NSO Policy FInal Draft

REPUBLIC OF THE PHILIPPINE
BUTUAN MEDICAL CENTER

BUTUAN CITY
POLICY MANUAL OF NURSING SERVICE

MA. CORAZON C. DE CASTRO,RN.,MN.,MAN
Nurse IV – OIC - CHIEF NURSE
NURSING SERVICE MANUAL OF POLICIES & PROCEDURES
MISSION
1. To provide the caring side of preventing illness, promoting, maintaining and restoring health to all
patients in the hospital and the community,
2. To conserve and stengthen the forces of the patients facing problems mentally, emotionally, spiritually To the New Nursing
and financially. Personnel
3. To provide and maintain accurate, complete and up to date records of the patient.
4. To promote good communication and harmonious interpersonal relations with the hospital
departments.
5. To produce a knowledgeable, skillful, competent nurse practitioner guided by a holistic approach Welcome to the BMC. This
through nursing process. handbook was prepared by
the Nursing Service Staff
and approved by the Chief
Nurse. This will provide you
with complete and precise
information about the
hospital; the objectives and
VISION
functions of the service; and
the most current policies
and procedures of the
department.
As a new staff member, this

handbook will enlighten
To the New Nursing Personnel
you of your role in your
service area and it is
Welcome to the Butuan Medical Center. This handbook was prepared by the Nursing Service Staff and approved expected that you form part
by the Chief Nurse. This will provide you with complete and precise information about the hospital; the objectives of a cohesive organization
and functions of the service; and the most current policies and procedures of the department. that strives to provide
As a new staff member, this handbook will enlighten you of your role in your service area and it is expected that you
form part of a cohesive organization that strives to provide efficient and effective service.
Think of the betterment of the organization rather than oneself.
.
THE FLORENCE NIGHTINGALE PLEDGE
I solemnly pledge myself before God and presence of this assembly;

To pass my life in purity and to practice my profession faithfully.
I will abstain from whatever is deleterious and mischievous
and will not take or knowingly administer any harmful drug.
I will do all in my power to maintain and elevate the standard
of my profession and will hold in confidence all personal matters
committed to my keeping and family affairs coming to my
knowledge in the practice of my calling.
With loyalty will I endeavor to aid the physician in his work,
and devote myself to the welfare of those committed to my care.
WHAT IS A PATIENT
The patient is the most important person in the hospital.
The patient is not dependent upon us – we are dependent on him.
The patient is not an interruption of our work – he is the purpose of it.
The patient is not an outsider to our business – he is our business.
The patient is a person and not a census or statistics .He has feelings, emotions, biases and wants.
It is our business to satisfy him.
The Nursing Service Administration recognizes the value and dignity of the individuals as members of the group. It
is guided by the concept that Nursing helps to assist and to strengthen the patient who is facing physical, emotional
and mental difficulties.
All members of the nursing service staff should be members of their respective professional organizations such as
the Philippine Nurses Association and the Integrated Midwives Association of the Philippines.
Members of the Nursing Staff are expected to be neat, prim and proper in appearance at all times. Faithfully
discharge their duties and responsibilities and comply with the hospital policies & procedures.
The philosophy of the nursing service is consistent with the philosophy of the hospital.
The hospital is dedicated to the delivery of the best possible patient care available
The nursing service administration recognizes the value and dignity of the individual as a member of the group
hence all action emanate from decisions of the majority as a principle of the democratic process
Philosophy of the hospital:
A dedication of the delivery of the best possible patient care available or more specifically to the meeting of the
physical, social, psychological and spiritual needs of the patients.
Philosophy of nursing care of patients:
The best possible quality patient care delivery.

B. Philosophy of nursing service expressed in terms of a set of beliefs upon which objectives can be constructed
and behavior directed.
We believe that the responsibility of the professional nurse involved in administering nursing services is to maintain
a quality of practice that will ensure patients of supportive, therapeutic and rehabilitative nursing care to enable
them to return home enriched spiritually and physically from hospital experience.
The nursing service administration is based on democratic way, which recognizes the value and dignity of the
individual as a member of the group.
C. Over-all objectives of the nursing service in writing:
1. To give a comprehensive nursing care to the patients and to help conserve and strengthen the forces of the
patient in facing problems mentally, emotionally, spiritually and physically.
2. The professional nurse practitioner will be helped to ;

a. Fulfill her professional role and takes her rightful place within the professional health team.
b. Develop collaborative relationship with her colleagues in medicine.
c. Devote her to the improvement of the professional practice as well as the provision of care.
D. Objectives of the nursing service in each service area:
1. Ward services:
a. To provide total, comprehensive bedside nursing care to every patient in the unit through proper
planning and implementation, taking into consideration the priority cases.
b. To give incidental health teachings to patients and watchers.
c. To execute hospital policies, maintain standards, cooperate with physicians, and carry a satisfactory
relationship with the community.
d. To provide adequate supplies, equipment and facilities.
e. To have accurate records.
2. Operating Room – Delivery Room Services:

a. To provide comprehensive assistance to various types of surgical
operations, deliveries and other related activities.
b. To provide necessary instruments, supplies, equipment in all surgical
operations.
c. To ensure observance of aseptic technique in all operative procedures.
d. To recognize and interpret symptoms indicative of changes in the
conditions of patients and cooperate with the other members of the operating team.
e. To coordinate activities with other hospital departments.
f. To maintain accurate required records and reports.
3. Out-patient department-emergency room:

a. To deliver a comprehensive out-patient medical and nursing services.
b. To observe aseptic technique in all surgical procedures.
c. To give health teachings to out-patients.
d. To coordinate activities and maintain good relations with other
hospital departments and the community.
e. To maintain accurate records and reports.
f. To plan to meet the needs of community areas and refer patients to
other agencies as necessary.
HOSPITAL AND NURSING SERVICE POLICIES AND PROCEDURES
Working hours
The standard working hour (government service) is 40 hours a week. The cycle of rotation with duration of 7 days is
from morning shift.
1. Shifting hours
Ward Services
7:00AM-3:00PM-morning shift
3:00PM-11:00PM- afternoon shift
11:00PM-7:00AM-night shift
The schedule of duties is prepared by Chief Nurse . The tentative one is first posted a week before, for the nursing
staff to see, before it is finally submitted to the Chief Nurse for recommending approval and to the Hospital Director
or Hospital Administrator for approval. A copy furnished to the Chief Nurse,all the Nurse’s stations, OR-DR, ER-
OPD, Nursing Bulletin Board, I.C.U., and N.I.C.U.
Each personnel is encouraged to view from time to time the Nursing Service Bulletin Board situated at the Blue
Station , Floor I , for the changes of schedule and important notices posted.
Shifting of schedule usually happens every Sunday, The Nurse II and Nurse I are rotated to Medical, Surgical,
Pediatric, Isolation and OB-Gyne wards. Nursing attendants are also likewise assigned in the above wards under
close supervision of the nurses. Rotation takes place every six months in a case method classification.
Once the Schedule of Duties is approved, the said schedule is final. The schedule may be altered only when a
problem of staffing arises.
1. Punctuality in reporting to duty
Nursing personnel is expected to report to duty 15 minutes before the scheduled time; for 7-3 shift, 3-11 shifts and
as well as the 11-7 shift. When personnel who arrive late, the accumulated minutes of late will be deducted on
his/her salary monthly, to avoid habitual tardiness in reporting.
2. Daily time records
Daily time records should be properly filled-up when one reports, and even on off-duties. Accuracy and
completeness of the records are expected from all personnel. Submission should be at end of the month for regular
staff, but for job order/casual/contractual staff the submission of daily time records will be at the middle and at the
end of the month. It should be submitted to the Chief Nurse.
3. Logbook or Bundy clock
Every personnel on duty are required to time in and out in the logbook and Bundy clock. If a logbook is use, it must
be placed near the Bundy clock area or at guard post on hospital entrance. For 11:00 PM- 7:00AM shift, the ER-
OPD personnel must close the logbook.
4. Off-duties
Each personnel are given two days off a week subject to the following;
a. Schedule of off duties immediately following or preceding day of absence, shall be
considered an absence upon discretion of the supervisor.
b. Request for exchange of duties between personnel should be put into writing
and shall be approved when justifiable. Anyone requesting for an exchange of
off duties should be the one to arrange with the requested staff.
c. Request should be written in advance, at least two weeks before the tentative
schedule will be posted in the Nurse’s Bulletin Board. Two days successive off
duties maybe allowed if there is an urgent need of it and request should be
submitted to the Chief Nurse.
5. Absences
a. Absence from duty with or without notices is to be reported to the office of the Chief Nurse and to the Nursing
Unit where the absentee is assigned. One day before reporting back to duty and on the day of reporting, the
employee must report in person and submit a written or verbal explanation to the Nursing Office.
b. Absence with notice and with valid reason, off-duties will not be forfeited.
c. When one of the staff of the nursing service has an emergency reason for absence; like sickness or death of
love one; the concerned staff must report or call immediately to the Nursing Office to notify the Chief Nurse/Asst.
Chief Nurse/Supervisor/Acting Supervisor, so that the schedule duties of the nursing service staff will be arranged.
d. Habitual absences should be automatically reported to H.R.M. Habitual absences means 3 absences or more in
a month without notice or late notice.
e. Regular, job order and contractual nursing staff with 5 to 6 absences should have a medical certificate or
supporting document.
6. Half days
a. First half day is not permissible unless in an emergency cases, and only with
prior notice. Half day is not obligatory but a privilege.
b. Half day will only be allowed if the ward is not busy and upon discretion of the
supervisor.
c. No advance half day will be allowed.
d. Half days without prior arrangement with the Nursing Supervisors/ Asst. Chief
Nurse /Chief Nurse is considered under time.
e. Half days are allowed only with the permission from the Chief Nurse, Asst. Chief
Nurse and Nursing Supervisors.
8. Leaves
a. Vacation Leave
It must be filed a week before a personnel goes on vacation leave after being granted by the Chief Nurse.
b. Sick leave
Sick leave must be filed upon assumption of duty. Sick leave of six days or more should have an accompanying
medical certificate, with a consultation from the Administrative Office.
c. Force leave
Force leave must be applied for in advance and cannot be credited to other leaves applied for. Force leave should
be filed until second week of December.
d. Special leave
Special leave like anniversary, birthday, enrollment, relocation and hospitalization must be filled a week before.
e. Maternity leave
a. Regular or permanent employee who have rendered two or more years of
continuous service shall be entitled to maternity leave with pay.
b. Regular or permanent who have rendered less than two years of continuous service shall be
entitled to maternity leave with half pay.
c. Temporary employees like job order/casual/contractual who have rendered
two or more years of continuous service shall be entitled to maternity leave without pay (that will depend on their
contract).
d. Leave of Absence (Memo Circular #06), S91 by Hospital Director portion.
In view thereof, all are enjoined to observe strictly the following;
No application for absences will be approved unless with previous consultation and agreed by your respective
Division Heads to wit;
1. Physician and Dentist – Hospital Director
2. Nursing Service – Chief Nurse
3. Administrative and Auxiliary Service – Administrative Officer
f. Extension of leave
fi. Extended leave without permission is insubordination and must report to the Chief Nurse with
Incidence Report and copied furnish to H.R.M.
fii. Extension of leave with permission request should be approved by the Chief Nurse.
Reminder:
- Notification of extended leave, from a personnel, and by text message thru cellular phone will be disapproved and
prohibited unless with a justifiable reasons. Henceforth, all leaves must be specific.
- Application and request for leave will be directed to the Division Head, none other and henceforth be arranged
directly. No written request will be entertained unless represented directly or in case of incapacity.
- Leave will be canceled at anytime due t exigency of the service whereby you will be recalled.
- Adherence to the Labor Code, rules and regulation will be strictly followed.
9. Resignations
Resignations must be filed one month before the date of effectively is granted.
10. Personnel Addresses
Nursing staff members are required to give the Nursing Office updated information regarding addresses and
telephone numbers.
11. Personal Records
Personal records are kept on each staff member including such

information as personnel data card performance evaluation record and
other pertinent records in the office of the Chief Nurse. Appointment
papers, leave credits, service and other personal files are kept by the
Administrative Office.
12. Established procedure for informing personnel when there is a change in policy
Section heads of the Nursing Service submit to the Chief Nurse changes in their sections for review and these are
presented to the staff for discussions during monthly meetings and finally to the Hospital Director for approval and
incorporated in the Nursing Service Manual which is provided in every Nursing Unit.
13. Leaving the ward or post while on duty
Everyone is expected to remain in her ward on duty. But for necessity before leaving the ward even for a short time,
the nurse or nursing attendant should notify someone in the ward of her/his whereabouts. The ward should
never be left without a responsible person to look after the patients and to attend to anyone who goes toward
or Nurse’s Station.
Taking meals outside the hospital premises is not permissible.

Allotted time for meals and snack:
Meal time- 30 minutes
Snack time – 15 minutes
Grocery/Marketing is not allowed
Pass slip is required for anyone who goes outside the hospital premises, which should be signed by the
Division Chief or the Hospital Director. For the 3-11PM and 11-7AM shift, the pass lip will be signed by
the physician on duty or nurse supervisor.
14. Entertaining visitors
Personal visitors should not be entertained while on duty.

Taking visitors around the hospital
In escorting visitors around the hospital, permission must be obtained from the Hospital Director, or the
Administrative Officer, Chief Nurse or P.O.D.
15. Uniforms
All nurses must wear complete uniforms while on duty – cap, school pin, required I.D. or nameplate, stocking or
white socks and white duty shoes. The cap is our distinction among all personnel wearing the white uniforms.
Although at night duty, ward personnel may use blue scrub suite with white pants and may not wear cap. On the
other hand, all special units such as OR-DR, ER-OPD, I.C.U. and N.I.C.U. are allowed to wear colored uniforms
with permission from the Chief Nurse and their Nurse Supervisors.
Nursing Attendants and midwives are requires to use the same uniforms as prescribed on the units they are
assigned, except for a nurse cap.
All nurses, midwives, nursing attendants must have watches with second hand while on duty.
Fines imposed for the following:

1. Jewelry that is large enough to attract attention especially big earrings – P 20.00 for every offence. Only
a small button-size earring is allowed.
2. Incomplete uniforms including not wearing of I.D. or nameplate – 20 pesos per item.
16. Telephone
-Personnel must avoid using telephone for unnecessary reasons.

-Telephone call can be answered by any of the personnel but preferably by the Nurse II.
- Telephone call should be answered promptly and with courtesy.
- Ward telephone shall be used only for official business.
- In answering the call, the following procedure must be observed;
a. Name of the answering
b. Position
c. Department
Example: Hello Good morning, this is Juan de la Cruz speaking, nurse in charge of blue station.
17.Silence
Silence must be strictly observed in the wards, halls, corridors and offices at all times. Please observe also self-
discipline.
18.Respect and courtesy
Respect and courtesy towards supervisors, co-workers, patients, visitors and the general public should always be
observed.
Personnel grudges among nursing service and personnel of other department must be avoided. If ever personnel
felt grudges, anger or remorse during giving health care, it should be set aside when dealing with patients.
Hospital personnel must address properly regardless of their positions.
19. Initiative to help one another
All members of the Nursing Service Staff have the initiative to help one another. Always remember that “No Man Is
an Island”. In case of mass casualties – vehicular accident or disaster / calamity ( more than 3 or 5 patients) staff
are obliged to help ER staff.
20. Honesty, Courtesy and Adherence to the hospital policies
Honesty, courtesy and adherence to the hospital policies and memorandum issued by this Office (Hospital Director)
are for strict compliance unless otherwise revoked or amended.
21. Loyalty and service oriented
All personnel are to pledge their loyalty and service this hospital and forget politics. Be an asset and not a liability.
22. Frequent Rounds
All shifts should make frequent rounds to check watchers sleeping with the patients, which are never allowed.
Everyone should be strict to conform regarding the rules and regulations of the hospital. One or two will not solve
the problem, but all of us should be concerned.
23. Staff Meeting
1. Monthly nursing staff meeting or Staff Development Activity is every first Friday or second Friday of the
month as scheduled.
2. Absence without sufficient and valid reasons considered absent and should file a leave as unanimously
approved by the members of the nursing service.
• A fine of P 30.00 for late.
24. Orientation
Orientation of new personnel shall be conducted by the Chief Nurse and Supervisors, most senior ward nurse and
nursing attendant, with the discretion from Chief Nurse. All new personnel shall begin to have a tour in the hospital
set-up, lecture-demo orientation and lastly ward rotation for a month and a half as specified by the Chief Nurse.
Orientation starts at ward.
For new personnel , advise to report or contract should be presented before orientation , and also he/she should
report upon completion of Human Resource Management Department requirements.
New personnel nursing dept. requirements are the following ;

• Personal Data
• Philippine Regulation Commission or PRC Identification
• Philippine Nurses Association or PNA Identification
• Special trainings such such Basic Intravenous Therapy Training is required but Basic Life Support and
Advance Life Support (BLS and ACLS) are optional
• Units of masteral is also optional
The following are prescribed rotation during orientation;

New personnel;
• One month morning shift (7-3) at blue station
• One month morning shift (7-3) at red station
• Two weeks afternoon shift (3-11) at green station
• Two weeks night shift (11-7) at pink station
Clinical instructor -One day per ward for one week on 7-3 shift
Volunteer nurse – the same orientation as new personnel except for night duty.
VOLUNTEER NURSE POLICIES
1. All volunteers are under the supervision of a regular employee.

2. Carries out doctors order.
3. Gives medication : oral and parental and treatment.
4. Performs nursing procedures.
5. Does referral to physician.
6. All documentation done must be written and signed legibly and countersigned by the staff on duty.
7. May do the incominmg or outgoing endorsement of patient during the shift.
8. Admits and discharges patients.
9. May accompany patient for transfer to other hospital and or performance of diagnostic
procedures.
10. Assists physician in performing diagnostic or minor surgical procedures.
11. Volunteers may assigned or rotated in the special areas after (1) one month from ward
orientation.
12. Can never receive any verbal or telephone orders from the physician for patients treatment or medications.
13. Should always remember the 10 rights in giving the medications.
14. Maintain strict observance of medical and surgical asepsis.
15. Monthly schedule of duty is made by the supervisor (III), any requests must be addressed to the chief nurse. Off
days are on Saturdays, Sundays and Holidays.
16. Informs the Nursing Service Office atleast one day before if and when you will be absent.
17. Volunteers will only be accepted with a signed contract from the HRMO.
18. Must adhere to the hospitals’ rules and regulations.
19. Must report to duty on time or 15 minutes before the time.
20. Must be incomplete uniform.
21. Must be clean and neat in appearance.
22. Must submit their daily time record to NSO at the end of the month.
23. Volunteer nurse’s notes must be countersigned by the regular staff.
24. Certification will be given according to the number of days that the volun teer reported.
NURSING SERVICE POLICIES ON AFFILIATION AND TRAINING OF STUDENTS
GENERAL OBJECTIVE :
To assist in teaching – learning needs of students to render the best quality nursing care.
SPECIFIC OBJECTIVES :
1. To establish and maintain acceptable standards of nursing care to students :
a. well organized
b. comprehensive
c. safe and effective nursing care
2. To provide the students with related learning experience utilizing the existing resources
effectively.
3. To assist Clinical Instructors in the supervision for qualitative learning

HOSPITAL POLICIES ON AFFILIATING STUDENTS
A. STUDENTS
1. Students should always be under the supervision of their Clinical Instructor (CI).
2. Patient assignment given to students should be at their level of training.
3. All students with hospital related activities must be in their proper school uniform or smock gown and
nameplates.
4. For students assigned in OR/DR and Emergency Room:
a. They can only get a case and be signed by the staff on duty if they have actually assisted and performed
procedures from the pre-operative to post-operative care.
b. They must adhere to the areas standard policies and procedures in the maintenance of surgical asepsis.
c. Case distribution is 2 schools per patient.
d. Signing of cases must be within two after the date of the case. For cases not
signed within 2 weeks will only be signed by the staff if the student brings
with her/him a letter of consideration from the level coordinator.
5. Only 3 students from the level IV will be assigned in ICU under the supervision
of their Clinical Instructor.
6. Clinical Instructor (CI) and students ratio per shift :
a. Ward - 1 (CI) : 12 Students
b. OR - 1 (CI) : 8 Students
c. DR - 1 (CI) : 8 Students
d. ER - 1 (CI) : 8 Students
7. Inform the staff immediately for any unusualties in the patients vital signs,
physical and mental observations, new doctors orders and medicines received
from the patient / watcher.
8. Document pertinent data legibly.
9. No erasures on your charting.
10. Charts must be returned to the nurses station for final checking by the staff at:
a. 1 pm – 7-3 shift
b. 9 pm – 3-11 shift
c. 5 am – 11-7 shift
11. Charting must be signed legibly countersigned by your CI and the staff.
12. Health teaching and patients interaction are more important than sitting,
chatting and making nonsense noise in the hospital lobby or patients unit.
13. Keep patients unit clean and tidy.
14. Respect and courtesy towards the patients, hospital personnel and the general public.
• Direct to delivery room (DR) or patients in labor brought to DR must only be endorsed
• If and when an incident with regards to patient care and hospital policy has been committed, a written
incidental report has to be made by the student, noted by the CI and to be submitted to the Nurse I or
Senior Nurse within the shift.
• PAR Presentations:
• Write a letter of request addressed to the Chief Nurse that you are going to invite a nursing service
personnel for the presentation.
• Indicate the invitation the date, time, venue, topic and what the staffs’ role for the presentation.
• Invitation must be given atleast one week before the date so as to arrange the schedule of the
staff and be ready for the topic for discussion.
• Patients charts and data must only be taken with permission from the following:
1. Patient
2. Physician in charge
3. Medical Records Section
4. Staff Nurse on duty
18. Survey questioners and interviews must be approved by the Chief Nurse
and Chief of hospital.
B. CLINICAL INSTRUCTORS (CI)
1. No clinical instructor will be allowed to follow up students without undergoing preceptorship for one week in the
different areas:
a. Wards
b. OR/DR – with completion of hands on experience as:
Scrub Nurse - 3
Circulating Nurse - 3
Actual / Handled - 3
Cord Care - 3
Assisted - 3
c. Emergency Room / OPD
2. Preceptorship is scheduled once a month and a written request must be received by the office one week before
the scheduled date. Please confirm the scheduled date if you can still be accommodated.
3. CI’s must be in complete uniform when on duty.
4. Orient students on the hospital policies and procedures, the different wards, special areas and administrative
offices.
5. Give students patient assignment at their level of training and competency.
6. Students schedule of duty must be received by the nursing service office one week before the scheduled duty.
No students schedule, no duty.
7. Use of the Conference Room:
a. Inform the Nursing Service Office one (1) day before or before your shift will start if you intend to use it for pre
and post conferences.
b. Keep it clean and tidy.
c. Switch off light, ceiling fans and air conditioner before you leave the room.
8. CI’s are responsible for the patients chart assigned to students.
9. CI’s and students must be in 15 minutes before endorsement time.
10. Always maintain observance of medical and surgical asepsis.
ORIENTATION GUIDE
Activities
Day 1 -(morning) Prayer 8AM Nurse III
Pre-orientation Evaluation 8:05AM
Mission-Vision of SMC 8:20AM Hospital Director
Organizational Structure 8:30 AM Administrative Officer
Introduction of Department/
Division Heads 8:45AM Assistant Hospital Director
a) Medical Dept.
b) Administrative Dept.
c) Nursing Service
d) Ancillary Dept.
Organizational Structure 9AM Chief Nurse
Mission-Vision of Nursing Service
Hospital and Nursing Service Policy
and Procedures 9:10AM Asst.Chief Nurse/TrainingOfficer
a. Working Hours
b. Classification and Accommodation of patient
c. Routine Procedures;
Carrying out doctor's order
• Medications and treatments
• Referrals
• Laboratory and X-rays
d. Documentation and Charting
e. Different wards and special areas
f. Respect and Courtesy
g. Affiliation and trainings of students
- Lunch Break 12NN
(afternoon) - Demo-return demo on the basic hospital nursing procedures and equipments
1 PM Training Officer
- Hospital Tour 3:45 PM
- End of the day activity 4PM
EVALUATION OF PERFORMANCE
Evaluation of performance is a continuous process made through progress notes (anecdotal records,
observations etc.) in order to make the evaluation s objectively as possible. The performance of personnel is
evaluated on the basis of his/her actual achievement on his/her Performance Target. This is the Performance
Evaluation System which is primarily concerned with the output requirement of every employee. Emphasis lays a
constant supervisor and supervises interaction. At the end of the evaluation period (6 months) supervisor and
supervisee discuss the result of the targets he has previously set. If he has not reach his targets, the supervisor
assists the employee by training, coaching, counseling and reassignment, If he still fails to reach his targets after
various means of assistance, appropriate disciplinary action should be taken against him/her. On the other hand,
the employee who excels in his job or in his achievement of his target should be given recognition. If he cannot be
promoted, other forms of reward for his exemplary performance should be given. Performance targets should be
submitted every first week of July and first week of January. Evaluation of performance targets is also submitted on
the above dates.
Rules in rating (performance evaluation system)

Minimum number of months to be rated is 6 months, less than 6 months there will be no rating. We are allowed to
use ball pen on self-evaluation and supervisors.
• Ward Services
Staff
Nurse III – 5
Nurse II - 12
Nurse I – 32
Nursing Attendants and midwives – 43
A. Classification and Accommodation of in-patients
I. FLOOR 1
II. FLOOR 2
B. Philhealth and hospital accommodation

Reservation of rooms should be only for 24 hours period and must be arranged by admitting clerk.
1. Philhealth patients excess medication should be return at pharmacy upon discharged order of the
physician.
2. Personal electrical appliances such as t.v., refrigerator, d.v.d, c.d., and other appliances are subject to a
fee.
3. Philhealth patients and watchers/ significant others should be informend to process their Philhealth
papers/requirements at the Philhealth section during the first day of admission on office hours.
4. Philhealth Circular No. 46 and 52, series 1999.
5. PhilHealth Circular No.52, s.1999, Increase in Medicare benefit amounts under the National Health
Insurance program.
6.PhilHealth Circular No.69, s.1999, Amendment to Circular 46, s.1999.
C. Routine procedure for admitting patients
1. Usually patients pass by the consultation room, ER-OPD and Admitting Section. The ER nurses must
carry out all the STAT orders by the physician.
2. Consent for breastfeeding should be signed to all waiting case or laboring mothers.
3. Initial vital signs must be taken and recorded. All pediatric patients must be weighed on admission.
Admission slip to each patient should be filed up by the admitting clerk during office hours and ER staff after office
hour.
4. Admitting nurse’s notes should be started in the ER-OPD department. For pregnant cases, admitting
nurse’s notes should include the age of gestation, gravidity and parity. In cases of direct DR, execution of doctor’s
order must be carried out by the DR personnel.
5. For newborn delivered at home, cord dressing must be demonstrated to the parents or caregiver before
discharged.
6. All admitted patients should be entered in the 24 hours sheet with corresponding admission slip.
Admission slips should be completed on clinical case record and it will be sent to the medical records for encoding
at a computer file.
7. As soon as the patient is brought to the ward or room and made comfortable; be courteous and
introduce yourself.
8. Take all vital signs on admission, as well as the neurological vital signs if necessary.
9. Carry-out physician’s order, request the entire necessary laboratory and sent it to laboratory
department, start medicines and venoclysis as prescribed.
10. For surgical cases, specific consent should be signed on admission as patient is scheduled for surgery.
Check all pre-operative orders. An immediate or close relative should also sign as witness.
11. Orient the patient and his companions about the hospital policies, ward, routines, and physical set-up
facilities.
12. Render admission care if necessary.
13. Philhealth patients are referred to Philhealth section.
14. Admitting nurses’ notes for medico-legal patient case should add “as alleged or as claimed” after the
patient’s complaints.
15. Patient’s to be admitted after office hours must first be actually seen and examined by the physician-
on-duty.
16. Nurse in the ward should be informed by the ER staff of any admission so that necessary preparation
will be done before the patient’s arrives.
17. Charts of patients on admission should be arranged chronologically.
18. The patients directory must be up to date and be followed-up every shift. All wards should have
patient’s directory.
D. Doctor’s order
Doctor’s order is usually written on the patients chart by the physician ordering it. In instances when verbal
orders, telephone orders or copied orders are received by the nurse, they should be written as per verbal order,
telephone order or copied order and later on should be countersigned by the physician concerned.
1. Verbal order
All verbal and telephone orders should be countersigned by the physician concerned within the shift.
2. Noting doctor’s order
Doctor’s order carried out must be noted at the end-left side of the order with the following notation;
a. Noted by
b. Signature of the Nurse
c. Date and time it was noted
1. All shifts should check with physician’s order sheet whether orders for that day are correctly followed
by the previous shift to avoid mistakes.
2. Final rechecking of the physician’s order must be done by the 3-11 shifts.
E. Medications
administered Medications are only after a physician’s order. In giving medications,
one should never forget the 10 rights of giving medications;
1. Right drug
2. Right patient
3. Right route
4. Right dose
5. Right time
6. Right assessment
7. Right documentation
8. Client’s right to education
9. Right evaluation
10. Clients right to refuse
1. Any discontinued medication ticket must be discarded and unused medicines be given back to the patient or at
the pharmacy ( Philhealth patient)
2. Medications are the responsibility of the nurse and should be charted accurately after administration.
3. All medicines taken by the patient whether they are bought, given by social worker or extra meds must be
listed down in the medication sheet.
4. All venoclysis and blood transfusion should be checked often and recorded in the form provided for. Venoclysis
and blood transfusion maybe given by the nurse after being referred to the physician and that he or she takes the
responsibility whatever happens to the patient. In case of blood transfusion the serial number on the bottle or to
owners’ name should be checked with result given by the laboratory.
5. Bottle number and due time of every intravenous fluids or blood transfusions used, should be written in the
intravenous fluids sheet as well as the bottle.
6. All medications given whether OD, BID, TID, QID etc...Must be recorded in the medication sheet.
7. Extra medicines are not to be brought outside by any personnel; it must be referred to the Medical Social
Worker section if not taken home by the patients.
8. Medicine cards or ticket of suspended or hold medicines should be discarded immediately and cancelled at
once in the Kardex.
9. Color of medicine cards or ticket and their frequency;
a. Blue – OD = 6AM for oral medicines and 8AM for injectables
b. Orange – BID = 6AM and 6PM
c. Yellow – TID = 6AM, 12NN and 6PM
d. Green – QID = 6AM, 10AM , 2PM and 6PM
e. White – PRN ( as necessary) ,Stat (Immediately) , single dose (given once), every hour, two hours, 4
hours, 6 hours, 8 hours and 12 hours. Medication should be cut in rectangular shape, with room number, date the
medicines was carried out, name of patient, the medicine’s generic name ,dosage ,timing and route. Example;
Room Number Last name, first name of patient

Medicine’s generic name dosage ,timing and route
Date carried out
10. All medicines whether emergency drugs or not, should be started upon receiving such medicines. An
antibiotic can be an emergency drug in stab cases because infection may develop immediately and patients’ life
might be threatened. ATS injection maybe started in the morning unless specified as “stat “order.
F. Referrals
• Any referral should be done by the ward staff and never by the patient or accompanying person. An
accompanying person referring to the doctor will not be entertained, yet he or she will be advised to verbalize complaints
to the nurse in charge. Referrals during office hours should be directed to the physician on duty.
• Refer all venoclysis before it is almost consumed to the physician-in-charge or physician-on-duty for follow
• The nurse or nursing attendant referring a case must have knowledge of the patients’ complaints.
• While calling a physician on duty for an emergency case at E.R., simultaneous preparation of the patient
must also be done.
G. Laboratory
ROUTINE REQUESTS;
• All requests must be properly made, with the patients name, age, sex, ward location and type of
examination to be performed, name of the requesting physician, date requested, type of admission – Philhealth, charity or
service, and pay accommodation. It should be signed by the one carrying out the order.
• Duplicate requests should be avoided. If repeat exam is requested on the same day or the next day, the
word “repeat” must be written on the requests slip.
• Requests for examination for different sections of the laboratory must be placed in separate request slip to
facilitate easy processing in the laboratory. Example, chemistry, hematology, blood bank etc.
• Specimen for routine exam such as urine, stool, and sputum collected before breakfast will be picked up
by the laboratory aide before 8:00 A.M. After 8:00 Am., but not after 5:00 pm., all specimens for routine exam will be sent
to the laboratory.
• Requests for hematology, immunology, and serology will be processed on the same day if submitted
before 5:00 pm.
• Requests for blood chemistry should be submitted to the laboratory before 6:00A.M. All requests submitted
after 6:00 A.M. are carried out the next day. Preparation of patient is fasting or nothing per oral;
6 hours fasting – glucose, total cholesterol
12 hours fasting – lipid profile, triglycerides
Other routine and special blood chemistry such as SGOT, SGPT, Alkaline
phosphatase and other enzymes serology determination, electrolytes such as
sodium, potassium and BUN, creatinine are non-fasting preparation.
Blood Chemistry requests on Sundays and holidays are limited to Stat requests
only. Blood specimens are not taken later than 6:00A.M.
• All requests for laboratory exam collected or submitted to the laboratory are to be recorded in the
laboratory tracker book or incoming logbook provided in the laboratory.
• Results of all laboratory examinations released should be recorded in the tracker logbook for results or
outgoing logbook and signed by the authorized person to receive results in the ward.
• Confidentiality of all results should be strictly followed.
• Results of routine exam done in the morning should be sent to the respective nurses’ station before
12noon, in the afternoon shift before 4:00P.M.and 9:00 A.M. in night shift.
• Routine exam for our patients are accepted from 8:00A.M. To 5:00P.M.
• All laboratory requests or specimens for surgical patients should be requested or taken, and performed
before the patient is brought into the operating room.
• Surgical specimens for biopsy should be sent to the laboratory immediately for proper preservation. These
should be properly labeled with the patients’ name, age, sex, ward location, type of operation done, organ or tissue taken
or submitted for exam, and date of operation and name of requesting physician.
• Emergency requests
The results of these examinations are necessary for the immediate management of
seriously ill patients. They will be processed at anytime and are divided into two categories.
• STAT (very urgent)
Results of the examinations are necessary between 30 minutes to
one hour after the request has been received by the laboratory personnel. These type of
emergency examinations are requested for life-threatening situations. Without the result of
the laboratory examinations the management of the patient cannot be given even on clinical
basis and for seriously ill patients for immediate management. The STAT request is given
first priority over other type of requests. The results are handed in immediately after the
exam has been completed.
• URGENT / RUSH / NOW
These emergency examinations are requested for the immediate
management of patient that cannot wait for the result on the next working day. Requests are
processed at any time and are given priority over routine requests. Depending on the type
of examinations and number of urgent and STAT requests, the result of these type of
requests are available 2 hours after the requests has been received in the laboratory.
• ASAP (as soon as possible)
Requests of this type, considered that this is not classified on the
above- mentioned emergency category, results of this type of requests can wait for the next
working day. This is given priority over routine requests. Patients specimen for biopsy with
filled up laboratory requests will be sent laboratory by the ward staff.
H. Radiology department
• Patients for X-ray especially with special routine procedure must be referred to the X-ray Dept.
• All X-ray requests will be sent to the X-ray dept. after being ordered and received in the ward logbook.
• Accompany patient to the X-ray dept. for the procedure.
A. Procedures for X-ray Exam for both in-patient and outpatient.
1. Properly filled up requests for X-ray stating;

a. Name of patient
b. Section or ward
c .Chief Complaints
d. Brief history and physical exam. Findings
e. Signature of the requesting physician
2. Any requests not properly filled up will be returned to the respective ward or section.
3. Indicate emergency to give priority otherwise the radiograph will be taken and processed
routinely.
B. Scheduling of Special Radiographic Procedures

Scheduling of cases not requiring patients’ preparation and for
which requests are delivered to X-ray dept. during the specified time of regular hours will be
performed if schedule is not loaded.
Examination for which request is received in the dept. after
specified hours, will be scheduled the next regular day.
Examination of cases not requiring preparation for which
requests are delivered to the X-ray dept. during off hours will be automatically for the next
regular working day.
C. Scheduling of cases requiring patient preparation
1. Special radiographic procedures requiring preparation should be

arranged during working hours for definite schedule.
2. For examination of emergency cases requiring patient preparation,
if request is received before 8:00A.M.of the regular working days
and patients have adequate preparation, the requested exam will be
performed, unless a specific data or instructions is included on the
procedure.
3. For IVP exam 1ml IV test dose should be given in the ward and bserve reaction
an hour prior to the scheduled time.
4. Prepare sterile equipment required and bring patient to the X-rayroom.
5. Responsibility for the proper preparation of the patient rests with the nursing staff.
Unless the patient is properly prepared, examination can be possible.
D. Procedures for submission of X-ray results

• Original copy will be submitted to the corresponding ward indicated in the X-ray request form.
• X-ray results will be released in less than 24 hours.
• X-ray results at the OPD will be released within the less possible time, unless there is unavailable doctor in
radiology to read such procedures. In that case, the patient may borrow plates for outside reading.
E. Procedure for borrowing X-ray films or records

• Anyone who borrows film will be responsible and should sign out for it.
• Borrowed films should be returned as soon as possible and sign in for the return.
F. Sending patients to X-ray room for Any X-ray Exam
• Patients’ X-ray requests should be sent first to X-ray dept. for assessment of payments.
• Request with control number issued by the cashier should be sent to X-ray room for the schedule.
I. Diets of patients (dietary dept.)
• Diet list should be checked and necessary changes be done by the nurse after the doctors rounds in time
for the collection by the dietary personnel which is usually at 10:AM
• The night duty nurse who makes the diet list ( 2 copies for each ward or station) should check with the
order sheet to avoid mistakes.
• Every shift must check the diet list.
• Kitchen staff is responsible in updating the kitchens’ copy diet list.
• Food from outside must not be allowed or tolerated. Only those prescribed by the physician will be given to
the patients.
DIETARY DEPT. RULES and REGULATIONS

1. Meals will be served in the following schedule:
Breakfast - 6:30A.M. to 7:00A.M.
Lunch - 11:00A.M. to 11:30A.M.
Supper - 4:00 P.M. to 4:00P.M.
2. Diet list will be taken from the different ward stations before
6:00A.M. for breakfast; 11:00A.M. for lunch and 4:00P.P.M. for
supper and be checked according to ward and its patients’, before bringing it down for actual preparation. Diet trays
brought outside should be properly covered.
After meals, trays should be collected, washed, sterilized and dried.
J. Nursing Care Plan
• A nursing care plan of a patient is accomplished on admission by the
admitting nurse.
• New doctors’ order should be transferred to the Kardex right away and
medicine and treatment tickets be made immediately by the nurse in-
charge of the ward.
• Endorsement of patient is through the kardex and should always be
updated.
• Summary of nursing care should be accomplished by the nurse in-
charge before going off.
K.Daily nursing care plan

Ii. Daily Care Of Patients
Early morning care
• Provide means for elimination, cleaning articles used in the wards.
Cleaning and disinfecting bedpans, urinals, etc.
The Patients’ Bed
- Occupied Bed
• Modification to meet the patients’ needs.
• Nursing care before the doctors’ rounds
• Bedside Care – giving of bed bath especially to bedridden patients.
• Environmental cleanliness
• Health teachings to patients and watchers.
Evening Care
• Sponge bath or assist patient in bathing himself or herself.
• Perineal care of OB and Gyne patients is routine and given as often as necessary. For discharge I.E., all
OB patients must be advised to do perineal care.
Iii. Vital Signs
Vital signs must be accurately taken and recorded according to doctors’ order. Not recorded is not done.
Vital signs taken must be signed by the nursing attendant on duty.
a. TEMPERATURE may vary with time of the day

ADULT: Oral = 37 C is considered normal but may vary from 35.8
Celsius to 37.3 Celsius.
Rectal = higher than oral by 0.4 Celsius to 0.5 Celsius
CHILDREN: Oral = 36 Celsius - 37.4 Celsius
Rectal = 36.2 Celsius - 37.8 Celsius
Axilary = 35.9 Celsius - 36.7 Celsius
b. PULSE
Normal adult pulse is 60 - 80 beats/min., regular in rhythm.
Elasticity of the arterial walls, blood volume and mechanical action of the heart muscles
are some of the factors that affect strength of the pulse wave, which is normally full and strong.
CHILDREN
AGE PULSE
Newborn - 70-170 beats/min.
11 months - 80-160 beats/min.
2 years - 80-130 beats/min.
c. RESPIRATION
Adult = normally 6 - 20 respirations/min.
Children:
Newborn - 30-50
11 months - 26-40
2 years - 20-30
4 years - 20-30
6 years - 20-26
8 years - 18-24
10 years - 18-24
Adolescence - 12-20 resp. /min.
d. BLOOD PRESSURE
Normal Range
Systolic = 95 – 140 mmHg *a difference of 5-10 mmHg between
arms are common.
Diastolic = 60-90 mmHg * going firm a recumbent to a standing
position can cause the systolic pressure to fall 10-15 mmHg and the diastolic
BMR (Basal Metabolic Rate)
Formula = Systolic minus Diastolic + Pulse Rate – 111 = BMR
Iiii.TREATMENTS
All patients receiving special treatments such as perilight exposure, nebulization,

application of alternate hot and cold compress, and hot sitz bath, should not be left
alone until the procedure is done.
Iiv. SPECIAL PROCEDURES
Patients for thoracentesis, paracentesis, NGT insertion, enema and HRT insertion should be properly instructed,
informed and prepared. Patients consent should be obtained before a special procedure is done.
Iv. INTAKE AND OUTPUT
1) Intake and output should be recorded in figure.

2) The night shift should total the intake and output of each patient.
3) I and O should not be discontinued unless ordered.
L. Preparation of patients scheduled for surgery

• Consent slip for operation.
• Of legal age patients should sign for themselves.
• For marital consent, both the husband and wife should affix their signature. Signature of a witness is also
necessary.
• Any patient below 21 years old cannot sign a consent slip.
• For D and C cases, the patient and a witness should sign the “release from responsibility for abortion”
form.
• Check with pre-operative routine procedure book (each station has a copy). There is a routine pre-
operative procedure for patients going to surgery, but the pre-operative medicines should be ordered.
• The 11-7 shift usually does the urethral catheterization to patient scheduled for operation, if ordered.
• Shaving of all female patients scheduled for operation is done by OR midwife and male patients by OR
male utility workers.
• Patients for surgery are recorded in the OR logbook before the day or time of operation. OR staff is
notified verbally.
• The ward nurse should notify the on duty OR nurse after the SOD or POD orders.
• Pre-operative B.P. is taken by the night shift before sending to OR.
• Laboratory results should be attached to the chart.
• Patients’ should be inspected by the nurse, and pre-operative checklist must be signed by the ward nurse
before sending the patient to surgery.
• Pre-operative patients’ gown must be worn by patient before sending them to OR.
• Pre-operative orders will be automatically discontinued after the operation unless ordered.
M. Dressing of surgical in-patients
• Surgeon in charge should be the only one to dress his patients’ wound unless properly endorsed to
another surgeon.
• Should the surgeon in charge needs assistance in dressing patients wounds, he can avail the services of
the ward nurse. Never the OR nurse, unless dressing will be done at the OR.
• Surgeon in charge should requests the materials and the ward nurse will get it from the CSR.
N. Communicable isolation technique

For Isolation Cases
• Basins for hand solution just outside the patients’ room should be changed as often as necessary. Lysol
solution 1:1000 is usually used.
• Isolation gown and mask must hang just outside the room.
• Syringes, needles used for contagious cases should be separated and soaked in Lysol solution for 24
hours only, which they should be cleaned and returned to the CSR.
• Visitors are limited.
O. Clergy services
• The nurse should be ready to assist in getting the clergy if the patient or family asks her help.
• The patient approaching death may or may not wish to see a religious counselor.
• Every effort should be made to get a clergy while the patient is conscious. If at all possible the nurse
should be familiar with the patients’ beliefs’ and wishes, which are respected and, every effort is made to meet them.
P. Deceases patients
Deceased patients’ are always pronounced dead by the physician. Special religious customs should never be
neglected. It is better to ask and be sure than to hesitate and neglect something, which is of real spiritual concern
to the patient or his family. The postmortem care is rendered. The deceased patient is transferred out from his bed,
not later than 10 minutes. Cadaver should not be endorsed to the next shift.
Q. DOA or dead on arrival
All DOA cases must be recorded in the OPD cards and record as well the emergency treatment given. Accounts
are settled by the relatives or if indigent or without relatives, he is referred to the hospitals’ Medical Social Worker.
Signing of death certificate, by the physician is a legal requirement and is necessary for burial preparations.
R. Disturbed patients
Disturbed patients are isolated and under the care of a psychiatrists or psychologist.
S. Patient transfer
>Transfer from a charity ward to a pay ward or room is considered pay from the time he was admitted to the
hospital after being referred to the administrative officer or after proper arrangement.
>Transfer from pay to charity: he is considered a charity case after settling accounts as a pay patient.
>Transfer to another hospital is first ordered by a physician who is after being requested by the patient. Accounts
are first settled with the administrative office before he is conducted by the ambulance to the hospital of his choice
or his families.
CHARTING AND RECORDING

Nurses Notes:
A. All charting must be written legibly.

B. Clinical case data must be filled up properly by the admitting section, nurse or nursing attendant. Maiden name
refers to married women only.
C. Nurses’ notes start from the morning shift and ends at 7:00 AM. , end of the night shift by drawing a line, instead
just sign her signature at the space provided. Only the nurse of night shift closes the 24 hours by drawing the two
red horizontal lines.
1.) Morning shift (7-3) uses the blue ink in charting.

2.) Afternoon shift (3-11) uses the black ink.
3.) Night shift (11-7) uses the red ink.
4.) In terminating intravenous fluid write the time and words “absorbed” and “discontinued”. If intravenous are
to be continued, chart as follows;
Bottle # + Types of solution + Amount of solution + Time followed + the word “added”
*A consensus imposed last February, 2006 nurses may chart directly at the venoclysis sheet upon starting,
receiving and discontinuing the intravenous solution. The following is an example;
DATE : SHIFT : Bottle no.: IV SOL’N: TIME STARTED:TIME ENDED:SIGN:REMARKS

2-8-06 : 3-11 : 1 : D5LR 1L : 3:30 P.M. : :J.Pogoy: started
: 11-7 : : 600cc : : :J.Galing: received
D. The space provided for the time in the nurses’ notes will be used for the time medicine or treatments were given.
The shift should be written in the middle of the page.
E. Observations about in-patients condition should be accurately charted or recorded.
F. If one shift fails to chart, please leave a space and endorse.
G. If there is a mistake in charting, draw a straight line over the word or sentence, and write “error” with your initial.
H. Never use abbreviations which cannot be understood and are not universally accepted.
I. Nurses should check the physician’s orders and medication sheet before charting in the nurses’ notes.
J. Make it a habit to write the patients’ name on every page of the chart.
K.13 Rules of charting to keep it legally safe (Appendix A).
L. Nurses notes should leave at least 1 inch space above and below each page.
M. Oxygen consumption must be updated every shift.
N. IVF follow up must be referred to the physician on duty.
PATIENT SUMARY SHEET
A. Temperature and respiration are recorded in blue pen and pulse rate in red pen, respectively.
B. The vertical lines indicate a 24 hours shift and divided into A.M.2-6-10-blue, and in P.M.-2-6-10-red. Upon
admission, encircle the normal TPR, put a dot on the patients’ TPR and draw a connecting line on the normal TPR.
On that space write down the word “admission” vertically.
C. There are 2 spaces provided for the urine and stool separated by dotted line. Fill the first space if the patient is
admitted at 2:00 P.M. and 10:00 P.M.
D. Indicate a “red star” on the day of the operation. First day of post-operative day starts a day after patient was
operated. Intake and output should be recorded in the space provided.
E. BP every day, TID, BID, QID, Every 4 hours should be recorded in three shifts.
F. If there is an order on pulse rate, please take it for one full minute and record it correctly. Nurses should also
check the TPR record before closing the chart.
ENDORSEMENT OF PATIENTS IN THE WARDS
1. The ward should not be endorsed by the outgoing nurse and nursing attendant nor should the incoming shift
accept until all the patients and everything pertaining to the respective wards are checked properly.
2. All patients must be advised to stay in their bed before the time of endorsement of the ward to facilitate the
proper endorsement.
3. Admission slips should be checked every shift.
4. Reading of the Nurses’ report by the outgoing staff and rounds of the incoming and outgoing shifts.
5. Endorsement of pre-operative medications shall be done after the endorsement.
6. Endorsement of patients and wards shall be done every shift before going off duty. Outgoing shift must not leave
the ward unless receives by the incoming shift.
7. Checking of equipment in every shift should be done strictly. Anyone who breaks a syringe should replace it as
soon as possible.
8. There should be proper endorsement of ER patients to ward nurses.
9. All medicines and IV fluids received should be recorded accurately, and endorsed actually to the next shift and
should there be any less, replacement should be done by the one responsible for it.
PROCEDURES FOR DISCHARGING A PATIENT
• Discharge of the patient should be ordered by the physician on the chart.

• No discharges on Sundays and Holidays. Billing should be done the day before. Payments may be
received by the pharmacist on holidays and Sundays but, should be properly recorded on chart for the one who
receives the payments. Such payments will be endorsed by the pharmacist to the cashier the following day.
• In case the companion wishes to take the patient Home against Medical Advice, a release paper must be
signed by them and witnessed by a relative.
• In Home per Request, the patient signs below the physicians’ order.
• All charts of going home patients are brought by the nursing attendant and processed for clearance from
the pharmacy, laboratory, x-ray dept. then forwarded to billing section. The clerk will bring all the charts to the wards.
• Payments are made in the Cashiers Office by the patients or watchers bringing along with them the
duplicate copy of the hospital bill. After paying the hospital bill, receipt of payment will be returned by the patient to the
ward nurse.
• The nurse in charge must give the necessary instructions about nursing procedures which might be
followed at home.
• Chart must be completed and arranged accordingly. As follows;
-Clinical case record

- Form 3 (Philhealth Member)
- Consent to care
- Breastfeeding consent
- TPR sheet
- Vital signs, FHB monitoring sheet
- Neuro vital signs
- Oxygen consumption sheet
- Intake and output monitoring sheet
- Medication Sheet
- Venoclysis sheet
- Specific consent
- Surgical Memo
- Anesthesia record
- Admission history
- Discharge summary
- Doctors order
- Nurses notes
- Laboratory results
- List of medications
• All medicare patients are to be reported to the medicare clerk on admission and upon discharges. They
are to be discharged only upon completion of papers. Pay patients are also to be recorded to the cashier for payments.
• All OB patients must have an IE note from the OB physician prior to discharge. The IE discharge note will
be attached in the physicians’ order sheet.
• The Nursing Attendant checks the linens, etc. borrowed by the patient as listed in his chart. Any less will
charged to the Nursing Attendant or Nurse on duty when the patient was discharged.
• All absconded patients must be discharged within 8 hours.
• For communicable cases, the room is immediately fumigated and labeled as such.
• Medico-legal cases should always be referred to the admitting physician before discharge.
• Expired patients must be transferred out to the morgue.
• Upon discharged of patient, patients’ unit or room must be immediately cleaned, ready for admission.
• All post op meds should be referred to physician in charge.
WARD SERVICES
Surgical ward
What Is -Surgical Nursing?
Individuals trained in the field of surgical nursing provide care to patients before, during and after surgical
procedures. Surgical nurses work as members of a surgical team that includes anesthesiologists, doctors and
technicians. If you'd like to join the medical-surgical nursing field, you need to develop multiple skills and have the
ability to work long hours.
Before Surgery (preoperative)

Surgical nurses prepare patients for their impending surgeries. They explain the surgical procedure to the patient
and answer any questions he may have about the surgery and recovery. Before heading into surgery, surgical
nurses monitor the patient's vital signs and perform any preoperative tests.
Surgery (intra-operative)
Nurses in the surgical nursing field often accompany patients into the operating room and assist during surgery.
While surgeons perform the operation, medical-surgical nurses monitor the patient's vital signs and pass surgical
instruments to the doctor.
After Surgery(post-operative)
Surgical nursing forms a critical part of post-surgical care. These nurses monitor patients continuously to ensure
that the recovery goes as scheduled. Medical-surgical nurses observe patients around the clock to stay abreast
of any complications or infections after surgery. Nurses also administer necessary medications and update
families and friends on a patient's condition.
Medical Ward
Medical Nurse
An medical nurse is responsible for the diagnosis and treatment of a patient in consultation with a doctor. The
medical specialty of internal medicine focuses on diagnosis and management of non-surgical, internal physical
ailments. The most competitive job applicants will be those holding a four-year nursing degree, and a registered
nurse.
Professional Responsibilities
A medical nurse is responsible for meeting with patients, performing comprehensive assessments, diagnosing
clinical ailments, designing a treatment plan and consulting with a doctor, when necessary. Another primary
responsibility lies in patient health education. A large part of the medical nurse's job function requires the
education of preventive care and the importance of a treatment plan.
Pediatric Ward
Pediatrics nurse
The pediatric nurse cares for patients from infancy through adolescence. She is a compassionate medical
professional who works in the pediatric intensive care unit or pediatric ward with other nurses, specialists and
pediatricians. It is her duty to administer the best care possible to the young patient. The pediatric nurse shares her
expertise with the patient's family many times a day and advocates for her patient.
Providing Care
• Pediatric nurses are "advanced nurses who treat all ages of children, from infancy to young adulthood,"
according to Nursing Online. Nurses often specialize in pediatrics because of a love for children and a desire to give the
best hands-on care possible. The pediatric nurse understands what children need. She knows that a child's body may
respond differently to an illness or disease than an adult's and require specialized care.
Sharing Information With Doctors
• The nurse communicates with doctors on a regular basis. She takes her orders, whether verbal or written,
from the doctor. Once the orders are followed, she keeps the doctor informed on the patient's response to medications
and procedures. If medical adjustments are required, the doctor examines the patient and discusses further treatment
with the nurse.
Communicating With Parents
• Nurses gives current updates to parents about medical procedures and the child's current condition. The
nurse often relays messages from the doctor to the parents when the doctor is not able to immediately meet with
parents. She may answer parents' questions and help locate resources the parent may need, such as the hospital social
worker.
Ease Patients' Fears
• Because the pediatric nurse works with young patients, she may have to ease a patient's nervousness
and fear of hospital procedures. With young patients, the nurse may cuddle the young child to soothe him or use
puppets to calm the child, making the hospital seem less intimidating. It may help to talk to an older child or find other
children within the pediatric ward for him to talk with.
OB-GYN Ward
OB-GYN nurse
OB-GYN stands for Obstetricians and Gynecology. OB-GYN nurses specialize in treating and preventing conditions
that affect the female anatomy. Experienced OB-GYN nurses are experts in issues concerning childbirth.
Support Functions
• OB-GYN Nurses support the physicians they work for by taking patient's medical histories and helping to
educate patients regarding sexually transmitted diseases, birth control and pre-natal care.
Clinical Functions
• OB-GYN nurses take samples and specimens, assist with gynecological exams and delivering babies.
OB-GYN nurses occasionally deliver babies on their own when the child arrives before the attending physician is able to
reach the hospital.
Considerations
• OB-GYN nurses must be willing to advocate all family planning options and participate in any related
procedures, regardless of their own personal beliefs.
Routine Care of the Newborns:
Babies delivered in our hospital and outside whose mothers are confined for post partum complications are
admitted for nursing care
All babies in this hospital should be given breast milk only unless medically contraindicated.
• No prelatic feedings to newborns.
• Explain to mothers that giving prelatic will interfere with breastfeeding, decreases eagerness to
breastfeeding, produce allergy and sense of inadequacy on the mother.
• Colostrums should be given to all newborn babies. Colostrums contains anti-bodies thus prevents
childhood diseases, like diarrhea and respiratory distress.
• All babies delivered by caesarian section without complications shall be breastfed within 4 to 6 hours.
Hospital staff should help attach the baby to the mother.
• All babies should be roomed-in within 24 hours after birth.
-Teach mother the importance of rooming-in, to facilitate mother and child bonding.
- Permits breastfeeding on demand.
- Allows for closer contact with the father and other members of the family.
• All mothers should be assisted to start breastfeeding immediately and should be taught the proper
breastfeeding methods.
- Demonstrate proper technique on manual breast milk expression.
• All mothers should be encouraged to breastfeed on demand.
- To help mothers produce more milk and prevent breast engorgement.
• Infant formula feeding bottles, pacifiers should not be stacked within the hospital premises.
(OR, DR, Ward, Pharmacy and Canteen)
- Discourage artificial feeding to the baby.
- Nipple confusion should be avoided.
• Mothers during their prenatal check up at OPD are required to attend breastfeeding lecture.
• Mothers will not be discharged if there is no milk flow.
• Mothers with no consent to breastfeed their babies will not admitted in this hospital.
• All names of mothers when discharged from the hospital will be forwarded to the City Health Office (CHO
for follow up of breastfeeding).Ask help from other agencies as support group for follow-up in the field such as;
- CHO staff (PRN or PH midwife)
- Barangay Health Workers
- Hilots
-NGO
- Family Planning Group
c. Care of Full Term Newborn
1.) Oxygen inhalation – PRN
2.) Suction PRN
3.) Watch for signs of respiratory distress.
4.) Care of the skin-newborn babies are given a daily sponge bath using warm water and any suitable
mild soap. When the cord is off, babies are given warm water bathe in a basin.
5.) Care of the umbilical stump = Antiseptic such as 70% alcohol is poured over the stump 2 or 3 times a
day.
6.) TPR should be taken every 4 hours. Temperature is taken per rectum for 3 minutes. Newborn with
fever should be referred at once to the POD or attending physician.
7.) Notify physician of any abnormalities.
d. Care of the Premature Newborn
1. Care immediately following delivery;

a.) When the birth of a low birth weight-infant is anticipated, the DR personnel should alert the NICU
as preparation can be made and the pediatrician can be summoned to be present at his birth.
b.) They should be put on critical list and R.O.D. should inform either or both the parents about this
condition.
c.) Detailed physical examination on admission of small premature should be done.
d.) Even the smallest infant should be placed with head low after delivery to promote postural
drainage of materials from the oro- pharynx except when definite contraindications exist. Immediately after birth,
mouth and throat should be aspirated gently. Resuscitation, Apgar and Millers scoring should be done, notify NICU
staff.
e.) Skin care on premature are given only dry bathe, using hypoallergenic soap and lukewarm water.
f.) Eye care and umbilical cord care is same as normal term babies.
g.) Vitamin K – premature receives a dose of 0.5 mg.
h.) Oxygen therapy;
1.) Premature born before 34 weeks gestation and weighing less than 3 lbs. may require
oxygen inhalation.
2.) Because of the increase risk of retrolental fibroplasias, the minimum required should be
administered.
3.) If the condition of the infant improves, oxygen concentration should be lowered, carefully in
small decrement until it could be discontinued.
Feeding – unless otherwise specified by the pediatrician, premature weighing over 4 pounds maybe fed as a
normal full term.
2. ROUTINE PREMATURE CARE;

A.) Isolate
B.) Terramycin ophthalmic to both eyes.
C.) Oxygen with moderate humidity.
D.) Temperature every 4 hours till stable.
E.) CR and PR every 30 minutes for first four hours, then every hour for 24 hours until stable.
F.) Suction gently PRN.
G.) Observe for respiratory distress.
H.) Notify physician for any abnormality.
I.) Keeping low birth babies warm by;
1. Letting the small baby sleep with her mother wrapped in the same blanket.
• Keeping the baby warm in the crib under a drop light if the mother is weak.
OPERATING ROOM AND DELIVERY SERVICES
Policies and Routines

1. Operating Room and Premises
a.) Nobody is allowed to enter the said operating room premises not unless they are in proper uniform (with
cap and mask, scrub suit and slippers).
b.) Street clothes overlapped with scrub suit is not allowed inside the operating room.
c.) Rubber slippers must be used inside the OR.
d.) No one is allowed to smoke in the operating room “clean area”
2. Schedule of operation –Everyday
- Emergency cases – anytime
- Departmental schedule of elective surgeries.
MWF - General Surgery
TTH - OB-Gyne
Wed. - EENT
- Saturday, Sunday and Holidays – No elective surgeries.
- All schedules of operation should be placed on a blackboard (OR, Green and Red Station) with the name
of patient, procedure, surgeon, assistant surgeon, type of anesthesia and anesthesiologist.
3. For scheduled surgeries, if materials are available the night before or early morning of surgery day, cutting
time for the first case will be 8:30 am. Surgeons and anesthesiologists will be notified by the ward staff as to
availability of patient materials.
- If ever there is simultaneous schedule of elective surgery. The first case will be the department scheduled
for the day.
- Emergency surgeries are priority schedule.
- If there is more than one case scheduled for the day, two or more cases will be done simultaneously on a
case to case basis that is depending upon the availability of the staff and anesthesiologists.
- No surgical cases, elective and otherwise will be operated until it is properly referred to the surgeon on duty
and OR department head. No surgery will be performed without an assistant, properly evaluated and approved by
the SOD or Head of the Department or by the Chief of the hospital. In extreme cases wherein the life of the patient
is in danger, the POD will use his discretion and apply emergency but will likewise refer the same.
- Shaving, urethral catheterization should be done at ward.
4. Pre-operative Preparation of patient for surgery
1.) Scheduled cases
- Shaving of female patient is done by the OR midwife, and male patient by the OR utility worker.
Shaving should be done by 3-11 shifts before bedtime.
- Vital signs is taken by 11-7 shift ward staff, before transport of patient to the OR.
- All patients schedule for surgery should be posted in the OR schedule logbook as soon as the doctors
order is made.
- Consent slip should be signed before any patient is brought to the OR, the ward staff should have the
consent signed. No procedure can be done without the patients’ written consent.
- Operation scheduled after 4:00 pm, Nurse II on 16 hours duty should be notified personally.
2.) Emergency Cases
- Preparation; shaving and catheterization included is done by the OR staff.
5. All surgical cases, their charts should be complete with history, P.E., laboratory exams, differential diagnosis
and impression within 24 hours.
6. 16 – Hours’ duty for emergency operation and deliveries.
- Nurse II, midwives, UW may have a 16 hours duty, and are to answer call on all emergency surgical
cases and deliveries brought to the hospital after office hours, in case of insurgency of staff. Their off duties will be
scheduled by the head of department later.
-Nurse III in the OR should check all patients scheduled for surgery if midwife or U.W. has done the
shaving and other preparations.
- Patient at labor room should be attended by the DR staff including documentation.
- In cases on pregnant patient that will be evaluated at DR, and the physician will decide that the patient will
undergo CS, the OR – DR staff will carry order.
- Transporting of patients for surgery, from the ward to OR, OR U.W. must be the one to get the patients for
surgery from the ward.
- The first assistant should not leave the surgeon until after the closure of peritoneum. For complete sponge
count, surgeon, assistant surgeon and anesthesiologists should also be made to sign in the sponge count book.
- Intravenous fluid insertion should be done by the ward nurse before bringing the patient to the operating
room. If the ward nurse is busy, insertion of IVF will be done in OR. The needle to be used must be intravascular
cannula gauge 18 and the site will be inserted is preferably at the anterior forearm and dorsal area.
- All pre-op medications and IVF will be prescribed by the anesthesiologist.
- The strict implementation of aseptic technique includes gowning of patients before transporting to the
operating room.
- The OR utility worker must be the one to get the patient for surgery from the ward 10 minutes before
scheduled time.
- OR utility worker is scheduled by the OR department head.
- Scheduling of OR cases depends on priority cases. Dirty cases will follow.
- Recording of surgeries, deliveries, etc.
a.) OR record book for major and minor operations.
b.) Surgical memorandum must be properly filled up and signed by the surgeon and anesthesiologist
(responsibility of the circulating nurse) after surgery.
c.) All procedures and treatments done in the DR must be recorded in a separate book.
d.) Filling up of Obstetrical Forms should be done by Nurse II in OR-DR services.

e.) All emergency drugs should always be on hand and be replaced after use.
f.) A copy of the Nursing Service Manual for the OR-DR available at all times (included – are also
hospital policies for the OR- DR.).
SUPPLIES AND EQUIPMENTS
• Requisitions direct to the property clerk by the Nurse III or Nurse II in the absence of the former.
• Inventory of supplies and equipments must be done on a monthly basis.
• Making of supplies like cotton balls, OS or gauze, vaginal or uterine packs.
• Medicines, catguts, local anesthesia, etc. are to be prescribed.
• Packing of linens, instruments, and gloves – ready for sterilization.
• DR oxygen tank with oxygen gauge will only be given to the ward in case of emergency, but with the
approval of the physician on duty.
PATIENT ON LABOR
1. The nurse ascertains;

Frequency of contraction
Duration of intensity
Whether the patient had previous labor pains
2. TPR, BP, FHB must be taken and recorded.
3. The nurse explains unfamiliar procedures and should be sure the patient understands the reasons before
she proceeds.
4. The nurse observes the patient closely and reports to the physicians any untoward symptoms.
a. Patient with FHB of above 160 or below 120, oxygen must be administered.
b. Place patient at left lateral position.
5. At the start of labor, the patient looks to the nurse for guidance and will cooperate well
if told what to except and what progress is being made. It is a great satisfaction to the
patient to know that she will never be left alone.
6. After all, patient must be monitored at ward for any possible bleeding. Ice compress
should be applies on post partum & CS.
7. Episiotomy wound / laceration must be sutured by the physician, midwife and nurse are
not allowed to do the suturing.
PREPARATION IN THE DELIVERY ROOM
• Vulva is shaved then washed with soap and water.

• The nurse and or the midwife should make every effort to have the patient void
frequently so that, urinary bladder will not be distended.
• The nurse should assist the physician during the delivery and in giving anesthesia.
• Prepare instruments for delivery.
• Washes vulva and does skin preparation.
• Patient is draped for delivery.
• Injection and IV fluids are given as ordered.
• The nurse or midwife should assist the physician in complicated deliveries like manual extraction of the
placenta, D and C.
• After delivery, vulva is cleaned diaper is applied before transporting in her room and is
endorsed properly.
IMMEDIATE CARE OF THE NEWBORN IN THE DELIVERY ROOM

• Must adhere to four essential of newborn.
The following are four essentials of newborn:
a. Immediate and thorough drying of the newborn
b. Early skin-to-skin contact between mother and newborn
c. Properly-timed cord clamping and cutting
d. Non-separation of newborn from mother for early breastfeeding
2. Suction nose, mouth and throat secretions in the trendelenberg position except premature newborns (horizontal
position).
3. Spread vernix caseosa by using sterile water.
4. Cord dressing – umbilical cord is clamped with forceps, then cord clamp.
5. All babies should receive Vitamin K 1 mg. IM at left buttocks, hepa-b vaccine 0.5 ml IM given at right buttocks,
and erythromycin ophthalmic ointment applied on both eyes.
6. Height and weight are taken and recorded.
7. Identification- each baby receives a bracelet containing the baby’s’ name. Footprints are also placed in the
baby’s’ record and it should be duplicated for philhealth requirement.
8. Admission Chart is made.
9. All newborns must be seen and examined by the pediatrician.
RECOVERY ROOM OR POST ANESTHETIC CARE UNIT
Purpose: To assist the patient in returning to a safe physiological level after an anesthesia, apply physiologic and
psychosocial knowledge., principles of asepsis and technical knowledge and skills necessary to promote, restore
and maintain the patients physiologic processes in a safe, comfortable and effective environment.
Specific Objectives:
• To be able to afford maximal care for patients immediately following an operation.
• To be able to meet a need for constant observation of patients at trained personnel’s until recovery from
anesthesia is stabilized sufficiency for safe transfer to patients’ room.
Policies:
• The RR is under the supervision of an anesthesiologist in coordination with a nursing supervisor (or a
Nurse II assigned to the RR) to directly supervise the activities in the area.
• Staffed by specially trained registered nurses and other nursing personnel.
• Evaluate patients continually by appropriate monitoring methods and frequent observations.
• Evaluate patients’ status by listening, watching and feeling augmented by electronic monitoring devices.
• Monitor particularly oxygenation, ventilation and circulation.
• Observe respiratory and circulatory functions and level of consciousness at frequent intervals.
• Patients’ remain in the unit they have reacted from anesthesia and their vital signs have stabilized.
• If ever there will be 2 patients inside the unit, they should be separated by screens or curtains.
• Hand washing is essential after each patient contact to prevent cross contamination.
• The anesthesiologists and medical staff must approve discharge criteria for RR nurse to determine
readiness for discharge.
• OR-DR staff must endorsed post op patient to ward including materials unused.
OUTPATIENT DEPT. and EMERGENCY ROOM SERVICES

Staff:
1 - Nurse III - 1
2 - Nurse II - 3
3 - Nurse I - 3 (2 contractual)
4 - Clerk I
5 - N.A. – 1
6 - Dental N.A. – 1
7 – Utility worker – 1
What is an emergency room?
It is a special unit where a patient is brought for treatment instituted as a means to save life.
What is an Out-Patient Department?
A hospital department where patients receive diagnosis, medical advise and or but do not stay overnight.
Emergency Room
I. Policies and Routines:
• Never leave the area unattended
• E.R. Must be kept and ready for use
• Defibrillator. ECG, suction machine, oxygen tank with gauge and other life-saving apparatus and
equipments must be ready at all times and must be inspected every shift if functioning.
• Assessment of CAB(ABC) of patient is very important.(Triage )
• Emergency drugs must be checked properly and used drugs must be replaced at once. List of E.R. Drugs
for replacements must be attached to patient's chart and must be followed-up for immediate substitution.
• If busy, the E.R. Staff may ask for assistance from the ward nurses for medical cases and O.R. Nurse on
duty for the surgical or ob-gyne cases. The ward supervisor could also be asked for assistance.
• Record all patients who are transferred to other hospital and D.O.A.'s (dead on arrival) as well.
If no vacancy;
a. Patient with referral note
-Take vital signs
-Inform the POD
- if possible, let the watchers sign the logbook/OPD card for transferred patients
b. Only the POD's can evaluate the patient's condition if it can still be transferred or not.
c. Walk-in patients
-Take vital signs and fill-out an OPD cardiopulmonary
- Inform the POD
- Give the STAT order
- Record in logbook with patient's/watcher signature
d. DOA (dead on arrival)
- If patient came in as DOA – death certificate will be issued at the CHO
-If it is an ER death – death certificate will be issued by the hospital
e. Keep list of all patients who come in the E.R. 24 hours a day.
f. Personal belongings should be deposited at the security guard station
g. Work flow is posted outside the unit to guide clients where they go.
h. Incidental reports must be written in the logbook and in an incidental report form provided for legal purposes. It must
have a duplicate copy.
I. Inform NSO from time to time with regards to incidents related to ER-OPD activities
j. Oxygen gauge availability and ward census should be checked by the ward nurse after rounds, and should be
submitted to E.R. Staff every shift. On the the other hand, E.R. Staff can also inquire from the ward nurse every
shift for updates on census. The last information on the availability of oxygen gauge inquires should be on the
supervisor or acting supervisor
k. Routine for Admission
1.) All patients for admission, emergency or non-emergency cases must go to the E.R. And must be recorded in
the admission Record Book provided.
2.) Patient's data and vital signs must be written correctly and legibly. Let the patient/watcher go to the admitting
section for interview.
3.) The admitting clerk should fill out the admission slip and chart.
4.) Consent to care and treatment must be signed by the patient or watcher.
5.) Physicians must be informed at once.
6.) Carry-out doctor's order – IVF and stat orders must be started at E.R.
7.) Complete blood count ad other stat laboratory exam must be requested immediately.
8.) Admission for OB patients;
a. Record patient's vital signs – BP, weight , temperature and FHB
b. Gravida and Parity, LMP and EDC
c. Note the internal exam findings of the physician in the nurses notes
d. OB physician will do the IE and final FHT taking before sending patient to D.R.
9.) Home and E.R. Deliveries
a. Cord dressing and routine newborn care must be done in the E.R.
b. For E.R. Deliveries – summary of parturition must be filed-up by ER staff
10.) Stat x ray will be performed to those patients who are restless and alone. He must be stabilized first in the
ward, there after x ray can be done.
l. Minor Surgery Routines
- Referral must be done by the doctor's concerned
1) All minor surgeries must be recorded in the ER surgical logbook.
2) Secure consent prior to operation procedures. For minor patients, parents or guardian must sign the consent for
surgical operation. For those patients who has no accompanying – anybody from the ER staff can sign the consent.
3) Philhealth patient must have a duplicate copy of the surgical memo.
4) Make sure that before the procedure, the patient should be properly prepared, as well as the instruments to be
used.
Provide INDEX box for updated SOP's of doctor/physician.
m. Transporting of Patient
1) Place patient in a stretcher or wheelchair and provide privacy
2) See to it that all linens are in place
3) Secure the patient with side rails
4)Endorse special treatments and procedures done at ER, latest vital signs
5) Reassure the patient
n. Student Affiliation
1) Affiliating students must be endorsed by their respective clinical instructors
2) They should wear proper uniform for their respective areas
3) They should be well informed of the policies and routines of the hospital
4) A clinical instructor should be present to follow up their students
5) Affiliating students whose cases have not been signed by the ER staff after two weeks, a letter of request must
be obtained from their C.I.
o. Code Blue Protocol -
1) All adult patient admitted at the ER with unstable vital signs should be attached to a cardiac monitor.
2) A triage officer will inform the IM resident within 30 mins. upon the arrival of the patient, in a case the IM
resident cannot attend the patient, other resident of the different department will be informed.
3) All physician and nurses attending adult patient are member of the code blue team.
4) The code blue personnel composed of at least 4 nurses and physician, must be oriented with BCLS and
ACLS.
5) Only the physician, who is the code blue leader, will activate the code blue.
6) a code blue will be announced hospital wide in order for the laboratory, radiology and pharmacy
department to be informed and will be ready for the STAT orders.
7) During the resuscitation, the 4 nurses will identify themselves as to their role during the code blue, 1
medication nurse,2 for alternate CPR and time recorder and the other will hold and charge the defibrillator.
8) All order should come from the blue leader, other orders are not considered.
9) Patient resuscitation will be based on the present guidelines American College Association revised 2010.
10) Post resuscitated patient will be admitted at the ICU, in case our ICU is not available the patient relative
should be advised to transfer to other hospital where ICU is available. If relatives refused to transfer the patient will
be admitted at the ward or private room near the nurse station.
11) Members of the family or the nearest kin will be informed at the patient condition and prognosis during
and post resuscitation.
12) All equipment during resuscitation are all in functional condition, at least 2 blades for the laryngoscope
and spare batteries, at least 3 different sizes of ET tube (7,7.5&8), ambubag with re breather, 12 electrodes, 2
mouth guard and 2 inches plaster.
13) All emergency drugs should be available in the E-cart, one assigned nurse will check the availability of
all the drugs every shift. In a case one of those drugs is not available, the nurse in-charge will inform the head
nurse and pharmacist for replacement. All drugs will replaced within 24 hours.
14) Physician and nurses will complete the resuscitation form, remarks will fill up for the monthly review of
the code blue.
Out-Patient Department
1. Consultation time
OPD = Monday - Friday – 8:00-12:00, 1:00- 5:00 P.M. Cut -off time 11A.M. And 4 P.M.
Saturday, Sundays and Holidays – no consultations
Dental Clinic = Monday – Friday 8:00 A.M. - 12:00 N.N. ; 1:00 P.M. - 5:00 P.M.
Medico-legal cases – anytime ; after office hour ER staff will accommodate such case.
• Procedures
1) Issue priority card numbers to patient on first come first serve basis
a. Consultation fee of 20 pesos is being paid for each OPD patient (per Sp Ordinance)
b. OPD card issued is for lifetime use
c. OPD medical record must not be brought out by the patient after consultations
2) Patient data should be written correctly and legibly in patient's OPD card
a. Patients name, age, sex, civil status, complete address and birth date (please print in the card)
b. Time patient comes in for consultations
c. Month must be written in words
d. Take and record patients vital signs
Adult – TPR and BP
Pediatrics – TPR and weight in kg.
OB – LMP, FHB, weigh and BP
e. All complaints must be concise and correctly describe, especially on medico-legal cases
3. )Ante natal patient – Gravida, Parity, LMP, EDC, BP and weigh must be recorded
a. Prenatal clients on their first clinic visit are required to attend lectures on:
• Breastfeeding Prenatal clients on their first clinic visit
• Family Planning
• Immunization
• HIV/Sexually Transmitted Disease/Infection
• Tuberculosis
• Hand washing
• Infection Control
• Nutrition Supplement
• Safe-motherhood and hygiene
• Renal Control Disease
• Newborn Screening
• Nutrition
b. Schedule of Lecture
Monday- Friday
4.) Medico-legal are attended by the POD
A. Vehicular accident = ambulatory
1)Treat patient for any abrasions or wound
2) Inform patient and accompanying to report the incident to the Police Station where the incident happened.
3) Write the driver's name and license number
4) Record the date and time of the consultation
What to note ;
a. date of incident
b. time of incident
• place of incident
• nature of incident
B. Animal bites
- All animal bite patients are refereed to the physician or to the rabies coordinator for management
What to note :
a) date and time patient was bitten
b) site of bite
c) type of bite
d) nature of bite
e) condition of biting animal
f) vaccination of biting animal
C. Rape case
- all rape cases should be attended by an OB-Gyne physician on duty or refereed to NBI
5). Dressings and other surgical procedures
6). Dental Procedures
7) Medical certificate for employment and other purposes must be referred to Medical Records Department
8) Injections
a) skin test after 30 minutes must be verified by a physician
b) ANST – Anti-tetanus Serum, Favirab, B-Complex
c) Tetanus toxoid, Verorab, Rabifur – no skin test needed
d) Patient with positive skin test must be refereed to the physician who ordered such drugs
9) Activities
A.)Oral Rehydration Therapy
-Patient with ORT should be place at the rehydration treatment unit
a) the nurse in charge must record the following;
1- frequency of stool
2- dehydration level
3- frequency of vomiting
4- oral fluid given
5- temperature
b) patient with severe dehydration must be referred immediately to the physician for admissions
B.) Family Planning
Clinic hours ; 8:00A.M. -1200 N.N. ; 1:00 P.M. - 5:00 P.M.
Service offered anytime :
a. family planning orientation
b. PAP's smear
c. IUD insertion
d. pills and condom dispensing
e. DMPA injections
f. newborn screening lecture
Monday -Wednesday and Friday
breastfeeding lecture includes hand washing, proper nutrition, personal hygiene
C.) GAD Corner
Provide reading materials
• Information and dissemination of proper waste management through color-coded garbage cans.
• Evaluation of whole activities through suggestion box, and evaluation survey form.
OTHER SCHEDULE :
Circumcisions:
Schedule – Monday – Friday – 2:00 – 4:00 P.M.
Minor Surgeries:
Consent
Separate Record Book
Emergency Cases
Emergency Services-
Emergency other than surgical or medico legal after office hours – if only one Nursing Attendant left she may
ask assistance for medical cases from Ward Nurses which ever station is not busy, and OR nurse on duty for
surgical cases ; and or if ward nurses are busy for medical cases may ask assistance from the latter.
Notify physician immediately.
For Traumatic Emergencies:
Vital signs should be taken.
Wounds should be washed with soap and water, and apply any antiseptic available.
For Fractures:
If stretcher – borne > don’t remove from stretcher.
Notify physician
Avoid unnecessary movements.
Immobilization with elastic bandage
For Unconscious patients;

Notify physician
Inquire from relatives if patient is diabetic note odor of breath (try to search for I.D. card)
Chest Injuries (sucking wound)

Apply sterilized wound with plaster to sucking wound with pressure dressing immediately.
No oxygen inhalation.
Vital signs
Notify POD, X-ray and laboratory immediately.
Place patient on high back rest to assist in adequate ventilation. (Unless contraindicated)
Ante- natal:
1 – 1st clinic visit of prenatal clients is required to attend prenatal clients is required to attend
prenatal lectures on breastfeeding, family planning, immunization, nutritional supplement, safe-motherhood and
hygiene (schedule MWF)
2 – Blood pressure, weight, LMP and EDC should be taken Family Planning:
Family Planning:
Services Offered:
A - IUD insertion
B - Pills and condom dispensing
C -DMPA injection
D - Tubal ligation
Clinic days:
Tuesday and Fridays 8-12 A.M. to 1 - 4 P.M.
Saturday – 8 – 12 A.M.
Tubal Ligation:
Tuesday and Friday – 8-12 A.M. to 1 – 4 P.M.
Admissions:
All admitted patients Emergency or non-emergency should pass the OPD, ER and should be
recorded in the logbook provided and or conducted by an ER staff to their respective wards for proper
endorsement. Admission slip should be filled up with patients’ name.
Animal Bites:
All patients for transfer to other hospitals should be provided with referral slip from the admitting
physician.
Home and ER Deliveries:
1 – Cord dressing should be done by ER staff and chart should be provided and charted.
CENTRAL SUPPLY ROOM SERVICES

Staff – under the supervision of the operating room and delivery room services:
1. Nursing Attendant - 1
POLICIES AND ROUTINES
• Procedures for the requisitions for ward staff:

Time – morning – 7:00A.M. – 4:00 P.M.
• Supplies and equipments:
• Supplies like sponges, cotton balls, etc., for ward use is done by filing up the requisition book of which
• datas’ include the following; date, Supplies and quantity
• Equipment to be borrowed like catheters individual syringes, ice caps, trays are written in a borrowers slip
• and should be returned clean.
• Sterile trays and needles are available for wards.
• Solutions like Lysol, soap solution, alcohol, beta dine are also to be requisitioned from the CSR.
• TRAYS AVAILABLE
Dressing
Cut-down set
Paracentesis set
Thoracentesis trays
Comunicable trays
• Breakages And Losses
Any losses or breakages should be reported to the CSR with a corresponding explanation on how it was
broken. The CSR then determines whether it has to be replaced or not.
• Requisitioning of equipments and supplies for ward use is done through the property section by the
nursing attendant, CSR nurse.
• Supplies like dressing sponges , cotton balls, nasal packs, top dressings are made by the CSR
• Sterilization of supplies and linens from all departments is done at the OR autoclave, if CSR autoclave is
unavailable.
• Hospital property should not be brought outside the hospital without proper permission.
• Inventory of ward equipment is done every month by the CSR staff.
• New equipments are demonstrated to the nursing staff.
• Endorsement of articles and equipments:
• Nursing attendants of each shift must have an actual endorsement of supplies and articles to the in-
coming shift nursing attendant. One may not receive if actual endorsement is not made.
NURSING SERVICE STANDING COMMITEES

Purpose:
To establish standards for safe and effective nursing care.
Memberships:
The Chief Nurse appoints the chairman of the various members of the different committees. The chairman
in turn selects her members from different level of the nursing staff for maximum participation.
The different committee shall formulate the guidelines including their days of meetings.
• POLICY COMMITEE
The Policy Committee establishes guides or policies for the personnel of the Nursing Service Division
which delineates responsibilities and prescribes the action to be taken under a given set of circumstances.
It periodically appraises policies followed by a revision, if indicated, develops new policies to meet present
and future needs, submits recommendations to the Chief Nurse regarding the development, revision or modification
of policies.
Policy Committee (see appendix D)
• STAFF DEVELOPMENT COMMITTEE

This committee plans for short and long range year round trainings program
Designed to upgrade the performance of nursing service personnel or through the introduction of new concepts,
increased knowledge in problems analysis and develop good working relations and positive attitude towards work.
These include orientation, leadership, skill training or on-the-job training program
Staff Development Committee (see appendix D)
• COMPLAINTS AND GRIEVANCES COMMITEE

The committee receives and reviews complaints and grievances within the Nursing Service
for the purpose of expediting fair and equitable adjustment of such, in accordance with the policies provided by the
Agency and Civil Service.
The Committee forwards to the Chief Nurse who in turns reviews and takes appropriate
action on the matter.
Complaints committee (see appendix D)
• SOCIALS COMMITTEE
This committee takes charge of the social activities and physical fitness program of the Nursing
Services. (See appendix D)
• HOSPITAL HEALTH EDUCATION COMMITTEE
This committee takes charge of planning, implementing, monitoring educational activities in the
hospital.
Chairman - Rene c. Mendez (HEPO Designate)
To coordinate with senior nurses of the wards and the supervising nurses.
• NURSING SERVICE AUDIT COMMITTEE
The nursing service audit is an official examination of nursing records for the purpose of
evaluation, verification and improvements. It is a successful tool in analyzing and evaluating nurses’
Bedside records and services as means of improving nursing care by revealing existing deficiencies.
(See appendix D)
A. It has its purpose:

1. The improvement of patient care.
2. It should provide data for utilization in the improvement of patient care program.
B. Objectives of the Nursing Audit Committee:
1. To provide a systematic review of the patients discharged records from the hospital.
2. To provide maintenance of the records of performance or each professional nurse or the staff.
3. To develop more valuable and pertinent information for the physician and the staff.
4. To develop and improve the quality of nursing and nursing notes.
5. To develop better cooperation between physician and nurses as a result of an improved quality of nursing
notes.
C. Function of the Committee
1. To act as liaison between the nursing service and medical staff
2. To serve as a means of correcting of short comings rather than disciplining.
3. To aid in establishing a cooperative spirit among the nursing personnel.
4. To keep confidential all information obtained when auditing to records.
D. Activities of the Committee:

The committee should meet twice a month and review the records of discharged patients. An audit may
have a segregated service .The records of all patients discharged from one unit may be audited at one meeting.
The time and period of the audit may vary as indicated by the size of the institution, but all succeeding audits
should be of the same time and period so as to make possible a comparison of the various reports. (See appendix
D)
QUALITY ASSURANCE PROGRAM
Quality Assurance - is the estimation of the degree of excellence in patient health outcomes and in activity, and
other resource outcomes.
- is a management process that provided a sound basis for decision making and problem
solving.
- Management of care by competent clinical nurses, and nurse managers ensures its quality of
that care.
Mission of quality assurance – is to ensure that the quality of patient care is optimal through unified program for
patient care evaluation.
Purpose of quality assurance:

>Is to ensure that all patients receive the optimal or maximum quality of care.
>Involves continuous action to improve deficiencies.
I. Philosophy:
The quality assurance program committee member believes that a well formulated quality assurance program
ensures quality patient care through a continuous program assessment and evaluation of patient care activities.
Through this program, quality care is maintained and delivered regardless of race, creed, social economic status
and political beliefs.
II. General Objectives:

Quality assurance program aims to develop an environment to assure continuous improvement in the quality
of nursing care delivered in the hospital.
III. Specific Objectives:

>To develop and implement a quality assurance program for the Surigao Medical Hospital nursing service.
>To develop and implement a regular in-service training in Quality Assurance for the nursing staff.
>To employ scientific approach in the assessment of existing patient care problems and institute remedial actions.
>To provide quality patient care anchored on well organized and evaluated patient care activities.
INTENSIVE CARE UINT POLICY
Critical care unit or intensive care unit

It is a specialized area equipped with monitoring, diagnostic and therapeutic devices caring for cardiac and non-
cardiac medical patients’ as well as surgical patients requiring intensive, continuous comprehensive medical and
nursing care by specialized trained staff.
General objectives
• To provide optimum care to all patients regardless of sex, religion, nationality and economic status
• To provide the best possible available line of treatment to pre-existing medical and nursing problems
• To start rehabilitation of patients as early as possible and be able to move out as soon as he or she
passes the critical period
Specific objectives
• To give specific care necessary for every patient in the unit
• To give clean and pleasant atmosphere in the whole stay of the unit
• To make sure that all equipment are all in working conditions for immediate use
• To provide complete emergency drugs for emergency use
• To guide patients in their daily activities while they are still in the unit
Physical set-up center and ICU staffing
The Surigao Medical Center ICU is located in the 2nd floor of the southern part of the hospital, near the
ramp stair and private rooms. It is a four bed capacity room equipped with cardiac monitors, defibrillator, built-in
oxygen, ventilators/respirators, IV infusion pump and other equipments that will aid in the prevention and
treatment of cardiopulmonary abnormalities. It is manned by competent staff trained to identify potential and
existing problems of the patient.
(See appendix E for the ICU Personnel staff and physician).
Admitting procedures
. All ICU admissions are classified as service, private cases and Philhealth cases
• Private Cases are admitted by their attending physician to the ICU are seen in the ER. Patients not
coming from ER can be directly admitted to the ICU after a prior communication and arrangement by the attending
physician.
• Admissions for ICU are evaluated by the POD
I. Indications for admission

• Neurological cases
• Medical sepsis that needs continuous monitoring except pulmonary infection or communicable diseases.
• Intubated patient
• Acute complicated myocardial infarction
• CHF (pulmonary edema)
• Critical care post-op patient
I
I. Contraindications for admissions
> Highly contagious (measles, mumps,
chicken pox, diphtheria in children, meningococcal
meningitis, meningococcemia, and advanced
pulmonary tuberculosis)
> CVA patients who are neurologically
hopeless
> Chronically ill but stable patients
> Terminally ill and DNR patient
> Psychiatric patients and uncontrollable
cases that may be harmful and disturbing to the unit.
Policies
> Nurse assigned should stay put at the
unit. She is not allowed to get out, unless there is
somebody to relieve.
> No smoking
> Maintenance of equipments’ unit so that
anytime it will be ready to use.
> Personnel should come on time and
should use complete uniform.
Measures in order to minimize environmental contamination and reduce bacterial colonization :
> Patient unit will be thoroughly scrubbed
with detergent and water every after discharge of
patient
> Adequate aseptic technique – proper
hand washing- must be re-emphasized to the staff
before and after each care of the patient.
> Unit facilitates and patient’s equipments
must be regularly and thoroughly cleaned and
disinfected with chlorine solution every after use and
dried in air.
> Periodic environmental sampling of unit
equipments will be conducted as necessary.
> Engineering will be responsible for
cleaning of air conditioner diffusers every patients
discharge.
Standard operating procedures
1.Admission
Admission of patient is arranged by the physician and nurse-in-charge of the unit.
• Sponge bath is done immediately if necessary and changing of kamisa, pajama, and ICU gown should be
done thereafter.
• Patient should be placed comfortably in bed.
• Vital signs should be taken immediately on admission.
• All physicians order during admission that is not carried out at ER should be followed-up at the ward.
• Information about the patient should be recorded in the logbook provided as;
• Data of patient
• Complaints
• Impression
• Orientation to patient and watchers regarding ICU policies should be given.
• Before transferring patient to ICU ,he/she should be cleaned, diaper changed , and catheterized if
necessary
2. Endorsement
- Receive endorsement from previous shift on time as to:
> Patient
> Patient’s condition
> IV fluids if any, catheter, NGT and other tubing attached to patient, cardiac monitor and other
equipments
> Level of IV fluids, type or IV and meds incorporated
> Note the scope of patient cardiac condition with the aid of cardiac monitor.
3.. Doctor’s rounds
> Rounds should be done once a day or as frequent as necessary.

> Orders in the chart should be carried out after the rounds.
> Thorough physical examination should be done by the physician in-charge.
> Case presentation monthly
4. Care of patient
> Check vital signs of patient regularly and note signs
and symptoms of the disease.
> Provide bedpans and urinals to patient if necessary.
> Serve meals to patient taken from the dietary dept.
and checked if it is the prescribed meal.
> Check IV lines and other tubing attached to patient
every now and then for patency.
> Attend to the needs of patient at all times.
> Turn patient from side to side every two hours when
awake and whenever necessary.
5. Medications
• All medications and IV follow-up should be placed at patient’s medicine box.
• Check all consumed medication and informed the doctor for follow-up prescriptions.
• Use medicine ticket using ten rights ;
• Right drug
• Right patient
• Right route
• Right dose
• Right time
• Right assessment
• Right documentation
• Client’s right to education
• Right evaluation
• Clients right to refuse
>Place IV ticket to on-going IVF of the patient with the following data’s;
• .Name
• Age and sex
• Name of fluids
• Medication incorporated
• IV rate
• Date and time started
• Signature of the nurse
6. Diet
• No food should be brought inside without checked by the staff.
• Foods to be given should come from the dietary dept. except when necessary upon doctor’s order.
• Diet of patient should be written in the diet list and any changes of diet should be posted immediately.
• Special diet should be referred to the dietician immediately.
7. Laboratory
• All laboratory requests should be brought to the laboratory with the logbook.
• All “stat” orders should bear the work “stat” in the request slip.
• Blood chemistry request should be sent to the laboratory a day prior to examination for further preparation,
if any.
• All x-ray requests should include the impression of the physician about the patient’s condition or diagnosis.
• All x-ray and laboratory result should be in before the doctor’s rounds, and should be attached in the chart.
• If only one ICU nurse on duty, he can request ward staff to bring specimen to laboratory
8. Patient’s hygiene and environment
• Morning sponge bath, personal hygiene and changing of bed linens and gowns should be done daily.
• Perineal care should be done to avoid unwanted smell.
• Physical and oral care should be done early morning.
• Application of bactericides is a must to all unconscious patients depending upon the doctor’s order.
• Provide slippers for ICU watchers.
9. Charting and recording
• The ICU nurse should be familiarized with all forms used.
• She/he should also observe all the problems presented by the patient and record it in the nursing problem
lis
• She should also record the vital signs
• She should also write the medications given in the medication sheet and affix his/her signature.
• Record I and O ,as well as vital signs accurately in the form provided.
• Record IVF hooked, typed, time and regulation of fluids.
• Attached all ECG results in the form provided.
• Complete patient’s data in all pages of patient’s chart.
• Check and update oxygen consumption.
10. Ward cleanliness
• The nurse assigned should help in cleaning and tidying the ICU.
• Slippers must be cleaned once a week and whenever necessary.
• General cleaning must be done once a month or when the room is vacated, by the utility worker assigned
assisted by the nurse in-charge.
• Fumigation of the room should be done after the general cleaning.
11.Linens
• All linens used should be recorded in the logbook for linens.
• No linens, pajama, kamisa and OR gown should be brought outside the hospital.
12. Visiting hours
• No visitors should be allowed inside the ICU except if necessary for the patient condition but with
permission of the attending physician and nurse assigned.
• Visiting hours;
9:00 AM – 10:30 AM
2:00 PM - 4:00 PM
13. Watchers
• No watchers are allowed inside except when needed by the patient.
• Watchers can enter the ICU on the following time ;
• Early AM when giving personal hygiene
• When patient defecated and needs assistance from the watchers.
• Turning the patient with the nurse around.
• Changing linens and gown of the patient.
• When the nurse goes out to refer the patient.
• Watchers should stay outside the unit or within the hospital premises.
14. Referrals
Referral is a must at the ICU when the condition of the patient needs so.
15. Break time
The nurse can take her/his break if there is somebody to relieve in his/her absence.
16. Discharge
Transferred-out of patient depends upon the discretion on the attending physician.
17. Visitors limitation
Only one visitors at a time is allowed and to use slippers and gown over their civilian clothes to maintain
asepsis in the environment.
Children below 7 years of age are restricted from getting inside the unit.
It is off limits to non-ICU and off duty staff of the hospital.
NEONATAL INTENSIVE CARE UNIT POLICY
Criteria for admission:
• Babies who are under observation for next 2 hours.
• Neonates with life threatening anomalies especially those affecting feeding and respiration.
• Asphyxiated neonate.
• Neonates with sign of meconium aspiration syndrome
• Neonates with maternal risk factor (ex. pre-eclampsia)
• Neonates on parental antibiotic
• SGA < 2000 gm and LGA >3750 gm
• Neonates who are thickly meconium stained
• Neonates with signs and symptoms of respiratory distress who need ventilator support.
• Preterm neonates 36 weeks and less by Ballard Scoring.
• Babies whose mother is incapable of caring for their babies like psychotic, alcoholic, drug addicts. With
CHF, severe infection and mothers admitted to the ICU.
Feeding policies:
• Breast milk is the only milk needed for feeding all newborn
• No glucose water is allowed
• All babies should be put to breast within n30 minutes after delivery.
• No artificial teats, pacifier or bottle should be given to breastfeeding infants.
Daily care of the newborn
• Nursery: Notify if mother develops fever within 24 hours postpartum. Examine neonate for possible
infection.
• Maintain body temperature within 4-8 hours at 36.7-37C
• Weighing of babies ;
Weigh daily at the same time, using the same weighing scale.
Drape scale with sterile sheet.
• Bath and daily skin care
Buttocks should be cleaned with cotton balls wet with sterile water after each voiding and bowel
movement.
• Nurses notes should include temperature, CR/HR, RR , amount of feeding given, feeding tolerance, color,
cry and activity of infant, unusual appearance and behavior, color, smell and consistency of stool on each shift.
• All nursery personnel and students rotating in nursery must wear appropriate attire.
• Visiting hours:
Only parents are allowed to enter the NICU once a day to visit their babies.
All mothers whose babies are stable and are still in the NICU will breastfeed their babies in the feeding
room as frequently as possible.
Policy on discharge
• All newborn should have a complete P.E.
• All record should be complete with ;
• Newborn record for all babies
• Maternal and obstetrical forms
• Final diagnosis
Instruction explained to the mother;
-feeding instruction
-take home medication
-cord care and general daily care of infants
All roomed-in babies should e discharged at least 24 hours after delivery. No baby should be discharged ahead of
the mother; except for some critical cases.
Only the mother can claimed the baby. In situation wherein the mother cannot come, the father/grandparents
can come to claim the baby.
Acknowledgement form should be sign by the parents/grandparents upon discharge.
Policy of deaths
• All deaths should be pronounced by a physician
• Family should be notified regarding baby’s death
• Death certificate should be properly filled-up by the pediatrician/resident on duty.
APPENDIX A
13 RULES OF CHARTING TO KEEP LEGALLY SAFE
• Write neatly and legibly.
• Use proper spelling and grammar. Steps to avoid spelling and grammatical errors;
• Keep a dictionary in charting cases.
• Past a list of commonly misspelled words.
• Write a clean concise sentence; avoid useless and unnecessarily long words.
• Clearly identify the subject of the sentence.
• Write with a blue or black ink and use appropriate time.

• Use authorized abbreviations.
• Transcribe orders carefully.
No matter who transcribe doctor’s orders, the Nurse I or Nurse II, a second person should double check
for accuracy. Night shift nurse usually do this by placing a time across the order sheet to indicate that all
orders above the time has been checked.
If the order is unclear ask the doctor who wrote it for classification before he leaves the unit.
Avoid taking telephone or verbal order and include the patient name.
6. Document complete information about medications
- If doubtful with the doctors order. Take these steps:
a. contact the doctor and discuss why you are questioning the medications or dose.
b. In your notes, document when you notified doctor, what you told him and have he responded.
c. If you decide to withhold a medication but you cant’ reach him, document your attempt to call him
and your reasoning for withholding medication.
d. If someone gives the medication make sure the persons’
name and the time are charted. Document your evaluation of the patients’ condition before and after the medication
was given.
e. Document factual information about the incident without casting blame.
7. Chart promptly.
8. Never chart nursing care or observations ahead of time.
9. Clearly identify are given by another member of the health care team.
10. Don’t leave any blank space on chart forms.
- A blank space implies that you failed to give complete care or assess the patient fully. If the information
asked for in the form doesn’t apply to the patient draw a line through the space and write N-A for not applicable.
11. Correctly identify late entries. Late entries are appropriate under the following circumstances.
a. if the chart was not available when you needed it, such as when the patient is away fro the unit.
b. when you need to add important information after you’ve completed your notes.
c. if you forget to write notes on a particular chart.
The best approach to this problem is:
• Add the entry to the first available line.
• Label the entry “late entry” to indicate that its out of sequence.
• Record that time and date of entry.
• In the body of entry, record the time and date it should have been done.
12. Correct mistaken entries properly.

- draw a single line through so it’s still readable.
- write the word “mistaken entry” above or beside mistaken words but don’t use “error”.
* Lawyer tend to associate the word error that affected the patient
* Place date and initial next to the words “mistaken entry” or M.E.
13. Don’t sound tentative
APPENDEX B
BREASTFEEDING POLICIES
For Successful Breastfeeding
• All hospital personnel, medical and non-medical will undergo orientation and training on breastfeeding and
lactation management. Conduct 18 hours lactation education and management training.
• All babies born in this hospital should be given breast milk, only unless medically contraindicated.
•No prelacteal feedings to newborns.
•Explain to mothers that giving prelacteal will interfere with breastfeeding, decreases eagerness to breastfeeding,
produce allergies and sense of inadequacy on the mother.
• All babies delivered shall be put to breast within thirty minutes after birth in D.R.
a. Promote mother-baby relationship or bonding.
b. Practice latching on second stage of labor.
4. Colostrums should be given to all newborn babies.
a. Colostrums contains antibodies thus prevents childhood diseases, like diarrhea and respiratory
diseases.
5. All babies delivered by caesarian section without complications shall be breastfeed within four to six hours.
Hospital staff should help attached the baby to mother.
6. All babies should be roomed- in within 24 hours after birth.
a. Teacher the mother the importance of rooming-in, to facilitate mother and child bonding.
b. Permits breastfeeding on demand.
c. Allows for closer contact with the father and other members of the family.
7. All mothers should be assisted to start breastfeeding immediately and should be taught the proper
breastfeeding method.
a. Demonstrate proper positioning of baby and mother.
b. Teach mother proper technique on manual breast milk expression.
8. All mothers should be encouraged to breastfeed on demand.
a. To help mothers produce more milk and prevent breast engorgement.
9. Infant formula feeding bottles, pacifiers should not be stock within the hospital premises (OR, DR, Ward,
Pharmacy, Canteen)
a. Discourage artificial feeding to the baby.
b. Nipple confusion should be avoided.
10. Mothers during their pre-natal check-up at OPD are required to attend breastfeeding lecture.
a. Feeding on demand
b. Rooming-in
c. Attachment
d. Disadvantages of pre-lacteal
e. Proper technique of manual expressed breastfeeding
f. SMC hospital policies on breastfeeding
11. Mothers with no consent to breastfeed their babies will not be admitted in the hospital.
12. Mothers will not be discharged if there is no milk flow.
a. Help mothers attach their babies for breastfeeding and proper positioning.
b. Demonstrate how to express breast milk.
13. All names of mothers when discharged from the hospital will be forwarded to the City Health Office
(CHO) for follow-up of breastfeeding.
Ask help from other agencies as support group for follow-up in the field such as;
>CHO staff (PHN and PH midwife)
>Baranggay health workers
>Helots
>NGO
>Family Planning Group
BREASTDEEDING POLICY (new)

1. Staff should be committed to the promotion of breastfeeding and should do everything possible to enhance the
woman’s confidence in her ability to breastfeed.
2. Within 30 minutes of birth, all mothers regardless of feeding intention will be given their babies to hold with skin-
skin contact for at least 30 minutes. Skin-skin contact may be provided by a family member when mother is unable
to do so and skin-skin contact later, encouraged in the postnatal ward or special area when baby and/or mother are
stable.
3. All mothers will be offered help to initiate breastfeeding within 30 minutes of birth. Further assistance will be
offered within 6 hours by a midwife to position and attach baby on breast.
4. Rooming-in is Hospital Policy and unless medically/clinically contraindicated, a mother and her baby will be
separated. Where separation of baby from mother is necessary, lactation will be encouraged and maintained.
5. Baby-led feeding will be practiced for all babies although in the early days the baby may need to be woken if
sleepy or if the mother’s breasts become overfull. When baby has finished feeding on one side the second breast
will be offered.
6. Breastfeeding mothers will be shown by the midwife how to express their breast milk by hand and pump if
necessary.
7. Supplements will only be given for clinical/medical need. All supplementary feeds/fluids will be recorded in the
baby’s hospital notes with indication for the giving the feed. Prescribed supplementary fluids will be given by cup or
NGT tube.
8. No teats/dummies/soothers will give to babies while breastfeeding is being established.
9. No advertising of breast milk substitutes, feeding bottles, teats or dummies is permissible. Mothers choosing to
formula feed their infants will be instructed on safe formula use during the postnatal period by the midwife before
discharge.
10. Before discharge, support services available in the community will be discussed with each mother.
B- Best for baby

R- Reduces the incidence of allergy
E- economical, No waste
A –Antibodies produces great immunity
S- Stool inoffensive hardly ever constipated
T-Temperature is always ideal
F-Fresh milk never goes off
E- Emotional Bonding
E- Easy once established
D- Digested easily within 2-3 hours
I – Immediately available
N- Nutritionally optimal
G-Gastroenteritis greatly reduced
EXECUTIVE ORDER-MILK CODE 51 – TO PROTECT AND PROMOTE BREASTFEEDING

REPUBLIC ACT 7600 – ROOMING –IN
WHAT EVERY HEALTH WORKER SHOULD KNOW ABOUT BREASTFEEDING AND ROOMING-IN?
Question: What are the benefits of breastfeeding?

Answer: The benefits are the following;
1. Breast milk is the ideal complete food for babies. It contains all the essential nutrition needed for adequate
nutrition and growth of the baby.
2. Breast milk especially colostrums has antibodies which protect the child against many childhood diseases e.g.
diarrhea, respiratory infection, etc.
3. Breastfeeding fosters a closer mother-child relationship/promotes bonding.
4. Breastfeeding helps mother prevent post-delivery hemorrhage and protects mother against cancer on the breast.
Q: What is the importance of rooming-in?
A: Rooming-in is important because it facilitates mother and child bonding, permits breastfeeding on demand and
allows for closer contact with the father and other family members.
Q: What is importance of feeding on demand?
A: It is importance to teach mothers to feed on demand because this helps mother’s breast to produce more milk
and prevents breast engorgement.
Q: What are the policies or procedures that can help promote breastfeeding in hospital maternity ward?
A: The following are the policies or procedures that promote breastfeeding in hospital maternity ward;
1. Early breastfeeding
2. 24-hour rooming-in
3. Demand feeding
4. No bottles, dummies or pacifiers
5. Helping mothers to attach babies
6. Build mother’s self-confidence
Q: How does pre-lacteal feeding interfere with breastfeeding?
A: Pre-lacteal feeding interferes with breastfeeding because of the following;
1. Babies decrease their eagerness to breastfeed when given pre-lacteals.
2. Giving pre-lacteals may develop/produce allergic reaction.
3. Pre-lacteals feeding give mothers sense of inadequacy/ have difficulty establishing breastfeeding.
4. Nipple confusion.
Q: What is the major cause of sore nipples?
A: The major cause of sore nipples is;
• Babies poor position and attachment when sucking.
• Baby does not take enough of the breast into his mouth- baby is sucking only the nipple.
Q: What is the most common cause of insufficient milk?
A: Babies is not breastfeeding frequently
Q: What is the common cause of breast engorgement?
A: The common cause of breast engorgement is ineffective breastfeeding during the first few days – baby is not
sucking frequently.
Q: What is the proper technique of manual milk expression?
A: The proper technique of milk expression observes the following key points:
1. Thumb on areola above the nipple and forefinger on the areola below the nipple.
2. Fingers opposite press inward towards chest wall.
3. Do not slide fingers on skin.
4. Repeat press-release for several minutes to stimulate milk ejection reflex.
5. Rotate around nipple to compress all sinuses.
Q: How do you know if the mother is properly positioned and attached to their infants for breastfeeding?
A: The mother is properly positioned and attached if the following is observed;
• Baby’s whole body close to his mother, facing her.
• Baby’s mouth wide open, lips flanged, chin touching breast, more to areola below nipple in mouth, cheeks
not drawn in,
• Rhythmic burst-pause sucking and swallowing.
TEN STEPS TO SUCCESSFUL BREASTFEEDING

A joint WHO/UNICEF statement (1989)
Every facility providing maternity services and care for newborn infants should;
1. Have a written breastfeeding policy that is routinely communicated to all health care staff.
2. Train all health care staff in skills necessary to implement this policy.
3. Inform all pregnant women about the benefits and management of breastfeeding.
4. Help mothers initiate breastfeeding within half-hour of birth,
5. Show mothers how to breastfeed, and how to maintain lactation even if they should be separated from their
infants.
6. Give newborn infants no food or drink other than milk unless medically indicated.
7. Practice rooming-in; allow mothers and infants to remain together 24 hours a day.
8. Encourage breast feeding in demand.
9. Give no artificial teats or pacifiers (also called dummies or soothers) to breastfeeding infants.
10. Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from hospital
or clinic.
Why breast feeding is Important?
Breastfeeding is important to children, to mothers and to families’ .Breastfeeding protects infant’s health. Children
who are not breastfed are more likely to be:
>Ill or die from infections such as diarrhea and gastrointestinal infections and chest infections.
>Underweight and not grow well, if they live in poor circumstances.
>Overweight and to have later heart problems, if they live in rich circumstances.
Breastfeeding is important to mothers. Women who do not breastfeed are more likely;
>To develop anemia and retain fat deposit during pregnancy, which may result in later obesity.
>To become pregnant soon after the baby’s birth.
>To develop breast cancer
>And to have hip fractures in older age.
In Addition;
>Breast milk is readily available. There is nothing to buy and in needs no preparation or storage.
>Breastfeeding is simple, with no equipment or preparation needed.
>If a baby is not breastfed, the family will need to buy replacement milk for the baby and find time to prepare feeds
and keep feeding equipment clean.
>If a baby is not breastfed, there may be loss of income through a parent’s absence from work to care for an ill
child.
Mother’s milk is all a baby needs;
>Exclusive breastfeeding is strongly recommended for the first six months. The baby does not need water, other
fluids or foods during this time.
>Breastfeeding continues to be important after the six months when other foods are given to the baby.
>A mother’s milk is especially suited for her own baby and changes from day to day, month to month and feed to
feed to meet the baby’s needs. The baby learns to tastes of the family foods through the flavors of breast milk.
>Mother’s milk is unique (special). Human milk is a living fluid that actively protects against infection. Artificial
formula provides no protection from infections.
APPENDIX C
SAFETY POLICIES FOR IN-PATIENTS
• Patient assisted during his initial activity after bed rest, 1st post operations day.
• Side rails up and in safe working condition.
• Restraints used as needed and applied properly.
• Safety precautions used for patients while in chairs or wheelchairs if needed.
• Patient and family understand the proper isolation techniques and the reasons for it.
• Contaminated articles (dressings, bed pans, urinals etc...) are cleaned disinfected properly.
• Proper signs displayed for patients’ safety (no smoking, with patients’ with or administration).
• Machines or electrical equipment at bedsides properly connected and maintained.
• Precautionary measures used as labeling drainage bottles (Thoracostomy tube).
• NPO signs posted for patients with such orders.
Appendix E
ACTUAL DUTIES
Actual Duties ICU
7am – 3pm Shift
• Reports for duty 15 minutes ahead of time.
• Receives endorsement from the outgoing shift.
• Makes ocular inspection to every patient and see to it that side rails are up and properly secured.
• Admits patients from Emergency Room and Trans – in from wards, Recovery Room and Operating –
Delivery room.
• Checks emergency drugs and medications.
• Checks equipments and articles if functional.
• Takes vital signs, measures intake and output and record.
• Gives medications oral and parenteral per doctors’ order.
• Renders nursing care to patients.
• Assists during doctors’ rounds and executes doctors’ order accurately.
• Prepares patients for diagnostic procedures.
• Refers patients condition, and laboratory results to physician in charge ( PIC ) or physician on duty
( POD ).
• Document patients condition, level of consciousness, medications and treatments done.
• Makes charges and follow up replacements of medicines taken at ICU stock.
• Checks diet list and gives NGT feeding as ordered.
• Maintains cleanliness in the unit and adheres to the infection control and waste management policies.
• Attends nursing service monthly meetings, post conferences and other hospital related activities.
• Endorses patient and unit to incoming shift.
3pm – 11pm
Delivery room.
• Assists during doctors’ rounds and executes doctors’ order accurately.
• Refers patient’s condition, and laboratory results to physician in charge (PIC) or physician on duty (POD).
11pm – 7am

Delivery room.
• Refers patients condition, and laboratory results to physician in charge ( PIC ) or physician on duty
( POD ).
Duties of the Central Supply Room Nursing Attendant

• Checks availability of supplies.
• Requests supplies and equipments from the general supply room.
• Cuts gauze for dressing sponges, packs and sterilizes.
• Makes cotton balls, cotton applicators, top dressing and other supplies.
• Provides clean and sterile hypo trays and towels.
• Sets up dressing tray ready for ward use.
• Washes, dries and packs catheters, tubes and injection towels ready for sterilization.
• Prepares soap solution and chlorine mixture for disinfection.
• Issues sterile supplies and articles to the wards.
• Follows up articles borrowed by the wards.
• Makes and records inventory of supplies, articles and equipments.
• Attends nursing service monthly meetings, post evaluation and other hospital related activities.
• Maintains cleanliness in the area and adhere to hospital infection control and waste management policy.
• Coordinates with other nursing units and other hospital departments.
• Under the direct supervision of Nurse III CSR in charge.
Actual Duties
Neonatal Intensive Care Unit
7am – 3pm
• Reports for duty 15 minute ahead of time.

• Receives endorsement from outgoing shift.
• Makes rounds, checks newborns condition, IV site, IV flow rates, baby’s’ sex and wrist tag.
• Checks incubators, suction machine and bililight if functional and reports to electrical department if out of
order.
• Checks E-kit and availability of oxygen supply.
• Takes vital signs, respiratory rate, cardiac rate and temperature.
• Admits newborns from OR, DR, DR and Trans – in from ward and carries out doctors’ order accurately.
• Renders immediate neonatal care for premature and for care newborns.
• Assesses and refers newborns’ condition like cyanosis, seizures, spasms and abdominal retractions.
• Gives medications, treatments, NGT and dropper feeding as ordered.
• Sterilizes feeding bottles, medicine glasses and droppers.
• Encourages mothers on milk banking.
• Instructs mothers on proper breastfeeding and neonatal care.
• Maintains medical sepsis when handling babies.
• Maintains cleanliness and orderliness in the area and adheres to hospital infection control and waste
management policy.
• Discharges newborns per doctors’ order.
• Coordinates with other hospital departments.
• Endorses newborns to in coming shift.
3pm – 11pm

order.
management policy.
11pm – 7am

order.
• Weighs newborns daily
• Bathes newborns daily unless contraindicated.
management policy.
Actual Duties Nurse II (Ward)

7am – 3pm

• Receives the endorsement from outgoing shift.
• Makes nursing rounds to all patients in her ward; checks level, flow and flow rate of IVF and blood
transfusion if any and checks patient’s condition.
• Assigns her staff in the unit for the weeks’ distribution of work load and prioritization of work.
• Checks emergency kit.
• Holds responsible that equipments are functional and supplies available.
• Accompanies and assists doctors’ during doctors’ rounds, checks and carries out doctors’ orders properly.
• Checks diet list.
• Admits and discharges patients.
• Gives medications, treatments and NGT feeding.
• Attach laboratory results to patients chart and refer accordingly.
• Administer insertion of IVF, blood and other blood components.
• Report to supervisor on any problems, unusualities, clarification on patient care and ward management.
• Prepares patients and assists physician for any diagnostic procedure performed in the ward.
• Sees to it that patients’ care are within the standard of nursing practice.
• Coordinates with the clinical instructors and students for the plan of patient care.
• Orients new personnel, clinical instructor and volunteers.
• Acts as a nurse supervisor in her absence.
• Adheres to the infection, prevention and waste management guideline.
• Maintains cleanliness and assert effort for innovative improvements.
• Updates kardex and floor census.
• Keeps abreast with the latest trends in nursing practice.
• Attends nursing service monthly meetings, weekly ward post conferences and other hospital related
activities.
• Endorse patients and unit to incoming shift.
3pm - 11pm

transfusion if any and checks patients’ condition.
• Accompanies and assists doctors’ during doctors’ rounds, checks and carries out doctors’ orders properly.
• Checks diet list.
• Attach laboratory results to patients chart and refer accordingly.
• Prepares patients and assists physician for any diagnostic procedure performed in the ward.
• Sees to it that patients’ care is within the standard of nursing practice.
• Orients new personnel, clinical instructor and volunteers.
• Maintains cleanliness in the area.
activities.
11pm - 7am

transfusion if any and checks patients’ condition.
• Checks and carries out doctors’ orders properly.
• Prepares diet list.
• Refers patients condition and laboratory results to physician on duty (POD)
• Sees to it that patient’s care is within the standard of nursing practice.
• Maintains cleanliness in the area.
activities.
Actual Duties Nursing Attendant (Ward )

7am - 3pm
• patients on close monitoring of vital signs, FHB and I & O
• measurement.
• Patients’ for special procedures and waiting case.
• Ward equipments, supplies and linens.
•
• Goes with the nursing rounds.
• Updates door and bed tags.
• Requests supplies from the CSR.
• Requests dressing tray for doctor’s use.
• Provides linens and keep beds tidy and bedside tables neat and clean.
• Takes vital signs and record.
• Reports to the nurse on duty any unusualities observed from the patients.
• Bathe newborn babies.
• Clean oxygen humidifiers and change suction tubing’s.
• Provides specimen bottles and instruct patients/watchers for collection of specimen and send it to the
laboratory.
• Maintains cleanliness and orderliness of the nurses’ station and patients unit at all times.
• Performs bedside nursing procedures like catheterization, enemas, HRT, O2 administration, nebulization,
changing of thora bottle and application of hot and cold compress per doctors’ order.
• Renders bedside nursing care to bedridden patients like oral care and perineal flushing.
• Attach laboratory results and arrange them accordingly.
• Receives patients’ medicines and IVF and record in the list of medicines.
• Complete patients’ data on the clinical case record and in every page of the patients’ chart.
• Processes charts for billing.
• Discharges patients and sees to it that all borrowed articles are clean and return them to CSR.
• Checks patients linens used before discharge.
• Renders post mortem care.
• Adheres to the infection, prevention and waste management guidelines.
• Attends nursing service monthly meetings, weekly ward post conference and other hospital related
activities.
• Endorse patients’ and unit to the incoming shift and goes with the nursing rounds.
3pm - 11pm
• patients on close monitoring of vital signs, FHB and I & O
• measurement.
•
• Requests supplies from the CSR.
• Requests dressing tray for doctor’s use.
• Provide linens and keep beds tidy and bedside tables neat and clean.
• Clean oxygen humidifiers and change suction tubing’s.
laboratory.
• Performs bedside nursing procedures like catheterization, enemas, HRT, O2 administration, nebulization,
• Discharges patients and sees to it that all borrowed articles are clean and return them to CSR.
• Checks patients linens used before discharge.
activities.
11pm - 7am
• Patients on close monitoring of vital signs, FHB and I & O
measurement.
• Provide linens and keep beds tidy and bedside tables neat and clean.
• Clean oxygen humidifiers and change suction tubings.
laboratory.
• Performs bedside nursing procedures like catheterization, enemas, HRT, O2 administration, nebulization ,
• Refills and arrange charts chronologically..
activities.
Actual Duties ER – OPD

Nurse III
• Responsible for the management and supervision of OPD – ER personnel, volunteer and affiliating
students.
• Makes weekly schedule for staff for the three shifts.
• Updates schedule of 8 hours and 24 hours physicians.
• Sees to it that standard operating procedures of different ER physician is accessible and updated.
• Maintains cleanliness and orderliness in the unit.
• Requests medicines, instruments, equipments and supplies at the pharmacy and the general supply room.
• Ensures observance and performance of aseptic technique in all operative procedure.
• Checks availability of supplies and ensures that all equipments are functional.
• Affords complete stock of emergency drugs as much as possible and provide an updated checklist.
• Provide ample time in the inventory of equipments monthly and bi-semester.
• Supervises nursing activities that will improve the skills of quality of care given to the patient.
• Holds post conferences and attends nursing service monthly meetings and other hospital related activities.
• Evaluates performance of staff every six (6) months.
• Goes on 8 hours duty when understaff.
• Ensures disaster preparedness of both the staff and supplies and emergency drugs to be used.
• Supervises and manages the workflow of the OPD – ER section.
• Plans and makes improvements and or innovations in the area.
Actual Duties ER Nurse II and Nurse I

7am – 3pm / 8am – 4pm
• Checks emergency drugs and equipments if functional.
• Admits and carries out stat orders during emergency cases.
• Assess patients’ condition and gives initial treatment according to SOP.
• Inform physicians and assists during internal examinations.
• Observes medical and surgical aseptic techniques.
• Prepares instruments and assists physician during minor surgical procedures, OB Gyne and Pedia-
medical cases.
• Sends patients for stat diagnostic procedures before transporting to ward.
• Cleans and dries instruments used ready for sterilization.
• Makes supplies like dressing sponges and cotton balls and changes disinfectant solutions.
• Attach to patients chart emergency drugs used and follow up replacement of such.
• Check stretcher siderails and provide patients private body parts privacy while transporting to ward.
• Maintain cleanliness and orderliness in the unit.
• Plans and makes innovative improvements in the area.
• Acts as Nurse III in her absence.
3pm - 11pm
• Admits and carries out stat orders during emergency cases.
medical cases.
• Sends patients for stat diagnostic procedures before transporting to ward.
11pm - 7am
• Admits and carries out “stat” orders during emergency cases.
medical cases.
• Sends patients for “stat” diagnostic procedures before transporting to ward.
Actual Duties OPD Nurse

8am - 4pm
• Gives specific assignments to OPD staff.
• Checks availability of supplies and articles in OPD.
• Gets supplies and instruments from the ER.
• Collects OPD cards from the different consultation rooms for filing.
• Prepare the numbers to be used for the day.
• Emphasizes the schedule of consultation time to the clients.
• Records correctly client’s biodata, chief complaints and vital signs.
• Does dressing of wounds and removal of stitches per doctors’ order.
• Refer to physician in charge with regards to patient’s complaints and illness.
• Administers medications and treatments per doctors’ order.
• Conducts lecture on prenatal and postnatal care, breastfeeding, diabetes and other health teachings.
• Sees to it that all OPD cards are properly filed according to patients case number and segregated as
special cases like medico-legal, rabies, pre-natal and the like.
• Checks flow chart if its still effective and recommends suggestions to improve the service.
• Attends post conferences and nursing service monthly meetings.
• Maintains cleanliness and orderliness in the area.
• Helps ER staff or may go on duty at ER when the need arises.
Actual Duties of OPD Nursing Attendant

8am - 5pm
• Maintains cleanliness and orderliness of the unit.
• Changes and refills dressing containers with sterile gauze, cotton balls and instruments.
• Checks that all equipments are functioning.
• Prepares and arranges OPD priority numbers before the start of the consultation.
• Accurately fills up patient’s data, chief complaints, weight, and vital signs in the patients’ card.
• Instructs and sends patient to their respective consultation rooms.
• Collects, sort and properly file OPD cards in their respective cabinets.
• Attends ER-OPD post conferences and nursing service monthly meetings.
• Helps and or goes on duty in the emergency room when needed.
Actual Duties of ER Nursing Attendant

7am - 3pm
• Reports to duty 15 minutes ahead of time.
• Receives endorsement from the outgoing shift
• Checks supplies and equipments if clean and functional.
• Makes, packs and sterilizes supplies for ER use.
• Takes patients complete data, and vital signs before admission.
• Informs physician of patients condition and assists during medical, obstetrical and surgical examinations.
• Prepares and assists physician during minor surgical procedures, OB-GYNE, medical and pediatric cases.
• Observes medical and surgical asepsis.
• Do after care of all instruments used ready for sterilization.
• Changes disinfectant soaking solutions for forceps and sharps.
• Tidy area before endorsement.
• Accompanies patient to the ward and endorse to ward staff.
• Endorses patient for other related activities to the next shift.
3pm - 11pm
• Informs physician of patients condition and assists during medical, obstetrical and surgical examinations.
11pm - 7am
• Informs physician of patients’ condition and assists during medical, obstetrical and surgical examinations.
APPENDIX F
CHECKLIST
CHECKLIST FOR HANDRUB WITH ALCOHOL-BASED FORMULATION
PREPARATION
• If hands not visibly dirty, locate alcohol-based hand rub container.
SKILLS/ACTIVITY PERFORMED SATISFACTORILLY
• Apply 5 ml. of hand rub product in a cupped hand and spread out to cover all surfaces.
• Rub hands palm to palm.
• Rub right palm over back of left hand with interlace fingers.
• Rub left palm over back of right palm with interlace fingers.
• Rub palm to palm with fingers interlaces.
• Rub back of fingers of right hand over palm of left hand with finger interlocked.
• Rub back of fingers of left hand over palm of right hand with finger interlocked.
• Rotationally rub right thumb while clasped in left palm.
• Rotationally rub left thumb while clasped in right palm.
• Rotationally rub backwards and forwards with clasped fingers of right hand in left palm.
• Rotationally rub backwards and forwards with clasped fingers of left hand in right palm.
CHECKLIST FOR DONNING AND REMOVING PPE (personal protective equipment)

PREPARATION
DONNING PPE
• Check the availability of all PPE, hand sanitizer and disposable bins.
• Do risk assessment on what procedure to be done to determine the appropriate PPE to be worn.
• Wash hands with soap and water or use alcohol-based hand rub.
• Don PPE in the following sequence:
• Gown first
• Mask or respirator covering nose and mouth
• Protective eyewear: visitor, face shield or goggles
• Gloves

• Remove PPE in the following sequence (not touching contaminated parts):
• Gloves
• Gown
• Hand hygiene
• Protective eyewear
• Discard PPE in waste container.
• Remove mask or respirator.
• Wash hands with soap and water or use alcohol-based hand rub.
CHECKLIST FOR CLEANING AND DISINFECTING REUSABLE RESPIRATORY EQUIPMENT

PREPARATION
• Perform routine hand hygiene.
• Put on the proper PPE
A gown
A rubber apron
Face shield or medical mask and protective eyewear
Rubber utility gloves
Cleaning and disinfecting suction catheters
• Fill a plastic container (or utility sink) with water.
• Using a brush and liquid or powder detergent, scrub tubing under the surface of the water, removing all
blood and other foreign matter.
• Pass soapy water through the catheters three times.
• Thoroughly rinse the instrument and other items with clean water three times (inside and outside).
• Select an appropriate method of HLD.
• Rinse with sterile or clean water.
• Air dries before use and storage.
Cleaning and disinfecting plastic airways
• Wash all surfaces with soap and water.
• Rinse with clean water until no soap remains.
Cleaning and disinfecting ventilator tubing
• Using a brush, wash with soap and water.
• Rinse with clean water until no soap remains.
Cleaning and disinfecting ambu bags and CPR face masks
• Wipe exposed surfaces with a gauze pad soaked in 60-90% alcohol or 0.5% chlorine. If surfaces are
soiled with organic substances such as blood or other body fluids, uese0.5% chlorine solution. Alcohol is not effective in
the presence of organic matter.
• Rinse immediately.
• Wash exposed surfaces with soap and water.
• Rinse with clean water.
PPE and hand hygiene after cleaning
• Remove all PPE without touching contaminated areas.
• Wash hands with soap and running water. Dry with a clean, individual towel or paper towel, or allow hands
to air dry.
OR
Rub hands with alcohol-based solution until the hands are dry (if hands are not visibly soiled).
CHECKLIST FOR HANDWASHING WITH SOAP AND WATER

PREPARATION
1. Check the availability of the sink, clean water, soap, towel and disposal waste bin.
2. Remove all jewelries.
3. Moisten hands thoroughly with soap and running water.
4. Thoroughly wash all areas of hands and fingers for at least 10-15 seconds.
5. Rub hands palm to palm.
6. Rub right palm over back of left hand with interlace fingers.
7. Rub left palm over back of right palm with interlace fingers.
8. Rub palm to palm with fingers interlaces.
9. Rub back of fingers of right hand over palm of left hand with finger interlocked.
10. Rub back of fingers of left hand over palm of right hand with finger interlocked.
11. Rotationally rub right thumb while clasped in left palm.
12. Rotationally rub left thumb while clasped in right palm.
13. Rotationally rub backwards and forwards with clasped fingers of right hand in left palm.
14. Rotationally rub backwards and forwards with clasped fingers of left hand in right palm.
15. Rinse hand thoroughly with clean water.
16. Dry with a personal towel or a single-use paper towel and use the towel to turn-off the faucet, or air dry hands.
17. Throw paper towel into the basket (is using personal towel, hang and allow to air dry).
CHECKLIST FOR TRACHEOSTOMY CARE AND ASSISTING AN ENDOTRACHEAL INTUBATION
I.Tracheostomy Care
Cleaning the Trach
-Wash your hands
-Unlock the inner cannula and remove it.
-Put a clean wet inner cannula inside the outer cannula.
-Clean the dirty cannula, Scrub it and soak it in 3 percent hydrogen peroxide
-When the bubbling stops, clean the cannula with the brush and disinfect the outer cannula with 70%
alcohol.
-Dress the stoma with betadine solution
-Rinse the inner cannula under running water
Using a Trach Bib
-Open a 4-inch by 4-inch gauze pad
-Cut the center of the gauze
-Place the bib under the trach plate with the "U"upright
Suctioning the Trach Tube
-Turn on the suction machine
-Fill the small bowl with some of the sterile water.
-Wash your hands.
-Take the suction catheter out of its package.
- Hook it to the suction tubing on the suction machine.
- Dip the catheter tip into the sterile water.
-Instruct the patient to take a few deep breaths.
-Gently thread the wet catheter into the trach tube.
- Advance the catheter 5 to 8 inches, until you feel it pushing against something.
-The control valve is the small hole near the end of the suction catheter that is in your hand. Covering
it starts the suction.
If the patient cough out the trach tube
-First use a syringe to take the air out of the cuff on the inner cannula, and then remove it from the
outer cannula.
-Put the obturator into the outer cannula.
-Insert the obturator and outer cannula through your stoma
II. Assisting an Endotracheal Intubation

Indications:
1. Inadequate oxygenation
2. Inadequate ventilation
3. Need to control and remove pulmonary secretions
4. Need to provide airway protection in an obtunded patient or a patient with a depressed gag reflex
1. Check the doctor’s order.

2. Prepare the materials at bedside
3. Ventilate the patient with the bag-valve combination for 1-2 minutes with 100% oxygen. After
ventilating the patient, the doctor will proceed the direct laryngoscopy and when visualizing the glottis
and vocal cords ,gently pass the tube next the laryngoscope blade through the vocal cords into trachea,
far enough so that the balloon is just beyond the cords. The doctor will withdraw the stylet/guide wire.
4. With 10 ml syringe, inflate the balloon with 5-8 ml of air.
5. Connect the bag-valve combination, and begin ventilation with 100% oxygen (attach to oxygen with
(8-10 L/min.). The doctor will confirm that the tube is properly positioned by listening to each side of the
chest; the breath sounds are equal in both sides of the thorax.
6. Clean the area with surgical sponge soak with sterile water.
7. Secure the ETT using adhesive tape around the tube.
8. Check the vital signs, and refer for any unusualities.
9.After care of used materials
TOTAL SCORE
APPENDIX G
ENVIRONMENTAL CARE AND WASTE MANAGEMENT
a) Routine cleaning is important to ensure a clean and dust free hospital
environment.
b) Administrative and office areas with no patient contact requires normal domestic
cleaning.
c) Patient area should be cleaned by wet mopping.
d) Areas visibly contaminated with blood or body fluids should be cleaned
immediately with detergent and water.
e) Isolation rooms and other areas that have patients with known transmissible infectious
diseases should be cleaned with a disinfectant solution at least daily.
f) After discharge of patients with transmissible infectious diseases, the room should be
under the ultraviolet light exposure for at least 8 hours.
PRINCIPLES OF WASTE MANAGEMENT

a) segregate clinical waste from non-clinical waste in dedicated container
b) transport waste in dedicated trolly
c) sharps should be placed in plastic container with lid
GENERAL NEEDLE STICK AND SHARP OBJECT GUIDELINES

a) Never recap use needles.
b) Never direct the point of a needle towards any part of the body except prior to injection.
c) Do not remove used needles from disposal syringes by hand and do not bend, break or
otherwise manipulate needles by hand.
d) Dispose of syringes, needles, scalpel blades and other sharp items in appropriate
puncture resistant containers which should be located as close as possible to the area in
which the items were used.
e) Avoid the use of re-usable syringes. Do not re-sterilize needles.
f) Care must be taken to prevent any injuries to the health care workers or to the patients
when using, cleaning or disposing of needles, scalpels or other sharp instruments or
devices.
AIRBORNE PRECAUTIONS are design to rteduce the transmission of diseases by the airborne route. Ex. Active
PTB, measles, chicken pox, hemorrhagic fever and pneumonia.
a) implement standard precaution
b) place patient in a single room
c) keep doors closed
d) use high filtration particulate respirator
e) limit movement of patient. If transport is necessary let patient wear mask.
DROPLET PRECAUTION
Droplet transmission occurs when there is adequate contact between the mucous membranes of the nose,
mouth and conjuctiva of a susceptible person.
a) standard precaution
b) place patient in a single room
c) wear surgical mask within 1 to 2 meters of the patient
d) let patient wear mask if transport is necessary
CONTACT PRECAUTION
diseases are transmitted by this route include colonization or infection with multiple antibiotics resistant
microorganism, enteric infections and skin infections.
a) implement standard precaution
b) isolate patient
c) wear clean, non sterile gloves and gown when entering the room if substancial contact
with the patient, environmental surfaces or items in the patient's room is anticipated.
d) limit movement of patient. If transport is required, use precautions to minimize the risk
of transmission.
PROCEDURE ON ISOLATION AND CONTAINMENT OF NASOCOMIAL INFECTION

a) In an open ward there should be adequate spacing between each bed to reduce the risk
of cross contamination/infection
b) If single rooms are not available patient cohorting is necessary
c) There should be hand washing, toilet and bathroom facilities.
GENERAL PPE GUIDELINES

a) Hand washing should always be performed despite PPE use.
b) remove and replace if necessary any damage or broken pieces of re-usable PPE
c) remove all PPE as soon as possible after completing the care and avoid contaminating
- the environment
- any other patient or worker
- yourself
d) discard all items of PPE carefully and perform hand hygiene immediately afterwards.

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REPUBLIC OF THE PHILIPPINE

BUTUAN MEDICAL CENTER

POLICY MANUAL OF NURSING SERVICE

NURSING SERVICE MANUAL OF POLICIES & PROCEDURES

As a new staff member, this

Think of the betterment of the organization rather than oneself.

I solemnly pledge myself before God and presence of this assembly;

Philosophy of nursing care of patients:

The best possible quality patient care delivery.

C. Over-all objectives of the nursing service in writing:

2. The professional nurse practitioner will be helped to ;

2. Operating Room – Delivery Room Services:

3. Out-patient department-emergency room:

1. Punctuality in reporting to duty

3. Logbook or Bundy clock

10. Personnel Addresses

11. Personal Records

Personal records are kept on each staff member including such

13. Leaving the ward or post while on duty

Taking meals outside the hospital premises is not permissible.

14. Entertaining visitors

Personal visitors should not be entertained while on duty.

Fines imposed for the following:

-Personnel must avoid using telephone for unnecessary reasons.

18.Respect and courtesy

19. Initiative to help one another

21. Loyalty and service oriented

22. Frequent Rounds

23. Staff Meeting

New personnel nursing dept. requirements are the following ;

The following are prescribed rotation during orientation;

VOLUNTEER NURSE POLICIES

1. All volunteers are under the supervision of a regular employee.

NURSING SERVICE POLICIES ON AFFILIATION AND TRAINING OF STUDENTS

3. To assist Clinical Instructors in the supervision for qualitative learning

B. CLINICAL INSTRUCTORS (CI)

Rules in rating (performance evaluation system)

B. Philhealth and hospital accommodation

Room Number Last name, first name of patient

1. Properly filled up requests for X-ray stating;

B. Scheduling of Special Radiographic Procedures

C. Scheduling of cases requiring patient preparation

1. Special radiographic procedures requiring preparation should be

D. Procedures for submission of X-ray results

E. Procedure for borrowing X-ray films or records

DIETARY DEPT. RULES and REGULATIONS

K.Daily nursing care plan

Iii. Vital Signs

a. TEMPERATURE may vary with time of the day

Adult = normally 6 - 20 respirations/min.

All patients receiving special treatments such as perilight exposure, nebulization,

1) Intake and output should be recorded in figure.

L. Preparation of patients scheduled for surgery

M. Dressing of surgical in-patients

N. Communicable isolation technique

CHARTING AND RECORDING

A. All charting must be written legibly.

1.) Morning shift (7-3) uses the blue ink in charting.

DATE : SHIFT : Bottle no.: IV SOL’N: TIME STARTED:TIME ENDED:SIGN:REMARKS

PATIENT SUMARY SHEET