that doctors, nurses and emergency medical personnel will not attempt emergency CPR if

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the patient’s breathing or heartbeat stops.
WILL suction the airway, administered oxygen, position for comfort, splint or immobilized, control
bleeding, provide pin medication, provide emotional support, and contact other appropriate health
care providers, and
WILL NOT administered chest compressions, insert an artificial airway, administered resuscitation
drugs, defibrillate or card overt, provide respiratory assistance (other than suctioning the airway and
administering oxygen), initiate resuscitation IV, or initiate cardiac monitoring.
TYPES OF DNR ORDERS
The diversity of patients, illnesses, and therapies that DNR orders are adapted to specific
circumstances. To ensure flexibility three types of DNR orders may be given for Unihealth
Parañaque Hospital & Medical Center:
 DNR Comfort Care

DNR Comfort Care orders activate the DNR at the time order is given. DNR Comfort Care
orders permit comfort care only both before and during a cardiac or respiratory arrest. The order
is generally regarded as appropriate for patients, who have a terminal illness, shot life
expectancy, little chance of surviving CPR, and s desire to let nature take its course in the face
of an impending arrest.
 DNR Comfort Care- Arrest

DNR Comfort Care- Arrest orders activate the DNR Protocol at the time of a cardiac or
respiratory arrest. A cardiac arrest occurs when there are no spontaneous respirations or there
is agonal breathing. The term DNR (without additional wording) when recorded in the medical
chart shall be considered a DNR Comfort Care- arrest order.
 DNR Specified
All other DNR orders are DNR Specified orders. DNR Protocol in some respect, either in
treatment modalities or in the timing of the protocol activation.

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 Living will
Living will is one type of advance directive. It is a written, legal document that describes the kind
of medical treatment or life-sustaining treatments you would want if you were seriously or
terminally ill. Living wills do not let you select someone to make decision for you.
 Patient Consent to a DNR Order

DNR is a medical order to be given only by authorized health care practitioners. DNR orders
generally should be given with the informed consent of the patient or the patient I surrogate
decision- maker. DNR orders are often considered for patients who are comatose or who
otherwise lack decisional capacity with whom this discussion has not occurred or cannot occur.
A surrogate may also.

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DO-NOT-RESUSCITATE (DNR) (A Guide for Patients and Families)
 DNR ORDER
When successful, restore heartbeat and breathing and allows patient to resume their previous
lifestyle. The success of CPR depends on the patient’s overall medical condition. When patients
are seriously ill or terminally ill, CPT may not work or may only partially work, leaving the patient
brain-damaged or in a worse medical state than before the heart stopped. In these cases, some
patients prefer to be cared for without aggressive efforts at resuscitation upon their death.
 REQUEST A DNR ORDER

All adult patients can request a DNR order. If you are sick an unable to tell your doctor that you
want a DNR order written, a family member or close friend can decide for you.
Right to request or receive other treatment affected by a DNR. A DNR order is only a decision
about CPR and does not relate to any other treatment.
 DNR orders ethically Acceptable

It is widely recognized by health care professionals, clearly, lawyers and others that DNR orders
are medically and ethically appropriate under certain circumstances. For some patients, CPR
offers more burdens than benefits, and may be against the patient’s wishes.
 Consent required for a DNR Order.

 Your doctor must speak to you before entering a DNR order if you are able to decide, unless
your doctor believes that discussing appropriate CPR with you would cause you severe
harm. In an emergency, it is assumed that all patients would consent to CPR. However, if a
doctor decides that CPR will not work, it is not provided.
 An adult patient may consent to a DNR order orally by informing a physician, or in writing,
such as a living will, if two witnesses are present. Before deciding about CPR, you should
speak with your doctor about your overall health and the benefits and burdens CPR you and
your doctor will assure that your wishes will be known.
 If you don’t want CPR and you request a DNR order, your doctor must follow your wishes or:
transfer your care to another doctor who will follow your wishes, begin a process to settle the
dispute if you are in a hospital. If the
 Dispute is not resolved with 72 hours; your doctor must enter the order or transfer you to the
care of another doctor.
 First, two doctors must determine that you are unable to decide about CPR. You will be told
of this determination and have right to object. If you become unable to decide about CPR,
and you did not tell your doctor or others about your wishes in advance, a DNR order can be
written *the consent of someone chosen by you, by a family member or by a close friend.

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The person highest on the following: a court appointed guardian (if there is one), your closest
relatives (spouse, child, parent, and sibling), and close friend.
 Circumstances can a Family member or close friend decide that a DNR should be written. A
family member or close friend can consent to a DNR order only when you are unable to
decide for yourself and you have not appointed someone to decide for you. Your Family
member or friend can consent to a DNR order when: you are terminally ill: or you are
permanently unconscious, CPR will not work (would be medically futile), CPR would impose
an extraordinary burden on you given your medical condition and the expected outcome of
CPR.
 Ability to make decisions about CPR and do not have anyone who can decide. A DNR order
can be written if two doctors decide that CPR would not work or if a court approves of the
DNR order. It would be best if you discussed your wishes about CPR with your doctor in
advance.
 Consent to a DNR order for Children. A DNR order can be entered for a child with the
consent of the child’s parent or guardian. If the child is old enough to understand and decide
about CPR, the child’s consent is also required for a DNR order.
 If I change my mind after a DNR order has been written. You or anyone who consents to a
DNR order for you can remove the order by telling your doctor, nurses or others of the
decision.
 DNR order transferred from hospital to another hospital or vice versa. The DNR order will
continue until a doctor examines you and devised whither the order should remain or be
cancelled. If the doctor decides to cancel the DNR order, you per anyone who decided for
you will be told and can ask that the DNR order be entered again.
NOTE: Hospitals must provide to patients a brochure developed by the UParHMC that describes the
DO- NOT- Resuscitation Law. The brochure must be furnished to the patient at or prior to the time of
admission. It must also be furnish to each member of the hospital’s staff involved in the provision of
medical care, and it must be posted in a public place in each hospital. Patient Self-determination Act
in 1902 Social Security Health Law 2979.
Cardiopulmonary Resuscitation (CPR) has been prospectively evaluated in a wide variety of clinical
situations. Knowledge of the probability of success with CPR could be used to determine its futility.
For instance, CPR has been shown to be having a 0% probability of success in the following clinical
circumstances: Septic shock, acute stroke, Metastatic cancer, Severe pneumonia. Survival from
CPR is extremely limited: Hypotension (2% survival), Renal failure (3%), AIDS (2%), Homebound
lifestyle (4%), Age greater than 70 (4% survival to discharge from hospital).

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PERITONEAL DIALYSIS
DEFINITIONS
Is the instillation of a dialysing solution and its subsequent removal from the peritoneal cavity
through a stylocath.
The purposes of this procedure are:
1. To aid in the removal of toxic substances and metabolic waste.
2. To remove excessive body fluid.
3. To assist in regulating the fluid balance of the body.
PROCEDURE
This procedure makes use of a Peritoneal Dialysis Record. The data on the Heading of this form
must be properly filled up. Below the Heading are the different columns to be filled up. Below the
Heading are the different columns to be filled up by the nurse according to the Doctor’s order. When
a patient is dialysed, the doctor usually orders the following:
 The type of dialysing solution he intends to use on his patient- impersol 1.5% or 4.5%
 Medicines to be incorporated like Heparin – if the 1st dialysate drained out is bloody; KCL if
patients serum K level is low, an antibiotic of choice – if dialysate becomes cloudy.
 Equilibration or Dwelling time – the length of time that is allowed for the solution to stay in the
peritoneum before its removal from the cavity. The usual time ordered is 30 minutes dwelling
time and 15 minutes draining time which becomes a 45 minutes cycle.
 The amount of solution to be infused per exchange like 1L/; 1.5L/ or as much as 2l/.
 The intended number of exchanges to be accomplished for this patient. Ex. 50 exchanges of
1.5L/ exchange or 50 exchanges of 1L/ exchange.
From the above orders, filling up the record will be as follows:

 Date when the bottle started
 Under the column impresol Sol. 1.5% 0r $.25% write the no. of bottle no. of bottle below solution
ordered.
 Medicine added to solution and the dosage, ex. Heparin .5ml.
 Solution In: - write the time when solution was started. Wait for it to be consumed then write the
finish time and the volume that was infused.

Doc. No. /Rev. No.
QUALITY PROCEDURE
MORPHINE ALERT
Morphine Alert or Morphine Watch is the term used for the activities ordered for a patient on a post-
operative epidural Morphine. This Morphine Watch as ordered by the Anaesthesiologist lessens
post-operative pain to the minimal and makes the patient’s recovery from anaesthesia uneventful
and less traumatic. It is started in the Recovery Room and is endorsed to the Floor nurse for close
monitoring as follows:
 Flat on bed for 24 hours; check BP & PR regularly.
 Monitor respiratory rate for one full minute for every 15-30 minutes for 8 to 16 hours. (Depending
on Doctor’s order.) Encourage deep breathing every time the respiratory rate is checked. Use
the morphine monitoring sheet for recording.
 If respiratory rate is 12 or below, the Nurse refers the patient to the ROD at once.
 The patient is observed for rashes and itchiness. These are referred to the ROD usually cold
compress is ordered, but if this measure is not effective. Benadryl 25-50 mg. Is ordered by the
doctor and given as I.V. tendon reflexes are checked by the anaesthesiologist who administered
the epidural morphine.

Doc. No. /Rev. No.
QUALITY PROCEDURE
HOW TO ADMINISTER THE SACRAMENT OF BAPTISM
The priest is the ordinary minister of the baptism. However in case of an emergency anyone else
who knows understands the value of the SACRAMENTS can and shall baptize.
A nurse who is baptizing shall pour ordinary water-(the matter of sacrament) on the forehead, not on
the hair, of the person being baptized, and say simultaneously while pouring water. “I baptize you in
the name of Father and the Son and the Holy Spirit”. (form of the Sacrament)
For Non-Catholic Patients: Ministers and pastors of non-Catholic patients shall be invited to the
hospital whenever their presence is requested.
If possible each patient shal be made aware of the availability of religious counsel and services. The
nurse facilitates and directs the patients request for religious practices and services to the Chaplain
Services or to the Father Chaplain.
Before calling a priest for the Anointing or Sacrament of the sick, it shall be Ascertained that:
 The patient is a Roman Catholic not belonging to other religion or sect.
 The patient if conscious accepts the visit or the anointing.
 The relatives of the patient who is unconscious, are not against the visit of the priest nor the
anointing or Sacrament of the sick
These points prevent embarrassing situations with the priest, relatives and companions.
“People turn to God in times of crisis and illness is among those times when people feel the need for
spiritual guidance and consolation Nurses, therefore, are in a unique position to bring spiritual aid to
their patients and to the patient’s families.”

Doc. No. /Rev. No.
QUALITY PROCEDURE
WHEN TO CALL A PRIEST
If the danger of the death is very remote, casual reference to the situation when the makes his
rounds is sufficient. In more acute cases it is necessary to notify the immediately.
Prompt spiritual attention shall be given in the case of cerebro-vascular accidents coma, pulmonary
edema, peritonitis, severe haemorrhage, any cardiac condition shock, serious accidents, all patients
with poor prognosis, and those in danger of death.
The priest shall be notified when a child is acutely ill. Although it is true that a baptized child before
use of reason is not a subject for the sacrament of the sick, the priest would want to investigate the
possibility of the use of reason occurring at an unusually early age. It is also possible be means of
restoring the child to health.
The priest shall be summoned to mental cases in danger of death unless it is certain that have never
possessed to use of reason. Even in this event the priest should be called since there might be
question on the administration of baptism or confirmation.
The priest shall be called promptly in the case of sudden deaths because it is possible that the
person could still be administered conditionally up to several hours after sudden death, where the
last blessings have not been given, call the priest immediately and sate the facts. The priest should
be called to any patient in critical condition even if his religion is not known. The request of a patient
or his relative to see a priest should be complied promptly. The nurse may assist the priest in the
anointing.

Doc. No. /Rev. No.
QUALITY PROCEDURE
SPIRITUAL CARE OF PATIENTS

The aspect of nursing care is part of the total or comprehensive nursing care rendered to every
individual patient regardless of creed, race or culture. The cooperative role of the nurse in this
aspect of care (together with the Chaplain and Sisters) is to become a moral support in her own
limited way in helping the patient and his relatives find value and meaning behind the suffering
caused by the disease or illness.
Orientations given to the patient or his relatives along this aspect of care are as follows:
 UParHMC has Chaplaincy Service where the priest is available for counselling and guidance.
 There are holy masses in the afternoon every Wednesday and Saturday 5pm. There are also
opportunities for confession in the Sacrament of Reconciliation.
 How to inform the Chaplain for the following:

o Confession and Holy Communion – the Supervisor or the nurses or aides of the unit through
their visits to patients receive the request for confession or Communion. The name of the
patient, room number and ward are written in a notebook, for referral to the Fr. Chaplain
either singly or on his regular visits to the patients.
o Sacrament of the sick – the Chaplain may be contacted if the patient so desires, but if the
patient is critical or in danger of death, the priest may be contacted through the telephone or
through the paging system. The nurse may assist during the administration of the sacrament.
 Preparation of the Patient
o For Confession – The Chaplain usually hears confession any time upon request of patients.
Visitors are asked to leave the patient’s room until confession is over.
o For Holy Communion – The sacred Specie is brought to the patient who is unable to go to
the Chapel because of his illness. Distribution of Holy Communion is usually done right after
the morning mass. The patient is given a partial morning care before the sacred Species is
brought to the room.
o For the Sacrament of the Sick – Before calling the Chaplain to administer the sacrament, the
patient’s religion is checked; (if conscious and coherent) the patient or his nearest relative is
prudently informed of the sacrament and the availability of the Chaplain to administer the
sacrament. If consent is given, the Chaplain is called and the Sister or a nurse may assist the
priest while the sacrament is being administered.
A conducive surrounding to foster an atmosphere of quiet and reverence is very much encourage
before, during, and after a patient’s reception of any of the Sacrament.

Doc. No. /Rev. No.
QUALITY PROCEDURE
TRAUMA PROTOCOL
PURPOSE
To establish a written document on how the trauma code is being carried in emergency room.
SCOPE
Duties and responsibilities of nursing and medical staff during Trauma Code.
DEFINITIONS
 Trauma – a bodily or mental injury caused by an external agent.
 ROD – Resident on Duty Physician
 ER – Emergency Room
 CSSR – Central Supply Room
 Dr. Trauman – name given for announcing Trauma Code
 CN – Chief Nurse
 ER NOD - Nurse on duty
RESPONSIBILITY
 ER Charge Nurse – may initiate to call for Trauma Code upon the discretion of the ROD.
 ROD – Physician over-all in charge of the Emergency Room, initiate Trauma Code
 ER NOD – Trauma Code responder to implement different nursing function and responsibilities
during the code.
 CN – responsible for initiating Code Critique for internal quality audit purposes.
 Hospital Director – over all in-charge of the Trauma Code in case of massive number of trauma
victims.
 CSSR Clerk – supply equipment and materials during code.
 Hospital Telephone Operator – will announce the code by using paging system to alert the staff
will respond to code.
REFERENCE DOCUMENT
MATERIAL

Doc. No. /Rev. No.
QUALITY PROCEDURE
PROCEDURES
 General Protocol
o The ER Charge Nurse and ROD assess the total number of victims before initiating a code
(The Trauma Code is only initiated if the number of casualties who arrived in the ER is more
than five victims). Upon the discretion of the ROD to call for Trauma Code, the ER nurse will
notify the operator to announce the code. The operator will announce 3 times “Dr. Trauman
please proceeds to ER”.
o Two ward nurses on duty from 5th floor respond immediately and assist/assess the victims.
o If there is no OR procedure, OR nurse on duty responds and assume the responsibility of
assisting the doctors for any wound suturing.
o The ER Supervisor or Charge Nurse or security personnel take the responsibility of
controlling the number of people entering the ER, and ER Consultant will notify the Hospital
Director at once.
o Ward Clerk on duty will stand by outside the ER. To wait for any additional supply.
o Radiology staff on duty standby’s for possible stat x-ray procedure.
o Healthcare Attendant and ambulance driver staff assists in transporting victim to x-ray, or to
other hospital.
o At the end of the code ER Charge Nurse secures all ER treatment record.
o ER clerk records all victims in the ER logbook.
 In case of Massive Number of Trauma Victims
o The OPD usual operation stops, all OPD clients are notified about the emergency scenario at
ER. All OPD rooms are open to accommodate other victims, doctors on duty at OPD will treat
victims and OPD nurse will assist.
o Ambulance driver starts transporting victims to other hospital, if the numbers of victims are
more than the total bed capacity of Ambulatory Department.
o CN or charge nurse of the day notifies the Hospital Director regarding the scenario and
possible transport of other victims to other facilities. Security department also gathers data,
assist in records, or call the police station if the nature of accident needs to be reported.
o The ER consultant takes full charge of the whole scenario and triaging victims.
o Unconscious victims, victims with multiple traumas, victims with severe shortness of breath
and burns, are treated first and placed on a stretcher, victims suffering from minor injuries
and ambulatory can stay outside the ER waiting area, ward clerk and CSSR clerk standby
will guard those victims.
o At the end of the Code the ER Charge Nurse secures all the ER Treatment Record.

Doc. No. /Rev. No.
QUALITY PROCEDURE
PROVISION ON EMERGENCY SITUATION
Under situation of cardiac and respiratory arrest, the GNU staffs (medical and nursing personnel)
shall be authorized to render emergency procedure like, cardio-pulmonary resuscitation (CPR),
defibrillation, and intubations. Since it is imperative for resuscitation that the above mentioned
procedures be instinctive and necessary when the need arise, said procedures will be done by the
ICU staff even without the consent and notification of the attending physician, provided that the latter
is duly notified at the earliest possible time following the arrest situation.
PROCEDURES:
1. Nurse staff initiates prompt ABC assessment prior to code blue announcement.
2. GNU staff informs all health care personnel (ROD, Respiratory therapies ,Orderlies)
3. Charge nurse critiques the code, control the number of people inside the room and assist the
family member.
4. Doctors / trained personnel are the only allowed to defibrillate the patient and turning the buttons
for increasing the joules on cardiac monitor, and responsible to shout for “clear “.
5. Before defibrillation the doctor announces the time and amount of joules. Right after defibrillation
the doctor announces the heart rhythm to the nurse recorder and command to continue CPR.
6. In giving emergency drug, the doctors notifies the nurse in charge for medication only mentions
twice which include name of the drug, desired dose and exact route of administration.
7. Prior to administration of the requested drug, the nurse in charge for medication announces
loudly the name of the drug, dosages, route to the recorder nurse to hear.
8. The doctor may terminate the code, if the code lasted for more than 45min. And if there is no
sign of reversing the patient life.
9. At the end of the code, nurse recorder gathers all the strips, indicating the name of the patient &
time. Completed the report not less than 24 hours.

Doc. No. /Rev. No.
QUALITY PROCEDURE
POST MORTEM GENERAL PROCEDURE
PURPOSE
To establish a documented procedure on a systematic approach in providing post mortem care.
SCOPE
This procedure covers when a patient is pronounced dead by the attending physician until the body
is transferred to funeral service.
DEFINITION
Post mortem care - care rendered to an expired patient before releasing him from the hospital.
RESPONSIBILITY
 Attending physician
o Responsible in attending patient during cardiopulmonary arrest until pronounced dead.
o Signs document in the patient’s chart including in the Death Certificate stating patient’s
diagnosis & cause of death.
 Resident on duty
o Signs document including the patient’s Death Certificate that indicates the diagnosis and
cause of Death of the patient with the permission of the attending physician.
 Nurse on Duty (NOD)
o Responsible in rendering a post mortem care.
o Facilitate early release of Death Certificate.
o Accomplishes/signs documents in the patient’s chart.
o Accomplishes / signs the gate pass, facilitate release of the cadaver.
 Funeral Service Staff
o Assist the nurse in transporting patient to the funeral service.
 Housekeeping
o Responsible in cleaning, disinfecting the patient’s room.
o Segregate patient’s solid waste / garbage.
 Billing Clerk
o Responsible for bringing patient’s chart & accomplished provisionary form to the records
section.

Doc. No. /Rev. No.
QUALITY PROCEDURE
 Medical Record Clerk

o Interview the immediate family member/ kin/ relative.
o Prepares / type Death certificate.
REFERENCE DOCUMENT
MATERIALS
 Cadaver tag (3 pcs.)
 Cotton ball
 Gauge 4x4
 Micropore tape (necessary for bodies with wound)
 Disposable gloves
 Face mask
 Patient’s gown / patient’s cloth
 Stretcher
 Death Certificate
 Wash cloth
PROCEDURES
 As soon as the patient is pronounced dead the physician informs the relatives about the cause of
death. Members of the family are requested to leave the room to prepare the body.
 NOD wears face mask & gloves
 NOD asks permission of the AP/ROD/JCOD to shut / switch off all equipment / apparatus
connected to the patient (e.g. mechanical vent)
 Straighten the body and slightly elevate the head then remove all the gadget attaches to the
body (from head down to the feet).
 If there are personal valuable (e.g. ring, watch, bracelet) remove and give them to the relatives.
If relatives are not present give them to the Security personnel.
o List all personal valuable taken from the patient with the corresponding specifications.
o Ask the relatives to sign for all items given to them. (If there is no relative, personal valuable
should endorse and store at cashier’s office).
 NOD renders a quick sponge bath (maintain privacy).
 Place the false teeth in mouth (if any) the upper set first, and close the mouth by placing a rolled
towel under the chin.
 Close the eyes with pressure or apply using finger tips for a moment.

Doc. No. /Rev. No.
QUALITY PROCEDURE
 If there are any wounds, change dressing and remove adhesive marks.
 Wrap the whole body with linen.
Note: NOD takes note of the linen number for record purposes
 While performing post mortem care, NOD instructs the other departments to facilitate the
patient’s discharge clearance and prepare & collect all the necessary charges from other
departments. And forward all charges to the cashier for payment. Gate pass will be issued after
payment.
 After completion of the post mortem care, NOD fills up three (3) cadaver tag with the following
information:
o Name
o Age
o Sex
o Civil status
o Date & time of death
o Cause of death
o Attending physician
o Signature of NOD
o Remark (indicate if infectious)
 Cadaver Tag is then tied on the specific part of the body
o Thumb
o Big Toe
o Outside the linen over the chest
NOTE: Yellow tag for infectious
White tag for non-infectious
 NOD gives the relative a chance to view the cadaver then cover the whole body with the top
sheet.
o NOD/AO notifies Funeral Service that body is ready for pick-up to their funeral home.
o NOD assists the funeral service staff in transferring the cadaver from bed to the stretcher.
o NOD/AO instructs one of the relative to contact a funeral service of their choice (explained
briefly the policy of the hospital).
 NOD instructs one relative to go to the record section to supply information necessary for the
release of Death Certificate.
 Hand down the statement of accounts to the patient’s relative and instruct them to proceed
to the cashier to settle the hospital bill.
 The NOD gives the provisionary Death Certificate to the ROD/JCON for proper documentation.
 As soon as the cadaver is transported/out of the room, NOD informs the housekeeping on duty

Doc. No. /Rev. No.
QUALITY PROCEDURE
to clean & disinfect the patient’s room. (Refer to Work Instruction on Proper Room Disinfection)
 Healthcare Attendant on duty assists the relatives to bring down their entire luggage and other
belongings.
 Informs the guard on duty about the status of the cadaver
o Bill ( settled / not yet settled )
o Hospital property ( linen patient’s gown)
 The NOD instructs the lobby guard to document in his logbook the date/ time cadaver pick-up by
the Funeral Service of choice by the relative (Identify the Funeral Service).
FLOWCHART
ATTACHMENT
 Sample Cadaver Tag
 Gate pass

Doc. No. /Rev. No.
QUALITY PROCEDURE
BLOOD AND BLOOD PRODUCT POLICIES AND PROCEDURES
MISSION
“The UNIHEALTH PARAÑAQUE HOSPITAL & MEDICAL CENTER blood bank is committed to
provide adequate, safe, accessible and rationally used blood supply through its voluntary blood
donation and blood networking program.”
VISION
“To be a state-of-the-art blood service facility operating on a fully voluntary, non-remunerated blood
donation system that will ensure safe, adequate, accessible and rationally used blood supply.
GENERAL OBJECTIVE
To establish a sufficient and self-sustainable Blood bank at Unihealth Parañaque Hospital & Medical
Center by providing safe blood transfusion practices and maintaining quality Blood Banking
standards.
SPECIFIC OBJECTIVES
 To obtain blood from voluntary donors and through networking to ensure safe transfusion and to
maintain the blood supply in the hospital at a comfortable level in order to ensure the availability
of blood at all times.
 To promote and practice the Department of Health’s program of 100% voluntary blood donation.
 To collect, process and dispense safe blood and blood products.
 To utilize the blood bank and it’s in the training of physicians and allies health personnel the art
of blood banking and transfusion medicine.
 To serve other hospitals within the zone or community who may need blood but lacks blood
banking facilities.
 To analyse, if not solve, blood transfusion reactions and other related problems.
 To ensure safe transfusion practices at all times by following strict quality and standards.
 To promote proper and efficacious utilization of blood and blood components.

Doc. No. /Rev. No.
QUALITY PROCEDURE
DUTIES AND RESPONSIBILITIES OF LABORATORY PERSONNEL
 CHAIRMAN OF THE LABORATORY

Requirements:
o Professional Regulation Commission registered with valid professional license.
o With valid certificate in Anatomic or Clinical Pathology from Philippine Board of Pathology
o With at least 6 months additional training in blood banking service in an institution recognized
by the Department of Health.
Job Description:
o Supervises the entire Blood Bank.
o Attends regular meetings with department’s key personnel and staff and ensures continuing
staff development.
o Attends business and scientific meetings and conferences pertaining to blood bank if
necessary.
o Reviews and approves revisions on SOP’s recommended by the blood bank head.
o Reviews and approves selection of equipment recommended by the blood bank head to be
used in the blood bank.
o Approves recommendation of the blood bank director for candidates for externship,
internship and regular staff positions.
o Reviews and approves recommendation of the blood bank head to be used in the ood bank.
o Approves requests of leaves, exchange of duties and schedule of duties as recommended by
the blood bank head.
o Approves requisition for reagents and other supplies.
o Approves policies and guidelines recommended by the blood bank head.
 BLOOD BANK HEAD

Requirements:
o With valid certification in Clinical Pathology from the Philippine Board of Pathology.
Job Description
o Maintaining the highest possible level of professional standards, accuracy of performance
and technical skill of personnel.
o Ensuring the requests is reasonable, practical, and compatible with the performance of the

Doc. No. /Rev. No.
QUALITY PROCEDURE
functions of the blood bank.

o Organizes and administers the section which includes solving problems related to the
functions of the unit.
o Establishes and updates Standard Operating Procedures for the blood bank.
o Selects and updates methods and procedures for examinations performed.
o Acts as consultants to solve transfusion reactions and related problems and recommends
management.
o Coordinates with other departments and attends meetings if necessary.
o Provides technical assistance in blood bank matters within the hospital and/or other
agencies.
o Screens and recommends personnel for appointment in the section. Evaluates current blood
bank personnel for possible promotions, salary increases and disciplinary actions.
o Gives assignments to various personnel. Reviews request for leaves, exchange of duties
and other matter pertaining to the scheduled duties which will be later subjected to approval
by the Chairman of the laboratory.
o Reviews, evaluates and recommends all requisition for equipment, reagents, glassware, and
other supplies for approval by the head of the laboratory.
o Conducts regular meetings with the blood bank personnel and/or chief medical technologist
for continuing staff development.
 CHIEF MEDICAL TECHNOLOGIST

Requirements:
o With at least 1 year on-the-job training or experience in blood banking services in an
institution recognized by the Department of Health.
Job Descriptions
o Sees to it that all the policies of the blood bank are being implemented.
o Supervises all blood bank personnel.
o Keeps record of procedures and manuals.
o Gives periodic tests to the medical technologists, externs, interns.
o Reports directly to the blood bank director.
o Attends seminars for the updates of blood banking procedures and transfusion medicine.
o Supervises the blood bank team during outreach programs of voluntary blood donation.
o Attends blood bank networking meetings.
o Prepares and finalizes medical technology interns’ grades for release to affiliated schools.
o Ensures that quality control is being applied in all blood banking procedures.

Doc. No. /Rev. No.
QUALITY PROCEDURE
o Supervises the preparation of the monthly report in the blood bank.

o Checks monthly schedule prepared by the section chief for approval by the blood bank
director.
 SENIOR MEDICAL TECHNOLOGIST

Requirements:
o Professional Regulation Commission registered with valid professional license and shall be
under the responsibility of the trained medical technologist.
Job Description:
o Receives endorsements and performs the duties of the section chief medical technologist
whenever the latter is on leave or absent.
o Prepare reports (e.g. monthly reports, consumption report, etc.)
o Makes issuance and requisition of supplies needed for everyday use.
o Monitors proper processing and handling of blood components like PRBC, platelet
concentrate, FFP, cryoprecipitate and washed PRBC.
o Keeps the section in good working condition and advises maintenance service for needed
repair of blood bank equipment.
o Supervises the junior medical technologists and the blood bank especially when a problem
arises.
o Runs quality control of every batch of typing sera, bovine and anti-human sera reagents.
o Checks and records expiration dates of all reagents and blood units.
o Checks and records temperature of blood bank refrigerator, ultra-low freezer, dry bath, and
refrigerated centrifuge before use.
o Performs blood typing on all in and out patients.
o Performs screening test on blood donors and phlebotomy of all qualified donors.
o Performs haemoglobin and haematocrit.
o Screens for HIV, HBV, HCV, syphilis, and malaria.
o Closely supervises donors before, during, and after phlebotomy.
o Performs blood component separation.
o Performs blood typing and compatibility testing of patients with donor units.
o Performs blood transfusion reaction investigation, rechecking for both clerical and non-
clerical possible error.
o Performs blood typing of the patient’s pre-transfusion specimen, patient’s post-transfusion
specimen, and donor unit.
o Repeats the compatibility testing of the patient’s pre-transfusion specimen with the donor
unit.

Doc. No. /Rev. No.
QUALITY PROCEDURE
o Checks patient’s urine for haemolysis.

o Performs Direct Antibody Test and Cold Agglutinin Test on patient’s blood.
o Draws blood from the donor unit for blood culture.
o Receives requests and specimens for blood examinations.
o Checks labels of test tubes containing the specimen.
o Checks if all necessary data in the request form are properly filled up.
o Records charge slip numbers.
o Completes donor records and vouchers.
o Records every unit of blood screened, bled, and purchased from another hospital.
o Receives and checks endorsement of blood bank apparatus.
o Releases blood with accompanying laboratory result to the ward.
o Checks the serial number of blood bags and serial number in reaction papers.
o Checks blood type of blood to be released.
o Checks the amount of blood requested and the amount to be released.
o Checks the reagents for everyday use.
o Prepares monthly billing for networking.
o Discards waste materials and other contaminated materials.
 MEDICAL TECHNOLOGY EXTERN

Requirements:
o A graduate of BS Medical Technology.
o Professional Regulation Commission registered and shall be under the supervision of a
trained medical technologist.
Job Description
o Under the supervision, goes on 8 hours shift as medical technologist on-the-job training
doing the following:
o Performs screening and phlebotomy of donors.
o Performs compatibility testing of patient’s blood with donor’s blood.
o Performs blood component separation.
o Receives requests and specimen for blood examination.
o Prepares blood bank daily census, donor census, and updates records on all blood units
received and issued.
o Discards waste materials like expired blood and contaminated materials.
 MEDICAL TECHNOLOGY INTERN

Duty and Responsibilities

Doc. No. /Rev. No.
QUALITY PROCEDURE
o Maintains cleanliness of laboratory instruments and glasswares used in the performance of

clinical laboratory procedures.
o Prepares glasswares, instruments, and cottonballs for sterilization.
o Maintains cleanliness of worktables and bleeding areas.
o Helps in the receipt of requests and specimens for blood examination in the absence of the
person in charge.
o Helps in answering incoming phone calls.
o Helps in releasing laboratory results to the ward and other important documents in to other
departments.
o Secures supplies in the Central Supply Room.
o Assists the medical technologist on duty in screening-test and compatibility testing.
o Assists the medical technologists during outreach programs.
GENERAL GUIDELINES AND POLICIES:

 The Blood Transfusion Service of the UNIHEALTH PARAÑAQUE HOSPITAL & MEDICAL
CENTER is available on a 24-hour basis and shall provide needed blood and blood products for
emergency cases and will facilitate networking if needed. It shall accommodate blood collection
from voluntary donors, qualified donors of patient with borrowed blood and qualified donors of
patients for elective surgery and/or medical therapy, Mondays through Sundays from 8:00 a.m.
to 10:00 p.m.
 All patients to be admitted as elective or emergency cases who will blood shall be informed of
the Blood Bank policies. The Attending physicians/nursing staff of the concerned
Unit/Department shall be responsible in informing the patient/relatives of the policies and
guidelines.
 Only emergency cases are allowed to borrow blood from the Blood Bank pool. Admitted patients
who suddenly developed life-threatening condition that requires blood transfusion can borrow
blood.
 Elective cases whether surgical or medical cases that will need blood are encourage to have
pre-donation of blood and should be discouraged to borrow blood Bank pool reserved for
emergency cases.
 The pathologist on his duty hours will supervise and facilitate donor screening. In case no
Pathologist is present, the most senior medtech assigned to blood bank will be in charge. Every
voluntary donor should be assisted by the medtech in charge in following the steps in blood
donation (refer to the attached page regarding Donors Flow Chart).
 The hospital shall facilitate transport of blood, blood products and blood donors, to and from the
issuing Blood Service Facility, if the hospital ambulance is available. If there is no ambulance,
the patient’s relative can be instructed on the proper handling and transport of blood and blood

Doc. No. /Rev. No.
QUALITY PROCEDURE
products.
TEST PERFORMED
 ABO and Rh typing (tube method)
 Cross Matching
 Coomb’s Test, Direct and Indirect]
 Donor Selection
 Blood Collection and storage
 Blood Screening for Transfusion Transmissible Infections (HIV1 and 2, HBsAG, HCV, Malaria
and Syphilis).
BLOOD BANK POLICIES AND PROCEDURES

 Request of Blood for Transfusion
o All requests for blood shall be prepared by the attending physician or the nurse on duty in the
prescribed form and signed legibly by the attending physician. It should be properly
accomplished including the number of units required, patient’s blood type and sent to the
Blood Bank.
o STAT request for blood should be accomplished in the same prescribed form and must be
sent immediately to the Blood Bank.
 Storage of Blood
o Any unit of blood obtained from outside (PNRC or any other blood bank) shall be brought
directly to the Blood Bank/Laboratory.
o The Laboratory staff in duty shall check the blood unit (appearance, condition, etc.), if it is
properly packed and transported and its label that must contain the serial number, blood
type, amount of blood, extraction and expiration dates. He/she shall then affix his/her
signature after noting the date and the time the blood is received in the appropriate logbooks
and ledgers.
o Any unit of blood and blood products obtained from outside (ex. PNRC or any other blood
bank) should be re-tested for HIV, HBsAg, Hepatitis C, Malaria and Syphilis. The attending
physician and the patient or nearest relative shall sign an “ACCEPTANCE OF
RESPONSIBILITY” form if they insist against the re-testing of their brought blood and blood
products.
 Request for Cross-matching
o Routine request for pre-operative patients shall be sent to the laboratory 1 day before the
scheduled operation.
o ALL STAT requests shall be attended to immediately.

Doc. No. /Rev. No.
QUALITY PROCEDURE
o All blood specimens for compatibility testing shall be extracted exclusively by laboratory
personnel.
 Issuance of Blood and Cross-matching results to the ward
o For STAT examinations, the nurse on duty shall be informed that the blood units are ready.
The ward personnel shall pick up the blood with cross-matching results attached from the
blood bank as needed.
o The transfusion requests shall be completed in the ward, signed by the attending physician,
and sent to the blood bank as needed.
o Upon the request of the attending physician except for massive transfusion, only one unit of
blood shall be issued at any one time. When the attending physician finds it necessary to get
more than one unit at a time, he/she shall be required to sign a waiver.
o If not used, the blood issued to the ward shall be returned to the Blood Bank within 30
minutes after issue.
o In case of sudden blood shortage, the attending physicians for elective procedures shall be
notified for possible cancellation or re-scheduling to give way for emergency cases.
 Unused and “Standby” Blood
o The Blood bank shall be notified if surgery is cancelled or postponed.
o Units of hospital bloodstock previously cross-matched for a particular patient but not used,
shall automatically be cross-matched for another patient 24 hours after scheduled
transfusion, unless written notification is sent to the Blood Bank for further need of blood.
o Blood unit/s previously cross-matched to patients scheduled for elective surgery shall
likewise be automatically cross-matched to other patients the morning after the scheduled
operation, unless written notification of further need is received by the blood bank.
o Units of blood from donors or blood banks outside the hospital, which have not been
transfused, shall automatically three (3) days after the scheduled transfusion.

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PROCEDURES ON BLOOD AND BLOOD PRODUCTS ADMISINTRATION

PURPOSE
To ensure proper and safe administration of blood and blood products.
SCOPE
This procedure covers from the time the blood transfusion is ordered by the doctor up to the
completion of transfusion.
DEFINITIONS
 Cross-matching - One of the several test used in blood typing, red blood cells of the donor of an
unknown blood type are mixed with sera of known blood types.
 Blood Typing - A test used to distinctly determine classes of human blood, identified clinically by
characteristic agglutination reactions.
 Blood - The fluid consisting of plasma which are suspended red and white blood cells and
platelets. It carries oxygen and nutrients to all the body tissues and waste products to the
excretory system
 Blood Product - Any of the several classes of human blood clinically packed used for transfusion.
 Vital signs - Refers to body temperature, pulse rate, respiratory rate and blood pressure of the
patient.
RESPONSIBILITY

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 Nurse on duty (NOD) - Carry out blood transfusion order written in the patient’s chart. Monitor
patient’s vital sign on blood transfusion, responsible for getting the Blood Product from the
laboratory.
 Attending Physician (AP) / Resident on duty (ROD) - Writes the order of blood transfusion in
the patient’s chart.
 Med-Tech on duty (MOD) - Responsible in the blood typing and cross-matching procedure of
blood products and in the preparation of blood product being requested.
REFERENCE DOCUMENT
MATERIAL
 Normal saline IV solution 0.9% 500ml/ 1 liter
 Blood Transfusion Set
 Disposable G.19 needle
 Cotton balls with alcohol
 Micropore tape
 Blood Requisition form to laboratory
 Gloves
 Appropriate blood product
 Tourniquet
PROCEDURES
1. Confirm Physician’s Order for Blood Products by reviewing doctor’s order. Send request for
blood typing and cross matching.
2. Identify patient who is to receive blood/ blood product by checking patient’s hospital identification
band and by asking the patient to identify him/herself.
3. Explain to the patient/ relative the purpose of Blood Transfusion. Have patient or guardian sign
consent for blood / blood product transfusion.
4. Ensure that a mainline intravenous access is established (using large bore needle gauge 18)
using Normal Saline (0.9 % NaCL). If IV access is already established, ensure that the tubing is
flushed with Normal Saline solution prior to blood / blood product administration.
DO NOT ADMINISTER ANY MEDICATION IN THE BLOOD INFUSION LINE.
5. Obtain baseline temperature, blood pressure, pulse, and respirations and record on patent’s
chart. Notify Physician if temperature is greater to 100.4 F (38 C) per axilla.
6. Wash hands. (Refer to Hand Washing Technique).
7. Select appropriate administration set

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a. Macro set – platelet concentrate, Fresh Frozen Plasma

b. BT set - Packed RBC, whole blood
8. Positively identify the blood component bag with the patients hospital number the donor number,
the blood type of patient and donor product, the blood product expiration date. This procedure
must be done by two licensed nursing personnel and signature must be affixed on the Blood
Component Compatibility sheet from laboratory.
9. Administer anti-histamine medication as ordered.
10. Call or request patient to identify them and check against hospital identification band.
Note: Never administer blood to any patient without Hospital Identification band or if any
discrepancies are found during patient-blood identification.
11. Inspect blood product container for leaks, puncture, or other problem.
12. Wear gloves and remove protector from blood unit outlet.
13. Place blood administration spike into blood unit using a twist motion until firmly
connected/hooked. Always have blood unit hanging while spiking to prevent accidental
puncturing of the bag.
14. Open clamp under blood unit and adjust flow rate using regulating clamp at distal end of tubing.
15. Change administration tubing after every 2 units of blood or before 4 hours has expired.
16. Never allow a unit of blood to infuse longer than 4 hours.
17. During the first 15 minutes of the transfusion, adjust rate of blood flow to 20 gtts/ minute or
approximately 2cc / min
18. Stay with the patient during the first 15 minutes of the transfusion to monitor for signs of allergic
reaction. After 15 minutes, if no reaction has occurred, repeat vital signs and record in Nurse’s
notes. Increase transfusion to desired rate of flow.
19. Continue to observe for signs of a reaction.
a. Elevated pulse or temperature
b. Chills
c. Urticaria / hives
d. Nausea / vomiting
e. Cough/ pulmonary edema/ wheezing
f. Flank pain/ hematuria
g. Prusitus
h. Dyspnea
20. IF A REACTION OCCURS, IMMEDIATELY STOP THE INFUSION AND INFORM AP AND
FOLLOW BLOOD TRANSFUSION REACTION PROCEDURE.
21. Brings down the unfinished blood product with the tubing to the Laboratory department for
confirmation of BT reaction.
22. Bring urine sample of patient if requested by the AP
23. After transfusion is completed without reaction to blood product, flush primary IV tubing and

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resume original IV solution and rate and return empty blood bag to the laboratory.
24. Repeat vital signs and record on patient’s vital signs sheet and document if a reaction did/ did
not occur.
DOCUMENTATION
1. Record vital signs in Nurse’s notes and on Vital signs sheet.
a. Before transfusion is commenced
b. Fifteen (15) minutes after transfusion is commenced.
c. Every hour during transfusion.
d. After transfusion is completed.
2. Record time blood/ blood product that has been discontinued including donor number, unit
number, and product.
3. Record patient’s assessment and tolerance to blood transfusion including IV site,
signs/symptoms or reaction, and other significant findings hourly during infusion.
4. If a blood transfusion related complication occurs, follow the Blood Transfusion reaction
procedure and document all clinical observations and interventions in the Nurse’s notes.
5. Return the remaining blood products in the laboratory for further study.
ATTACHMENTS

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POLICIES ON VOLUNTARY BLOOD DONATION

PURPOSE
To establish guidelines regarding the provisions of voluntary blood donation.
POLICIES
All prospective donors shall be sent to blood bank where donor screening tests and laboratory
examinations shall be done to determine if they are fit to donate blood and can cause no harm to
possible recipients
 General guidelines in the selection of prospective regular donors:
o Age: 18-60yrs of age (consent is required for donors younger than 18yrs old).
o Weight: at least 50kgs, not obese.
o Blood Pressure: 90-140mmHG systolic; 60-90mmHG diastolic.
o Pulse Rate: 50-100beats/minute; regular rhythm.
o Temperature: afebrile (37 C or below).
o Hemoglobin: 12.5g/Dl.
o Hematocrit: 42-52% in males; 38-48% for females.
o No history of jaundice (Hepatitis A,B,C), malaria, diabetes, heart disease, active tuberculosis,
epilepsy, severe hypertension or on medications for the above illness.
o Should have no signs of infection at the time of donation or for the past week.
o No previous blood transfusion for the past 12 months.

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o For females, no pregnancy for the past 6 months.

 Blood Replacement
o Replacement of blood borrowed for use in emergency cases shall be explained to the
patient’s relatives and friends by the attending physician and/or the nurses.
 Blood Donor Replacement
o Patients shall replace blood units procured from the Blood Bank with equivalent number of
units though not necessarily of the same ABO/Rh type.
o For small volume transfusions, like neonatal transfusions & sometimes in adult cases
requiring only 50-100, 1 unit whole blood shall be donated.
o For every unit of Whole Blood/PRBC/Platelet concentrate/washed PRBC transfused, patient
shall provide 2 qualified donors.
o For every unit of cryoprecipitate/Cryosupernate/FFP transfused, patients shall provide 1
qualified donor.
o For mobile blood donations sponsored by patients, there shall be a minimum of 60 qualified
donors and replacement of 1:2.
o For emergency cases, blood shall be issued to patients but should be replaced within 30
days from the date of transfusion. It shall be charged automatically to a patient’s bill refunded
upon prompt replacement.
o For non-emergency and elective surgical cases which may require blood transfusion, donors
shall be provided as pre-deposit or during the time of need
o Unused deposited blood after the patient has been discharged shall be considered as a
voluntary donation to the Blood Bank pool.
o Blood units procured from other hospital or blood banks without proper coordination with our
blood bank shall not be accepted as replacement for units transfused.
NOTE: in cases of extreme emergency, uncross-matched or partially cross-matched blood

may be released by blood bank only when the attending physician accepts responsibility for
the risk involved in transfusing such blood by signing an ACCEPTANCE OF
RESPONSIBILITY” form. The blood bank shall notify the physician about the result as soon
as available. No compatibility label should be attached to the blood pack.
o All labels attached to the blood bags shall be filled out properly. Cross - matching results
should be in patients chart before transfusion can be started.
o Type specific plasma products (platelets, fresh frozen plasma, cryoprecipitate,
cryosupertanate) need not to be cross matched.
o Blood awaiting transfusion shall be kept in the blood bank refrigerator for storage of whole
and packed red cells at 1c -6c and the plasma freezer for storage of Fresh Frozen Plasma,

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cryoprecipitate and cryosupernate at -30c. Platelets are restored on a horizontal shaker at

room temperature only.
o Non- emergency request for blood shall be sent to the blood bank 24 hours prior to
contemplate procedure.
o Unless notice is made to the Blood Bank to retain blood for particular patient, all reserved
units if not notified shall be freed for 24 hours.
o Incompatible cross-matching result shall be referred to the pathologist on duty.
POLICIES IN NETWORKING
PURPOSE
To sustain provisions regarding the blood bank networking system.
POLICIES
 UParHMC shall borrow blood and blood components needed through the networking system.
UParHMC shall replace each borrowed unit by collecting blood from two qualified donors of any
type brought by patient/relative. A screening fee is charge to patient/relative to defray the cost of
blood bag and screening examination if only one (1) qualified donor is available per unit
borrowed.
Note: The service fee varies from the time to time depending on the current costs of blood bag
and other materials used for screening computed at cost.
 Swapping of blood units of different blood types shall be entertained provided that:
o The requesting agency does not have the specific type of blood in their stock and such blood
is needed for emergency purposes.
o The UParHMC Blood Bank has ample supply of the specific type of blood being requested.
o The exchange will not result to oversupply of swapped unit.
Note: if the purpose of the swapping is to replenish the insufficient supply of the requesting

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agency in order to avoid an acute shortage, the request to swap is not justified.
 Patients/Relatives for as much possible shall not be directly involved in transfusion concerning
networking of blood. Transactions are made among Blood Service facilities.
 Charging non-replacement fees (Blood Processing Fees) shall be discouraged and should be
used only as a last resort.
GUIDELINES AND POLICIES FOR EMERGENCY CASES

PURPOSE
To sustain guidelines for provisions of emergency cases in the blood bank.
POLICIES
 Patients who require blood on emergency basis shall be given blood coming from the Blood
Bank Pool (When type specific blood is available) A maximum of (3) units per patient per request
at a time can be secured. The relatives of the patients should be asked to look for donors and
should bring them in before the three (3) units of blood are transfused OR before the patient is
discharged from the hospital to avoid delay.
 If the patient/relatives have no donors, the attending physician and/or nursing staff shall facilitate
the procedure in filling out the data in the Promissory Note and have the patient/relative and the
attending physician affix their signatures on the promissory note.
 The attending physician and/or nursing staff of the concerned Unit/Department shall be
responsible for explaining the policies of blood replacement for borrowed blood to blood to the
patients/relatives and they shall act as guarantors for the units of blood borrowed.
 Patient/relatives shall be responsible in replacing the borrowed units of blood. For each unit
used, the patient/relatives shall bring in two (2) donors of any blood type.
 Bringing in of blood donors shall be accommodated only from Monday to Saturday, but no donor

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shall be asked to return for bleeding the following day, UNLESS extremely necessary.
 If there’s no available blood for transfusion in the laboratory and the patients shall be bled in the
hospital that will issue the blood unit/s for the patient.
 Blood that has not been screened for the transfusion transmissible infections shall not be
transfused EXCEPT when one or more test cannot be performed in time in the face of a life
threatening emergency, the attending physician shall document the presence of such an
emergency upon requesting unscreened or partially screened blood from the blood bank. Patient
and or relatives must be properly informed and must give their consent in writing.
 Compatibility testing as prescribed by DOH shall be carried out on all whole blood and red cells.
In life threatening emergencies, this shall be completed after the blood has been issued.
 Cases of emergency are those in which whole blood or red cells are urgently needed to save the
life of the patient. The attending physician shall certify in writing to the extreme necessity of
transfusion, even if due to lack of time, the blood product has not been fully screened or the
standard test for compatibility with the recipient have not been completed. In such cases, upon
presentation of the written request and certification, the blood bank may release the blood
products to the attending physician or his representative for blood transfusion
GUIDELINES AND POLICIES FOR ELECTIVE CASES
PURPOSE
To ensure guidelines pertaining to blood products needed for elective cases.
POLICIES
 All patients to be admitted for any elective surgical or medical procedures, who will potentially
need blood, shall be required by the physician and/or nursing staff to bring in donors.
 For each contemplated blood unit the patient is going to use, he/she shall bring two (2) donors of
any blood type and no screening fee will be charged for every (2) qualified donors.
 No patient shall be admitted and/or scheduled for elective surgical or medical procedures without
pre-deposited blood.
 Patients for elective procedures shall secure a clearance from the laboratory as part of the
admitting requirement. The clearance will state if the number of blood units are already
deposited in the Blood Bank.
o They shall bring their donors two (2) days preceding the day of admission, between 10am to
4pm from Monday to Saturday together with the request for blood.
o The request for blood must be properly filled-up with the specific blood type and number of
units of blood needed including the date of elective surgical procedure and/or the date of

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blood transfusion for medical procedures.

o No donor of patients for elective procedures shall be accommodated on Monday to Saturday
after 2pm and on Sundays and holidays. However, upon patient request donors can come to
the laboratory during Sundays and holidays between 7:00am to 2:00pm provided that they
notify the laboratory at least 3 days in advance and that they will bring a minimum number of
4 donors, otherwise they will not be accommodated.
 Blood donated or blood acquired through networking for a particular patient and was not used
shall automatically be donated to the Blood Bank pool; or it can be used to replace borrowed
blood from other hospital under the NVBSP, provided that the patient/relatives will show proof
from said hospital. (This last scheme is only applicable if they are transferred to that particular
hospital).
 Patient/s with pre-deposited blood and who are admitted or transferred to another hospital:
o Shall notify the laboratory of their intent to get their blood deposit within 72 hours (3 days)
after the patient was admitted to another hospital, or else their blood deposited will be
considered as donation to the hospital.
o The patient’s relative must show proof in writing that their patient was admitted to another
hospital. The BTS shall in turn issue a letter addressed to the hospital that the blood unit/s be
intended for that particular patient.
o In cases wherein the Attending Physician from this hospital certifies that there is really a
need for the patient to be transfused with blood at the hospital where the patient was
transferred, then the laboratory shall immediately release their pre-deposit blood at the care
of the relatives with proper instructions regarding handling and transport of the said blood
unit/s from the laboratory personnel.
 Reserved blood that are not used during operation or during medical procedures after 24 hours
shall automatically be returned to the Blood bank pool, unless a special request is made to retain
the blood for the blood for the same patient for another 24 hours. (Form to be used – Request for
blood form)

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POLICIES IN AUTOLOGOUS BLOOD TRANSFUSION

PURPOSE
To establish guidelines regarding autologous blood transfusion that covers for pre-surgical donation
cases.
POLICIES
NOTE: Pre-deposited (pre-surgical donation) is the only method of autologous transfusion done in
the hospital. Intraoperative blood salvage and acute normovolemic hemodilution are not done.
 Physician shall encourage healthy patients who are scheduled for elective procedures to deposit
blood prior to surgery, taking into consideration the benefits of the procedure:
For the Blood Bank:
o Ready availability of blood for rare blood types
o Availability of blood for those with difficult cross-match.
o For the Donor-patient:
o Safety of transfusion of homologous blood eliminates risks of transmitting infectious blood-
borne diseases and risks due to errors in cross matching.
o Stimulation of erythropoiesis by repeated phlebotomies. There is increment rise in

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haemoglobin and hematocrit in patients who pre-donated.

o Reduction in cost of blood. Serologic tests for blood-borne infections and cross matching are
not done.
 The physician shall interview the prospective donor-patient and does physical examination.
 The blood bank shall do haemoglobon and hematocrit determinations and ABO-Rh typing.
(Haemoglobin = 35%)
 If the donor passes the interview, physical examination and heamoglobin and hematocrit
determinations, the physician shall secure consent for autologous blood transfusion.
 The patient-donor shall be bled one (1) unit per donation following this autologous blood
donation schedule:
o 17-19 days prior to surgery
Note: The last bleeding should not be closer to 72 hours prior to surgery. Bleeding should be done at
least 3 days to 1 week interval. Haemoglobin and hematoctrit should be determined prior to each
donation. The amount extracted depends on the height and weight of the donor-patient.
 Ferrous Sulfate and other haematinics shall be started prior to extraction of blood and continued
for 6 months.
 The blood bank shall use a special tag in labelling autologous blood bearing the following
information:
o Patient’s name
o ABO and Rh group
o Date of Expiry
o “FOR AUTOLOGOUS USE ONLY”
 If autologous blood is not used, the pathologist shall determine if the blood is qualified to go out
into the Blood bank pool to be used as heterologous blood.
 If it passes the initial screening done by the pathologist, the following serologic examinations
shall be done.
o HIV 1&2
o Hepatitis B and C
o Malaria
o Syphilis (RPR)
 If the above serologic examinations are negative, the label “FOR AUTOLOGOUS USE ONLY”
shall be removed and the blood is transferred to the Blood Bank pool to be used as heterologous
blood.
OTHER POLICIES REGARDING BLOOD PRODUCTS

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 All borrowed blood shall be replaced during office hours between 7:00am to 2:00pm Mondays to
Saturdays. On Sundays, holiday and after 2:00pm-no donors will be accommodated because of
inadequate manpower. (The guiding principle in this policy is that the patient’s life was saved
because the BTS of the VGH provided them with blood, hence it is only appropriate that they
have to sacrifice their time to accommodate our set-up).
 All borrowed blood shall be replaced by qualified donors, for every unit (450 ml or 250ml)
borrowed blood; it has to be replaced with two (2) qualified donors (donors that passed the
screening criteria) no fee will be collected for processing of blood.
 For those who cannot comply with the number of blood replacement, 1:2 (blood units borrowed:
number of donors needed to replace the borrowed blood), the following guidelines shall be
implemented.
o One (1) unit (250 ml or 450ml) of borrowed blood, which was replaced by one qualified donor
only, the patient/relative, has to pay for the screening fee for every unit not replaced.
o Per unit (250 ml or 450 ml) or borrowed blood that was not replaced by a qualified donor, the
relative has to pay for the corresponding charges for every unit.
 Under the blood Replacement Program, patients/relative/donors shall be instructed by the
attending physician and/or nursing staff to go to the laboratory under the following
circumstances:
o If the donors passed the P.E. portion of the blood donor interview sheet.
o If the patient/relatives decided to pay the specific charges enumerated above instead of
providing qualified donors to replace the borrowed blood.
o If the patient relatives will secure clearance.

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POLICIES ON ENVIRONMENTAL SYSTEM AND CONTROL

PURPOSE
To ensure guidelines of an environmental system that covers the maintenance and cleanliness
needed for the whole institution.
POLICIES
LIGHTING
 Electricity is provided by the Meralco. In case of power failure or scheduled power cut-off,
emergency generator shall be used.
 Efficient system of lighting shall be observed all the time with or without the aid of the Meralco.
AIR-CONDITIONING
 An individual air conditioning unit shall be available in all OR theatre.
 For the maintenance of the unit the following shall be observed:

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QUALITY PROCEDURE
o Filter must be cleaned or changed regularly during general cleaning day.

o Nurse in-charge shall see to it that their unit is put off as soon as work in the operating room
theatre is finished.
o Air-conditioning unit shall be removed from their outlet as soon as power cut –off is present.
o Nurse in charge shall remind or notify the technician on duty for any malfunctioning of the air-
condition unit.
CLEANLINESS OF THE OPERATING ROOM
Damp dusting with alcohol is done every morning after sweeping the floor. Mopping with disinfectant
follows. The same is done every after a clean case. For septic cases, the same procedure is done
first then exposure to ultraviolet rays of all equipment’s and the entire for 30 minutes to one hour is
observed. Schedule of general cleaning day is every other week. All equipment’s are brought out of
the OR for dump dusting at sterile anteroom. One the OR is empty of equipment, the floors and walls
are cleaned with soap and water. When dried, the equipment’s are returned back and general
fumigation of the entire OR theatre one after the other.
Safety Measure
 In case of fire
o All members of the staff are aware of the availability of fire extinguisher inside the unit.
Orientation to its use shall be done to all new staff members.
 Anesthetic Hazards
o Due to all effects of the anesthetic agents during its use in induction of anesthesia, exhaust
tubes from anesthesia machine leading to the back corridor of the OR shall be installed.

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POLICY AND PROCEDURE ON CONTINGENCY PLAN

PURPOSE
To ensure a documented policy that covers the contingency plan for the nursing personnel
concerning the attendance, schedule, endorsement and incident reports.
POLICIES
ATTENDANCE POLICY
 Every GNU Staff Nurse shall report on duty at least 30 minutes before the scheduled shift (CUT-
OFF-TIME)
 The Nurse must log at the finger scan (applicable for regular, probationary, and contractual staff
only). For trainees, they are required to punch their time card at the Bundy clock
 Tardiness means arriving after the cut-off time (less than 30 minutes before the shift)
 For those who will be absent shall notify the Supervisor on duty ONLY at least four hours before

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the scheduled shift
ENDORSEMENT POLICY
 Endorsement shall be done systematically using the updated medical care plan as a guide.
 The out-going nurse shall endorse on time whether or not she has finished completing the
documentation
 The out-going nurse shall make sure that medications to be used for the next shift are available
or requested.
 The out-going nurse shall make sure that recording and documentation on patient’s chart is
complete.
 Incoming nurse shall listen and must take note of special endorsement.
 Both the outgoing and the incoming nurses shall do patient rounds after endorsement.
 The incoming nurse shall be the one to receive and carry out doctor’s orders for patient’s
assigned to her that fall on the time of her shift.
 Medications shall not to be endorsed except on unusual cases.
SCHEDULE POLICY
 Schedule of shift shall be changed every two weeks.
 The nurse shall request for their preferred OFF duties ahead of time before the final schedule is
approved by the Chief Nurse by notifying the Supervisor or plot their OFF on the temporary
schedule sheet.
 Once the final schedule is approved, changes shall not be made except for emergency reasons
and staffing solution purposes.
 Request for change of schedule shall be made 2 days before the expected date of change and
should be duly authorized by the Supervisor. The nurse shall also accomplish the “Change of
Schedule” slip to be approved by the Chief Nurse.
 Only the Supervisors shall be allowed to write/change entries on the final schedule sheet.
Unauthorized changing of schedule is not allowed.
DISCIPLINARY ACTIONS
 TARDINESS
The Level of reprimand for the following tardiness is as follows:
o 2 days of tardiness within the schedule = Verbal warning
o days of tardiness within the schedule = Written report
o days of tardiness within the schedule = Suspension based on code of discipline
 ABSENCES

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Absent Without Official Leave (AWOL)

o 1st offense – Verbal warning
o 2nd offense – Incident report
o 3rd offense – Suspension based on code of discipline
 The following guidelines must be abided:
o Strictly at least 4 hours notification ahead of time
o Submit a medical certificate signed by a CONSULTANT before reporting on duty.
o Submit an Incident Report
o No TEXT notification, the staff must inform via phone call. Notification of absence must be
done 4 hours prior to scheduled shift.
SUBMSSION OF INCIDENT REPORT IS REQUIRED FOR THE FOLLOWING CASES
 No entry on Standing Order Sheet

 No entry on Medication Sheet
 No medication card done
 Medication card not discarded of meds are discontinued or changed
 Incomplete Nurses’ notes, I and O, vital signs record, etc.
POLICY THAT GOVERN CARE OF PATIENTS WITH SPECIAL NEEDS

PURPOSE
To provide and ensure accessibility and effective care and communication on patient’s with special
needs and their companions
POLICIES
 Special Child patients: example – ADHD patient, Cerebral Palsy patient
o The Nurse on duty shall identify first the physical condition of the patient with certain
condition like inability to communicate and physical disability.
o Nurse on duty shall uniquely identify the proper treatment ordered by the Attending
Physician.
o The nurse on duty shall be able to recognize the needs of the patient with special need
o Nurse on Duty shall cooperate with the members of the family, especially during invasive

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procedures that has to be done to the patient:

 During IV insertion
 Diagnostic procedures such as, CT scan, EEG, CXR and others.
 Pregnant Patient
o The nurse on duty shall properly identify the patient by submitting a pregnancy test; from the
Emergency Room the female patient must have the test before giving any treatment and
doing some procedures.
o Privacy shall be provided in the patient especially during Internal Examination (IE).
o For pregnant patients with at least 20 weeks AOG, a fetal heart tone through the use of fetal
Doppler shall be done to ensure the viability of the fetus.
o The nurse on duty shall properly inform the Medical team about the condition of the patient
especially during the procedure that may cause harm to the fetus such as radiologic
examinations. Lead apron can be worn during radiologic if procedure is highly needed.
POLICIES AND PROCEDURES FOR TRAINING, SUPERVISION AND

EVALUATION OF PROFESSIONALS WHO ADMINISTER DRUGS
PURPOSE
The Unihealth Parañaque Hospital & Medical Center (UParHMC, Inc.) considers the orientation of
staff to the organization as a mandatory requirement. UParHMC, Inc. will ensure that every
employee and volunteer is given a relevant programme of orientation, both organization-wide and
within their departments. This is both a central responsibility and the responsibility of the department
in which the new staff member’s works. Orientation and induction is first step in a formal process of
human resource preparation and development.
APPLICATION

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This procedure is to be followed by all staff members throughout UParHMC, Inc.
DEFINITIONS
For the purposes of this Procedure.

 Orientation: is taken to mean a process for formally introducing and initiating a new employee
into the values and culture of the organization and to the policies and procedures of the
organization.
 Staff member: is taken to mean any person appointed to work for UParHMC, Inc. in any of its
departments/units/clinics/practices, whether the appointment is permanent, temporary or casual.
OBJECTIVES
To help the employees become efficient and effective on the preparation and administration of
drugs.
POLICY
 All newly hired employees shall undergo an orientation program to start on his first day of
employment.
 All newly hired registered nurses shall undergo IV Therapy training seminar and must have the
valid ID.
PROCEDURES
Registered Nurses on duty must:
 Check the written order for completeness and accuracy.
 Do find time to know more about the drug of the patient in receiving-from PIMS, Drug literature or
pharmacy.
 Request the medication from the pharmacy
 Check the medication dispensed by the pharmacy through the medication ticket. Medical care
plan and doctor’s order prior to the preparation.
 Preparation of medication will be done with the supervision of the supervisor/head nurse/charge
nurse on duty.
 Supervisor/Head Nurse/Charge Nurse on duty will sign the medication ticket after the
preparation of medications to ensure the correct dosage and patient.
 If newly hired registered nurses, the Head Nurse/Charge Nurse will go with the staff in giving
medications.

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 After giving medications staff will sign on the medication ticket to ensure that medication was
administered to the right patient.
POLICIES AND PROCEDURES FOR THE MANAGEMENT AND USE OF

MEDICAL DEVICES
INTRODUCTION
The use of medical devices by the staff and patients present a moral and legal duty. This is to
ensure that the equipment does not pose danger to the health and safety of employees, staff and the
general public. This policy regarding management and use of medical devices shall be read in
relation to the accompanying procedures to ensure that these devices are used and managed
competently and safely. It requires that employers guarantee, so for as far is reasonably practicable,
the health, safety and welfare of their employees, and any other people that may be affected by the
work activity.

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PURPOSE
To make sure that the policy regarding equipment usage are not only understood by its user and
suitable for its intended purpose but the equipment should be maintained in a safe and reliable
condition and can be used with confidence.
Staff should be able to demonstrate that appropriate arrangements for managing the equipment are
in place, including necessary training and regular maintenance.
Individual practitioners have a duty of care not to use equipment they are not trained for and that
they understand the arrangements for maintenance and repair.
AIMS AND OBJECTIVES
Aims
The aims of this policy are:

 To protect the health and safety of staff, patients, visitors and general public.
 For effective and appropriate management of medical devices and equipment by ensuring
that all medical devices are: suitable for intended purpose; maintained in a safe and reliable
condition; used only by competently and properly trained staff; appropriately decontaminated.
 To increase staff awareness of the principles and importance of equipment management.
 To ensure that managers and individual members of staff are aware of their responsibilities in
the use, procurement, training and maintenance of medical devices.
Objectives
The objectives of medical devices management are:

 To use policy to support the development of procedures that will instil a safer, more efficient
and high quality management of all medical devices.
 To investigate reported incidents involving medical devices and the reporting of faults and
deficiencies in medical devices and equipment.
 Establish and maintain a standardized list of equipment and medical devices so that
appropriate training can be organized that can be timely and accurate and that appropriate
procurement of the most cost effective and medically efficient devices is carried out.
 Organize and maintain timely and effective staff’s training so all relevant staff have a clear
understanding of the equipment they use, including its operation, maintenance,
decontamination and procurement.
 Establish planned and preventive maintenance programmed for all medical devices and
equipment.

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 Establish systems and procedures to ensure that where appropriate all medical devices and
equipment are cleaned, disinfected and or decontaminated in accordance with the latest
guidance.
STAFF ROLE AND RESPONSIBILITIES
Heads of Department: are responsible for ensuring that local procedures are in place to manage all
aspects of the use of medical devices and equipment in their department. They must see to it that all
staff using medical devices are aware of the potential risks, and are properly trained regarding the
safety of equipment.
Supplies Department: is responsible for the purchase and receipt of equipment and for ensuring
that all new electrical equipment are transferred to the relevant section of the department for
acceptance testing prior to being delivered to the user, unless in circumstances where equipment
must ensure that arrangements for acceptance testing, is organized before the equipment is used.
Radiology Staff: Radiology employees have legal duty to take care of their own and other safety
when using equipment at work.
KEY AREAS IN THE MANAGEMENT OF MEDICAL DEVICES AND EQUIPMENT
Incidents involving medical devices may arise from various causes:

 shortcomings in the instructions for use
 lack of servicing or maintenance
 locally initiated modifications or adjustments
 shortcomings in user practices or training
Defective Items:
 The following actions shall be taken when a defective item has been identified:
 Warning notices/tape shall be placed on all defective equipment to prevent accidental use
 All material evidence shall be labelled and kept secure, under the charge of a responsible
member of staff
 A record shall be made of all readings, settings and positions of switches, valves, dials,
gauges, indicators, together with any photographic evidence and eye witness reports. This

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record should be witnesses and the witness should also make a personal written report.
 If devices are required for use, defective parts shall be removed so the equipment can
continue to be used.
 Any parts removed in such circumstances shall be quarantined and securely stored pending
investigation.
 Staff shall be made aware of the need for increased vigilance and extra caution during use.
 Defective items shall not be allowed to be repaired, returned to the supplier or discarded
before an investigation has been carried out.
Compilation of an Inventory
The maintenance of a complete and up-to-date inventory of equipment is an essential requirement

for medical devices management and accounting purposes. In addition to this the information also
includes details of where each item is located, the training needs/dates of staff using the equipment
and maintenance history.
TRAINING, COMMUNICATION, & REVIEW
Training
Training shall be included in the induction program for new staff and update training for existing staff
will be developed.
Training requirements for staff in the use of individual medical devices and equipment this will be
used to identify and prioritize training for staff.
Communication
A copy of this policy shall be made available to all staff. They will be notified of a new or reviewed
policy system.
Review

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The policy shall be reviewed every two years or as and when significant changes make earlier
review is necessary.
Medical Device used in Patient Care Services Department
Medical Device – equipment used for the diagnosis or treatment of disease, or for monitoring of
patients.
a. Pulse Oxymeter
b. Defibrillator
c. Computer System
d. BP Apparatuses
e. Stethoscopes
f. Digital Thermometers
g. Air-conditioning units
h. Negatoscopes
i. Infusion Pumps/Syringe Pumps
j. Cardiac Monitors
k. Oxygen Regulators
POLICIES & PROCEDURES ON THE STORAGE AND DISPOSAL OF

MEDICAL DEVICES AND EQUIPMENT
PURPOSE
To maintain a proper practice in storage and disposal of medical devices and equipment.
POLICIES
The procedure on storage and disposal of Medical Devices and Equipment are not being practiced
in Patient Care Services Department. If there is a need for disposing the medical devices the
following procedures shall be observed:
 If the machine has a defect or cannot be used it is usually placed inside the storage room.
 The Department will report and surrender the equipment with defect to the Purchasing
Department for management and proper monitoring.
 The machine with defect should have the proper documentation, coordination and approval

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from the Chief Nurse and Administrative Officer.
User Maintenance
User care procedures are likely to include:

 Careful cleaning and if necessary sterilizing
 Formal inspection, including leads and ancillary devices
 Functional checks
 Daily user calibration checks (or as identified by the user manual)
 Annual calibration of equipment where required
 Ensuring any consumables required for the device is in place, regularly checked and
replacements.
Cleaning and Decontamination

 The user/professional shall make all equipment socially clean before being presented for
maintenance or repair of for re-use in patient care. Disposable cloths should be used.
 It is very important that electrical equipment is not unduly wetted as this not only damages
the equipment, but also creates an electrical shock hazard.
Storage
Effective storage of medical equipment ensures that they are not damaged and ready for use at all
times. Ineffective storage could result in equipment being damaged and in the case of battery driven
devices, uncharged. Manufacturer’s information and instruction both on storage conditions and shelf
life should be followed.

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UPARHMC WASTE SEGREGATION PROGRAM
INTRODUCTION
Hospital and all healthcare facilities are sources of dangerous waste which is a hazardous
community. Personnel handling hospital waste are at a high risk of contracting blood-borne
diseases, Same with people who collect and transport waste. The rapid increase in technology and
utilization of the different medical supplies increases the risk of transmitting disease via careless
handling, transport, and disposal practices.
Waste disposal is one of the perennial problems nationwide, the hospital being aware of the
government campaign regarding waste disposal, formulate the following guidelines.
Waste Categories
 Health waste is categorized as follows:

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 General waste
 Pathological waste
 Radioactive waste
 Chemical waste
 Infectious and potentially infectious, sharps, pharmaceutical waste and pressurized
containers.
 Colour coding of the various categories:
 Black – collection of non-infectious, dry non-biodegradable waste
 Green – collection of dry & wet non-infectious biodegradable waste (food & wet paper)
 Yellow – collection of infectious and pathologic waste
 Red – collection of hazardous, chemical waste (optional in some areas)
 Orange – collection of radioactive waste (optional in some areas)
Care and Disposal of Waste
 Waste baskets and containers lined with 3 colors of plastic bags shall be made available in
patient’s rooms, visiting areas and treatment rooms. The red and orange colored plastic bags are
available upon request from the CSR or housekeeping. Waste segregation posters should be
available and visible as guide for disposal throughout the hospital premises.
 At the end of the day or as needed, these plastic bag liners shall be secured and discarded in
larger plastics. These shall be removed from the premises to a designated pick-up point for
disposal.
 After use, all IV bottles shall be emptied in a sink should be immediately flushed with running
water followed with sodium hypocholirite.
 Used needles shall immediately be placed in sharp proof containers.
 Used disposable syringe shall be discarded in another container and disposed in a similar way.
Storage Method
 The general waste shall be stored at concrete storage bins individually packed in the prescribed
color of plastic bags.
 The infectious waste shall be stored at in 25-litre pail, which is properly sealed and labelled
infectious and stored at the concrete storage bin.
 The sharps shall be stored at a non-punctured plastic container and be packed at red plastic
bags and stored at the concrete storage bins.
 The radioactive waste in their original container shall be packed at orange plastic bags and then
stored at the concrete storage bin.
Waste Disposal
 All general waste shall be collected by the Public Utility Department.
 All infectious waste as well as sharps shall be collected also by the infectious waste disposal
collectors (Chevaliers) with designated tags on plastic bags.

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POLICIES AND PROCEUDURES INDICATING THE EXTENT OF

DUPLICATE ASSESSMENTS & TREATMENTS PERFORMED BY
TRAINEES
PURPOSE
To identify the extent of duplicate assessments and treatments done by trainees specifically student
nurses that are affiliated with our hospital.
DEFINITIONS OF TERMS
 Students – include all persons place or rotating through UParHMC as part of the Related
Learning Experience which is a requirement in the nursing curriculum. Students receive
academic credit for the experience and time at the hospital, the individual is subject to all
rules and limitations associated with the hospitable policy.

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POLICIES
 The Student Affiliation Agreement Policy shall establish that all students rotating in
UPARHMC, as part of their educational program at College, University are properly
authorized and oriented. In addition, the policy is intended to protect the interests and the
rights of the patients of UPARHMC.
 Students shall provide nursing care following the guidelines set by UPARHMC.
 Students shall assume responsibility for patient care consistent with their level of
achievement, level of competency, course objectives, and level of experience with the
assistance of their respective clinical coordinator.
 All plans for patient care shall be discussed with the patient’s staff nurse prior to the delivery
of care together with the clinical instructor.
ALL STUDENTS WHO ROTATE IN UNIHEALTH PARANAQUE HOSPITAL & MEDICAL CENTER
SHALL BE GUIDED AND SUPERVISED BY THEIR RESPECTIVE CLINICAL INSTRUCTOR.

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ANNEX
Republic of the Philippines

Congress of the Philippines
Metro Manila
Twelfth Congress
Second Regular Session
Begun and held in Metro Manila, on Monday, the twenty-second day of July, two thousand two.

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Republic Act No. 9173 October 21, 2002
AN ACT PROVIDING FOR A MORE RESPONSIVE NURSING PROFESSION, REPEALING FOR THE
PURPOSE REPUBLIC ACT NO. 7164, OTHERWISE KNOWN AS "THE PHILIPPINE NURSING ACT OF
1991" AND FOR OTHER PURPOSES
Be it enacted by the Senate and the HOUSE OF REPRESENTATIVES of the Philippines in Congress
assembled:
ARTICLE I
Title
Section 1. Title. - This Act shall be known as the "Philippine Nursing Act of 2002."
ARTICLE II
Declaration of Policy
Section 2. Declaration of Policy. – It is hereby declared the policy of the State to assume responsibility for the
protection and improvement of the nursing profession by instituting measures that will result in
relevant NURSING EDUCATION, humane working conditions, better CAREER prospects and a dignified
existence for our nurses.
The State hereby guarantees the delivery of quality basic health services through an adequate nursing
personnel system throughout the country.
ARTICLE III
Organization of the Board of Nursing
Section 3. Creation and Composition of the Board. - There shall be created a Professional Regulatory Board
of Nursing, hereinafter referred to as the Board, to be composed of a Chairperson and six (6) members. They
shall be appointed by the president of the Republic of the Philippines from among two (2) recommendees, per
vacancy, of the Professional Regulation Commission, hereinafter referred to as the Commission, chosen and
ranked from a list of three (3) nominees, per vacancy, of the accredited professional organization of nurses in

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the Philippines who possess the qualifications prescribed in Section 4 of this Act.
Section 4. Qualifications of the Chairperson and Members of the Board. - The Chairperson and Members of
the Board shall, at the time of their appointment, possess the following qualifications:
(a) Be a natural born citizen and resident of the Philippines;
(b) Be a member of good standing of the accredited professional organization of nurses;
(c) Be a registered nurse and holder of a master's degree in nursing, education or other allied medical
profession conferred by a college or university duly recognized by the Government: Provided, That the
majority of the members of the Board shall be holders of a master's degree in nursing: Provided,
further, That the Chairperson shall be a holder of a master's degree in nursing;
(d) Have at least ten (10) years of continuous practice of the profession prior to appointment: Provided,
however, That the last five (5) years of which shall be in the Philippines; and
(e) Not have been convicted of any offense involving moral turpitude; Provided, That the membership
to the Board shall represent the three (3) areas of nursing, namely: nursing education, nursing service
and Community Health Nursing.
Section 5. Requirements Upon Qualification as Member of the Board of Nursing. - Any person appointed as
Chairperson or Member of the Board shall immediately resign from any teaching position in any school,
college, university or institution offering Bachelor of Science in Nursing and/or review program for the local
nursing board examinations or in any office or employment in the government or any subdivision, agency or
instrumentality thereof, including government-owned or controlled corporations or their subsidiaries as well as
these employed in the private sector. He/she shall not have any pecuniary interest in or administrative
supervision over any institution offering Bachelor of Science in Nursing including review classes.
Section 6. Term of Office. - The Chairperson and Members of the Board shall hold office for a term of three (3)
years and until their successors shall have been appointed and qualified: Provided, That the Chairperson and
members of the Board may be re-appointed for another term.
Any vacancy in the Board occurring within the term of a Member shall be filled for the unexpired portion of the
term only. Each Member of the Board shall take the proper Oath of Office prior to the performance of his/her
duties.
The incumbent Chairperson and Members of the Board shall continue to serve for the remainder of their term
under Republic Act No. 7164 until their replacements have been appointed by the President and shall have

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been duly qualified.
Section 7. Compensation of the Board Members. - The Chairperson and Members of the Board shall receive
compensation and allowances comparable to the compensation and allowances received by the Chairperson
and members of other professional regulatory boards.
Section 8. Administrative Supervision of the Board, Custodian of its Records, Secretariat and Support
Services. - The Board shall be under the administrative supervision of the Commission. All records of the
Board, including applications for examinations, administrative and other investigative cases conducted by the
Board shall be under the custody of the Commission. The Commission shall designate the Secretary of the
Board and shall provide the secretariat and other support services to implement the provisions of this Act.
Section 9. Powers and Duties of the Board. - The Board shall supervise and regulate the practice of the
nursing profession and shall have the following powers, duties and functions:
(a) Conduct the licensure examination for nurses;

(b) Issue, suspend or revoke certificates of registration for the practice of nursing;
(c) Monitor and enforce quality standards of nursing practice in the Philippines and exercise the
powers necessary to ensure the maintenance of efficient, ethical and technical, moral and professional
standards in the practice of nursing taking into account the health needs of the nation;
(d) Ensure quality nursing education by examining the prescribed facilities of universities or College of
Nursing or departments of nursing education and those seeking permission to open nursing courses to
ensure that standards of nursing education are properly complied with and maintained at all times. The
authority to open and close colleges of nursing and/or nursing education programs shall be vested on
the Commission on Higher Education upon the written recommendation of the Board;
(e) Conduct hearings and investigations to resolve complaints against nurse practitioners for unethical
and unprofessional conduct and violations of this Act, or its rules and regulations and in connection
therewith, issue subpoena ad testificandum and subpoena duces tecum to secure the appearance of
respondents and witnesses and the production of documents and punish with contempt persons
obstructing, impeding and/or otherwise interfeming with the conduct of such proceedings, upon
application with the court;
(f) Promulgate a Code of Ethics in coordination and consultation with the accredited professional
organization of nurses within one (1) year from the effectivity of this Act;
(g) Recognize nursing specialty organizations in coordination with the accredited professional
organization; and
(h) Prescribe, adopt issue and promulgate guidelines, regulations, measures and decisions as may be
necessary for the improvements of the nursing practice, advancement of the profession and for the
proper and full enforcement of this Act subject to the review and approval by the Commission.
Section 10. Annual Report. - The Board shall at the close of its calendar year submit an annual report to the
President of the Philippines through the Commission giving a detailed account of its proceedings and the

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accomplishments during the year and making recommendations for the adoption of measures that will upgrade
and improve the conditions affecting the practice of the nursing profession.
Section 11. Removal or Suspension of Board Members. - The president may remove or suspend any member
of the Board after having been given the opportunity to defend himself/herself in a proper administrative
investigation, on the following grounds;
(a) Continued neglect of duty or incompetence;

(b) Commission or toleration of irregularities in the licensure examination; and
(c) Unprofessional immoral or dishonorable conduct.
ARTICLE IV
Examination and Registration
Section 12. Licensure Examination. - All applicants for license to practice nursing shall be required to pass a
written examination, which shall be given by the Board in such places and dates as may be designated by the
Commission: Provided, That it shall be in accordance with Republic Act No. 8981, otherwise known as the
"PRC Modernization Act of 2000."
Section 13. Qualifications for Admission to the Licensure Examination. - In order to be admitted to the
examination for nurses, an applicant must, at the time of filing his/her application, establish to the satisfaction
of the Board that:
(a) He/she is a citizen of the Philippines, or a citizen or subject of a country which permits Filipino
nurses to practice within its territorial limits on the same basis as the subject or citizen of such
country: Provided, That the requirements for the registration or licensing of nurses in said country are
substantially the same as those prescribed in this Act;
(b) He/she is of good moral character; and
(c) He/she is a holder of a Bachelor's Degree in Nursing from a college or university that complies with
the standards of nursing education duly recognized by the proper government agency.
Section 14. Scope of Examination. - The scope of the examination for the practice of nursing in the Philippines
shall be determined by the Board. The Board shall take into consideration the objectives of the nursing
curriculum, the broad areas of nursing, and other related disciplines and competencies in determining the
subjects of examinations.
Section 15. Ratings. - In order to pass the examination, an examinee must obtain a general average of at

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least seventy-five percent (75%) with a rating of not below sixty percent (60%) in any subject. An examinee
who obtains an average rating of seventy-five percent (75%) or higher but gets a rating below sixty percent
(60%) in any subject must take the examination again but only in the subject or subjects where he/she is rated
below sixty percent (60%). In order to pass the succeeding examination, an examinee must obtain a rating of
at least seventy-five percent (75%) in the subject or subjects repeated.
Section 16. Oath. - All successful candidates in the examination shall be required to take an oath of
profession before the Board or any government official authorized to administer oaths prior to entering upon
the nursing practice.
Section 17. Issuance of Certificate of Registration/Professional License and Professional Identification Card. -
A certificate of registration/professional license as a nurse shall be issued to an applicant who passes the
examination upon payment of the prescribed fees. Every certificate of registration/professional license shall
show the full name of the registrant, the serial number, the signature of the Chairperson of the Commission
and of the Members of the Board, and the official seal of the Commission.
A professional identification card, duly signed by the Chairperson of the Commission, bearing the date of
registration, license number, and the date of issuance and expiration thereof shall likewise be issued to every
registrant upon payment of the required fees.
Section 18. Fees for Examination and Registration. - Applicants for licensure and for registration shall pay the
prescribed fees set by Commission.
Section 19. Automatic Registration of Nurses. - All nurses whose names appear at the roster of nurses shall
be automatically or ipso facto registered as nurses under this Act upon its effectivity.
Section 20. Registration by Reciprocity. - A certificate of registration/professional license may be issued

without examination to nurses registered under the laws of a foreign state or country: Provided, That the
requirements for registration or licensing of nurses in said country are substantially the same as those
prescribed under this Act: Provided, further, That the laws of such state or country grant the same privileges to
registered nurses of the Philippines on the same basis as the subjects or citizens of such foreign state or
country.
Section 21. Practice Through Special/Temporary Permit. - A special/temporary permit may be issued by the
Board to the following persons subject to the approval of the Commission and upon payment of the prescribed
fees:
(a) Licensed nurses from foreign countries/states whose service are either for a fee or free if they are
internationally well-known specialists or outstanding experts in any branch or specialty of nursing;
(b) Licensed nurses from foreign countries/states on medical mission whose services shall be free in a

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particular hospital, center or clinic; and

(c) Licensed nurses from foreign countries/states employed by schools/colleges of nursing as exchange
professors in a branch or specialty of nursing;
Provided, however, That the special/temporary permit shall be effective only for the duration of the project,
medical mission or employment contract.
Section 22. Non-registration and Non-issuance of Certificates of Registration/Professional License or

Special/Temporary Permit. - No person convicted by final judgment of any criminal offense involving moral
turpitude or any person guilty of immoral or dishonorable conduct or any person declared by the court to be of
unsound mind shall be registered and be issued a certificate of registration/professional license or a
special/temporary permit.
The Board shall furnish the applicant a written statement setting forth the reasons for its actions, which shall be
incorporated in the records of the Board.
Section 23. Revocation and suspension of Certificate of Registration/Professional License and Cancellation of
Special/Temporary Permit. - The Board shall have the power to revoke or suspend the certificate of
registration/professional license or cancel the special/temporary permit of a nurse upon any of the following
grounds:
(a) For any of the causes mentioned in the preceding section;

(b) For unprofessional and unethical conduct;
(c) For gross incompetence or serious ignorance;
(d) For malpractice or negligence in the practice of nursing;
(e) For the use of fraud, deceit, or false statements in obtaining a certificate of registration/professional license
or a temporary/special permit;
(f) For violation of this Act, the rules and regulations, Code of Ethics for nurses and technical standards for
nursing practice, policies of the Board and the Commission, or the conditions and limitations for the issuance
of the temporarily/special permit; or
(g) For practicing his/her profession during his/her suspension from such practice;
Provided, however, That the suspension of the certificate of registration/professional license shall be for a
period not to exceed four (4) years.
Section 24. Re-issuance of Revoked Certificates and Replacement of Lost Certificates. - The Board may, after
the expiration of a maximum of four (4) years from the date of revocation of a certificate, for reasons of equity
and justice and when the cause for revocation has disappeared or has been cured and corrected, upon proper
application therefor and the payment of the required fees, issue another copy of the certificate of
registration/professional license.
A new certificate of registration/professional license to replace the certificate that has been lost, destroyed or

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mutilated may be issued, subject to the rules of the Board.
ARTICLE V
Nursing Education
Section 25. Nursing Education Program. - The nursing education program shall provide sound general and
professional foundation for the practice of nursing.
The learning experiences shall adhere strictly to specific requirements embodied in the prescribed curriculum
as promulgated by the Commission on Higher Education's policies and standards of nursing education.
Section 26. Requirement for Inactive Nurses Returning to Practice. - Nurses who have not actively practiced
the profession for five (5) consecutive years are required to undergo one (1) month of didactic training and
three (3) months of practicum. The Board shall accredit hospitals to conduct the said training program.
Section 27. Qualifications of the Faculty. - A member of the faculty in a college of nursing teaching
professional courses must:
(a) Be a registered nurse in the Philippines;

(b) Have at least one (1) year of clinical practice in a field of specialization;
(c) Be a member of good standing in the accredited professional organization of nurses; and
(d) Be a holder of a master's degree in nursing, education, or other allied medical and health sciences
conferred by a college or university duly recognized by the Government of the Republic of the
Philippines.
In addition to the aforementioned qualifications, the dean of a college must have a master's degree in
nursing. He/she must have at least five (5) years of experience in nursing.
ARTICLE VI
Nursing Practice
Section 28. Scope of Nursing. - A person shall be deemed to be practicing nursing within the meaning of this
Act when he/she singly or in collaboration with another, initiates and performs nursing services to individuals,
families and communities in any health care setting. It includes, but not limited to, nursing care during
conception, labor, delivery, infancy, childhood, toddler, preschool, school age, adolescence, adulthood, and
old age. As independent practitioners, nurses are primarily responsible for the promotion of health and

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prevention of illness. A members of the health team, nurses shall collaborate with other health care providers
for the curative, preventive, and rehabilitative aspects of care, restoration of health, alleviation of suffering, and
when recovery is not possible, towards a peaceful death. It shall be the duty of the nurse to:
(a) Provide nursing care through the utilization of the nursing process. Nursing care includes, but not
limited to, traditional and innovative approaches, therapeutic use of self, executing health care
techniques and procedures, essential primary health care, comfort measures, health teachings, and
administration of written prescription for treatment, therapies, oral topical and parenteral medications,
internal examination during labor in the absence of antenatal bleeding and delivery. In case of suturing
of perineal laceration, special training shall be provided according to protocol established;
(b) establish linkages with community resources and coordination with the health team;
(c) Provide health education to individuals, families and communities;
(d) Teach, guide and supervise students in nursing education programs including the administration of
nursing services in varied settings such as hospitals and clinics; undertake consultation services;
engage in such activities that require the utilization of knowledge and decision-making skills of a
registered nurse; and
(e) Undertake nursing and health human resource development training and research, which shall
include, but not limited to, the development of advance nursing practice;
Provided, That this section shall not apply to nursing students who perform nursing functions under the direct
supervision of a qualified faculty: Provided, further, That in the practice of nursing in all settings, the nurse is
duty-bound to observe the Code of Ethics for nurses and uphold the standards of safe nursing practice. The
nurse is required to maintain competence by continual learning through continuing professional education to
be provided by the accredited professional organization or any recognized professional nursing
organization: Provided, finally, That the program and activity for the continuing professional education shall be
submitted to and approved by the Board.
Section 29. Qualification of Nursing Service Administrators. - A person occupying supervisory or managerial
positions requiring knowledge of nursing must:
(a) Be a registered nurse in the Philippines;

(b) Have at least two (2) years’ experience in general nursing service administration;
(c) Possess a degree of Bachelors of Science in Nursing, with at least nine (9) units in management
and administration courses at the graduate level; and
(d) Be a member of good standing of the accredited professional organization of nurses;
Provided, That a person occupying the position of chief nurse or director of nursing service shall, in addition to
the foregoing qualifications, possess:
(1) At least five (5) years of experience in a supervisory or managerial position in nursing; and
(2) A master's degree major in nursing;

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Provided, further, That for primary hospitals, the maximum academic qualifications and experiences for a chief
nurse shall be as specified in subsections (a), (b), and (c) of this section: Provided, furthermore, That for chief
nurses in the public health nursing shall be given priority. Provided, even further, That for chief nurses in
military hospitals, priority shall be given to those who have finished a master's degree in nursing and the
completion of the General Staff Course (GSC): Provided, finally, That those occupying such positions before
the effectivity of this Act shall be given a period of five (5) years within which to qualify.
ARTICLE VII
Health Human Resources Production, Utilization and Development
Section 30. Studies for Nursing Manpower Needs, Production, Utilization and Development. - The Board, in
coordination with the accredited professional organization and appropriate government or private agencies
shall initiate undertake and conduct studies on health human resources production, utilization and
development.
Section 31. Comprehensive Nursing Specialty Program. - Within ninety (90) days from the effectivity of this
Act, the Board in coordination with the accredited professional organization recognized specialty organizations
and the Department of Health is hereby mandated to formulate and develop a comprehensive nursing
specialty program that would upgrade the level of skill and competence of specialty nurse clinicians in the
country, such as but not limited to the areas of critical care, oncology, renal and such other areas as may be
determined by the Board.
The beneficiaries of this program are obliged to serve in any Philippine hospital for a period of at least two (2)
years and continuous service.
Section 32. Salary. - In order to enhance the general welfare, commitment to service and professionalism of
nurses the minimum base pay of nurses working in the public health institutions shall not be lower than salary
grade 15 prescribes under Republic Act No. 6758, otherwise known as the "Compensation and Classification
Act of 1989": Provided, That for nurses working in local government units, adjustments to their salaries shall be
in accordance with Section 10 of the said law.
Section 33. Funding for the Comprehensive Nursing Specialty Program. - The annual financial requirement
needed to train at least ten percent (10%) of the nursing staff of the participating government hospital shall be
chargeable against the income of the Philippine Charity Sweepstakes Office and the Philippine Amusement
and Gaming Corporation, which shall equally share in the costs and shall be released to the Department of
Health subject to accounting and auditing procedures: Provided, That the department of Health shall set the
criteria for the availment of this program.
Section 34. Incentives and Benefits. - The Board of Nursing, in coordination with the Department of Health

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and other concerned government agencies, association of hospitals and the accredited professional
organization shall establish an incentive and benefit system in the form of free hospital care for nurses and
their dependents, scholarship grants and other non-cash benefits. The government and private hospitals are
hereby mandated to maintain the standard nurse-patient ratio set by the Department of Health.
ARTICLE VIII
Penal and Miscellaneous Provisions
Section 35. Prohibitions in the Practice of Nursing. - A fine of not less than Fifty thousand pesos (P50,000.00)
no more than One hundred thousand pesos (P100,000.00) or imprisonment of not less than one (1) year nor
more than six (6) years, or both, upon the discretion of the court, shall be imposed upon:
(a) any person practicing nursing in the Philippines within the meaning of this Act:
(1) without a certificate of registration/professional license and professional identification card or
special temporary permit or without having been declared exempt from examination in accordance
with the provision of this Act; or
(2) who uses as his/her own certificate of registration/professional license and professional
identification card or special temporary permit of another; or
(3) who uses an invalid certificate of registration/professional license, a suspended or revoked
certificate of registration/professional license, or an expired or cancelled special/temporary permits; or
(4) who gives any false evidence to the Board in order to obtain a certificate of registration/professional
license, a professional identification card or special permit; or
(5) who falsely poses or advertises as a registered and licensed nurse or uses any other means that
tend to convey the impression that he/she is a registered and licensed nurse; or
(6) who appends B.S.N./R.N. (Bachelor of Science in Nursing/Registered Nurse) or any similar
appendage to his/her name without having been conferred said degree or registration; or
(7) who, as a registered and licensed nurse, abets or assists the illegal practice of a person who is not
lawfully qualified to practice nursing.
(b) any person or the chief executive officer of a judicial entity who undertakes in-service educational programs
or who conducts review classes for both local and foreign examination without permit/clearance from the
Board and the Commission; or
(c) any person or employer of nurses who violate the minimum base pay of nurses and the incentives and
benefits that should be accorded them as specified in Sections 32 and 34; or
(d) any person or the chief executive officer of a juridical entity violating any provision of this Act and its rules
and regulations.
ARTICLE IX
Final Provisions
Section 36. Enforcement of this Act. - It shall be the primary duty of the Commission and the Board to

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effectively implement this Act. Any duly law enforcement agencies and officers of national, provincial, city or
municipal governments shall, upon the call or request of the Commission or the Board, render assistance in
enforcing the provisions of this Act and to prosecute any persons violating the same.
Section 37. Appropriations. - The Chairperson of the Professional Regulation Commission shall immediately
include in its program and issue such rules and regulations to implement the provisions of this Act, the funding
of which shall be included in the Annual General Appropriations Act.
Section 38. Rules and Regulations. - Within ninety (90) days after the effectivity of this Act, the Board and the
Commission, in coordination with the accredited professional organization, the Department of Health, the
Department of Budget and Management and other concerned government agencies, shall formulate such
rules and regulations necessary to carry out the provisions of this Act. The implementing rules and regulations
shall be published in the Official Gazette or in any newspaper of general circulation.
Section 39. Reparability Clause. - If any part of this Act is declared unconstitutional, the remaining parts not
affected thereby shall continue to be valid and operational.
Section 40. Repealing Clause. - Republic Act No. 7164, otherwise known as the "Philippine Nursing Act of
1991" is hereby repealed. All other laws, decrees, orders, circulars, issuances, rules and regulations and parts
thereof which are inconsistent with this Act are hereby repealed, amended or modified accordingly.
Section 41. Effectivity. - This act shall take effect fifteen (15) days upon its publication in the Official
Gazette or in any two (2) newspapers of general circulation in the Philippines.
Approved,
FRANKLIN DRILON JOSE DE VENECIA JR.

President of the Senate Speaker of the House of
Representatives
This Act, which originated in the House of Representative was finally passed by the House of Representatives and the
Senate on October 15, 2002 and October 8, 2003 respectively.
OSCAR G. YABES ROBERTO P. NAZARENO

Doc. No. /Rev. No.
QUALITY PROCEDURE
Secretary of Senate Secretary General

House of Represenatives
Approved: October 21, 2002
GLORIA MACAPAGAL-ARROYO
President of the Philippines
REPUBLIC ACT No. 7877
AN ACT DECLARING SEXUAL HARASSMENT UNLAWFUL IN THE EMPLOYMENT, EDUCATION OR

TRAINING ENVIRONMENT, AND FOR OTHER PURPOSES.
Be it enacted by the Senate and House of Representatives of the Philippines in Congress assembled:
Section 1. Title. - This Act shall be known as the "Anti-Sexual Harassment Act of 1995."
Section 2. Declaration of Policy. - The State shall value the dignity of every individual, enhance the

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QUALITY PROCEDURE
development of its human resources, guarantee full respect for human rights, and uphold the dignity of
workers, employees, applicants for employment, students or those undergoing training, instruction or
education. Towards this end, all forms of sexual harassment in the employment, education or training
environment are hereby declared unlawful.
Section 3. Work, Education or Training -Related, Sexual Harassment Defined. - Work, education or training-
related sexual harassment is committed by an employer, employee, manager, supervisor, agent of the
employer, teacher, instructor, professor, coach, trainer, or any other person who, having authority, influence or
moral ascendancy over another in a work or training or education environment, demands, requests or
otherwise requires any sexual favor from the other, regardless of whether the demand, request or requirement
for submission is accepted by the object of said Act.
(a) In a work-related or employment environment, sexual harassment is committed when:
(1) The sexual favor is made as a condition in the hiring or in the employment, re-employment
or continued employment of said individual, or in granting said individual favorable
compensation, terms of conditions, promotions, or privileges; or the refusal to grant the sexual
favor results in limiting, segregating or classifying the employee which in any way would
discriminate, deprive or diminish employment opportunities or otherwise adversely affect said
employee;
(2) The above acts would impair the employee's rights or privileges under existing labor laws;
or
(3) The above acts would result in an intimidating, hostile, or offensive environment for the
employee.
(b) In an education or training environment, sexual harassment is committed:
(1) Against one who is under the care, custody or supervision of the offender;
(2) Against one whose education, training, apprenticeship or tutorship is entrusted to the
offender;
(3) When the sexual favor is made a condition to the giving of a passing grade, or the granting
of honors and scholarships, or the payment of a stipend, allowance or other benefits,
privileges, or consideration; or
(4) When the sexual advances result in an intimidating, hostile or offensive environment for the

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QUALITY PROCEDURE
student, trainee or apprentice.
Any person who directs or induces another to commit any act of sexual harassment as herein defined,
or who cooperates in the commission thereof by another without which it would not have been
committed, shall also be held liable under this Act.
Section 4. Duty of the Employer or Head of Office in a Work-related, Education or Training Environment. - It
shall be the duty of the employer or the head of the work-related, educational or training environment or
institution, to prevent or deter the commission of acts of sexual harassment and to provide the procedures for
the resolution, settlement or prosecution of acts of sexual harassment. Towards this end, the employer or head
of office shall:
(a) Promulgate appropriate rules and regulations in consultation with and joint1y approved by the
employees or students or trainees, through their duly designated representatives, prescribing the
procedure for the investigation of sexual harassment cases and the administrative sanctions therefor.
Administrative sanctions shall not be a bar to prosecution in the proper courts for unlawful acts of
sexual harassment.
The said rules and regulations issued pursuant to this subsection (a) shall include, among others,
guidelines on proper decorum in the workplace and educational or training institutions.
(b) Create a committee on decorum and investigation of cases on sexual harassment. The committee
shall conduct meetings, as the case may be, with officers and employees, teachers, instructors,
professors, coaches, trainors, and students or trainees to increase understanding and prevent
incidents of sexual harassment. It shall also conduct the investigation of alleged cases constituting
sexual harassment.
In the case of a work-related environment, the committee shall be composed of at least one (1)
representative each from the management, the union, if any, the employees from the supervisory rank,
and from the rank and file employees.
In the case of the educational or training institution, the committee shall be composed of at least one
(1) representative from the administration, the trainers, instructors, professors or coaches and students
or trainees, as the case may be.
The employer or head of office, educational or training institution shall disseminate or post a copy of
this Act for the information of all concerned.
Section 5. Liability of the Employer, Head of Office, Educational or Training Institution. - The employer or head

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QUALITY PROCEDURE
of office, educational or training institution shall be solidarily liable for damages arising from the acts of sexual
harassment committed in the employment, education
or training environment if the employer or head of office, educational or training institution is informed of such
acts by the offended party and no immediate action is taken.
Section 6. Independent Action for Damages. - Nothing in this Act shall preclude the victim of work, education
or training-related sexual harassment from instituting a separate and independent action for damages and
other affirmative relief.
Section 7. Penalties. - Any person who violates the provisions of this Act shall, upon conviction, be penalized
by imprisonment of not less than one (1) month nor more than six (6) months, or a fine of not less than Ten
thousand pesos (P10,000) nor more than Twenty thousand pesos (P20,000), or both such fine and
imprisonment at the discretion of the court.
Any action arising from the violation of the provisions of this Act shall prescribe in three (3) years.
Section 8. Separability Clause. - If any portion or provision of this Act is declared void or unconstitutional, the
remaining portions or provisions hereof shall not be affected by such declaration.
Section 9. Repealing Clause. - All laws, decrees, orders, rules and regulations, other issuances, or parts
thereof inconsistent with the provisions of this Act are hereby repealed or modified accordingly.
Section 10. Effectivity Clause.- This Act shall take effect fifteen (15) days after its complete publication in at
least two (2) national newspapers of general circulation.
Approved:
(Sgd.) EDGARDO J. ANGARA

President of the Senate
(Sgd.) JOSE DE VENECIA, JR.

Speaker of the House of Representatives
This Act is a consolidation of House Bill No. 9425 and Senate Bill No. 1632 was finally passed by the House of

Doc. No. /Rev. No.
QUALITY PROCEDURE
Representatives and the Senate on February 8, 1995.
(Sgd.) EDGARDO E. TUMANGAN

Secretary of the Senate
(Sgd.) CAMILO L. SABIO

Secretary General
House of Representatives
Approved: February 14, 1995
(Sgd.) FIDEL V. RAMOS

Republic of the Philippines

Congress of the Philippines
Metro Manila
Thirteenth Congress
Third Regular Session
REPUBLIC ACT NO. 9439 April 27, 2007

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QUALITY PROCEDURE
AN ACT PROHIBITING THE DETENTION OF PATIENTS IN HOSPITALS AND MEDICAL CLINICS ON

GROUNDS OF NONPAYMENT OF HOSPITAL BILLS OR MEDICAL EXPENSES
Be it enacted by the Senate and House of Representatives of the Philippines in Congress assembled:
SECTION 1. It shall be unlawful for any Hospital or Medical Clinic in the country to detain or to otherwise
cause, directly or indirectly, the detention of patients who have fully or partially recovered or have been
adequately attended to or who may have died, for reasons of nonpayment in part or in full of hospital bills or
medical expenses.
SEC. 2. Patients who have fully or partially recovered and who already wish to leave the hospital or medical
clinic but are financially incapable to settle, in part or in full, their hospitalization expenses, including
professional fees and medicines, shall be allowed to leave the hospital or medical clinic, with a right to demand
the issuance of the corresponding medical certificate and other pertinent papers required for the release of the
patient from the hospital or medical clinic upon the execution of a promissory note covering the unpaid
obligation. The promissory note shall be secured by either a mortgage or by a guarantee of a co-maker, who
will be jointly and severally liable with the patient for the unpaid obligation. In the case of a deceased patient,
the corresponding death certificate and other documents required for interment and other purposes shall be
released to any of his surviving relatives requesting for the same: Provided, however, That patients who
stayed in private rooms shall not be covered by this Act.
SEC. 3. Any officer or employee of the hospital or medical clinic responsible for releasing patients, who
violates the provisions of this Act shall be punished by a fine of not less than Twenty thousand pesos
(P20,000.00), but not more than Fifty thousand pesos (P50,000.00), or imprisonment of not less than one
month, but not more than six months, or both such fine and imprisonment, at the discretion of the proper court.
SEC. 4. The Department of Health shall promulgate the necessary rules and regulations to carry out the
provisions of this Act.
SEC. 5. If any provision of this Act is declared void and unconstitutional the remaining provisions hereof not
affected thereby shall remain in full force and effect.
SEC. 6. All laws, decrees, orders, rules and regulations or part thereof inconsistent with this Act are hereby
repealed or amended accordingly.
SEC. 7. This Act shall take effect fifteen (15) days after its publication in two national newspapers of general
circulation.
Approved,

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QUALITY PROCEDURE
MANNY VILLAR JOSE DE VENECIA JR.

President of the Senate Speaker of the House of
Representatives
This Act which originated in the House of Representatives was finally passed by the House of Representatives and the
Senate on June 7, 2005 and February 19, 2007, respectively.
OSCAR G. YABES ROBERTO P. NAZARENO

Secretary of Senate Secretary General
House of Represenatives
Approved: April 27, 2007
GLORIA MACAPAGAL-ARROYO

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POLICIES ON PATIENT'S RIGHTS TO CARE

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POLICIES ON PATIENT‘S RIGHTS TO CONSENT

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POLICIES ON THE PATIENT'S RIGHTS FREEDOM OF CHOICE

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POLICIES ON PATIENT'S RIGHTS OF INCOMPETENT PATIENTS

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POLICIES ON PATIENT/FAMILY EDUCATION

1. Patient/family education shall be an interdisciplinary and collaborative process designed to

NEEDS ASSESSMENT FACTORS

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issues, health maintenance and disease prevention, and available hospital or

PATIENT TEACHING INTERVENTION, EVALUATION, AND RESOURCES

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POLICIES ON PATIENT AND FAMILY INVOLVEMENT IN CARE DECISION

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POLICIES ON INVOLVEMENT OF PATIENTS AND FAMILIES IN MAKING

II. RIGHT TO DIGNITY

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POLICIES ON RIGHT TO APPROPRIATE CARE BASED ON RELIGIOUS

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POLICIES THAT ADDRESS PATIENT’S NEEDS FOR CONFIDENTIALITY

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