PROCEDURES MANUAL FOR GOVERNMENT HOSPITALS

3RD EDITION

PROCEDURES MANUAL FOR GOVERNMENT HOSPITALS 3 rd Edition

PROCEDURES MANUAL FOR GOVERNMENT HOSPITALS

Copyright 2021 by the Department of Health. All rights reserved. Subject to the acknowledgement of the Health Facility Development Bureau (HFDB), Department of Health, the Manual may be freely abstracted, reproduced or translated in part or in whole for noncommercial purposes only. If the entire Manual or substantial portions will be translated or reproduced, permission should be requested from the HFDB. Printed in the Republic of the Philippines.

National Library Cataloging-in-Publication Data
ISBN

Published by

Department of Health

San Lazaro Compound Rizal Avenue, Sta. Cruz, Manila 1003 PHILIPPINES

PRODUCTION CREDITS

Project Leaders: Dr. Terence John M. Antonio

Ms. Madeliene Gabrielle M. Doromal

Ms. Clara Francesca A. Roa

Copy Editor: Ms. Camille Ann C. Ople

Cover Design: Ar. Jean Paolo L. Policarpo

Development of this Manual was initiated, completed and subsequently published through the HFDB. For inquiries, contact the Bureau:

Phone: +63 2 8651 7800 locals 1401, 1403, 1408

Email Address: hfdb@doh.gov.ph

Republic of the Philippines Department of Health OFFICE OF THE SECRETARY

AUTHORIZATION

In accordance with the authority vested on the Secretary of Health, it is hereby declared that the policies and standards in the Procedures Manual for Government Hospitals, Third Edition shall guide the organization, management, operations and activities of the various services, departments, sections, and unit in the Department of Health (DOH) hospitals. The Manual may be used as reference by the local government and other hospitals and health facilities.

This Authorization shall take effect upon signing, and shall remain in effect until revised and updated by the DOH.

FRANCISCO T. DI QUE III, MD, MSc Secretary of Health

Republic of the Philippines Department of Health OFFICE OF THE SECRETARY

MESSAGE FROM THE SECRETARY OF HEALTH

Through the enactment of the Universal Health Care (UHC) by virtue of Republic Act No. 11223, the Department of Health (DOH) continues to lead the nation's development of a productive, resilient, equitable, and people-centered health system, with the central goal of ensuring that all Filipinos gain equitable access to quality and affordable health care goods and services, while also guaranteeing their protection against financial risk.

The DOH realises the fact that the demand for health services shall continue to grow, and thus recognizes that the only appropriate response to this is the continuous improvement of the operations of hospitals and other health facilities, as well as

the continuous development of the standards and policies relevant to health facility development. It is on this significant premise that this manual is crafted.

This Procedures Manual for Government Hospitals resonates from the strategies outlined in the F1 Plus' Service Delivery Pillar. The standards defined in this manual shall serve as guide and reference for hospital administrators, health service providers, and hospital support staff as they uphold the mandates of the UHC Act with improved computer-based information systems.

We are confident that these standards shall set our health facilities upon the right direction to ensure their readiness for the future of Philippine public health. This manual has also been imbued with the learnings gained by the entirety of the health sector from the global pandemic response. Through our steadfast work and enthusiastic collaboration to steer the entire Philippine health sector, we are optimistic that the vision of Universal Health Care for all Filipinos shall be ultimately achieved.

FRANCISCO T. DI QUE III, MD, MSc

Secretary of Health

Republic of the Philippines Department of Health

OFFICE OF THE SECRETARY

MESSAGE

The Department of Health's vision is for Filipinos to be among the healthiest in Southeast Asia and in Asia. The Universal Health Care (UHC) and the DOH's FOURmula One Plus for Health of F1 Plus provided a strategic direction in realizing this vision. The Health Facilities and Infrastructure Development Team (HFIDT) seeks to ensure the availability of adequate health services, foster proficient management of health sector resources for health facility development, and ensure the efficient and effective health facility

operations with the use of technology to empower patients through a people-centered approach to health services.

We proactively support the DOH's objective of providing all Filipinos better access to appropriate health care services without experiencing financial hardship. We serve with values of professionalism, integrity, responsiveness, compassion and excellence, to produce a more responsive health system that could guarantee better health outcomes for patients across all levels of care.

The Health Facility Development Bureau (HFDB), one of the Bureaus under the HFIDT, has undertaken the development of the Procedures Manual for Government Hospitals, in accordance with their mandate to develop policies, standards and plans related to health facilities and hospitals. This manual shall serve as the health facilities' reference in implementing the standard operating procedures of the different units or services of the hospital to ensure continuous quality improvement in the delivery of health care services.

We invite hospital administrators, medical and allied medical personnel and support staff, all other stakeholders, as well as other hospitals under the administration of the local government units, to promote and adopt these standards, to guide the determination to elevate the quality of our country's health care system.

Thank you and more power to all!

LILIBETH C. DAVID, MD, MPH, MPM, CESO I

Undersecretary of Health

Health Facilities and Infrastructure Development Team

Republic of the Philippines Department of Health

OFFICE OF THE SECRETARY

FOREWORD

The Health Facility Development Bureau (HFDB) of the Department of Health (DOH) is at the forefront in implementing the Integrated Hospital Operations and Management Program (IHOMP), which aims to standardize the management systems and procedures to enhance the preventive, promotive and curative roles of government and private hospitals.

Cognizant of the ever-changing milieu and the variance of procedures and services across the different hospitals, the HFDB constantly renews and consolidates the standards and operation systems of hospitals nationwide. Through development workshops and consultative meetings with key technical advisers, the HFDB ensures that information contained in this updated edition of the Procedures Manual for Government Hospitals are evidence-based and relevant.

The updated guidelines have been anchored to the fundamental premises of Universal Health Care (UHC) and the DOH's main strategic platform to boost UHC, the FOURmula One Plus for Health (F1+). It has incorporated the patient's vantage point and has considered how it integrates with the hospital administration. Moreover, this manual provides guidance on the implementation of information systems such as the DOH Integrated Hospital Operations Management Information System (iHOMIS) in response to permeating technological advancements.

This Manual will be periodically reviewed and revised to address new ideas that may arise overtime and shall be updated as new applicable regulations and guidelines are published. The HFDB encourages feedback from various stakeholders and users of this manual. But meanwhile, I hope that this manual will serve a useful purpose, especially for hospital administrators who handle a broad array of constituents and concerns.

MA. THERESA G. VERA, MD, MSc, MHA, CESO III

Director IV

Health Facility Development Bureau

ACKNOWLEDGEMENT

We would like to extend our sincerest appreciation to the different members of various expert groups of the different hospital services. The development of the Procedures Manual for Government Hospitals would have not been completed without the efforts and participation of these select technical working group members from the Emergency Department, Pharmacy, Medical Social Work, Nutrition-Dietetics, Laboratory, Nursing Service, Patient Safety, Infection Prevention and Control, etc. Their expert inputs and knowledge has added value and dignified the very essence of this material.

Also, this initiative has been accomplished through the tireless commitment and dedication from the advisers and technical staff of the Health Facility Development Bureau. We are grateful for the hard work that you have put into the creation of this manual. Their cooperation in the development of this manual is a manifestation of the HFDB's core values of excellence, integrity, collaborativeness, people-centeredness and team Work, which they have all proudly exemplified.

We would also like to extend our gratitude to the different offices in the Department of Health, namely the Procurement Service, the Knowledge Management and Information Technology Service, especially the IHOMIS Team, and the Administrative Service. Their generosity in sharing your expertise has helped in ensuring the refinement of the contents of this manual.

Last but definitely not the least, we would like to thank the DOH Hospitals who have provided their inputs and concurred in the consolidated procedures in this manual. Their enthusiastic contribution to the manual development has proven their commitment to continuous quality improvement in the provision of facility-based health care to Filipinos. With their full support, and as we enjoin our other stakeholders' cooperation, we could effectively steer the health sector towards the achievement of universal health care.

DEFINITION OF TERMS

Terminology	Definition
Annual Operational Planning	The version of the Local Investment Plan for Health (LIPH) that is prepared every year of the three-year planning cycle. this is an LGU spending plan document that sets the budgetary resources it expects to have for the year and the performance targets for this period. It may also refer to the indicative operational plan or OPlan for the succeeding fiscal year of the DOH. It is the basis of the budget proposal of the DOH Units or programs as opposed to the work and financial plan (WFP), which is based in the NEP or the GAA.
Annual Procurement Plan (APP)	An itemized list of goods and services, infrastructure projects and consulting services required for a calendar year planned for procurement out of the funds allotted to an agency.
Authorized Borrower	A person authorized by the owner of the health record or by a legitimate borrower to gain access to the specific record in accordance with the law and hospital policy/order.
Bidding Documents	Documents issued by the Procuring Entity as the bases for bids, furnishing all information necessary for a prospective bidder to prepare a bid for the infrastructure projects, goods, and/or consulting services required by the Procuring Entity.
Bromage Score	The most frequently used measure of motor block. In this scale, the intensity of motor block is assessed by the patient's ability to move their lower extremities.
Chief of the Administrative Service (CAS)	An officer occupying the highest position in the Hospital Operations and Patient Support Service, formerly known as the Administrative Service, such as Chief Administrative Officer (CAO) or Supervising Administrative Officer (SAO).
Condemnation	The act of destroying by burning, pounding, throwing, or any other method by which the valueless property of the government is disposed beyond economic recovery.
Cost Centers	Departments/sections/units of the hospital which does not generate income from its operations.

Disposal	The act of parting with, alienation of, or giving up supplies or property. It is the end of the life cycle of a government property.
Donation	Assets/properties acquired through contribution or donations from the private sector, other government agencies both local and foreign and non-government organization.
Health Facility	An institution that has health care as its core service, function or business. Health care pertains to the maintenance or improvement of the health of individuals or populations through the prevention, diagnosis, treatment, rehabilitation and chronic management of disease, illness, injury, and other physical and mental ailments or impairments of human beings.
Inspection	Examination of supplies or services (including materials and components) to determine whether the supplies and services conform to contract requirement.
Insurers	Refer to local health insurance officers of PhilHealth, health maintenance organizations and private health insurance companies issued certificates of authority by the Insurance Commission, and those identified by DOH and PhilHealth.
Integrated Hospital Operations and Management Information System (IHOMIS)	A computer-based information system developed by the Department of Health - Knowledge Management and Information Technology Service (DOH-KMITS)
Integrated Hospital Operations and Management Program (IHOMP)	Refers to the program under the Health Facility Development Bureau (HFDB) that ensures the implementation of standards and guidelines aimed to improve efficiency and effectiveness of health care services through creation and use of information for clinical, administrative, and monitoring purposes in hospitals and other health facilities.
Inventory	An itemized list of supplies or property on hand containing designation or description of each specific article with its valuation.

Negotiated Procurement	A method of procurement of goods, infrastructure projects and consulting services, whereby the procuring entity directly negotiates a contract with a technically, legally, and financially capable supplier, contractor, consultant or, where allowed, an individual consultant, only in cases provided under Sec. 53 of Republic Act No. 9184 and Sec 53, Rule XVI of its Implementing Rules and Regulations.
Nutrition and Dietetics Service	It is one of the major services of the hospital and plays an integral part of the total patient care service. This is organized and integrated with other units and departments/services of a hospital and is designed to ensure the provision of optimal nutrition care and quality food service.
Nutrition Care Process (NCP)	Systematic problem-solving method that nutrition and dietetics professionals utilize to critically think and make decisions to address nutrition-related problems and provide safe and effective quality nutrition care. NCP consists of four distinct steps which are interrelated and interconnected: Nutrition Assessment, Nutrition Diagnosis, Nutrition Intervention, and Nutrition Monitoring and Evaluation.
Partograph	Partograph is a Greek word meaning "Labor Curve". Partograph comes as a pre-printed one-page form on which labor observations are recorded, it provides a graphic overview of the progress of labor and records information about maternal and fetal condition during labor.
Patient Health Record/Health Record	Formerly known as Medical Record, is a chronological written account of a patient's examination and treatment that includes the patient's medical history and complaints, the physician's physical findings, the results of diagnostic tests and procedures, and medications and therapeutic procedures.
Point of Service (POS)	Refers to the program provided by the General Appropriations Act (GAA) 2017 to register non-PhilHealth members into the National Health Insurance Program (NHIP) thereby providing them immediate entitlement to PhilHealth benefits.
Preventive Maintenance	Correct operation and servicing, systematic inspection and detection and correction of the cause of equipment failures before they occur or develop into major defects.

Project Procurement Management Plan (PPMP)	It is an itemized list of the estimated quantity of supplies or property needed for the entire fiscal year by the end-user unit, with complete description as to kind, quantity, quality and the estimated cost
Property Accountability	The obligation imposed by lawful order or regulation of an official for keeping accurate record of property. The person having this obligation may or may not have actual possession of the property.
Revenue Centers	Departments/sections/units of the hospital which generate income from its operations.
Software Maintenance	Activities intended to keep the IHOMIS useful at all times.
Unit-Dose Drug Distribution System (UDDDS)	A pharmacy-coordinated method of dispensing and controlling medication in organized healthcare settings.

Table of Contents

Messages		i
Foreword		iv
	Acknowledgments
	Definition of Terms	vi
Part I –	INTRODUCTION	1
	Background and Rationale	2
	Objectives	3
	Scope and Coverage	3
Part II –	DESCRIPTION AND FLOW CHARTS OF THE PROCEDURES	5
	Chapter 1 Medical and Nursing Service Procedures	7
A.	Out Patient Department (OPD) Procedures	7
	OPD Consultation Procedures	7
B.	Emergency Department (ED) Procedures	10
	Emergency Room Department General Workflow	10
	Triage Procedure	12
	Management Of Patients	13
	ED Patient Disposition – Discharged Against Medical Advice	14
C.	Patient Conduction	16
	Patient Conduction	16
D.	General Admission Procedures	17
	General Admission Procedures	17
E.	Ward Admission Procedures	19
	Ward Admission Procedures	19
F.	General Discharge Procedures	22
	General Discharge Procedure	22
G.	Disposition of Cadaver	24
	Procedure For Disposal Of Cadaver	24
H.	Labor Room/Delivery Room Procedures	26
	Procedure On Transfer From Delivery Room To OB Ward	26
	Patient Care In The Labor Room	28

I.	Obstetrics (OB) Ward Procedures	30
	OB Ward Admission Procedure	30
J.	Perioperative Procedures	32
	Procedure On Pre-Operative Surgery (For Major Elective Surgery)	32
	Procedure For The Preparation Of Patient Prior To Transfer To OR	35
	Procedure For Patient Care In The Operating Room	36
	Procedure for Patient Care in the Post-Anesthesia Care Unit (PACU)	40
K.	Department of Pathology Procedures	42
	General Laboratory Procedure For Emergency Department Patients	42
	General Laboratory Procedure For In-Patients	44
	General Laboratory Procedure For Out-Patients	46
	General Laboratory Procedure For Histopathology Examination	48
L.	Radiology Procedures	50
	General Procedure for Radiology Examination	50
M.	Central Sterile Supply Department (CSSD) Procedures	53
	Preparation of the Project Procurement Management Plan (PPMP) for Annual Procurement Plan of Medical Supplies	53
	Requisition of Supplies	55
	Dispensing of Supplies	58
	Receiving and Sterilization of Used Articles	60
	Issuance of Sterile Articles	63
	Routine Preparation of Supplies for Sterilization	64
	Articles to be Condemned/Disposed	66
	Chapter 2 Allied Health Professional Service Procedures	68
N.	Medical Social Work (MSW) Department Procedures	68
	Availment of Medical Social Work Department (MSWD) Services in the Out-Patient Department	69
	Availment of Medical Social Work Department (MSWD) Services in the Emergency Department	70
	Availment of Medical Social Work Department (MSWD) Services for In-Patients	72
O.	Pharmacy Department Procedures	74
	Filling of Prescription for Out-Patient Department and the General Public	74
	Filling of Prescription for In-Patient	76
	Procedure on Unit Dose Dispensing	78
P.	Nutrition And Dietetics (ND) Department Procedures	80
	Referral Procedure for Nutrition Care Process (NCP)	80

	Ward Rounds	82
	Food Preparation and Distribution	84
Q.	Hospital Health Information Management (HHIM) Department Procedures	86
	Processing of Health Records for File	86
	Collection and Processing of Data from Patient Health Record	88
	Collection and Processing of Data from 24-hour Floor Census	89
	Preparation of Statistical Report	90
	Processing of Certificate of Live Birth (COLB)	92
	Release of Certificate of Death/Fetal Death (COFD)	94
	Issuance of Medical Certificate and Other Clinical Documents	96
	Release of Information to Insurance Verifier	98
	Disposal of Valueless Health Records	100
	Retrieval of Patient's Records for Authorized Borrowers	102
	Chapter 3 Hospital Finance Service (HFS) Procedures	103
	Issuance of Statement of Accounts	103
	Processing of Discharge Clearance	106
	Processing of Phil Health Claims	107
	Preparation of Summary of Bills Rendered	109
	Preparation of Budget Proposal	110
	Processing of Collection and Deposits	111
	Processing of Disbursements	113
	Processing of Purchase Order	115
	Processing of Disbursement Voucher (DV) for Payment	117
	Processing of Obligation Request and Status (ORS) and Budget Utilization Request and Status (BURS)	120
	Preparation and Submission of Statement of Appropriations, Allotments, Obligations, Balances and Disbursements (SAAOBD)	122
	Financial Report Process	124
Service	Chapter 4 Procedures Under the Hospital Operations and Patient Support	128
A.	General Administrative Procedures	128
	Operational Planning	128
	Processing of Documents	131
	Conduct of Meetings	134
	Decision Making Process	136
B.	Human Resource Management	138

	Recruitment, Selection and Promotion	138
	Application for Leave	143
	Employee Welfare and Benefits – Request for Payment of Personnel Claims	145
	Employee Welfare and Benefits – Request for Payment of Personnel Claims (1st Salary/Terminal Leave Pay)	147
	Employee Welfare and Benefits – Payroll Preparation	149
	Employee Welfare and Benefits – Request for Service Record/Certification	151
C.	Central Information Management	153
	Incoming and Outgoing Records	153
	Network Operations – Software Troubleshooting	154
	Network Operations – Hardware Troubleshooting	156
D.	General Services	158
	D.1 Engineering
	Preventive Maintenance Program	158
	Corrective Maintenance	160
	Rehabilitative Maintenance Program	164
	Ambulance Dispatching	166
	Use of Hospital Vehicle	168
	Submission of Reports	170
	D.2 Housekeeping, Linen and Laundry, and Security
	Maintenance of Cleanliness and Sanitation	171
	Collection/Transport of Hospital Waste	173
	Issuance of Clean Linen	175
	Collection and Laundry of Soiled Linen	176
	Inventory of Linens (in the Linen and Laundry Stock Room)	179
	Inventory of Linens (in Clinical Areas)	180
	Production of Linen	182
	Disposal of Condemned Linen	184
	Deployment of Security Guards	185
	Conduct of Investigation	187
E.	Property and Supply Management	188
	Procedure on Acquisition by Transfer	188
	Procedure on Acquisition by Donation	192
	Procedure on Acquisition by Manufacture/Fabrication	196

	Procedure on Construction by Administration	198
	Procedure on Bonding Accountable Officer	201
	Procedure on the Receipt, Inspection, Acceptance, and Recording Deliveries of Inventory Items and Equipment	203
	Procedure on the Requisition and Issuance Inventory Items	206
	Procedure on the Requisition and Issuance of Equipment	208
	Procedure on the Physical Inventory of Supplies and Equipment	210
	Procedure on Property Repair	214
	Procedure in Insuring Government Property	217
	Procedure in Transferring Property Accountability	219
	Procedure in the Request for Relief from Property Accountability	221
	Procedure in the Preparation of Inventory and Inspection Report of Unserviceable Property	224
	Procedure in the Preparation of Waste Material Report	228
	Procedure in Public Bidding	230
	Procedure in Sale Thru Negotiation	235
	Procedure in Transfer of Property	238
	Procedure in Donation	240
	Procedure in Condemnation/Destruction of Property	242
Part III –	References	243
Part IV –	Appendices	245
	DOH Administrative Order No. 44-A s. 1999
	Summary Report of Walkthrough for the Web-Based IHOMIS

xiv

PART I INTRODUCTION

BACKGROUND AND RATIONALE

The approval of Republic Act No. 11223, also known as the Universal Health Care (UHC) Act is a major milestone in the healthcare system of the Philippines. The Act aims to ensure that all Filipinos are guaranteed with equitable access to quality and affordable health care goods and services, and protected against financial risk.¹ One of the strategic thrust to attain this is through Improved Access to Quality Hospitals and Health Care Facilities. In line with the thrust of the Department of Health (DOH), the Health Facility Development Bureau (HFDB) is tasked to lead in the development of health facility standards, policies, programs and plans including structural and clinical management of the different services, departments and units.² These standards aim to provide a people-centered approach for the delivery of health services, and to ensure accessibility of essential quality health services at appropriate levels of care.

To achieve universal health coverage for all Filipinos, the expansion of the health services is inevitable. Thus, the need for a more comprehensive and clear set of procedures geared towards better performance in the health system. The hospitals and other health facilities have been continuously improving, not only in terms of their infrastructure and equipment, but also in terms of the quality of services they render.

As a guide to the implementation and management of these health services especially in government hospitals, HFDB is currently updating the manual of standards for each services and departments under the Integrated Hospital Operations and Management Program (IHOMP). This procedures manual is best used in conjunction with the following manuals:

• 1. Manual of Organization and Management of the Administrative and Finance Service for Hospitals;
• 2. Hospital Property and Supply Management Manual;
• 3. Hospital Nursing Service Administration Manual;
• 4. Hospital Pharmacy Management Manual;
• 5. Hospital Nutrition and Dietetics Service Management Manual;
• 6. Manual for Medical Social Workers Fifth Edition;
• 7. Manual of Standards for Infection Control in Health Care Facilities;
• 8. Quality Management Systems in Clinical Laboratories;
• 9. Manual of Standards and Guidelines on the Management of Hospital Emergency Department; and
• 10. Health Care Waste Management Manual
• 11. Revised Organizational Structure and Staffing Standards for Government Hospitals

The development of health facility standards, policies and plans; likewise, extends to the development of information and communication technology (ICT) infrastructure. In modern times, the health system also strives to be at par with the advancement of technology, specifically those that are beneficial to the various health facilities. For hospitals, the integrated Hospital Operations and Management Information System (iHOMIS) was developed through the Knowledge Management and Information Technology Service (KMITS).

¹ Sec. 3 (b) Republic Act No. 11223, 23 July 2018

² DOH Department Memorandum No. 2019-0010, Functional Directions for the Health Facilities and Infrastructure Development Team

The system was designed based on the manual of standards and operations of the hospitals under IHOMP as enumerated above. It was initially implemented in selected DOH, LGU and private hospitals in 2003. Throughout the years, the functionalities of iHOMIS expanded into generating needed data for various disease registries and other information systems. Currently, iHOMIS has integrated the requirements of the Philippine Health Insurance Corporation (PhilHealth) to enable the submission of needed data for membership verification and claims processing. Moreover, in coordination with the Commission on Audit (COA), the system is envisioned to link the financial aspect of the system to the electronic New Government Accounting System (eNGAS).

The DOH through its platform FOURmula One (F1 Plus) for Health recognizes the relevance of generating and utilizing data and information for evidence-based planning, policy development, program implementation and decision making in the health sector.³ Thus, all health facilities shall be required to submit health-related and financial data and to make accessible to the public prices of health services and goods being offered. Given this intent, all health service providers and insurers shall maintain a health information system that is consistent with DOH standards.⁴

In response to this directive, a workshop for the development of a Procedures Manual for Government Hospitals was conducted in January 28-31, 2020. The manual is an output from the expertise of selected Technical Working Group (TWG) members of the different manuals being reviewed and updated, technical staff of HFDB and DOH-retained hospitals. Likewise, the members of the iHOMIS Team participated in the said workshop to provide a perspective on the technicalities of the system.

The manual seeks to provide guidance and assistance in the complete translation of the standards into the iHOMIS. In addition to this, the manual seeks to ensure the compliance of the hospitals to the standards even after its translation into the hospital information system.

OBJECTIVES

The manual seeks to provide guidance in the incorporation, translation, and upgrading of the manual standards into the iHOMIS. Moreover, the manual aims to provide government hospitals with updated and integrated procedures that shall assist them in the delivery of quality health services for all Filipinos.

SCOPE AND COVERAGE

The manual consists of general procedures under the different services and departments available in a hospital. These procedures have been written in such a way as to accommodate and provide discretion to the hospitals in terms of the specific details and strategy in its implementation, while still being consistent with the standards.

³ DOH Administrative Order No. 2018-0014, Strategic Framework and Implementing Guidelines for FOURmula One Plus for Health

⁴ Sec. 36, Republic Act No. 11223, 23 July 2018

The manual is applicable to government hospitals; however, the following limitations have been identified:

• 1. Provides only minimum required steps in a procedure, which gives the hospitals prerogative to introduce modifications (i.e additional steps/procedures, or variation in forms, etc). Provided, that a.) DOH standards are still complied with, especially in the computerization or automation of hospital systems; and b.) major steps are still present to ensure the same desired outcome/output.
• 2. The procedures aim to provide the systems administrators/computer programmers an overview of simplified standards to assist them in the translation or upgrading of the system.
• 3. The procedures shall be understood and interpreted in consonance with the manual of standards, policies and plans of the hospitals.

PART II DESCRIPTION AND FLOW CHARTS OF THE PROCEDURES

DESCRIPTION and FLOW CHARTS of the PROCEDURES

This part includes the description and corresponding flowchart of the procedures of the different services and departments in a hospital.

A hospital is defined as a place devoted primarily to the maintenance and operation of health facilities for the diagnosis, treatment and care of individuals suffering from illness, disease, injury or deformity, or in need of obstetrical or other surgical, medical and nursing care. ⁵ Hospitals are classified based on ownership as government and private. A government health facility may be under the national government, DOH, Local Government Unit (LGU), Department of National Defense (DND), Philippine National Police (PNP), Department of Justice (DOJ), State Universities and Colleges (SUCs), Government Owned and Controlled Corporations (GOCC) and others. Moreover, they are classified according to their functional capacity as Level 1, Level 2 and Level 3 (Teaching/Training).

Table 1 shows the summary of the procedures included in this manual. These procedures are best construed when used together with the manual of standards under IHOMP.

	Name of Service/Department/Area	No. of Procedures
Medical and Nursing Service Procedures
1	Out Patient Department (OPD)	1
2	Emergency Department (ED)	4
3	Patient Conduction	1
4	General Admission Procedure	1
5	Ward Admission Procedure	1
6	General Discharge Procedure	1
7	Disposition of Cadaver	1
8	Labor Room/Delivery Room	2
9	Obstetrics (OB) Ward	1
10	Perioperative	4
11	Department of Pathology	4
12	Radiology Department	1
13	Central Sterile Supply Department (CSSD)	7
	Allied Health Professional Service Procedures
14	Medical Social Work Department (MSWD)	3
15	Pharmacy Department (PD)	3
16	Nutrition and Dietetics Department	3
17	Hospital Health Information Management (HHIM)	10
	Department
	Hospital Finance Service Procedures
18	Hospital Finance Service (HFS)	12
	Hospital Operations and Patient Support Service Procedures
19	Hospital Administrative Service Procedures	29
20	Property and Supply Management	20
	TOTAL	109

⁵ Department of Health (DOH) Administrative Order no. 2012-0012, Rules and Regulations Governing the New Classification Hospitals and Other Health Facilities in the Philippines, Definition of Terms and Acronyms, July 2012

Chapter 1 Medical and Nursing Service Procedures

The Medical Services consists of various departments, sections and units that form part and contribute to the overall efficiency of hospital operations. Likewise, the Nursing service is a vital component in the hospital that provides direct and indirect patient care. These services constitute the largest number of the medical and healthcare professionals and is the most predominant components of the hospitals.

A. Out Patient Department (OPD) Procedures

1. OPD Consultation Procedures

Description	Person/Department Responsible	Interface/Form/ Document
1. Classify patient as URGENT or NON-URGENT. Determine appropriate service.	Nurse or Physician	Triage Form
2. Data Gathering: Vital signs.	Nurse/Nurse Attendant	OPD Health Record
3. Preparation of Health Record. 3.1 For NEW patients, issuance of Hospital card and generation of patient health record. 3.2 For OLD patients, retrieval of records. 3.3 Issues priority number to patients. Then refer to appropriate clinic/department.	Hospital Health Information Management (HHIM) Staff Nurse	OPD Health Record
4. Medical Examination/Evaluation of the patient. 4.1 Orders/Issues Laboratory requests and prescribes medicines, treatment, diagnostic and procedures.	Physician	Inter-Department Referral Form; Admission Slip; Inter Agency Referral Form; Lab. Request; Prescription; Diagnostic Examination Request
5. Facilitates Medical Orders/Requests	Nurse	OPD Health Record; Referral Slip

5.1 Refers to ancillary services or allied health services as
necessary.
5.2 If no medical orders/requests,
provide health
instructions/health education.
6. Disposition of patient	Physician	OPD Health Record
a. If for admission, refer to Chart
No. 7 for the General
Admission Procedure.
b. If for referral, refer to the
procedures in the Medical
Social Work Department
Manual.
c. If for discharge, refer to Chart
No. 9 for the General
Discharge Procedure.
7. Issuance of the Charge	Billing	Charge Slip/SOA
Slip/Statement of Account
(SOA)* which reflects charges
made for treatment and other
procedures or supplies.
*for minor surgeries, hemodialysis
etc.
8. Classifies patient as to Socio	Medical Social	MSWD Assessment
Economic Status based on Patient	Worker (MSW)	Tool; Charge
Classification issuances.		slip/SOA
9. Collection of payment.	Cashier	Official Receipt (OR)
10. Discharges patient and provides	Nurse	OPD Health Record
health education and home
instructions

Chart No. 1: OPD Consultation Procedures

B. Emergency Department (ED) Procedures

2. Emergency Department General Workflow

Description	Person/Department Responsible	Interface/Form/ Document
1. Patient arrives in the ED seeking consult or treatment.
2. Patients are assessed and classified based on the triage classification system being used by the hospital, and are tagged accordingly. Refer to triage procedures process flow for the details. Note: Activate triaging process for emerging and re-emerging diseases in cases of	Triage officer (Physician or Nurse)	Patient Tag; Triage Record form
surge/pandemic.
3. Registration and preparation of health record. Record time of patient ED admission.	HHIM Staff	ED Health record (ED patient data sheet)
4. Transfers to the treatment area of the identified concerned unit or department.	Emergency Department (ED) Staff
5. Performs immediate care and work up. Refer to the Chart no. 4: Management of Patients. 5.1 Refers to ancillary services or allied health services as necessary.	Physicians and nurses	ED Chart (Emergency Treatment Record and ED assessment and disposition); Request slips (Lab, diagnostic); Referral form
6. Follows appropriate disposition procedures for: a. Discharged and Sent Home b. Discharged Against Medical Advice (DAMA) c. Referred/transferred to other health facility d. Absconded e. Admitted to Ward f. ED Death/Dead on Arrival (DOA)	Physicians and nurses	ED Chart (Emergency Treatment Record and ED assessment and disposition)

Chart No. 2: Emergency Department General Workflow

3. Triage Procedure

Description	Person/Department Responsible	Interface/Form/ Document
1. Assessment done by the triage officer not later than 5 minutes; measures vital signs; encode data in ED Registry System; Issuance of Emergency Department treatment record/chart.	Triage Officer (TO) Registry Clerk	Triage Record Form
2. Determines the urgency of the patient status using triage classification system in place (i.e 3-point system: emergent, non-urgent, urgent or 5-point system). Refer to the ED manual and hospital Standard Operating Procedures (SOPs) for details. a. If the patient is identified as ER case, proceed to no. 3. If NOT, refer to OPD. Note: Prompt referral to OPD shall be done to provide the appropriate care to the patient. The Nurse-in-charge/ the Physician in charge shall ensure a coordinated and efficient referral to the OPD.	Triage Officer (TO) or training medical personnel	Triage Record Form
3. Transfers patient to the appropriate treatment area.	Emergency Department (ED) Staff	Not Applicable

Chart No. 3: Triage Procedures

4. Management of Patients

	Description	Person/Department Responsible	Interface/Form/ Document
1.	Receives patient in the treatment area of the respective clinical department.	Staff of respective clinical department
2.	Conducts assessment of patient and provides initial management (diagnostic and therapeutic).	Physician	Informed consent for treatment; ED Assessment and Disposition; Request slips (diagnostics and therapeutics)
3.	Management based on protocol of hospital. 3.1 Carries out physician's order 3.2 Coordinates with allied health services or ancillary services/departments if necessary	Physician and Nurse	Consent form for selected procedures; ED Assessment and Disposition
4.	Conducts re-assessment and gives patient disposition.	Physician	ED Assessment and Disposition

Chart No. 4: Management of Patients

5. ED Patient Disposition – Discharged Against Medical Advice (DAMA)

Description	Person/Department Responsible	Interface/Form/ Document
1. Verbalizes refusal for further treatment in the hospital.	Patient/caregiver
2. Explains the condition, prognosis and medical consequences if patient/responsible person refuses admission and further treatment. Refers to MSWD for Psychosocial counselling of patient/caregiver.	Physician	Referral to MSWD slip
3. Conducts Psychosocial counselling	MSWD
4. If patient insists for DAMA, writes order on disposition of patient in treatment record.	Physician	Patient's treatment record
5. Explains DAMA Form	Nurse	DAMA Form
6. Accomplishes the Discharged Against Medical Advice (DAMA) Form, duly signed by person responsible.	Person responsible	DAMA form
7. Secures the signed DAMA form by attaching it to patient record.	Physician
8. Issues clearance and discharge slip	Registered Nurse (RN)	Clearance and discharge slip
9. Patient or relative proceeds to billing for appropriate charges and payment assessment.	Person responsible
10. Refer to the Hospital Finance Service (HFS) procedures for payment processing	HFS
11. Verifies upon submission the accomplished clearance/discharge slip	Physician/RN
12. Prepares discharge abstract and aftercare instructions	Physician and RN

Chart No. 5: ED Patient Disposition – Discharged Against Medical Advice (DAMA)

C. Procedure on Patient Conduction

6. Patient Conduction

Person/Department Responsible	Interface/Form/ Document
Attending Physician	Health record;
	Clinical abstract;
	Inter-agency;
	referral slip;
	discharge
	summary
	Health record;
	request forms (for
	concerned
	offices/units); trip
	ticket
	Referral Form
Properly endorses patient to receiving	Orders patient for conduction for the (AP) for going home upon discharge. necessary Nurse concerned for conduction of patient to other health may vehicle; The assigned physician, nurse and/or AP and/or Nurse or Medical Social Worker accompanies Medical Social Worker AP and/or Nurse or Medical Social Worker

Chart No. 6: Patient Conduction

D. General Admission Procedure

7. General Admission Procedure

	Description	Person/Department Responsible	Interface/Form/ Document
1.	Writes Order that patient is for admission.	Physician
2.	Carries out physician's order by issuing admission slip and providing instructions.	Nurse on duty (NOD)	Admission Slip
3.	Verifies patient's PHIC membership. 3.1 If yes, refer to PhilHealth CARES for verification of status of membership. 3.2 If not, refer to MSWD for enrollment.	Admitting Staff	PHIC Verification slip
4.	Asks patient/caregiver room preference (i.e private, basic, etc.) and checks availability of accommodation. 4.1 Explains room amenities and cost to patient/caregiver to assist them in decision making.	Admitting Staff	Admission Slip
5.	Coordinates with concerned units/departments (i.e MSWD, Billing, PhilHealth CARES, Physician) for information verification.	Admitting Staff
6.	Encodes data relevant to the admission of the patient and prints clinical cover sheet. Explains thoroughly informed consent to admission/confinement.	Admitting Section	Clinical Cover Sheet; Informed Consent to admission
7.	Notifies the NOD in the appropriate ward about the Admission	Admitting Section
8.	Transfers patient to Ward/Room of assignment.	Nursing Attendant	Patient's Health Record
9.	Receives patient and chart.	Ward Nurses	Patient's Health Record

Chart No. 7: General Admission Procedures

E. Ward Admission Procedure

8. Ward Admission Procedures

		Person/Department	Interface/Form/
Description		Responsible	Document
1. Receives Nurse.	notification from Admitting Section. Prepares patient's bed assignment, medical supplies and materials needed based on the information from the Admitting Unit and Emergency Department (ED)	Nurse	Clinical Cover Sheet
2. bedside table, bed tag/number, etc.)	Prepares patient's unit/ room (bed,	Nursing Attendant	Bed Tag
3. Record from OPD/ER Nurse. 3.1 data; 3.2 assigned room/bed; and 3.3 Orients patient/ of his/her departments and services.	Receives patient and his/her Health Checks Patient Health Record as to completeness and veracity of Accompanies patient to his/her caregiver on hospital policies, physical set-up ward and other	Nurse	Patient's Health Record
4. Assess patient's status: Vital consciousness, findings in the Record.	condition/health signs, level of nutrition screening (clinical condition and intake/weight and height history) and documents patient's Health	Nurse	Patient's Health Record; Nutrition Screening Tool
5. the following:  laboratory procedures preparation;   medications and effect if any;  treatment procedures; or 	Carries out Doctor's Order not done. Instructs patient/caregiver for any of or diagnostic to be done and its dietary/nutritional requirement; its action, side referrals to other services/depts.	Nurse	Patient's Health Record; Doctor's order and progress notes
6. directory.	Enters patient's data in the daily ward census, kardex, diet list and ward	Nurse	Census Logbook; Daily Ward Census; Kardex; Diet List

7. Informs the physician on duty of new admission and refer pertinent findings necessary for the plan of care or management.	Nurse
8. Documents patient care activities, observations, interventions through Focus, Data, Actions, Result (FDAR) and medications and treatment given/administered.	Nurse	Patient's Health Record; Nurses Notes; Medication sheet; IV Fluid Sheet; Intake and Output Monitoring sheet; Temperature, Pulse, Respiratory rate (TPR); Vital signs
9. Completes Admission documents in the Chart (ie History, PE and 1st Ward notes).	Physician	Patient's Health Record
10. Update the chart for any progress or new orders  Facilitate referral to other services/ specialty (if applicable)	Physician	Patient's Health Record Doctor's Notes
11. Request Nurse on Duty to read back new orders if there are any.	Physician	Doctor's Notes
12. Facilitates new orders (if applicable, documents patient care activities, observations, interventions through FDAR and medications and treatment given/administered.	Nurse	Patient's Health Record; Nurses Notes; Medication sheet; IV Fluid Sheet; Intake and Output Monitoring sheet; Temperature, Pulse, Respiratory rate (TPR); Vital signs

Chart No. 8: Ward Admission Procedures

F. General Discharge Procedure

9. General Discharge Procedure

Description	Person/Department Responsible	Interface/Form/ Document
1. Gives order for discharge and instructions.	Physician	Emergency assessment and disposition form; Doctor's order sheet; clinical cover sheet
2. Carries out doctor's order and provides discharge planning/aftercare instructions to patient and caregiver which may include but is not limited to the following: a. Medications; b. Follow-up; c. Warning signs; d. Post-partum care; and e. Dietary Instructions.	Nurse and other allied health service/department concerned.	Discharge summary; WHO Safe Child Checklist
3. Consolidates all charges and forwards to billing section.	Clerk
4. Informs all revenue centers and MSWD that patient is for discharge.	Billing and Claims Department (BCD)
5. Revenue centers forwards remaining charge slips to Billing and Claims Department. MSWD forwards classification and funding grants to Billing and Claims Department.	Revenue centers and MSWD
6. Generates Statement of Account (SOA).	BCD	Statement of Account (SOA)
7. Provides copy of the SOA and explains to patient/caregiver.	BCD
8. Refers patient/caregiver to the Cash Operations Department (COD) for payment.	BCD	Official Receipt
9. Processes payment and issues discharge clearance to patient/caregiver.	Cash Operations Department (COD)	Discharge Clearance and Official Receipt.
10. Receives accomplished discharge clearance from patient/caregiver.	Staff	Clearance/discharge slip
11. Accomplishes discharge summary and completes entry in chart.	Physician	Discharge summary, Patient Health Record
12. Issues discharge summary, clearance and gate pass to patient/caregiver.	Nurse	Discharge summary, Clearance.

Chart No. 9: General Discharge Procedure

G. Procedure for Disposition of Cadaver

10. Disposal of Cadaver

Description	Person/Department Responsible	Interface/Form/ Document
1. Receives endorsed Cadaver with	Morgue Technician	Cadaver' Tag,
accomplished identification.		Cadaver ID form
2. Registers in the Morgue Registry	Morgue Technician	Morgue Registry
Logbook		Logbook
3. Verifies endorsement note and	Morgue Technician	Morgue Registry
cadaver tag to determine if cadaver		Logbook;
is infectious.		Nurse's
 For Non-Infectious,		Endorsement
Cadaver are deposited in the		Form
Morgue Freezer
 For Infectious Cadaver,
must ensure that it is placed
in an air-tight cadaver bag
prior to deposit in morgue
freezer
4. If Cadaver is unclaimed (Retention	Morgue Technician	Hospital Standard
Time is 3-5 days as stated in the		Operating
Sanitation Code of the Philippines):		Procedures (SOP)
Follows the procedure/guidelines
for disposal of unclaimed cadaver
and submits/refers list of unclaimed
to the MSWD
If cadaver is claimed:

Receive Notice of Release of Cadaver
 Verify identity of claimant
 Identification of cadaver by the verified claimant
 Verify that proper vehicle for transport is used
5. Records the release of Cadaver in	Morgue Technician	Morgue Registry
the Morgue Registry Logbook		Logbook

Chart No. 10: Disposal of Cadaver

H. Labor Room/Delivery Room Procedures

11. Procedure on Transfer from Delivery Room to OB Ward

Description	Person/Department Responsible	Interface/Form/ Document
1. Orders transfer of patient post- partum.	Resident on Duty / OB	Patient Health Record
Checks status of mother and baby and coordinates with Admitting section. If the status of the mother and baby is critical, refer to PACU/NICU. If not critical, then refer to OB ward/room. Refer to chart no. XX for OB ward admission process.	Delivery Room (DR) Nurse	Patient Health Record
3. Completes the Delivery Room (DR) charting using the Focus-Data-Actions-Response (FDAR) method and accomplishes Certificate of Live Birth (COLB)	DR Nurse	DR Charting (FDAR); COLB
4. Accomplishes charge slip and forwards to Billing Section	DR Nurse	Charge slip
5. Endorses Mother and Baby to: 5.1 PACU/NICU for critical care; or 5.2 OB ward/room for non-critical care	DR Nurse	Checklist Medication Medical Record Latest Vital Signs

Chart No. 11: Procedure on Transfer from Delivery Room to OB Ward

12. Patient Care in the Labor Room

Description	Person/Department Responsible	Interface/Form/ Document
1. Receives patient from ER-LR.	Labor Room (LR) Nurse	Patient Health Record; Labor Room Record; informed consent to ; referral slip
Monitors progress of labor (Vital 2. signs, Fetal Heart Tone, Contractions, Internal Examination, etc.) and provides feedback to physician	LR Nurse/Midwife	Patient Health Record/Labor Room Record
3. Continuously assesses current status which includes but is not limited to the following: a. Name, Age, Age of Gestation (AOG), Last Menstrual Period (LMP), Previous Menstrual Period (PMP), OB Score (GPS Score) b. Vital signs and Internal Examination (I.E) c. Partograph (Supplemental to the patient health record)	Physician	Labor Room Record
4. Determines if the Patient is High Risk. a. Checks if there is a need for additional diagnostic examination. b. If Yes, refers to appropriate department for co management.	Physician
5. Carries out doctor's order and continuously monitors the progress of labor. Refers to physician as necessary.	LR Nurse	Doctor's Order and Progress Notes
6. Transfers patient to the Delivery Room (DR)/Operating Room (OR) as the case may be.	LR Nurse/Midwife/Nursing Attendant

Chart No. 12: Patient Care in the Labor Room

I. Obstetrics (OB) Ward Procedures

13. OB Ward Admission Procedure

Description	Person/Department Responsible	Interface/Form/ Document
1. Notifies ward for new admission.	Admitting Staff
2. Receives mother & baby and transport to assigned bed/room.	Ward Nurse	Health Record of mother and baby
3. Thorough Physical assessment of both Mother & Baby (vaginal bleeding, contracted uterus).	Ward Nurse	WHO Safe Child Birth Checklist
4. Carries out post-partum Orders and documents and conducts Nutrition Screening.  Medication/Treatment  Nursing care  Vital signs  Therapeutic diet  Diagnostic examinations	Ward Nurse	Health Record of mother and baby; diagnostic request slip
5. Determines if the patient is on Therapeutic Diet. 5.1 If YES, refers to Nutritionist Dietitian for Nutrition Care Process (NCP). 5.2 If NO, include in diet list.	Ward Nurse	NCP; diet list
6. Provides patient care management.	Medical Team	Patient health record.

Chart No. 13: OB Ward Admission Procedure

J. Perioperative Procedures

14. Procedure on Pre-Operative Surgery (For Major Elective Surgery)

Description	Person/Department Responsible	Interface/Form/ Document
1. Explains the procedure to the patient and family.	Surgeon	Physician's Admitting Order Sheet Informed consent form (Surgery)
2. Facilitate signing of informed consent.	Surgeon / Ward Nurse	Informed Consent Form
Note: Check policy on validity of informed consent.
3. Writes the order for surgery and schedule, including referral to anesthesia, internal medicine for co management, prophylactic antibiotic, intravenous hydration, schedule of fasting, bowel preparation if needed.	Surgeon	Patient Database Form; Histopathology Request Form
4. Endorses the orders to the nurse-on duty.	Surgeon	Patient Database Form; Histopathology Request Form
5. Accomplishes the following: Patient Database Form, Safe Surgery Checklist, Histopathology Request Form.	Surgeon	Patient Database Form; Histopathology Request Form
6. Places Surgical Marking (if needed) to ensure correct site.	Surgeon	Patient Database Form; Histopathology Request Form
7. Carries-out doctor's order after read back. 7.1 Refer to MSWD for Psychosocial interventions. 7.2 If Cardio-Pulmonary Clearance is needed, refers to Internal Medicine (IM) or other appropriate department. If cleared, or no CP Clearance needed, Proceed to number 4.	Ward Nurse	Patient's chart

7.3 If not cleared, facilitates orders by other departments needed for clearance then refer back to appropriate department.
8. Prepares OR proposal form.	Ward Nurse	OR Proposal Form
9. Forwards OR Proposal to OR.	Ward Nurse
10. Receipt of OR Proposal and makes necessary preparation for operation	OR Nurse
11. Schedules proposal for operation and informs Anesthesia Department of OR Proposal.	OR Nurse
12. Visits and assesses the patient and make pre-operative order (i.e. NPO; IVF medications, etc.) Also assesses the need for further labs, specific	Anesthesiologist
clearances, makes recommendations for optimization of patient for surgery.	Internist
13. Informs surgeon of anesthesia department's orders and carries out order of the Anesthesiologist.	Ward Nurse
14. Requests for Pre-operative medications and other medications needed intraoperatively.	Ward Nurse

Chart No. 14: Procedure on Pre-Operative Surgery (For Major Elective Surgery)

15. Procedure for the Preparation of Patient Prior to Transport to OR

Description	Person/Department Responsible	Interface/Form/ Document
1. Coordinates with ward nurse-on duty regarding the transfer of patient to OR	OR Nurse
2. Prepares necessary interventions for the patient	Ward Nurse	Pre-operative Checklist
3. Calls the Operating Room to confirm transfer of the patient.	Ward Nurse
4. Transfers the patient from ward to Operating Room.	Ward Nurse/Nursing Attendant	Patient's Chart
5. Endorses patient to Operating Room Nurse	Ward Nurse

Chart No. 15: Procedure for the Preparation of Patient Prior to Transport to OR

16. Procedure for Patient Care in the Operating Room

Description	Person/Department Responsible	Interface/Form/ Document
1. Receives the patient from the ward nurse to the OR complex. 1.1 Confirms patient's identity,	Circulating Nurse	Patient ID Wrist Tag
surgical site, consent, etc. 1.2 Checks if all pre-operative medications were given and all materials for the procedure are available for use. Informs the anesthesiologist of the patient.		Pre-Operative Checklist
2. Validates Pre-operative checklist and reassessment of the patient done 2.1 Anesthesiologists may opt to give	Circulating Nurses	Pre-Operative Checklist
pre-medications (i.e. sedatives) to the patient, then give oxygen here.	Anesthesiologist
3. Transfers the patient to the operating room and on to the operating table	Anesthesiologist Circulating nurse/ Nursing attendant
4. Accomplishes the SIGN-IN part of Surgical Safety Checklist. The following has been confirmed: a. Identity b. Site c. Procedure d. Consent e. Site Marking	Circulating Nurse/Anesthesiologist	Surgical Safety Checklist
5. Prepares the following: 5.1 Takes and records the initial vital signs of the patient. 5.2 Checks materials needed for the induction of anesthesia are readily available. 5.2.1 Checks the patency of the intravenous fluid line anesthesia machine, any emergency medications, checks the airway instruments, etc.	Anesthesiologist
6. Inducts anesthesia, monitors and records the status of the patient	Anesthesiologist	Anesthesia Record
7. Prepares the OR pack, OR instruments, needles and sponges,	Scrub Nurse

and other special instruments or equipment.
8. Performs surgical hand washing,	Surgeon
proper gowning and gloving.	Scrub Nurse
9. Performs counting of instruments,	Circulating Nurse	OR Checklist
needles and sponges, dictates and	Scrub Nurse
record the number prior to operation
10. Disinfects operative site and place	Surgeon
sterile drapes over the patient.
11. Accomplishes the TIME-OUT part	Circulating	Surgical Safety
of Surgical Safety Checklist.	Nurse/Anesthesiologist	Checklist
12. Performs the operation.	Surgeon	OR Checklist
	Circulating Nurse	Nurse's Notes
	Anesthesiologist
13. Records the cutting time and end of	Anesthesiologist	Anesthesia
surgery. Monitors and records the		Record
status of the patient.	Circulating Nurse
		Patient's Chart
14. Performs counting of instruments,	Circulating Nurse	OR Checklist
needles and sponges, dictates and	Scrub Nurse	Nurse's Notes
records the number prior to closure of
operative site and records it.
15. Informs surgeon of the completeness	Circulating Nurse	OR Checklist
of the instruments, needles and
sponges.
16. Closes the operative site and places	Surgeon
top dressing.
17. Stabilizes vital signs and level of	Anesthesiologist	Anesthesia
conscious of patient.		Record
18. Accomplishes the following	Surgeon	OR Technique
documents:	Circulating Nurse	Nursing
18.1 Operative Technique	Anesthesiologist	Documentation
18.2 Nursing documentation		Patient's chart
18.3 Anesthesia record		Surgical Safety
18.4 Post-operative orders		Checklist
19. Cleanses and keeps the patient dry.	Scrub Nurse
Transfers the patient to the stretcher.
Provides blanket and keeps side rails
up. Collects, places and labels
specimen in a container with 10%
formalin solution.
20. Accomplishes the SIGN OUT part of	Circulating	Surgical Safety
Surgical Safety Checklist.	Nurse/Anesthesiologist	Checklist
21. Provides oxygen during transport,	Anesthesiologist
ensures that patient's vital signs are
stable prior to transfer out of the OR.
22. Transfers and endorses the patient to	Surgeon	Patient's Chart
PACU.	Anesthesiologist
	Circulating Nurse

Chart No. 16: Procedure for Patient Care in the Operating Room

Operating Room (OR)

17. Procedure for Patient Care in the Post-Anesthesia Care Unit (PACU)

	Description	Person/Department Responsible	Interface/Form/ Document
1.	Receives patient from the operating room: hand-off by the anesthesiologist	PACU Nurse	Patient ID Wrist Band Patient's Chart
2.	Monitors and records the following: 2.1 Initial Vital Signs – heart rate, respiratory rate, oxygen saturation, ECG; 2.2 Initial Observations; 2.3 Level of Consciousness; 2.4 Pain Scale; and 2.5 Bromage Score (if under regional anesthesia)	PACU Nurse	PACU Record
3.	Carries out post-operative orders.	PACU Nurse	Patient's Chart
4.	Continuously monitors and documents all observations and nursing interventions. 4.1 Vital Signs; 4.2 Level of Consciousness; 4.3 Pain Scale; 4.4 Bromage Score (if applicable); 4.5 All observation and management intervention made	PACU Nurse	PACU Record
5.	Informs anesthesiologist regarding status and readiness for transfer of patient to ward.	PACU Nurse
6.	Evaluates the patient if can already be transferred to the ward (using Modified Aldrete Scoring System or Post Anesthesia Discharge Scoring System) 6.1 If yes, writes doctor's order for transfer of patient. 6.2 If not, continuously monitors patient, then evaluates again for status. May have the option to transfer to ICU or special care unit if needed	Anesthesiologist	Doctor's Order
7.	Carries out Doctor's Order	PACU Nurse	Doctor's Order
8.	Informs Ward Nurse regarding transfer of patient	PACU Nurse
9.	Facilitates transfer of patient to ward	PACU Nurse
10.	Endorses patient and patient record to ward nurse	PACU Nurse	Patient's Chart, PACU Record

Chart No. 17: Procedure for Patient Care in the Post-Anesthesia Care Unit (PACU)

K. Department of Pathology Procedures

18. General Laboratory Procedure for Emergency Department Patients

Description	Person/Department Responsible	Interface/Form/ Document
1. Orders the patient's laboratory request, Short Turn Around Time (STAT).	Physician	Laboratory request form/ ER Treatment Record
2. Forwards the request to the laboratory.	ED staff	Laboratory request form
3. Receives, verifies completeness of data and encodes/logs laboratory request: 3.1 If complete, proceeds to Step 4. 3.2 If incomplete, facilitates or coordinates with source of request.	Laboratory Staff (LS)/Clerk	Laboratory request form
4. Collects samples in the ED (Refer to Primary Sample Collection Manual)	Phlebotomist/Medical Technologist (MT)	Primary Sample Collection Manual
5. Processes sample (refer to the institutional technical manual)	MT	Technical manual of the Health Facilities
6. Validates and signs the result of the laboratory test requested	Section head/Chief Medical Technologist(CMT) and Pathologist	Laboratory result form
7. Releases result/s to ED via either of the following platforms: 7.1 Laboratory Information System; 7.2 Hard Copy; or 7.3 Electronic Health Record (EHR)/iHOMIS.	LS/Clerk	Laboratory result form

Note: The hospital shall establish turnaround time for every laboratory procedure.

Chart No. 18: General Laboratory Procedure for Emergency Department Patients

19.General Laboratory Procedure for In-Patients

Description	Person/Department Responsible	Interface/Form/ Document
1. Orders the patient's laboratory request.	Physician	Laboratory Request Form/Patient's Health Record
2. Forwards the request to the laboratory.	Nurse	Laboratory Request Form
3. Receives, verifies completeness of data and encodes/logs lab request: 3.1 If complete, proceeds to Step 4. 3.2 If incomplete, facilitates or coordinates with source of request.	Laboratory Staff (LS)/Clerk	Laboratory Request Form
4. Checks availability of test procedure. 4.1 If test is available, proceed to Step 5. 4.2 If test is not available, refer to Referral System Guidelines of the Laboratory.	Medical Technologist (MT)	Referral System Guidelines of the Laboratory
5. Collects samples in the ward (Refer to Primary Sample Collection Manual).	Phlebotomist/ MT	Primary Sample Collection Manual
6. Processes sample (refer to the institutional technical manual).	MT	Technical manual of the Health Facilities
7. Validates and signs the result of the laboratory test.	Section head/Chief Medical Technologist (CMT) and Pathologist	Laboratory Result Form
8. Releases result/s to the corresponding wards or area via the following platforms: 8.1 Laboratory Information System; 8.2 Hard Copy; or 8.3 Electronic Health Record (EHR)/iHOMIS.	LS/Clerk	Laboratory result form

Chart No. 19: General Laboratory Procedure for In-Patients

20. General Laboratory Procedure for Out-Patients

	Description	Person/Department Responsible	Interface/Form/ Document
1.	Orders the patient's laboratory request.	Physician	Laboratory Request form
2.	Brings the request to the laboratory.	Patient/Caregiver	Laboratory Request form
3.	Receives, verifies completeness of data and encodes/logs lab request: 3.1 If complete, proceeds to Step 4. 3.2 If incomplete, facilitates or coordinates with source of request.	Laboratory Staff (LS)/Clerk	Laboratory Request form
4.	Checks the availability of test procedure. 4.1 If test is available, proceed to Step 5. 4.2 If test is not available, refer to Referral System Guidelines of the Laboratory.	Medical Technologist (MT)	Referral System Guidelines of the Laboratory
5.	Verifies and encodes/logs charges 5.1 If patient can pay, direct patient/caregiver to Cashier then returns to receiving for validation of payment. 5.2 If patient is unable to pay, refers the patient/caregiver to MSW/Malasakit then returns to receiving for validation of endorsement from MSW.	LS	Charge slip; MSW Referral Form
6.	Collects the samples in the Laboratory (Refer to Primary Sample Collection Manual). 6.1 For specimen (i.e. blood, skin scrapings, etc.), proceed to collection and extraction. 6.2 For specimen (i.e. urine, stool, sputum, etc.), the patient shall submit sample.	Phlebotomist/ Medical Technologist (MT)	Primary Sample Collection Manual
7.	Processes sample (refer to the institutional technical manual).	MT	Technical manual of the Health Facilities
8.	Validates and signs the result of the laboratory test.	Section head/Chief Medical Technologist (CMT) and Pathologist	Laboratory result form
9.	Releases result/s to client: 9.1 Laboratory Information System; 9.2 Hard Copy; or 9.3 Electronic Health Record (EHR)/ iHOMIS.	LS/Clerk	Laboratory result form

Chart No. 20: General Laboratory Procedure for Out-Patients

21.General Laboratory Procedure for Histopathology Examination

Description	Person/Department Responsible	Interface/Form/ Document
1. Receives the laboratory request.	Laboratory Staff (LS)/Clerk	Laboratory request form
2. Brings the request & specimen to the laboratory.	Client	Laboratory request form
3. Determines if the request is for in or out patient. 3.1 If outpatient, proceeds to the cashier for payment. 3.2 If inpatient, receives the specimen with request.	LS/Clerk	Laboratory request form
4. Receives, verifies completeness of data and encodes/logs laboratory request: 4.1 If complete, proceeds to Step 5. 4.2 If incomplete, facilitates or coordinates with source of request.	LS/Clerk	Laboratory request form
5. Logs/registers in the Logbook and assigns Biopsy Specimen Number.	Medical Technologist (MT)	Biopsy Specimen Logbook
6. Describes and cuts specimen organ/tissue into tissue sections for processing.	Pathologist	Histopathology worksheet
7. Processes tissue section based on the histopathology tissue processing procedure & protocol.	MT	Histopathology worksheet
8. Performs microscopic examination on the processed sample (based on protocol).	Pathologist	Histopathology worksheet
9. Transcribes and encodes findings and description (based on prescribe protocol).	Pathologist	Histopathology worksheet
10. Reviews printed report form and affixes signature	Pathologist	Histopathology Result Form
11. Releases Final Report to Client with claim stub (Results are confidential and released in a sealed envelope).	LS/Clerk	Releasing Logbook
Note: For Frozen Section, releases the result immediately to the OR-Surgeon.

Note: Client refers to either patient, caregiver or healthcare worker for this particular procedure.

Chart No. 21: General Laboratory Procedure for Histopathology Examination Start Yes Receives the laboratory request Brings the request and specimen to the laboratory Determines if the request is for in our out patient Receives the specimen with request No In patient? Receives, verifies completeness of data and encodes/logs laboratory request Yes Complet No e data? Facilitates or coordinates with source of request Logs/registers in the Logbook and assigns Biopsy Specimen Number Describes and cuts specimen organ/tissue into tissue sections for processing Processes tissue section based on protocol Performs microscopic examination on the sample If Outpatient, proceed to the cashier for payment Department of Pathology/ Laboratory Client Department of Pathology/ Laboratory

Releases Final Report to Client with Claim Stub End

Transcribes and encodes findings and description

Reviews printed report form and affixes signature

L. Radiology Procedures

22. General Procedure for Radiology Department

	Description	Person/Department Responsible	Interface/For m/Document
1.	Orders the patient's radiologic procedure and writes the request.	Physician	Request form/ ER Treatment Record
2.	Forwards the request to the Radiology Department. 2.1 For Chest X Ray, proceed to Step 3. 2.2 For CT scan, MRI, ultrasound and other special radiologic requests, organize a schedule prior to the procedure. A special preparation (ex. fasting or bowel preparation) may be advised to the patient before the scheduled procedure.	ED/OPD/Ward staff	Request form
3.	Receives, verifies completeness of data and encodes/logs request: 3.1 If complete, proceeds to Step 4. 3.2 If incomplete, facilitates or coordinates with source of request.	Radiology Staff (RS)/Clerk	Request form
4.	Encodes/logs charges for the procedures for processing of payment: 4.1 If patient can pay, directs patient/caregiver to Cashier then returns to the counter for validation of payment. 4.2 If patient is unable pay, refers the patient/caregiver to MSW/Malasakit then returns to receiving for validation of endorsement from MSW.	Radiology Staff (RS)/Clerk	Charge Slip/ Request form/ Official Receipt/MSW endorsement
5.	Performs the radiologic procedures as indicated in the request form and sends the film/digital image to the radiologist on duty.	Radiology Staff (RS)	Technical manual of the Health Facilities
6.	Checks and scans the quality of film/digital image before allowing the patient to leave the premises.	Radiology Staff (RS)
7.	Reads and interprets the result of the radiologic procedure.	Radiologist/ Sonologist	Technical manual of the Health Facilities

8. Validates and signs the result of the	Section head/Chief	Result form
Radiologic procedure requested.	Radiologic
	Technologist(CRT)
	and Radiologist
9. Releases result/s to Emergency	RS/Clerk	Result form/
Department/Out Patient		Film/ Compact
Department/Wards via either of the		Disk/ Flash
following platforms:		Drive
9.1 Radiological/Hospital Information
System;
9.2 Hard Copy; or
9.3 Electronic Health Record
(EHR)/iHOMIS.

Chart No. 22: General Procedure for Radiology Examination

M. Central Sterile Supply Department (CSSD) Procedures

23. Preparation of Project Procurement Management Plan (PPMP) for Annual Procurement Plan of Medical Supplies

	Description	Person/Department	Interface/Form/
1.	Schedules meeting with the	Responsible CSSD Head,	Document Memorandum,
	end-users.	Procurement	Minutes of
		Department/	meeting
		Materials and
		Supplies
		Management
		Department or
		Office
2.	Preparation of Project	End-user/Technical	PPMP
	Procurement Management Plan	Working Group
	(PPMP) per area.	(TWG)
3.	Submission of prepared PPMP	End-user	PPMP
	to CSSD
4.	Collation and review of	CSSD Head/Procurement	PPMP
	submitted PPMP.	Department/Materials and
	4.1 Checking of inventory	Supplies Management
	4.2 Identification of fast-moving	Department or Office
	medical supplies
	4.3 Inclusion of new medical
	supplies
	4.4 Sorting of medical supplies
	with similar specification
5.	Finalization of PPMP	Procurement Department/	PPMP
	5.1 Presentation of PPMP to end	Materials and Supplies
	users.	Management Department
	5.2 Revision of PPMP	or Office
6.	Submission of final PPMP to	CSSD/Budget and	PPMP
	Procurement Office.	Planning Unit or section
7.	Consolidation of PPMP into	Procurement	PPMP; APP
	Annual Procurement Plan (APP).	Department/BAC
		Secretarial
8.	Updates monthly physical count	Procurement Department/	PPMP;
	inventory (as basis for making	Materials and Supplies	Supplementary
	amended PPMP/Supplemental	Management Department	PPMP
	PPMP).	or Office

Chart No. 23: Preparation of Project Procurement Management Plan (PPMP) for Annual Procurement Plan of Medical Supplies

24. Requisition of Supplies

	Description	Person/Department	Interface/Form/
		Responsible	Document
1.	Monitors stock level of supplies. 1.1 For supplies below stock level, instructs Central Sterile Supply Department (CSSD) Nurse/Attendant to prepare requisition.	Central Sterile Supply Department (CSSD) Head/Supervisor	Requisition and Issuance Slip (RIS); Stock Card and Monitoring form for Medical supplies; Standard Stock Level List
2.	Disseminates information on status of new supplies, materials, and instruments to concerned areas/units.	CSSD Head/Materials and Supply Management Department (MSMD)	Memorandum
3.	Prepares Requisition Issuance Slip (RIS) and forwards the same to the CSSD Head/Chief Nurse/Chief Administrative Officer (CAO) for approval.	Midwife/Nursing Attendant (NA)/CSSD Staff/ End-users	Requisition and Issuance Slip (RIS); Stock Transfer Requisition (STR)
4.	Signs RIS and forwards the same to the Supply Officer. For disinfectants, signs request slip and forwards the same to the Materials and Supplies Management Office/Department.	CSSD head or supervisor/Chief Nurse/CAO	Requisition and Issuance Slip; Stock Transfer Requisition (STR)
5.	Requests the medical supplies and forwards the Requisition and Issuance Slip (RIS) and/or prescriptions to Central Sterile Supply Department.	CSSD head/Staff to Materials and Management Office.	Materials Management System Stock/Expense Transfer Issuance Slip; Stock Transfer Requisition (STR)
6.	Checks and prints the requested medical supplies thru Materials Management System.	Supply Officer/ Storekeeper/Warehouse man/Designate	Materials Management System Stock/Expense Transfer Issuance Slip
7.	Evaluates request and determines the stock level.	Supply Officer/ Storekeeper/ Warehouseman/ Designate	Materials Management System Stock/Expense Transfer Issuance Slip
8.	Indicates quantity and items available/ withdrawable in the RIS.	Supply Officer/ Storekeeper /	Stock Cards; Stock Transfer Requisition (STR)

ate/MSMD Staff
Supply Officer/	Requisition and
Storekeeper/Warehouse	Issuance Slip;
man/Designate	Stock Transfer
	Requisition (STR)
CSSD head/Chief	Requisition and
Nurse	Issuance Slip;
	Stock Transfer
	Requisition (STR)
CSSD head/Chief	Requisition and
	Issuance Slip;
	Stock Transfer
	Requisition (STR)
	Materials
	Management
	System
	Stock/Expense
	Transfer Issuance
	Slip
	Requisition and
	Issuance Slip;
	Stock Transfer
	Requisition (STR)
	Stock card
	Warehouseman/Design Nurse Supply Officer/ Storekeeper/Warehouse man/Designate CSSD Staff CSSD Staff

Chart No. 24: Requisition of Supplies

Central Sterile Supply Department (CSSD)

25. Dispensing of Supplies

Description	Person/Department Responsible	Interface/Form/ Document
1. Monitors stock level of supplies. 1.1 For supplies below stock level, instructs Clinical areas/Attendant to prepare	CSS/End users	Stock Cards, Materials Management System Stock/Expense Transfer Issuance Slip; Requisition Issuance
requisition 2. Requests the medical supplies and forwards the Requisition and Issuance Slip (RIS) and/or prescriptions to Central Sterile Supply Department. Note: Cut-off time will depend on the hospital policy/guidelines.	Nurse/Nursing Attendant on duty, End users	Form/Slip (RIS) RIS; Materials Management System Stock/Expense Transfer Issuance Slip
3. Checks the requisition slip and availability of medical supply	CSSD Staff-on duty	Stock Cards, Materials Management System Stock/Expense Transfer Issuance Slip
4. Renders the requisition slip and print the Stock Transfer Issuance (STI) Slip in duplicate copies	CSSD Staff-on duty	Materials Management System Stock/Expense Transfer Issuance Slip
5. Prepares the requested and available medical supplies.	CSSD Staff-on duty	Materials Management System Stock/Expense Transfer Issuance Slip
6. Records the dispensed medical supplies on the Stock Cards.	CSSD Staff-on duty	Stock cards/Bin Card
7. Calls/informs the requesting area when the medical supplies are ready for pick up	CSSD Staff-on duty	Stock cards/Bin Card
8. Checks and receives the medical supplies; affixes their signature on the Stock Transfer Issuance (STI) Slip	Nurse/Nursing Attendant on duty, End-users	RIS; Materials Management System Stock/Expense Transfer Issuance Slip

Chart No. 25: Dispensing of Supplies

26. Receiving and Sterilization of Used Articles

This procedure presupposes that the used articles/items have been cleaned by the endusers. Articles in this procedure may refer to both instruments and supplies that needs to be sterilized. The steps may vary depending on the set-up of the hospital and there can be subprocedures on certain steps that needs to be elaborated. Provided, that the standards are still complied with.

	Description	Person/Department Responsible	Interface/Form/ Document
1.	Delivers used articles to the CSSD (from clinical area and special areas).	Ward Nursing Attendant	Borrowers Log Sheet/Sterilization Logbook
2.	Receives the used articles from the concerned area/s.	CSSD Counter Clerk/Nursing Attendant	Borrowers Log Sheet/Sterilization Logbook
3.	Checks for completeness of items. Indicates missing items on the borrower's slip. Borrower acknowledges missing items/parts, if any.	CSSD Counter Clerk/Nursing Attendant	Borrowers Log Sheet/Sterilization Logbook
4.	Forwards articles to the designated washers.	CSSD Counter Clerk/Nursing Attendant/Utility Worker
5.	Sanitize hands and wear proper PPE intended for disinfection before starting the procedure	CSSD Staff	Guidelines
6.	Washes, disinfects, dries, and inspects articles	Nurse Attendant	Guidelines, Issuance slip
7.	Packs articles/items. Put labels indicating the contents and the date of sterilization according to the manufacturer's instructions. Ensures presence of indicator/autoclave tape to determine if article/items were already sterilized.	CSSD/Nurse/Nursing Attendant	Autoclave Tape, Chemical indicator strip, Sterilization tag
8.	Categorizes articles/items/supplies into Non-critical, semi-critical, and Critical items prior to sterilization or autoclaving.	CSSD/Nurse/Nursing Attendant
9.	Places articles in the autoclave/EO Gas/Plasma Sterilizer for sterilization; and follows manufacturer's instruction.	CSSD/Nurse/Nursing Attendant	Autoclave Process Log sheet
10.	Sorts sterilized packed articles/items for storage or for withdrawal/release.	CSSD/Nurse/Nursing Attendant	Guidelines, Biological Indicator Log

Note: For articles stored, follow the rule "first in first out" based on date of sterilization. The storage must observe aseptic techniques and infection control measures.		sheet, Surveillance form
11. Informs units/end-users concerned that sterilized articles are ready for use/withdrawal/distribution.	CSSD/Nurse/Nursing Attendant	Borrowers Log Sheet
12. Releases/Dispenses all sterilized articles to respective special areas and wards. 12.1Ensures that articles are protected from damage and contamination during transport.	CSSD Staff	Sterilization Logbook
13. Records/documents use/withdrawal/release of articles/items.	CSSD Counter Clerk/Nursing Attendant/Utility Worker	Borrowers Log Sheet; logbook

Chart No. 26: Receiving and Sterilization of Used Articles

27. Issuance of Sterile Articles

	Description	Person/Department Responsible	Interface/Form/ Document
1.	Receives borrower's slip (2 copies)	CSSD	Borrowers Log
	duly signed by the end-user/	Staff/Midwife/Nursing	sheet, Issuance
	borrower.	Attendant	Slip
2.	Prepares articles and supplies listed	CSSD	Borrowers Log
	on the borrower's slip and places	Staff/Midwife/Nursing	sheet, Issuance
	them on a tray/receptacle.	Attendant	Slip
3.	Checks items against the borrower's	CSSD	Borrowers Log
	slip and signs clearance for release.	Staff/Midwife/Nursing	sheet, Issuance
		Attendant	Slip
4.	Issues articles to the borrower,	CSSD	Borrowers Log
	together with the copy of the slip.	Staff/Midwife/Nursing	sheet, Issuance
		Attendant	Slip
5.	Receives the sterile articles and	Recipient/End-user	Request and
	signs the request for autoclave and		Issuance Forms
	issuance form

Chart No. 27: Issuance of Sterile Articles

28. Routine Preparation of Supplies for Sterilization

	Description	Person/Department Responsible	Interface/Form/ Document
1.	Sanitizes hands and wear proper PPE intended for sterilization before starting the procedure	CSSD Staff/Attendant/Utility Worker	Guidelines
2.	Conducts visual inspection and do self-test on the machine according to manufacturer's instructions before proceeding to the process.	CSSD Staff/Attendant/Utility Worker	Procedure Manual of Machine
3.	Uses the biological indicator for validation of sterilization process to maintain the effectiveness of sterilization.	CSSD Staff/Attendant/Utility Worker	Borrowers Log Sheet
4.	Identifies supplies/instruments/packs for sterilization.	CSSD Staff/OR Nurses/Nursing Attendant/Midwife	Incoming and Outgoing Log sheet
5.	Prepares and labels needed supplies and packs them individually or in bulk, or wraps them in appropriate types of material in the clean area.	CSSD Staff/Attendant/Utility Worker	Autoclave slip, Labels: Surgical Instrument and Sets (i.e AP Set, Mior Set, Thyroid set, TAHBSO set)
6.	Loads the items in the machine for sterilization according to manufacturer's instruction. Sterilizes the items.	CSSD Staff/Attendant/Utility Worker	Procedure Manuals; Autoclave/steriliz ation logbook
7.	Checks sterilized supplies and instruments if the sterilization process met the standard.	CSSD Head/Nurse	Biological Indicator; Autoclave tape and Chemical Indicator Strip; Sterilization Logbook
8.	Stores the instruments in a clean dry environment in a manner that maintains the integrity of the package.	CSSD Staff/ Nurse	Room Thermometer; Guidelines
Note: from	Sterile items should be protected damage or contamination during transport from storage area of point of use.
9.	Updates stock card and Autoclave Process Log sheet.	CSSD Clerk/Nursing Attendant	Autoclave Process Log Sheet

Chart No. 28: Routine Preparation of Supplies for Sterilization

29. Articles to be Condemned/Disposed

	Description	Person/Department Responsible	Interface/Form/ Document
1.	Endorses items to the CSSD.	End-user/CSSD Staff	Incoming and outgoing log sheet/Request Form/Request slip for Condemned/ Disposed Articles; Log sheet
2.	Receives and lists articles to be condemned/disposed.	CSSD Staff/Nursing Attendant	Incoming and outgoing log sheet
3.	Accomplishes and signs Return Slip in two copies (1 copy for Supply Officer/MSMD and 1 copy for CSSD) and forwards the same to the Chief Nurse for approval.	CSSD Staff/Materials management/Engineeri ng and Maintenance Personnel/BIOMED	Incoming and outgoing log sheet, Condemned Forms/Slip; Return Slip Form
4.	Approves the Return Slip and returns the same to the CSSD personnel.	Chief Nurse/Disposal Committee/Materials Management Staff	Incoming and outgoing log sheet
5.	Returns items to the Supply Officer/Storekeeper/Warehousema n for their eventual disposal.	CSSD Staff/Nursing Attendant	Incoming and outgoing log sheet, Condemned Certificate
6.	Condemns/Disposes Articles.	Materials Management Section/Property and Supply
7.	Updates stock card.	CSSD Staff/Nursing Attendant	Stock Cards/Bin Card
8.	Files return slip.	CSSD Staff/Nursing Attendant	Incoming and outgoing log sheet
9.	Updates inventory.	CSSD Staff/Nursing Attendant	Stock Cards/Bin Card, Inventory log sheet

Chart No. 29: Articles to be Condemned/Disposed

Chapter 2 Allied Health Professional Service Procedures

Allied Health Professional Service is composed of professional departments that aim to prevent, diagnose and treat a range of conditions and illnesses and often work within a multidisciplinary health team to provide the best patient outcome. This chapter covers the major procedures under the various allied health departments.

N. Medical Social Work Department (MSWD) Procedures

30. Availment of Medical Social Work Department (MSWD) Services in the Out-Patient Department

	Description	Person/Department Responsible	Interface/Form/ Document
1.	Directly seeks MSWD for assistance	Patient / Patient Relative	Referral Form / Bill Charges
2.	Refers the patient/care giver to MSW	Physician/ Nurse/ Billing and Claims Department	Referral Form / Bill Charges
3.	Receives referral from OPD Nurse / attending Physician / Billing	Medical Social Worker (MSW)	Referral Form
4.	Verifies if patient's treatment is covered by Phil Health and determines through Point of Service Onsite Rapid Enrollment Portal, if membership is active.	MSW	POS Portal
5.	Orients patient/relative of the purpose of assessment and facilitates consent signing	MSW
6.	Conducts screening interview / eligibility assessment	MSW	MSWD Assessment Tool
7.	Registers Patient	MSW	Registry Logbook
8.	Conducts orientation on hospital policies and availment of MSWD services	MSW	Daily Accomplishment Report
9.	Provides appropriate MSW intervention based on Patient's need / problem:  Enrolls to Point of Service (POS)  Refers to Malasakit Center  Psychosocial intervention  Pre-Admission Planning	MSW	Form POS Portal, Unified Intake sheet, Referral Form, Progress Report, Daily Accomplishment Report

Chart No. 30: Availment of Medical Social Work Department (MSWD) Services in the Out-Patient Department

31. Availment of Medical Social Work Department (MSWD) Services in the Emergency Department

Description	Person/Department Responsible	Interface/Form/ Document
1. Provides all services / necessary assistance	ER Nurse / Attending Physician
2. Refers patient / care giver with psychological and social problems to MSW	ER Nurse / Attending Physician	Referral Slip
3. Conducts ER rounds or coordinates with ED Team and identifies high risk patients in need of MSW intervention	Medical Social Worker (MSW)
4. Receives referral and assesses level of crisis situation and provides Psychological First Aid or Psychosocial Support	MSW	Referral Slip, MSW Progress Notes
5. Verifies PhilHealth Membership through Point of Service Onsite Rapid Enrollment Portal	MSW	PHIC Portal
6. Facilitates contract signing	MSW	Contract Consent Form
7. Conducts eligibility assessment	MSW	MSWD Assessment Tool
8. Registers new patient at general registry logbook	MSW	Registry Logbook
9. Conducts orientation on hospital policies and availment of MSWD services	MSW	Daily Accomplishment Report
10. Provides appropriate MSW intervention based on Patient's need / problem:  Enrolls to POS  Refers to Malasakit Center  Psychosocial intervention  Pre Admission Planning	MSW	Form POS Portal, Unified Intake sheet, Referral Form, Progress Report Daily Accomplishment Report

Chart No. 31: Availment of Medical Social Work Department (MSWD) Services in the Emergency Department

32. Availment of Medical Social Work Department (MSWD) Services for In-Patients

Description	Person/Department Responsible	Interface/Form/ Document
1. Processes requirements for admission.	Admitting Section Staff
2. Receives referral or list of new	Medical Social Worker	Notice of
admission from Admitting Section	(MSW)	Admission /
		Admitting Order
3. Facilitates contract signing	MSW	Contract Consent
		Form
4. Conducts psychosocial assessment	MSW	MSWD
		Assessment Tool
5. Verifies PHIC membership	MSW	PHIC Portal &
5.1 If active member, instructs		PHRF Form
relative to proceed to billing for
processing.
5.2 If inactive member, identifies if:
 Financially capable, instructs
Patient to pay contribution; or
 Financially incapable, enroll
the Patient to PHIC-POS
6. Conducts orientation to Patient /	MSW
Caregiver on hospital polices and
services
7. Registers the new Patient and issues	MSW	Registry Logbook
service card		/ Service Card
8. Forwards patient classification to	MSW	Progress Notes
admitting section and billing and		Form / Daily
claims department		Accomplishment
		Report

Chart No. 32: Availment of Medical Social Work Department (MSWD) Services for In-Patients

O. Pharmacy Department (PD) Procedures

33. Filling of Prescription for Out-Patient Department and the General Public

Description	Person/Department	Interface/Form/
1. Receives prescription from the patient.	Responsible Pharmacist	Document Prescription
2. Validates type of prescription:	Pharmacist	Ordinary
2.1 Ordinary Prescription		Prescription and
2.1.1 Name of patient, age, sex and		Special
date;		Prescription
2.1.2 Name of drug, dosage
strength, dosage form,
frequency and quantity; and
2.1.3 Name and signature of
Physician and License
Number.
2.2 Special Prescription
2.2.1 Refer to 2.1.1 to 2.1.3.
2.2.2 Special Prescription Form
for Dangerous Drugs
(SPFDD).
2.2.3 S2 License.
2.2.4 Work Address of Physician.
3. Checks availability of the drug:	Pharmacist	Charge Slip
3.1 If available, prepares the Charge Slip.
3.2 If not available, informs patient.
4. Instructs patient to proceed to cashier	Pharmacist	Charge Slip
for payment.
5. Accepts the payment and issues the	Cash Operations	Official Receipt
Official Receipt.	Department	(OR)
6. Receives and validates Official	Pharmacist	OR
Receipt.
7. Indicates Official Receipt Number on	Pharmacist	OR, Charge slip
the Charge Slip and stamps Official
Receipt as claimed.
8. Prepares the medication	Pharmacist	Charge slip
9. Dispenses and provides medication	Pharmacist
counseling
10. Records issued medicines on patient	Pharmacist	Patient
medication profile		Medication
		Profiles
11. Records issued medicines for	Pharmacy Staff	Stock Card
inventory and files prescription

Chart No. 33: Filling of Prescription for Out-Patient Department and the General Public

34. Filling of Prescription for In-Patient

Description	Person/Department Responsible	Interface/Form/D ocument
1. Receives the prescription from the requesting ward.	Pharmacist	Prescription
2. Validates the type of prescription: 2.1 Ordinary Prescription 2.1.1 Name of patient, room/bed number, age, sex and date	Pharmacist	Ordinary Prescription and Special Prescription
2.1.2 Name of drug, dosage strength, dosage form, frequency and quantity
2.1.3 Name and signature of Physician and License Number
2.2 Special Prescription
2.2.1 Refer to 2.1.1 to 2.1.3
2.2.2 Special Prescription Form for Dangerous Drugs (SPFDD)
2.2.3 S2 License
2.2.4 Work Address of Physician
3. Checks availability of the drug:	Pharmacist	Prescription
8.4 If available, prepare the drugs and/or
medicines.
8.5 If not available, suggest alternative
drugs and medicine to the physician.
8.5.1 If physician approves the
suggestion, proceed to
Number 3.1
8.5.2 If physician disapproves
suggestion, provide the drugs
and/or medicines through
Special/ Emergency Purchase
then proceed to 3.1
9. Prepares Charge slip.	Pharmacist	Charge Slip
10. Prepares drugs and medicines	Pharmacist	Prescription
11. Dispenses drugs and/or medicines to the	Pharmacist	Prescription
requesting ward.
12. Receives drugs and medicines by the	Nursing Attendant	Prescription and
requesting ward and affixes signature on		charge slip
the Charge Slip.
13. Records issued medicines on patient medication profile	Pharmacist	Patient Medication Profiles
14. Records issued medicines for inventory and files prescription	Pharmacy Staff	Stock Card
15. Submits the Charge Slip to the Billing and Claims Department.	Pharmacy Staff	Logbook

Chart No. 34: Filling of Prescription for In-Patient

35. Procedure on Unit Dose Dispensing

Description	Person/Department Responsible	Interface/Form/ Document
1. Reviews patient's chart.	Pharmacist	Patient Health Record
2. Prepares/updates Patient Medication Profile (PMP).	Pharmacist	PMP
3. Checks and validates each drawer of Unit Dose Cart.	Pharmacist
4. Prepares drugs and medicines sufficient for twenty-four (24) hours dosage regimen of patient.	Pharmacist
5. Prepares Charge Slip.	Pharmacist	Charge Slip
6. Delivers medicines to ward.	Pharmacist
7. Receives drugs and medicines by requesting ward and affixes signature on the Charge Slip.	Nurse on duty	Pharmacy Charge Slip
8. Records issued medicines on patient medication profile.	Pharmacist	Patient Medication Profiles
9. Records issued medicines for inventory and files prescription.	Pharmacy Staff	Stock Card
10. Submits the Charge Slip to the Billing and Claims Department.	Pharmacy Staff	Logbook

Chart No. 35: Procedure on Unit Dose Dispensing

P. Nutrition and Dietetics (ND) Department Procedures

36. Referral Procedure for Nutrition Care Process (NCP)

Description	Person/Department Responsible	Interface/Form/ Document
1. Receives patient in the ward. 2. Conducts screening to identify nutritionally at risk patient. a. If the patient is nutritionally at risk, refers to physician. See item no. 3. b. If the patient is NOT nutritionally at risk, conducts periodic re	Nurse Nurse	Nutrition Screening and Referral Tool (adult and pedia)
screening after 3 days. 3. Validates screening done by nurse. Conducts assessment, gives order for patient management then refers to RND for nutritional assessment.	Physician	Nutrition Screening and Referral Tool (adult and pedia); Anthropometric data, Biochemical or laboratory results, and Clinical Examinations
4. Conducts nutritional assessment and develops/prepares the Nutrition Care Plan (NCP) for the patient based on nutrition diagnosis. The RND selects and plans nutrition interventions appropriate to the needs of the patients. Revisions of the NCP shall be made accordingly after re-assessment of patient.	Registered Nutritionist-Dietitian (RND)	Anthropometric data, Biochemical or laboratory results, Clinical Examinations and Dietary Assessment; Medical Nutrition Therapy Form (NCP)
5. Endorses NCP to physician for approval.	RND	Medical Nutrition Therapy Form (NCP)
6. Implements NCP to meet the patient's nutritional needs.	RND

Note: Refer to the Nutrition Care Plan Algorithm found in the Hospital Nutrition and Dietetics Service Management Manual, 3rd Edition.

Chart No. 36: Referral Procedure for Nutrition Care Process (NCP)

37.Ward Rounds

	Description	Person/Department Responsible	Interface/Form/ Document
1.	Conducts patient rounds.	RND
2.	Reviews patient's chart (i.e progress in	RND	Patient's Health
	diet, Anthropometric Data,		Record
	Biochemical or laboratory results,
	Clinical Examinations and Dietary
	Assessment)
3.	Conducts interview to monitor food	RND
	intake, acceptability, and quality or
	efficiency of service.
	a. Nurse
	b. Patient c. Caregiver
4.	Evaluates nutrition problem and gives	RND	Progress Notes
	recommendation for medical nutrition
	therapy, changes diet accordingly,
	documents in the POMR or patient's
	chart.
	4.1 If patient is with nutrition
	problems, refer to no. 5.
	4.2 If none, proceed to no. 6.
5.	Endorses to concerned	RND
	departments/units as deemed
	necessary.
6.	Continuously monitors nutrition status	RND	MNT Form
	of patient with no identified problems.		(NCP)/Progress
			Notes
7.	Provides diet counselling and other	RND	Diet Handouts
	nutrition interventions based on the
	identified problems.
8.	Documents nutrition intervention done.	RND	Patient's Health Record

Chart No. 37: Ward Rounds

38. Food Preparation and Distribution

Description	Person/Department Responsible	Interface/Form/ Document
1. Receives diet lists of admitted patients.	RND	Diet list
2. Interprets diet lists and prepares food	RND	Food Daily
daily census.		Census; diet tag
a. Determines no. of patients with
therapeutic and regular diet;
b. Modifies menu of the day in
accordance to the identified diet,
and;
c. Prepares diet tag
3. Instructs Chef/Cook to prepare and cook	RND	Food Daily
food based on the food daily census.		Census
4. Verifies prepared food with diet list.	RND	Diet list;
		Diet tag
5. Dishes out food according to diet tag.	Food Service
	Worker (FSW)
6. Distributes food tray to patients	FSW
7. Collects soiled food trays.	FSW
8. Monitors and evaluates food intake,	RND
acceptability, and quality or efficiency of
service.

Chart No. 38: Food Preparation and Distribution

Q. Hospital Health Information Management (HHIM) Department Procedures

39. Processing of Health Records for File

Description	Person/Department Responsible	Interface/Form/ Document
1. Forwards/Submits health records to HIMD within 24 hours from discharge.	Nurse	Receiving logbook
2. Validates health record against the submitted floor census for discharged patients.	HIMD Staff	Floor census for discharged
3. Sorts/reassembles according to prescribed sequence.	Administrative Assistant of HIMD	Prescribed sequence of health records (portions)
4. Performs analysis to determine completeness of health record based on a checklist. 4.1 If not complete, issues deficiency slip and refer to concerned doctors/nurses for completion. 4.2 If complete, proceed to No. 5.	HIMD Staff	Health Record Analysis Checklist; Deficiency slip
5. Assigns ICD codes for statistical purposes.	Clinical coders/Statistician	Annual Statistical Report
6. Collects statistical data from health records.	Clinical coders/Statistician	Matrix forms for statistical report
7. Files records according to adopted filing system	Administrative Assistant of HIMD	Health record

Chart No. 39: Processing of Health Records for File

40. Collection and Processing of Data from Patient Health Record

Description	Person/Department Responsible	Interface/Form/ Document
1. Receives patient's health record from	HIMD Staff	Patient's health
clinical coder.		record
2. Records/encodes raw data from the	HIMD Staff	Daily analysis of
patient's health record daily.		hospital service
3. Collates and consolidates data from the	Statistician
daily analysis of hospital service for
monthly analysis of hospital service.
4. Furnishes copy to the Medical Center	HIMD Staff
Chief /Chief of Hospital (MCC/COH),
Chief of Medical Professional Staff
(CMPS), and Chief Nurse.
5. Consolidates monthly reports to	HIMD Staff
quarterly/semi-annual and annual
reports.
6. Files one copy of the monthly reports.	HIMD Staff

Chart No. 40: Collection and Processing of Data from Patient Health Record

41. Collection and Processing of Data from 24-hour Floor Census

Description	Person/Department Responsible	Interface/Form/ Document
Prepares and submits 24-hour Floor 1.	Head Nurse	Daily Floor
Census from each wards.		Census
Acknowledges receipts of the duplicate 2.	HIMD Staff	Daily Floor
copy of the floor census.		Census
Validates all floor census reports into 3.	HIMD Staff	Hospital Daily
hospital daily census.		Census
Consolidates, collects and records data 4.	Statistician	Hospital Daily
from the hospital daily census for		Census
statistical purposes.
Furnishes copy to the COH/MCC, 5.	HIMD Staff	Hospital Daily
CMPS, and Chief Nurse.		Census
Files one copy of the hospital daily 6.	HIMD Staff	Hospital Daily
census.		Census

Chart No. 41: Collection and Processing of Data from 24-hour Floor Census

42.Preparation of Statistical Report

	Description	Person/Department Responsible	Interface/Form/ Document
1.	Collects and consolidates data from the different units/sections (pharmacy, laboratory, radiology, dietary, and other concerned offices) at the end of each month.	Statistician	Statistical report; reports of operating units
2.	Computes for the required hospital indicators (e.g. bed occupancy rate, average length of stay, etc.) based on the collected data from the 24-hour hospital census report and health records.	Statistician	Statistical report; Reports of operating units
3.	Determines the ten leading causes of morbidity and underlying causes of mortality.	Statistician	Statistical report
4.	Validates hospital statistical report through coordination with the concerned units/departments and the patient health records committee.	Statistician/HIMD Head	Statistical report
5.	Reviews and affixes initials on the hospital statistical report.	HIMD Head	Statistical report
6.	Reviews and approves the statistical report and forwards the transmittal letter to the COH for review and signature.	Chief Medical Professional Staff/Head of the Allied Health Professional Service	Statistical report and transmittal letter
7.	Approves and signs statistical report.	COH/Medical Center Chief	Statistical report and transmittal letter
8.	Submits statistical report to DOH and through the Online Hospital Statistical Reporting System (OHSRS).	Statistician	Statistical report and transmittal letter
9.	Retains a file copy of the report and transmittal letter.	Statistician/HIMD staff	Statistical report and transmittal letter

Chart No. 42: Preparation of Statistical Report

43.Processing of Certificate of Live Birth (COLB)

Description	Person/Department Responsible	Interface/Form/ Document
1. Assists patient/companion in accomplishing the pre-form; affix thumb mark if cannot sign.	Nurse/Midwife/ Nursing Aide	Preform
2. Signs the portion "Prepared by" (Pre form only).	Nurse/Midwife/ Nursing Aide	Preform
3. Validates data and signs pre-form. 3.1 If unmarried, Affidavit to Use the Surname of the Father (AUSF) shall be signed together with registration. 3.2 If the mother is minor, the biological mother or father of the minor conforms to the AUSF.	Informant/Father/ Mother	Preform/ASUF
4. Forwards/endorses COLB and pre-form to HIMD.	Nurse / Nursing Aide	Pre-form
5. Transcribes official COLB.	HIMD staff	Official and Pre form
6. Reviews and signs COLB.	Physician/Nurse and informant	Official and Pre form
7. Prepares transmittal for submission to local civil registry office (LCRO)	HIMD/Designated HIMD Staff	Transmittal
8. Submits COLB with transmittal to LCR for registration.	Hospital Staff	Official

Chart No. 43: Processing of Certificate of Live Birth (COLB)

44. Release of Certificate of Death/Fetal Death (COFD)

	Description	Person/Department Responsible	Interface/Form/ Document
1.	Facilitates signing of pre-form	Nurse	Pre-form of COD/COFD
2.	Confirms accuracy and correctness of information.	Informant/Relative	Pre-form of COD/COFD
3.	Accomplishes medical certificate of cause of death (MCCOD) with time intervals and other necessary entries	Attending Physician	Logbook (receiving), Preform of COD/COFD
4.	Forwards patient's health record with the pre-form Certificate of Death/Fetal Death to HIMD and observes the provisions of Non-Disclosure Agreement.	Nursing Aide	Patient Health Record, Pre form of COD/COFD
5.	Reviews completeness and transcribes in the official form, then forwards to designated HIMD staff for review.	Admin. Assistant / Transcriptionist/ designated HIMD staff	Patient Health Record, Pre form of COD/COFD and Official COD/COFD
6.	Presents any proof of identity of next of kin/legal guardian of the deceased (i.e. Valid ID/barangay certificate/sworn statement) and hospital clearance	Relative/Claimant	Official COD
7.	Advises/instructs relative/claimant on the COD Registration to LCR: a. Securing of signature of embalmer; and; b. Registering with LCR	Admin Assistant	Official COD
8.	Acknowledges receipt in logbook	Relative/Claimant	Official COD

Chart No. 44: Release of Certificate of Death/Fetal Death (COFD)

45. Issuance of Medical Certificate and Other Clinical Documents

Description	Person/Department Responsible	Interface/Form/ Document
1. Accomplishes request form.	Client/Requesting Party	Request form
2. Receives request and establishes identity of requesting party.	HIMD Staff	Valid ID
3. Validates data in the request form	HIMD Staff	Request form
4. Issues charge slip for payment 4.1 Advises patient to go to cashier for payment. 4.2 If patient expresses inability to pay, refer to MSWD.	HIMD Staff	Charge slip
5. Validates official receipt.	HIMD Staff	Official receipt; Certificate requested
6. Provides claim stub	HIMD Staff	Claim stub
7. Retrieves health record and transcribes requested certificate.	HIMD Staff	Patient Health Record
8. Routes the requested certificate for signing.	HIMD Staff	Medical/Medico legal certificate
9. Signs the requested certificate.	Attending physician/Medical Director	Medical/Medico legal certificate
10. Presents claim stub.	Client/Requesting Party	Claim stub; Certificate requested
11. Releases requested certificate to requesting party.	HIMD Staff	Claim stub; Certificate requested
12. Acknowledges receipt of certificate.	Client/Requesting Party	Logbook

Chart No. 45: Issuance of Medical Certificate and Other Clinical Documents

46. Release of Information to Insurance Verifier

Description	Person/Department Responsible	Interface/Form/ Document
1. Accomplishes request form and submits waiver indicating authorization from patient	Insurance Verifier	Request form; Patient Waiver
2. Validates identification of the Insurance Verifier and files original copy of waiver.	HIMD staff	Duly accomplished Request Form; Patient Waiver; Valid ID of the Insurance Verifier
3. Issues clearance to release information 3.1 If cleared, proceed to No. 5. 3.2 If not cleared, notifies the insurance verifier.	Data Protection Officer (DPO)/ HIMD staff	Duly accomplished Request Form; Patient Waiver; photocopy of the valid ID of the Insurance Verifier
4. Retrieves and reproduces requested documents	HIMD Staff	Duly accomplished Request Form
5. Issues charge slip to insurance verifier and advises to pay at cashier	HIMD Staff	Charge slip
6. Authenticates reproduced copies and hands over to admin assistant	HIMD Head	Health records requested
7. Presents OR to HIMD 8. Acknowledges receipt of requested document.	Insurance Verifier Insurance Verifier	Official Receipt Logbook

Chart No. 46: Release of Information to Insurance Verifier

47. Disposal of Valueless Health Records

Description	Person/Department Responsible	Interface/Form/ Document
1. Initiates the disposal of valueless health records based on the records disposition schedule.	HIMD staff	Records Inventory and Appraisal (Form 1) Records Disposition Schedule (Form 2)
2. Culls out valueless records	HIMD staff
3. Prepares request to dispose of records and forwards to the Chief of Medical Professional Service (CMPS)	HIMD staff	Request letter
4. Endorses request to dispose of records to RMIC	Chief of Medical Professional Staff (CMPS)	Request letter
5. Recommends request to dispose of records and submits to COH for approval	Records Management and Improvement Committee (RMIC)	Request for Authority to Dispose of Records (Form 3)
6. Approves request for authority to dispose	Medical Center Chief/Chief of Hospital
7. Submits request to NAP	RMIC
8. Receives, evaluates and assigns a representative to evaluate & examine records for disposal.	National Archives of the Philippines (NAP)
9. Approves the submitted request for authority to dispose with analysis report and recommended manner for disposal	NAP Director	Authority to dispose
10. Coordinates with concerned offices/agencies (concerned departments/unit, COA, NAP, official buyer) for witnessing and disposal of valueless health records	RMIC/ Hospital Operations and Patient Support Service (HOPSS)	Letter of availment for NAP official buyer
11. Disposes valueless health records through sale (public bidding or official buyer of NAP as per recommendation of NAP)	RMIC/ NAP/COA/ NAP Official buyer
12. Issues OR to official buyer	Cashier
13. Signs Certificate of Disposal and provides copy to concerned offices	RMIC/ NAP/COA/ NAP Official buyer	NAP Form No. 6 Certificate of Disposal of Records
14. Files copy of the Certificate of Disposal from NAP.	RMIC	Certificate of Disposal

Chart No. 47: Disposal of Valueless Health Records

48. Retrieval of Patient's Records for Authorized Borrowers

Description	Person/Department Responsible	Interface/Form/ Document
Submits duly accomplished request 1.	Borrower	Request form; to
form.		include in the
		form the non
		disclosure
		agreement
Verifies identity of borrower. 2.	HIMD staff	Logbook
Approves request of the borrower. 3.	HIMD Head/	Request form
	Data Privacy Officer
Verifies requested health record. 4.	HIMD staff	Request form
Retrieves patient's health record from 5.	HIMD staff	Request form
file.
Accomplishes the tracking 6.	HIMD staff	Request form;
system/tracer card.		tracer card
Provides access to the health records to 7.	HIMD staff	Patient health
the borrower within HIMD.		record

Chart No. 48: Retrieval of Patient's Records for Authorized Borrowers

Chapter 3 Hospital Finance Service (HFS) Procedures

Financial management in a hospital setting is the process of seeking the optimal financing, allocation, and control of all resources of the health care organization. The Financial Management Cluster is responsible for financial transactions of the hospital such as: accounting, budgeting, billing and claims, and cash management.

49. Issuance of Statement of Accounts

Description	Person/Department Responsible	Interface/Form/ Document
1. Orders patient's discharge and fills up necessary documents.	Physician	PhilHealth documents (i.e CF2, CF4)
2. Forwards Notice of Discharge with necessary documents to Billing and Claims Department (BCD).	Nurse	Notice of Discharge, PhilHealth documents (i.e CF2, CF4)
3. Receives Notice of Discharge and informs all revenue/cost centers of all scheduled discharges. Note: The term "revenue centers" and "cost centers" may be used interchangeably since this manual is intended for government hospitals that is not necessarily income generating.	Billing Staff	Notice of Discharge, PF Charge Slip and PhilHealth documents (i.e CF2, CF4)
4. Forwards remaining charges and clearance slips.	Revenue/Cost centers	Charge slips and clearance slips.
5. Collates all charges pertaining to the patient into a Statement of Account (SOA).	Billing Staff	Charge slip
6. Processes statement of account accordingly and applies all applicable discounts following order of charging: 6.1 All mandatory discounts (Senior Citizen or PWD, etc.) if applicable.	Billing Staff	Notice of Discharge, PF Charge Slip and PhilHealth documents (i.e CF2, CF4)

6.2 Appropriate PhilHealth benefit based on ICD 10/RVS code indicated by the attending physician. 6.3 Other insurance benefits. 6.4 Medical Assistance.
7. Prints and issues Statement of Account (SOA).	Billing Staff	SOA
8. Explains to patient/caregiver the SOA. 8.1Refers patient to the Credit & Collection Unit/MSWD for any issues on excess hospital bill. Note: Refer to the Hospital Finance Service Manual, Chapter 11, Billing and Claims Department for the Credit and Collection Process.	Billing Staff	SOA
9. Advises patient/caregiver to proceed to Cash Operations Department for payment and clearance.	Billing Staff	SOA
10. Documents data on the summary of bills rendered report. Refer to Chart no. 52 for preparation of the said report.	Billing Staff	Summary of Bills Rendered

Chart No. 49: Issuance of Statement of Accounts

50. Processing of Discharge Clearance

Description	Person/Department Responsible	Interface/Form/ Document
1. Receives Statement of Account.	Cash Operation Staff	Statement of Account
2. Collects payment for excess hospital bill and issues OR.	Cash Operation Staff	Official Receipt (OR)
3. Issues OR and records the amount paid transaction in the Cash Receipt Journal (CRJ).	Cash Operation Staff	CRJ
4. Issues Discharge Clearance.	Cash Operation Staff	Discharge Clearance

Chart No. 50: Processing of Discharge Clearance

51. Processing of PhilHealth Claims

Description	Person/Department Responsible	Interface/Form/ Document
1. Verifies the completeness correctness of all documents 1.1 If yes, fills up CF2 Part II items 9 & 10 (ICD 10 or RVS Code) and	and Claims Staff	PhilHealth documents (i.e CF1, CF2, CF4) Members Data
Part IV. Sorts all the documents for PhilHealth claim and forwards to the designated signatory/ies	authorized	Record Birth Certificate if Newborn Laboratory & X
1.2 If no, returns to the concerned office to complete the document and information needed.		ray Results Operative Record Statement of Account CSF
2. Scans required documents encodes member & information, professional fees, final diagnosis, and data in CF2	and Claims Staff patient	PhilHealth documents (i.e CF1, CF2, CF4)
3. Attaches scanned documents to e claims portal	Claims Staff	PhilHealth documents (i.e CF1, CF2, CF4)
4. Transmits online the Claims	PhilHealth Claims Staff	PhilHealth documents (i.e CF1, CF2, CF4)
5. Documents Transmitted Claims	Claims Staff	Report of Transmitted Claims
6. Monitors status of transmitted claims	Claims Staff	Report of RTH and Denied Claims
7. Receives feedback from PhilHealth	Claims Staff	Report of RTH and Denied Claims
8. Complies to requirements/documents	necessary Claims Staff

Chart No. 51: Processing of PhilHealth Claims

52. Preparation of Summary of Bills Rendered

Description	Person/Department Responsible	Interface/Form/ Document
1. Review of the Summary of Discharge if all were listed/recorded.	Billing Staff	Statement of Account; Summary of Bills Rendered (SBR)
2. Generates three (3) copies of Summary of Bills Rendered for the Month.	Billing Staff	SBR
3. Reviews and signs the report.	Head, Billing and Claims Section	SBR
4. Submits two (2) copies of the reports to accounting Department on or before the th day of the following month. 5	Billing Staff	SBR
5. Files one (1) copy of SBR.	Billing Staff	N/A

Chart No. 52: Preparation of Summary of Bills Rendered

53. Preparation of Budget Proposal

Description	Person/Department Responsible	Interface/Form/ Document
1. Attends forum and receives Budget Call	MCC, FMO,	Budget Proposal
guidelines from DBM.	Accountant, Budget	and Schedule of
	Head	Activities
2. Issues Hospital Memorandum for the	MCC	Hospital
submission of budget proposal.		Memorandum
3. Collects and consolidates necessary	Budget Staff
data needed for budget deliberation		Budget Proposal
from concerned offices.
4. Conducts Budget Deliberation for	Hospital Budget
validation of proposals.	Deliberation	Budget Proposal
	Committee
5. Finalizes Budget Proposal based on the	Head, Budget	Budget Proposal
results of budget deliberation.	Department
6. Forwards to the FMO II and MCC the	Head, Budget	Budget Proposal
finalized Budget Proposal for	Section
review/initial/approval.

Chart No. 53: Preparation of Budget Proposal

54. Processing of Collections and Deposits

Description	Person/Department Responsible	Interface/Form/ Document
1. Receives charge slip/order of payment/statement of account (SOA) from clients outpatient/creditors/Billing and Claims Department (BCD) – for in patients.	Collecting Officer	SOA, Charge Slip, SOA, Order of Payment
2. Receives cash/check from clients/creditors/BCD.	Collecting Officer	Check
3. Issues official receipts (OR) for payment from clients/creditors.	Collecting Officer	OR
4. Encodes all ORs in the Cash Receipts Record (CRR).	Collecting Officer	OR, CRR
5. Tallies Cash Collections for the day against Cash Receipts Record (CRR).	Collecting Officer	CRR
6. Prepares deposit slip/remittance advice for deposit to Authorized Government Depository Bank (AGDB) based on the remittance of collecting officer.	Head Collection Unit	Deposit Slips
7. Reviews & signs the Deposit Slips (DS).	Head of the Cash Operations	Deposit Slips
8. For Pick up by Authorized Gov't. Depository Bank (AGDB). 8.1 If yes, head of the cash operations deposits through pick up by the AGDB the collection together with the deposit slips. 8.2 If no, requests for transport service from the Engineering and Facilities Management Departments to bring cash/checks to AGDB. 8.3 For LGU, remits to the Provincial or Municipal Treasurer's Office.	Bonded Collecting Officer	Deposit Slips

Chart No. 54: Processing of Collections and Deposits

55. Processing of Disbursements

	Description	Person/Department Responsible	Interface/Form/ Document
1.	Receives duly approved DV in 3 copies	Cash of Operations	Disbursement
	together with complete Supporting Documents (SDs).	Staff	Voucher (DV), SDs
2.	Checks completeness of signatories on the DV and identifies fund source.	Cash of Operations Staff	DV
3.	Prepares payment through checks / Advice to Debit Account (ADA) with Advice of Check Issued and Cancelled (ACIC) if applicable.	Cash of Operations Staff	ADA with ACIC
4.	Records the checks / ADA to Check and Advices to Debit Account Disbursement Records (CkADADRec).	Cash of Operations Staff	Check, ADA
5.	Verifies completeness of signature on the DV. Reviews the amount of the check against the DV and SDs. Signs the check.	Cash of Operations Staff	DV, SDs
6.	Forwards the set of documents to the authorized countersigning official	Cash of Operations Staff	DV
7.	Receives signed Check / ADA from authorized signatories.	Cash of Operations Staff	Check, ADA
8.	Secures Official Receipt from the payee and attaches to the disbursement voucher.	Cash of Operations Staff	Official Receipt, DV

Chart No. 55: Processing of Disbursements

56. Processing of Purchase Order (PO)

	Description	Person/Department Responsible	Interface/Form/ Document
1. the face of the PO.	Receives the PO with the supporting documents. Stamps "RECEIVED" and indicate the date of receipt on	Accounting Staff (Receiving)	Purchase Order, OBR/BUR
2. supplier	Records in the logbook for PO, with the corresponding number, name of and total contract amount and OBR/BUR number.	Accounting Clerk	Purchase Order, OBR/BUR, Logbook
3.	Reviews, verifies and checks the propriety of supporting documents.	Head of Accounting	Purchase Order, OBR/BUR
4. OBR/BUR.	Verifies and checks the source of fund as indicated in the attached	Accounting Clerk	OBR/BUR
5. Checks as appropriateness. 5.1 with 5.2 If not,	to completeness of supporting documents and as to its If complete, forwards the PO all the supporting documents for processing. returns to originating office with noted deficiencies.	Accounting Clerk	Purchase Order, OBR/BUR
6. contract amount.	Records in the fund control record book, the PO number and date, name of creditor, and the total	Accounting Clerk	Purchase Order
7. the PO.	Signs availability of funds portion of	Accounting Clerk	Purchase Order
8. approval.	Forwards to Head of Agency for	Accounting Clerk	Purchase Order

Chart No. 56: Processing of Purchase Order Forwards the PO with supporting documents for processing Forwards to Head of Agency for approval Complete documents? Returns to originating office with noted deficiencies Start Receives and Stamps the PO with the supporting documents Records the PO in the logbook Reviews, verifies and checks the propriety of supporting documents Verifies and checks the source of fund as indicated in the attached OBR/BUR Records the PO in the fund control record book Signs availability of funds portion of the PO Yes No Accounting Department

End

57. Processing of Disbursement Voucher (DV) for Payment

Description	Person/Department Responsible	Interface/Form/ Document
1. Stamps "RECEIVED" and indicates the date of receipt in the face of the DV.	Accounting Staff	Disbursement Voucher (DV)
2. Assigns DV number and records in the corresponding receiving Logbook.	Accounting Staff	DV, Logbook
3. Checks as to completeness of supporting documents and as to its appropriateness. 3.1 If complete, forwards the DV with all the supporting documents for processing. 3.2 If not, returns the DV and supporting documents with noted deficiencies to the concerned office.	Accounting Staff	DV, Supporting Documents
4. Indicates source of fund based on the attached Obligation Request (OBR)/Budget Obligation Request (BUR).	Accounting Staff	DV, OBR/BUR
5. Retrieves index if with prior payment.	Accounting Staff	DV, supporting documents
6. Checks if with prior payment. 6.1 If YES, returns DV to concerned office, if ORS/BURS tallies with DV. 6.2 If NO prepares NORSA/NBURSA	Accounting Staff	DV, ORS/BURS NORSA/NBURS A
7. Reviews the DV and supporting documents, and prepares Journal entries on box B.	Accounting Staff	DV, JEV
8. Records DV in the index of payment. Initials and forwards to Head of the Accounting.	Accounting Staff	DV
9. Retrieves RANCA / RANTA from file and determines availability of Cash. 9.1 If Yes, reviews and signs box C of DV. 9.2 If No, retains voucher at the accounting awaiting availability of cash.	Head of the Accounting (HOA)	DV, Registry of Allotments and Notice of Cash Allocation (RANCA) / Registry of Allotment and Notice of Transfer of Allocation (RANTA)
10. Forwards to the Head of the agency for approval.	Accounting Staff	DV

Chart No. 57: Processing of Disbursement Voucher (DV) for Payment

58. Processing of Obligation Request & Status (ORS) and Budget Utilization Request & Status (BURS)

Description	Person/Department Responsible	Interface/Form/ Document
1. Prepares ORS/BURS including DV/Payroll, Contract/Purchase Order (PO) and other Supporting Documents (SDs).	Unit concerned	ORS/BURS including DV/Payroll, Contract/Purchase Order (PO) and other Supporting Documents (SDs).
2. Receives and checks the completeness of the documents based on attached checklist and stamps "Received" and indicates the date of receipt in the ORS/BURS. Records in the logbook and forwards to Budget Staff 2.1 If Yes, verifies availability of allotment/budget based on the Registry of Allotments, Obligations and Disbursements (RAOD). 2.2 If No, returns to the concerned office with noted deficiencies.	Receiving/Releasing staff	ORS/BURS, Purchase Order, Disbursement, Voucher, Payroll, Contract of Service, Logbook
3. Assigns number on the ORS/BURS based on the control logbook. Records the amount in the Registry of Allotment, Obligation and Disbursement, initials in Box B then forwards all documents to Head of Budget for signature	Budget Staff	ORS/BURS, Logbook
4. Reviews the ORS and SDs & Certifies availability of allotment and purpose of obligation/ utilization	Head, Budget Department	ORS, SDs
5. Forwards ORS/BURS and SDs to Accounting Department for the processing of claim. Retains copy of ORS/BURS for monitoring of obligation/ utilization status. Refer to Chart No. 55 for the Processing of Disbursement.	Receiving/ Releasing Staff	ORS/BURS, SDs

Chart No. 58: Processing of Obligation Request & Status (ORS) and Budget Utilization Request & Status (BURS)

59. Preparation and Submission of Statement of Appropriations, Allotments, Obligations, Balances and Disbursements (SAAOBD)

Description	Person/Department Responsible	Interface/Form/ Document
1. Gathers data from different Registry of Allotments and Obligations (RAO); summarizes and encodes in the SAAOBD Report. Signs the prepared by portion and forwards to the Head of Budget.	Budget Staff	SAAOBD Report
2. Reviews and Certifies the Report.	Budget Staff	SAAOBD Report
3. Validation/Verification as to correctness of the data entered. 3.1 If correct, Certifies the Correctness of the report. 3.2 If incorrect, returns to budget staff for revision.	Head of Budget	SAAOBD Report
4. Initials the report and forwards to FMO for approval.	Head of Budget	SAAOBD Report
5. Approves the report and forwards to MCC for signature.	FMO	SAAOBD Report
6. Approves and signs report. Sends back to budget office.	MCC	SAAOBD Report
7. Submits the report to DOH through email on or before the 10th day of the following month.	Budget Staff	SAAOBD Report

Chart No. 59: Preparation and Submission of Statement of Appropriations, Allotments, Obligations, Balances and Disbursements (SAAOBD)

60. Financial Report Process

			Person/Department		Interface/Form/
Description			Responsible		Document
1. Receives reports	from	different	Receiving Staff		Cash Operations
departments:					Report of
					Checks Issued
					(RCI)/Report of
					ADA Issued
					(RADAI)
					Report of
					unreleased
					checks
					Report of
					Collections and
					Deposit (RCD)
					Payroll
					Billing and Claims
					Report of Bills
					Rendered (RBR)
					Materials
					Management Section
					Daily Report of
					Deliveries
					Report of
					Supplies and
					Materials Issued
					Report of
					Donation
					Inventory and
					Inspection
					Report of
					Unserviceable
					Property
					(IIRUP)
					Reports of Lost
					Stolen Destroyed
					Damage
					Property
					(RLSDDP)
					Pharmacy
					Department
					Drugs and
					Medicines
					Consumption
					Reports
					Laboratory
					Central Supply
					Room
					Dental
					Dietary
					Radiology

2.	Reviews and checks report against the	Accounting Staff	Supporting
	supporting documents.		Documents
	2.1 If with discrepancies, return to
	concerned section for correction.
3.	Based on reports submitted, classifies,	Accounting Staff	Check & Cash
	summarizes and records each account		Disbursement Journal,
	with corresponding account code and		CRJ,
	prepares the following special journals:		RCD, GJ
	3.1 Check Disbursement Journal – for
	Report of Check Issued (RCI).
	3.2 Cash Receipts Journal – for Report
	of Collection and Deposit (RCD).
	3.3 Cash Disbursement Journal – for
	payroll.
	3.4 General journal (GJ) for other
	reports non cash transactions
	adjustments.
4.	Based on Special Journals (SJ), prepares	Accounting Staff	SJ, JEV, Chart of
	appropriate Journal Entry Voucher		Accounts
	(JEV). Refer to Chart of Accounts of
	GAM
5.	Reviews Journal Entry Voucher	Accounting Staff	JEV
	prepared by Accounting Staff
6.	Posts the monthly summarized journal	Accounting Staff	SJ, GJ, GL
	entries from the Special Journals and
	General Journal (GJ) to the respective
	General Ledgers (GL).
7.	Posts the source / summarizing	Accounting Staff	SLs
	documents to the respective Subsidiary
	Ledgers (SLs).
8.	Foots and Extracts the balances of GLs	Accounting Staff	GLs, SLs
	and SLs	(AS)/Head of the
		Accounting (HOA)
9.	Based on the General Ledgers, prepares	AS/HOA	GLs, Post-Closing
	Post-Closing Trial Balance.		Trial Balance
10.	Reconciles the supporting schedules	AS/HOA	Post-Closing Trial
	presented in the Notes to Financial		Balance
	Statements with the amounts in the Post
	Closing Trial Balance.		JEV, GJ
	10.1 If not reconciled, prepares the
	necessary corrections through JEV.
	Records the JEV in the GJ
11.	Posts the GJ in the respective GLs, and	AS/HOA	GJ, Post-Closing Trial
	prepares the revised Post-Closing Trial		Balance
	Balance.
12.	Reviews and signs "Certified Correct	AS/HOA	Post-Closing Trial
	by" portion of the Post-Closing Trial		Balance
	Balance and supporting schedules
13.	Based on the Post Closing Trial Balance	AS/HOA	Post-Closing Trial
	prepares the Financial Statements:		Balance,
	a. Statement of Financial Position		Financial Statement
	b. Statement of Financial Performance
	c. Statement of Cash flows
	d. Statement of Net Assets/Equity

e. Statement of Comparison between Budget and Actual Amounts; and
f. Notes to Financial Statements.
14. Submits report to Commission on Audit	AS/HOA	FS
and DOH

Chart No. 60: Financial Report Process

Chapter 4 Procedures under the Hospital Operations and Patient Support Service (HOPSS)

The Hospital Operations and Patient Support Service **(**HOPSS) plays an equally important role in the cure and care aspects of health care delivery system through the provision of necessary and timely support services.

A. General Administrative Procedures

61. Operational Planning

This process involves all units handling the documents, not just the Chief Administrative Service (CAS). There may be concerns/policies/plans/programs that needs to be presented to the Executive Committee or the Management Committee, while others can be addressed/resolved/approved on the Department/Division Level.

Description	Person/Department Responsible	Interface/Form/ Document
1. Notifies concerned staff.	Chief of the	Intra-Office
	Administrative Service	Memorandum;
	(CAS) Staff/Planning	Letters; Hospital
	Officer or Unit	Personnel Order;
		Notice of
		Meeting; Email
		and other forms
		of acceptable
		communications
2. Drafts plans and programs. Submits to	Chief Administrative	N/A
Division Head for review and	Office (CAO)/CAS
recommendation.	Staff, Planning Officer
	or Unit
3. Reviews plans and programs	CAO/Planning Officer	N/A
4. Discusses with concerned staff/units.	Medical Center	N/A
	Chief/Chief of Hospital
	(MCC/COH), CAS

5. Presents Operational Plan (OP) to	MCC/COH and	N/A
Executive Committee.	Division Heads
	Concerned, CAS Staff
6. Finalizes plans and programs. Presents	MCC/COH and	N/A
consolidated OP to Expanded	Division Heads
Management Committee.	Concerned, CAS Staff
7. Submits to Chief of Hospital/Medical	MCC/COH and	Hospital Order or
Center Chief of the hospital for	Division Heads	Hospital
approval.	Concerned, CAS Staff	Memorandum
		(draft)
8. Records, files and releases documents	CAS Staff	Incoming and
to the appropriate/concerned unit, as		Outgoing Routing
applicable.		Documents Log
9. Takes action on the submitted	MCC/COH	N/A
documents.
10. Distributes copies of approved	CAS Staff/ Concerned	Intra-Office
documents to concerned units/staff, if	Unit	Memorandum;
necessary.		Letters; Hospital
		Personnel Order;
		Notice of
		Meeting; Email
		and other forms
		of acceptable
		communications

Chart No. 61: Operational Planning

62.Processing of Documents

Description	Person/Department Responsible	Interface/Form/ Document
1. Checks completeness and legality of documents. Note: Cut-off time of receiving documents shall be determined by the hospital if deemed necessary, to give time for CAO Staff to enter/encode data on PR/PO Monitoring Spreadsheet.	Receiving Staff / Chief Administrative Office (CAO) Staff	Incoming and Outgoing Routing Documents Log, Monitoring spreadsheet, Record book/logbook, Document/Letter (communications) ; Document tracking System and other forms of acceptable communication
2. Receives and records them.	Receiving Staff	Incoming and Outgoing Routing Documents Log; Record book, Document/Letter; Document Tracking System and other forms of acceptable communication
3. Arranges in the designated folder all documents received according to the type of document.	Receiving Staff	Document/Letter
4. Forwards to Chief Administrative Officer (CAO)	Receiving Staff	Document/Letter
5. Reviews, signs/initials and/or takes action on the submitted documents. In the absence of the CAO, the OIC CAO shall act on his behalf.	Chief of the Administrative Service (CAS)/Chief Administrative Officer (CAO)	Administrative Memorandum/ Administrative Order/ Notice of Meeting/ Hospital Order or Hospital Memorandum (draft)/ Disbursement Vouchers/ Purchase Orders/ Checks/ Request

Procedures Manual for Government Hospitals, 3rd Edition

		for Documents/ ID Application Forms/ Payroll/ various communications for action and information of concerned areas
6. Forwards to releasing staff.	CAS Staff	Record book, Document/Letter
7. Records, releases/distributes approved documents to concerned office.	Releasing Staff (i.e Administrative Assistant or Officer)	Incoming and Outgoing Routing Documents Log/monitoring data base
8. Files documents, if required.	Releasing Staff	Record book, Document/Letter

Chart No. 62: Processing of Documents

63. Conduct of Meetings

This procedure shall be applicable for meetings arranged by the Administrative Service since other meetings are arranged and coordinated by the concerned Division/Staff.

	Description	Person/Department Responsible	Interface/Form/ Document
1.	Endorses a Notice of Meeting to the Office of the Medical Center Chief/	Section Head/Division Head/Committee	Notice of Meeting
	Chief of Hospital (MCC/COH)	Chairman
2.	Approves the Notice of Meeting.	Medical Center Chief/ Chief of Hospital (MCC/COH)	Notice of Meeting
3.	Receives request/Releases notice of meetings.	Chief of the Administrative Service (CAS) Staff/Chief Administrative Office (CAO) Staff	Notice of Meeting, Receiving copy of the Notice of Meeting; Record Book
4.	Schedules meetings.	CAS	N/A
5.	Notifies concerned unit/person through phone call, text/messenger or email.	CAS Staff	Notice of Meeting
6.	Conducts and records meetings	CAS Staff and other concerned department/units	N/A
7.	Submits report/minutes of meeting to the office of the MCC/COH	Section Head/Division Head/Committee Chairman	Minutes of meeting

Chart No. 63: Conduct of Meetings

64. Decision Making Process

There may be concerns/requests/queries that need not be submitted to the Office of the Medical Center Chief/Chief of Hospital and can be addressed/resolved/approved on the Division Level (Medical, Nursing, HOPSS and Finance).

Description	Person/Department Responsible	Interface/Form/ Document
1. Receives request/concerns/queries.	Chief of the Administrative Service (CAS) Staff/Chief Administrative Office (CAO) Staff	Incoming and Outgoing Routing Documents Log
2. Assesses problems/issues.	CAS, Division Heads	N/A
3. Discusses problem/issues with concerned staff/section.	CAS, Division Heads and concerned staff/section	N/A
4. Makes recommendation/s and endorses to the MCC	CAS, Division Heads and concerned staff/section	N/A
5. Approves the recommendation/s or orders other solution.	Medical Center Chief/ Chief of Hospital (MCC/COH)	N/A
6. Notifies concerned unit/person.	CAS Staff	Incoming and Outgoing Routing Documents Log (various communications for action and information of concerned areas/Hospital Orders/Hospital Memoranda/Adm inistrative Orders/Administr ative memoranda)

Chart No. 64: Decision Making Process

B. Human Resource Management

65. Recruitment, Selection, and Promotion

	Description	Person/Department	Interface/Form/
		Responsible	Document
1.	Prepares list of vacant positions for publication.	Administrative Officer (HRMO)/HRM Staff concerned	CSC FORM 9 Revised 2018 "List of Vacancies in Government"
2.	Post list at CSC/agency's bulletin boards.	HRMO/HRM Staff concerned	CSC FORM 9 electronic copy and DOH prescribed Notice of Vacancy
3.	Assesses applications and prepares list of qualified applicants. a. Initial Screening by HRMO; and b. Document Review by the respective Division Screening Committee.	HRMO/HRM Staff concerned/HRMPSB	Document Review Form/Applicant's Documents(Submit ted requirement, Written and technical exams)/ Scoring Criteria
4.	Conducts/Schedules examination (general and technical) for Qualified applicants. ● General to be prepared by HRMO. ● Technical to be prepared by Division/Organization Group where the vacancy exist.	HRMO/HRM Staff concerned, End-user	N/A
5.	Prepares list of shortlisted applicants who passed the examination for endorsement to HRMPSB.	HRMO/HRM Staff concerned/HRMPSB	Report of Shortlisted applicants
6. Note:	Conducts Character Investigation to applicants who pass the examination. Applicable to applicant/s from	HRMO/HRM Staff concerned	Questionnaire for Background Investigation
	outside the hospital.
7.	Schedules HRMPSB deliberation.	HRMPSB Secretariat	Notice of Meeting/Deliberati on and Behavioral Event Interview; Job Competency Interview Form
8.	Notifies qualified applicants and the HRMPSB for the schedule of interview.	HRMO/HRM Staff concerned/ HRMPSB Secretariat	E-mail/ Text messages and call; Letter

9. Interviews qualified Applicants	Human Resource Merit Promotion and Selection Board (HRMPSB)	Interview Sheet (Entry Level /Promotion)
10. Deliberates results of the screening process based on set criteria.	HRMPSB	Consolidated List of Evaluation/ Comparative Assessment Report (CAR) and Minutes of the SPB Meeting
11. Submits the comparative evaluation results to the Chief of Hospital/Medical Center Chief.	HRMPSB Secretariat	CAR/Endorsement of Ranking of Applicants
12. Chooses from the list of qualified candidates for appointment.	Chief of Hospital/Medical Center Chief (COH/MCC)	CAR and Minutes of the HRMPSB Meeting
13. Notifies applicants not chosen.	Administrative Officer (HRMO)	Regret Letter email and/or email and SMS
14. Notifies the candidate for appointment for submission of requirements.	HRMO/HRM Staff concerned	Notice of Appointment/Chec klist on Appointment
15. Prepares appointment for approval. Note: May include the role of HRMO at the appointment to certify that all requirements have been complied and reviewed.	HRMO/HRM Staff concerned	CS Form No. 32 Revised 2018 Oath of Office/ CS Form No. 4 Revised 2018 Certification of Assumption / DBM-CSC Form No. 1 Position Description Form (Revised Version No. 1, s. 2017) Cs Form 33 A Revised 2018 Appointment Form
16. Reviews/Recommends the approval of appointment to the Chief of Hospital/Medical Center Chief.	Chief of the Administrative Service (CAS)/CAO/HRMSP B Chairperson	CS Form No. 32 Revised 2018 Oath of Office/ CS Form No. 4 Revised 2018 Certification of Assumption / DBM-CSC Form No. 1 Position Description Form (Revised Version No. 1, s. 2017) Cs Form 33 A Revised

		2018 Appointment
		Form
17. Approves /Signs the appointment	Chief of	CS Form No. 32
and posts in three (3) conspicuous	Hospital/Medical	Revised 2018 Oath
places in the agency a notice	Center Chief	of Office/ CS Form
announcing the appointment of an	(COH/MCC)	No. 4 Revised 2018
employee a day after the issuance of		Certification of
appointment for at least fifteen (15)		Assumption /
calendar days.		DBM-CSC Form
		No. 1 Position
Note: Posting requirement is pursuant to		Description Form
Rule XIII, Sec. 193, Letter m, of the 2017		(Revised Version
Omnibus Rules on Appointment and Other		No. 1, s. 2017) Cs
Human Resource Actions (Revised July		Form 33 A Revised
2018).		2018 Appointment
		Form

Chart No. 65: Recruitment, Selection, and Promotion

66. Application for Leave

Refer to DOH Department Order No. 2015-0260: Authorized Signatories for Certain Transactions in the Department of Health dated December 1, 2015, Item 6, for authorized signatories for application of all types of leave of absence.

Description	Person/Department Responsible	Interface/Form/ Document
1. Accomplishes prescribed application for leave manually or through the Personnel Information System.	Employee	CS Form No. 6 Revised 1998(Leave Form)
2. Forwards to HRM Office for certification of balance of leave credits.	Employee	Leave Form Application CS Form No. 6
Note: If the application was made through the Personnel Information System/HRIS, the balance of leave credits will be indicated on the leave application.
3. Forwards to immediate supervisor for action.	Employee	Leave Form Application CS Form No. 6/accomplished leave application
4. Recommends approval /disapproval.	Immediate Supervisor	Leave Form Application CS Form No. 6//accomplished leave application
5. Processes application.	HRM Staff	Leave Form Application CS Form No. 6
6. Signs leave credit certification and initials action taken for approval of the Division Chief concerned/Chief of Hospital/Medical Center Chief.	Supervising Administrative Officer (SAO)	Leave Form Application CS Form No. 6
7. Approves/Disapproves recommendation.	Division Chief concerned/Chief of Hospital/Medical Center Chief	Approved/Disappro ve Box on Leave Form Application CS Form 6
8. Records action taken on personnel index.	HRM Staff	Outgoing Logsheet; approved leave application; Employees Leave Card Index / Leave Application/Emplo yees Electronic Leave Ledger

Chart No. 66: Application for Leave

67. Employee Welfare and Benefits – Request for Payment of Personnel Claims

Description	Person/Department Responsible	Interface/Form/ Document
1. Submits request and requirements	Employee	Daily Time
for payment to HRMO		Record/Leave
		Application for
		Terminal Leave
		Benefits; Letter of
		intent to
		retire/endorsemen
		t letter; letter of
		intent to monetize
		earned leave
2. Checks completeness of	HRM staff concerned	Checklist of
requirements.		Requirements;
		Clearance;
		approved
		application of
		terminal leave;
		affidavit of no
		pending case
3. Forwards to Budget Office for	HRM staff concerned	Obligation
Obligation and Funding		Request
4. Prepares Obligation Request and	Budget Office/Unit	Obligation
forwards to Accounting		Request
Office/Unit.
5. Prepares Disbursement Voucher	Accounting Staff	Disbursement
(DV)		Voucher (DV)
6. Reviews and signs voucher.	CAO or HRM	Disbursement
	Supervising	Voucher and
	Administrative Officer	Obligation
	(SAO)	Request

Chart No. 67: Employee Welfare and Benefits – Request for Payment of Personnel Claims

68. Employee Welfare and Benefits –Request for Payment of Personnel Claims (1st Salary/Terminal leave pay)

Description	Person/Department Responsible	Interface/Form/ Document
1. Submits all requirements needed for preparation of voucher for 1st salary and terminal leave pay	HRMO Staff for Hiring/Separation	st salary 1 voucher/terminal leave voucher
2. Prepares the voucher for st 1 salary and terminal leave pay	HRMO Staff for Payroll/ Sub-unit head for payroll	st salary 1 voucher/terminal leave voucher
3. The HRMO Staff for Payroll prints out the voucher to be reviewed by the payroll sub-unit head.	HRMO Staff for Payroll/ Sub-unit head for payroll	st salary 1 voucher/terminal leave voucher
4. The SAO-HRMO reviews and signs the voucher.	SAO-HRMO	st salary 1 voucher/terminal leave voucher
5. The HRMO Staff for Payroll forwards the signed voucher to the Accounting Section on the set deadline.	HRMO Staff for Payroll; Accounting Section	st salary 1 voucher/terminal leave voucher

Chart No. 68: Employee Welfare and Benefits –Request for Payment of Personnel Claims (1st Salary/Terminal leave pay)

69. Employee Welfare and Benefits – Payroll Preparation

Description	Person/Department Responsible	Interface/Form/ Document
1. Checks Daily Time Record (DTR), personnel index, Personnel Movement Report (includes reports of separated employees, LWOP, Renewal, etc.), reports on personnel without DTR, personnel absent for ten (10) days without approved	HRM Staff concerned	Daily Time Record (DTR) with attached leave application and Certificate of Appearance (OT/OB);
leave. 2. Prepares payroll and forwards to Accounting Office for Check and Balance. Revises payroll (if applicable) and prepares	HRM Staff concerned	Hospital Order General Payroll: Obligation Request
disbursement voucher and forwards to CAO/SAO.		Individual Payroll: Disbursement Voucher and Obligation Request
3. Reviews, signs certification and initials disbursement voucher.	SAO/CAO	General Payroll: Obligation Request Individual
		Payroll: Disbursement Voucher and Obligation Request
4. Forwards the signed payroll register and disbursement voucher to the Accounting Unit/Office on set deadline.	SAO/CAO/HRMO Staff for Payroll/Staff concerned	General Payroll: Obligation Request
		Individual Payroll: Disbursement Voucher and Obligation Request

Chart No. 69: Employee Welfare and Benefits – Payroll Preparation

70. Employee Welfare and Benefits – Request for Service Record/Certification

Description	Person/Department Responsible	Interface/Form/ Document
1. Submits request indicating the purpose.	Employee	Requisition of
		Documents
2. Prepares requested document and	HRM staff	Service Record
forwards to Supervising	concerned	(GSIS Form PO
Administrative Officer (SAO).		202); Certificate
		of Employment
		(COE)
3. Reviews and initials document.	Supervising	Service Record
	Administrative	(GSIS Form PO
	Officer (HRMO)	202); Certificate
		of Employment
4. Forwards to the Chief of the	Supervising	Requisition of
Administrative Service (CAS) for	Administrative	Documents/
signature.	Officer (HRMO)	Outgoing
		Logbook; Service
		Record; COE
5. Reviews and signs the document.	Chief of the	Service Record;
	Administrative	COE
	Service/Chief of
	Hospital/Medical
	Center Chief
6. Returns to HRM for release.	Staff Concerned	Service Record;
		COE; Document
		Log sheet

Chart No. 70: Employee Welfare and Benefits – Request for Service Record/Certification

C. Central Information Management

71. Incoming and Outgoing Records

	Description	Person/Department Responsible	Interface/Form/ Document
1.	Receives and records incoming	CIM Staff concerned	Record
	documents.		book/logbook,
			document/letter
2.	Sorts and forwards to immediate	CIM Staff concerned	Record
	supervisor.		book/logbook,
			document/letter,
			Routing slip
3.	Reviews and takes corresponding	Head, CIM	Document/Letter,
	action.		Routing slip
4.	Acts on instruction.	CIM Staff concerned
5.	Records and releases outgoing	CIM Staff concerned	Record
	documents.		book/logbook,
			Document/Letter
			Soft copy (Excel
			File)

Chart No. 71: Incoming and Outgoing Records

72. Network Operations – Software Troubleshooting

This procedure shall apply to hospitals using the integrated Hospital Operations and Management Information System (iHOMIS).

Description		Person/Department Responsible	Interface/Form /Document
1. Submits request/report to Systems Administrator for any technical support needed on the program. If with accomplishes/completes request form electronically.	glitch or iHOMIS, service	Concerned Unit or Area of the hospital/ IT Implementers/designated staff/End-users	Service Request Form
2. Receives request for support from the system custodian or head of the department/unit who are the process owner of the system.	technical	System Administrator/designated staff/Computer Maintenance Technologist/IHOMP Unit Staff	Service Request Form
3. Evaluates/identifies the nature of the requested technical support (i.e glitch, customization/modification, integration).		System Administrator/designated staff/Computer Maintenance Technologist/IHOMP Unit Staff	N/A
4. Takes appropriate action/s on the following: a. Resolves reported glitches. May seek assistance from Regional IT KMITS, as necessary. b. Endorses the customization/modification or integration KMITS and/or HFDB for action.	or DOH requested to DOH	System Administrator/designated staff/Computer Maintenance Technologist/IHOMP Unit Staff	Service Request Form/Endorsem ent Letter
5. Maintains the sustainability HOMIS and other IT programs.	of	System Administrator/designated staff/Computer Maintenance Technologist/IHOMP Unit Staff
6. Maintains general records/reports.		System Administrator/designated staff/Computer Maintenance Technologist/IHOMP Unit Staff	Service Reports

Chart No. 72: Network Operations – Software Troubleshooting

73. Network Operations – Hardware Troubleshooting

Description	Person/Department Responsible	Interface/Form /Document
1. Prepares request for troubleshooting of hardware.	Implementer/designated staff/End-user	Online Job Order Request System (JORS)/Service Request Form
2. Assess request based from the details entered by the requesting employee.	System Administrator/designated staff/Computer Maintenance Technologist/IHOMP Unit Staff	N/A
3. Conducts troubleshooting and prepares the necessary report and requisition of materials if warranted.	System Administrator/designated staff/Computer Maintenance Technologist/IHOMP Unit Staff	Service Report/Report of Waste Material/Purcha se Request
4. Refers to DOH-KMITS for necessary technical assistance.	System Administrator/designated staff/Computer Maintenance Technologist/IHOMP Unit Staff	Service Request Form
5. Maintains general records/reports	System Administrator/designated staff/Computer Maintenance Technologist/IHOMP Unit Staff	Service Reports/ICT Equipment Inventory

Chart No. 73: Network Operations – Hardware Troubleshooting

D. General Services

D.1 Engineering

74. Preventive Maintenance Program

	Description	Person/Department Responsible	Interface/Form/ Document
1.	Prepares and submits preventive maintenance program.	Unit Heads in charge	Equipment Maintenance Plan (EMP) Form/Preventive Maintenance Schedule
2.	Evaluates the program.	Head, Engineering Department/Section	For approval of EMP
3.	Signs and certifies the necessity and prioritization of the program.	Head, Engineering Department/Section	Interface
4.	Forwards the plan to the Chief of the Administrative Service.	Head, Engineering Department/Section	Annual Procurement Plan
5.	Reviews, evaluates and recommends for the approval of the Chief of Hospital/Medical Center Chief.	Chief of the Administrative Service (CAS)	Endorsement/Inte rface
6.	Approves the plan.	Chief of Hospital/Medical Center Chief (COH/MCC)	Endorsement/Inte rface
7.	Distributes Equipment Maintenance Plan to End-users, as necessary.	Head, Engineering Department/Section	N/A

Chart No. 74: Preventive Maintenance Program

75. Corrective Maintenance

Description	Person/Department Responsible	Interface/Form/ Document
1. Accomplishes the Job Order	Requesting unit head	Job Order Form,
Request.	concerned	Logbook
2. Forwards to Engineering	Requesting unit head	Job Order Form,
Department/Section for evaluation. 3. Determines/Assigns nature of work	concerned Engineering	Logbook Job Order Form,
required.	Department/Section Office Staff	Logbook
4. Produces and signs the Job Order Request for endorsement.	Engineering Department/Section Office Staff	N/A
5. Forwards Job Order Request to concerned unit.	Engineering Department/Section Office Staff	Job Order Form, Logbook
6. Estimates and determines the required resources.	Engineering unit head concerned	Job Order Form
7. Prepares request for required supplies and materials.	Engineering unit head concerned	Purchase Request form/Request Issuance Slip
8. Forwards to stockroom in charge.	Engineering unit head concerned	Purchase Request form/Job Order/Issuance Slip/Borrower Slip/RIS
9. Checks the availability of supplies and materials. 9.1 If available, issues the supplies and materials to Engineering unit concerned. Then proceed to No. 9. 9.2 If not available, returns RIS with the notation of non-availability then proceed to nos. 10 to 15 before doing procedure no. 9.	Designated staff concerned	Purchase Request form/Daily consumption of materials, Bin Card, RIS
10. Prepares the schedule of work and assigns the staff to do the work.	Engineering unit head concerned	Job Order Form, Consumption Report
11. Prepares the PR for non-available supplies and materials needed.	Engineering unit head concerned	Purchase Request form, RIS, supplemental, Bin Card
12. Forwards the PR to Chief Engineering Department/Section for initial.	Engineering Department/Section Office Staff	Purchase Request form, logbook, Supplemental PPMP

13. Reviews and determines whether	Head, Engineering	Purchase
the items will be procured though	Department/Section	Request/Petty
petty cash or regular purchase.		Cash Voucher,
		Logbook,
		Supplemental
		PPMP
14. Forwards the PR to the Chief of the	Head, Engineering	Transmittal form,
Administrative Service (CAS) for	Department/Section	Supplemental
action.		PPMP
15. Reviews and signs the RIS and	Chief of the	Purchase
initials the PR for approval of the	Administrative Service	Request/RIS/TOR
Chief of Hospital/Medical Center	(CAS)
Chief.
16. Signs/approves PR and forwards to	Chief of	Transmittal form,
Procurement Unit.	Hospital/Medical	PR,
	Center Chief	Supplemental,
	(COH/MCC)	Logbook

Chart No. 75: Corrective Maintenance

76. Rehabilitative Maintenance Program

	Description	Person/Department Responsible	Interface/Form/ Document
1.	Prepares and forwards requests for rehabilitation work to the Chief of the Administrative Service (CAS)	Requesting unit head concerned	Annual Procurement Plan; Purchase Request (PR) form/Scope of Work, Logbook
2.	Reviews and evaluates request and forwards it to the Chief of Hospital/Medical Center Chief (COH/MCC)	Chief of the Administrative Service (CAS)	PR, Supplemental, logbook, Transmittal form
3.	Approved request for rehabilitative work.	Chief of Hospital/Medical Center Chief (COH/MCC)	PR, Logbook, Transmittal form
4.	Forwards to Chief , Engineering Department/Section	COH/MCC	Transmittal form
5.	Facilitates the presentation of plans, specification, estimates and scope of work.	Head, Engineering Department/Section	N/A
6.	Forwards to CAS.	Head, Engineering Department/Section	Transmittal form
7.	Reviews and recommends approval.	Chief of the Administrative Service (CAS)	Transmittal form
8.	Approves and forwards to BAC for mode of procurement.	COH/MCC	Transmittal form

Chart No. 76: Rehabilitative Maintenance Program

77. Ambulance Dispatching

	Description	Person/Department Responsible	Interface/Form/ Document
1.	Checks request for completeness/availability of ambulance.	Motorpool Dispatcher or Designated Personnel	Checklist of motor vehicle endorsement; Ambulance Order; Ambulance Trip ticket form
2.	Accomplishes Ambulance Trip Ticket prior to actual date and time of conduction.	Emergency Department (ED) Staff/Ward Staff	Ambulance Trip ticket form
3.	Verifies completeness of trip ticket request and Prioritizes ambulance conduction schedule.	ED Management and Administrative Officer (EDMAO)/Designated Personnel	Ambulance Trip ticket form
4.	Notifies Driver on-duty and gives trip ticket	Motorpool Dispatcher or designated personnel	Ambulance Trip ticket form; Ambulance Conduction Logbook
5.	Gets key ambulance and conducts patient per approved trip ticket and properly scheduled per logbook.	Ambulance Driver	Ambulance Conduction Logbook
6.	Deploys to destination	Designated personnel/Ambulance Driver	Ambulance Trip Ticket form
7.	Parks the ambulance and performs aftercare.	Designated personnel/Engineering Facilities Management (EFM) and Housekeeping	Ambulance Trip Ticket form
8.	Surrenders key to Information Staff on-duty and completes trip ticket	Ambulance Driver	Ambulance Trip Ticket form
9.	Records completeness of the trip	EDMAO/designated personnel/EFM	Ambulance Conduction Logbook

Chart No. 77: Ambulance Dispatching

78. Use of Hospital Vehicle

Description	Person/Department Responsible	Interface/Form/ Document
1. Accomplishes the request for use of vehicle.	Requesting Unit concerned	Vehicle Request Form; Trip Ticket Issuance on Administrative Trips Logbook
2. Forwards to motor pool dispatcher/transport office for availability of vehicle.	Requesting Unit concerned	Vehicle Request form
3. Verifies availability of driver and vehicle.	Dispatcher/Supervisor	Vehicle Request form
4. Indicates availability of vehicle and designated driver.	Dispatcher/Supervisor	Vehicle Request form
5. Prepares Trip Ticket.	Dispatcher	Drivers Trip ticket form
6. Forwards to the Chief Administrative Officer (CAO) or Transport Unit Supervisor.	Dispatcher	Drivers Trip ticket form
7. Evaluates and approves request for use of vehicle and trip ticket.	Chief of the Administrative Service (CAS)/Supervisor/Unit Head	Vehicle Request & Drivers Trip ticket form
8. Releases the approved trip ticket.	CAS/Supervisor/Unit Head	Drivers Trip ticket form
9. Designates the driver concerned and furnishes the driver a copy of the approved trip ticket.	Dispatcher /Supervisor	Vehicle Request Form; Trim Ticket
10. Checks the vehicle as to readiness and availability of tool kit.	Duty Driver	Daily routine before/after driving; Checklist of Motor Vehicle
11. Indicates in the trip ticket the beginning mileage.	Duty Driver	Drivers Trip ticket form
12. Furnishes the security guard on duty a copy of the trip ticker.	Duty Driver	Drivers Trip ticket form
13. Checks trip ticket and vehicle before allowing its exit.	Security Guard on duty at the gate.	Drivers Trip ticket form
14. Upon return, have the trip ticket signed by passenger; completes data on the trip ticker and reports to motor pool dispatcher.	Duty Driver	Drivers Trip ticket form

Note: All trips must be covered by an approved trip ticket prior to the date and time of travel.

Chart No. 78: Use of Hospital Vehicle

79. Submission of Reports

Description	Person/Department Responsible	Interface/Form/ Document
1. Prepares the corresponding Monthly Report of Trips per auditing/accounting regulation and submits to the Head, Engineering Department/Section.	Supervisor/Dispatcher	Drivers Trip ticket form/Replenishment of Diesel & Gasoline used/ Monthly consumption of Fuel for Transportations and Generator sets
2. Reviews and certifies the correctness of the report.	Head, Engineering Department/Section	Monthly consumption of Fuel for Transportations and Generator sets/approved Reports
3. Forwards to the Chief of the Administrative Service (CAS) for approval.	Head, Engineering Department/Section	Monthly consumption of Fuel for Transportations and Generator sets/approved reports

Chart No. 79: Submission of Reports

D.2 Housekeeping, Linen and Laundry, and Security

80. Maintenance of Cleanliness and Sanitation

Description	Person/Department Responsible	Interface/Form/ Document
1. Cleans, sanitizes and disinfects comfort rooms, lavatories and all assigned areas. This is done in strict compliance to the Infection Prevention and Control Measures. There are three (3) levels of disinfection: a. Surface Decontamination thru Air Spray Machine; b. Wall-to-wall cleaning being done by the Institutional Workers; and c. Surface Decontamination thru UV Robot Machine.	Service janitors/staff designated/contracted	Checklist Monitoring form/monitoring sheet; Work Performance Checklist for Janitorial Services; Comfort Checklist room Monitoring
2. Keeps housekeeping tools in proper places after use.	Service janitors/staff designated/contracted	Monitoring form/Checklist of housekeeping tools and other equipment
3. Collects and places garbage at designated area for pick-up.	Service janitors/staff designated/contracted	Waste disposal form; Logbook
4. Cleans waste cans.	Service janitors/staff designated/contracted	Logbook

Chart No. 80: Maintenance of Cleanliness and Sanitation

81. Collection/Transport of Hospital Waste

	Description	Person/Department Responsible	Interface/Form/ Document
1.	Conducts regular inspection of waste storage and maintains its cleanliness and sanitation.	Designated staff/Housekeeper/Pollu tion Control Officer	Logbook; Waste Disposal Monitoring Form
2.	Monitors garbage collection.	Designated staff	Logbook/Monitor ing Sheet; Waste Segregation Checklist
3.	Records collection done by contracted service providers. Secures Certificate of Treatment (COT) and Certificate of Disposal (COD).	Designated staff	Pull out slip form/logbook, COT and COD
4.	Sweeps, collects garbage from the different hospital units strictly observing the policies on waste segregation. Inspects and do proper waste segregation.	Service janitors/staff designated/contracted	Waste Segregation Policy and Checklist
5.	Transports garbage to transient storage area.	Service janitors/staff designated/contracted/ Housekeeping Services	Logbook; Waste Segregation Checklist
6.	Stores waste at appropriate storage in color-coded trash bags. Follows waste segregation/sorting policy.	Service janitors/staff designated/contracted/ housekeeping services	Logbook
7.	Cleans/Disinfects garbage bins, storage area and surroundings.	Service janitors/staff designated/contracted	Logbook
8.	Submits monthly report to Head of Housekeeping Department/Section.	Service janitors/staff designated/contracted	Logbook; Accomplishment Report form

Chart No. 81: Collection/Transport of Hospital Waste

82. Issuance of Clean Linen

Description	Person/Department Responsible	Interface/Form/ Document
1. Submits request slip for required linen.	Nursing Attendant/Nurse concerned	Request Slip/logbook; Linen Issuance Form
2. Checks availability of linen and issues requested linen.	Linen staff concerned	Issuance form/logbook; Linen Inventory Stock Card
3. Records issuance.	Linen staff concerned	Linen Issuance form; logbook

Chart No. 82: Issuance of Clean Linen

83. Collection and Laundry of Soiled Linen

Description	Person/Department Responsible	Interface/Form/ Document
1. Sorts, accounts, lists and returns soiled linen.	Nursing Attendant/Nurse concerned	Dispatch form/logbook for Outsource linens and gowns; Logbook for receiving of soiled, balancing and dispensing of clean linen both clinical and non clinical areas
2. Verifies and records the returned soiled linen from the wards /other units.	Linen and Laundry receiving staff	Daily inventory of Linen from other wards/ Logbook for Outsource linens and gowns Logbook for receiving of soiled, balancing and dispensing of clean linen both clinical and non clinical areas
3. Informs nursing attendant of unaccounted/missing linen.	Linen and Laundry receiving staff	Phone call/notice of missing linen; Logbook for Official Receipt (OR) of Paid Lost Linen
4. Forwards/transports soiled linen to Sorting Area.	Linen and Laundry receiving staff	Dispatch form Tally sheet form; Logbook for

			Outsource linens and gowns Logbook for receiving of soiled, balancing and dispensing of clean linen both clinical and non clinical areas
5.	Segregates the dirty from soiled linen. Soaks linen coming from infectious areas.	Linen and Laundry receiving staff
6.	For In-House: a. Disinfects and washes soiled linen. b. Sorts, records and stores clean linen. For Contractual:	Laundry staff concerned	Logbook/report of soiled and clean linen; Pick-up receipt; Delivery Receipt
a. b.	Accounts and records the soiled linen and releases to the contracting agency. Sorts, accounts and records returned clean linen.
7.	Sorts, Records/Accounts, and stores clean linen.	Laundry staff concerned	Logbook/report of soiled and clean linen; Pick-up receipt; Delivery Receipt

Chart No. 83: Collection and Laundry of Soiled Linen

84. Inventory of Linens (in the Linen and Laundry Stock Room)

Description	Person/Department Responsible	Interface/Form/ Document
1. Records and updates stock cards.	Linen and Laundry Head/Designated Staff	Stock card form
2. Conducts physical inventory of linens and supplies and materials on stock.	Linen and Laundry Head/Designated Staff	Stock card form
3. Prepares and submits reports of inventory.	Linen and Laundry Head/Designated Staff	Report of Physical Inventory of Linen and Supplies/Inventor y Report; Stock card form
4. Identifies and reports linen for condemn or recycling.	Linen and Laundry Head/Designated Staff	Logbook, Waste Material Report; List of Condemned Items and Checklist for Disposal

Chart No. 84: Inventory of Linens (in the Linen and Laundry Stock Room)

85. Inventory of Linens (in Clinical Areas)

	Description	Person/Department Responsible	Interface/Form/ Document
1.	Conducts monthly inventory of linen.	Nursing Staff concerned/Linen and Laundry Head	Stock Card form/Logbook
2.	Reconciles records of linen receipt and returned.	Nursing Staff concerned/Linen and Laundry Head	Linen Issuance Form
3.	Prepares summary reports and issues updated inventory custodian slip.	Nursing Staff concerned/Linen and Laundry Head	Logbook
4.	Acknowledges inventory custodian slip.	Nursing Staff concerned/Linen and Laundry Head	Logbook
5.	Reports missing or unaccounted linen to immediate head.	Nursing Staff concerned/Linen and Laundry Head	Logbook for Official Receipt (OR) of Paid Lost Linen
6.	Validates the report and submits report to Chief of the Administrative Service (CAS).	Immediate head concerned	Consumption Report and Accomplishment Report
7.	Recommends appropriate action to the Chief of Hospital/Medical Center Chief (COH/MCC)	Chief of the Administrative Service (CAS)	N/A

Chart No. 85: Inventory of Linens (in Clinical Areas)

86. Production of Linen

Description	Person/Department Responsible	Interface/Form/ Document
1. Determines the linen requirements.	Linen and laundry Head	Job Order Request Form. logbook
2. Prepares purchase request for raw materials and supplies.	Linen and laundry Head	Purchase Request Form; Consumption report
3. Inspects and accepts deliveries of raw materials and supplies.	Linen and laundry Head	Delivery Receipt, RIS
4. Instructs linen staff for the desired finished product.	Linen and laundry Head	Job Order Request Form
5. Cuts and sews linen as per desired finished products.	Tailor/seamstress/linen staff concerned.	Log book/Notebook
6. Checks the sewed linen for conformity to specifications.	Linen and laundry Head	Log book/Notebook; Job Order Request Form
7. Returns to staff for coding/marking.	Linen and laundry Head	Tally Sheet form; Job Order Request Form
8. Inspects coded/marked linen.	Linen and laundry Head	Job Order Request Form
9. Inspects sewed linen on conformity with specification.	Linen and laundry Head	Job Order Request Form
10. Keeps inventory logbook of all hospital linen with corresponding costs.	Linen and laundry Head	Inventory form/Logbook of produced linen; Job Order Request Form

Chart No. 86: Production of Linen

87. Disposal of Condemned Linen

	Description	Person/Department Responsible	Interface/Form/ Document
1.	Sorts and inspects torn and worn	Linen and Laundry	Log book/Notebook;
	out linens.	Head/Designated Staff	List of Condemned
			Items & Checklist
			for Disposal; Waste
			Material Report
2.	Separates torn/worn out linens	Linen and Laundry	Log book/Notebook
	for recycling or condemn.	Head/Designated Staff
3.	Prepares itemized list of linen for	Linen and Laundry	Condemn form
	condemn and forwards to	Head/Designated Staff	Logbook
	Property and Supply.
4.	Prepares report of condemned	Administrative	Condemn form
	linen and forwards to the Chief of	Officer/Designated
	Administrative Service (CAS).	Head, Property and
		Supply
5.	Signs/Initials and forwards to	Chief of Administrative	Condemn form
	Chief of Hospital/Medical	Service (CAS)	w/ Letter
	Center Chief (COH/MCC) for
	approval.

Chart No. 87: Disposal of Condemned Linen

88. Deployment of Security Guards

	Description	Person/Department	Interface/Form/
		Responsible	Document
1.	Prepares schedule of the duty. The Detachment Commander is the one in charge of the schedule of duty.	Head, Security Department/Section	Monthly/Semi Monthly/weekly Schedule of Duties In-House Security form, Deployment Schedule
2.	Checks posted guards. A shift in charge and the detachment commander checks guards posted.	Head, Security Department/Section	Monthly Schedule of Duties Variance Security Agency; logbooks
3.	Inspects entry/exit points of employee, patients and public including bags/luggage. These guards assigned at the Main gate, back gate and Emergency room access door.	Posted Security Guard	In-House Security & Security Agency on-duty
4.	Inspects/Records incoming and outgoing vehicles.	Posted Security Guard: Roving guards and guards posted near the parking area.	Vehicle Trans Out & In form/Wehicle Record Form; Logbook; Trip Ticker; Deliveries and outgoing materials form
5.	Records unusual/incident reports and submits to shift in charge for endorsement to detachment commander.	Posted Security Guard	Incident & Accident Report form
6.	Conducts rounds and inspects buildings, facilities and premises to ensure safety of patients and hospital personnel.	Roving Security Guard	Roving Logbook; Census Form; Security Log sheet Form
7.	Records observations and prepares reports if warranted.	Roving Security Guard	Logbook, Incident Report
8.	Reviews report/s, takes appropriate action and forwards report to Chief of Administrative Service (CAS).	Head, Security Department/Section	Incident & Accident Report form; logbook, Daily Monitoring Form

Chart No. 88: Deployment of Security Guards

89. Conduct of Investigation

Description	Person/Department Responsible	Interface/Form/ Document
1. Receives and reviews incident report. 2. Conducts preliminary investigation	Head, Security Department/Section/ Detachment Commander Head, Security	Security Logbook; Complainant Statement Form Incident Report
of report of incidents. Submits to Hospital Security Head for endorsement to Chief Administrative Officer (CAO) for annotation or action plan.	Department/Section/ Detachment Commander	Logbook; CCTV non-Disclosure agreement
3. Endorses report to Chief of Administrative Service (CAS)	Head, Security Department/Section	Logbook; Incident Report Form, Final Investigation Report

Chart No. 89: Conduct of Investigation

E. Property and Supply Management

90. Procedure on Acquisition by Transfer

The Property Transfer Report (PTR) is used for the transfer of property from the Central Office to the Regional Office or Hospital. While the Property Acknowledgment Receipt (PAR)/Inventory Custodian Slip (ICS) is used for the transfer of property accountability within the hospital/organization.

Description	Person/Department Responsible	Interface/Form/ Document
1. Requests transfer of property from other government agency. Writes letter of request to the Head of the benefactor agency.	Medical Center Chief/Chief of Hospital (MCC/COH)	Letter Request; Deed of Donation/Letter of Intent
2. Checks, inspects and receives property.	Supply Officer, Inspection Acceptance Committee, Materials Management Staff	Property Transfer Report (PTR) Calibration Report, Equipment Delivery Checklist
3. Signs in the "Received by" portion of the Property Transfer Report (PTR) upon acceptance of the transferred property.	MCC/COH, Supply Officer, Materials Management Staff	Property Transfer Report (PTR)
4. Forwards the PTR to the Materials Management Section/Property and Supply Section.	MCC/COH Materials Management Staff	Property Transfer Report (PTR)
5. Requests appraisal of the transferred property if the amount is not indicated in the PTR to the Appraisal Committee.	Supply Officer	Letter Request and PTR; Appraisal Report
6. Conducts appraisal and submits report to the Materials Management Section/Property and Supply Section.	Appraisal Committee	Appraisal Report
7. Prepares Delivery Report (DR)/Notice of Delivery (NOD) and Inspection and Acceptance Report (IAR). Note: Encodes and print system generated	Supply Officer	Delivery Report (DR)/NOD and Inspection And Acceptance Report (IAR)
IAR, if applicable. 8. Requests inspection of the appraised transferred property to the Inspection Committee.	Supply Officer	IAR, PTR and/or Appraisal Report

9. Conducts inspection of the appraised transferred property. Prepares/signs and indicates date of inspection in the "Inspection" column of the IAR.	Inspection Committee	IAR
10. Signs and indicates the date of receipt in the "Acceptance"	Supply Officer	IAR
11. Submits the IAR with supporting documents to the Commission on Audit (COA) and Accounting Section.	Supply Officer	IAR, PTR and/or Appraisal Report
12. Prepares the following: ● Stock Card (SC) and Bin Card (BC) for supplies and materials; ● Property Card (PC) for Semi Expendable Equipment (SE) and Property, Plant, and Equipment (PPE)	Stock Custodian/Property Custodian/Supply Officer/Materials Management Staff	Stock Card (SC); Inventory Tag; Bin Card (BC); Property Card (PC); Property Tag
13. Submits the IAR, DR, PTR and/or Appraisal Report to Accounting Section. Keeps PTR File of Supply Officer.	Supply Officer/Materials Management Staff	IAR, DR, PTR and/or Appraisal Report
14. Records the transferred property in the books of accounts.	Chief Accountant	Books of Accounts; Supply Ledger Card; and PAR
15. Prepares the following: ● Supplies Ledger Card (SLC) for Semi-Expendable Equipment (SE); ● Property, Plant and Equipment Ledger Card (PPELC) for Property, Plant and Equipment (PPE)	Chief Accountant/Accounting Department	Supplies Ledger Card (SLC) Property, Plant and Equipment Ledger Card (PPELC)

Chart No. 90: Procedure on Acquisition by Transfer

91. Procedure on Acquisition by Donation

Description	Person/Department Responsible	Interface/Form/ Document
1. Receives Letter of Intent to Donate.	Medical Center Chief/Chief of Hospital (MCC/COH) or Materials Management SAO	Letter of Intent to Donate; Memorandum of Agreement
2. Requests for the following data: ● For supplies and materials: name and description, quantity, cost, expiry date, if applicable; ● For equipment: name and specification, quantity, cost, status/condition.	MCC/COH or Materials Management Staff	Letter Request and List of Items for Donation/Letter of Request of Donation with Specification; Property Transfer Report (PTR)
3. Chooses the needed items from the list.	End-user/MET, Supply Officer or Engineer	List of Items for Donation, Letter Request with Specification
4. Prepares Donation Receipt Form.	MMS Staff	Donation Receipt Form (DRF)
5. Submits recommendation to the Medical Center Chief/Chief of Hospital (MCC/COH).	End-user/MET, Supply Officer or Engineer	Donation Receipt Form (DRF);Letter of Recommendation; Letter request; List of Items donated with Quantity and Specification
6. Approves/Disapproves the Letter of Intent to Donate/DRF based on the recommendation.	MCC/COH	Approval Letter; Donation Receipt Form (DRF)
7. Checks and receives the donated items listed in the Deed of Donation.	Supply Officer/Materials Management Staff/Inspector/End User/Inspection and Acceptance Committee	Donation Receipt Form (DRF); Deed of Donation
8. Requests appraisal of the donated items if the cost is not indicated in the Deed of Donation to the Appraisal Committee.	Supply Officer	Letter Request and Deed of Donation

9. Conducts appraisal and submits report to the Materials Management Section.	Appraisal Committee	Appraisal Report
10. Prepares Delivery Report (DR)/NOD and Inspection And Acceptance Report (IAR).	Supply Officer	Delivery Report (DR) and Inspection And Acceptance Report (IAR)
11. Requests inspection of the appraised-donated items to the Inspection Committee.	Supply Officer	IAR, Deed of Donation and/or Appraisal Report
12. Conducts inspection of the appraised-donated items. Signs and indicates the date of inspection in the "Inspection" column of the IAR.	Inspection Committee	IAR; Deed of Donation and Sales Invoice
13. Signs and indicates the date of receipt in the "Acceptance" column of the IAR.	Supply Officer	IAR
14. Submits the IAR with supporting documents to the Commission on Audit (COA) and Accounting Section.	Supply Officer	IAR, DR, Deed of Donation and/or Appraisal Report
15. Prepares the following: ● Stock Card (SC) and Bin Card (BC) for supplies and materials; ● Property Card (PC) for equipment and attaches Property Tag	Stock Custodian/Property Custodian/Materials Management Staff	Stock Card (SC) Bin Card (BC); Property Card (PC); and Property Tag
16. Forwards the Deed of Donation, IAR and supporting documents, Appraisal Report to the Accounting Section.	Supply Officer	IAR, DR, Deed of Donation and/or Appraisal Report
17. Records the donated items in the books of accounts.	Chief Accountant/Materials Management SAO	Books of Accounts
18. Prepares the following: ● Supplies Ledger Card (SLC) for supplies and materials.	Chief Accountant/Materials Management SAO	Supplies Ledger Card (SLC)
● Property, Plant and Equipment Ledger Card (PPELC) for equipment.		Property, Plant and Equipment Ledger Card (PPELC)

Chart No. 91: Procedure on Acquisition by Donation

92. Procedure on Acquisition by Manufacture/Fabrication

	Description	Person/Department Responsible	Interface/Form/ Document
1.	Receives materials from the Property and Supply Section.	End-user/Engineering and Facility Management (EFM) Staff	Requisition and Issuance Slip
2.	Fabricates/Manufactures materials into finished products according to indicated in EFM.	End-user/Engineering and Facility Management (EFM) Staff	JOB ORDER by End-user; Consumption Report on the raw materials used to fabricate an asset
3.	Prepares stock cards for manufactured supplies.	End-user/Materials Management Staff	N/A
4.	Submits report of fabricated/manufactured items to the Property and Supply Section containing the following data: a. Name and description b. Quantity c. Cost of materials d. Cost of direct labor	End-user/EFM Staff	N/A
5.	Requests inspection of the items to determine conformity with the report	Supply Officer/ Materials Management Staff	Inspection Acceptance Report; ICS/PAR
6.	Conducts inspection and submits report to the Property and Supply Section. (Internal Inspection of Fabricated Item)	Property Inspector/EFM Engineer	IAR; Delivery Checklist
7.	Prepares Property Card and IAR for fabricated properties and submits report to Accounting Section.	Supply Officer/ Materials Management Staff	Property Card/RIS/ICS; Inspection and Acceptance Report (IAR)
8.	Records the fabricated properties in the books of accounts and prepares PPELC.	Chief Accountant	Supply Stock Card for ICS and Property Card for Equipment; RPCPPE/RPCI

Chart No. 92: Procedure on Acquisition by Manufacture/Fabrication

93.Procedure on Construction by Administration

Description	Person/Department Responsible	Interface/Form/ Document
1. Prepares Purchase Request (PR) supported with the scope of work, bill of materials and the estimated cost of the project based on approved Annual Procurement Plan (APP).	Engineer/End-user in coordination with EFMO	Purchase Request (PR)
2. Approves PR.	Medical Center Chief/Chief of Hospitals (MCC/COH)	Purchase Request (PR)
3. Procures required materials.	Bids & Awards Committee (BAC) / Procurement Officer	Purchase Order (PO); Notice To Proceed (NTP); Certification of Availability of Funds (CAF); Obligation Request and Status (ORS) or Budget Utilization Request and Status (BURS); BAC Resolution; and Notice of Award (NOA)
4. Implements the project upon receipt of the required materials.	Engineer	N/A
5. Prepares the following upon completion of the project: ● Project Accomplishment Report indicating the name of the project, date started, date completed, estimated cost and the actual cost incurred, etc.	Engineer	Project Accomplishment Report and List of Scrap/Unused Materials

● List of Scrap and/or unused materials
6. Requests inspection of the project.	Engineer	N/A
7. Conducts inspection and submits report.	Inspection Committee/Property Inspector/EFM Engineer	Inspection Report
8. Submits the Inspection Report with Project Accomplishment Report to Accounting Section.	Engineer	Inspection Report and Project Accomplishment Report
9. Submits list and returns unused and/or scrap materials to Materials Management Section/Property and Supply Section.	Engineer/Material Management Section	List of Scrap/Unused Materials/Return Slip for Unused RM/Waste Materials Report for Disposal
10. Acknowledges receipt of materials: ● For unused materials, mark the list "Returned to Stock" and record it in the Stock Card (SC) and submits copy of list to Accounting Section. ● For scrap materials, prepares Waste Materials Report (WMR) and forwards to Disposal Committee.	Supply Officer/Materials Management Section	Stock Card (SC) and Waste Materials Report (WMR)

Chart No. 93: Procedure on Construction by Administration

94. Procedure on Bonding Accountable Officers

	Description	Person/Department Responsible	Interface/Form/ Document
1.	Designates accountable officer.	Medical Center Chief/Chief of Hospital (MCC/COH)	Hospital Order/Memorand um
2.	Fills out the application for bonding and attaches required documents.	Accountable Officer	General Form no. 57
3.	Signs endorsement in the application for bonding of appointed and/or designated accountable officer.	MCC/COH	General Form no. 57/Approved Endorsement
4.	Prepares Disbursement Voucher (DV) for bond premium.	Accountable Officer	Disbursement Voucher (DV)
5.	Processes the DV.	Accountant	DV
6.	Prepares and signs check.	Cashier	Check
7.	Approves the DV and signs check.	MCC/COH	DV; Check
8.	Submits application for bonding and remits check to the Bureau of Treasury.	Cashier/Liaison Officer	General Form no. 57; Check; Official Receipt

Chart No. 94: Procedure on Bonding Accountable Officers

95. Procedure on the Receipt, Inspection, Acceptance and Recording Deliveries of Inventory Items and Equipment

Description	Person/Department Responsible	Interface/Form/ Document
1. Receives delivered goods after verifying conformity with the checklist.	Supply Officer/ Receiving Staff/ Materials Management Staff/Warehouseman/ SAO; End-User	Purchase Orders/ Contract Agreement/ Delivery Receipt/ Official Receipt/ SI
2. Checks specification of items and signs "Accepted for Use" stamp	End-User, Inspection Committee	N/A
3. Signs "Received" portion of the Sales Invoice (SI) and/or Delivery Receipt (DR), indicating the date of receipt.	Supply Officer/Materials Management Staff	Sales Invoice (SI) and/or Delivery Receipt (DR)/IAR
4. Prepares Notice of Delivery/Sales Invoice and Inspection And Acceptance Report (IAR).	Supply Officer/ Materials Management Staff	Notice of Delivery (NOD)/Sales Invoice and Inspection and Acceptance Report (IAR)
5. Requests inspection of the delivered goods to the Inspection Committee.	Supply Officer/Materials Management Staff	Request form/NOD
6. Conducts inspection of the delivered goods.	Inspection Committee/Property Inspector	NOD and Purchase documents
7. Prepares and Signs the Inspection and Acceptance Report (IAR), indicating the date of inspection. If delivery is not in order, indicate notation on the IAR.	Inspection Committee/Property Inspector/Supply Officer	IAR
8. Fills out and signs in the "Acceptance" column of the IAR. Indicates date.	Supply Officer/End user/Materials Management Staff	IAR and purchase documents

9. Submits the IAR with supporting documents to the Commission on Audit (COA) and Accounting Section.	Supply Officer	IAR, DR, SI, PO and Purchase Request (PR)
10. Prepares the following: ● Stock Card (SC) and Bin Card (BC) for supplies and materials; ● Property Card (PC) for Semi-Expendable Equipment (SE) and Property, Plant, and Equipment (PPE) and attaches Property Tag	Materials Management Staff /Stock Custodian/Property Custodian	Stock Card (SC) Bin Card (BC); Property Card (PC); and Property Tag
11. Records issuances in Stock Card, Bin Card, Property Card, and RPCPPE. Note: For hospitals with Electronic Inventory System, modification of this step may be allowed provided that standards are still complied with.	Supply Officer/Materials Management Staff	SC, BC, PC and RPCPPE

Chart No. 95: Procedure in the Receipt, Inspection, Acceptance and Recording Deliveries of Inventory Items and Equipment

96. Procedure on the Requisition and Issuance of Inventory Items

Description		Person/Department Responsible	Interface/Form/ Document
1.	Prepares Requisition and Issue Slip (RIS). Inputs requested items in RIS through Hospital Information System (HIS), if applicable.	End-user	RIS
2.	Approves the RIS.	Authorized Official (CMPS/SAO)	RIS
3.	Forwards approved RIS to the Materials Management Section/Property and Supply Section.	Supply officer/End-user	Stock Card/RIS
4.	Assigns RIS control number and records in the logbook. RIS number is electronically generated if with HIS.	Storekeeper/Warehouse man	RIS and RIS Logbook
5.	Approves issuance.	SAO in MMS	RIS
6.	Issues supplies and records issuance in the Bin Card.	Storekeeper/Warehouse man	Bin Card
7.	Fills out and signs "Issuance" portion of the RIS.	Storekeeper	RIS
8.	Receives supplies and signs in the "Received by" portion of the RIS	End-user	RIS
9.	Receives copy of the RIS, files in numerical order and updates Stock Card (SC). Updates Stock Card.	Materials Management Staff	RIS and Stock Card (SC); Material Inventory System
10. Note:	Prepares Report of Supplies and Materials issued (RSMI) and attaches copies of RIS and SAI. For those with Hospital Information System (HIS) in place, attachment of RIS and SAI may not applicable.	Storekeeper/Materials Management Section,	Report of Supplies and Materials Issued (RSMI); RIS; SAI
11.	Submits RSMI with the attached RIS to the Accounting Section.	Supply Officer	RSMI; RIS

Chart No. 96: Procedure on the Requisition and Issuance of Inventory Items

97. Procedure on the Requisition and Issuance of Equipment

Description	Person/Department Responsible	Interface/Form/ Document
1. Prepares Requisition and Issue Slip (RIS) and Stock Transfer Requisition (STR).	End-user	Requisition and Issue Slip (RIS); Stock Transfer Requisition (STR); Material Inventory System
2. Approves RIS and STR.	Authorized Official/Material Management SAO/Supply Officer	RIS; STR; Material Inventory System
3. Assigns RIS control number, records RIS in the logbook and prepares Property Acknowledgment Receipt (PAR) for Property, Plant and Equipment (PPE) or Inventory Custodian Slip (ICS) for Semi Expendable Equipment (SE).	Property Custodian/PAS Staff	RIS; RIS Logbook; Property Acknowledgment Receipt (PAR); Inventory Custodian Slip (ICS)
4. Issues the equipment.	Property Custodian/Material Management SAO/PAS Staff	PAR
5. Receives the equipment.	End-user	Inspection and Acceptance Report; Duplicate RIS
6. Signs and obtains copies of RIS, STR and PAR or ICS.	End-user	Duplicate of RIS, STR and PAR or ICS
7. Files RIS numerically. Files PAR or ICS numerically and chronologically per accountable officer. (Property number and ICS number is manually generated in PAR)	Property Custodian/MMS Staff	RIS; PAR or ICS
8. Records issuance in the Property Card (PC) for PPE and SE.	Property Custodian/Material Management Staff	Property Card (PC); Stock Card (SC)

Chart No. 97: Procedure on the Requisition and Issuance of Equipment

98. Procedure on the Physical Inventory of Supplies and Equipment

Description	Person/Department Responsible	Interface/Form/ Document
1. Designates member of the Inventory Committee.	Medical Center Chief/Chief of Hospital (MCC/COH)	Memorandum of Hospital Personnel Designation/Hospit al Order (HO)
2. Prepares and recommends Hospital Order (HO) for the creation of the Inventory Committee.	MCC/COH/Chief Administrative Officer/HR	Memorandum of Hospital Personnel Designation/Hospit al Order (HO)
3. Issues/Approves Hospital Order.	MCC/COH	Memorandum of Hospital Personnel Designation/Hospit al Order (HO)
4. Disseminates Hospital Order to the member of the Inventory Committee	Human Resource Management Officer	Memorandum of Hospital Personnel Designation/Hospit al Order (HO)
5. Formulates guidelines in inventory taking. Orientation of new inventory committee members based on existing Quality Policy (QP).	Inventory Committee	N/A
6. Prepares materials needed in the conduct of inventory.	Inventory Committee	RPCI/RPCPPE; PAR/ICS
7. Approves guidelines in inventory taking, as may be incorporated in the QP.	MCC/COH	N/A
8. Issues memorandum meeting before inventory proper.	Inventory Committee	Memorandum
9. Conducts physical count of properties in the presence of concerned accountable officers and COA/Internal Audit representatives at least once a year for equipment and twice a year for supplies and materials.	Inventory Committee	N/A
10. Prepares Initial Report on the Physical Count of Property, Plant	Inventory Committee	Report on the Physical Count of

and Equipment (RPCPPE) / Report on the Physical Count of Inventories (RPCI) for reconciliation with Accounting and Materials Management Section.		Property, Plant and Equipment (RPCPPE); Report on the Physical Count of Inventories (RPCI)
11. Reconciles discrepancy. ● The inventory listing of supplies and materials shall be checked against the Stock Card (SC), Supplies Ledger Card (SLC) and the control accounts. ● The inventory listing of the equipment shall be checked against the Property Card (PC); Property, Plant, and Equipment Ledger Card (PPELC); and the General Ledger (GL).	Inventory Committee, Accountant and Supply Officer/Materials Management Staff	Stock Card (SC), Supplies Ledger Card (SLC); Property Card (PC); Property, Plant, and Equipment Ledger Card (PPELC); and the General Ledger (GL).
12. Prepares final Inventory Reports	Inventory Committee	RPCPPE; RPCI/Inventory Reports
13. Approves the Inventory Reports	MCC/COH	RPCPPE; RPCI/ Inventory Reports
14. Forwards the reports to the Materials Management Section/Property and Supply Section, copy furnished COA and Accounting Section.	Inventory Committee/Supply Office/Materials Management Staff	RPCPPE; RPCI/ Inventory Reports
15. Approves reports.	MCC/COH	N/A

Chart No. 98: Procedure in the Physical Inventory of Supplies and Equipment

99. Procedure on Property Repair

Description		Person/Department Responsible	Interface/Form/ Document
1. Prepares Property (PRF).	Repair Form	End-user/Accountable Officer	Property Repair Form/Biomed/EFM Job Order Form for repair
2. Assesses and certifies the cause of the breakdown of property.		Biomed/EFM Staff	Certification of Fair Wear and Tear
3. Reviews and approves the PRF.		Department/Unit Head/Biomed/EFM Head	PRF
4. Verifies the ownership property through the Property Card (PC). ● If the property warranty, supplier notifies the Engineering and Facilities Section. ● If the property is out of warranty, documents to Engineering and Facilities Management Section for action.	of the is under contacts the immediately and Management forwards all appropriate	Supply Officer/ PAS/ ENG Staff	Property Card (PC); Warranty Certificate
5. Evaluates the condition property, if repairable. ● For in-house repair: a. not, prepares Request (PR); b. upon receipt parts; c. Surrenders appropriate action.	of the economically Prepares Requisition and Issue Slip (RIS) if parts needed are available; if Purchase Proceeds with the repair of spare the waste materials to the Materials Management Section for	Engineer/Maintenance Staff	Requisition and Issue Slip (RIS); Pre-Repair and Post-Repair Inspection Report; Equipment Status Report, Purchase Report (PR) for items unavailable or Outside repair
● For outside repair: a. Certifies property defective	that the is found and needs outside repair, and that		Certification

there is no
qualified/competent staff
who can perform the
repair;
b. Fills up the Pre-Repair
and Post-Repair
Inspection Report;
c. Submits all documents to
Property Inspector for
appropriate action
d. Prepares and submits PR
based in the findings of
the Property Inspector.
Note: If the property is not economically
repairable, prepares certification that the
property is beyond economical repair and

returns to end-user/accountable officer.

Chart No. 99: Procedure on Property Repair

100. Procedure in Insuring Government Property

Description	Person/Department Responsible	Interface/Form/ Document
1. Prepares the Property Inventory Report (PIR) using the form prescribed by the GSIS.	Supply Officer/Materials Management Staff	Property Inventory Report (PIR)
2. Approves the report.	Medical Center Chief/Chief of Hospital (MCC/COH)	PIR Form (COA Form)
3. Submits report to the GSIS.	Accounting Section/Materials Management Staff (MMS)	PIR
4. Prepares Disbursement Voucher (DV) upon receipt of bill of payment of insurance premium and submits to the Accounting Section.	Supply Officer	Disbursement Voucher (DV)
5. Processes the DV.	Accountant	DV
6. Prepares and signs the check.	Cashier	Check
7. Approves the DV and signs the check.	MCC/COH	DV; Check
8. Remits payment to GSIS (Insurance Policy)	Cashier / Liaison Officer/MMS	Check; Official Receipt
9. Receives insurance policy.	Accounting/Liaison Officer	Insurance Policy
10. Submits the insurance policy to the Materials Management Section.	Liaison Officer	Insurance Policy
11. Receives the insurance policy for safekeeping.	Accounting/Supply Officer/MMS	Insurance Policy

Chart No. 100: Procedure in Insuring Government Property

101. Procedure in Transferring Property Accountability

The Property Transfer Report (PTR) is used for the transfer of property from the Central Office to the Regional Office or Hospital. While the Property Acknowledgment Receipt (PAR)/Inventory Custodian Slip (ICS) is used for the transfer of property accountability within the hospital/organization.

Description	Person/Department Responsible	Interface/Form/ Document
1. Requests transfer of property accountability. Uses the Property Acknowledgement Receipt (PAR) for properties amounting to more than Fifteen Thousand Pesos (Php 15,000); and the Inventory Custodian Slip (ICS) for properties amounting to less than Fifteen Thousand Pesos (Php 15,000).	Outgoing Officer/Materials Management Staff	Property Acknowledgment Receipt (PAR)/Inventory Custodian Slip (ICS)
2. Conducts joint physical inventory of property.	Supply Officer, Outgoing and Incoming Officers/Materials Management Staff	PAR/ICS; Report on the Physical Count of Inventories (RPCI), Report on the Physical Count of Property, Plant and Equipment (RPCPPE)
3. Prepares PAR/ICS for incoming officer.	Supply Officer/Materials Management Supply	PAR/ICS
4. Signs PAR/ICS.	Incoming Officer/Materials Management Supply	PAR/ICS
5. Receives signed PAR/ICS and furnishes copy to outgoing officer.	Supply Officer/Materials Management Supply	PAR/ICS
6. Updates Property Card (PC) and files PAR/ICS	Supply Officer/Materials Management Supply	Property Card (PC); PAR/ICS
7. Furnishes copy of PAR/ICS to Accounting Section for updating of the Property, Plant and Equipment Ledger Card (PPELC).	Supply Officer	PAR/ICS; Property, Plant and Equipment Ledger Card (PPELC)

Chart No. 101: Procedure in Transferring Property Accountability

102. Procedure in the Request for Relief from Property Accountability

Description	Person/Department Responsible	Interface/Form/ Document
1. Fills up and submits the Report of Lost, Stolen, Damaged or Destroyed Property (RLSDDP) immediately to report/notify the lost, stolen, damaged or destroyed property to the Medical Center Chief/Chief of Hospital and the Materials Management Section.	Accountable Officer	Report of Lost, Stolen, Damaged or Destroyed Property (RLSDDP)/Inciden tal Report
2. Informs the accountable officer on the process/requirements for the request for relief from accountability.	Supply Officer/Materials Management Supply	Communication Letter
3. Submits RLSDDP to the COA Auditor within thirty (30) days supported by the following documents: 3.1 Affidavit executed by the accountable officer stating the following facts: a. Property lost and its valuation; b. Actual date in which the absence was first noted; c. Manner of disappearance; d. Efforts put forth to recover the same; e. Provisions made to safeguard the property; and f. Date when the loss was reported to the auditor and the police authorities. 3.2 Joint Affidavit of two (2) disinterested persons cognizant of the facts and circumstances about the loss. In case it is not possible to obtain the statement of two (2) disinterested persons and only one is available, or none at all, such fact should be set forth in the affidavit of the person requesting relief, giving the reasons thereto;	Accountable Officer	RLSDDP; Affidavit; Joint Affidavit; Final Police Report; Certification from Police / Fire Chief / Provincial / Governor / Mayor; Inspection Report; Property Acknowledgment Receipt (PAR) Affidavit of the accountable officer; affidavits of two (2) disinterested persons cognizant of the facts and circumstances of the loss; Final Investigation Report

3.3 Final Police Report showing the steps taken by the police authorities to recover the property lost and to apprehend the suspect/s and the present status of the case; 3.4 Comments and/or recommendation of the MCC/COH; 3.5 Certification from Police/Fire Chief/Provincial Governor/Mayor or other competent authority as to the destruction brought about by natural calamity and/or insurgency, if applicable; 3.6 Inspection Report on the extent of damage on insured property, if applicable; Evidence of the immediate issuance of the notice of loss of accountable forms as required under COA Circular no. 84-233 dated August 24, 1984 if applicable; 3.7 Copy of Property
Acknowledgement Receipt (PAR) for property lost.
4. Receives COA decision and furnishes copy to accountable officer.	MCC/COH	COA Decision
5. Implements COA decision and informs the Materials Management Section/Property and Supply Section for appropriate action.	MCC/COH	COA Decision
6. Acts in accordance with COA decision.	Accountable Officer	COA Decision
7. Prepares proper documentation.	Supply Officer/Accountant/M aterials Management Staff	COA Decision

Chart No. 102: Procedure in Request for Relief from Property Accountability

103. Procedure in the Preparation of Inventory and Inspection Report of Unserviceable Property

Description	Person/Department Responsible	Interface/Form/ Document
1. Certifies property as irreparable and/or beyond economical repair.	Engineer/MET/ PAS Staff/ Inspection Officer	Certification; Equipment Status Report
2. Returns property with Property Acknowledgment Receipt (PAR) to the Materials Management Section and accomplishes Return Slip Form.	Accountable Officer	Return Slip Form; Property Acknowledgement Receipt (PAR)
3. Verifies property against PAR and Property Card (PC).	Supply Officer	PAR; Property Card (PC)
4. Receives the property if found in conformity with the PAR and PC. If not, returns and advises Accountable Officer on the actions to be taken.	Supply Officer	PAR; PC
5. Attaches inventory tag on received property.	Supply Officer	Inventory Tag; PAR/ICS
6. Cancels PAR and updates PC	Supply Officer/ PAS Staff	PAR/ICS; PC
7. Prepares Inventory and Inspection Report of Unserviceable Property (IIRUP).	Supply Officer/ PAS Staff	Inventory and Inspection Report of Unserviceable Property (IIRUP)
8. Forwards the IIRUP to the Accounting Section for indication of depreciation value of unserviceable property.	Supply Officer	IIRUP
9. Indicates the depreciation value and returns the report to Materials Management Section/Property and Supply Section.	Accountant/ Appraisal Committee	IIRUP; Appraisal Form
10. Forwards report to Disposal Committee.	Supply Officer	IIRUP; Waste Material Report/Return Slip

Procedures Manual for Government Hospitals, 3rd Edition

11. Inspects property and establishes	Disposal	IIRUP; Waste
the floor price.	Committee/Appraisal	Material
	Committee	Report/Return Slip
12. Fills up the appraisal column of the report and recommends mode of disposal.	Disposal Committee	IIRUP; Resolution of the Disposal Committee
13. Approves mode of disposal.	MCC/COH	Resolution of the Disposal Committee
14. Implements approved mode of disposal.	Disposal Committee	Resolution of the Disposal Committee

Chart No. 103: Procedure in Preparation of Inventory and Inspection Report of Unserviceable Property

104. Procedure in the Preparation of Waste Material Report

Description	Person/Department Responsible	Interface/Form/ Document
1. Returns waste materials to Materials Management Section and fills up Return Slip Form. Waste material is kept is in Engineering Warehouse	Engineer	Return Slip Form
2. Checks and receives waste materials.	Supply Officer/EFM
3. Prepares Waste Materials Report (WMR) and forwards to Disposal Committee for Inspection.	Supply Officer/ PAS Staff	Waste Materials Report (WMR)
4. Conducts inspection and recommends appropriate mode of disposal.	Disposal Committee/Inspection Officer	Letter of Recommendation
5. Approves recommendation.	Medical Center Chief/Chief of Hospital/Supply Officer/	Letter of Recommendation; Resolution of the Disposal Committee
6. Implements approved mode of disposal.	Disposal Committee	Waste Material Report

Chart No. 104: Procedure in Preparation of Waste Material Report

105. Procedure in Public Bidding

Description	Person/Department Responsible	Interface/Form/ Document
1. Prepares Invitation to Bid (ITB) and other bidding documents.	BAC Secretariat	Invitation to Bid (ITB)
2. Approves the Content of ITB	BAC	Invitation to Bid (ITB)
3. Advertises the Invitation to Bid/Request for Expression of Interest shall be: ● Posted at any conspicuous place reserved for this purpose in the premises of the Procuring Entity concerned, for seven (7) calendar days as certified by the head of the BAC Secretariat of the Procuring Entity concerned; and ● Posted continuously in the PhilGEPS website, the website of the Procuring Entity concerned, if available, and the website prescribed by the foreign government or international financing institution, if applicable, for seven (7) days starting the date of advertisement.	BAC Secretariat	Invitation to Bid (ITB); Technical specifications/scop e of work/Terms of Reference and bidding documents
Note: For procuring entities that cannot post its opportunities in the PhilGEPS for justifiable reasons, they shall continue to publish their advertisements in a newspaper of general nationwide circulation (2016 Implementing Riles and Regulations of Republic Act no. 9184).
4. Conducts Pre-Bidding Conference and issues Supplemental Bid Bulletin, if any.	BAC, BAC Secretariat, TWG, Observers and Suppliers, End users	PPMP, APP, Purchase Request, CAF, Terms of Reference; Philippine Bidding Documents
5. Issues payment order and bid documents to interested bidders	BAC Secretariat	Biding Documents: Instructions to Bidders (ITB) and

upon payment of a non-refundable fee.		Terms and Condition of Sale; Bid Quotation Form; Payment Order Form; Financial Bid Form
6. Receives bids with bond in sealed envelopes with proof of payment for the bidding documents	BAC Secretariat	Bid Proposal (Technical and Financial component); Duly signed instructions to Bidders and Terms and Conditions of Sale; Bid Quotation Form; and Bid Security (Original copy and 1 photocopy of the original)
7. Opens bid proposal on date, time, date and place set in the presence of bidders or their duly authorized representatives and observers (if any). There should be at least two (2) observers present, who shall not have the right to vote (Sec. 13 of the 2016 IRR of RA 9184)	BAC Secretariat and TWG	Bid Proposal (Technical and Financial component); Abstract of Bids as Read and Eligibility Checklist
8. Conducts Bid Evaluation and presents results of the evaluation.	BAC, BAC Secretariat and TWG	Bidding documents; Abstract of Bids as Calculated; TWG/Bid Evaluation Report
9. Presents Post Qualification Evaluation Report and issues Notice for Post Qualification/Disqualification Evaluation to lowest calculated bidders.	BAC, BAC Secretariat and TWG	Post-Qualification requirements; TWG/Post qualification/disqua lification Evaluation Report; Letter to Suppliers/Contract ors
10. Prepares BAC resolution recommending award to the Lowest Calculated Responsive Bid (LCRB) in case of goods/services and infrastructure projects and Highest Rated and Responsive Bid (HRRB) in case of consulting services.	BAC Secretariat	BAC Resolution recommending Award

11. Approves BAC recommendations.	Medical Center Chief/Chief of Hospital (MCC/COH)	Resolution
12. Prepares Notice of Award (NOA).	BAC Secretariat	Notice of Award (NOA)
13. Approves NOA.	MCC/COH	NOA
14. Affixes conforme on the NOA.	Authorized representative of the Supplier/Contractor/S ervice Provider/Consultant	Conforme; NOA
15. Issues NOA.	BAC Secretariat	NOA
16. Posts/posting of Performance Security as required under Sec. 39 of the 2016 Revised IRR of RA No. 9184.	Supplier/Contractor/Pr ovider/Consultant	Performance Security
17. Prepares and signs Contract of Agreement and Notice to Proceed	BAC, BAC Secretariat, CAO, Accounting, FMO, Legal Officer	Contract Agreement and Notice to Proceed
18. Approves Contract of Agreement and Notice to Proceed	MCC/COH	Contract Agreement and Notice to Proceed
19. Issues approved Contract Agreement to Supplier/Contractor Service/Consultant for notarial purposes.	BAC Secretariat	Contract Agreement
20. Notarizes Contract Agreement	Legal/Supplier or Contractor	Contract Agreement
21. Issues Notice to Proceed to Suppliers or Contractors	BAC Secretariat	Notice to Proceed
22. Forwards Contract Agreement and Notice to Proceed to Materials Management Sections	BAC Secretariat	Contract Agreement and NTP

Chart No. 105: Procedure in Public Bidding

106. Procedure in Sale Thru Negotiation

Description	Person/Department Responsible	Interface/Form/ Document
1. Prepares resolution recommending the sale thru negotiation for approval of the Medical Center Chief/Chief of Hospital (MCC/COH)	Disposal Committee	Resolution; List of Unserviceable PPE
2. Approves recommendation and returns to Disposal Committee for appropriate action.	Medical Center Chief/Chief of Hospital (MCC/COH)	Resolution
3. Conducts negotiation. 4. Prepares resolution recommending	Disposal Committee Disposal Committee	Resolution
award. 5. Approves recommendation. 6. Prepares Notice of Award (NOA).	MCC/COH Disposal Committee	Resolution Notice of Award
7. Signs NOA and returns to Disposal Committee.	MCC/COH	(NOA) NOA
8. Issues NOA to buyer.	Disposal Committee	NOA
9. Secures approved gate pass from Materials Management Section for the release of property.	Disposal Committee	Gate Pass
10. Notifies COA to witness the release of property.	Disposal Committee	Letter
11. Supervises the immediate hauling of the items upon presentation of official receipt of full payment within five (5) working days from the date of the NOA.	Disposal Committee	Official Receipt; Terms and Condition of Sale and Instructions to Bidders
12. Records the sale in Inventory and Inspection Report of Unserviceable Property (IIRUP)/Waste Materials Report (WMR) and submits to Materials Management Section/Property and Supply Section	Disposal Committee, Accounting	Inventory and Inspection Report of Unserviceable Property (IIRUP)/ Waste Materials Report (WMR)
13. Records disposition in the Property Card (PC), if applicable.	Supply Officer	Property Card (PC)
14. Furnishes copy of IIRUP/WMR to Accounting Section.	Supply Officer	IIRUP / WMR
15. Drops sold items in IIRUP/WMR from the books of accounts and provide copy of Journal Entry Voucher (JEV) to Materials Management Section/Property and Supply Section	Accountant	Journal Entry Voucher (JEV)

Chart No. 106: Procedure in Sale Thru Negotiation

107. Procedure in Transfer of Property

Description	Person/Department Responsible	Interface/Form/ Document
1. Approves transfer of property.	Medical Center Chief/Chief of Hospital (MCC/COH)	Property Transfer Report(PTR)/ Memorandum of Agreement
2. Prepares Property Transfer Report (PTR) or Invoice Receipt for Property (IRP)	Supply Officer	Property Transfer Report (PTR) or IRP
3. Signs "Approved by" portion of the PTR.	MCC/COH	PTR
4. Issues approved gate pass for the release of property.	Supply Officer/EFM	Gate Pass
5. Transfers property and secures signature of the Head of Agency in the "Received by" portion of the PTR.	Supply Officer	PTR; Gate Pass
6. Provides copy of PTR to the receiving agency.	Supply Officer	PTR/IRP
7. Records transfer of property in the Property Card (PC) and submits copy of PTR to Disposal Committee and Accounting Section.	Supply Officer	Property Card (PC)
8. Drops transferred item from the books of accounts and provide a copy of Journal Entry Voucher (JEV) to Materials Management Section.	Accountant	Journal Entry Voucher (JEV)

Chart No. 107: Procedure in Transfer of Property

108. Procedure in Donation

Description		Person/Department Responsible	Interface/Form/ Document
1.	Receives request for donation of property.	Medical Center Chief/Chief of Hospital (MCC/COH)	Letter Request; Property Transfer Report/Memorandu m of Agreement
2.	Approves request.	MCC/COH	Letter Request
3.	Prepares Property Transfer Report (PTR).	Supply Officer	Property Transfer Report (PTR)
4.	Signs "Approved by" portion of PTR.	MCC/COH	PTR
5.	Issues approved gate pass for the release of property.	Supply Officer	Gate Pass; IRP
6.	Releases the property and secures signature of the Head of Agency in the "Received by" portion of the PTR.	Supply Officer	PTR; Gate Pass
7.	Provides copy of the PTR to the receiving agency.	Supply Officer	PTR
8.	Records donation in the Property Card (PC) and submits copy of the PTR to Disposal Committee and Accounting Section for dropping the item from the books of accounts.	Supply Officer	Property Card (PC) / PTR
9.	Drops the donated items from the books of accounts and provides copy of Journal Entry Voucher (JEV) to Materials Management Section.	Accountant	Journal Entry Voucher (JEV)- Appendix 36

Chart No. 108: Procedure in Donation

109. Procedure in Condemnation/Destruction of Property

Description	Person/Department Responsible	Interface/Form/ Document
1. Notifies COA to witness the condemnation/destruction of property.	Disposal Committee, Supply Officer
2. Condemns/destroys property.	Disposal Committee, Supply Officer	JORS/Receipt of Payment
3. Signs Waste Materials Report (WMR).	Supply Officer	Waste Materials Report (WMR); Property gate/pass receipt of payment
4. Files WMR for reference.	Supply Officer	WMR; Property gate/pass receipt of payment

Chart No. 109: Procedure in Condemnation/Destruction of Property

PART III REFERENCES

List of References

• 1. Hospital Nursing Service Administration Manual 4th Edition, Department of Health, 2019
• 2. Hospital Pharmacy Management Manual 4th Edition, Department of Health, 2020
• 3. Hospital Nutrition and Dietetics Service Management Manual 3rd Edition, Department of Health, 2020
• 4. Manual for Medical Social Workers 5th Edition, Department of Health, 2010
• 5. Manual of Organization and Management of the Administrative and Finance Service for Hospitals 2008 Revised Edition, Department of Health, 2008
• 6. Hospital Property and Supply Management Manual 1st Edition, Department of Health, 2008
• 7. National Standards in Infection Control for Healthcare Facilities Revised Edition, Department of Health, 2009
• 8. Manual of Standards on Quality Management System in the Clinical Laboratory 2nd Edition, Department of Health, 2019
• 9. Manual of Standards and Guidelines on the Management of the Hospital Emergency Department, Department of Health
• 10. Revised Organizational Structure and Staffing Standards for Government Hospitals CY 2013 Edition, Department of Health, 2013
• 11. Hospital Health Information Management Manual 4th Edition, Department of Health, 2021
• 12. Healthcare Waste Management Manual 4th Edition, Department of Health, 2020
• 13. Manual of Standards for Management of Hospital Finance Service 1st Edition, Department of Health, 2021
• 14. Manual of Procedures for Hospitals 2nd Edition, Department of Health, 1994
• 15. Procedures Manual for Provincial and District Hospitals, Department of Health, 2003
• 16. Guidelines on the Implementation of the National Health Facility Registry, issued through DOH Administrative Order No. 2019-0060 dated December 20, 2019
• 17. New Rules and Regulations Governing the Regulation of Clinical Laboratories in the Philippines, issued through DOH Administrative Order No. 2021-0037 dated June 11, 2021

PART IV APPENDICES

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

• October 18, 1999

ADMINISTRATIVE ORDER NO. 44-4 s. 1999

SUBJECT: Guidelines for the implementation of the INTEGRATED

HOSPITAL OPERATIONS AND MANAGEMENT PROGRAM

(IHOMP) within the Philippine Hospital System

I. INTRODUCTION

The Integrated Hospital Operations and Management Program (IHOMP) formerly Hospital Epidemiology Program (HEP) serves as a hospital based information system designed to provide relevant and timely information for decision making. The program was re-conceptualized in 1995 and expanded in 1997, in response to present information needs and evolving requirements among hospitals.

This set of guidelines is hereby prescribed to improve hospital performance through sound and efficient clinical care and management systems with the endview of providing quality health services.

II. PROGRAM GOALS AND STRATEGIES

A. Goals

Enhance the preventive and promotive role of hospitals (both government and private) through the improvement of management systems and procedures within the hospital.

B. Objectives

B.1. General Objective

To institutionalize the Integrated Hospital Operations and Management Program (IHOMP) within the hospitals.

Signed AD Received in the Records Section on 4

1

• 1. To implement the IHOMP preferably within a computer-based environment.
• 2. To build on and integrate existing hospital information systems.
• 3. To standardize the flow of information within and among hospitals.
• 4. To fully utilize hospital data/information for evidence-based decision making.
• 5. To develop computer software for the program based on the Department of Health standards and the International Classification of Diseases.

C. Strategies

1. Program Planning

This shall cover the development of policy guidelines and implementing mechanisms such as organizing working committees.

Logistic Support

This concerns the development of software, distribution of IEC materials for hospital.

3. Capability Building

This shall cover the upgrading of the human resource skills and capabilities and provision of technical assistance.

4. Social Mobilization

This shall cover the orientation of the program linkages of the different hospital service components and networking.

5. Monitoring and Evaluation

This shall refer to the initial assessment of existing hospital operation and management systems and also monitoring of the compliance to the requirements of IHOMP.

D. Key Activities

In support to the strategies, the following activities shall be undertaken:

• 1. Development of a national quality management program e.g. quality assurance program.
• 2. Accreditation of all hospitals by the DOH and Philippine Health Insurance Program.
• 3. Provision of regular annual budget for the implementation and sustenance of the Integrated Hospital Operations and Management Program (IHOMP) by the hospitals.
• 4. Regular reporting on hospital performance, including comparison with national performance standards.
• 5. Providing name for technology updates.
• 6. Conduct of annual consultative workshop.
• 7. Holding of Integrated Hospital Operations and Management Program (IHOMP)-Activities Updates.
• 8. Networking at all levels of the hospital system.
• 9. Sharing of technical information and expertise.

E. KEY RESULT AREAS

The following are the key result areas to be able to sustain/maintain the IHOMP:

• 1. Availability of adequate hardware and appropriate software.
• 2. Timely analysis of data.
• 3. Well timed availability of information.
• 4. Appropriate, valid and reliable information are produced by the program.
• 5. Qualified and trained staff with a plantilla position assigned to implement the program.
• 6. Trained, competent and readily available system administrator or equivalent.
• 7. Adequate space and facilities are available for program operations.
• 8. Compliance to IHOMP guidelines and procedure.
• 9. Utilization of information by hospital management and clinical staff as reflected in their plans and programs.
• 10. Monitoring and evaluation results are used to continuously improve the quality of information generation.

III. IMPLEMENTING GUIDELINES

• 1. The IHOMP shall be implemented by phases; phase I shall include the identified forty four (44) pilot hospitals (Annex A); phase II shall cover the government and private tertiary hospitals; phase III shall include all secondary and primary hospitals.
• 2. IHOMP implementation shall be fully supported by various committees, working groups and several services and units in the Department of Health per attached organizational structure and their function under Annex B.
• 3. Specific Activities as listed in Annex C shall be undertaken for the IHOMP implementation on the basis of set guidelines.

IV. FUNDING

The expenses for Software Development shall be charged against the funds of the Hospital Management Information System (HMIS) component of the Integrated Community Health Service Project (ICHSP). The expenses for the Human Resource Development shall be charged against the Hospital Operations and Management Service (HOMS), DOH and the Hospital Regulation and Management System component (HRMS) of ICHSP.

V. EFFECTIVITY

This Order shall take effect immediately.

ALBERTO G. ROMUALDEZ, JR., M.D.

Secretary of Health

ANNEX A

Region	Name	Classification	Category
I	Ilocos Training and Regional Medical Center	Government	Tertiary
II CAR	Cagayan Valley Medical Center	Government	Tertiary
(Apayao	Amma Jadsac District Hospital	Government	Primary
,	Apayao District Hospital	Government	Secondary
•	Flora District Hospital	Government	Secondary
	Kabugao District Hospital	Government	Primary
(Kalinga)	Juan M. Duyan District Hospital	Government	Secondary
(rramiga)	Kalinga District Hospital	Government	Primary
	Pinukpuk District Hospital	Government	Primary
	Western Kalinga District Hospital	Government	Primary
	Kalinga Provincial Hospital	Government	Secondary
Benguet	Baguio General Hospital and Medical	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	Tertiary
Deliguet	Center
NCR	Valenzuela District Hospital	Government	Secondary
11010	Jose Reyes Memorial Medical Center	Government	Tertiary
	San Lazaro Hospital	Government	Tertiary
	Philippine Children's Medical Center	Government	Tertiary
	Philippine Orthopedic Center	Government	Tertiary
	Research Institute for Tropical Medicine	Government	Tertiary
	The Medical City	Private	Tertiary
	Capitol Medical Center	Private	Tertiary
	Quezon City General Hospital	Government	Tertiary
	Fairview General Hospital	Private	Secondary
	Alabang Medical Clinic	Private	Secondary
	Mianaria medicar Crimo	-	•
77 7	Brooke's Point District Hospital	Government	Primary
IV	Coron District Hospital	Government	Secondary
		Government	Secondary
	Cuyo District Hospital	Government	Secondary
	Taytay District Hospital	Government	Primary
	Roxas Medicare Hospital	Government	Primary
	Narra Municipal Hospital	Government	Secondary
•	Puerto Princesa Provincial Hospital	Government	Tertiary
	Batangas Regional Hospital
VI	Guimaras Provincial Hospital	Government	Secondary
	Western Visayas Medical Center	Government	Tertiary

$\mathbf{XI}$	Norala District Hospital	Government	Secondary
	Lake Sebu Municipal Hospital	Government	Primary
	Polomolok Municipal Hospital	Government	Primary
	South Cotabato Provincial Hospital	Government	Tertiary
	Davao Regional Hospital	Government	Tertiary
CARAGA	Albor District Hospital	Government	Primary
	Del Carmen District Hospital	Government	Primary
	Dinagat Island District Hospital	Government	Primary
	Siargao District Hospital	Government	Secondary
	Mainit Medicare Hospital	Government	Primary
	CARAGA Regional Ĥospital	Government	Secondary

ANNEX B

IMPLEMENTING STRUCTURE AND THEIR FUNCTIONS, ROLES, AND RESPONSIBILITIES:

A. OFFICES, SERVICES, BUREAUS, UNITS, COMMITTEES

• 1. National Level/Advisory Committee
  • 1.1. The IHOMP Advisory Committee (IHOMAC)
    • a) Composition

The IHOMP Advisory Committee shall be composed of regular representative of Offices mandated in Department Order Nos. 352-C s. 1996, 388-B s. 1997 and 595-I s. 1997.

b) List of Function

The IHOMP Advisory Committee shall have the following functions:

• Review and evaluate existing programs related to IHOMP and recommend appropriate policies, guidelines and standards related to Integrated Hospital Operations and Management Program (IHOMP).
• Review the findings of the assessment and monitoring team and recommend appropriate action to the Hospital Director for improvement of the program.
• Provide directional plans to the technical working group on the budgetary allocations of the program.
• Initiate linkages with the other health care facilities, private hospitals and local government units and integrated public health programs to support and cooperate with the program.
• 1.2 The Integrated Hospital Operations and Management Technical Working Group (IHOMTWG)
  • a) Composition

The Integrated Hospital Operations and Management Program Technical Working Group (IHOMTWG) shall be composed of members as stated in Department Order No. 278-k s. 1999 dated July 8, 1999.

b) List of Function

The National Technical Working Group shall:

• Prepare and recommend guidelines and procedures to IHOMAC regarding human resources capability, assessment and monitoring of Integrated Hospital Operations and Management Program (IHOMP) implementation.
• Organize, plan and evaluate integrated hospital operations and management activities.

Monitor the effective implementation of the integrated hospital operations and management policy guidelines.

Coordinate with IHOMAC regarding issues and concerns encountered

during the implementation.

Act as Secretariat to Integrated Hospital Operations and Management Advisory Committee meeting.

• Provide regular updates regarding the status of the Integrated Hospital Operations and Management Program (IHOMP).
• Provide technical and other necessary support to all hospitals participating / implementing the program.

DOH Central

2.1 Bureau/Services/Program

• a.) The following DOH Bureau/Services/Program and Non-Government Organization shall be involved in IHOMP:
  • 1. Hospital Operations and Management Service (HOMS)

2. Management Advisory Service (MAS)

• 3. Health Intelligence Service (HIS)/Field Epidemiology Training Program (FETP)
• 4. Bureau of Licensing and Regulations (BLR)
• 5. Philippine Health Insurance Corporation (PHIC)
• 6. Integrated Community Health Service Project (ICHSP)
• 7. Philippine Hospital Association (PHA)

b.) List of Functions

1. HOMS

• Lead office in the implementation of IHOMP.

• Coordinate with the different offices of the DOH involved in IHOMP.

• Initiate plans and programs relative to the implementation of IHOMP.

• Monitoring and evaluation hospital performance.

• Coordinate with ICHSP for funding requirements.

• Coordinate with PHIC in the preparation of IHOMP software to come up with an applicable and appropriate system which can be shared by both agencies.

• Plan for the establishment of the IHOMP Support Unit to directly oversee the operationalization of the program.

• Plan for the marketing of IHOMP software in coordination with MAS and other identified agencies e.g. PHA, other.

• Conceptualize policy guidelines on patent and ownership issue of Hospital Operation Management Information System (HOMIS) software in coordination with other concerned offices.

• Standardize technical hospital data elements and upgrade systems in coordination with MAS.

• Develop a software maintenance and upgrading scheme for future activities.

• Provide HIS/FETP data/information from HOMIS for consolidation with the public health data/information to come up with national health picture.

• Conceptualize and conduct required trainings relative to IHOMP.

Ensure quality control and protocols.

Coordinate issuances of the information system and synthesizing the data

2. MAS

Provide technical support in the software development of a computerized hospital information system.

Provide assistance in the installation of the HOMIS computerized

software.

• Conduct orientation and in-house training on the use of the installed system.
• Assist HOMS in the monitoring and evaluation of HOMIS for the first two years of implementation and in customizing modules developed by the hospital to be compatible with the HOMP software.

Render technical assistance in the maintenance of the system to hospitals using IHOMP/UHOMP software.

Training of hospital staff involved in software operation.

• Coordinate with HOMS in the Information Technology (IT) standardization of data elements and systems upgrading.

Define IT configuration for each hospital.

Develop software maintenance and upgrading scheme for future thisting

• Formulate functional/technical design of the system.

3. HIS/FETP

Coordinate with HOMS in the identification of data elements of public health significance to be incorporated in the IHOMP.

Assist HOMS in monitoring the implementation of the IHOMP for the first two years.

Coordinate with HOMS in data/information of epidemiological significance for feedback of public health and hospitals.

• Assist HOMS and other offices involved in the program activities in evaluating the capability of the prioritize hospital to implement IHOMP.
• ♦ Assist in monitoring and evaluation on the initial implementation of IHOMP for the first two years.
• ♦ Formulate functional/technical design of the system.

4. BLR

• Assist HOMS and other offices involved in assessing the capability of the priority hospitals to implement Integrated Hospital Operations and Management Program (IHOMP).
• Assist HOMS in monitoring the implementation of the Integrated Hospital Operations and Management Program (IHOMP) for the first two years.
• Coordinate with HOMS relative to the status of pilot hospitals

5. PHIC

• Coordinate with HOMS during the preparation of IHOMP software to be able to input required information from the different private and government hospitals which are significant to PHIC criteria.
• Coordinate with MAS and HOMS on the planned integration of the IHOMP and PHIC information system at the national level.

6. ICHSP

• Ensure the proper utilization of funds in the developmental phases of IHOMP software.
• Monitor the different pilot hospitals in coordination with HOMS and MAS
• Disseminate information about IHOMP to the different pilot hospitals.
• Provide HOMS status report on the IHOMP pilot implementation.

7. PHA

• Coordinate with HOMS and MAS in order to input data/information needs of the private hospitals as stakeholder in the IHOMP Software.
• Render technical assistance to private hospitals for them to meet the IHOMP/UHOMP requirements to facilitate its implementation.
• Work out plans for the marketing of the IHOMP Software in coordination with HOMS and MAS.
• Recommend policy guidelines requiring IHOMP pilot hospitals to furnish HOMS generated data/information from the system.

2.2 IHOMP Consultants

The Program local technical consultants shall be availed until the IHOMP is established.

Functions:

Shall provide assistance in the conceptualization and direction of the planned activities for the IHOMP. • Shall coordinate with the other program consultants, program managers and HOMS staff regarding the expected output of IHOMP.

• Shall assist the drafting of policy / guidelines for the IHOMP

implementation.

• Shall provide advice to the Program Manager and to the different committees relative to the effective and efficient implementation of the program.

Shall be available for consultation relative to the formulated policies /

guidelines on the program implementation.

• Shall participate in the conduct of the evaluation / assessment of the existing Hospital Information System and data base software for its relevance to the proposed data base for the Integrated Hospital Operations and Management Program (IHOMP).

Shall be available upon proper scheduling for assessment / evaluation of the existing Integrated Hospital Operations and Management

Program (IHOMP) in identified hospitals.

Shall attend and make presentations as necessary in meetings and workshops relative to the conduct of the program.

3. Regional Health Office

Function:

Assist in the assessment and monitoring of hospitals regarding IHOMP implementation.

Establish Regional Integrated/Unified Hospital Operations and Management Program (IHOMP) Unit

4. Regional IHOMP Unit:

Function:

• Assist and provide technical assistance, data/information relative to Integrated Hospital Operations and Management Program (IHOMP) when available.
• Coordinate with pilot hospitals and HOMS regarding Integrated Hospital Operations and Management Program (IHOMP) implementation.

5. Hospitals

• 5.1 The Hospital Epidemiology Units (HEU) or Integrated Hospital Operations and Management Program Unit (IHOMPU/) as mandated in Department Circular No. 124 s. 1995, and those that shall create similar units be directly under the Chief of Hospital / Medical Center Chief (Annex B) to ensure the utilization of the data / information in planning and decision-making.

• 5.2 The HEU/ IHOMP manpower requirement of Record Officers/Designates, Statisticians and Clerk/Computer Operator shall be lodged in the Medical Record Service in addition to their regular function, within the first two (2) years of IHOMP implementation.

• 5.3 The Integrated Hospital Operations and Management Program (IHOMP) shall have the following functions:

  • Assume the over-all supervision, control and monitoring of the unit.
  • Facilitate the accurate and timely collection and submission of data.
  • Formulate appropriate guidelines for the collection, analysis interpretation and use of information.
  • Provide information to the management committee for planning and decision-making.

• 5.4 Integrated Hospital Operations and Management Program Unit (IHOMPU) Composition and Functions

5.4.1 Decision Makers

Composition

• Chief of Hospital / Medical Center Chief or its equivalent for private hospitals or corporation
• · Administrative Officers or its Equivalent
• Chief Nurses or its Equivalent

Functions

• Proper utilization of data/ information generated by the system to ensure effective hospital operations and management.
• Data/ Information to be utilized in quality improvement.
• Quality data from the system can be used for effective and sensible planning and decision making.
• Ensure the sustainability of the program.

5.4.2 Implementors

Composition and Functions

• Chief of Clinics or its Equivalent

  • to act as the head and coordinator of the program.

• Epidemiologist / Designate / RESU Head

  • coordinate with the other members of the team in the interpretation of data
  • ensure the accuracy of inputs and utilization of the administrative and financial
  • assist the chairman in the collection and utilization of the clinical data
  • interpret clinical data, incidence and prevalence
  • coordinate with the Regional Epidemiology Surveillance Unit

• Nurse III

  • Coordinate with the epidemiologist in the interpretation of clinical

• Ensure the collation and utilization of data from the Nursing Service.

• Ensure the accuracy, completeness and timeliness reports from the different units.

• Records Officer/Designates

  • ensure the completeness of clinical data
  • synthesize data collected and assures quality of data

• Statistician

  • collection, processing and presentation of data in an acceptable format.

• Clerk / Computer Operator

  • encode/input of data.

ORGANIZATIONAL STRUCTURE OF THE INTEGRATED HOSPITAL OPERATIONS AND MANAGEMENT PROGRAM (IHOMP)

-Omen i

SPECIFIC ACTIVITIES:

The following activities shall be employed / established for the Integrated Hospital Operations and Management Program (IHOMP) implementation:

1. Assessment of Hospitals:

• 1.1. Assessment teams shall be composed of IHOMAC, IHOMTWG and Consultants, when available.
• 1.2. HOMS technical staff, in coordination with the selected members of the National Technical Working Group, shall perform assessment of the non-pilot hospitals.

2. Logistic Support:

• 2.1. DOH National, Regional Offices and targeted hospitals, shall include budget allocation (MOOE, Personal Services and Capital Outlay for Hardware), for the Integrated Hospital Operations and Management Program (IHOMP) activities.
• 2.2. Development of information, education campaign materials, e.g. printer.
• 2.3. DOH Central Office and Regional Health Offices shall provide a transport service for the assessment and monitoring activities.
• 2.4. Software / Program, shall be provided by HOMS / MAS.
• 2.5. The following positions shall be incorporated in the standard hospital staffing pattern and shall be created within three (3) years:

*Staff Unit (IHOMPU):

• ♦ Epidemiologist (MS III)
• ♦ Nurse (N III)
• Records Officer (RO II)
• ◆ Statistician (Stat. II)
• ♦ Computer Operator (CO II)

However, appropriate parallel positions shall be created in smaller hospitals.

3. Capability Building (Human Resource Development):

• 3.1. The San Lazaro Hospital, Research Institute for Tropical Medicine and Rizal Medical Center shall be developed as Training Centers.
• 3.2. The Training Centers shall have the following functions:
  • Formulate Institutional Epidemiology Program, in coordination with the Epidemiology Societies and Health Manpower Development and Training Service (HMDTS).
  • ♦ Implement Epidemiology Training Program on a regular basis.
  • ♦ Conduct the accreditation of prospective epidemiologists.
  • ◆ Provide feedback / report to the Hospital Operations and Management Service (HOMS), through the Integrated Hospital Operations and Management Advisory Committee (IHOMAC), regarding the performance / accomplishment of the trainees.
• 3.3. Training programs shall be initiated and implemented together with the HMDTS.

3.4 Targeted hospitals shall send appropriate / specified staff required for the training.

4. Computer Training

Training of computerized systems shall be conducted by Management Advisory Service (MAS).

5. Planning and Research

• 5.1 Planning for HEP activities shall include meeting of the IHOMAC, IHOMTWG and consultative workshops with the Chiefs of Hospitals / Medical Center Chiefs.
• 5.2 Research activities shall include studies, program evaluation on strategies and other methods on the establishment and institutionalization of Integrated Hospital Operations and Management Program (IHOMP).
• 5.3 Establish a basis for evaluating the appropriateness and timeliness of medical care.
• 5.4 Plan health care delivery systems.
• 5.5 Conduct epidemiological and clinical research.

6. Recording and Reporting

Establish system for recording and reporting. The following levels of reporting shall be followed to ensure the timely availability of data / information:

6.1 Levels of reporting

A. National Level

The Central-DOH (HOMS) shall perform the following functions:

• Collation and processing of Integrated Hospital Operations and Management Program (IHOMP) Data by the Data Management Unit of HOMS.
• Interpretation of processed data by a Committee formed by HOMS.
• Proper utilization of processed data by the identified clients / users.

B. Hospital Level

The hospital shall perform the following functions:

• Submission of Integrated Hospital Operations and Management Program (IHOMP) Report every semester on or before the 1^st week of the succeeding semester.
• Collation, processing of EPI-data by the Medical Record Service.
• Processing of significant collected data by the hospital epidemiology committee.
• Utilization of the proposed data institutionally.

7. Quality Control

Development of Quality and Control Protocol.

Indicators for this quality and control protocol will be developed.

The following measures shall be observed in hospitals:

• 7.1 Complete, accurate, reliable and prompt patient discharge diagnosis.
• 7.2 Accurate and prompt billing records.
• 7.3 Complete, accurate, reliable and prompt financial and managerial records.
• 7.4 Accurate ICD-10 Coding.

8. Monitoring and Evaluation

• 8.1 IHOMAC / IHOMTWG / Consultant shall be responsible in monitoring of targeted hospital.
• 8.2 Hospitals found not implementing and sustaining the program shall be assisted in their particular problem area by HOMS.
• 8.3 HOMS technical staff in coordination with selected members of the Integrated Hospital Operations and Management Technical Working Group (IHOMTWG) shall continue monitoring and evaluating the program.
• 8.4 Evaluation of the program shall be conducted twice (per semester) a year for at least two (2) years then yearly thereafter.
• 9. Government Health and other Insurance Reimbursement
  • 9.1 Serve as basis of medicare and health insurance reimbursement.
• 10. Utilization of Hospital Information System Output
  • 10.1 Serve as basis in the formulation of standards of health care.
  • 10.2 Serve as basis in the formulation of national hospital performance standards.

SPECIFIC GUIDELINES:

Resource Requirements:

• 1. Human Resource
  • 1.1 The staff to be trained shall have the commitment and dedication to perform the task after the training.
• 2. Equipment
  • 2.1 Computer
  • 2.2 Software
  • 2.3 Back-up
  • 2.4 Server
• 3. Software
  • 3.1 Licensed Software
  • 3.2 Modular Design

• Module I (Basic) includes the medical records, admitting section, social service and billing.

• Module II (Regular) includes the laboratory, radiology, central supply section, pharmacy and operating room, emergency room, outpatient department and wards.

  • Module III (De Luxe) includes the financial and administrative services

4. Space

The hospital shall provide a minimum space/room for the Integrated Hospital Operations and Management Program Unit (IHOMPU) to accommodate 3 computers, back up, server, tables and chairs.

• 5. Budget (PS, MOOE & CO)
  • 5.1 Budget for Personal Service, MOOE and Capital Outlay shall be allocated by each hospital for the program.

SUMMARY REPORT

Walkthrough of the Web-Based Integrated Hospital Operations and Management Information System (IHOMIS)

I. Background

The Integrated Hospital Operations and Management Information System (IHOMIS) is transitioning into a web-based platform. There are three (3) Modules in the system with a total of twenty-four (24) components. Of the total components, 79% (19 out of 24) have been fully developed or completed while 21% (5 out of 24) is still under construction of the IHOMIS Team from the Knowledge Management and Information Technology Service (KMITS).

In line with the current migration of the iHOMIS to the web-based platform, the Health Facility Development Bureau (HFDB) in coordination with KMITS, conducted a series of walkthroughs from February to March 2021. Moreover, the conduct of the said walkthrough is in response to the discussions made with the various systems administrators of the hospitals utilizing IHOMIS during the Program Implementation Review in 2019. The objective of the walkthrough is to ensure that the said system is compliant to the DOH standards; updated based on the current policies and issuances; and aligned with various directives under the Universal Health Care (UHC) Act.

The walkthrough was conducted per component and was presided by the various technical advisers and staff of the Policy, Planning, and Program Development Division (PPPDD).

II. Objective

The walkthrough aims to:

• 1. Update the IHOMIS system based on the current standard procedures;
• 2. Ensure the consistency of the system with the current policies related to hospital standards and operations;
• 3. Provide technical inputs and assistance in the development and transition to the web-based platform.

III. Methodology

The HFDB technical staff assigned to the different components of IHOMIS assessed the existing web-based IHOMIS in terms of technical completeness and linkage with the different components/modules. Mr. Alvin Icaonapo, ISA II from KMITS presented the features of the web-based version of the system and demonstrated how it will be navigated by the end-users in the hospitals.

The table below shows the list of the components subjected to the assessment, the respective technical staff assigned and the date the walkthrough was conducted.

Table 1: Schedule of the Walkthrough per Component

	ole 1: Schedule of the Walk Component/s	Technical Adviser/Staff	Date Conducted
15 =	Module 1
1	Admission/Discharge (EMR)	Ms. Madeliene Gabrielle Doromal and Dr. Terence John Antonio	March 9, 2021
2	Outpatient Department (OPD)	Ms. Madeliene Gabrielle Doromal and Dr. Terence John Antonio	March 9, 2021
3		Dr. Terence John Antonio	February 8, 2021
4	Medical Social Work (MSW) Department	Ms. Madeliene Gabrielle Doromal	March 26, 2021
5	Billing	Ms. Madeliene Gabrielle Doromal/Ms. Donna Jennifer Nokom	February 2, 2021
6	Cashiering	Ms. Madeliene Gabrielle Doromal/Ms. Donna Jennifer Nokom	February 4, 2021
7	PhilHealth	Ms. Madeliene Gabrielle Doromal/Ms. Donna Jennifer Nokom	February 2, 2021
8	eClaims	Ms. Madeliene Gabrielle Doromal/Ms. Donna Jennifer Nokom	February 4, 2021
9	Medical Records (Registry only)	Ms. Faye Diana Chua/Ms. Myca Galat	February 15, 2021
10	Referral (inter-agency and intra-agency)	Ms. Madeliene Gabrielle Doromal	Under construction by KMITS
Н	Module 2
11	Nursing Care/Ward	Mr. Erickson Feliciano/Ms. Clara Francesca Roa	February 10, 2021
12	Doctor's Order	Dr. Terence John Antonio	February 8, 2021
13	Pharmacy Department	Ms. Faye Diana Chua	February 5, 2021
14	Central Supply and Sterilization	Mr. Erickson Feliciano/Ms. Clara Francesca Roa	March 16, 2021
15		Dr. Hyacinth Balderama/Mr. Richard Ramones	March 17, 2021
16	Radiology	Dr. Hyacinth Balderama/Mr. Richard Ramones	March 9, 2021
17	Nutrition and Dietetics Department	Ms. Josephine Guiao	February 17, 2021 and March 10, 2021
18	Dental Service	Ar. Jean Paolo Policarpo/Mr. Richard Ramones	Under construction by KMITS
19		Ar. Jean Paolo Policarpo/Mr. Richard Ramones/Ms. Clara Francesca Roa	March 17, 2021
20	Philippine Integrated	Mr. Erickson Feliciano/Ms. Joy Padrigano/EB	Under construction by KMITS

21	Hospital Statistical Report Generation	Ms. Faye Diana Chua/Ms. Myca Galat	March 15, 2021
22	Operating Room (OR)	Dr. Terence John Antonio/Dr. Hyacinth Balderama/Dr. Armaine Bel Santos	Under construction by KMITS
	Module 3
23	Electronic New Government Accounting System (eNGAS)	Ms. Madeliene Gabrielle Doromal/Ms. Donna Jennifer Nokom	February 18, 2021
24	Inventory	PPPDD Staff	Under construction by KMITS

Currently, HFDB has completed the conduct of the walkthrough for 100% (19 out of 19) of the developed/existing components. On the other hand, the components under construction or development are targeted to be completed not later than October of this year.

Based on the timeline provided by KMITS (Annex B), the following are the specific target dates:

Module	Component/Module	Target Date of Completion
Module 1	Referral System	May 2021
	Malasakit
	Point of Service (POS)
Module 2	Operating Room (OR)	May 2021
	Dental Service	June 2021
	Philippine Integrated Disease	June 2021
	Surveillance and Response (PIDSR)
Module 3	Inventory (Drugs and Medicines:	September 2021
	Medical Supplies; and Hospital	4 -
	equipment)
All modules	Revision of the existing modules based on	October 2021
	comments/suggestions of HFDB in the
	walkthrough

IV. General Observations Across All Modules

The similar observations noted from across the modules or components have been clustered to provide for the summary of the HFDB technical inputs and recommendations. The detailed assessment per component is provided in Annex A of this report.

A. Contents

The migration of the Power Builder (PB) version to the Web-based system is still ongoing. Hence, the assessment identified a lot of gaps in terms of its contents. In general, the data sets migrated from the PB version need to be

updated in consonance with the current policies and standards applicable to the hospitals.

In addition to this, it has been emphasized in the walkthrough that the forms needed for the development of the modules are available in the HFDB manual of standards. For purposes of the system, the completeness of the data sets should be checked in comparison to the data and information found on these forms.

The inputs and recommendations are subdivided according to the actions that need to be taken by KMITS and the module or component where the action is to be applied.

1. For Updating/Revision. The technical inputs are based on the current policies and standards issued in relation to the hospitals. The terminologies used, classifications, and tab/drop down items were likewise updated, among others.

Category/Module/ Component	Details
Terminologies	PHIC: Direct and Indirect membership
	Basic and Non-Basic Accommodation
	• Financially Capable and Financially incapable
	• Patient disposition to automatically reflect when patient died, use the term "EXPIRED"
	• From Staffing pattern to Human Resource Complement
	Dietary to Nutrition and Dietetics Service
	• From CSR to Central Supply and Sterilization
	Department (CSSD)
	• Laboratory: from urgent to STAT
Cashiering and eClaims	The diagnosis should be the same as the diagnosis encoded in the PhilHealth CF-2 Form
Pharmacy	Revise Drug Classification
	Colorized unserved, served and partially served requests
	Chronological latest and unserved on top
	Move charge slip column to the left
Doctor's Order	• Listed required data sets for triage, doctor's chart and nurse's notes.
Nursing Care/ward	From "List of Procedure/Examination" to 2 separate lists or tabs. – List of Diagnostic Tests and List of Treatment Procedures

HHIM/ Medical Records	Update type of Separation for Civil Status Complete the list of gender category Include height and weight on patient Profile Alert transferred to history of Nursing care Disability transferred to Physical exam BUTTON for endorsement on discharge between Ward and the Records (details in Annex A)
Nutrition and Dietetics	Update contents of Diet Tag Auto generate BMI, alert for underweight Identified and listed the contents of the Diet List; Diet Tag; Diet Types and Tube Feeding
Admission/Discharge	Type of Accommodation: Basic and Non-Basic Mode: Ambulance conducted, self-conducted, others as specified. Ward: library will depend on hospital Basic information: include SEX Transfer "HAS TB?" to Doctor's Module SOAP Update data sets of the Admission summary using the Clinical Cover Sheet found in HHIM Manual
Laboratory	Clarification on STATUS: Active and Inactive only Priority – Urgent and Routine Refer to Annex A for others
MSWD	Psychosocial Assessment updated version Inclusion in the Chart of the Tool

2. For Inclusion. The following items were identified for inclusion in the presented web-based system. The details include sub-components of the modules, additional features and other relevant details necessary to comply with the standards.

Category/Module/ Component	Details
Billing and PHIC	Charging System Running/Partial Bill and Alert Status for Patients who have not yet settled their bill Referral to MSS/MSW for patients not enrolled in POS/Inactive members Incorporate Order of Charging
Cashiering and eClaims	Releasing of payments
Pharmacy	Charging of medicines; outpatient charging; inventory management; return of medicines and emergency cart.
Doctor's Module	Inventory of e-cart Charging and Billing

AT : 00 000 1	141
Nursing Care/Ward	Alert system or notification for NEW Admission Nurse's notes following the FDAR format Monitoring sheets (IV Fluid, TPR, Medication Sheet, Intake and Output, Blood and Blood
	Component Sheet)
	Nutrition Screening Tool
	• Drop down selection should be clustered by set or
	by procedure with quantity. But option to ADD
	ITEM. Initial list of the sets provided by HFDB.
	• Computerize the requisition of items in the e-cart.
Nutrition and Dietetics	Nutrition Referral
rydullion and Diciones	Nutrition Screening Tool for Adult and Pedia
	Nutrition Screening 1001 for Adult and Fedia Nutrition Assessment Form or the Medical Nutrition
	Therapy Form
	•Insert formulas for the Nutrition Monitoring and
	Evaluation (details in Annex A)
	BUTTON for approval
77.5.1.5	Meal report/Diet List/Diet Registry
eNGAS	• To complete the cashflow: Summary of Bills
	rendered, Journal of Bills Rendered; Individual
	Subsidiary Ledger; Cash Receipt Record; Inventory
	and Issuance for Pharmacy and MSS
Radiology	• Time ordered
	• Override draft report once there is finalized report.
	Use TABS or BUTTONS for this function.
	Picture archiving of images
	• Film should be accessible and can be magnified
CSSD	• Notification if supply is in CRITICAL LEVEL.
	Based on the Nursing Manual, this pertains to
	Minimum Stock Level which is the basis for re-
	order when the stock reaches this level. It shall be
	the responsibility of the hospital to determine the
	minimum stock level based on the actual usage. Re-
	order lead time shall be considered.
	Mechanism in the system to indicate if supply is not
	available
	Real Time Inventory
	CSSD Library to be determined by the hospital
Laboratory	Specimen Tab
Laborator y	1
MCWD	Registry of Patients Migration of Data in the Breathand in American
MSWD	• Migration of Data in the Psychosocial Assessment
	in the UIS of Malasakit Center
	Migration of Data to the POS and PCSO System
	Referral of Admitting to MSWD
	Referral of ER, OPD and Ward to MSWD
	MSWD Progress Notes in the Chart
	• Classification in the CFS within 72 hours
	• Forwarding of Classification to Billing and
	Admitting
	Referral to Malasakit Center

	• View of Bill
	Statistical Report (Monthly)
	Psychosocial Profile (Annually)
Admitting	Integration of the Discharge information from the EMR
OPD	• Triaging
	Forwarding to the different Departments
	• EMR
	Doctors order to the Nurses for preparation of requests
	• Referral
	System for followup
ER	Triaging
	• Forwarding to different Departments
	• EMR
	Admitting Orders
	• VA

3. For Deletion. These are parts or portions of the system that are recommended to be removed from the specific component or module.

Category/Module/ Component	Details
Pharmacy	SALT Column
	Decimal places in Strength Column
Nursing Care/Ward	Charge Slip under Prescription
Nutrition and Dietetics	• Kardex, deletion confirmed by ND TWG. Likewise, kardex was deleted in the updated ND manual.
Admission/Discharge	Case Number (please note that what was retained is the Hospital Number which is considered as the ultimate patient identifier)

B. Integration and linkage across departments

• 1. Majority of the components recommended the inclusion of "trigger buttons" that may help in the flow of information from one component to the other. These are as follows:
  • i. Trigger or link from Nursing care/ward module to Nutrition module for referral of Nutritionally at risk patients. Nutrition care process should start at the nursing service or ward because the nurse will be the one to accomplish the Nutrition screening tool:

• ii. For MAY GO HOME order carried out by Nurse in ward, trigger button will forward the patient health record to Billing for clearance:

• iii. For CLEARANCE by Cashier. The Cash Operations will issue the approved or accomplished clearance for patients being discharged;

• iv. Add NOTIFICATION through SMS, email, etc to inform the other concerned areas that the procedure has been conducted or the results are already available for viewing; and

• v. NOTIFICATION from CSSD to ward to prompt them that the requested supplies are ready for pick-up. Button in the ward module to confirm that supplies issued are COMPLETE and RECEIVED.

• 2. The generation of the Statistical Report on a daily, monthly and annual basis shall be extracted from the data encoded and collected from the different modules.
• 3. The importance of adding Audit Trail in the transactions done by all members of the team with accounts.
• 4. Ensure interoperability of the Laboratory Module to the Laboratory Information System (LIS). This would mean that the Final result should be reflected in the Patient Health Record.
• 5. There are a total of seven (7) registries. These registries have their own system, that is lodged in the iHOMIS as its mother system. It is linked to iHOMIS for data collection or extraction. During the walkthrough, 4 out of 7 of the registries were presented. The remaining registries are under construction/development of KMITS.
  • i. Chronic Obstructive Pulmonary Disease (COPD) Registry
    • Duplication of data entry or encoding. As per KMITS, only 30% of the form is encoded, 70% is generated from data already in the system.
  • ii. Diabetes Registry Form
    • Trigger is Diet and BMI
  • iii. Coronary Artery Disease
    • Trigger is Diet and BMI
  • iv. Fireworks Related Injury (FWRI) Survey

For all the registries, it is recommended to review the patient health record and other data encoded. This is to compare the data already being collected and encoded by IHOMIS to the forms prescribed by each of the registries. This will allow the determination of how much of the needed information may be extracted from the said system.

C. Security Features

• 1. All the components or modules have identified the necessary access rights that should be granted to the different members of the team. The access includes editing and viewing rights. This may be implemented through assignment of individual accounts.
• 2. There are certain procedures that need the approval, conforme or signature of an authorized personnel. The recommendation is to replace them with buttons understood to mean approval or clearance. In addition to this, the possibility of providing electronic signatures was also recommended.
• 3. In consideration to the "hybrid" implementation of the PB and webbased IHOMIS, the hospital shall implement measures to ensure compliance to the standards and other requirements.
• 4. The systems administrator of the hospital shall have complete access rights over the IHOMIS. Moreover, the systems administrator shall be responsible for the oversight of the implementation and maintenance of the IHOMIS.

IV. Recommendations

• 1. HFDB to review and revise the Procedures Manual for Government Hospitals according to the discussions made during the series of walkthroughs, to ensure integration of procedures.
• 2. HFDB to provide the necessary documents, forms, data sets, and technical assistance related to the development of the web-based IHOMIS.
• 3. KMITS to prioritize the development and completion of the web-based IHOMIS. Subsequently, to schedule a meeting to present the completed IHOMIS, that is fully migrated to the web-based platform and fully compliant with the hospital manual of standards. The presentation should showcase the specific recommendations made during the walkthrough and simulate the implementation of the said system in the hospital setting.
• 4. KMITS to consider alternative options or approaches in the development of the web-based IHOMIS and the health facility/hospital Dashboard. The series of walkthroughs revealed several gaps in terms of the completeness and consistency of its content; integration and linkages across the various modules/components; and system errors. This recommendation took into consideration and recognized the workload of KMITS in terms of system/application development.
• 5. HFDB and KMITS to devise a transition plan for the implementation of the web-based IHOMIS in the hospitals already utilizing the PB version. This is in consideration of the possible hybrid implementation of the two (2) versions of the system.
• 6. KMITS to conduct pilot testing in selected hospitals before the roll-out implementation of the web-based version of the IHOMIS.
• 7. Continuous coordination and collaboration of HFDB and KMITS, as well as their regional counterparts, for systems improvement and maintenance.

Prepared by:

CLARA FRANCESCA A. ROA, RN Development Management Officer III Health Facility Development Bureau

wants and oaron

Reviewed by:

MADELIENE GABRIELLE M. DOROMAL, RSW, MSW

DMO IV/IHOMP Program Manager Health Facility Development Bureau

Approved by:

TERENÇE JOHN M. ANTONIO, MD-MBA

Medical Officer IV/OIC-Division Chief

Policy, Planning and Program Development Division

Health Facility Development Bureau

Noted by:

MA. THERESA G. VERA, MS, MSc, MHA, CESO III

Director IV

Health Facility Development Bureau

DEPARTMENT OF HEALTH HEALTH FACILITY DEVELOPMENT BUREAU SAN LAZARO COMPOUND, STA.CRUZ MANILA