MANUAL OF PROCEDURES FOR HOSPITALS

DEPARTMENT OF HEALTH REPUBLIC OF THE PHILIPPINES

MANUAL OF PROCEDURES FOR HOSPITALS

Department of Health Republic of the Philippines

The second edition of the Manual of Procedures for Hospitals is a publication of the Health Finance Development Project of the Department of Health.

This publication was made possible through support provided by the U.S. Agency for International Development (A.I.D.), under the terms of Contract No. 492-0446-C-00-2114-00. The opinions expressed herein are those of the author(s) and do not necessarily reflect the views of the U.S. Agency for International Development.

AUTHORIZATION MESSAGE FOREWORD PREFACE ACKNOWLEDGMENTS LIST OF CHARTS LIST OF FORMS LIST OF ABBREVIATIONS INTRODUCTION

		Page No
	PART I - THE DEPARTMENT OF HEALTH
Chapter	·
I.	DOH OBJECTIVES AND GENERAL FUNCTIONS	1
II.	THE DOH ORGANIZATION	3
III.	THE DOH HOSPITAL SYSTEM	5
	PART II - HOSPITAL PROCEDURES
Chapter
IV.	HOSPITAL OPERATIONS SUMMARY FLOW	7
V,	OUT-PATIENT DEPARTMENT PROCEDURES	11
VI.	EMERGENCY ROOM PROCEDURES	15
VII.	ADMISSION PROCEDURES	19
VIII.	WARD PROCEDURES	21
-	Admission to Ward Carrying-Out Doctor's Orders	21 22
	Daily Patient Care	22
	Pre-Óperative Procedures	23
IX.	OPERATING ROOM PROCEDURES	25
	Preparation of the OR	25
	Patient Care in the OR	25 26
f)	Post-Operative Procedures	/.h

			Page No.
	X.	LABOR ROOM/DELIVERY ROOM PROCEDURES	27
		Preparation of the LR/DR	27
		Patient Care in the LR/DR	27
	XI.	CENTRAL SUPPLY ROOM	29
		Requisition of Supplies	29
ı		Receiving and Sterilization of Used Articles	30
I		Issuance of Sterile Articles	30
l		Articles for Condemnation	30
ĺ		Routine Preparation of Supplies for Ready Use	31
1	XII.	REFERRAL PROCEDURES	35
l		To Other Health Facilities	35
l		To Other Departments Within the Hospital	35
	XIII.	DISPOSITION OF PATIENT	39
		Discharge of Patient	39
		Discharge of Patient Against Medical Advice	40 .
		Issuance of Clearance Certificate	40
-	XIV.	DISPOSITION OF CADAVER	45
		Preparation of Cadaver in the Ward	45
		Receiving in Morgue	45
		Release of Cadaver to Claimant	45
		Autopsy	46
	XV.	LABORATORY PROCEDURES	47
	•	OPD Patient	47
		In-Patient	48
		ER Patient	49
		Blood Cross-Matching	49
		Release of Donor's Blood	50
		Request for Histopath Examination	51
	XVI.	RADIOLOGY PROCEDURES	55
		OPD Patient	55
		In-Patient	56
		ER Patient	57
		X-ray Findings	57
	XVII.	SUPPORT SERVICES	61
		Medical Social Services	61
	ř.	Classification of OPD Patients	61
		Classification of ER Patients	62
		Classification of Patients for Admission (In-Patients)	63
		Social Casework Process for Hospital Patients Social Casework Process on Cases Referred	63
		by a Community Agency	L1
		Social Groupwork Process	64 65
		E	$\omega$

		Page INC
	Community Organization	65
	Auxiliary Service	66
	Pharmacy	66
	Semestral Submission of Required Drugs and
	Medication for Official Price List	66
	Regular Requisition and Procurement
	of Drugs and Medicine	67
	Acceptance of Deliveries and Storage
	and Preservation of Drugs and Medicine	67
	Filling-up of Prescriptions for In-Patients	68
	Filling-up of Prescriptions for Out-Patients	68
	Disposal of Expired or Damaged Drugs and Medicine	69
	Dietary Service	70
	Menu Planning	70
	Food Procurement (Open Market Purchase)	.70
	Receiving and Storage	70
	Food Preparation and Production	71
	Service and Distribution	71
	Medical Records Service	72
	Preparation of Hospital Census Report	72
	Issuance of Medical Certificates for Medico-Legal Cases	72
	Preparation of Birth Certificate	73
	Issuance of Death Certificate	73
	Release of Clinical Information to Insurance Verifier	74
	Retrieval of Patient's Chart for In-Hospital Borrowers	75
	Processing of Medical Records Received for File	75
	Linen and Laundry	76
	Collection of Soiled Linens	76
	Preparation and Distribution of Clean Linens to Ward	76
	Repair and Disposal of Linens	77
XVII.	ADMINISTRATIVE SERVICES	101
7 h T 11.	Budgeting	101
	Preparation of the Work and Financial Plan	101
	Budget Preparation	101
	Billing and Medicare	102
	Billing of Patient	102
a normal regional in the	Processing of Philippine Medical Care Commission
	(PMCC) Forms	103
	\

APPENDICES REFERENCES

Republic of the Philippines Department of Health OFFICE OF THE SECRETARY

SAN LAZARO COMPOUND RIZAL AVENUE, STA. CRUZ MANILA, PHILIPPINES TEL. NO. 711-60-80

AUTHORIZATION

January 6, 1994

In accordance with the authority vested on the Secretary of Health, I hereby declare the policies, regulations, and instructions in this Manual of Procedures for Hospitals shall govern the organization, management, and activities of government hospitals until modified by order of the Department of Health or by law.

AN M. FLAVIER, M.D., MPH

Republic of the Philippines DEPARTMENT OF HEALTH OFFICE FOR HEALTH FACILITIES, STANDARDS AND REGULATION

San Lazaro Cmpd., Sta. Cruz Manila Tel No. 711-95-72, Fax No. 711-95-09

MESSAGE

January 6, 1994

The Hospital Operations and Management Service of the Department of Health has been tasked to develop operations manuals specifically for DOH hospitals that may be of use to other public and private hospitals.

These manuals would serve as standard reference materials for DOH hospitals to aid administrators and practitioners in following standard operating procedures in the management and practice of the different hospital services or units. Likewise, it may also serve as a reference guide for other public and private hospitals.

These manuals provide guidelines in the performance of duties and responsibilities of hospital personnel as well as outline steps necessary in the effective and efficient operation of each unit or service. The procedures in these manuals will assist them in the process necessary to operate an effective and efficient hospital.

This is an attempt to develop standards and achieve uniformity of procedures in different hospitals.

JUAN R NAÑAGAS, M.D.

Undersecretary on Health Facilities, Standards and Regulations

Republic of the Philippines Department of Health OFFICE OF THE SECRETARY

SAN LAZARO COMPOUND RIZAL AVENUE, STA. CRUZ MANILA, PHILIPPINES TEL. NO. 711-60-80

FOREWORD

This Manual of Procedures for Hospitals is a tool which could be utilized by hospital administrators as standard operating procedures in the management of the different services or units of the hospital.

The procedures in this manual will assist administrators in the day-to-day process necessary to operate an effective and efficient hospital. It provides guidelines in the performance of duties and responsibilities of hospital personnel. Steps of activities necessary in the effective and efficient implementation of the operation of each service or unit is herein outlined.

This is a humble attempt to achieve and develop a common reference document for the DOH hospitals and other private and public hospitals which may find this manual a practical and effective tool in hospital administration.

MA. MARGARITA M. GALON, M.D., M.H.A.

Director III Hospital Operations and Management Service

PREFACE

The revision of the 1979 Policy and Procedures Manual for Hospitals of the Department of Health (DOH) has long been overdue. Myriad changes have taken place within and outside the DOH in the past years. The Department has grown in structure, thrust and responsibility. Client expectations for better and wider services, not to mention the demand for a

more aggressive preventive care, has also been increasingly felt.

Amidst the changing environment and increased expectations, the hospitals remain the base entities of the Department's service delivery structure. That is why the Office for Hospitals and Facility Services (OHFS) of the Department has vigorously pursued its role in policy formulation, standards development, program monitoring, and the provision of specialized assistance in the operation of hospitals and the management of facilities. Its activities have been keenly focused on addressing the needs and problems of the hospitals.

The signing of the Local Government Code on 10 October 1991 marked a turning point in the role of the Department vis-a-vis the hospitals. While changes in the functional relationships are expected, the need to maintain a standard for hospital services and efficient management of resources remains. The challenge brought about by shifts in administrative and functional interfaces will be greater. These will be more marked during the interim years of 1992-1993 which will establish the pace and foundation for the quality of services to be maintained or improved in the coming years.

We, at the Hospital Operations and Management Service (HOMS), recognize the urgent need to update the 1979 Manual to serve as guide and basic material for both the hospital administrators and staff, and the DOH management. It is our contribution to the Department's commitment to improve the health care delivery system. Alongside, it complements the hospital's persistent efforts to upgrade their components and services.

This Manual of Procedures for Hospitals is an aid to facilitate the improved operations of the hospitals and the management of facilities. The steps and procedures described in the manual are simple prescribed approaches. As each hospital is unique and in view of the organizational changes which could result from the adoption of the Local Government Code, we hope that hospital administrators would be able to formulate internal and operating policies responsive and adaptable to their peculiar needs.

Through this humble effort, we join hands with the hospitals and the rest of the DOH facilities and offices in fulfilling the goal of quality patient

CELSO B. CATAQUIZ, M.D. Medical Specialist III Hospital Operations and Management Service

ACKNOWLEDGMENTS

A. Hospital Operations and Management Service

1. Josefina L. Albao Medical Social Work Adviser
1. Celso B. Cataquiz Medical Specialist III
1. Mercy D. Coral Nurse V 4. Donatila R. Esplanada - Nurse V
1. Esther T. Feliciano Dietary Adviser
1. Marion P. de Guzman Nurse V
1. Emmanuel M. Lagustan Medical Records Adviser
1. Amor Cita M. Pallera Pharmacy Adviser

B. Bulacan Provincial Health Office

Eduardo Aquino Medical Specialist III Venancio Banzon Provincial Health Officer I
1. Francisco Capistrano Chief of Hospital
1. Elizabeth Clemente Nutritionist-Dietitian II
1. Virginia Cruz Chief Nurse
1. Miriam Eusebio Nutritionist-Dietitian III
1. Remedios Gonzales Chief Nurse
1. Tomasita Lucas Supervising Nurse
1. Alicia Montano Food and Drug Regulation
- Officer II
1. Felizardo Roll Administrative Officer III
1. Lourdes Santos Administrative Officer II
1. Eduardo Valencia Chief of Hospital
1. Wilfredo de Vera Medical Specialist I
1. Loida Yanga Storekeeper II

C. Region X

Northern Mindanao Regional Training Hospital

1. Evelyn Clarete Chief, Medical Professional
Services (MS III)
1. Generoso Lai Administrative Officer III
1. Lilia Mejia Chief Nurse
1. Consolacion Verendia Assistant Chief Nurse
1. Erlinda Yap Administrative Assistant

Bukidnon Provincial Hospital

1. Dolenia Barroso Chief Nurse
1. Inocentes Dagohoy Provincial Health Officer I
1. Ineda Valdorza Administrative Officer III
1. Francis John Varias - Medical Officer III

Mayor Hilarion A. Ramiro Sr. General Hospital

1.	Gilda Adlawan	_	Utility Worker
2.	Rafael Calalang Jr.	-	Chief of Clinics
3.	Pearl Marie Carpio	-	Administrative Officer III
4.	Jessebel Estella	_	Supervising Nurse
5.	Florencia Magtuba	~	Nutritionist-Dietitian II
6.	Lynn Mugar	-	Records Officer I
7.	Helen Nazareno	-	Supervising Nurse
8.	Charita Neri	-	Medical Social Service
			Officer I
9.	Belma Ramillete	-	CSR-in-Charge
			(Registered Midwife)
10.	Teresita Saa		Chief Nurse
11.	Alice Seares	~	Medical Technologist II
12.	Edna Solis	-	Nursing Attendant
13.	Vivian Tan	-	Senior Operating
			Room Nurse

Initao District Hospital

1.	Felix Abejar	-	Chief of Hospital
2.	Chuchi Kaw Hoc	-	Chief Nurse
3.	Marjorie Mansequiao	-	Administrative Officer

Tudela Municipal Hospital

1.	Victor Alinas Jr.		Medical Officer V
2.	Aida Roasul-Bienes	-	Pharmacist/Administrative
			Assistant-Designate
3.	Emma Cagaanan	-	Senior Nurse

Regional Health Office No. X

1.	Susan Dongaldo	-	Provincial Health Officer I
2.	Pedro Hilario	_	Administrative Officer V

LIST OF CHARTS

1	CHART No.	TITLE	PAGE NO
	1.	Hospital Operations: Summary Flow	8
i	2.	Hospital Operations General Flow Chart	9
1	3.	OPD Procedures	13
ĺ	4.	Emergency Room Procedures	17
I	5.	Admission Procedures	20
	6.	Central Supply Room: Requisition of Supplies	32
I	7.	Central Supply Room: Receiving, Sterilization/
-		Preparation, and Issuance of Articles	33
	8.	Central Supply Room: Articles for Condemnation	34
	9.	Disposition of Patient:	•
	=	Referral to Other Health Care Facilities	36
	10.	Disposition of Patient: Referral to Other
		Departments within the Hospital	37
	11.	Disposition of Patient: Discharge of Patient	42
	12.	Disposition of Patient:
		Discharge of Patient Against Medical Advice	43
	13.	Laboratory Procedures: OPD Patient	52
	14.	Laboratory Procedures: In-Patient	53
	15.	Laboratory Procedures: ER Patient	54
	16.	Radiology Procedures: OPD Patient	58
	17.	Radiology Procedures: In-Patient	59
	18.	Radiology Procedures: ER Patient	60
	19.	Medical Social Service	78
	20.	Medical Social Service:
		Classification of OPD Patients	79
	21.	Medical Social Service:
		Classification of ER Patients	80
	22.	Medical Social Service: Classification of Patients for Admission
		(In-Patients)	81
	23.	Pharmacy	82
	24.	Pharmacy: Semestral Submission of	32
	۷٦.	Required Medicines for Official Price Sched	ule 83
	25.	Pharmacy: Regular Requisition and Procurement	,,_c 00
	25.	of Drugs and Medicines	84
	No.

CHART	NO. TITLE	PAGE NO.
		TA
26.	Pharmacy: Acceptance of Deliveries	85
27.	Pharmacy: Filling of Prescriptions for In-Patients	86
28.	Pharmacy: Filling of Prescriptions for Out-Patient	s 87
29.	Pharmacy: Disposal of Waste Materials	88
30.	Dietary Service	89
31.	Dietary Service: Menu Planning	90
32.	Dietary Service: Food Procurement
	(Open Market Purchase)	91 .
33.	Dietary Service: Receiving and Storage	92
34.	Medical Records Service	93
35.	Medical Records Service: Issuance of Medical
	Certificate for Medico-Legal Cases	94
36.	Medical Records Service:
	Preparation of Birth Certificates	95
37.	Medical Records Service:
	Issuance of Death Certificates	96
38.	Medical Records Service: Release of Clinical
	Information to Insurance Verifier	97
39.	Medical Records Service:
	Processing of Patient's Chart Received for Fil-	e 98
40.	Linen and Laundry	99
41.	Administrative Services: Budget Preparation	105
42.	Billing and Medicare:
	Processing of Medicare Forms	106

LIST OF FORMS

FORM NO. DESCRIPTION

1.	Out-Patient, Record
2.	Doctor's Order/Nurse's Compliance Sheet
3.	Informed Consent to Surgery,
	Anesthesia, or Other Procedures
4.	Clinical Cover Sheet
5.	Notification Slip for Operation
6.	Vital Signs Record
7.	Clinical Summary
8.	Inter-Agency Referral Slip
9.	Discharge Summary
10.	Clearance Certificate
11.	Discharge Against Medical Advice
12.	Statement of Account
13	Autopsy Report
14.	Laboratory Examination
15.	Income Proof Sheet
16.	MSS OPD Referral Slip (MSS Form #2)
17.	Certificate of Indigency (MSS Form #14)
18.	Charge Slip
19.	Blood Cross-Matching Result
20	Blood Transfusion Reaction Form
21.	Laboratory Request for Examination
22.	X-ray Report Form
23.	Intake Survey Sheet (MSS Form #1)
24.	Responsibility Slip (MSS Form #7)
25.	GO/NGO Referral Slip (MSS Form #4)
26.	Monthly Casework Statistics (MSS Form #9
27.	MSS Progress Report (MSS Form #5)
28.	Home Study Form (MSS Form #6)
29.	Social Groupwork Activity (MSS Form #10)
30.	Admissions and Discharge Record

FORM NO. DESCRIPTION

31.	Official Narrative (MSS Form #12)
32.	Statistical Report (MSS Form #13)
33.	Waste Material Report
34.	Statement of Daily Market Purchases
35.	Hospital Daily Census Report
36.	Written Request (Waiver)
37.	Medical Certificate
38.	Request for Access to Medical Record
39.	Admission Record
40.	Referral Sheet (Institutional)
41.	X-ray Request
42.	Requisition Order Slip of Drugs and Medicines
43.	Consent of Recipient to Operation,
	Transplantation or Grafting of Tissue
44.	Ward Referral to Medical Social Service
	(MSS Form #3)
45.	Community Organization Activity
	(MSS Form #11)
46.	MSS Report of Daily Activities (MSS Form #8)
47.	Serology
48.	MSS Hospital Network Referral Social Case Study
	(MSS Form #15)

LIST OF ABBREVIATIONS

AO - Administrative Order

BFAD - Bureau of Food and Drugs

BP - Blood Pressure

CBA - Committee on Bids and Awards

CBC - Complete Blood Count COA - Commission on Audit COH - Chief of Hospital

CSC - Civil Service Commission

CSR - Central Supply Room

CT - Clotting Time

DAMA - Discharge Against Medical Advise

DDB - Dangerous Drug Board DO - Department Order DOA - Dead on Arrival

DOH - Department of Health DOS - Doctor's Order Sheet

DPC - Drug Procurement Committee

DR - Delivery Room ECG - Electrocardiogram ER - Emergency Room FSW - Food Service Worker

HOMS - Hospital Operations and Management Service

HR - Heart Rate

IPS - Income Proof Sheet LCR - Local Civil Registrar

LR - Labor Room

MRS - Medical Records Service MSS - Medical-Social Service MSW - Medical Social Worker NA - Nursing Attendant NDP - National Drug Policy NPO - Nil Per Orem

OHFS - Office for Hospitals and Facilities Services

OPD - Out-Patient Department

OR - Operating Room

OSR - Office of Standards and Regulations

PLS - Procurement Logistics Service

PMCC - Philippine Medical Care Commission

PR - Pulse Rate

PTC - Pharmacy Therapeutics Committee RAHS - Residents Admitting History Sheet RER - Reimbursement Expense Receipt

RIV - Requisition Issue Voucher

RR - Recovery Room

SDMP - Statement of Daily Market Purchases

SPB - Systems and Procedures Bureau

WFP - Work and Financial Plan

WL - Ward Liaison

WMR - Waste Material Report

INTRODUCTION

Background

The Hospital Operations and Management Service (HOMS) of the DOH began updating the 1979 Policy and Procedures Manual for Hospitals on the first quarter of 1991. HOMS sought the assistance of the Systems and Procedures Bureau (SPB) of the Department of Budget and Management in this undertaking. Whereupon teams from SPB and HOMS, consisting of three (3) members each, were organized. Prior to this undertaking, HOMS has already compiled data on procedures and forms from different hospitals. The advisers and specialists of HOMS served as resource persons.

To substantiate the procedures drawn, the HOMS-SPB joint study group sought the assistance of the staff of the various units of the Bulacan Provincial Hospital, and the Baliwag, Calumpit, San Miguel and Sta. Maria District Hospitals. On-site observation, interviews, and workshops were conducted in the development of the procedures covering the various aspects of hospital operations. The revision of the manual focused on the flowcharts, procedures, and forms.

The first draft submitted by the study group in July 1991 was presented to the resource persons from the Bulacan hospitals during a validation workshop. This was later presented to a group of hospital personnel in Region 10 to test the applicability of the manual to various hospital levels. Among the hospitals which participated in the testing workshop were the Northern Mindanao Regional Training Hospital, Bukidnon Provincial Hospital, Mayor Hilarion Ramiro Sr. General Hospital, Initao District Hospital, Tudela Municipal Hospital, and Misamis Occidental Provincial Hospital. The valuable inputs and insights from the various technical and administrative specialists, and the medical personnel of the Department and the hospitals greatly helped in the completion and revision of the manual.

Nature and Intent

This manual seeks to guide administrators and staff in the operations and management of hospitals with the objective of ensuring the efficient and effective delivery of services. Alongside, it hopes to provide useful information for decision-making, administrative planning, and development. With the enactment of the Local Government Code of 1991, this manual becomes a necessary guide to the hospitals at the local government level where maintaining and ensuring a standard quality of hospital service is of utmost concern.

The manual suggests or prescribes procedures and approaches which hospital staff could find helpful. Activities, however, should not be restricted to those described in this manual. Hospital administrators and staff should be able to develop improvements applicable to conditions existing in the hospital and its environment and responsive to the needs of its clients/patients. While a step by step description has been made

While a step-by-step description has been made, users should be aware that some activity areas do not necessarily follow a sequential flow. Some would involve simultaneous undertakings as in the case of patient care and the conduct of work-ups. We trust the users judgment in understanding and determining these areas.

Scope

This manual covers the basic activities in the standard units of a hospital. Among the activities are those conducted in the Out-patient Department (OPD), Emergency Room (ER), Ward, Laboratory and Radiology, Operating Room (OR), Labor Room (LR) and Delivery Room (DR), Central Supply Room (CSR), Billing Section and Cashier; the Support Services such as Dietary, Pharmacy, Medical Social Service (MSS), Medical Records, Linen and Laundry; and the Administrative Service focusing on hospital budget preparation procedures. Activities covered by general guidelines or standard procedures in the national or department level have been excluded (e.g., the procedures on personnel administration and accounting which should conform with existing Civil Service Commission (CSC) and Commission on Audit (COA) rules and regulations).

While reporting should be integrated in the activities of the hospital and its units, this has also been excluded since report preparation is a regular responsibility which does not require further detailing as in the step-by-step procedure.

A standard hospital structure was not mentioned in the discussion of the DOH organization. This is to give way to structural and functional changes which are expected to result from the issuance of the implementing guidelines of the Local Government Code. Despite organizational changes, the procedures described in this manual could still be adopted and serve as standard guides in hospital operation.

Composition and Presentation

The manual is composed of two (2) main parts, both of which are divided into different chapters. Part I is a general description of the Department's functions and organization, and the hospital system. Part II contains the flowchart diagrams and the procedures for hospital operations. The flowchart diagrams provide a summary of the procedures and activities. The procedures, presented in a play-script form, show the responsibility centers (units or persons) and the corresponding actions. (For guides on how to better understand the Flowchart Diagram and the Play-script Procedure, refer to Annex 1). Sample forms have also been attached for easy reference.

Proviso

HOMS under the Office for Hospitals and Facility Services (OHFS) is responsible for updating and revising the manual. Proposals for changes and improvements may be submitted for the approval of the Secretary of Health through the Undersecretary, Office for Hospital and Facility Services, Attention: The Director, Hospital Operations and Management Service.

PART I THE DEPARTMENT OF HEALTH

DEPARTMENT OF HEALTH OBJECTIVES AND GENERAL FUNCTIONS

Article XIII, Sections 11 and 12 of the 1986 Constitution provides that "the State shall adopt an integrated and comprehensive approach to health development which shall endeavor to make essential goods, health, and other social services available to all people at affordable cost. There shall be priority for the needs of the underprivileged, sick, elderly, disabled, women, and children. The State shall endeavor to provide free medical care to paupers."

With this mandate, the DOH is responsible for the promotion, protection, preservation, or restoration of the health of the people through the provision and delivery of health services and through the regulation and encouragement of providers of health goods and services.

True to its role and functions as the government's main instrument for responding to health concerns, the DOH advocates that health is a basic human right and that a continuum of services must be provided to ensure the enjoyment of this right especially by the poor.

Executive Order No. 119 issued on 30 January 1987 identifies the DOH's powers and functions as follows:

* Define the national health policy; formulate and implement a national health plan within the framework of the government's general policies and plans; and to present proposals to appropriate authorities on national issues which have health implications;
* Provide for health programs, services, facilities, and other requirements as may be needed subject to availability of funds and administrative rules and regulations;
* Assist, coordinate, or collaborate with local communities, agencies, and interested groups including international organizations in activities related to health;
* Administer all laws, rules, and regulations in the field of health, including quarantine laws and food and drug safety laws;
* Collect, analyze, and disseminate health statistical and other relevant information on the country's health situation, and require the reporting of such information from appropriate sources;
* Propagate health information and educate the population on important health, medical, and environmental matters which have health implications;
* Undertake health and medical research and conduct training in support of its priorities, programs, and activities;
* Regulate the operation of, and, issuance of licenses and permit to government and private hospitals, clinics and dispensaries, laboratories, blood banks, drugstores, and such other establishments which by the nature of their functions are required to be regulated by the Department;
* Issue orders and regulations concerning the implementation of established health policies;
* Perform other functions as established by law or as ordered by higher authorities.
* Administer all laws, rules, and regulations in the field of health, including quarantine laws and food and drug safety laws;
* Collect, analyze, and disseminate health statistical and other relevant information on the country's health situation, and require the reporting of such information from appropriate sources;
* Propagate health information and educate the population on important health, medical, and environmental matters which have health implications;
* Undertake health and medical research and conduct training in support of its priorities, programs, and activities;
* Regulate the operation of, and, issuance of licenses and permit to government and private hospitals, clinics and dispensaries, laboratories, blood banks, drugstores, and such other establishments which by the nature of their functions are required to be regulated by the Department;
* Issue orders and regulations concerning the implementation of established health policies; and
* Perform other functions as established by law or as ordered by higher authorities.

THE DEPARTMENT OF HEALTH ORGANIZATION

The Office of the Secretary of Health exercises general management and supervision over the various units and offices of the Department. Directly under the Office of the Secretary is the Executive Committee for National Field Operations which is further composed of two structures: one is composed of the fifteen (15) special hospitals and medical centers and the other, of the thirteen (13) regional health offices. The Philippine Medical Care Commission (PMCC) and the Dangerous Drugs Board (DDB) are, likewise, attached to the DOH. Regional offices exercise technical supervision over the PMCC and the DDB.

As reorganized under Executive Order No. 119 in 1987, the Department of Health is divided into five (5) offices, namely:

* Office for Public Health Services;
* Office for Hospitals and Facilities Services (OHFS);
* Office for Standards and Regulations (OSR);
* Office for Management Services; and
* Office of the Chief of Staff.

Each office is headed by an undersecretary who is assisted by an assistant secretary.

The Office for Public Health Services is composed of nine (9) service structures delineating the preventive, promotive, and curative programs of the Department, to wit:

* Malaria Control Service
* Schistosomiasis Control and Research Service
* Tuberculosis (TB) Control Service
* Communicable Disease Control Service
* Maternal and Child Health Service
* Family Planning Service
* Nutrition Service
* Dental Health Service
* Environmental Health Service

The OHFS is tasked with establishing a public hospital system which provides effective and efficient patient care that is affordable, accessible, available, and acceptable. The office is composed of four (4) service structures:

* Hospital Operations and Management Service (HOMS)
* Radiation Health Service
* Health Infrastructure Service
* Hospital Maintenance Service

The OSR is responsible for the formulation of regulatory services for health facilities and institutions. Under the OSR are two (2) bureaus and a national office, namely:

* Bureau of Research Laboratories
* Bureau of Licensing and Regulations
* National Quarantine Office

The Bureau of Food and Drugs (BFAD) was detached from the OSR and placed under the National Drugs Policy (NDP) Implementation Project.

The Office for Management Services renders support services to various offices and entities of the Department through the following services:

* Administrative Service
* Finance Service
* Management Advisory Service
* Health Manpower Development and Training Service
* Procurement and Logistics Service
* Biological Production Service

The Office of the Chief of Staff coordinates, plans, and provides information, education, and legal services. It is composed of the following seven components:

* Legal Services
* Financial Operations and Frontline Services Audit
* Community Health Service
* Public Information and Health Education Service
* Health Intelligence Service
* Internal Planning Service
* Foreign Assistance and Coordination Service

THE DEPARTMENT OF HEALTH HOSPITAL SYSTEM

The DOH Hospital System is basically a three-tier mode, involving a network of 537 government hospitals. The three levels are tertiary, secondary and primary. Each level has well-defined roles, functions, capabilities, facilities, organizational structure, and staffing standards. This categorization allows a provision of a hierarchy of services utilizing appropriate resources at each level.

The tertiary level is composed of specialty centers, specialized hospitals, medical centers, regional hospitals, and provincial or general hospitals. Tertiary hospitals have capabilities and facilities for providing medical care to cases requiring sophisticated diagnostic and therapeutic equipment and the expertise of trained specialists in the sub-specialties. Special and specialty centers, in particular, are equipped with expensive and sophisticated diagnostic and therapeutic facilities for a specific medical problem area.

The secondary level consists of district hospitals with capabilities and facilities for medical care to cases requiring hospitalization. It also has the expertise of trained specialists.

The primary level is composed of municipal and medicare hospitals which have facilities and capabilities for first contact emergency care and hospitalization for simple cases.

The goal of the DOH Hospital System is to develop an effective network of facilities which are available, accessible, acceptable, and affordable. The DOH hospital will not only be a center for curative care but also a venue for preventive medicine. The system shall also provide efficacious alternatives to in-patient care and promote a wider use of allied medical professionals and paramedical personnel.

The following are the number of hospitals under government supervision, and the respective bed capacities per classification:

THE DOH HOSPITAL SYSTEM

Classification	Number	Bed Capacity
1. Specialty	4	953
2. Special	5	7,750
3. Medical Centers	8	2,950
4. Regional	14	3,950
5. Provincial	74	7,695
6. District	276	10,385
7. Municipal	60	605
8. Medicare	87	1,250
9. Sanitaria	8	4,920
10. Research	1	50
TOTAL	537	40,508
	Table I

PART II HOSPITAL PROCEDURES

HOSPITAL OPERATIONS SUMMARY FLOW

A patient may enter the hospital system through the OPD or the ER. From these two units, a patient may either be sent home, referred to other health facilities, or admitted to the wards. In the ward, the patient receives care from doctors and nurses and services from the different support units such as Pharmacy, Dietary, CSR, Laboratory, Radiology, MSS, and Medical Records. Upon admission, the patient is classified in terms of his ability to pay. Before a patient is discharged, or referred to another health facility, he must pass through the Billing Section and Cashier's Offices for his financial obligations to the hospital. (See Charts 1 & 2)

OUT-PATIENT DEPARTMENT PROCEDURES (Chart No. 3)


Responsibility	Action
"Old" OPD Patient (OPD/ID Cardholder)	1a.		nts ID card to the OPD /NA/Records Clerk.
or New-Patient	1b.		sts for OPD ID card from the /Nursing Attendant.
OPD Nurse/ Nursing Attendant (NA)/ Records Clerk issues		1b.1	Fills up OPD chart (patient's data) and issues an ID card to the patient. [Form I]
	2.	Registe logboo	ers patient's name in the OPD ok.
OPD Nurse	3.	Forwards chart to the OPD Nurse.
	4.	Calls patient's name, gets vital sig and records findings on the OPD cha
	5.		patient and gives OPD chart to
Physician	6.		ines patient, evaluates, and ines the medical care needed.
	7a.	If the gives p the par	patient is in for medical care, rescriptions and instructions to tient.
	7b.	orders ray exa the O Radiol	patient is in for work-up, gives for the laboratory, ECG, or x-amination and refers patient to PD Nurse. (See Laboratory/ogy Procedures for OPD Patient, ers XV and XVI)
		7b.1	Upon receipt of the laboratory, ECG or X-ray results, evaluates results, notes on the patient's chart, and gives prescription and instructions to the patient.

	7c. -	If the patient needs to be confined, accomplishes Doctor's Order Sheet (DOS) [Form II] and Resident's Admitting History Sheet (RAHS) and forwards it to the Admitting Unit. (See Admission Procedures, Chapter VII)
Physician	7d.	If the patient needs referral to other health facilities or to other departments within the hospital. (See Referral Procedures, Chapter XII)
	8.	Records observations, impressions, diagnosis, and treatment rendered on the OPD Chart.
	9	Gives OPD chart to the Nurse/Medical Records.
OPD Nurse/ Medical Records	10.	Records and files OPD Chart.

EMERGENCY ROOM PROCEDURES

(Chart No. 4)

Responsibility	Action
ER Nurse	1.		s to patient immediately for ncy measures.
	2.	signs,	and refers patient to the an on duty.
Physician	3.	Exami	nes patient and writes orders for ation/medical care.
ER Staff	4a.	resusc	signs are absent, gives immediate itative measures, and refers to the physician on duty.
Physician		4a.1	If resuscitative measures fail, pronounces patient as Dead on Arrival (DOA).
Nurse/Nursing Attendant Physician		4a.2 4a.3	Gives post-mortem care. Refers to the medico-legal officer or police authority.
	5a.	signs a	ent is for admission, writes and admitting orders, and notifies (See Admission Procedures, er VII)
	5b.	orders imme Blood	ent is for surgery, writes statistical s on the patient's chart for diate work-up like Complete Count (CBC), urinalysis and/ cial procedures.
		5b.1	Prepares and signs request and gives it to the Nurse. (See Laboratory/Radiology Procedures for ER Patient, Chapter XV and XVI)

Manual of Procedures for Hospitals

5c. If patient is for referral to other health facilities, prepares referral documents.

(See Referral Procedures, Chapter XII)
5d. If the patient is for discharge, instructs patient/relative to comply with the discharge requirements. (See Disposition of Patient, Chapter XIII)

ADMISSION PROCEDURES (Chart No. 5)

	Responsibility	Action
The second second second second	Nurse	1.	Receives Doctor's Order Sheet (DOS) and Resident's Admitting History Sheet (RAHS) from the OPD/ER Doctor.
-		2a.	If from ER, immediately executes the doctor's stat orders.
		2b.	If from OPD, enters patient's data in the admission logbook.
		3.	Has consent for medical or surgical intervention signed by the patient or his/her nearest relative. [Form III]
The state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the s		4.	Fills up Clinical Cover Sheet [Form IV], Face Sheet, Admission and Discharge Sheet, etc., and In-Patient Record Card.
Committee Control of the Control		5.	Forwards Clinical Cover Sheet and In- Patient Record and refers patient or relative to the Medical Social Worker for classification. (See Classification of Patients for Admission (In-Patients),
			Section A - MSS, Chapter XVII- Support Services)
	Nurse	6.	Notifies ward of the new admission and sends patient's Clinical Cover Sheet and chart to the designated ward.
	Nursing Attendant (NA)/ Utility Worker	7.	Directs patient and brings the patient's chart to the designated ward. (See Admission to Ward, Chapter VIII - Ward Procedures)

WARD PROCEDURES

8.1 Admission to Ward

Responsibility	Action
Upon notice of admission:
Ward Nurse	1.	Prepares bed assignment, individual patient's supplies, and materials needed based on the information from the admitting unit.
Nursing Attendant (NA)	2	Prepares patient's unit (bed, bed tag, bedside table, etc.)
Upon arrival of patient in the ward:
Ward Nurse	3.	Accompanies patient to his/her designated unit.
	4.	Assesses patient's condition and records findings in the chart.
	5.	Orients patient/companion to the hospital unit and policies.
	6.	Plans nursing care of the patient.
	7.	Performs admission care and carries out orders.
	8.	Initiates implementation of medical management like requests for examination, medication, treatment, and referrals.
	9.	Informs other units such as the laboratory, pharmacy, x-ray, etc. of the needs and requirements of the patient.
	10.	Discusses with patient or companion the medical or nursing care plan and the extent of his/her participation.
	100

Manual of Procedures for Hospitals

Checks chart to ensure that consent 11. — for medical or surgical intervention has been signed by either the patient or his/ her nearest kin. Charts observations, measures, and 12. medications administered to the patient. Enters patient's name in the daily ward 13. census, Kardex and diet list. Updates ward directory. Ward Nurse/NA 14. Prepares diet list and forwards it to 15. Ward Nurse the dietary.

8.2 Carrying-out Doctor's Orders

Responsibility	Action
Ward Nurse	1.	After doctor's rounds, receives, and copies medical management from the patient's chart to the nurse's book or Kardex.
	2.	Fills-up medication or treatment cards.
	3.	Carries out medication treatment orders.
	4.	Prepares requests for routine examinations and sends them to the departments concerned. (See Laboratory/Radiology Procedures for In-Patient, Chapter XV or XVI)

8.3 Daily Patient Care

Responsibility	Action
Outgoing Nurse	1.	Endorses, to the incoming nurse, the shift's activities and special treatment, and medications which need to be carried out.
	2.	Makes rounds with the incoming nurse and introduces the latter to newly admitted patients and those needing intensive care.
Incoming Nurse	3.	Takes note of patients needing special care.
Outgoing Nurse	4.	Endorses drugs to the incoming nurse and signs out.
Incoming Nurse	5.	Reads Kardex and analyzes reports.
	6.	Prepares plan of work and determines resources and priorities.
	7.	Provides nursing care and carries out medical treatment.
	8.	Records patient care activities and observations made.

es request for surgery and forwards	Prepar	Ţ	uo	Surge
		:	r before the operation	кер У
		Action	Yailidisno	Respo
•	nres	Proced	Pre-Operative	₽.8

Assists ward nurse in carrying- out patient care when needed.	12a.4	3
Oversees utilization of the ward supplies and equipment.	12a.3
Observes staff nurses to determine their level of competency.	2.621
by the ward nurse.	12a.1		ę	Murse
s rounds of patients:	Make	12a.	roins2\gaisiv	_
tors activities and patients' status.	inoM	.11	SinV	Ward
sses management of patients with hysician.		10.
necessary.		6
•

		,
procedures to be done.
Prepares patient psychologically and spiritually, and orients him/her on the	.01	Physician/Nurse
Ensures that all OR needs are complete.	6	OR Murse
medication and prepares the drugs needed.	-
Prepares prescription for pre-operative	.8	Anesthesiologist
operation schedule
Informs anesthesiologist of the	Z	Szid Murse
the schedule of operation.
Nurse and informs the Ward Nurse of		(320) J -
Enters request in the OR logbook	.9	(AO) mooA gaitstagO
Forwards request to the OR Nurse.	٤٠	SzuV bisW
Ward Murse.		Senior Resident
Approves request and refers it to the	.₽	Chief of Hospital (COH)/
his nearest kin.
already been signed by the patient or
consent for surgical intervention has	••
Inspects chart and sees to it that the	· .£
Forwards request for surgery to the COH/Senior Resident for approval.	.2	szuV bisW
it to the Ward Nurse. [Form V]
Prepares request for surgery and forwards	Ţ	Surgeon
. 31	-	g .
	r	A day before the operation:
	Action
	Action	Responsibility A day before the operation:
	Action	A day before the operation:
ures	Action	Responsibility A day before the operation:
out patient care when needed.	Action	Responsibility A day before the operation:
12a.4 Assists ward nurse in carrying- out patient care when needed.	Action	Responsibility A day before the operation:
supplies and equipment. 12a.4 Assists ward nurse in carrying- out patient care when needed. \nures	Action	Responsibility A day before the operation:
I2a.3 Oversees utilization of the ward supplies and equipment. I2a.4 Assists ward nurse in carrying-out patient care when needed.	Action	Responsibility A day before the operation:
their level of competency. 12a.3 Oversees utilization of the ward supplies and equipment. 12a.4 Assists ward nurse in carrying-out patient care when needed. \nures	Action	Responsibility A day before the operation:
12a.2 Observes staff nurses to determine their level of competency. 12a.3 Oversees utilization of the ward supplies and equipment. 12a.4 Assists ward nurse in carrying-out patient care when needed.	Action	Responsibility A day before the operation:
Dy the ward nurses to determine their level of competency. 12a.3 Oversees utilization of the ward supplies and equipment. 12a.4 Assists ward nurse in carrying-out patient care when needed.	Action	8.4 Pre-Operative P. Responsibility A day before the operation:
12a.1 Supervises nursing care provided by the ward nurse. 12a.2 Observes staff nurses to determine their level of competency. 12a.3 Oversees utilization of the ward supplies and equipment. 12a.4 Assists ward nurse in carrying-out patient care when needed.	Action Action	Nurse 8.4 Pre-Operative F Responsibility A day before the operation:
Makes rounds of patients: 12a.1 Supervises nursing care provided by the ward nurse. 12a.2 Observes staff nurses to determine their level of competency. 12a.3 Oversees utilization of the ward supplies and equipment. 12a.4 Assists ward nurse in carrying- out patient care when needed. \nures	l2a.	Supervising/Senior Nurse 8.4 Pre-Operative P Responsibility A day before the operation:
Monitors activities and patients' status. Makes rounds of patients: 12a.1 Supervises nursing care provided 12a.2 Observes staff nurses to determine their level of competency. 12a.3 Oversees utilization of the ward supplies and equipment. 12a.4 Assists ward nurse in carrying- out patient care when needed. our patient care when needed.	Action Action	Nurse 8.4 Pre-Operative F Responsibility A day before the operation:
Monitors activities and patients' status. Makes rounds of patients: 12a.1 Supervises nursing care provided by the ward nurse. 12a.2 Observes staff nurses to determine their level of competency. 12a.3 Oversees utilization of the ward supplies and equipment. 12a.4 Assists ward nurse in carrying- supplies and equipment. 12a.4 Assists ward nurse in carrying- supplies and equipment.	II. ISa. Action	Supervising/Senior Nurse 8.4 Pre-Operative P Responsibility A day before the operation:
Discusses management of patients with the physician. Monitors activities and patients' status. Makes rounds of patients: 12a.1 Supervises radf nurses to determine their level of competency. 12a.2 Observes staff nurses to determine their level of competency. 12a.3 Oversees utilization of the ward supplies and equipment. 12a.3 Oversees utilization of the ward out patient care when needed.	l2a.	Supervising/Senior Nurse 8.4 Pre-Operative P Responsibility A day before the operation:
when necessary. Discusses management of patients with the physician. Monitors activities and patients' status. 12a.1 Supervises nursing care provided by the ward nurse. 12a.2 Observes staff nurses to determine their level of competency. 12a.3 Oversees utilization of the ward supplies and equipment. 12a.3 Oversees utilization of the ward out patient care when needed.	10. 12a. 12a.	Supervising/Senior Nurse 8.4 Pre-Operative P Responsibility A day before the operation:
Discusses management of patients with the physician. Monitors activities and patients' status. Makes rounds of patients: 12a.1 Supervises radf nurses to determine their level of competency. 12a.2 Observes staff nurses to determine their level of competency. 12a.3 Oversees utilization of the ward supplies and equipment. 12a.3 Oversees utilization of the ward out patient care when needed.	II. ISa. Action	Supervising/Senior Nurse 8.4 Pre-Operative P Responsibility A day before the operation:

.51

.11

Ward Murse

Puts a tag on the patient's bed indicating the schedule and kind of operation.

Noutifies dietary section of the operation to

Instructs patient/watcher on NPO (Vil

be performed on the patient

Per Orem) starting midnight.

Supervising Nurse/ Senior Nurse	14.	Checks preparations made for patient's operation.
Ward Nurse/	15a.	Prepares patient:
Nursing Attendant		15a.1 Performs procedures (e.g., enema) as needed.
		15a.2 Conducts preliminary preparation of the operative site.
		15a.3 Reminds patient on NPO.
		15a.4 Reassures the patient.
Ward Nurse	16.	Fills-up and signs checklist of pre- operative preparations and gives it to the Senior Nurse.
Senior Nurse	17.	Checks and signs checklist and returns it to the Ward Nurse.
Ward Nurse	18.	Puts checklist in the patient's chart.
Early Morning of the Operation Day:
Ward Nurse	19.	Removes jewelry, contact lenses, prosthetic teeth, etc. and gives it to the patient's companion for safekeeping.
	20.	Gives cleansing enema, if ordered.
	21.	Inspects operative site and checks completeness of pre-operative medications.
	22.	Rechecks the checklist of pre-operative medications.
Nurse	23.	Takes vital signs (Blood Pressure (BP)/ Temperature/Pulse Rate (PR) or Heart Rate (HR)/Respiratory Rate and level of consciousness.
. *	24.	Gives pre-operative medications as scheduled.
OR Nursing Attendant/ Ward Utility Worker	25.	Transfers patient to the OR with the chart and other needed medications and supplies.
Ward Nurse	26.	Endorses patient to the OR Nurse.

OPERATING ROOM PROCEDURES

9.1 Preparation of the OR

Responsibility	Action
Nursing Attendant (NA)	1.	Disinfects OR before and after use.
Circulating Nurse	2.	Opens OR pack.
	3.	Prepares set-up for the particular operation.
	4.	Arranges pack on top of the instrument table.
	5.	Opens additional packs needed for the particular operation.
Scrub Nurse	6.	Continues setting-up as needed.
	7.	Prepares suturing set and sponges.
Circulating Nurse	8.	Counts and writes on the board the number of sponges, instruments, and needles.
Scrub Nurse	9.	Rechecks counting.

9.2 Patient Care in the OR

Responsibility	Action
Circulating Nurse and Anesthesiologist	1.	Receives patient and checks if all the pre-operative requirements are administered.
Circulating Nurse	2.	Checks operative site, sterilizes the skin, and drapes the patient.
	3.	Places patient in the prescribed position to protect nerves from undue pressure.
Scrub Nurse		Sets—instruments and supplies according to the specified order and the type of operation to be performed.

Manual of Procedures for Hospitals

	5.	Counts sponges and instruments and dictates to the Circulating Nurse.
Circulating Nurse	6.	Writes on the board the number of
	7.	Anticipates the needs of the scrub I vuisc.
Anesthesiologist	8.	Checks medicines needed for the
	9.	Prescribes substitutes for medicines which are not available.
	10.	Industry anacthesia.
Scrub Nurse	11.	Anticipates the needs of the surgeon during operation.
Before surgeon closes tl	ne operation	n:
Circulating Nurse and Scrub Nurse	12.	Check and tally the number of instruments
Anesthesiologist	13.	Checks vital signs and logs them in the appethesia record.
Nurse	14.	Records vital signs in the patient's chart.
9.3 Post-Operat Responsibility Operating Room (	Actio	on
Operating Room ( Scrub Nurse	OR): 1.	Removes all straps, cleans, and covers
		the patient. Takes vital signs of the patient.
	2.	Takes patient to the recovery room.
	3.	Disinfects OR after use.
	4.	Disinfects OR area
Recovery Room (F	₹R):	4***
Nurse	5.	Monitors patient's condition and records in the chart all observations made.
	6.	Refere to the physician when needed.
	7.	Places tissues removed in the appropriate containers and labels them. (For Histopath Examination, see Chapter XV, Section 15.6)
	250	ACC.
When patient regains	consciousn:	C00.
When patient regains OR/RR Nurse	consciousne 8.	Informs Ward Nurse of the patient's transfer to the ward. Endorses patient to the Ward Nurse.

LABOR ROOM / DELIVERY ROOM PROCEDURES

10.1 Preparation of the LR/DR

Responsibility	Action
Nursing Attendant (NA)	1.	Disinfects LR/DR before and after use.
DR Nurse	2.	Opens DR pack.
	3.	Prepares set-up for the particular procedure.
	4.	Opens and arranges additional packs on top of the instrument table.
	5.	Counts and writes on the board the number of sponges, instruments, and needles.

10.2 Patient Care in the LR/DR

Responsibility	Action
_DR Nurse	1.	Receives patient and gets her informed consent.
	2.	Assesses and records patient's condition including vital signs, blood pressure, weight, and fetal heart beat. [Form VI]
	3.	Notifies Obstetrician of the admission.
	4.	Prepares patient for examination.
Obstetrician	5.	Assesses patient.
	6.	Orders preparation for delivery like enema, CBC, CT, and urine examination.
	7.	Orders patient to be brought to either the LR or DR, as the case may be.
DR Nurse	8.	Prepares patient for labor.

	9.	Monitors patient's vital signs and fetal heart tone.
	10.	When patient is ready for delivery, calls the obstetrician.
Obstetrician	11.	Attends to the delivery.
	12.	Records medical intervention/management.
DR Nurse	13.	Carries out legal orders of the physician.
	14.	Prepares and attaches ID tags to both mother/patient and baby.
	15.	Prepares charge slips for supplies used during delivery and attaches a copy to the patient's chart.
	16.	Endorses the mother to the Ward Nurse.
Nursing Attendant (NA) DR Nurse	17. 18.	Takes the mother to the ward. While the mother is being taken care of, suctions the baby and wraps him well.
	19.	Assesses baby's condition and refers to the physician.
	20a.	Endorses baby to the Ward Nurse.
•		20a.1 For complicated cases; endorses the baby to the nursery staff.

Central Supply Room (CSR)

11.1 Requisition of Supplies (Chart No. 6)

	Responsibility	Action
	CSR Head	1a.	Checks stock level and availability of the supplies.
			1a.1 For supplies below 50% stock level, instructs CSR Nurse/Attendant to prepare requisition.
	Nursing Attendant (NA)	2.	Prepares requisition slip and forwards it to the CSR Head/Chief Nurse.
	CSR Head/Chief Nurse	3.	Signs requisition slip and forwards it to the Supply Officer.
	Supply Officer	4.	Evaluates request and determines the stock level.
		5.	Indicates quantity and items available/withdrawable in the requisition slip.
		6.	Prepares Requisition Issue Voucher (RIV) and forwards it to the CSR Head/Chief Nurse.
-	GSR Head/Chief Nurse	7.	Recommends approval of RIV and forwards it to the COH.
	Chief of Hospital (COH)	8.	Approves RIV.
	Property and Supply Unit	9.	Issues items requested to the CSR-designated recipient.
	CSR Recipient	10.	Receives supplies and signs the RIV.
	CSR Recorder	11.	Enters items requested and withdrawn in the stock card.

11.2 Receiving and Sterilization of Used Article (Chart No. 7)

	•
Responsibility	Action
Nursing Attendant (NA)	1.	Delivers used articles to the CSR. (from clinical area)
CSR Counter Clerk	2.	Receives and checks used articles.
	3a.	Indicates missing items, if any, in the borrower's slip.
Borrower	3b.	Acknowledges missing items, if any.
CSR Counter Clerk	4.	Places articles in isolation directly inside the autoclave for a five (5) minute sterilization.
	5.	Files borrower's slip for the report- preparation.
	6.	Forwards items to the designated washers.
CSR Nurse/Attendant	7.	Rewashes, dries, and packs articles.
· ·	8.	Labels packs indicating the contents and the date of sterilization.
•	9.	Places articles in autoclave for sterilization.
	10.	Sorts sterilized packed articles.
	11.	Informs units/end-users concerned that sterilized articles are ready for use/withdrawal.

11.3 Issuance of Sterile Articles

Responsibility	Action
CSR Counter Clerk/ Personnel	1.	Receives borrower's slip (2 copies) duly signed by the Ward Nurse.
	2.	Prepares articles and supplies listed in the borrower's slip and places them in a tray.
CSR Nurse	3.	Checks prepared articles and supplies and clears release of said items being borrowed.
CSR Counter Clerk/ Personnel	4.	Issues articles to the Ward Nursing Attendant/borrower.
Ward Nursing Attendant/ Borrower	5.	Checks items against the borrower's slip, signs, and forwards the slip to the CSR Counter Clerk.
CSR Counter Clerk/ Personnel	6.	Issues copy 2 of slip to the borrower and files original copy.

11.4 Articles for Condemnation (Chart No. 8)

Responsibility	Action
Ward Nursing Attendant	1.	Delivers items to be condemned to the CSR.
CSR Counter Clerk/ Personnel	2.	Lists articles to be condemned, including boxes and wrappers, in the return slip (2 copies) and signs it.
	3.	Gives copy 2 of the slip to the Ward Nursing Attendant.
	4.	Stores items for turnover to Property and Supply for their eventual disposal.
	5.	Forwards original copy of the return slip to the CSR Recorder.
CSR Recorder	6.	Updates stock card.
	7.	Files return slip.

11.5 Routine Preparation of Supplies for Ready Use

Responsibility	Action
CSR Head	1.	Instructs Nurse/Attendant to prepare the necessary supplies.
Nurse/Attendant	2.	Prepares needed supplies and packs them individually or in bulk, or wraps them with clean paper.
	3.	Labels packs and sterilizes items.
Nurse	4.	Checks sterilized supplies.
Nursing Attendant (NA)	5.	Updates stock card.

CENTRAL SUPPLY ROOM REQUISITION OF SUPPLIES

CHART NO. 7 CLINICAL AREA ISSUANCE OF STERILE ARTICLES CENTRAL SUPPLY ROOM RECEIVING, STERILIZATION/ PREPARATION and ISSUANCE of ARTICLES PREPARATION OF STERILE SUPPLIES FOR READY USE STERILIZATION OF USED ARTICLES *USED ARTICLES CLINICAL AREA

CENTRAL SUPPLY ROOM ARTICLES FOR CONDEMNATION

REFERRAL PROCEDURES

12.1 To Other Health Facilities (Chart No. 9)

Responsibility	Action
Physician	1.	Prepares clinical summary, accomplishes referral slip, and gives it to the Nurse. [Form VII]
		Note: The physician may coordinate with other health facilities for referral purposes (i.e. networking).
Nurse	2.	If necessary, arranges for ambulance conduction of the patient.
Nursing Attendant (NA)	3.	Brings patient's chart to the Billing Section.
Billing Section	4.	Bills patient and refers patient to the Cashier.
	5.	If patient is unable to pay part or full, refers the patient to Medical Social Worker (MSW). (Authorized personnel may act in case the MSW is not available).

12.2 To Other Departments Within the Hospital (Chart No. 10)

Responsibility	Action
Physician	1.	Accomplishes interdepartmental slip or referral slip within the hospital. [Form VIII]
	2.	Attaches laboratory and x-ray results and provisional diagnosis.
Senior Resident	3.	Approves referral.
Nurse	4.	Sends referral slip to the physician to whom the patient is being referred to.
Physician to whom the patient is being referred to	5.	Examines patient and evaluates together with the referring physician.

DISPOSITION OF PATIENT REFERRAL TO OTHER HEALTHCARE FACILITIES

DISPOSITION OF PATIENT REFERRAL TO OTHER DEPARTMENTS WITHIN THE HOSPITAL

DISPOSITION OF PATIENT

13.1 Discharge of Patient (Chart No. 11)

Responsibility	Action
Attending Physician	1.	Examines and evaluates patient.
,	2.	Indicates, in patient's chart, that he/she may go home.
	= -3,	Writes discharge instructions and prescription needed for home treatment. [Form IX]
45	4.	Completes diagnosis in the patient's chart and forwards it to the Ward Nurse.
		Note: Doctors should sign all orders.
Ward Nurse	5.	Reviews chart for completeness.
es.	6.	Gives discharge instructions and health education to the patient and informs the patient of the date of follow-up/check-up.
	7.	Prepares Clearance Certificate [Form X] and discharge notice. (See Section 3 - Issuance of Clearance Certificate, this chapter)
Patient/Companion	8.	Presents duly accomplished Clearance Certificate and official receipt, if pay patient, to the Ward Nurse.
Ward Nurse	9.	Sees to it that all equipment/ items previously issued to the patient are returned.
	10.	Discharges patient.
F	11.	Cancels name of patient in the diet list and patient's directory.
	12.	Attaches Clearance Certificate to the patient's records.

13.2 Discharge of Patient Against Medical Advice (Chart No. 12)

Responsibility	Action	l
Patient/Relative	1.	Requests discharge against medical advice.
Ward Nurse	2.	Refers request to attending physician.
Attending Physician/ Resident-on-Duty	3.	Advises patient/relative on implications and consequences of discharge against medical advice (DAMA). [Form XI]
	4.	Indicates DAMA on patient's chart.
Ward Nurse	5.	Fills up DAMA form and requests patient/ relative to sign.
Patient/Relative	6.	Signs DAMA form and returns it to the Ward Nurse.
Ward Nurse	7.	Reviews chart for completeness.
	8.	Gives discharge instructions and health education to the patient and informs patient of date of follow-up/check-up.
•	9.	Prepares Clearance Certificate and discharge notice. (See Section 3 - Issuance of Clearance Certificate, this chapter)
Patient/Companion	10.	Presents duly accomplished Clearance Certificate and OR, if pay patient, to the Ward Nurse.
Ward Nurse	11.	Sees to it that all equipment/ items previously issued to the patient are returned.
	12.	Discharges patient.
	13.	Cancels name of patient in the diet list and patient's directory.
•	14.	Attaches Clearance Certificate to the patient's records.

13.3 Issuance of Clearance Certificate

Responsibility	Action	1
Physician	1.	Writes discharge orders and forwards them to the Ward Nurse.
Ward Nurse	2.	Checks patient's record for discharge instructions and physician's signature.
	3.	Prepares Clearance Certificate in duplicate.
	4.	Instructs patient/companion to secure clearance with the other units concerned, namely, X-ray, Laboratory and Pharmacy.
X-ray/Laboratory/	5.	Checks patient's accountabilities.
Pharmacy	6.	If patient has unsettled accounts, indicates amount in the Clearance Certificate.

	7.	Initials in appropriate space of the Clearance Certificate and instructs patient to proceed to the Billing section.
Billing Section	8.	Checks patient's jacket and prepares Statement of Account [Form XII] according to MSS classification.
	9.	Initials the Clearance Certificate and instructs patient/companion to pay to the Cashier.
Cashier	10.	Receives payment and indicates official receipt number in the Clearance Certificate.
	11.	Issues official receipt (copy 1) to the patient/companion and signs Clearance Certificate.
	12.	Instructs patient/companion to forward Clearance Certificate to the Ward Nurse.
Ward Nurse	13.	Checks if all equipment/items previously issued to patient have been returned.
	14.	Checks if Clearance Certificate have been properly accomplished.
	15.	Signs in appropriate space.
	16.	Issues copy 1 of Clearance Certificate to the patient/ companion and gives final instructions.
	17.	Attaches copy 2 of Clearance Certificate to the patient's chart to be forwarded to the MRS.

DISPOSITION OF CADAVER

14.1 Preparation of Cadaver in the Ward

Responsibility	Action
Nursing Attendant / Ward Nurse	1.	Removes everything attached to the patient and endorses personal belongings to the relative/watcher.
6	2.	If unidentified, deposits personal belongings to the property custodian.
	3.	Provides post-mortem care.
	4a.	Sends cadaver to morgue.
		4a.1 For abandoned cadavers, coordinates with the MSS for appropriate action.

14.2 Receiving in Morgue

Responsibility	Action
Morgue Attendant	1.	Receives cadaver and records receipt in the logbook.
	2.	Keeps and maintains cadaver until it is claimed.

14.3 Release of Cadaver to Claimant

Responsibility	Action
Morgue Attendant/ Nursing Attendant	1.	Receives notice of release of cadaver from the claimant.
	2.	Releases cadaver to the claimant and indicates in the logbook the date and time of release and the name of the claimant.
Claimant	3.	Receives cadaver and countersigns in the logbook.

14.4 Autopsy

Responsibility	Action
Ward Nurse	1.	Prepares and secures consent of the patient's relative for post-mortem examination.
	2.	Informs pathologist.
Morgue Attendant	3.	Takes cadaver to the autopsy room.
Pathologist	4.	Performs autopsy on the cadaver.
•	5.	Prepares autopsy report [Form XIII] and files it.
	6.	Explains autopsy report to the family of the deceased.
Autopsy Attendant	7.	Endorses cadaver to the morgue.

LABORATORY PROCEDURES

15.1 OPD Patient (Chart No. 13)

Responsibility	Action
OPD Nurse	1.	Form X	request for laboratory examination (IV) and instructs patient to submit on to the laboratory.
Patient/Companion	2.	Presents the spe	s laboratory request and submits cimen to Laboratory Aide.
Laboratory Aide	3.	Receives	s laboratory request and specimen, ords it in the logbook.
	4a.	patient	es charge slip and instructs the companion to proceed to the section.
		4a.1	Forwards specimen and laboratory request to the Medical Technologist.
Medical Technologist	4b.	Exami	nes specimen.
		4b.1	Writes result in standard form and records it in the logbook.
		4b.2	Forwards result to the Laboratory Head.
Laboratory Head	4c.	Review the Me	vs and signs result and gives it to edical Technologist.
Medical Technologist	4d.	Release or to t	es result to the patient the requesting physician.
Patient/Companion	5.	Present	ts charge slip to the Billing section.
Billing Section	6.	Indica inform	ntes amount in charge slip and ns patient of cost.
	7.		s amount in the Income Proof [Form XV]
	8a	Refers	patient to the Cashier.

		8a.1 If patient is unable to pay part or full amount, fills up MSS referral slip [Form XVII] and refers the patient to the MSW.
Medical Social Worker (MSW)	8b.	Assesses and categorizes the patient.
	8c.	Indicates in the MSS referral slip the amount the patient is able to pay as donation, or prepares the Certificate of Indigency for truly indigent patient.
	8d.	Logs recommendation and forwards it to the COH or designate for the appropriate action.
Chief of Hospital (COH)/ Designate	8e.	Acts on MSW recommendation and returns to MSW.
Medical Social Worker (MSW)	8f.	Records COH's approval/action.
	8g.	Instructs patient to forward MSW approved recommendation to the Billing section.
Billing Section	8h.	If patient is classified as indigent per Certificate of Indigency [Form XVII], issues clearance to patient; if patient is to pay a partial amount as donation, bills patient according to MSW action and refers patient to the Cashier.
Cashier	9.	Receives payment and issues an official receipt to the patient.
	10.	Records payment.

15.2 In-Patient (Chart No. 14)

Responsibility	Action
Ward Nurse	1.	Prepares request for laboratory examination.
Nursing Attendant (NA)	2.	Logs request in the logbook and submits request to the laboratory.
Laboratory Aide/ Medical Technologist	3.	Receives request and reminds NA to give appropriate instructions to the patient.
Ward Nurse	4.	Records instructions given in the patient's chart.
Before 8:00 the following m	orning:
Medical Technologist	5.	Takes request and proceeds to the ward to get the sample needed for the requested procedure.
	6.	Labels specimen taken and proceeds to the laboratory for examination.
	7.	Records result in the results logbook and in the result form.
•	8.	Gives result to the Laboratory Head.

Laboratory H	Iead 9.	Reviews and signs result and submits it to the Medical Technologist.
Medical Tech	nologist 10.	Prepares charge slip in duplicate and attaches one copy to the result form.
	11.	Forwards charge slip to the Billing section.
Billing Sectio	on 12.	Enters transactions in Income Proof Sheet (IPS).
	13.	Files charge slip in a jacket.
Laboratory A	ide 14.	Delivers laboratory result to the ward concerned and asks the recipient to sign in the logbook.
Ward Nurse	15.	Attaches result to the patient's chart.

15.3 ER Patient (Chart No. 15)

Responsibility	Action
Nurse	1.	Sends signed request to the laboratory.
Medical Technologist	2.	Performs examination and notifies requesting physician of the result.
	3.	Prepares charge slip [Form XVIII] and sends it to Billing.
		Note: For required work-ups in the third shift, the charge slip may be prepared the following day. However, the Chief of Hospital or Resident-on-Duty may authorize the Medical Technologist on duty.
Billing Section	4.	Files charge slip in patient's jacket.
	5.	If requested, notifies patient/companion of cost incurred.

15.4 Blood Cross-Matching

	Responsibility	Action
	Physician	1.	Requests for blood cross-matching.
	Nursing Attendant	2.	Logs request in the logbook and submits the blood for cross-matching to the Medical Technologist with a request signed by the physician.
	Medical Technologist	3.	Goes to the ward to extract blood from the patient.
		4.	Brings properly labeled specimen to the laboratory.
		5.	Determines type of the patient's blood and retypes the donor's blood.
1		6a.	Examines the donor's blood.

If there is hemolysis, no cross-6a.1 matching is performed. Examines donor's blood for compatibility. 7. If the patient's and donor's blood are 8a. found to be compatible, stores blood until transfusion is performed. If not compatible, returns blood to the owner and instructs the ward to secure another unit. Records data in the logbook. 9. Fills up the Blood Cross-Matching 10. Result Form [Form XIX], signs, and submits it to the Laboratory Head. Reviews and signs result form and 11. Laboratory Head returns it to the Medical Technologist. Prepares charge slip in duplicate and 12. Medical Technologist attaches one copy to the result form. Forwards charge slip to the Billing section. 13. Files charge slip in jacket and enters the 14. Billing Section transaction in the Income Proof Sheet (IPS). Delivers result to the ward concerned and 15. Laboratory Aide asks the recipient to sign in the logbook. Attaches result to patient's chart. 16. Ward Nurse

15.5 Release of Donor's Blood

Responsibility	Action
Nursing Attendant (NA)	1.	Gets the Blood Cross-Matching Result Form from the patient's chart and presents it to the Laboratory.
Medical Technologist	2.	Locates the serial number from among the blood units stored in the blood bank refrigerator.
	3.	Gives blood to the NA.
Nursing Attendant (NA)	4.	Signs-out in the blood bank logbook and records the serial number.
	5.	Brings the blood to the Ward Nurse.
Ward Nurse	6.	Notifies the attending physician of the receipt of the blood unit.
Attending Physician	7.	Performs the transfusion of the blood to the patient.
Ward Nurse	8.	Records in the Transfusion Reaction Form [Form XX] any vital signs and reactions observed in the patient.
	9.	Signs the Transfusion Reaction Form.

Nursing Attendant (NA)	10.	Returns the completely filled up Transfusion Reaction Form to the laboratory.
Laboratory Personnel	11.	Receives the reaction form for filing.

15.6 Request for Histopath Examination

15.0 10044052101	F
Responsibility	Action
Surgeon	1.	Prepares request for histopath examination.
Medical Specialist/ Resident Physician/ Medical Intern/Ward Nurse	2.	Sends or takes specimen and request to the laboratory.
Medical Technologist	3.	Receives specimen, labels it properly, and records it in the logbook.
	4.	Places specimen in a container with formalin.
Pathologist	5.	Performs the sectioning and dictates gross description of the section.
Medical Technologist	6.	Writes down dictated description on the surgical pathology request.
	7.	Performs the processing, blocking, cutting, staining, and mounting.
	8.	Refers to the pathologist.
Pathologist	9.	Interprets slides and gives final diagnosis.
	10.	Describes the microscopic pathology on the request.
	11.	Submits it to the Laboratory Aide.
Laboratory Aide	12.	Types surgical pathology report and submits it to the Pathologist.
Pathologist	13.	Reviews and signs surgical pathology report and submits it to the Medical Technologist.
Medical Technologist	14.	Records report in the record book for histopath examinations and files one copy.
	15.	Prepares charge slip in duplicate and attaches one copy to the Histopath Surgical Pathology Report.
	16.	Forwards charge slip to the Billing section.
Billing Section	17.	Files charge slip in patient's jacket and enters transaction in the Income Proof Sheet (IPS).
Laboratory Aide	18.	Delivers report to the ward concerned and asks the recipient to sign in the logbook.

LABORATORY PROCEDURES IN-PATIENT

LABORATORY PROCEDURES ER PATIENT

RADIOLOGY PROCEDURES

16.1 OPD Patient (Chart No. 16)

Responsibility	Action	1
OPD Physician	1.	Prepares request for examination [Form XXI] and instructs the patient to proceed to the X-ray room for an examination.
_Patient	-2.	Presents request to the Laboratory Technician.
Laboratory Technician	3.	Receives request and records it in the logbook.
	4a.	If patient is in for special procedures, schedules patient.
		4a.1 Indicates in the registry card the date the patient has to return for special procedures.
		4a.2 Gives advice on the required preparations.
	5.	Performs specified examination(s).
	6.	Files request.
	7.	Informs patient of scheduled release of result (either to the patient or to the physician).
	8.	Prepares charge slip and instructs the patient/companion to proceed to Billing section.
Patient/Companion	9.	Presents charge slip to the Billing section.
Ü	10.	Indicates amount in charge slip and informs the patient/companion of the cost incurred.
	11 a.	Refers patient to Cashier.
		11a.1 If patient is unable to pay in part or in full the amount, fills up MSS referral slip and refers patient to the MSW.

Medical Social Worker (MSW)	11b.	Assesso 11b.1	es and categorizes the patient. Indicates in the MSS referral slip the amount the patient is able to pay as donation, or prepares the Certificate of Indigency for truly indigent patients.
		11b.2	Logs recommendation and forwards it to the COH or designate for the appropriate action.
Chief of Hospital (COH)/ Designate	11c.	Acts on MSW recommendation and returns it to the MSW. Records COH's approval/action. Instructs patient to forward MSV approved recommendation to the Billing section. If patient is classified as indigent p certificate of indigency, issues clearant to patient; if patient is to pay partion full amount as donation, bill patient according to MSW action ar refers patient to the Cashier.
Medical Social Worker	11 d.
	11e.
Billing Section	11f.
Cashier	12.		es payment and issues an official to the patient.
	13.		s payment and enters the transaction Income Proof Sheet (IPS).

16.2 In-Patient (Chart No. 17)

Responsibility	Action
Physician	1.	Prepares and signs request for x-ray examination.
Nursing Attendant (NA)	2.	Logs request in the logbook.
Ward Nurse	3.	Coordinates with x-ray unit for scheduling.
X-ray Technician	4.	Notifies Ward Nurse about the schedule of the patient and gives advice on the preparations to be made.
Nursing Attendant (NA)	5.	Takes doctor's request and patient to the x-ray unit.
X-ray Technician	6.	Receives request and records it in the logbook.
	7.	Performs x-ray examination or schedules patient for special procedures.
	8.	Forwards result to the Ward Nurse.
Ward Nurse	9.	Inserts result in the patient's chart and forwards it to the physician.

X-ray Technician	10.	Prepares charge slip, indicates number of films used and forwards it to the Billing section.
Billing Section	11.	Inserts charge slip in the patient's jacket.
	12.	Enters transaction in the Income Proof Sheet (IPS).

16.3 ER Patient (Chart No. 18)

Responsibility	Action	1
Physician	1.	Prepares and signs request for x-ray examination.
Nurse-on-Duty	2.	Informs X-ray Unit of the examination to be done.
X-ray Technician	3.	Performs examination and notifies the requesting physician of the result.
	4.	Prepares charge slip and sends it to the Billing section.
Billing Section	5.	Files charge slip in the patient's jacket and notifies the patient/ companion of the cost incurred.
	6.	Enters transaction in the Income Proof Sheet (IPS).

16.4 X-ray Findings

· ·	_
Responsibility	Action
X-ray Technician	1.	Takes film with request to the Radiologist.
Radiologist	2.	Reads, interprets, and writes down the findings.
X-ray Personnel	3.	Types findings on X-ray Result Form [Form XXII] (2 copies) and submits it to the Radiologist.
Radiologist	4.	Reviews result, signs and forwards it to the X-ray Personnel.
X-ray Personnel	5.	Files copy 2 of the result.
	6a.	Forwards copy 1 of the result:
		6a.1 To the ward for in-patient.
		6a.2 To the physician for OPD or ER patient.
	7.	Fills up the Daily Report Form.

RADIOLOGY PROCEDURES ER PATIENT

SUPPORT SERVICES

17.1.1 Classification of OPD Patient (Chart No. 20)

Responsibility	Action
OPD Referring Staff	1.	Fills up MSS Referral Slip (MSS Form #2) and forwards it to the MSW.
Medical Social Worker (MSW)	) 2a.	If patient has psychosocial problems, conducts the necessary casework intervention.
-		2a.1 Collaborates with OPD staff concerning the patient's problem.
	3.	Conducts intake interview, fills up and files the Intake Sheet (MSS Form #1). [Form XXIII]
¥	4.	Evaluates and classifies the patient per DO No. 435-B s. 1990.
	5a.	If patient is classified as Class C (partial sharing/donation), indicates it in the MSS Form #2.
		5a.1 If patient is classified as Class D (complete social service), indicates it in the MSS Form #2 and fills-up the Certificate of Indigency (MSS Form #14).
	6.	Forwards it to the COH for approval.
		Note: For amounts below P500.00, approval of the COH is not required.
Chief of Hospital (COH)	7a.	Reviews and approves recommendation.
		7a.1 For Class D patients, also signs the MSS Form #14.

	8.	Returns MSS Form #14 to the MSW.
Medical Social Worker (MSW)	9.	Records in the logbook the patient's name and the action taken.
	10a.	If classified as Class D, refers the patient back to OPD.
		10a.1 If classified as Class C, gives referral slip to the patient and refers him/her to the Cashier.
Cashier	10b.	Receives patient's donation/payment and issues the official receipt.
	10c.	Refers the patient back to OPD.
Patient	10d.	Presents official receipt to OPD staff/Nurse.
Out-Patient Department (OPD)	11.	Conducts necessary examination.
17.1.2 Classification of E	mergei	ncy Room Patients (Chart No. 21)
Responsibility	Action	1
Emergency Room Staff	1.	When patient's condition stabilizes, collaborates with the MSW on patients with psychosocial and economic problems.
	2.	Fills up MSS Referral Slip (MSS Form #2) and refers the patient to the MSW.
Medical Social Worker (MSW)	3a.	Interviews patient, family members, or significant persons; accomplishes the Intake Sheet (MSS Form #1).
		3a.1 When necessary, conducts an intensive casework, crisis intervention, and advocacy role.
	4.	Accomplishes Responsibility Slip (MSS Form #7). [Form XXIV]
	5.	Classifies patient and forwards recommendation forms (MSS Form #2) to the COH.
Chief of Hospital (COH)	6.	Reviews, approves, and returns the forms to the MSW.
Medical Social Worker (MSW)	7.	Files Intake Sheet.
, , ,	8.	Informs patient/family and ER Staff of the approved action.
Patient/Family	9.	Assumes responsibility for treatment and/or hospitalization in accordance with the approved action.
Medical Social Worker (MSW)	10.	Taps community resources for other needs of the patient (use MSS Form #4). [Form XXV]
	11.	Documents all case studies and files them accordingly.

17.1.3 Classification of Patient for Admission (In-patient) (Chart No. 22)

Responsibility	Action
Admitting Unit	1.	Forwards list of admission and refers the patient to the MSW. [Form XXX]
Medical Social Worker (MSW)	2.	Conducts intake interview on patient or relative and fills up the Intake Sheet (MSS Form #1). [Form XXIII]
	3.	Classifies patient according to DO No. 435-B s. 1990 (and other issuances) and indicates classification in the Clinical Cover Sheet of the patient's chart.
	4.	Returns Clinical Cover Sheet to the Admitting Unit.
,	5.	Establishes rapport and briefs patient/relatives on hospital policies, rules, and regulations.
	6.	Performs initial casework as necessary.
	7.	Documents classification and casework activity.
	8	Files accordingly.

Responsibility	Action
Attending Physician/ Nurse/Other Services	1.	Fills up MSS Referral Slip (MSS Form #3) and sends it to the MSS.
Medical Social Worker (MSW)	2.	Enters patient's name, address, and other data in the Monthly Casework Statistics (MSS Form # 9) [Form XXVI].
	3.	Confers with referring physician/nurse-in-charge.
	4.	Interviews patient/family members.
	5.	Evaluates data gathered and comes up with the social diagnosis and treatment.
	6.	Prepares a casework process recording with the intake sheet as the face sheet. (Adds blank sheet as needed for the process recording.)
	7.	Fills up in brief MSS Progress Report Form (MSS Form #5) [Form XXVII] and inserts it in the chart as ready reference for referring physician/other team members. Henceforth, progress of case shall be entered accordingly.

1. Schedules series of interviews with patient/family and consultation/ collaboration with physician/other team members.
2. Recommends direct purchase of blood/ medicine/other medical needs of deserving patients and forwards it to COH/AO for approval.
Chief of Hospital (COH)/ 10. Approves recommendation for direct purchase and returns it to the MSW.

Medical Social Worker (MSW) 11. Makes necessary arrangements with the business office for provision of direct purchase.
- 12. Taps community resources if necessary (use MSS Form #4).
- 1. Makes home visits and follows up as needed (use MSS Form #6). [Form XXVIII]
- 1. Attends to the discharge planning of patient.
- 1. Completes all documentation and files them accordingly upon discharge of the patient.
- 1. Conducts periodic follow-up of patient after discharge as indicated by the physician.
- 1. Records other daily activities (MSS Form #8).

Responsibility	Action
Referring Agency	1.	Submits summarized case study to support the referral.
	2.	Follows up progress of the case by coordinating regularly with the MSW.
	3.	Provides needs of the referred patient as required.
Medical Social Worker (MSW)	4.	Receives summarized case study from the referring agency.
	5.	Performs necessary casework intervention and establishes a continuing working relationship with the referring agency.
Referring Agency	6.	Coordinates with the MSW for the discharge planning of the patient.
	7.	Documents all casework proceedings and files them accordingly.

ı
	Responsibility	Action
	Medical Social Worker (MSW)	1.	Makes periodic program on Groupwork Activity and forwards it to the COH/AO for approval.
	Chief of Hospital (COH)/ Administrative Officer (AO)	2.	Approves program for implementation by the MSW.
	Medical Social Worker (MSW)	3.	Gathers patients/relatives/watchers in preparation for the groupwork activity
		4.	Invites resource persons from the different hospital services as needed for the groupwork activity.
		5a.	Introduces group activity:
l			5a.1	Socialization/Recreation
			5a.2	Briefing on hospital policies, rules, and regulations, public and human relations
			5a.3	Values education/re-orientation
			5a.4	Play/Group therapy
		-	5a.5	Livelihood program
			5a.6	Health education
		6.		monthly report of groupwork (use MSS Form #10). [Form XXIX]

17.1.7 Community Organization
Responsibility	Action	•
Medical Social Worker (MSW)	1.	Compiles listing of community resources (Government Organizations (GO), Non-Government Organizations (NGO), philanthropic families and individuals, volunteers, etc.) for ready reference.
	2.	Establishes ongoing linkages and coordination with these community resources.
	3.	Based on casework findings, refers deserving patients to any of these community agencies which could meet their needs (use MSS Forms #4) and to other hospitals for networking (use Form #15).
	4.	Initiates or participates in community outreach programs in the hospital's catchment area.
	5.	Follows-up and visits homes of patients as required (use MSS Form #6).

	incoming
	pic individual
to COH/AO for official acknowledgment
of their act	ivities/donatic	ns.

Chief of Hospital (COH)/ Administrative Officer (AO)

Acknowledges activities/donations and gives direction for issuance of such to patients or to concerned service for safekeeping and proper disposition.

Documents all activities emanating from GO, NGO, philanthropic individuals and volunteers coordinating with the hospital. (MSS Form #11)
Includes such activities in the official narrative (MSS Form 12) [Form XXXI] and statistical report (MSS Form 13) [Form XXXII].

17.1.8 Auxiliary Service

Responsibility

Action

Medical Social Worker (MSW)

1. Consultative Advisory Service
1. Social action.
1. Social administration.
1. Social research.
1. Education and training.
1. Public and human relation.
1. Specific-services.
1. Volunteer service.

17.2 Pharmacy (Chart No. 23)

17.2.1 Semestral Submission of Required Drugs and Medicines for Official Price List (Chart No. 24)

Responsibility

Action

Department Heads/ Pharmacy and Therapeutics Committee (PTC) 1. Submits list of drugs and medicines needed by the respective departments to the PTC*, for evaluation and endorses the same to the Pharmacist.

Pharmacist

Consolidates drugs and medicine requirements of departments indicating therapeutic classifications on generic nomenclature with complete drugs and medicine specifications, initials and forwards it to the Chairman, PTC for recommendation.

	Chairman, PTC	3.	Recommends approval of list and forwards it to the COH.
	Chief of Hospital (COH)	4.	Approves list and returns it to the Pharmacist.
	Pharmacist	5.	Forwards list of hospital requests to the DPC of the Region or the DOH PLS.
	Drug Procurement Committee (DPC) / Procurement and Logistics Service (PLS)	6.	Consolidates lists and prepares the bid documents.
	DPC/Commission on Bids and Awards (CBA)	7.	Conducts bidding and submits results to the Evaluation Committee.
	Evaluation Committee	8.	Evaluates and submits recommendations to DPC/CBA.
	DPC/CBA/PLS	9.	Prepares awards and price list for dissemination.
- 1

or DOH Therapeutics Committee

17.2.2. Regular Requisition and Procurement of Drugs and Medicines (Chart No. 25)

Responsibility	Action	1
Pharmacist	1 .	Determines stock level and prepares stock position sheet and Requisition Issue Voucher (RIV) of needed drugs and medicines with complete specifications based on the official price list.
•	2.	Forwards RIV to the Chief, Medical Professional Staff, or designate for review/initial.
Chief, Medical Professional	3.	Initials RIV and forwards it Staff/Designate to the AO.
Administrative Officer (AO)	4.	Reviews/initials RIV and forwards it to the COH.
Chief of Hospital (COH)	5.	Approves and forwards RIV to the Supply officer
Supply Officer	6.	Prepares action documents and processes them accordingly.

As a general rule, reordering point should be at 50% stock level.

17.2.3. Acceptance of Deliveries, Storage, and Preservation of Drugs and Medicines (Chart No. 26)

Responsibility	Action
Supply Officer	1.	Receives deliveries in the presence of the Pharmacist, representative of COA, and agency Inspection Committee.

Agency Inspection Committee	2.	Takes random samples and forwards them to the BFAD for testing.
	3.	Prepares inspection report, attaches BFAD test result and forwards it to the Supply Officer.
Supply Officer	4.	Prepares voucher for payment, and attaches inspection reports and other supporting documents.
	5.	Issues drugs and medicines to the Pharmacist.
Pharmacist	6.	Receives drugs and medicines for proper storage, preservation and records them accordingly.

17.2.4 Filling-up of Prescriptions for In-Patients (Chart No. 27)

0 -			,
Responsibility	Action	.s
Nursing Attendant (NA) Ward Liaison (WL)	1.		nts prescription signed by the ding physician to the nacist.
Pharmacist	2.	availa	ugs and medicines are not able, instructs the NA/WL/t/client accordingly.
	3a.	If drug	gs and medicines are available
		3a.1	Fills up prescription if the patient is indigent.
		3a.2	it is for a partial/full payment. Any problem in the
			classification of the patients refer to the MSW.
Medical Social Worker (MSW)		3a.3	Reclassifies patients accordingly.
Cashier		3a.4	Receives payment and issues official receipt.
Pharmacists	4.		ites official receipt number in the iption and fills up the same.
	5.		ds medicine issued and files iption.

Note: For Dangerous drugs, follow procedures per the Dangerous Drugs and Generics Acts.

17.2.5. Filling up of Prescriptions for Out-Patients (Chart No. 28)

Responsibility	Action	18
Patient/client	1.	Presents prescription signed by a physician to pharmacist
Pharmacist	2a.	Notes prices on prescription and instructs the patient/client to pay to the Cashier.

			-
			2a.1	If patient cannot afford to pay, refers the patient to the MSW.
	Medical Social Worker (MSW)		2a.2	Evaluates and classifies patient/ client and advise them accordingly.
	Cashier		2a.3	Receives payment and issues an official receipt to the patient/ client.
	Patient/Client	3.		its official receipt and ption to the Pharmacist.
	Pharmacist	4.		es official receipt number on the ption and fills up the same.
		5.	Issues 1	medicine to the patient/ client.
		6.	Record prescrip	s medicines issued and files the ption.
1

Note: For Dangerous drugs, follow procedures per the Dangerous Drugs and Generics Acts.

17.2.6 Disposal of Expired or Damaged Drugs and Medicines (Chart No. 29)

Responsibility	Action	s
Pharmacist	1.	Segregates expired or damaged drugs and medicines with their specifications and value in the Waste Material Report (WMR). [Form XXXIII]
	2.	Signs and submits WMR to the AO.
Administrative Officer (AO)	3.	Reviews and recommends approval of WMR to the COH.
Chief of Hospital (COH)	4.	Approves and forwards WMR to the Resident Auditor.
Resident Auditor	5.	Verifies actual condition of the drugs and medicines recommended for condemnation.
	6.	Recommends proper way of disposal, signs and returns WMR to the pharmacy for appropriate action.
Pharmacist	7.	Informs Disposal Committee.
Disposal Committee	8.	Conducts proper disposal as recommended and forwards WMR to the Accounting Section for dropping from the books of accounts.
Pharmacist	9.	Drops from the records quantity and value of disposed drugs and medicines.

17.3 Dietary Service (Chart No. 30)

Responsibility	Action
Dietitian	1.	Prepares cycle menu for the week.
	2.	Submits cycle menu plan to the COH/AO for approval.
Chief of Hospital (COH)/ Administrative Officer (AO)	3.	Reviews and approves weekly cycle menu plan and returns it to the Dietitian.
Dietitian	4.	Posts approved weekly cycle menu on the bulletin board for the guidance of the dietary personnel.

17.3.2 Food Procurement (Open-Market Purchases) (Chart No. 32)

Responsibility	Action
Dietitian	1.	Checks any leftover cooked/uncooked foodstuffs.
	2.	Checks menu for the day.
•	3.	Checks patients' census.
	4.	Determines requirement for various types of diets.
	5.	Determines quantity to be purchased based on the data gathered above.
	6.	Prepares procurement list or Market Order form.
	7.	Gives instructions to the assigned marketer of food items needed.
Assigned Marketer	8.	Purchases food items according to the given instructions.

Note: Each item purchased must be supported by an official receipt or reimbursement expense receipt (RER) for liquidation purposes.

17.3.3 Receiving and Storage (Chart No. 33)

Responsibility	Action	;
Dietitian	1.	Upon arrival of the purchased foodstuffs, checks all items according to the specifications and quantity required as indicated in the procurement list.
	2.	Lists all items on the Statement of Daily Market Purchases (SDMP). [Form XXXIV]
	3.	Presents purchased food items to the Inspection Committee representative.

Inspection Committee	4.	Checks food items against the SDMP, and Representative signs, indicating "inspected".
Dietitian	5.	Records all purchased items and amount incurred, as reflected in the SDMP.
	6.	Turns over food items to the assigned dietary personnel.
Assigned Dietary Personnel	7.	Brings perishable food items to the food preparation area and stores them in the proper places.
Dietitian	8.	Prepares reimbursement voucher and forwards it to the AO.
Administrative Officer (AO)	9.	Checks reimbursement voucher and forwards it to the Accounting Unit.

17.3.4 Food Preparation and Production

Responsibility	Action
Dietitian	1.	Determines number of persons and types of diets to be served, based on the daily meal census record book.
	2.	Determines equivalent quantity of food to be prepared/cooked.
	3.	Instructs Cook/FSW on the quantity of food and the menu to be prepared.
Cook	4.	Requisitions all items needed for cooking.
Food Service Worker (FSW) Cook	5.	Prepare and cook menu items.
Food Service Worker (FSW)	6.	Washes all used kitchen utensils and cleans the cooking area.

17.3.5 Service and Distribution

Responsibility	Action
Dietitian	1.	Checks meal census every meal time to include referrals, if there is any.
	2.	Prepares diet tags accordingly.
Food Service Worker (FSW)	3.	leansfers cooked food to the distribution area.
	4.	Prepares food trays for dishing out.
Dietitian/ Food Service Worker (FSW)	5.	Dish out and apportion cooked food on the patients' trays.
Food Service Worker (FSW)	6.	Classifies and groups food trays by wards.
	7.	Loads dish-out trays to the respective food conveyors.

Dietitian	8.	Checks loaded food trays according to the diet orders or prescriptions of patients.
Food Service Worker (FSW)	9.	Distributes food to the patients.
Dietitian	10.	Makes ward rounds and supervises food trays distribution as needed.
Food Service Worker (FSW)	11.	After meal time, collects and brings back used food trays to the Dietary Service.
	12.	Washes food trays for the next service use.

17.5 Medical Records Service (MRS) (Chart No. 34)

17.5.1 Preparation of Hospital Census Report

Responsibility	Action
Statistician	1.	Collates 24-hour floor census [Form XXXV] report forwarded by the nursing service.
~	2.	Prepares census report (4 copies) and forwards them to the Medical Records Officer.
Medical Records Officer	3.	Reviews report.
`	4.	Enters report in the worksheet for the monthly report.
Statistician/ Medical Records Librarian	5.	Files hospital census report.

17.5.2 Issuance of Medical and Medico-Legal Certificates (Chart No. 35)

(
Responsibility	Action
Medical Records Clerk	1.	Receives formal request for medico- legal certificate from an authorized party or a police authority.
	2.	Retrieves medical records from file.
	3.	Seeks clearance from the Attending Physician.
	4.	Instructs requesting party to pay the fee to the Cashier.
	5.	Types certification on the Medical Certificate Form (Form #37) in triplicate.
	6.	Forwards it to the Attending Physician and other physicians concerned for review and signature.
Attending Physician & Other Physicians Concerned	7.	Signs certificate and returns it to the Medical Records Section.

Medical Records Clerk	8.	Affixes seal of the hospital on the certificate and forwards it to the COH (Only for Medico-Legal Certificates.)
Chief of Hospital (COH)	9.	Attests/Signs certificate and returns it to the Medical Records Section.
Authorized Party	10.	Presents official receipt to the Medical Records Clerk.
Medical Records Clerk	11.	Records in the logbook, indicating the official receipt number and releases the certificate to the Authorized Party.
	12.	Attaches copy 3 to the patient's medical chart and files.

17.5.3 Preparation of Birth Certificates (Chart No. 36)

Responsibility	Action
Parent	1.	Fills-up draft form.
Ward Nurse/	2.	Interviews parent and verifies data.
	3.	Signs blank official birth certificate form.
	4.	Forwards draft form and the official form to the MRS.
Medical Records Clerk	5.	Types data into the official form (4 copies) and forwards it to the Ward Nurse.
Ward Nurse	6.	Checks the official birth certificate and forwards it to the attending physician.
Attending Physician	7.	Signs birth certificate and returns it to the MRS.
Medical Records Clerk	8.	Prepares list of birth certificates and letters of transmittal to the Local Civil Registrar and forwards them to the Medical Records Head.
Medical Records Head	9.	Signs transmittal letter and returns it to the Medical Records Clerk.
Medical Records Clerk	10.	Forwards birth certificates and transmittal letter to the Local Civil Registrar.
	11.	Files copy of list of birth certificates and transmittal letters.
	12.	Upon receipt of registered birth certificates, files a copy in the patient's medical record.

17.5.4 Issuance of Death Certificate (Chart No. 37)

Responsibility	Action
Nurse on Duty	1.	Prepares death certificate (5 copies) and forwards it to the attending physician.
Attending Physician	2.	Completes and signs death certificate and returns it to the Nurse.

Nurse	3.	Checks accuracy and completeness of data and forwards it to the Releasing/Information Clerk.
Releasing/Information Clerk	4.	Records in official logbook and releases four (4) copies (copies 1, 3, 4 and 5) of the death certificate to the patient's relative.
Patient's Relative	5.	Acknowledges acceptance of the death certificate and signs on the logbook.
Releasing/Information Clerk	6.	Advises patient's relative to register the death certificate to the Local Civil Registrar (LCR)
	7.	Forwards copy 2 of the death certificate to the MRS.
Medical Records Clerk	8.	Files death certificate accordingly.

17.5.5 Release of Clinical Information to Insurance Verifier (Chart No. 38)

Responsibility	Action
Medical Records Clerk	1.	Receives written request (waiver) from the authorized insurance verifier.
	2.	Retrieves patient's chart from the permanent file.
	3.	Authenticates signature of the patient on the waiver.
	4.	Informs Attending Physician of the request.
Attending Physician	5.	Determines whether or not the information may be released and advises the medical records clerk accordingly.
Medical Records Clerk	6.	Upon clearance, advises insurance verifier to pay the required verification and duplication fees to the hospital Cashier.
	7.	Upon presentation of official receipt by the insurance verifier, photocopies requested portion of the patient's chart and/or allows verifier to go over the chart.
	8.	Forwards photocopied portion to the Medical Records Head.
Medical Records Head	9.	Authenticates photocopy, affixes hospital's seal, and returns it to the Medical Records Clerk.
Medical Records Clerk	10.	Records in the official logbook and releases photocopied information to the insurance verifier.
	11.	Requests insurance verifier to acknowledge the receipt of the information.
	12.	Files waiver/request in patient's permanent file.

17.5.6 Retrieval of Patient's Chart for Authorized Borrowers

Responsibility	Action
Requesting Party/Borrower	1.	Submits duly accomplished request form to the Authorized Medical Records Clerk.
Medical Records Clerk	2.	Verifies patient's number from the master patient index.
	3.	Retrieves chart from the file.
	4.	Records in the logbook, indicating the name of the patient, the requesting party/authorized borrower, the date when borrowed, and the name of recipient of the patient's chart.
	5.	Releases patient's chart to the authorized borrower.
Authorized Borrower	6.	Signs logbook.

17.5.7 Processing of Medical Records Received For File (Chart No. 39)

J		-
	Responsibility	Action
	Medical Records	1.	list of	s all charts received against the discharges as reflected in the Census Report.
		2.	Record	ls all charts received.
		3.	on the	es the master patient index based e list of admission and checks tient's assigned unit number.
		4.	Forwards charts to the Assembly Clerk.
	Assembly Clerk	5.		nges the record according to the rd format.
		6.		rds reassembled records to the is Clerk.
	Analysis Clerk	7.	Analyz	es data on patient's chart
		8a.	slip, att	are incomplete, fills in deficiency caches it to chart and returns it to d/ clinical unit concerned.
	Ward/Clinical Unit		8a.1	Upon receipt of incomplete chart and deficiency slip, fills in the required data and signs it.
			8a.2	Returns completed chart and slip to the MRS.
	Medical Records Personnel		8a.3	Receives and forwards it to the Analysis Clerk.
	Analysis Clerk		8a.4	Completes data analysis.
1

	9.	Forwards completed chart to Coding and Indexing Clerk.
Coding and Indexing Clerk	10.	Codes and indexes diseases and operations as per prescribed code tools.
	11.	Forwards coded chart to the Filing Clerk.
Filing Clerk	12.	Sorts out coded chart according to the terminal digit-filing system and prepares the folders.
	13.	Files charts.

17.6 Linen and Laundry (Chart No. 40)

17.6.1 Collection of Soiled Linen

Responsibility	Action
Linen Personnel	1.	Collects, sorts, and counts linen.
	2.	Records number of sorted linen in the collection logbook.
Ward Personnel	3.	Signs logbook and indicates the date of collection.
Linen Personnel	4.	Places collected linen in bags and endorses them to the laundry.
Laundry Worker	5.	Counts and tallies the number of soiled linen received with the collection logbook.

17.6.2 Preparation and Distribution of Clean Linen to Ward

Responsibility	Action
Laundry Worker	1.	Forwards clean linen to the linen room.
Linen Personnel	2.	Receives, sorts, counts, and records linen in the appropriate logbook.
	3.	Segregates torn or damaged linen for repair or recycling.
	4.	Fills out distribution logbook based on the requests of the units.
	5.	Forwards distribution logbook to the Linen Head for signature.
Linen Head	6.	Signs distribution logbook.
Linen Personnel	7.	Packs linen and distributes them accordingly.
Ward Personnel	8.	Checks linen received and countersigns the logbook.

Linen Personnel	9.	Reports receipt of clean linen by the ward personnel to the Linen Head and presents logbook for checking.
Linen Head	10.	Checks for accuracy and completeness of recording.
Linen Personnel	11.	Files logbook in the designated area.

17.6.3 Repair and Disposal of Linen

Responsibility	Action	1
Linen Head	1.	Sorts and inspects torn linen.
	2.	Counts and segregates reparable linen from irreparable ones.
Linen Personnel	3.	Records reparable linen in the logbook and endorses them to the Sewing/Repair Room.
Seamstress/Tailor	4.	Receives and repairs torn linen.
	5.	Records repaired linen and endorses them to the Linen Personnel.
For irreparable linen:
Linen Personnel	6.	Prepares list of linen to be disposed and sends them to the Supply Unit for disposal.
Supply Unit	7.	Accomplishes Report of Waste Materials form and endorses it to the concerned signatories.
592	8.	Disposes linen accordingly.

Procedures Manual, 2nd Edition CY1994, Part 1

Document Info

MANUAL OF PROCEDURES FOR HOSPITALS

MANUAL OF PROCEDURES FOR HOSPITALS

TABLE OF CONTENTS

AUTHORIZATION

Republic of the Philippines DEPARTMENT OF HEALTH OFFICE FOR HEALTH FACILITIES, STANDARDS AND REGULATION

MESSAGE

Republic of the Philippines Department of Health OFFICE OF THE SECRETARY

FOREWORD

PREFACE

ACKNOWLEDGMENTS

A. Hospital Operations and Management Service

B. Bulacan Provincial Health Office

C. Region X

Northern Mindanao Regional Training Hospital

Bukidnon Provincial Hospital

Mayor Hilarion A. Ramiro Sr. General Hospital

Initao District Hospital

Tudela Municipal Hospital

Regional Health Office No. X

LIST OF CHARTS

LIST OF FORMS

FORM NO. DESCRIPTION

FORM NO. DESCRIPTION

LIST OF ABBREVIATIONS

INTRODUCTION

Background

Nature and Intent

Scope

Composition and Presentation

Proviso

PART I THE DEPARTMENT OF HEALTH

DEPARTMENT OF HEALTH OBJECTIVES AND GENERAL FUNCTIONS

THE DEPARTMENT OF HEALTH ORGANIZATION

THE DEPARTMENT OF HEALTH HOSPITAL SYSTEM

THE DOH HOSPITAL SYSTEM

PART II HOSPITAL PROCEDURES

HOSPITAL OPERATIONS SUMMARY FLOW

OUT-PATIENT DEPARTMENT PROCEDURES (Chart No. 3)

EMERGENCY ROOM PROCEDURES

Manual of Procedures for Hospitals

ADMISSION PROCEDURES (Chart No. 5)

WARD PROCEDURES

8.1 Admission to Ward

Manual of Procedures for Hospitals

8.2 Carrying-out Doctor's Orders

8.3 Daily Patient Care

OPERATING ROOM PROCEDURES

9.1 Preparation of the OR

9.2 Patient Care in the OR

Manual of Procedures for Hospitals

LABOR ROOM / DELIVERY ROOM PROCEDURES

10.1 Preparation of the LR/DR

10.2 Patient Care in the LR/DR

Central Supply Room (CSR)

11.1 Requisition of Supplies (Chart No. 6)

11.2 Receiving and Sterilization of Used Article (Chart No. 7)

11.3 Issuance of Sterile Articles

11.4 Articles for Condemnation (Chart No. 8)

11.5 Routine Preparation of Supplies for Ready Use

CENTRAL SUPPLY ROOM REQUISITION OF SUPPLIES

CENTRAL SUPPLY ROOM ARTICLES FOR CONDEMNATION

REFERRAL PROCEDURES

12.1 To Other Health Facilities (Chart No. 9)

12.2 To Other Departments Within the Hospital (Chart No. 10)

DISPOSITION OF PATIENT REFERRAL TO OTHER HEALTHCARE FACILITIES

DISPOSITION OF PATIENT REFERRAL TO OTHER DEPARTMENTS WITHIN THE HOSPITAL

DISPOSITION OF PATIENT

13.1 Discharge of Patient (Chart No. 11)

13.2 Discharge of Patient Against Medical Advice (Chart No. 12)

13.3 Issuance of Clearance Certificate

DISPOSITION OF CADAVER

14.1 Preparation of Cadaver in the Ward

14.2 Receiving in Morgue

14.3 Release of Cadaver to Claimant

14.4 Autopsy

LABORATORY PROCEDURES

15.1 OPD Patient (Chart No. 13)

15.2 In-Patient (Chart No. 14)