Chapter I - Planning

OVERVIEW
In the summer of 1975, Doctors’ Caesar and Anita Somoso rented a 2-
storey, 2 door apartments and set up a 10 bed medical clinic. At the time the
facility can offer basic laboratory services (X-ray, blood examination, urinalysis,
fecalysis) and primary health care. It was named Clinica Somoso. Six months
after the inception, Social Security System has recognized and accredited this
clinic with Medicare privileges. This made our clinic the first lying-in hospital in
this community. After one year of operation, we increased the bed capacity to 25
because people now recognized that they need not to go to Davao City or
Tagum, Davao del Norte for their health needs and or confinements knowing
they can be diagnosed and treated well here. It is a fact that convenience is also
a factor considered by most patients.
Two years after the 25 bed capacity was approved, we applied for a
secondary level licensure which was again approved by Department of
Health/Medicare so again, and we became the first secondary hospital in
Panabo, Davao del Norte. The name was changed to Somoso General Hospital.
Gradually, but not progressively we continued to improve our hospital and
decided to build our own facility. From across-were the old clinic was established,
a 3 storey building was built. By now we have increased to a 50-bed capacity
hospital. Today the hospital enjoys the expertise of specialist in all departments,
a well equipped laboratory (including X-Ray, ECG, Ultrasonography) and
managed people who are not only competent but compassionate as well. With
the growing population (mostly due to migration, better job opportunities) and
expanding agribusiness (mainly bananas and other tropical fruits), again the
need to increase our bed capacity comes to mind.
We, competent doctors, committed, dedicated to serve our constituents
not only in Panabo City but the neighboring towns/cities as well, grouped
ourselves into a corporation. Today, we are only a step away to realize our long-
time dream and that is to build a state-of-the-art facility.

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 VISI0N-MISSION STATEMENT OF THE HOSPITAL

VISION

SOMOSO GENERAL HOSPITAL INC., a secondary level envisions to

be a center of a quality health care, complete with latest equipments and
diagnostic facilities, well trained and compassionate medical specialists and staff
working towards the attainment of optimum health for all.

MISSION

SOMOSO GENERAL HOSPITAL INC., is committed to provide quality

health care services to the community through health education, preventive,
diagnostic, and curative medicine, in a manner that is recognized as specific
evidence based, honest, compassionate and cost- competitive that strengthening
the community’s status.

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 VISION-MISSION STATEMENT OF THE NURSING DEPARTMENT

VISION

To create a department of nursing in which the quality of nursing care are

truly beneficial, health promotive and provided by competent, committed and
dedicated nursing staff who are sensitive to the client’s emotional spiritual,
mental and cultural needs.

MISSION

To establish a community of dedicated and specially trained, highly

skilled nursing staff whose approach to patient care is holistic in nature, utilizing
the latest in medical nursing technology.

OBJECTIVES OF NURSING SERVICES

General:

To provide quality nursing care.

Specific:

1. To establish and maintain acceptable standards of nursing care.

2. To provide the nursing personnel with opportunities for continuing
education and straining.
3. To conduct and participate in researches related to nursing and nursing
care.
4. To strengthen linkages with the other components and agencies outside
the health facility: and
5. To provide nursing and midwifery students with related learning
experiences.

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 HOSPITAL POLICIES

A. Policies Governing the Practice of Nursing (WARD)

Uniform

1. Nurses must wear properly their prescribed uniform and their ID’s while on
duty.
2. Uniform must always be clean and tidy.
3. Hair properly fixed.
4. Nursing shoes must be clean and noiseless.
5. Slippers, step-in and sandals are allowed only in specific areas (OR, DR,
Nursery), and hem dialysis unit.
B. Reporting and Endorsement

1. Nurses must report on time to receive endorsement.

2. Proper endorsement must be made before going off duty.
3. The outgoing staff must leave their department in good order.
C. Communication

1. Silence must be maintained at all times and in all areas.

2. Communication must be made in low voices and not within the hearing
distance of the patients.
3. Extra silence must be maintained and observed during night time.
4. Nurses must not argue in front of the patient.
5. Complaints from the patients and/or the public must be referred to the
immediate superior.
6. Nursing personnel must always remember their responsibility and liability
and must not reveal confidential information and privilege communication.
This refers not only to the information found in the chart but also to
whatever is learned or seen by them by attending the patient.

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D. Gossip and Rumor Mongering

 While on the duty and within the hospital premises, employees are
prohibited from gossiping or engaging in rumor mongering.
E. Loitering

1. Nurses whether on or off duty are not allowed to loiter around the hospital
premises except if responding to calls related to the nature of his/her work,
or securing salary from the payroll office.
2. Nurses who are either suspended or on leave shall not be allowed to loiter
along the corridors.
F. Breakage and Losses of Equipments

 All nurses are held liable for breakage and loss equipment. Loss or
destruction due to his/her negligence is subject to disciplinary
action.
G. Meeting

 All staff nurses are enjoined to be present at the regular meeting

called by the administration.
H. Notices

1. Due attention must be given to notices as they are posted in the bulletin
board of the wards, department or at the lobby.
2. Only authorized persons with due permission from the administrator may
only post notices and posters.
3. No anonymous notices shall be allowed to be posted in any part of the
hospital or premises, and no authorized person shall post notices of
whatever nature or anonymous letters in any walls or bulletin board of the
hospital and/or surrounding premises.

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I. Telephone Calls

1. Nursing personnel are not allowed to deliver any messages or telephone

call for the patient without first referring the matter to the head/charged
nurse on duty.
2. Hospital telephone is purposely sanctioned for official use and should not
be used for matter.

J. Intoxicating Liquor or Beverages

1. All employees are not allow to bring liquor or beverages inside the
hospital.
2. Any employees are not allowed to stay in the premises of the hospital
while under the influence of the intoxicating liquor or beverages, or when
they even smell of liquor.

K. Courtesy

1. Regardless of position held, nursing personnel must exercise at all times

outmost courtesy, tact and conduct required of the person of a good public
relation.
2. All shall likewise be courteous to the superior, their equal and fellow
employees.
3. Superiors should be considerate to their subordinates but not to the extent
of violating the rules of discipline.
4. Public reprimand and counseling must be avoided.

L. Medication Error

Failure and/ or wrong administration of drugs (including wrong patient,

wrong route, wrong dose, wrong time and failure to document).

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 a. Without adverse/harmful effect to the patient
1st offense - incidental report

- Counseling
- Minimum of 1 day suspension
2nd offense - incidental report

- Counseling
- Minimum of 5 days suspension
3rd offense - Dismissal

b. With mild to moderate adverse effect

1st offense - incidental report

- Counseling
- Minimum of 5 days suspension
2nd offense - Possible dismissal or advice for resignation

c. With severe adverse effect or consequent death of the patient –Dismissal.

M. Negligence/ malpractice without consequent harmful effect to the

patient

1st offense - Incidental Report

- Counseling
- Minimum of 1 day suspension
nd
2 offense - Incidental Report

- Counseling
- Minimum off 5 days suspension
3rd offense - Subject for jury, possible dismissal or advice for resignation

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N. Grave Negligence/malpractice in relation to the practice of nursing
resulting to complication and deformities.

1st offense - Incidental Report

- Counseling
- 1 month suspension
2nd offense - Dismissal

O. Grave Negligence/malpractice in relation to the practice of nursing

resulting to complication and consequent death.

1st offense - Dismissal

* All offenses by a nurse or group of nurses are subject to careful investigation

and channeled to proper authority. The specific sanctions mentioned above will
serve as a guide in the administration of disciplinary action.

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 EMERGENCY ROOM

General Policies:

o Patient coming in the emergency room should be given the highest

priority.
o Financially incapable critical patients should be provided with
immediate/ emergency care before referring to other situation. Utilize
any indigent stock if necessary.
o No communicable diseases are to be admitted in the ward. They
will be admitted in a private room. If none is available, the patient is
then referred to another hospital.
o Proper documentation should be observed in all procedures.
o Only one watcher is allowed in the emergency room. Relatives of
the patient should stay at the waiting area.
o Patient in the Emergency should be observed for 1-2 hours and
then transferred to room of choice.

Patient Care

o Always do the routine care

- Initial vital Signs
- Call patient first name to gain trust and to make them comfortable
- Gather pertinent data regarding the patient or significant others
- Double check patient’s document for completion of data before
transporting the patient to the room of choice.
o Inform ROD as soon as patient arrives at ER.
o Check clarity orders before carrying them out.
o Diagnostic request should have a complete data regarding the
patient. Write on the upper right corner of any request the name of
the company patient connected.

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 o Do all necessary procedures and STAT medication orders before
transporting the patient to the room of choice.
o In cases of DOA’s post mortem and after care of the area should be
done immediately. It is only consider DOA if no signs of life are obtained,
and the physician declared it as DOA.
o Patients who have signs of life should be give appropriate care and
resuscitation a necessary.
o Patient for admission, the nurse on duty should be inform before
transporting the patient.
o Patient for transfer to other hospital, the following procedure prior to
transport.
a. Life saving measure
b. Stabilization of the vital signs
c. Accomplishment of the patient record
d. Referral slip properly accomplish by ROD
e. All charges must be forwarded to billing section for proper charging

Patient’s Right

o Patient must sign consent before a procedure or care to be done.

o All patient’s records and data are considered as confidential.
o A patient has the right to know every procedure to be done.

Emergency Medicine

o Maintain a stock level of each medicine in 2 pieces.

o IV Fluid stock level must be maintained at 2 bottles.
o Replace/ Replenish all medicine supplies used every shift.
o Monitor expiry dates of all medicine. Expiry medicine should be
used first.

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 o
Minor Operating Procedures

o Secure consent and approval before the procedure.

o Observed sterile technique at all times.
o Manageable cases can be handled by Resident on duly, unless if
it needs to be referred to consultants.
o Proper documentation should be observed.

Out Patient Department

o Let patient fill up the patients information sheet

o Write the necessary Vital signs
o Prioritize patients for physician consultation
o Give instruction and health teaching
o Assist patient to cashier for necessary payments
Equipment

o Nurse on duty should check the equipments before and after

his duty.
o The nurse must see to it the all equipments are functioning
well, in good condition and ready to use.
o Defective non-functioning should immediately be reported to
the maintenance department for repair.
- All detective non- functioning equipments should be labeled ” OUT
OF ORDER”.
- All equipments received should be recorded in the receive logbook.
o Equipments borrowed by other department should be recorded at the Barrowers
logbook and signed by person borrowing.
o When in use, the nurse must see to it that the instruments or equipment handled
properly.

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o Routine care for all equipment should be done regularly.
o Any loses of any equipments and instruments accountable to all
ER personnel especially the nurse on duty.
o Equipments to be sent out for repair should only be endorsed to
the personal-in-charge. Never endorsed to anyone.

Personnel

o All personnel should wear the prescribe uniform.

o Identification card must be worn all the time while on duty.
o Working shifts:
7:00 am – 3:00pm

3:00 pm - 11:00 pm

11:00 pm – 7:00 am

o Recording on the patients card must be on 3-11 shifts and indexing every
11-7 shifts.
o All personnel on duty must be on the area 15 minutes ready for
endorsement.
o Incoming and outgoing ER-OPD personnel must check all equipments and
endorsement must be made every shift.
o Checking for the adequacy of supplies must be every shift.
o Outgoing personnel should do after care of the unit. Cleanliness of the
area must be maintained.
o May provide assistance to other unit when it is needed.
o All personnel must observe economy supplies and cost cutting measures.
o Must notify co-personnel every time he/she leaves the unit.

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Information Management

o Medico-legal cases must be recorded in medico-legal logbook.

Patient card with the following data TOI,DOI, POI,NOI.
o Patients data must have complete NAME, AGE, SEX, STATUS,
ADDRESS, DATE OF BIRTH and CHIEFT COMPLAIN.
o Forms
Consent for admission

Authorization for Performance of Operations and other

Procedures

o Operation Report Slip

o OPD Minor Surgery for OPD minor surgery
o Surgical Memorandum for admission
o Obstetric Sheet
o High Risk Evaluation
o Labor
Safe Practice Environment

o All sharps and needles should be dispose in a sharp container with cover.
o Separated bloody sheets from non bloody sheets.
o Soaking solution for sharps instruments must be change regularly every
14 days.
o Soak instruments to soaking solution 15-30 min. then transfer to dry sterile
pan with cover and keep sterile.
o Observe precautions with handling needles and blood components.
o Always observe hand washing before and after procedure/ handling
patients.

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 Department: DR (DELIVERY ROOM)

Personal Requirement

1. Proper uniform is encourage for every personnel in the delivery room

i. Freshly laundered scrub suits
ii. Clean cap and mask
iii. Slippers (color coding)
2. Personnel with communicable diseases or those infected skin lesions are
not allowed to work in this area.
Working Schedule

1. The head of the department is responsible for the schedule of the staff.
2. The ward medicating nurse or floater nurse is in assisting DR cases.
Endorsement

1.Outgoing ward medicating nurse or floater nurse must see to it that the
delivery room are clean and supplies are refilled every after procedure.

2. Incoming shift should also check the instruments, supplies as early as

possible to avoid problem.

Patient Care

I. Patient access to DR

1. The delivery Room provides signage for patients direction.

2. Outsiders are not allowed to go beyond the door of the DR.

II. Patients Requirements

1. All laboratory results must be attach to patient chart.

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 2. All patient wheeled to DR must wear patient gown.
III .Patients Right

1. The patient has the right to know every procedure to be done.

2. The patients’ safety and monitoring must be given to priority.

3. Accurate and proper documentation must be observed.

Safe Practice and Environment

I. Environment and DR Sanitation Equipments

1. Traffic should be minimized in the area. Only authorized persons are

allowed to enter the area.

2. Routine and terminal cleaning of the area should be maintain monthly

with the use of disinfectant recommended by infection control committee.

3. Keep delivery room clean all time.

II. Instruments and Equipments

1. Routine cleaning, decontamination and sterilization of equipment and

instruments are done according to standards recommended by infection
control committee.

2. Follow principle of sterile technique in handling all articles and instruments

used in the delivery room.

3. Change soaking solution regularly.

III. Garbage Disposal

1. Garbage must be disposed every after procedure.

2. All blood components and placenta must be place in container and dispose
properly per recommendation by hospital waste management committee.

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 3. All needles must be disposed and discarded in sharp container approved
by the hospital waste management committee.

Personnel Safety

1. Observe precaution in handling blood components.

2. Always wear gloves in cleaning the area.

3. Proper handwashing must be observed at all times.

Records / Logbook

1. Keep all DR records confidential.

2. Only authorized person allowed to get the logbook and records.

3. Proper recording and updating DR logbook every after

procedure.

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 Deparment : OR (Operating Room)

Objectives:

1. To ensure a smooth and efficient functioning of the operating

room.
2. Enhance better relationship among surgeons,
anesthesiologist and the OR staff.
3. Find ways to reduce cost of operation and help increase the
revenues of the operating room.
4. Minimize occurrence of infection.
I. Personal Requirement

1. The OR head must be registered nurse with OR training and have

comprehensive understanding in OR nursing principle and
technique.

2. The OR staff must be registered nurse with the knowledge in

application of general nursing principles to patient care.

3. The OR technician is unregistered nurse with or without experience.

II. Health and Hygiene

1. All OR staff must be healthy. They must be free from any

communicable diseases.

2. The OR staff must be in good physical and mental condition needed

to withstand the stress that the job in the OR requires.
III. Working Schedule

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 1. The ward medicating nurse or floater nurse is responsible in assisting
OR procedure.
2. On call OR personnel must be ready and available anytime for any
STAT procedure.
VI. Attire on duty

1. Scrub suits, closed cap and masks should be worn in the OR.
2. OR personnel are not allowed to wear any jewelry when assisting
operation.
3. OR personnel should wear smock gown when going out of the unit.
NO PART OF THE SUIT MUST BE EXPOSED.
4. If smock gown is not available, the staff should change his / her
clothes before leaving the OR.

Patients Right

Legal Requirement

1. All patients for surgery must have an operative consent for

anesthesia. This must be properly filled up and explained to the
patient by the nurse securing the consent.
2. Two persons of legal age must witness the signing of the operative
consent.
3. No patient who is below 18 years old allowed to sign an operative
consent.
4. Operative consent for tubal ligation and vasectomy must be sign both
husband and wife.
Patient Care

I. Patient access to operating room

1. The operating room provides signage for patients direction.
2. Only authorized person are allowed to enter the area.
II. Scheduling the patients for surgeries

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 1. Elective cases: First come-First serve basis, as far as notice receive by
OR personnel
2. Emergency: all emergency cases should take all precedence over all
cases or priority over elective cases.
3. The OR personnel must be inform immediately for any scheduled
operation and notify also for any changes / cancellation of surgery.
4. The OR personnel are expected to prepare the OR ahead of the
schedule time.
5. OR nurses have the right to question schedules, which did not comply
with the requirements provided by the hospital.
6. Surgeries should start at the exact time scheduled.
7. Surgical procedure for all potentially infected cases should be done
last.
8. Communicable cases which need surgical procedure should be
determine by the attending physician.

Patient Requirement

1. All laboratory results must be in patients chart before patient taken to

OR.
2. The physical preparation of all surgical patients’ elective or
emergency, skin and bowel preparation should be observe.
3. Pre-anesthetic order depends of the anesthesiologist or the surgeon
when to give pre-anesthetic medication.
4. Patient must be properly attired before wheeled to OR.
5. The patient should be at all the OR 30 min. to one hour before the
schedule time of operation.
6. Completeness of the patient chart, consent, pre operative and
checklist must be in to patient chart prior to surgery.
7. Relatives of patient who are doctor, nurses only allowed to enter OR
with a proper permission of the surgeon.

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 8. Relatives of patient who do not belong to above are not allowed to
enter but can be allowed to enter upon surgeons’ permission.

Closing Incision

1. Instruments, sponges, needles blade should be tallied before closing

the incision.
2. Scrub nurse is responsible for accounting of all instruments, needles
and specimen.
3. Circulating nurse is in charge of all written reports and records.
4. In the case, the final count does not tally with the initial count all
efforts must be exerted by the instruments and circulating nurse to
locate the missing.
Specimen

1. Specimen taken will be given directly to the laboratory, properly

labeled with accompanying histopathology request form.
2. Histopathology form must be filled up completely by the surgeon.
3. Specimen must be recorded in the OR biopsy logbook.
4. Surgeons who will bring the specimen outside should also sign the
specimen logbook.
5. Foreign bodies removed from medico-legal cases such as bullets
should be recorded and kept in the OR department.

OR Records/ Logbook
1. Keep all OR records confidential.
2. Only authorized person are allowed to get the OR records and
logbook.
3. Proper recording and updating of OR procedure.
4. Monthly report of OR procedure.
Supplies

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 1. The OR head must observe monthly inventory of supplies and actual
counting of stocks.
Safe Practice and Environment
I. OR Sanitation
1. General cleaning of the OR scheduled monthly.
2. Routine cleaning, decontamination and sterilization of equipments and
instruments are done according to the standard recommended by the
hospital infection control committee.
3. Routine cleaning of OR should be maintain with the use of disinfectant
approved by the infection control committee.
4. Communicable cases need surgical procedure should be properly
screened or determined by the attending physician.
III. Sterility and Cleanliness
1. Keep OR area clean all the time.
2. Follow all principles of sterile technique, if in doubt the sterility consider
unsterile.
3. All articles and instruments used in surgery must be sterile.
4. None sterile person must avoid going near sterile area.

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 Department Ward: Ward/Suite and Private Room

Personal Requirement

Uniform

1. Nurses and midwives must wear prescribed uniform with identification card.

2. Nurses and midwives must wear white shoes.

Working schedule

1. Working schedule of each department including off is to be prepared by

the department head or supervisor.

2. All nursing personnel must work 8 hours per day with a rotary shift.

3. Shifting hours

7:00am-3:00pm

3:00pm-11:00pm

11:00pm-7:00 am

4. For the good of service, employees must observe strictly the schedule
assign to them.

5. Off duties must be taken only on designated days per schedule.

6. Special request for off duty must be made two days before the
planning of the schedule depending upon the availability of personnel
and condition in the ward.

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 7. Changes of duties must be discouraged , But if it is really needed
personnel concern must inform the head of department for approval.

Reporting and Endorsement

1. Nurses and midwives must always be punctual to receive endorsement.

2. No one must leave the department in good and proper order for the next
shift.

3. Proper endorsement must be made before going off duty.

Discipline

While on duty Nursing staff are not allowed

1. To smoke

2. To entertain visitors and personal calls unless necessary and urgent.

3. To loiter around the hospital premises.

4. To spend time gossiping

5. To read newspaper or comics borrowed from patients

6. To sell any items or do any personal business transactions

7. To work under the influence of liquor.

Communication in the Nurses station

1. The staff must talk in low voice to maintain an atmosphere of silence

2. Communication between nursing staff must be made in low voice in

order not to be heard by patients.

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 3. During night, efforts must be exerted to maintain atmosphere of silence

4. Complaint from patient shall be referred to your immediate supervisor or

department head

5. Non-medical employees must avoid giving advise, discuss, compare or

criticize in front of patient, treatment, prescription or similar matter.

6. Employees must always remember their responsibility concerning

CONFIDENTIAL COMMUNICATIONS. This refers not only to the
information contained in the chart but also to whatever is learned or
seen by them while working in the hospital.

Patient Care

1. The nursing unit provides signage for patients directions.

2. Patient must be informed regarding the hospital policy.

3. Patient has the right to know every procedure to be done.

4. Patient safety and monitoring must be given top priority.

5. Accurate and proper documentation must be observed.

Safe Practice

1. All sharps and needles shall be dispose in sharp container with cover

2. Observe precautions when handling needles and blood components

3. Always observe hand washing before and after procedures

Services Offered

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The services offered by Somoso General Incorporated are:

• Hospitalization
• Out-patient and Company Leadership
• Major and Minor Operation
• Maternity and Lying-in
• Consultations
• Surgery and Orthopedics
• Internal Medicine
• Pediatrics
• OB-Gyne
• Family Planning
• Dental Care

• Laboratory:
 CBC  Potassium test
 Platelet count  Widal test
 Hemoglobin count  UA
 Hematocrit count  Fecalysis
 Blood typing  Pregnancy test
 Clotting time  Gram stain
 Bleeding time  Semenalysis
 FBS • X-ray
 Criatinine  Chest X-ray
 Serum uric acid  Skull Series
 Blood Urea Nitrogen  Spines
 Lipid profile  Abdomen
 Malarial smear  Hips
 HbsAg  Upper extremities

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  Lower extremities  Abdomen
 Chest
 Hips
 Lower extremities
• Ultrasonography
 Upper extremities

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 Patients care Classification System

The patient care classification system is a method of grouping patients

according to the amount and complexity of their nursing care requirements and
the nursing time and skill they require. This assessment can serve in determining
the amount of nursing care required, generally within 24 hours, as well as the
category of nursing personnel who should provide that care.

Classification Categories

Level I- Self Care or Minimal Care – patient can take a bath on his own,
feed himself, feed and perform his activities of daily living.

Level II- Moderate or Intermediate Care – patients under this level need
some assistance in bathing, feeding or ambulating for short periods of time.

Level III- Total or Intensive Care – patients under this category are
completely dependent upon the nursing personnel. They provided complete bath,
are fed, may or may not be unconscious, with marked emotional needs, with vital

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signs more than three times per shift, may be on continuous oxygen therapy and
with chest or abdominal tubes.

Level IV- Highly Specialized or Critical Care – patients under this level
need maximum nursing care. Patients need continuous treatment and
observation; with many medications, IV piggy backs; vital signs every 30
minutes; hourly output.

Table 1. Categories or levels of care of patients, nursing care hours needed per
patient per day and ratio of professionals to non-professionals.

Levels of Care NCH Needed per pt. Ratio of Prof. to

per day Non-prof.

Level I 1.5 5:45

Self Care or

Minimal Care

Level II 3.5 60:40

Moderate or

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 Intermediate Care

Level III 4.5 65:35

Total or Intensive Care

Level IV 6.0, 7 or higher 70:30

Highly Specialized 80:20

or Critical Care

Table 2. Percentage of patients at various levels of care per type of hospital.

Percentage of patients in Various Level of Care

Type of Hospital Minima Moderat Intensive Highly

l Care e Care Care Specialized.
Care

Primary Hospital 70 25 5 -

Secondary -
Hospital
65 30 5

Tertiary Hospital 30 45 15 10

Special Tertiary 10 25 45 20
Hospital

Distribution by Shifts

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 Studies have shown that the morning or day shift needs the most number
of nursing personnel at 25 to 51 percent; for the afternoon shift 34 to 37 percent;
and for the night shift 15 to 18 percent. In the Philippines the distribution usually
followed is 45 percent for the morning shift, 37 percent for the afternoon shift,
and 18 percent for the night shifts.

Staffing formula

The Somoso Hospital is secondary Hospital with 50 bed capacity.

1. Categorize the patients according to levels of care needed.

50 (patients) x .65 = 32.5 patients needing minimal care

50 (patients) x .30 = 15 patients needing moderate care

50 (patients) x .5 = 25 patients needing intensive care

72.5

2. Find the number of nursing care hours (NCH) needed by patients at each
level of care per day.

32.5 patients x 1.5 (NCH needed at level I) = 48.75 NCH/day

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 15 patients x 3 (NCH needed at level II) = 45 NCH/day

25 patients x 4.5 (NCH needed at level III) = 112.5 NCH/day

206.25 NCH/day

3. Find the total NCH needed by 50 bed capacity per year.

206.25 x 365 (days / year) = 75,281.25 NCH/year

4. Find the actual working hours rendered by each nursing personnel per
year.

8 (hrs/day) x 213 (working days /year) = 1,704 (working hours/day)

5. Find the total number of nursing personnel needed.

a. Total NCH per year = 75,281.25 = 44

Working hours/year 1,704

b. Relief x Total Nsg. Personnel = 44 x .15 = 7

c. Total Nursing Personnel needed = 44 + 7 = 51

6. Categorize to professional and non-professional personnel. Ratio of

professionals to non-professionals in a secondary hospital is 60:40.
51 x .60 = 31 Professional nurse

51 x .40 = 20 nursing attendants

7. Distribute by shifts.
31 nurses x .45 = 14 nurses on AM shift

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 31 nurses x.37 = 11 nurses on PM shift

31 nurses x .18 = 6 nurse on night shift

Total 31 nurses

20 nursing attendants x .45 = 9 nursing attendants on AM shift

20 nursing attendants x .37 = 7 nursing attendants on PM shift

20 nursing attendants x .18 = 4 nursing attendants on night shift

Total 20 nursing attendants

Chapter III-Directing

Job Assignment Policies

Transfers and Change of Assignments

It is the policy of the hospital to change the employee’s assignment, or to
transfer him to different areas of work within the hospital whenever the
exigencies of the services requires.
Assignments have varied duration as defined as follows:
• Assignment – any change of assignment for an indefinite period
• Temporary Assignment – any change of assignment for a definite
period, up to a maximum of six (6) calendar months. Any
assignment that goes beyond six months shall be considered
definite.

Job Rotation
To ensure knowledge on all areas of work in the department, job rotation
is encouraged. And all around exposure to different work areas is an advantage

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to both hospital and employees. The hospital maximizes its human resources,
while employees gain additional knowledge that they can utilize for their own
personal and professional advancement.

Semi Annual:
Evaluate staff nurses and attendants.
Yearly:
Do inventory of the nursing office. Make a yearly schedule of vacation
leave.
Job relation:
Responsible to the administrator for the good care of all patients.

SPECIFIC FUNCTIONS, DUTIES AND RESPONSIBILITIES

POSITION TITLE: CHIEF NURSE

MAIN RESPONSIBILITES:
The Nursing Service Management which is headed by the Chief Nurse
has functions which involve the administration, direction and maintenance of the
nursing service in accordance with the prescribed standards of the hospital
policies and procedure.

RESPONSIBILITES
1. Gets attainable goals for the nursing service taking consideration the
hospital policy and aims.
2. Prepares job description of the head nurse for the nursing unit.
3. Initiates staff development and or education. Must conduct at least one in
service training education every three months.
4. Plan for the improvement of the nursing service.

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 5. Promote harmonious and effective working relationship among nursing
personnel, medical staff, patients and subordinate.
6. Prepare a yearly budget for the nursing unit.
7. Prepare weekly schedule for nursing personnel.
8. Recommend for promotion for deserving nurses.
9. Revise nursing policy and nursing procedure manual yearly.
10. Perform related works that may be assigned from time to time.
Weekly:
Check on work schedule and sees to it that there is adequate staffing of
the unit.
Monthly:
Conduct staff meeting as often as necessary.

POSITION TITLE: NURSE SUPERVISOR

MAIN RESPONSIBILITES:
1. Supervises and coordinates activities of nursing personnel engaged in
specific nursing services such as obstetrics, pediatrics, medical, surgical,
for two or more patient care unit and also assigned to such areas as
operating room, out-patient and special areas.
2. Participates with the chief nurse in the development and implementation of
the philosophy and objectives for nursing services.
3. Supervises Head Nurses in carrying their responsibilities in the
management of nursing care. Evaluates performance of Head Nurses and
Nursing Care as a whole and suggest modifications. Inspects unit areas to
verify that patient needs are met.
4. Participates in planning of work and coordinates activities with other
patient care units and with those of related department.
5. Consult with the Head Nurses on specific nursing problems and
interpretation of hospital policies.
6. Supervises maintenance of personnel in nursing records.

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 7. Participate in the interview of pre-screened applicants and make
recommendations for employing or terminating personnel.
8. Assists the Chief Nurse in formulating unit budget.
9. Performs related works that maybe assigned from time to time.

POSITION TITLE: HEAD NURSE

DUTIES AND RESPONSIBILITES:
1. Directs and supervises nursing staff in provision of nursing care and
ensure the availability of support services which facilitate the care.
2. Interprets philosophies, goals, standards, policies and procedure.
3. Participates in varying degree in policy formation and decision making with
other members of the nursing administration.
4. Responsible for delivering care that is therapeutically effective and safe as
well as cost-effective.
5. Supervises and coordinates all patient care on the unit, including
communication with physicians.
6. Assumes 24-hour responsibility for the unit.
7. Confronts and resolves conflict involving staff, physician, patients and
personnel.
8. Schedules daily activities of the unit, including assignment planning,
scheduled meal and break time conferences.
9. Provides feedback to each employee on a planned basis including a
yearly observation.
10. Meets regularity with nursing administration for feedback and problem
solving.
11. Aids in the implementation of new policies and procedures.
12. Implements, evaluates and revised plan to meet unit goals.
POSITION TITLE: STAFF NURSE
The staff nurse is responsible for assessing the physiological,
psychosocial and spiritual needs and or problems for each patients in his or her
unit.

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DUTIES AND RESPONSIBILITES:
1. Charts and records administration of medication and treatment and
observes patients for deviation from normal condition.
2. Obtains sputum, urine and other specimens for laboratory examinations.
3. Gives general nursing services in and outpatient facility, gives oral,
intramuscular and other medications and records their administration,
discusses and reviews his/her judgment of patients condition and
otherwise treats and cares for physical ill patients.
4. Instructs and assists the subsidiary staff in the performance of routine
patient care including the taking and charting of routine nursing
procedures such as temperatures, pulse, respiration, in making beds,
changing linens, keeping order, lifting and moving patients, in giving baths
and rubs, caring for personal effects.
5. Performs work that may be assigned from time to time.
POSITION TITLE: OR/DR NURSE
DUTIES AND RESPONSIBILITES:
1. Supervises nursing attendants, orientation and supervision of nursing
students/nursing aids affiliates.
2. Checks OR/DR instruments, supplies, emergency drugs, oxygen tanks,
regulator gauge, suction machine, anesthesia machine, and emergency
packs.
3. Checks equipments and reports those that out of order.
4. Conducts inventory of emergency drugs, surgical supplies and
instruments every after OR/DR used.
5. Maintains sterility of OR/DR complex, instruments and other supplies.
6. Maintains records of all OR/DR procedures in the logbook and make
monthly report.
7. Conducts monthly sanitation of OR/DR complex.
8. Changes soaking solution monthly.
9. Performs monthly and annual inventory of all surgical supplies, drugs, and
instruments.

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 10. Performs other related works that may be assigned from time to time.

POSITION TITLE: NURSING ATTENDANT

DUTIES AND RESPONSIBILITES:
1. Checks and receives articles from outgoing aide.
2. Accounts all linens during the shift and endorses the next shift.
3. Give/Perform simple treatments like perineal care, SS enema,
refilling of hot water bags and ice caps.
4. Takes vital signs, weight of the patient.
5. Provide specime vials, collects urine and stool specimen and sends
them to the laboratory.
6. Answers patient’s calls and delivers messages.
7. Provides clean linen and makes bed, serves and empties bedpans.
8. Shaves patient for surgery.
9. Maintains cleanliness and orderliness of the patient’s unit at all
times.
10. Sees to it that all beds are complete with linen and pillows.
11. Removes all beds or discontinued equipment from patient areas,
cleans and returns to the utility room.

Employment Procedure
1. Head Nurse
a. Secures and fills up a Manpower Request Form (duplicate copy)
b. Inform the Chief Nurse of the need of additional staff and submit
manpower request form.
2. Chief Nurse
a. Evaluates the need for additional personnel.
b. Inform the Hospital Administrator of the need.
c. Schedules applicants for qualifying examination.

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 d. Deliberate results and schedule qualified applicants for an
interview.
e. Informs and schedule qualified applicants for orientation.
3. Hospital Administrator
a. Approves request from the chief nurse.
b. Participates in the panel interview of the qualified applicants.

LINE of COMMUNICATION

Communication is described as a two-way process, yet in an organization, it is

four dimensional.

The Somoso General Hospital Inc. was using the downward communication, the
traditional line of communication is from superior to subordinate which may pass
through various levels of management. In this line of communication the
communication is primarily directive and activities are coordinated at various
levels of the organization. Communication aims to impart what the personnel
need to know, what they are to do and why they are to do these.

Environmental Factors Affecting Nurses Work

Factors:

 Salaries and wages of the hospital may not compete with the salary
rate of the global market and other medical institutions.
 Maternity leave causes conflict of schedules and addition cause for
the nurse and the organization as well.
 Possible personal biases between the heads and the staffs.
 A need for a new technology to aid the personnel’s need and as
well as the patients.
 Conflict and misunderstanding between the staff and practicing
nurses.

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  Dissatisfaction of patients, regarding the quality of care provided by
the staff.
 Disturbances or conflict on self whether cognitive or affective.

Chapter IV-Controlling

Board of Directors

President Anita B. Somoso, M.D

Vice President Henry D. Derla, M.D.
Chairman Rizaldo R. Gonzales, M.D.
Corporate Secretary Romeo M. Natividad, M.D.
Corporate Treasurer Sabiniano C. Caballes, Jr., M.D.
Members: Sandra A. Garcia, M.D.
Anthony Voltaire B. Somoso, M.D.

It is the body that formulates policies and is responsible for coordinated

management and control of the entire hospital operation.

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Powers and Duties:
• The BOD, as a body, but not by any of the Directors acting in their
individual capacity, has general supervision and control of the affairs of
the cooperative hospital.
• It prescribes policies consistent with law, the By-Laws and resolutions of
the Meetings for management of its business and the guidance of its
members, officers and employees.
• The members of the BOD are jointly and severely responsible for
transaction, acts or omissions made in violation of law, the By-laws or the
resolutions of the Meetings, except those who entered protest at the time
when such transaction, act or omission was acted upon.

HOSPITAL OFFICERS

ANITA B. SOMOSO, M.D. President/Medical Director

RIZALDO R. GONZALES, M.D. Hospital Administrator
MS. GEMMA C. MANOS Accounting Supervisor
MS. DIODORA N. OLORVIDA Admin. /BOD Secretary

CLINICAL DEPARTMENT
SANDRA A. GARCIA, M.D. Chief of Clinics
RIZALDO R. GONZALES, M.D. Head-OB-Gyne Department
HENRY D. DERLA, M.D. Head-General Surgery
Department
LINO S. ARANJUEZ, M.D. Head-Orthopedics Department
SABINIANO C. CABALLES, JR., M.D. Head-Pediatric Department
ROMEO M. NATIVIDAD, M.D. Head-Medicine Department

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ROMEO S. PONCE, M.D. Head-Anesthesia Department
CLAIRE NOROŃA, Dietician
ANELYN J. SIBLOS Pharmacist
JOVERT S. YUNSAY Medtech Head
HERLYN I. PAGLINAWAN Radiologist

NURSING SERVICE
CORAZON T. SUBITO, R.N. Chief Nurse
JOANNE V. TACARDON, R.N. Nurse Supervisor
APRIL LOVE SOLILAPSI OR/DR Head Nurse
JOCELYN C. BALON, R.M. ER/OP Department Head

10 GOLDEN RULES OF GOOD BUSINESS

1. A customer is the most important person in any business.

A SGHI man must, at all the times, be conscious of how he can satisfy his
customer. The customer is important because all hospital efforts are directed to
his ultimate satisfaction. The customer is king. Therefore, his expectations must
be met.

2. A customer is not dependent to us; we are dependent on him.

A SGHI man owes his customer his income and he is dependent on him
whether directly or indirectly. The hospital’s survival is dependent on his
customer. Therefore, a SGHI may exist for his customer.

3. A customer is not an interruption of our work: he is the purpose of it.

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 A SGHI man works for his customer. The end result of his work is always
to provide satisfaction to his customer. Furthermore, SGHI man’s reason for
working is not solely hoe himself but more importantly, for his customer.
Therefore, the purpose of his work is his customer.

4. A customer does us a favor when he calls; we are not doing him a favor
by serving him.

A SGHI man’s opportunity to provide quality products and services to his

customer is a sign of customer approval. When there is opportunity to provide
product and services, the customer is providing business to the hospital.
Therefore, the customer does a favor for a hospital through business
opportunities.

5. A customer is a part our business-not an outsider.

A SGHI man’s real partner in business is his customer. The customer is

the moving force that propels the Hospital business. As a partner, a SGHI man
must see to it that the customer is also benefiting from the Hospital’s business.
Therefore, a SGHI man must protect the mutual interest of thr hospital and the
customer.

6. A customer is not cold statistic; he is a flesh-and-blood and blood human

being feelings and emotions.

A SGHI man must be sensitive the concern of his customer. The customer
expects that he be treated with care and that his dignity be respected. Therefore,
a SGHI man has to treat his customer the way he would like others to treat him .

7. A customer is not someone to argue or match wits with.

A SGHI man must never consider his customer as adversary. In fact, the
customer has the right to complain with his expectation of the Hospital’s products
and services are not met. Complaints, in reality are feedback for the SGHI man
to improve his products and services to the customer. When there is feedback, it

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is an opportunity for the SGHI man to provide value-added service to satisfy his
customer.

8. A customer is a person who brings us his wants; it is our job to fill those
wants

A SGHI man should respond his customer’s needs and wants. The
customers’ needs and wants provide business opportunities to the Hospital.
Without them, there is no reason for the Hospital to exist. The job of every SGHI
man must, therefore, be towards the fulfillment his customer’s needs and wants.

9. A customer is deserving of the most courteous and attentive treatment we

can give him.

A SGHI man is expected to provide courteous service his customer at all

the times and under all condition because next of the quality of the products is
the quality of service that the Hospital provides. It is the quality of service that
separates the Hospital’s products from its competitors. Therefore, a SGHI man’s
relationship and service to his customer must be properly managed.

10. A customer is the life blood of this and every business.

A SGHI man must always be aware that the life if his Hospital’s business
is his customer. Taking care of his customer is tantamount to taking care of
himself and the Hospital. Therefore, customer satisfaction is the only assurance
of the SGHI man and his Hospital to exist.

POLICIES AND PROCEDURES

Rest and Holidays

Rest Days

Saturdays and Sundays are normally considered the regular rest days for
all employees except for those whose rest days are designate on other days.

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Work rendered on such rest days shall be paid with the applicable rate and
corresponding overtime premiums.

Legal Holidays

The hospital observes legal holidays that are considered paid non-working
days. Should employs be required to report for work during holidays, they shall
be entitled to additional holiday pay and corresponding overtime premiums to
such days.

Special Holidays

The hospital likewise observes special holidays which may be declared by

the government as working or non-working days. However, these special
holidays are exclusive of legal mentioned earlier and are considered paid. Should
such days be considered as non-working days, employees who are required to
work shall be entitled to appropriate overtime premium.

ID Cards

Once a probationary employee becomes a regular employee, the hospital

will issue an identification card and they shall wear it while in the hospital
premises.

In case they lose their ID card they shall submit a written notice to the
human department and they shall replace it at their own expense.

If they resign or terminate their employment with the hospital, they are
required to return the ID cards to the human resource Department as part of their
clearance requirements.

Outside Activities

While the employee’s off-day time is their personal concern, yet they are
expected to be always conscious of their responsibilities and commitment to the

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hospital. Should they decide to pursue further studies or to engage in extra work,
they should first secure permission from the hospital to protect proper company
image and their health as well as the interest of their co-employees’.

Professional Conduct

The hospital upholds professionalism among its officers and employees

especially in their attitude and conduct in dealing with one another as well as its
client, most particularly with regards to the following aspects.

Evaluation tool

Suggestion box.

Work Decorum

Prescribed Office Attire and Uniforms

The hospital shall prescribe the kind of uniforms to be worn for the
respective days of the week. However, employees maybe excused from wearing
the priscribed uniforms only for justifiable reasons, such as:

• Loss or death of one’s family members.

• Pregnancy

• Other valid reasons analogous to the above.

This exception to the rule does not apply to those employees working in
clinical departments.

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 In case any of the employees’ uniform is lost, damaged or becomes
unusable before its replacement date is due, they shall submit a written notice to
the Human Resource department and they shall be given a grace period of one
month to have it made.

Failure to wear prescribed uniforms without a valid reason shall subject

them to disciplinary action.

Work Attendance

Work Schedule

Regular workdays are Monday thru Saturday. Working hours are from
8:00am to 12:00nn – 1:00pm to 5:00pm for employees on regular day duty and
7:00am to 3:00pm, 3:00 to 11:00pm, and 11:00pm to 7:00am for employees
engaged on shift work.

Working schedule of each department including On and Off is to be

prepared by the Department Head or Supervisor and approve by the
administrator, Medical Director.

Employees shall render eight hours of work per day; provide that they
follow their official schedule issued by their Department Heads or Supervisors:
provided further that they shall be subject to the rotation of duty as practiced by
the hospital or “On Call” and “Emergency Call” when he exigencies of service
demand even on rest days and /or legal Holidays and/or Sundays OFF duties
must taken only on designated days per schedule.

If there is any request of change.

Break Periods

Those on regular duty are entitled to two 15-minute coffee break periods
(one in the morning and the other in the afternoon) and a meal break from
12:00nn to 1:00pm. Those engaged on shift work are entitled to a 15-minute
coffee break period and a 30- minute meal break for every 8 hour shift’

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Daily Time Records

The daily time record (DTR) is the official record of the time an employee
renders work on a particular day which serves as the basis for the payment of his
compensation for the said day.

Employees are required to accomplish their DTR by personally punching

in and out on the scheduled time. In case they have failed to do so, their
immediate superior should sign his initials behind the hand written in or out.
Otherwise, it will be presumed that the employee did not report on that particular
day.

Unauthorized alteration: falsification of entries on the cards, forgery of the

approving officer’s initials: and punching of another employee’s DTR are
prohibited and covered under Employees Discipline Code.

Absences

If employees are unable to work for some valid reason (s) during any
working day, they must properly notify their immediate superior at once. For
details, refer to the section on Absence Notification procedures covered under
the Leave Benefits program. Unauthorized absences shall be considered
Absence Without Official Leave (AWOL), and shall subject the employee to
disciplinary action.

Overtime

Should employees are required and authorized by their immediate

superior to work beyond their regular work period; they are entitled to premium
payments for every hour that they render for every overtime work.

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 They shall accomplish the Overtime Authority Form that contains their
name together with the nature of work to be done and shall indicate the actual
start and end of approve overtime work rendered.

They must accomplish the overtime authority form before doing the actual
overtime dult signed by their immediate superior.

Pre-Employment Requirements
New employees must secure and submit to the Human Resource
Department (HRD) the following basic pre-employment requirements:
• Latest ID picture (1x1)
• BIO-DATA
• Letter of Intent
• Transcript of Records/S.O.
• College Diploma
• Professional License
• Previous Employer Clearance
• Police Clearance
• Social Security System Number/Philhealth Number
• Tax Identification Number

Pre-Employment Orientation
Prior to employment with SGHI, prospective employees shall undergo a
pre-employment orientation program conducted by the HRD. It shall contain the
following:
• History
• Organizational Structure
• Personnel Policies and Benefits
Employees shall also fill up pertinent documents and forms such as:
• Employee Data Sheet
• SSS Membership Form

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 • Pag-Ibig Membership Form
• Identification Card
• Bank Signature Card

Reporting for Work

Upon turnover of the employee to his section/department, he shall report
to his immediate superior for necessary orientation on his new work assignment.

YOU AND YOUR JOB

Employees in our institution fall into main categories-regular, probationary
– and are either daily-rated monthly rated.
1. Regular employees are those issued permanent appointment after having
undergone a period of probation during which their fitness to become
regular employees of the Company from the standpoint of experience,
skill, physical capability, and education has been determined.
2. Probationary employees are those undergoing a six month period of trial
and observation during which both the employee and the Institution
determine whether or not a permanent appointment will be issued. During
the employee’s probationary period, the employment relationship maybe
terminated at any time by either the company or the employee.

You can be sure that whatever position you are occupying as an

employee of the institution is an important one. Otherwise, we should not hire
to fill it in the first place. We, therefore, depend on you to carry out your duties
and responsibilities well for in doing so, you affect the manner in which your
fellow employees carry out theirs. If you remember this always, you will find it
worthwhile and necessary to do your best in your job so that the department
or section of which you are a part may succeed – and you with it.
Wherever you may be assigned, you will be under a
Supervisor/Department Head to whom you have to report. Your
Supervisor/Department Head plays an important role in your work life. In

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 carrying out his responsibilities, he is expected to assign and explain your job
to you, help you learn and become proficient in it, and provide you with ready
assistance in your work problems.
When you do not understand clearly some explanations or instructions
given by your Supervisor/Department Head, do not hesitate to ask question.
Many times it is better to ask him directly than to ask your fellow employees
what you are suppose to. You will get match more out of your job if you keep
in close touch with your Supervisor/Department Head. Check with him from
time to time to make sure you’re on the right track. He will always be ready to
give you a helping hand.

Employment Records
Updating Personal Data and Status
During employment, employees are required to promptly give written
notice to HRD on any change in personal data/status, such as, but not limited to:
• Civil Status
• Number of dependents
• Home address
• Educational attainment
• Government exams passed
• Courses/seminars taken

Permanent Employment Record

The hospital maintains permanent employment record.
This record contains the following:
• Employment Summary (biodata, psychological reports)
• Appointment/Salary records
• Performance/Disciplinary record
• Copies of Certificates of seminar attendance, ratings of exams passed,
and diploma of courses/degrees completed .

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DISCIPLINE OF STAFF
Discipline is a means that a department uses to bring Staff Nurses behavior
under control. Its purpose is not retribution but to impress upon staff nurses the
need to do things the prescribed manner. It also serves as a warning to staff
nurses that the department will not tolerate any willful violation of its rules and
regulations or proper conduct and behavior.

PROCEDURE
1. Immediate investigation of the offences must be done to determine the
facts.
• The staff involve will be required to submit a written report in 2
copies within the first 24 hours of the incident to be submitted to
his/her immediate supervisor.
• Immediate supervisor conducts initial investigation of the incident
and submit the original copy of the written report together with the
investigation results and recommendations to the chief nurse.
• Chief Nurse evaluates the incident and does the final investigation.
2. Impose Proper Disciplinary Actions
• Imposing of disciplinary actions should be based on the weight of
offences as determined by the nursing department.

Class 1 Offences
1.1 Intentionally fails to cooperate in Hospital activities.
1.2 Does not notify the Hospital Officers when he will be absent from duty even if
the absence is planned.
1.3 Fails to report immediately lost/damages of hospital properties and
equipments.

Disciplinary Measures

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 First Offence Counseling
Second Offence Written Reprimand
Third Offence Suspension for 3
working days
Fourth Offence Indefinite
Suspension

Class 2 Offences
2.1 Frequently or habitual reports to work late on the prescribed work
schedule.
2.2 Frequent absents from work without justifiable reason.
2.3 Avoids assigned work.
2.4 Sleeping while on duty.
2.5 Does unsatisfactory work as determined by a committee that evaluates
said work.
2.6 Does not return to work upon the expiration of the approved leave of
absence.
2.7 Prolonged absence without notifying the Hospital officers of the reason.
2.8 Disregarding prohibition notices and signs such as no smoking in “NO
SMOKING area”.
2.9 Disregarding hospital regulation relating to sanitation, cleanliness and
orderliness.
2.10 Using hospital materials, supplies and equipments other than for
which it is intended.
2.11 Using the hospital telephone for personal reasons during or outside
the official time except on extreme emergencies or with permission from
hospital authorities.
2.12 Showing discourtesy or disorderly conduct inside the hospital
premises, e.g. towards patient.

Disciplinary Measures

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First Offense Written Reprimand
Second Offense Suspension for 5 working
days
Third Offense Dismissal

Class 3 Offences
3.1 Punching or filling-up somebody else’s time card or logbook
3.2 Leaving work assignments and hospital premises during official time without
the approval from the Department Head.
3.3 Using the hospital-owned transportation facility other than for which it is
intended without any authorization and approval.
3.4 Falsely testifying for or against the hospital employee who is subject of the
investigation.
3.5 Hiding vital information which is of interest to the hospital during the
investigation or when called upon to provide information on the matter.
3.6 Fails to meet or submit to security and safety requirements of the hospital.
3.7 Bringing intoxicating drinks and or using habit-forming drugs inside the
hospital or work premises.
3.8 Bringing and concealing or displaying a gun or any deadly weapon inside
the hospital premises anytime of the day.
3.9 Provoking a co-employee, guest or a patient to a fight during official time
inside hospital premises.
3.10 Unsatisfactory performance of his official duties and responsibilities
whether ministerial, discretionary or is required to perform within a reasonable
length of time without justifiable cause.

Disciplinary Measures
First Offense Suspension for 7 working days
Second Offense Dismissal

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Class 4 Offences
4.1 Inflicting body injury to another person or co-employee inside the hospital
premises anytime of the day.
4.2 Threatening or intimidating any hospital employee or officer during office
hours and inside hospital premises.
4.3 Intentionally damaging hospital property and equipment.
4.4 Performing any actions constituting theft or robbery of hospital property.
4.5 Using hospital manpower, materials, money and time to do an authorized
work or for personal profit.
4.6 Replacing hospital equipment, materials and supplies with another of inferior
quality or cheaper value.
4.7 Offering or accepting anything in exchange for a job, work assignment, or
favorable work conditions.
4.8 Disobeying hospital orders to perform his duties and responsibilities without
justifiable cause.
4.9 Causing the hospital operation to lose time and money due to gross of
negligence or inefficiency in the performance of official duties and
responsibilities.
4.10 Willfully giving out restricted or confidential hospital information to those
not authorized to possess such information.
4.11 Favoring suppliers in exchange of kickbacks or buying materials and
supplies at a higher cost when these can be bought at a lower for personal
profit.
4.12 Falsification of travel expense reports, receipts or documents making the
amount to appear more than what actually spent on which reimbursement is
based.
4.13 Performing an act which jeopardizes or puts the hospital reputation and
good will to bad light.
4.14 Instigating, conspiring and/or encouraging other employees to go against
the administration of the hospital.

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Disciplinary Measures
First Offense Dismissal

Chapter V

CONCLUSION

Somoso General Hospital Inc. in general has fair and reasonable system
of organization and standards of giving patient care. Although there are some
lapses and discrepancies that needs attention base on our observations and
recommendations, the hospital and the medical team that works hand in hand to
promote the quality of care still have done their part to uplift the quality and
precision of providing care to their patients.

The building on which the Somoso General Hospital Inc. has been
operating is quite dilapidated and is almost fire hazard because of its structure
and the materials its made of. On these regard, the management is now building

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a new building in which a state-of-the-art facilities and systematized organization
of departments will be present, leading us to speculate that the lapses,
discrepancies and our recommendations will be answered fortunately with
positive response.

Employees in the hospitals were kind and generous enough to cater

guest/visitors courteously as per observation during our hospital visit. As of the
moment, the hospital has 17 Registered Nurses and 8 Nursing Attendants
according to the inputs and information we had gathered. This brought us into
conclusion that the hospital was understaffed and undermanned.

Lastly, the Somoso General Hospital Inc. is determined to endow quality

care and service to the community as well as the nearby municipalities and
barangays surrounding Panabo City. The hospital is proud to say that they are
the only one in Panabo City that entertains patients who doesn’t have enough
money to pay for their down payment in cases of emergencies. In lieu of this,
other hospitals should imitate this kind of system because this brings out the
policy of our government to provide quality and affordable health care.

RECOMMENDATIONS

1. It is an advantage for Somoso General Hospital Inc., to hire multi-skilled

workers, to promote quality health care services, but the organizations
have to be cautious not to give too much task that may cause conflict in
obligations and responsibilities and conflicts of interest
2. Somoso General Hospital Inc. should improve comfort rooms and have
proper ventilation in each ward to provide comfort and accessible to all
patient.
3. Somoso General Hospital Inc. should provide a parking lot to have a good
accommodation

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4. Somoso General Hospital Inc. should have a clear direction of FIRE EXIT
so that it will be easily seen by the patient or any people that are inside the
establishment.
5. Somoso General Hospital Inc. should expand the area on their emergency
room to cater more patients.
6. Somoso General Hospital Inc. should provide a bed in the ward which is
comfortable to the patient.

7. Emergency room door should be convenient and easy to open.

8. Ideally the hospital must have 31 nurses and 20 nursing attendants.

REFERENCE

• Somoso General Hospital Inc.

• Nursing Management towards Nursing Care, 3rd Edition by Lydia M.

Venzon, RN, MAN, FPCHA and Jennifer M.V. Nagtalon, BSN, RN

• www.google.com

• www.wikipedia.com

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