KEY PERFORMANCE INDICATOR

Blood Transfusion
This shape represents a table slicer. Table slicers are supported in Excel or later.
SIGN OUT If the shape was modified in an earlier version of Excel, or if the workbook was saved in Excel 20
HUGS & KISSES the slicer can't be used.

TIME OUT
DELAY
FALL RISK
SBAR
IPSG 1
GLUCOMETER
HIGH ALERT
TELEPHONE/VERBAL
ORDER

PAIN
CORRECT ID

Breast Milk

IV CANNULATION

KPI COMPLIANCE

IPSG 1: COMPLIANCE RATE WITH CORRECT 100%

PATIENT IDENTIFICATION
Timeliness of Reporting Panic Result of Glucometer
DELAY OF CALLING PHYSICIAN 0%
IPSG 2 IMPROVE EFFECTIVE
COMMUNICATION (Telephone/Verbal Order/
Panic Result)
IMPROVE EFFECTIVE COMMUNICATION
(IPSG NO. 2) Telephone Order, Verbal Order
Compliance Rate
IMPROVE EFFECTIVE COMMUNICATION 100%
(IPSG NO. 2) SBAR
COMPLIANCE ON SAFETY OF HIGH ALERT 100%
MEDICATION
COMPLIANCE WITH NON OR SURGICAL TIME
OUT PROCEDURE
NON OR TIME OUT MONITORING FORM
Compliance with Fall Risk Assessment 100%
SAFETY IN BLOOD TRANSFUSION
Blood and Blood Products Tracking Form
SUCCESS RATE OF INSERTING IV CANNULA
ON FIRST ATTEMPT SHEET
Compliance with Hugs and Kisses
Rate of Breastfeeding Newborn during Hospital Stay 0%
Proper Identification of Expressed Breast Milk
MONTHLY PRESSURE INJURY 0%
PAIN ASSESSMENT COMPLIANCE RATE
 LABOR AND DELIVERY

KEY PERFORMANCE INDICATOR

120%
later. 100.00% 100.00%
100.00% 100.00%
100%
k was saved in Excel 2007 or earlier, 80%

60%

40%

20%
0.00% 0.00% 0.00%
0%

OMPLIANCE
 HOME

TOR

%00% 100.00%

0.00% 0.00%
 NURSING DEPARTMENTAL INDICATORS
EMERGENCY ROOM DEPARTMENT
MONTHLY COMPLIANCE RATE (%)
2022
Target
INDICATOR NAME JAN FEB MARCH APRIL MAY JUN JUL AUG SEPT OCT NOV DEC
Rate
96.46 99.09 97.23 97.51 99.04 97.6 98.7 99.26
Success rate of inserting IV cannula on 1st
95
attempt 97.41 96.19 97.17 96.85 97.21 97.9 99.7

100 100 100 100 100 100 100 100

Pain Assessment Compliance Rate 100
99.29 99.83 99.67 100 100 100 100

Legend:

NA- Not Applicable Area Compliance Rate Overall Compliance Rate

Prepared by: Julie Ann Lazarra Approved by: Mr. Rami Khalil Qtaish
(A) Nursing QI Coordinator
 NURSING DEPARTMENT
HOSPITAL WIDE INDICATORS
OVERALL MONTHLY COMPLIANCE RATE (%)
2022
Target
INDICATOR NAME JAN FEB MARCH APRIL MAY JUN JUL AUG SEPT OCT NOV DEC
Rate

IPSG INTERNATIONAL PATIENT SAFETY GOAL

Compliance Rate with correct patient

1 NC NC NC NC NC 83.3 NC 100
identification

Telephone Order, Verbal Order Compliance Rate 100 100 100 100 100 100 100 100

Timeliness of Reporting Panic result of

100 100 100 100 100 100 100 100
2 Glucometer
Nursing SBAR Compliance Rate 0.41 0 1.57 3.75 2.43 3.78 0 0

Delay of Physician Answering Nurses Phone Calls 99.13 100 100 100 100 99.9 100 100

3 Compliance on safety of High alert medication 100 100 100 100 100 100 100 100
Compliance with Non OR Surgical Time Out
100 100 100 100 100 100 100 100
Procedure
5 IC c/o Infection Control Team
6 Compliance with Fall Risk Assessment 0 0 0 0 0 0 0 100 0
NURSING LIBRARY OF MEASURES
Compliance of Blood and Blood Component
0.54 0 0 0 0.21 0 0 NC 0
Transfusion
Patient Fall Incident 0 0 0 0 0 0 0 0.0023 0 0 0 0 0
Legend: NC – No Case

Prepared by: Julie Ann Lazarra Approved by: Mr. Rami Khalil Qtaish
(A) Nursing QI Coordinator
 NURSING DEPARTMENTAL INDICATORS
EMERGENCY ROOM DEPARTMENT
DATA AGGREGATION
2022
JULY

Non compliance- unit

30.00%
27.27%

25.00%

20.00%

15.00%

10.00%

5.00%

0.00%

1. Monitor staff performance with regards to cannulation.

2. All newly hired nurses will undergone IV therapy training course as a mandatory requirement before they will
handle patient to ensure staff competency.
3. With available Vein Finder Machine (Accuvein) to aid staff in finding difficult vein.
4. Monitoring staff compliance with adherance to policy. The nurse can insert cannula for two attempts, if failed
Charge Nurse will insert or call the Nursing Supervisor to arrange the most Senior staff or expert Nurse or
Phlebotomy Nurse, if still failed the Nurse can call the anesthesiologist on call to insert cannula.
 LABOUR & DELIVERY KEY PERFORMANCE IN
KPI TYPES CHECK IF DATA COLLECTOR
DONE

HOSPITAL WIDE OB GYNE IPSG 1

HOSPITAL WIDE OB GYNE IPSG 2

HOSPITAL WIDE ✘
LD IPSG 2

HOSPITAL WIDE LD IPSG 2

HOSPITAL WIDE OB GYNE IPSG 2

HOSPITAL WIDE OB GYNE IPSG 2

HOSPITAL WIDE OB GYNE IPSG 3

HOSPITAL WIDE OB GYNE IPSG 4

HOSPITAL WIDE LD IPSG 4

HOSPITAL WIDE OB GYNE IPSG 4

HOSPITAL WIDE OB GYNE IPSG 6

NURSING LIBRARY
OB GYNE
OF MEASURES

NURSING LIBRARY
LD
OF MEASURES

UNIT KPI LD

UNIT KPI OB GYNE

UNIT KPI LD

UNIT KPI OB GYNE

 SUBMIITTED BY:

KPI OWNER L&D HEAD NURSE

KPI OWNER L&D Quality Coordinator
KPI AUDITOR OB GYNE HEAD NURSE
KPI AUDITOR OB GYNE Quality Coordinator
R & DELIVERY KEY PERFORMANCE INDICATOR REVIEW
PERIOD

KEY PERFORMANCE INDICATOR JULY 2023

IPSG 1: COMPLIANCE RATE WITH CORRECT PATIENT IPSG 1 1

IDENTIFICATION

Timeliness of Reporting Panic Result of Glucometer GLUCOMETER 1

COMMUNICATION RECORD BOOK FOR DOCTORS DELAY 1

IPSG 2 IMPROVE EFFECTIVE COMMUNICATION PANIC 1

(Telephone/Verbal Order/ Panic Result)

IMPROVE EFFECTIVE COMMUNICATION (IPSG NO. 2) Telephone TELEPHONE/VERBAL ORDER

1
Order, Verbal Order Compliance Rate

IMPROVE EFFECTIVE COMMUNICATION (IPSG NO. 2) SBAR

SBAR 1

HIGH ALERT
COMPLIANCE ON SAFETY OF HIGH ALERT MEDICATION 1

COMPLIANCE WITH NON OR SURGICAL TIME OUT TIME OUT 1

PROCEDURE
NON OR TIME OUT MONITORING FORM NON-OR 1

COMPLETION OF SIGN OUT PROCEDURE IN NON – OR AREA SIGN OUT 0

FALL RISK
Compliance with Fall Risk Assessment 1

Blood Transfusion
SAFETY IN BLOOD TRANSFUSION 1

Blood and Blood Products Tracking Form BT TRACKING 1

SUCCESS RATE OF INSERTING IV CANNULA ON FIRST IV CANNULATION

1
ATTEMPT SHEET

Compliance with Hugs and Kisses HUGS & KISSES 1

Percentage of newborns compliance with correct CORRECT ID 1

ID

PAIN ASSESSMENT COMPLIANCE RATE

PAINBREASTMILK
PRESSURE
EXPRESSED INJURY 1

19
 SUBMIITTED BY: DATE SUBMITTED
THELMA BOYLES 31569/ L&D 7/30/2023
7/30/2023
YURAIDEL AMPATUAN/OB GYNE 7/30/2023
STEPHANIE AQUINO/ OB GYNE 7/30/2023
 LABOR AND
MAP DELIVERY
NON DATA AGGREGAT
COMPLIANCE SAMPLES
NUMERATOR
DENOMINATOR combined COMPLIANC COMMENTS COLECTED
E

128 128 100% 0.00% ADMISSION 0 DONE AUDITORS

0 0 NO CASE 0
LACKING SAMPLES MUST BE
AT LEAST 64

0 128 0% 0.00% 0 0 Pease Follow up KPI

GRAPHS
LACKING SAMPLES MUST BE
NO CASE 0 AT LEAST 64
ATTENDANCE

0 0 NO CASE 0
LACKING SAMPLES MUST BE
AT LEAST 64

128 128 100% 0.00% 0 128 DONE

PETHEDINE
128 128 100% 0.00% INJECTION
128 DONE

0 0 NO CASE 1
LACKING SAMPLES MUST BE
AT LEAST 64
NA NA NO CASE 0
LACKING SAMPLES MUST BE
AT LEAST 64

0 0 0 0

129 129 100% 0.00% On Admission 130 DONE

0 0 no bt reaction 4
LACKING SAMPLES MUST BE
AT LEAST 64

0 0 0 0
LACKING SAMPLES MUST BE
AT LEAST 64

0 0 0 0
LACKING SAMPLES MUST BE
AT LEAST 64

0 0

0 0

130 130 100% 0.00% 0 130 DONE

 DATA AGGREGATION

AUDITORS

GRAPHS

ATTENDANCE
 NURSING DEPARTMENT
PI Auditors Attendance
To be log by Unit CN on duty
UNIT: LABOR AND DELIVERY MONTH JULY 2023
CN ON
NO. DATE NAME ID NO. DUTY
NAME/ID KPI
NO.
Pain , bt,ipsg1, ham,
1.         21/0/62023 stephanie aquino 180184
fall risk, sbar,
2.         22/06/2023 stephanie aquino 180184 hk,bt, pain, gluco
Pain , bt,ipsg1, ham,
3.         23/06/2023 stephanie aquino 180184
fall risk, sbar,
Pain , bt,ipsg1, ham,
4.         24/06/2023 stephanie aquino 180184
fall risk, sbar,
Pain , bt,ipsg1, ham,
5.         25/06/2023 stephanie aquino 180184
fall risk, sbar,
6.         26/06/2023 stephanie aquino 180184 hk,bt, pain, gluco
Pain , bt,ipsg1, ham,
7.         27/06/2023 stephanie aquino 180184
fall risk, sbar,
8.         28/06/2023 stephanie aquino 180184 hk,bt, pain, gluco
Pain , bt,ipsg1, ham,
9.         1/7/2023 stephanie aquino 180184
fall risk, sbar,
Pain , bt,ipsg1, ham,
10.     2/7/2023 stephanie aquino 180184
fall risk, sbar,
Pain , bt,ipsg1, ham,
11.     3/7/2023 stephanie aquino 180184
fall risk, sbar,
Pain , bt,ipsg1, ham,
12.     9/7/2023 stephanie aquino 180184
fall risk, sbar,
Pain , bt,ipsg1, ham,
13.     13/7/2023 stephanie aquino 180184
fall risk, sbar,
ipsg2,
14.     20/7/2023 stephanie aquino 180184 h&k,panic,bt,time
out,gluco,non or
15.    
16.    
17.    
18.    
19.    
20.    
21.    
22.    
23.    
24.    
25.    
26.    
27.    
28.    
29.    
30.    
31.    
32.    
33.    
34.    
35.    
36.    
37.    
38.    
39.    
40.    
41.    
42.    
43.    
44.    
45.    
46.    
47.    
48.    
49.    
50.    
51.    
52.    
53.    
 H
O
M
E
Nursing Department
Key Performance Improvement
Unit/Area : LABOR AND DELIVERY Review Period: JULY 2023

Proper Identification of Expressed Breast Milk

CRITERIAS:
1. Addressograph of the mother was applied in the bottle/container.
2.Addressograph of the baby was applied in the bottle/container.
3.Container used for expressed breast milk is appropriate. (Sterile feeding bottles, Milk Bags/Syringes).
Expressed breast milk stored in milk bag must be double-bagged with zip lock plastic bag/stored inside a
rigid plastic container.
4. Expressed breast milk containers were properly labeled. Noting the date and time it was pumped.
5.
6. Expressed
Nurse whobreast milkthe
will store stored shouldbreast
expressed not exceed
milk to100
theml per milk bag
refrigerator or freezer wrote her initials and ID
number.
7. First in, first use policy is followed.
KEY CODES: PRESENT/YES=1 ABSENT/NO=0 NOT APPLICABLE = N/A
Mothers File Baby's File Criterias Total
No. Staff ID No. Number Number
Date
Compliance Remarks
1 2 3 4 5 6 7
1 ###
2 ###
3 ###
4 ###
5 ###
6 ###
7 ###
8 ###
9 ###
10 ###
11 ###
12 ###
13 ###
14 ###
15 ###
16 ###
17 ###
18 ###
19 ###
20 ###
21 ###
22 ###
23 ###
24 ###
25 ###
26 ###
27 ###
28 ###
29 ###
30 ###
31 ###

Page 20 EBM
 Proper Identification of Expressed Breast Milk
CRITERIAS:
1. Addressograph of the mother was applied in the bottle/container.
2.Addressograph of the baby was applied in the bottle/container.
3.Container used for expressed breast milk is appropriate. (Sterile feeding bottles, Milk Bags/Syringes).
Expressed breast milk stored in milk bag must be double-bagged with zip lock plastic bag/stored inside a
rigid plastic container.
4. Expressed breast milk containers were properly labeled. Noting the date and time it was pumped.
5.
6. Expressed
Nurse whobreast milkthe
will store stored shouldbreast
expressed not exceed
milk to100
theml per milk bag
refrigerator or freezer wrote her initials and ID
number.
7. First in, first use policy is followed.
KEY CODES: PRESENT/YES=1 ABSENT/NO=0 NOT APPLICABLE = N/A
Mothers File Baby's File Criterias Total
No. Staff ID No. Number Number
Date
Compliance Remarks
1 2 3 4 5 6 7
32 ###
33 ###
34 ###
35 ###
36 ###
37 ###
38 ###
39 ###
40 ###
41 ###
42 ###
43 ###
44 ###
45 ###
46 ###
47 ###
48 ###
49 ###
50 ###
51 ###
52 ###
53 ###
54 ###
55 ###
56 ###
57 ###
58 ###
59 ###
60 ###
61 ###
62 ###
63 ###
64 ###
65 ###
66 ###
67 ###
68 ###
69 ###
70 ###
71 ###
72 ###

Page 21 EBM
 Proper Identification of Expressed Breast Milk
CRITERIAS:
1. Addressograph of the mother was applied in the bottle/container.
2.Addressograph of the baby was applied in the bottle/container.
3.Container used for expressed breast milk is appropriate. (Sterile feeding bottles, Milk Bags/Syringes).
Expressed breast milk stored in milk bag must be double-bagged with zip lock plastic bag/stored inside a
rigid plastic container.
4. Expressed breast milk containers were properly labeled. Noting the date and time it was pumped.
5.
6. Expressed
Nurse whobreast milkthe
will store stored shouldbreast
expressed not exceed
milk to100
theml per milk bag
refrigerator or freezer wrote her initials and ID
number.
7. First in, first use policy is followed.
KEY CODES: PRESENT/YES=1 ABSENT/NO=0 NOT APPLICABLE = N/A
Mothers File Baby's File Criterias Total
No. Staff ID No. Number Number
Date
Compliance Remarks
1 2 3 4 5 6 7
84 ###
85 ###
86 ###
87 ###
88 ###
89 ###
90 ###
91 ###
92 ###
93 ###
94 ###
95 ###
96 ###
97 ###
98 ###
99 ###
100 ###
101 ###
102 ###
103 ###
104 ###
105 ###
106 ###
107 ###
108 ###
109 ###
110 ###
111 ###
112 ###
113 ###
114 ###
115 ###
116 ###
117 ###
118 ###
119 ###
120 ###
121 ###
122 ###
123 ###
124 ###

Page 22 EBM
 Proper Identification of Expressed Breast Milk
CRITERIAS:
1. Addressograph of the mother was applied in the bottle/container.
2.Addressograph of the baby was applied in the bottle/container.
3.Container used for expressed breast milk is appropriate. (Sterile feeding bottles, Milk Bags/Syringes).
Expressed breast milk stored in milk bag must be double-bagged with zip lock plastic bag/stored inside a
rigid plastic container.
4. Expressed breast milk containers were properly labeled. Noting the date and time it was pumped.
5.
6. Expressed
Nurse whobreast milkthe
will store stored shouldbreast
expressed not exceed
milk to100
theml per milk bag
refrigerator or freezer wrote her initials and ID
number.
7. First in, first use policy is followed.
KEY CODES: PRESENT/YES=1 ABSENT/NO=0 NOT APPLICABLE = N/A
Mothers File Baby's File Criterias Total
No. Staff ID No. Number Number
Date
Compliance Remarks
1 2 3 4 5 6 7
125 ###
126 ###
127 ###
128 ###
Total Compliance of each activities NA NA NA NA NA NA NA

Total Compliance of overall activities 0% ###

Audited by : ARNEL APATTAD Date Submitted: 9/15/2022

(Name/ID #/Unit)
1st Data Collector

ASWANI KRISHNAN
(Name/ID #/Unit)
1st Data Collector

Page 23 EBM
 H
O
M HOME
E
Nursing Department
Key Performance Improvement
Unit/Area LABOR AND DELIVERY Review Period: JULY 2023

Rate of Breastfeeding Newborn during Hospital Stay

CRITERIAS:
1. 1. Physician encourage breastfeeding
2. Nurse or Patient Teaching Coordinator educate and encourage the breastfeeding
3. Rooming in and Initiation of Breastfeeding done.
4. Breastfeeding initiation was documented on the file
KEY CODES: PRESENT/YES=1 ABSENT/NO=0 NOT APPLICABLE = N/A
Mothers File Baby's File Criterias Total
No. Staff ID No. Number Number
Date
Compliance Remarks
1 2 3 4
1 ###
2 ###
3 ###
4 ###
5 ###
6 ###
7 ###
8 ###
9 ###
10 ###
11 ###
12 ###
13 ###
14 ###
15 ###
16 ###
17 ###
18 ###
19 ###
20 ###
21 ###
22 ###
23 ###
24 ###
25 ###
26 ###
27 ###
28 ###
29 ###
30 ###
31 ###
32 ###
33 ###

Page 24 RBF
 Rate of Breastfeeding Newborn during Hospital Stay
CRITERIAS:
1. 1. Physician encourage breastfeeding
2. Nurse or Patient Teaching Coordinator educate and encourage the breastfeeding
3. Rooming in and Initiation of Breastfeeding done.
4. Breastfeeding initiation was documented on the file
KEY CODES: PRESENT/YES=1 ABSENT/NO=0 NOT APPLICABLE = N/A
Mothers File Baby's File Criterias Total
No. Staff ID No. Number Number
Date
Compliance Remarks
1 2 3 4
34 ###
35 ###
36 ###
37 ###
38 ###
39 ###
40 ###
41 ###
42 ###
43 ###
44 ###
45 ###
46 ###
47 ###
48 ###
49 ###
50 ###
51 ###
52 ###
53 ###
54 ###
55 ###
56 ###
57 ###
58 ###
59 ###
60 ###
61 ###
62 ###
63 ###
64 ###
65 ###
66 ###
67 ###
68 ###
69 ###
70 ###
71 ###
72 ###

Page 25 RBF
 Rate of Breastfeeding Newborn during Hospital Stay
CRITERIAS:
1. 1. Physician encourage breastfeeding
2. Nurse or Patient Teaching Coordinator educate and encourage the breastfeeding
3. Rooming in and Initiation of Breastfeeding done.
4. Breastfeeding initiation was documented on the file
KEY CODES: PRESENT/YES=1 ABSENT/NO=0 NOT APPLICABLE = N/A
Mothers File Baby's File Criterias Total
No. Staff ID No. Number Number
Date
Compliance Remarks
1 2 3 4
84 ###
85 ###
86 ###
87 ###
88 ###
89 ###
90 ###
91 ###
92 ###
93 ###
94 ###
95 ###
96 ###
97 ###
98 ###
99 ###
100 ###
101 ###
102 ###
103 ###
104 ###
105 ###
106 ###
107 ###
108 ###
109 ###
110 ###
111 ###
112 ###
113 ###
114 ###
115 ###
116 ###
117 ###
118 ###
119 ###
120 ###
121 ###
122 ###
123 ###
124 ###

Page 26 RBF
 Rate of Breastfeeding Newborn during Hospital Stay
CRITERIAS:
1. 1. Physician encourage breastfeeding
2. Nurse or Patient Teaching Coordinator educate and encourage the breastfeeding
3. Rooming in and Initiation of Breastfeeding done.
4. Breastfeeding initiation was documented on the file
KEY CODES: PRESENT/YES=1 ABSENT/NO=0 NOT APPLICABLE = N/A
Mothers File Baby's File Criterias Total
No. Staff ID No. Number Number
Date
Compliance Remarks
1 2 3 4
125 ###
126 ###
127 ###
128 ###
Total Compliance of each activities NA NA NA NA

Total Compliance of overall activities ###

YURAIDEL AMPATUAN/OB
Audited by : GYNE Date Submitted: 7/30/2023
(Name/ID #/Unit)
1st Data Collector

STEPHANIE AQUINO/ OB GYNE

(Name/ID #/Unit)
1 Data Collector
st

Page 27 RBF
 H
O
M
E
NURSING DEPARTMENT
Blood and Blood Products Tracking Form
Unit/Area:LABOR AND DELIVERY Month: JULY 2023

DATE AND DATE AND

TYPE OF AMOUNT
No. Date Patient File No. TIME TIME REMARKS
BLOOD TRANSFUSED
STARTED FINISHED

1 ###

2 ###

3 ###

4 ###

5 ###

6 ###
7 ###
8 ###
9 ###
10 ###
11 ###
12 ###
13 ###
14 ###
15 ###
16 ###
17 ###
18 ###
19 ###
Page 28 BT TRACKING
 DATE AND DATE AND
TYPE OF AMOUNT
No. Date Patient File No. TIME TIME REMARKS
BLOOD TRANSFUSED
STARTED FINISHED

20 ###
21 ###
22 ###
23 ###
24 ###
25 ###
26 ###
27 ###
28 ###
29 ###
30 ###
31 ###
32 ###
33 ###
34 ###
35 ###
36 ###
37 ###
38 ###
39 ###
40 ###
41 ###
42 ###
43 ###
44 ###
45 ###
46 ###
47 ###
48 ###
49 ###
50 ###
51 ###
52 ###

Page 29 BT TRACKING
 DATE AND DATE AND
TYPE OF AMOUNT
No. Date Patient File No. TIME TIME REMARKS
BLOOD TRANSFUSED
STARTED FINISHED

53 ###
54 ###
55 ###
56 ###
57 ###
58 ###
59 ###
60 ###
61 ###
62 ###
63 ###
64 ###
65 ###
66 ###
67 ###
68 ###
69 ###
70 ###
71 ###
72 ###
84 ###
85 ###
86 ###
87 ###
88 ###
89 ###
90 ###
91 ###
92 ###
93 ###
94 ###
95 ###
96 ###

Page 30 BT TRACKING
 DATE AND DATE AND
TYPE OF AMOUNT
No. Date Patient File No. TIME TIME REMARKS
BLOOD TRANSFUSED
STARTED FINISHED

97 ###
98 ###
99 ###
100 ###
101 ###
102 ###
103 ###
104 ###
105 ###
106 ###
107 ###
108 ###
109 ###
110 ###
111 ###
112 ###
113 ###
114 ###
115 ###
116 ###
117 ###
118 ###
119 ###
120 ###
121 ###
122 ###
123 ###
124 ###
125 ###
126 ###
127 ###
128 ###

Page 31 BT TRACKING
 DATE AND DATE AND
TYPE OF AMOUNT
No. Date Patient File No. TIME TIME REMARKS
BLOOD TRANSFUSED
STARTED FINISHED

###
Collected by THELMA BOYLES 31569/ L&D Date Submitted: 9/15/2022
(Name/ID #/Unit)

1st Data Collector

0
(Name/ID #/Unit)
1st Data Collector

Page 32 BT TRACKING
 H
O
M
E
IPSG 2 IMPROVE EFFECTIVE COMMUNICATION

Unit/Area:LABOR AND DELIVERY Month: 1/11/2022

Indicate if
Telephone/Verb STAFF ID#
No. Date of Reporting Patient File No. COMMENTS
al Order/ Panic
Result
1 ###
2 ###
3 ###
4 ###
5 ###
6 ###
7 ###

Page 33 IPSG 2
 Indicate if
Telephone/Verb STAFF ID#
No. Date of Reporting Patient File No. COMMENTS
al Order/ Panic
Result
8 ###
9 ###
10 ###
11 ###
12 ###
13 ###
14 ###
15 ###
16 ###
17 ###
18 ###
19 ###
20 ###
21 ###
22 ###
23 ###
24 ###
25 ###
26 ###
27 ###
28 ###
29 ###
30 ###
31 ###
32 ###
33 ###
34 ###
35 ###

Page 34 IPSG 2
 Indicate if
Telephone/Verb STAFF ID#
No. Date of Reporting Patient File No. COMMENTS
al Order/ Panic
Result
36 ###
37 ###
38 ###
39 ###
40 ###
41 ###
42 ###
43 ###
44 ###
45 ###
46 ###
47 ###
48 ###
49 ###
50 ###
51 ###
52 ###
53 ###
54 ###
55 ###
56 ###
57 ###
58 ###
59 ###
60 ###
61 ###
62 ###
63 ###
64 ###
Page 35 IPSG 2
 Indicate if
Telephone/Verb STAFF ID#
No. Date of Reporting Patient File No. COMMENTS
al Order/ Panic
Result
65 ###
66 ###
67 ###
68 ###
69 ###
70 ###
71 ###
72 ###

Page 36 IPSG 2
 Indicate if
Telephone/Verb STAFF ID#
No. Date of Reporting Patient File No. COMMENTS
al Order/ Panic
Result
84 ###
85 ###
86 ###
87 ###
88 ###
89 ###
90 ###
91 ###
92 ###
93 ###
94 ###
95 ###
96 ###
97 ###
98 ###
99 ###
100 ###
101 ###
102 ###
103 ###
104 ###
105 ###
106 ###
107 ###
108 ###
109 ###
110 ###
111 ###
112 ###
Page 37 IPSG 2
 Indicate if
Telephone/Verb STAFF ID#
No. Date of Reporting Patient File No. COMMENTS
al Order/ Panic
Result
113 ###
114 ###
115 ###
116 ###
117 ###
118 ###
119 ###
120 ###
121 ###
122 ###
123 ###
124 ###

Page 38 IPSG 2
 Indicate if
Telephone/Verb STAFF ID#
No. Date of Reporting Patient File No. COMMENTS
al Order/ Panic
Result
125 ###
126 ###
127 ###
128 ###
###
Collected by THELMA BOYLES 31569/ L&D 9/15/2022
(Name/ID #/Unit)

1st Data Collector

0
(Name/ID #/Unit)
1st Data Collector

Page 39 IPSG 2
 HOME

COMMUNICATION RECORD BOOK FOR DOCTORS

Unit/Area: LABOR AND DELIVERY MONTH: JULY 2023

Nurse in Duty Specialty of the Doctor’s Name & I.D. Time of Time TIME
No. Date Remarks
and I.D. No. Doctor Number Call answered
DIFF

1 0:00 ###
2 0:00 ###
3 0:00 ###
4 0:00 ###
5 0:00 ###
6 0:00 ###
7 0:00 ###
8 0:00 ###
9 0:00 ###
10 0:00 ###
11 0:00 ###
12 0:00 ###
13 0:00 ###
14 0:00 ###
15 0:00 ###
16 0:00 ###
17 0:00 ###
18 0:00 ###
19 0:00 ###
20 0:00 ###
21 0:00 ###
22 0:00 ###
23 0:00 ###
24 0:00 ###
25 0:00 ###
26 0:00 ###
27 0:00 ###
28 0:00 ###
29 0:00 ###
30 0:00 ###
31 0:00 ###
32 0:00 ###
33 0:00 ###
34 0:00 ###
35 0:00 ###
36 0:00 ###
37 0:00 ###
38 0:00 ###
39 0:00 ###
40 0:00 ###

Revised: 5-2022
Legend: Indicate the time the doctor answer the call within 15 minutes
Indicate the time the doctor answer the call more than 15 minutes
 COMMUNICATION RECORD BOOK FOR DOCTORS

Unit/Area: LABOR AND DELIVERY MONTH: JULY 2023

Nurse in Duty Specialty of the Doctor’s Name & I.D. Time of Time TIME
No. Date Remarks
and I.D. No. Doctor Number Call answered
DIFF
41 0:00 ###
42 0:00 ###
43 0:00 ###
44 0:00 ###
45 0:00 ###
46 0:00 ###
47 0:00 ###
48 0:00 ###
49 0:00 ###
50 0:00 ###
51 0:00 ###
52 0:00 ###
53 0:00 ###
54 0:00 ###
55 0:00 ###
56 0:00 ###
57 0:00 ###
58 0:00 ###
59 0:00 ###
60 0:00 ###
61 0:00 ###
62 0:00 ###
63 0:00 ###
64 0:00 ###
65 0:00 ###
66 0:00 ###
67 0:00 ###
68 0:00 ###
69 0:00 ###
70 0:00 ###
71 0:00 ###
72 0:00 ###
73 0:00 ###
74 0:00 ###
75 0:00 ###
76 0:00 ###
77 0:00 ###
78 0:00 ###
79 0:00 ###
80 0:00 ###
81 0:00 ###
82 0:00 ###
83 0:00 ###
84 0:00 ###
85 0:00 ###
86 0:00 ###
87 0:00 ###
88 0:00 ###

Revised: 5-2022
Legend: Indicate the time the doctor answer the call within 15 minutes
Indicate the time the doctor answer the call more than 15 minutes
 COMMUNICATION RECORD BOOK FOR DOCTORS

Unit/Area: LABOR AND DELIVERY MONTH: JULY 2023

Nurse in Duty Specialty of the Doctor’s Name & I.D. Time of Time TIME
No. Date Remarks
and I.D. No. Doctor Number Call answered
DIFF
89 0:00 ###
90 0:00 ###
91 0:00 ###
92 0:00 ###
93 0:00 ###
94 0:00 ###
95 0:00 ###
96 0:00 ###
97 0:00 ###
98 0:00 ###
99 0:00 ###
100 0:00 ###
101 0:00 ###
102 0:00 ###
103 0:00 ###
104 0:00 ###
105 0:00 ###
106 0:00 ###
107 0:00 ###
108 0:00 ###
109 0:00 ###
110 0:00 ###
111 0:00 ###
112 0:00 ###
113 0:00 ###
114 0:00 ###
115 0:00 ###
116 0:00 ###
117 0:00 ###
118 0:00 ###
119 0:00 ###
120 0:00 ###
121 0:00 ###
122 0:00 ###
123 0:00 ###
124 0:00 ###
125 0:00 ###
126 0:00 ###
127 0:00 ###
128 0:00 ###

Collected by : ###
THELMA BOYLES 31569/ L&D Date Submitted: 7/30/2023
(Name/ID #/Unit)

1st Data Collector

0
(Name/ID #/Unit)
2ND Data Collector

Revised: 5-2022
Legend: Indicate the time the doctor answer the call within 15 minutes
Indicate the time the doctor answer the call more than 15 minutes
 Nursery Department
Key Performance Improvement
Compliance with Hugs and Kisses

Total number of
Total Percentage of Newborn with
newborn that is compliance to Hugs and Kisses
Number of admitted in Nursery
compliance with
Hugs and Kisses
JANUARY
FEBRUARY
MARCH
APRIL
MAY
JUNE
JULY
AUGUST
SEPTEMBER
OCTOBER
NOVEMBER
DECEMBER
0 0

Audited by : YURAIDEL AMPATUAN/OB GYNE

(Name/ID #/Unit)
1 Data Collector
st

STEPHANIE AQUINO/ OB GYNE

(Name/ID #/Unit)
2nd Data Collector

Date Submitted: 9/15/2022

 H
O
M HOME
DALLAH HOSPITAL - NAMAR NURSING QUALITY INDICATOR
PERFORMANCE IMPROVEMENT
NURSING DEPARTMENT E
DEPARTMENT/UNIT AUDITED: LABOR AND DELIVERY Review Period: JULY 2023
PAIN ASSESSMENT COMPLIANCE RATE
Activities:
1. Was the patient assessed for pain on admission by Physician
2. Was the patient assessed for pain on admission by Nurse
3. Is an appropriate pain scale used to indicate level of pain
4. Is pain assessment tool commenced within 30 minutes of his/her admission.
5. Was there a re-assessment of pain as per hospital policy.
KEY CODES: PRESENT/YES=1 ABSENT/NO=0 NOT APPLICABLE = N/A
Date Activities Total
No. Staff ID No. File No.
Compliance Remarks
Reviewed 1 2 3 4 5

1 tin 180996 20166323 21-06-2023 N/A 1 N/A N/A N/A 100% ADMISSI+R19:R30ON
2 tin 180996 20166323 21-06-2023 N/A N/A 1 N/A N/A 100% PAIN ASSESSMENT
3 arlen 181258 20166323 21-06-2023 N/A N/A N/A 1 N/A 100% PAIN SCALE ASSESSMENT TOOL
4 sreeya 182010 20166246 21-06-2023 N/A N/A N/A N/A 1 100% PAIN RE-ASSESSMENT
5 k.kailasam 182151 20166246 21-06-2023 N/A 1 N/A N/A N/A 100% ADMISSION
6 s. 182262 20166246 21-06-2023 N/A N/A 1 N/A N/A 100% PAIN ASSESSMENT
7 maryann 31814 20107437 21-06-2023 N/A N/A N/A 1 N/A 100% TRANS IN PAIN ASSESSMENT
8 rachell 180270 20107437 21-06-2023 N/A 1 N/A N/A N/A 100% ADMISSION
9 lyn 180273 20107437 21-06-2023 N/A N/A 1 N/A N/A 100% indicate level of pain
10 jally 180306 909193 22-06-2023 N/A N/A N/A 1 N/A 100% 30 minutes of his/her admission
11 mj 180410 909193 22-06-2023 N/A 1 N/A N/A N/A 100% ADMISSION
12 jesica 180499 909193 22-06-2023 N/A N/A 1 N/A N/A 100% indicate level of pain
13 tin 180996 1689973 23-06-2023 N/A N/A N/A 1 N/A 100% 30 minutes of his/her admission
14 arlen 181258 1689973 23-06-2023 N/A 1 N/A N/A N/A 100% ADMISSION
15 sreeya 182010 1689973 23-06-2023 N/A N/A 1 N/A N/A 100% indicate level of pain
16 k.kailasam 182151 20168227 24-06-2023 N/A N/A N/A 1 N/A 100% 30 minutes of his/her admission
17 s. 182262 20168227 24-06-2023 N/A 1 N/A N/A N/A 100% ADMISSION
18 maryann 31814 20168227 24-06-2023 N/A N/A 1 N/A N/A 100% indicate level of pain
19 k.kailasam 182151 20043602 24-06-2023 N/A N/A N/A 1 N/A 100% 30 minutes of his/her admission
20 s. 182262 20043602 24-06-2023 N/A 1 N/A N/A N/A 100% ADMISSION

Page 44 PAIN
 PAIN ASSESSMENT COMPLIANCE RATE
Activities:
1. Was the patient assessed for pain on admission by Physician
2. Was the patient assessed for pain on admission by Nurse
3. Is an appropriate pain scale used to indicate level of pain
4. Is pain assessment tool commenced within 30 minutes of his/her admission.
5. Was there a re-assessment of pain as per hospital policy.
KEY CODES: PRESENT/YES=1 ABSENT/NO=0 NOT APPLICABLE = N/A
Date Activities Total
No. Staff ID No. File No.
Compliance Remarks
Reviewed 1 2 3 4 5
21 maryann 31814 20043602 24-06-2023 N/A N/A 1 N/A N/A 100% indicate level of pain
22 rachell 180270 20083007 24-06-2023 N/A N/A N/A 1 N/A 100% 30 minutes of his/her admission
23 lyn 180273 20083007 24-06-2023 N/A 1 N/A N/A N/A 100% ADMISSION
24 jally 180306 20083007 24-06-2023 N/A N/A 1 N/A N/A 100% indicate level of pain
25 sreeya 182010 1691628 24-06-2023 N/A N/A N/A 1 N/A 100% 30 minutes of his/her admission
26 k.kailasam 182151 1691628 24-06-2023 N/A 1 N/A N/A N/A 100% ADMISSION
27 s. 182262 1691628 24-06-2023 N/A N/A 1 N/A N/A 100% indicate level of pain
28 maryann 31814 20159448 24-06-2023 N/A N/A N/A 1 N/A 100% 30 minutes of his/her admission
29 k.kailasam 182151 20159448 24-06-2023 N/A 1 N/A N/A N/A 100% ADMISSION
30 s. 182262 20159448 24-06-2023 N/A N/A 1 N/A N/A 100% indicate level of pain
31 maryann 31814 20166153 24-06-2023 N/A N/A N/A 1 N/A 100% 30 minutes of his/her admission
32 rachell 180270 20166153 24-06-2023 N/A 1 N/A N/A N/A 100% ADMISSION
33 sreeya 182010 20166153 24-06-2023 N/A N/A 1 N/A N/A 100% indicate level of pain
34 k.kailasam 182151 20168304 25-06-2023 N/A N/A N/A 1 N/A 100% 30 minutes of his/her admission
35 s. 182262 20168304 25-06-2023 N/A 1 N/A N/A N/A 100% ADMISSION
36 maryann 31814 20168304 25-06-2023 N/A N/A 1 N/A N/A 100% indicate level of pain
37 k.kailasam 182151 1590774 25-06-2023 N/A N/A N/A 1 N/A 100% 30 minutes of his/her admission
38 s. 182262 1590774 25-06-2023 N/A 1 N/A N/A N/A 100% ADMISSION
39 maryann 31814 1590774 25-06-2023 N/A N/A 1 N/A N/A 100% indicate level of pain
40 rachell 180270 20165224 25-06-2023 N/A N/A N/A 1 N/A 100% 30 minutes of his/her admission
41 tin 180996 20165224 25-06-2023 N/A 1 N/A N/A N/A 100% ADMISSION
42 sreeya 182010 20165224 25-06-2023 N/A N/A 1 N/A N/A 100% indicate level of pain
43 k.kailasam 182151 20168404 25-06-2023 N/A N/A N/A 1 N/A 100% 30 minutes of his/her admission
44 s. 182262 20168404 25-06-2023 N/A 1 N/A N/A N/A 100% ADMISSION
45 maryann 31814 20168404 25-06-2023 N/A N/A 1 N/A N/A 100% indicate level of pain

Page 45 PAIN
 PAIN ASSESSMENT COMPLIANCE RATE
Activities:
1. Was the patient assessed for pain on admission by Physician
2. Was the patient assessed for pain on admission by Nurse
3. Is an appropriate pain scale used to indicate level of pain
4. Is pain assessment tool commenced within 30 minutes of his/her admission.
5. Was there a re-assessment of pain as per hospital policy.
KEY CODES: PRESENT/YES=1 ABSENT/NO=0 NOT APPLICABLE = N/A
Date Activities Total
No. Staff ID No. File No.
Compliance Remarks
Reviewed 1 2 3 4 5
46 k.kailasam 182151 20168446 25-06-2023 N/A N/A N/A 1 N/A 100% 30 minutes of his/her admission
47 s. 182262 20168446 26-06-2023 N/A 1 N/A N/A N/A 100% ADMISSION
48 maryann 31814 20168446 26-06-2023 N/A N/A 1 N/A N/A 100% indicate level of pain
49 rachell 180270 20164836 26-06-2023 N/A N/A N/A 1 N/A 100% 30 minutes of his/her admission
50 tin 180996 20164836 26-06-2023 N/A 1 N/A N/A N/A 100% ADMISSION
51 s. 182262 20164836 26-06-2023 N/A N/A 1 N/A N/A 100% indicate level of pain
52 maryann 31814 20168408 26-06-2023 N/A N/A N/A 1 N/A 100% 30 minutes of his/her admission
53 rachell 180270 20168408 26-06-2023 N/A 1 N/A N/A N/A 100% ADMISSION
54 tin 180996 20168408 26-06-2023 N/A N/A 1 N/A N/A 100% indicate level of pain
55 sreeya 182010 20168550 27-06-2023 N/A N/A N/A 1 N/A 100% 30 minutes of his/her admission
56 k.kailasam 182151 20168550 27-06-2023 N/A 1 N/A N/A N/A 100% ADMISSION
57 s. 182262 20168550 27-06-2023 N/A N/A 1 N/A N/A 100% indicate level of pain
58 s. 182262 20146329 27-06-2023 N/A N/A N/A 1 N/A 100% 30 minutes of his/her admission
59 maryann 31814 20146329 27-06-2023 N/A 1 N/A N/A N/A 100% ADMISSION
60 rachell 180270 20146329 27-06-2023 N/A N/A 1 N/A N/A 100% indicate level of pain
61 tin 180996 1087603 28-06-2023 N/A N/A N/A 1 N/A 100% 30 minutes of his/her admission
62 sreeya 182010 1087603 28-06-2023 N/A 1 N/A N/A N/A 100% ADMISSION
63 k.kailasam 182151 1087603 28-06-2023 N/A N/A 1 N/A N/A 100% indicate level of pain
64 s. 182262 20168132 28-06-2023 N/A N/A N/A 1 N/A 100% 30 minutes of his/her admission
65 s. 182262 20168132 28-06-2023 N/A 1 N/A N/A N/A 100% ADMISSION
66 maryann 31814 20168132 28-06-2023 N/A N/A 1 N/A N/A 100% indicate level of pain
67 rachell 180270 1160651 28-06-2023 N/A N/A N/A 1 N/A 100% 30 minutes of his/her admission
68 tin 180996 1160651 28-06-2023 N/A 1 N/A N/A N/A 100% ADMISSION
69 sreeya 182010 1160651 28-06-2023 N/A N/A 1 N/A N/A 100% indicate level of pain
70 k.kailasam 182151 20155257 28-06-2023 N/A N/A N/A 1 N/A 100% 30 minutes of his/her admission

Page 46 PAIN
 PAIN ASSESSMENT COMPLIANCE RATE
Activities:
1. Was the patient assessed for pain on admission by Physician
2. Was the patient assessed for pain on admission by Nurse
3. Is an appropriate pain scale used to indicate level of pain
4. Is pain assessment tool commenced within 30 minutes of his/her admission.
5. Was there a re-assessment of pain as per hospital policy.
KEY CODES: PRESENT/YES=1 ABSENT/NO=0 NOT APPLICABLE = N/A
Date Activities Total
No. Staff ID No. File No.
Compliance Remarks
Reviewed 1 2 3 4 5
71 s. 182262 20155257 28-06-2023 N/A 1 N/A N/A N/A 100% ADMISSION
72 s. 182262 20155257 28-06-2023 N/A N/A 1 N/A N/A 100% indicate level of pain

Page 47 PAIN
 PAIN ASSESSMENT COMPLIANCE RATE
Activities:
1. Was the patient assessed for pain on admission by Physician
2. Was the patient assessed for pain on admission by Nurse
3. Is an appropriate pain scale used to indicate level of pain
4. Is pain assessment tool commenced within 30 minutes of his/her admission.
5. Was there a re-assessment of pain as per hospital policy.
KEY CODES: PRESENT/YES=1 ABSENT/NO=0 NOT APPLICABLE = N/A
Date Activities Total
No. Staff ID No. File No.
Compliance Remarks
Reviewed 1 2 3 4 5
73 maryann 31814 905061 28-06-2023 N/A N/A N/A 1 N/A 100% 30 minutes of his/her admission
74 rachell 180270 905061 28-06-2023 N/A 1 N/A N/A N/A 100% ADMISSION
75 tin 180996 905061 28-06-2023 N/A N/A 1 N/A N/A 100% indicate level of pain
76 sreeya 182010 20136355 29-06-2023 N/A N/A N/A 1 N/A 100% 30 minutes of his/her admission
77 k.kailasam 182151 20136355 29-06-2023 N/A 1 N/A N/A N/A 100% ADMISSION
78 s. 182262 20136355 29-06-2023 N/A N/A 1 N/A N/A 100% indicate level of pain
79 s. 182262 20153841 29-06-2023 N/A N/A N/A 1 N/A 100% 30 minutes of his/her admission
80 s. 182262 20153841 29-06-2023 N/A 1 N/A N/A N/A 100% ADMISSION
81 maryann 31814 20153841 29-06-2023 N/A N/A 1 N/A N/A 100% indicate level of pain
82 rachell 180270 20168542 29-06-2023 N/A N/A N/A 1 N/A 100% 30 minutes of his/her admission
83 tin 180996 20168542 29-06-2023 N/A 1 N/A N/A N/A 100% ADMISSION
84 sreeya 182010 20168542 29-06-2023 N/A N/A 1 N/A N/A 100% indicate level of pain
85 k.kailasam 182151 1328480 29-06-2023 N/A N/A N/A 1 N/A 100% 30 minutes of his/her admission
86 s. 182262 1328480 29-06-2023 N/A 1 N/A N/A N/A 100% ADMISSION
87 s. 182262 1328480 29-06-2023 N/A N/A 1 N/A N/A 100% indicate level of pain
88 maryann 31814 1340092 30-06-2023 N/A N/A N/A 1 N/A 100% 30 minutes of his/her admission
89 rachell 180270 1340092 30-06-2023 N/A 1 N/A N/A N/A 100% ADMISSION
90 s. 182262 1340092 30-06-2023 N/A N/A 1 N/A N/A 100% indicate level of pain
91 s. 182262 20044018 30-06-2023 N/A N/A N/A 1 N/A 100% 30 minutes of his/her admission
92 maryann 31814 20044018 30-06-2023 N/A 1 N/A N/A N/A 100% ADMISSION
93 rachell 180270 20044018 30-06-2023 N/A N/A 1 N/A N/A 100% indicate level of pain
94 tin 180996 20167655 30-06-2023 N/A N/A N/A 1 N/A 100% 30 minutes of his/her admission
95 sreeya 182010 20167655 30-06-2023 N/A 1 N/A N/A N/A 100% ADMISSION
96 k.kailasam 182151 20167655 30-06-2023 N/A N/A 1 N/A N/A 100% indicate level of pain
97 s. 182262 20168725 30-06-2023 N/A N/A N/A 1 N/A 100% 30 minutes of his/her admission

Page 48 PAIN
 PAIN ASSESSMENT COMPLIANCE RATE
Activities:
1. Was the patient assessed for pain on admission by Physician
2. Was the patient assessed for pain on admission by Nurse
3. Is an appropriate pain scale used to indicate level of pain
4. Is pain assessment tool commenced within 30 minutes of his/her admission.
5. Was there a re-assessment of pain as per hospital policy.
KEY CODES: PRESENT/YES=1 ABSENT/NO=0 NOT APPLICABLE = N/A
Date Activities Total
No. Staff ID No. File No.
Compliance Remarks
Reviewed 1 2 3 4 5
98 s. 182262 20168725 30-06-2023 N/A 1 N/A N/A N/A 100% ADMISSION

Page 49 PAIN
 PAIN ASSESSMENT COMPLIANCE RATE
Activities:
1. Was the patient assessed for pain on admission by Physician
2. Was the patient assessed for pain on admission by Nurse
3. Is an appropriate pain scale used to indicate level of pain
4. Is pain assessment tool commenced within 30 minutes of his/her admission.
5. Was there a re-assessment of pain as per hospital policy.
KEY CODES: PRESENT/YES=1 ABSENT/NO=0 NOT APPLICABLE = N/A
Date Activities Total
No. Staff ID No. File No.
Compliance Remarks
Reviewed 1 2 3 4 5
99 maryann 31814 20168725 30-06-2023 N/A N/A 1 N/A N/A 100% indicate level of pain
100 rachell 180270 20149320 30-06-2023 N/A N/A N/A 1 N/A 100% 30 minutes of his/her admission
101 s. 182262 20149320 30-06-2023 N/A 1 N/A N/A N/A 100% ADMISSION
102 s. 182262 20149320 30-06-2023 N/A N/A 1 N/A N/A 100% indicate level of pain
103 maryann 31814 1358907 30-06-2023 N/A N/A N/A 1 N/A 100% 30 minutes of his/her admission
104 rachell 180270 1358907 30-06-2023 N/A 1 N/A N/A N/A 100% ADMISSION
105 tin 180996 1358907 30-06-2023 N/A N/A 1 N/A N/A 100% indicate level of pain
106 sreeya 182010 20145320 01-07-2023 N/A N/A N/A 1 N/A 100% 30 minutes of his/her admission
107 k.kailasam 182151 20145320 01-07-2023 N/A 1 N/A N/A N/A 100% ADMISSION
108 s. 182262 20145320 01-07-2023 N/A N/A 1 N/A N/A 100% indicate level of pain
109 s. 182262 20168772 01-07-2023 N/A N/A N/A 1 N/A 100% 30 minutes of his/her admission
110 maryann 31814 20168772 01-07-2023 N/A 1 N/A N/A N/A 100% ADMISSION
111 rachell 180270 20168772 01-07-2023 N/A N/A 1 N/A N/A 100% indicate level of pain
112 s. 182262 20168773 01-07-2023 N/A N/A N/A 1 N/A 100% 30 minutes of his/her admission
113 s. 182262 20168773 01-07-2023 N/A 1 N/A N/A N/A 100% ADMISSION
114 maryann 31814 20168773 01-07-2023 N/A N/A 1 N/A N/A 100% indicate level of pain
115 rachell 180270 20148475 02-07-2023 N/A N/A N/A 1 N/A 100% 30 minutes of his/her admission
116 tin 180996 20148475 02-07-2023 N/A 1 N/A N/A N/A 100% ADMISSION
117 sreeya 182010 20148475 02-07-2023 N/A N/A 1 N/A N/A 100% indicate level of pain
118 k.kailasam 182151 1600274 02-07-2023 N/A N/A N/A 1 N/A 100% 30 minutes of his/her admission
119 s. 182262 1600274 02-07-2023 N/A 1 N/A N/A N/A 100% ADMISSION
120 s. 182262 1600274 02-07-2023 N/A N/A 1 N/A N/A 100% indicate level of pain
121 maryann 31814 20146595 02-07-2023 N/A N/A N/A 1 N/A 100% 30 minutes of his/her admission
122 rachell 180270 20146595 02-07-2023 N/A 1 N/A N/A N/A 100% ADMISSION
123 maryann 31814 20146595 02-07-2023 N/A N/A 1 N/A N/A 100% indicate level of pain

Page 50 PAIN
 PAIN ASSESSMENT COMPLIANCE RATE
Activities:
1. Was the patient assessed for pain on admission by Physician
2. Was the patient assessed for pain on admission by Nurse
3. Is an appropriate pain scale used to indicate level of pain
4. Is pain assessment tool commenced within 30 minutes of his/her admission.
5. Was there a re-assessment of pain as per hospital policy.
KEY CODES: PRESENT/YES=1 ABSENT/NO=0 NOT APPLICABLE = N/A
Date Activities Total
No. Staff ID No. File No.
Compliance Remarks
Reviewed 1 2 3 4 5
124 rachell 180270 20140995 02-07-2023 N/A N/A N/A 1 N/A 100% 30 minutes of his/her admission
125 tin 180996 20140995 02-07-2023 N/A 1 N/A N/A N/A 100% ADMISSION
126 maryann 31814 20140995 02-07-2023 N/A N/A 1 N/A N/A 100% indicate level of pain
127 rachell 180270 47149 02-07-2023 N/A N/A N/A 1 N/A 100% 30 minutes of his/her admission
128 tin 180996 47149 02-07-2023 N/A 1 N/A N/A N/A 100% ADMISSION
129 k.kailasam 182151 47149 02-07-2023 N/A N/A 1 N/A N/A 100% indicate level of pain
130 k.kailasam 182151 20080911 02-07-2023 N/A N/A N/A 1 N/A 100% 30 minutes of his/her admission
Total Compliance of each activities NA 100% 100% 100% 100%
Total Compliance of overall activities 100%

Audited by YURAIDEL AMPATUAN/OB GYNE Date Submitted: 9/15/2022

(Name/ID #/Unit)
1st Data Collector

STEPHANIE AQUINO/ OB GYNE

(Name/ID #/Unit)
2nd Data Collector

Page 51 PAIN
 DALLAH HOSPITAL - NAMAR HOME
PERFORMANCE IMPROVEMENT
NURSING QUALITY INDICATOR
NURSING DEPARTMENT

DEPARTMENT/UNIT AUDITED: LABOR AND DELIVERY REVIEW PERIOD: JULY 2023

COMPLETION OF SIGN OUT PROCEDURE IN NON – OR AREA

CRITERIAS:
1. Confirm the name of surgical/invasive procedure
performed.
2. Specimen taken identified & labeled (To read back
specimen labeling including patient name and file
number.
3. Correct side and site
3. Patient specific post-op concerns were discussed.
KEY CODES: PRESENT/YES = 1 ABSENT/NO = 0 NOT APPLICABLE = N/A
DATE CRITERIAS
NO. PATIENT MR NUMBER TOTAL COMMENTS
REVIEWED 1 2 3 COMPLIANCE

1 ###
2 ###
3 ###
4 ###
5 ###
6 ###
7 ###
8 ###
9 ###
10 ###
11 ###
12 ###
13 ###
14 ###
15 ###
16 ###
17 ###
18 ###

Page 52 of 111
KEY CODES: PRESENT/YES = 1 ABSENT/NO = 0 NOT APPLICABLE = N/A
DATE CRITERIAS
NO. PATIENT MR NUMBER TOTAL COMMENTS
REVIEWED 1 2 3 COMPLIANCE

19 ###
20 ###
21 ###
22 ###
23 ###
24 ###
25 ###
26 ###
27 ###
28 ###
29 ###
30 ###
31 ###
32 ###
33 ###
34 ###
35 ###
36 ###
37 ###
38 ###
39 ###
40 ###
41 ###
42 ###
43 ###
44 ###
45 ###
46 ###
47 ###
48 ###
49 ###
50 ###

Page 53 of 111
KEY CODES: PRESENT/YES = 1 ABSENT/NO = 0 NOT APPLICABLE = N/A
DATE CRITERIAS
NO. PATIENT MR NUMBER TOTAL COMMENTS
REVIEWED 1 2 3 COMPLIANCE

51 ###
52 ###
53 ###
54 ###
55 ###
56 ###
57 ###
58 ###
59 ###
60 ###
61 ###
62 ###
63 ###
64 ###
65 ###
66 ###
67 ###
68 ###
69 ###
70 ###
71 ###
72 ###
73 ###
74 ###
75 ###
76 ###
77 ###
78 ###
79 ###
80 ###
81 ###
82 ###

Page 54 of 111
KEY CODES: PRESENT/YES = 1 ABSENT/NO = 0 NOT APPLICABLE = N/A
DATE CRITERIAS
NO. PATIENT MR NUMBER TOTAL COMMENTS
REVIEWED 1 2 3 COMPLIANCE

83 ###
84 ###
85 ###
86 ###
87 ###
88 ###
89 ###
90 ###
91 ###
92 ###
93 ###
94 ###
95 ###
96 ###
97 ###
98 ###
99 ###
100 ###
101 ###
102 ###
103 ###
104 ###
105 ###
106 ###
107 ###
108 ###
109 ###
110 ###
111 ###
112 ###
113 ###
114 ###

Page 55 of 111
KEY CODES: PRESENT/YES = 1 ABSENT/NO = 0 NOT APPLICABLE = N/A
DATE CRITERIAS
NO. PATIENT MR NUMBER TOTAL COMMENTS
REVIEWED 1 2 3 COMPLIANCE

115 ###
116 ###
117 ###
118 ###
119 ###
120 ###
121 ###
122 ###
123 ###
124 ###
125 ###
126 ###
127 ###
128 1 1 1 100% ###
TOTAL COMPLIANCE – EACH CRITERIA 100% 100% 100% 100%
###
TOTAL COMPLIANCE – ALL CRITERIA 100%

Audited by : Date Submitted:

(Name/ID #/Unit)
1st Data Collector

Page 56 of 111
 H
O
M HOME
E
IMPROVE EFFECTIVE COMMUNICATION (IPSG NO. 2)
Telephone Order, Verbal Order Compliance Rate
DATA COLLECTION FORM
Unit/Area:LABOR AND DELIVERY Month & Year: JULY 2023

Mode of Communication Compliance

No. Date Review STAFF ID Patient File No. Remarks
Verbal Order Telephone YES (1) NO (0)
Order

1 NO CASE
2 ###
3 ###
4 ###
5 ###
6 ###
7 ###
8 ###
9 ###
10 ###
11 ###
12 ###
13 ###
14 ###
15 ###
16 ###
17 ###
18 ###
19 ###
20 ###
21 ###
22 ###
23 ###
24 ###
25 ###
26 ###
27 ###
28 ###
29 ###
30 ###
31 ###
32 ###
33 ###
34 ###
35 ###

Page 57 TV ORDER
 H
O
M HOME
E
IMPROVE EFFECTIVE COMMUNICATION (IPSG NO. 2)
Telephone Order, Verbal Order Compliance Rate
DATA COLLECTION FORM
Unit/Area:LABOR AND DELIVERY Month & Year: JULY 2023

Mode of Communication Compliance

No. Date Review STAFF ID Patient File No. Remarks
Verbal Order Telephone YES (1) NO (0)
Order

36 ###
37 ###
38 ###
39 ###
40 ###
41 ###
42 ###
43 ###
44 ###
45 ###
46 ###
47 ###
48 ###
49 ###
50 ###
51 ###
52 ###
53 ###
54 ###
55 ###
56 ###
57 ###
58 ###
59 ###
60 ###
61 ###
62 ###
63 ###
64 ###
65 ###
66 ###
67 ###
68 ###
69 ###
70 ###
71 ###
72 ###

Page 58 TV ORDER
 H
O
M HOME
E
IMPROVE EFFECTIVE COMMUNICATION (IPSG NO. 2)
Telephone Order, Verbal Order Compliance Rate
DATA COLLECTION FORM
Unit/Area:LABOR AND DELIVERY Month & Year: JULY 2023

Mode of Communication Compliance

No. Date Review STAFF ID Patient File No. Remarks
Verbal Order Telephone YES (1) NO (0)
Order

84 ###
85 ###
86 ###
87 ###
88 ###
89 ###
90 ###
91 ###
92 ###
93 ###
94 ###
95 ###
96 ###
97 ###
98 ###
99 ###
100 ###
101 ###
102 ###
103 ###
104 ###
105 ###
106 ###
107 ###
108 ###
109 ###
110 ###
111 ###
112 ###
113 ###
114 ###
115 ###
116 ###
117 ###
118 ###
119 ###
120 ###
121 ###
122 ###
123 ###
124 ###

Page 59 TV ORDER
 H
O
M HOME
E
IMPROVE EFFECTIVE COMMUNICATION (IPSG NO. 2)
Telephone Order, Verbal Order Compliance Rate
DATA COLLECTION FORM
Unit/Area:LABOR AND DELIVERY Month & Year: JULY 2023

Mode of Communication Compliance

No. Date Review STAFF ID Patient File No. Remarks
Verbal Order Telephone YES (1) NO (0)
Order

125 ###
126 ###
127 ###
128 ###
###
Audited by : YURAIDEL AMPATUAN/OB GYNE Date Submitted: 9/7/2022
(Name/ID #/Unit)
1st Data Collector

STEPHANIE AQUINO/ OB GYNE

(Name/ID #/Unit)
2ND Data Collector

Page 60 TV ORDER
 H
O
M HOME
E
IMPROVE EFFECTIVE COMMUNICATION (IPSG NO. 2)
Telephone Order, Verbal Order Compliance Rate
DATA COLLECTION FORM
Unit/Area:LABOR AND DELIVERY Month & Year: JULY 2023

Mode of Communication Compliance

No. Date Review STAFF ID Patient File No. Remarks
Verbal Order Telephone YES (1) NO (0)
Order

1 NO CASE
2 ###
3 ###
4 ###
5 ###
6 ###
7 ###
8 ###
9 ###
10 ###
11 ###
12 ###
13 ###
14 ###
15 ###
16 ###
17 ###
18 ###
19 ###
20 ###
21 ###
22 ###
23 ###
24 ###
25 ###
26 ###
27 ###
28 ###
29 ###
30 ###
31 ###
32 ###
33 ###
34 ###
35 ###

Page 61 PANIC
 H
O
M HOME
E
IMPROVE EFFECTIVE COMMUNICATION (IPSG NO. 2)
Telephone Order, Verbal Order Compliance Rate
DATA COLLECTION FORM
Unit/Area:LABOR AND DELIVERY Month & Year: JULY 2023

Mode of Communication Compliance

No. Date Review STAFF ID Patient File No. Remarks
Verbal Order Telephone YES (1) NO (0)
Order

36 ###
37 ###
38 ###
39 ###
40 ###
41 ###
42 ###
43 ###
44 ###
45 ###
46 ###
47 ###
48 ###
49 ###
50 ###
51 ###
52 ###
53 ###
54 ###
55 ###
56 ###
57 ###
58 ###
59 ###
60 ###
61 ###
62 ###
63 ###
64 ###
65 ###
66 ###
67 ###
68 ###
69 ###
70 ###
71 ###
72 ###

Page 62 PANIC
 H
O
M HOME
E
IMPROVE EFFECTIVE COMMUNICATION (IPSG NO. 2)
Telephone Order, Verbal Order Compliance Rate
DATA COLLECTION FORM
Unit/Area:LABOR AND DELIVERY Month & Year: JULY 2023

Mode of Communication Compliance

No. Date Review STAFF ID Patient File No. Remarks
Verbal Order Telephone YES (1) NO (0)
Order

84 ###
85 ###
86 ###
87 ###
88 ###
89 ###
90 ###
91 ###
92 ###
93 ###
94 ###
95 ###
96 ###
97 ###
98 ###
99 ###
100 ###
101 ###
102 ###
103 ###
104 ###
105 ###
106 ###
107 ###
108 ###
109 ###
110 ###
111 ###
112 ###
113 ###
114 ###
115 ###
116 ###
117 ###
118 ###
119 ###
120 ###
121 ###
122 ###
123 ###
124 ###

Page 63 PANIC
 H
O
M HOME
E
IMPROVE EFFECTIVE COMMUNICATION (IPSG NO. 2)
Telephone Order, Verbal Order Compliance Rate
DATA COLLECTION FORM
Unit/Area:LABOR AND DELIVERY Month & Year: JULY 2023

Mode of Communication Compliance

No. Date Review STAFF ID Patient File No. Remarks
Verbal Order Telephone YES (1) NO (0)
Order

125 ###
126 ###
127 ###
128 ###
###
Audited by : YURAIDEL AMPATUAN/OB GYNE Date Submitted: 9/7/2022
(Name/ID #/Unit)
1st Data Collector

STEPHANIE AQUINO/ OB GYNE

(Name/ID #/Unit)
2ND Data Collector

Page 64 PANIC
 DALLAH HOSPITAL - NAMAR
PERFORMANCE IMPROVEMENT NURSING QUALITY INDICATOR HOME
NURSING DEPARTMENT
GRAPHS
DEPARTMENT/UNIT AUDITED: LABOR AND DELIVERY REVIEW PERIOD: 8/1/2022
ATTENDANCE
SAFETY IN BLOOD TRANSFUSION
CRITERIAS:
1.     Patient three full names and medical record -        Nurse/technician checking the blood pre-transfusion
and bedside
-        Nurse/technician completing/terminating the blood
2.     Doctor’s order written for Blood Transfusion unit
-        Type of blood (i.e., PRBC, FFP, Whole blood, Cryoprecipitate 8.     Compatibility sticker
-        Number of Unis to be transfused -        One (1) in the bag matching the issued blood bank slip
-        Number of hours to complete (to consider urgency of BT, i.e. fast drip) -        One (1) in the record sheet matching the bag and the
issued slip
3.     Consent for BT -        One (1) in the syringe (for neonates only)
-        Arabic/English Translation 9.     Vital signs monitored as per BT protocol (unless urgent)
-        Full name of patient or parent/guardian/representative in print and signature -        Baseline vital signs taken
-        Full name of witness, signature and ID Number -        During transfusion
4.     Patient blood group and RH type. -        Post transfusion
5.     Two staff verify the patient’s identity prior to blood drawing for cross match of blood grouping 10.   Blood unit complete
6.     Full name of prescribing and checking doctor, signature and ID Number -        Amount transfused
7.     Full name of: -        Date and time finished
-        Nurse/technician getting the blood from the blood bank 11.   Transfusion reaction/action box filled up
-        If yes, action taken
KEY CODES: PRESENT/YES = 1 ABSENT/NO = 0 NOT APPLICABLE = N/A
DATE CRITERIAS
PATIENT MR TOTAL
NO. NUMBER COMPLIANCE COMMENTS
REVIEWED 1 2 3 4 5 6 7 8 9 10 11
1 20166575 8/7/2023 1 1 1 1 1 1 1 1 1 1 1 100% no bt reaction
2 20166575 8/7/2023 1 1 1 1 1 1 1 1 1 1 1 100% no bt reaction
3 20166575 8/7/2023 1 1 1 1 1 1 1 1 1 1 1 100% no bt reaction
4 20170059 13/7/23 1 1 1 1 1 1 1 1 1 1 1 100% no bt reaction
5 ###
6 ###
7 ###
8 ###
9 ###
10 ###
11 ###
12 ###
Page 65 of 111
KEY CODES: PRESENT/YES = 1 ABSENT/NO = 0 NOT APPLICABLE = N/A
DATE CRITERIAS
PATIENT MR TOTAL
NO. NUMBER COMPLIANCE COMMENTS
REVIEWED 1 2 3 4 5 6 7 8 9 10 11
13 ###
14 ###
15 ###
16 ###
17 ###
18 ###
19 ###
20 ###
21 ###
22 ###
23 ###
24 ###
25 ###
26 ###
27 ###
28 ###
29 ###
30 ###
31 ###
32 ###
33 ###
34 ###
35 ###
36 ###
37 ###
38 ###
39 ###
40 ###
41 ###
42 ###
43 ###
44 ###
45 ###

Page 66 of 111
KEY CODES: PRESENT/YES = 1 ABSENT/NO = 0 NOT APPLICABLE = N/A
DATE CRITERIAS
PATIENT MR TOTAL
NO. NUMBER COMPLIANCE COMMENTS
REVIEWED 1 2 3 4 5 6 7 8 9 10 11
46 ###
47 ###
48 ###
49 ###
50 ###
51 ###
52 ###
53 ###
54 ###
55 ###
56 ###
57 ###
58 ###
59 ###
60 ###
61 ###
62 ###
63 ###
64 ###
65 ###
66 ###
67 ###
68 ###
69 ###
70 ###
71 ###
72 ###
73 ###
74 ###
75 ###
76 ###
77 ###
78 ###

Page 67 of 111
KEY CODES: PRESENT/YES = 1 ABSENT/NO = 0 NOT APPLICABLE = N/A
DATE CRITERIAS
PATIENT MR TOTAL
NO. NUMBER COMPLIANCE COMMENTS
REVIEWED 1 2 3 4 5 6 7 8 9 10 11
79 ###
80 ###
81 ###
82 ###
83 ###
84 ###
85 ###
86 ###
87 ###
88 ###
89 ###
90 ###
91 ###
92 ###
93 ###
94 ###
95 ###
96 ###
97 ###
98 ###
99 ###
100 ###
101 ###
102 ###
103 ###
104 ###
105 ###
106 ###
107 ###
108 ###
109 ###
110 ###
111 ###

Page 68 of 111
KEY CODES: PRESENT/YES = 1 ABSENT/NO = 0 NOT APPLICABLE = N/A
DATE CRITERIAS
PATIENT MR TOTAL
NO. NUMBER COMPLIANCE COMMENTS
REVIEWED 1 2 3 4 5 6 7 8 9 10 11
112 ###
113 ###
114 ###
115 ###
116 ###
117 ###
118 ###
119 ###
120 ###
121 ###
122 ###
123 ###
124 ###
125 ###
126 ###
127 ###
128 ###
TOTAL COMPLIANCE – EACH CRITERIA 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%
###
TOTAL COMPLIANCE – ALL CRITERIA 100%

YURAIDEL
Audited by : AMPATUAN/OB GYNE Date Submitted 7/30/2023
(Name/ID #/Unit)
1st Data Collector
STEPHANIE AQUINO/ OB
GYNE
(Name/ID #/Unit)
2ND Data Collector

Page 69 of 111
 DALLAH HOSPITAL - NAMAR
PERFORMANCE IMPROVEMENT IPSG 1
NURSING DEPARTMENT

DEPARTMENT/UNIT AUDITED: LABOR AND DELIVERY Review Period: 1-Aug-22

COMPLIANCE RATE WITH CORRECT PATIENT IDENTIFICATION

Activities: CRITERIAS:
1 Before taking blood and other specimen for clinical testing A. I.D. Band with three full names & medical record number
2 Before administering blood and blood products B. I.D. band matched with the medical record number.
3 Before drug administration C. Identify the patient by asking 3 full names & match with the I.D. Band.
4 Before any interaction to the patient, treatment and procedures
Before giving/delivering patient's
5 prescribed diet
KEY CODES: PRESENT/YES=1 ABSENT/NO=0 NOT APPLICABLE = N/A
1 2 3 4 5
PATIENT CRITERIAS TOTA CRITERIAS CRITERIAS
TOTA
CRITERIAS
TOTA
CRITERIAS TOTAL
REMARKS
NO. DATE STAFF ID FILE L TOTAL L L COMMENTS
NUMBER COMP COMPL COMP COMP COMPL
A B C LIANC A B C IANCE A B C LIANC A B C LIANC A B C IANCE TOTAL
SUGGESTION
E E E
1 21-06-2023 tin 180996 20166323 N/A N/A N/A N/A N/A N/A N/A N/A N/A 1 1 1 100% N/A N/A N/A 100% ADMISSION

2 21-06-2023 tin 180996 20166246 N/A N/A N/A N/A N/A N/A N/A N/A N/A 1 1 1 100% N/A N/A N/A 100% VITAL SIGNS

3 21-06-2023 arlen 181258 20107437 N/A N/A N/A 1 1 1 100% N/A N/A N/A N/A N/A N/A N/A N/A N/A 100% MEDICATION

4 22-06-2023 sreeya 182010 909193 N/A N/A N/A N/A N/A N/A N/A N/A N/A 1 1 1 100% N/A N/A N/A 100% TRANSFER
k.kailasam
5 23-06-2023 182151 1689973 N/A N/A N/A N/A N/A N/A N/A N/A N/A 1 1 1 100% N/A N/A N/A 100% ADMISSION

6 24-06-2023 s. 182262 20168227 N/A N/A N/A N/A N/A N/A N/A N/A N/A 1 1 1 100% N/A N/A N/A 100% VITAL SIGNS

7 24-06-2023 maryann 31814 20043602 N/A N/A N/A N/A N/A N/A N/A N/A N/A 1 1 1 100% N/A N/A N/A 100% CTG

8 24-06-2023 rachell 180270 20083007 N/A N/A N/A N/A N/A N/A 1 1 1 100% N/A N/A N/A N/A N/A N/A 100% MEDICATION

9 24-06-2023 lyn 180273 1691628 N/A N/A N/A N/A N/A N/A N/A N/A N/A 1 1 1 100% N/A N/A N/A 100% TRANS IN

10 24-06-2023 jally 180306 20159448 N/A N/A N/A N/A N/A N/A N/A N/A N/A 1 1 1 100% N/A N/A N/A 100% VITAL SIGNS

11 24-06-2023 mj 180410 20166153 N/A N/A N/A N/A N/A N/A N/A N/A N/A 1 1 1 100% N/A N/A N/A 100% CTG

12 25-06-2023 jesica 180499 20168304 N/A N/A N/A N/A N/A N/A N/A N/A N/A 1 1 1 100% N/A N/A N/A 100% IV FLUIDS ADMINISTRA

13 25-06-2023 tin 180996 1590774 1 1 1 100% N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A 100% HVS INVESTIGATION

14 25-06-2023 arlen 181258 20165224 N/A N/A N/A N/A N/A N/A N/A N/A N/A 1 1 1 100% N/A N/A N/A 100% IV FLUIDS ADMINISTRA

15 25-06-2023 sreeya 182010 20168404 N/A N/A N/A N/A N/A N/A N/A N/A N/A 1 1 1 100% N/A N/A N/A 100% GLUCO CHECKED
k.kailasam
16 26-06-2023 182151 20168446 N/A N/A N/A N/A N/A N/A N/A N/A N/A 1 1 1 100% N/A N/A N/A 100% ENDORSE TO NEXT SHIF

17 26-06-2023 s. 182262 20164836 N/A N/A N/A N/A N/A N/A 1 1 1 100% N/A N/A N/A N/A N/A N/A 100% MEDICATION

18 26-06-2023 maryann 31814 20168408 N/A N/A N/A N/A N/A N/A N/A N/A N/A 1 1 1 100% N/A N/A N/A 100% ADMISSION
k.kailasam
19 27-06-2023 182151 20168550 N/A N/A N/A N/A N/A N/A N/A N/A N/A 1 1 1 100% N/A N/A N/A 100% VITAL SIGNS

20 27-06-2023 s. 182262 20146329 N/A N/A N/A N/A N/A N/A N/A N/A N/A 1 1 1 100% N/A N/A N/A 100% CTG

21 28-06-2023 maryann 31814 1087603 N/A N/A N/A N/A N/A N/A N/A N/A N/A 1 1 1 100% N/A N/A N/A 100% IV FLUIDS ADMINISTRA

22 28-06-2023 rachell 180270 20168132 N/A N/A N/A N/A N/A N/A N/A N/A N/A 1 1 1 100% N/A N/A N/A 100% BABY IDENTIFICATION

23 28-06-2023 lyn 180273 1160651 N/A N/A N/A N/A N/A N/A N/A N/A N/A 1 1 1 100% N/A N/A N/A 100% TRANSFER PATIENT TO

24 28-06-2023 jally 180306 20155257 N/A N/A N/A N/A N/A N/A N/A N/A N/A 1 1 1 100% N/A N/A N/A 100% ADMISSION

Page 70 of 111
 DALLAH HOSPITAL - NAMAR
PERFORMANCE IMPROVEMENT IPSG 1
NURSING DEPARTMENT

DEPARTMENT/UNIT AUDITED: LABOR AND DELIVERY Review Period: 1-Aug-22

COMPLIANCE RATE WITH CORRECT PATIENT IDENTIFICATION

Activities: CRITERIAS:
1 Before taking blood and other specimen for clinical testing A. I.D. Band with three full names & medical record number
2 Before administering blood and blood products B. I.D. band matched with the medical record number.
3 Before drug administration C. Identify the patient by asking 3 full names & match with the I.D. Band.
4 Before any interaction to the patient, treatment and procedures
Before giving/delivering patient's
5 prescribed diet
KEY CODES: PRESENT/YES=1 ABSENT/NO=0 NOT APPLICABLE = N/A
1 2 3 4 5
PATIENT CRITERIAS TOTA CRITERIAS CRITERIAS
TOTA
CRITERIAS
TOTA
CRITERIAS TOTAL
REMARKS
NO. DATE STAFF ID FILE L TOTAL L L COMMENTS
NUMBER COMP COMPL COMP COMP COMPL
A B C LIANC A B C IANCE A B C LIANC A B C LIANC A B C IANCE TOTAL
SUGGESTION
E E E
25 28-06-2023 sreeya 182010 905061 N/A N/A N/A N/A N/A N/A N/A N/A N/A 1 1 1 100% N/A N/A N/A 100% VITAL SIGNS
k.kailasam
26 29-06-2023 182151 20136355 N/A N/A N/A N/A N/A N/A N/A N/A N/A 1 1 1 100% N/A N/A N/A 100% CTG

27 29-06-2023 s. 182262 20153841 N/A N/A N/A N/A N/A N/A N/A N/A N/A 1 1 1 100% N/A N/A N/A 100% IV FLUIDS ADMINISTRA

28 29-06-2023 maryann 31814 20168542 N/A N/A N/A N/A N/A N/A 1 1 1 100% N/A N/A N/A N/A N/A N/A 100% MEDICATION
k.kailasam
29 29-06-2023 182151 1328480 N/A N/A N/A N/A N/A N/A N/A N/A N/A 1 1 1 100% N/A N/A N/A 100% BABY IDENTIFICATION

30 30-06-2023 s. 182262 1340092 N/A N/A N/A N/A N/A N/A N/A N/A N/A 1 1 1 100% N/A N/A N/A 100% TRANSFER PATIENT TO

31 30-06-2023 maryann 31814 20044018 N/A N/A N/A N/A N/A N/A N/A N/A N/A 1 1 1 100% N/A N/A N/A 100% ADMISSION

32 30-06-2023 rachell 180270 20167655 N/A N/A N/A N/A N/A N/A N/A N/A N/A 1 1 1 100% N/A N/A N/A 100% VITAL SIGNS

33 30-06-2023 sreeya 182010 20168725 N/A N/A N/A N/A N/A N/A N/A N/A N/A 1 1 1 100% N/A N/A N/A 100% CTG
k.kailasam
34 30-06-2023 182151 20149320 N/A N/A N/A N/A N/A N/A N/A N/A N/A 1 1 1 100% N/A N/A N/A 100% IV FLUIDS ADMINISTRA

35 30-06-2023 s. 182262 1358907 N/A N/A N/A N/A N/A N/A 1 1 1 100% N/A N/A N/A N/A N/A N/A 100% MEDICATION

36 01-07-2023 maryann 31814 20145320 N/A N/A N/A N/A N/A N/A N/A N/A N/A 1 1 1 100% N/A N/A N/A 100% BABY IDENTIFICATION
k.kailasam
37 01-07-2023 182151 20168772 N/A N/A N/A N/A N/A N/A N/A N/A N/A 1 1 1 100% N/A N/A N/A 100% TRANSFER PATIENT TO

38 01-07-2023 s. 182262 20168773 N/A N/A N/A N/A N/A N/A N/A N/A N/A 1 1 1 100% N/A N/A N/A 100% ADMISSION

39 02-07-2023 maryann 31814 20148475 N/A N/A N/A N/A N/A N/A N/A N/A N/A 1 1 1 100% N/A N/A N/A 100% VITAL SIGNS

40 02-07-2023 rachell 180270 1600274 N/A N/A N/A N/A N/A N/A N/A N/A N/A 1 1 1 100% N/A N/A N/A 100% CTG

41 02-07-2023 tin 180996 20146595 N/A N/A N/A N/A N/A N/A N/A N/A N/A 1 1 1 100% N/A N/A N/A 100% IV FLUIDS ADMINISTRA

42 02-07-2023 sreeya 182010 20140995 N/A N/A N/A N/A N/A N/A 1 1 1 100% N/A N/A N/A N/A N/A N/A 100% MEDICATION
k.kailasam
43 02-07-2023 182151 47149 N/A N/A N/A N/A N/A N/A N/A N/A N/A 1 1 1 100% N/A N/A N/A 100% BABY IDENTIFICATION

44 02-07-2023 s. 182262 20080911 N/A N/A N/A N/A N/A N/A N/A N/A N/A 1 1 1 100% N/A N/A N/A 100% TRANSFER PATIENT TO

45 03-07-2023 maryann 31814 20168416 N/A N/A N/A N/A N/A N/A N/A N/A N/A 1 1 1 100% N/A N/A N/A 100% ADMISSION
k.kailasam
46 03-07-2023 182151 20168916 N/A N/A N/A N/A N/A N/A N/A N/A N/A 1 1 1 100% N/A N/A N/A 100% VITAL SIGNS

47 03-07-2023 s. 182262 20068193 N/A N/A N/A N/A N/A N/A N/A N/A N/A 1 1 1 100% N/A N/A N/A 100% CTG

48 03-07-2023 maryann 31814 20100199 N/A N/A N/A N/A N/A N/A N/A N/A N/A 1 1 1 100% N/A N/A N/A 100% IV FLUIDS ADMINISTRA

Page 71 of 111
 DALLAH HOSPITAL - NAMAR
PERFORMANCE IMPROVEMENT IPSG 1
NURSING DEPARTMENT

DEPARTMENT/UNIT AUDITED: LABOR AND DELIVERY Review Period: 1-Aug-22

COMPLIANCE RATE WITH CORRECT PATIENT IDENTIFICATION

Activities: CRITERIAS:
1 Before taking blood and other specimen for clinical testing A. I.D. Band with three full names & medical record number
2 Before administering blood and blood products B. I.D. band matched with the medical record number.
3 Before drug administration C. Identify the patient by asking 3 full names & match with the I.D. Band.
4 Before any interaction to the patient, treatment and procedures
Before giving/delivering patient's
5 prescribed diet
KEY CODES: PRESENT/YES=1 ABSENT/NO=0 NOT APPLICABLE = N/A
1 2 3 4 5
PATIENT CRITERIAS TOTA CRITERIAS CRITERIAS
TOTA
CRITERIAS
TOTA
CRITERIAS TOTAL
REMARKS
NO. DATE STAFF ID FILE L TOTAL L L COMMENTS
NUMBER COMP COMPL COMP COMP COMPL
A B C LIANC A B C IANCE A B C LIANC A B C LIANC A B C IANCE TOTAL
SUGGESTION
E E E
49 03-07-2023 rachell 180270 20168961 N/A N/A N/A N/A N/A N/A 1 1 1 100% N/A N/A N/A N/A N/A N/A 100% MEDICATION

50 03-07-2023 tin 180996 20028283 N/A N/A N/A N/A N/A N/A N/A N/A N/A 1 1 1 100% N/A N/A N/A 100% BABY IDENTIFICATION

51 04-07-2023 s. 182262 20137780 N/A N/A N/A N/A N/A N/A N/A N/A N/A 1 1 1 100% N/A N/A N/A 100% TRANSFER PATIENT TO

52 04-07-2023 maryann 31814 20140867 N/A N/A N/A N/A N/A N/A N/A N/A N/A 1 1 1 100% N/A N/A N/A 100% ADMISSION

53 04-07-2023 rachell 180270 20033199 N/A N/A N/A N/A N/A N/A N/A N/A N/A 1 1 1 100% N/A N/A N/A 100% VITAL SIGNS

54 04-07-2023 tin 180996 20047088 N/A N/A N/A N/A N/A N/A N/A N/A N/A 1 1 1 100% N/A N/A N/A 100% CTG

55 04-07-2023 sreeya 182010 1659604 N/A N/A N/A N/A N/A N/A N/A N/A N/A 1 1 1 100% N/A N/A N/A 100% IV FLUIDS ADMINISTRA
k.kailasam
56 05-07-2023 182151 20145535 N/A N/A N/A N/A N/A N/A 1 1 1 100% N/A N/A N/A N/A N/A N/A 100% MEDICATION

57 05-07-2023 s. 182262 20144859 N/A N/A N/A N/A N/A N/A N/A N/A N/A 1 1 1 100% N/A N/A N/A 100% BABY IDENTIFICATION

58 05-07-2023 s. 182262 20039736 N/A N/A N/A N/A N/A N/A N/A N/A N/A 1 1 1 100% N/A N/A N/A 100% TRANSFER PATIENT TO

59 06-07-2023 maryann 31814 20169180 N/A N/A N/A N/A N/A N/A N/A N/A N/A 1 1 1 100% N/A N/A N/A 100% ADMISSION

60 06-07-2023 rachell 180270 20128304 N/A N/A N/A N/A N/A N/A N/A N/A N/A 1 1 1 100% N/A N/A N/A 100% VITAL SIGNS

61 06-07-2023 tin 180996 20166178 N/A N/A N/A N/A N/A N/A N/A N/A N/A 1 1 1 100% N/A N/A N/A 100% CTG

62 06-07-2023 sreeya 182010 20157661 N/A N/A N/A N/A N/A N/A N/A N/A N/A 1 1 1 100% N/A N/A N/A 100% IV FLUIDS ADMINISTRA
k.kailasam
63 06-07-2023 182151 20046513 N/A N/A N/A N/A N/A N/A 1 1 1 100% N/A N/A N/A N/A N/A N/A 100% MEDICATION

64 06-07-2023 s. 182262 20156612 N/A N/A N/A N/A N/A N/A N/A N/A N/A 1 1 1 100% N/A N/A N/A 100% BABY IDENTIFICATION

65 07-07-2023 s. 182262 20167489 N/A N/A N/A N/A N/A N/A N/A N/A N/A 1 1 1 100% N/A N/A N/A 100% TRANSFER PATIENT TO

66 07-07-2023 maryann 31814 20154817 N/A N/A N/A N/A N/A N/A N/A N/A N/A 1 1 1 100% N/A N/A N/A 100% ADMISSION

67 07-07-2023 rachell 180270 1462795 N/A N/A N/A N/A N/A N/A N/A N/A N/A 1 1 1 100% N/A N/A N/A 100% VITAL SIGNS

68 07-07-2023 tin 180996 1331522 N/A N/A N/A N/A N/A N/A N/A N/A N/A 1 1 1 100% N/A N/A N/A 100% CTG

69 08-07-2023 sreeya 182010 20166575 N/A N/A N/A N/A N/A N/A N/A N/A N/A 1 1 1 100% N/A N/A N/A 100% IV FLUIDS ADMINISTRA
k.kailasam
70 08-07-2023 182151 20146300 N/A N/A N/A N/A N/A N/A 1 1 1 100% N/A N/A N/A N/A N/A N/A 100% MEDICATION

71 08-07-2023 s. 182262 20169490 N/A N/A N/A N/A N/A N/A N/A N/A N/A 1 1 1 100% N/A N/A N/A 100% BABY IDENTIFICATION

72 08-07-2023 s. 182262 20166815 N/A N/A N/A N/A N/A N/A N/A N/A N/A 1 1 1 100% N/A N/A N/A 100% TRANSFER PATIENT TO

Page 72 of 111
 DALLAH HOSPITAL - NAMAR
PERFORMANCE IMPROVEMENT IPSG 1
NURSING DEPARTMENT

DEPARTMENT/UNIT AUDITED: LABOR AND DELIVERY Review Period: 1-Aug-22

COMPLIANCE RATE WITH CORRECT PATIENT IDENTIFICATION

Activities: CRITERIAS:
1 Before taking blood and other specimen for clinical testing A. I.D. Band with three full names & medical record number
2 Before administering blood and blood products B. I.D. band matched with the medical record number.
3 Before drug administration C. Identify the patient by asking 3 full names & match with the I.D. Band.
4 Before any interaction to the patient, treatment and procedures
Before giving/delivering patient's
5 prescribed diet
KEY CODES: PRESENT/YES=1 ABSENT/NO=0 NOT APPLICABLE = N/A
1 2 3 4 5
PATIENT CRITERIAS TOTA CRITERIAS CRITERIAS
TOTA
CRITERIAS
TOTA
CRITERIAS TOTAL
REMARKS
NO. DATE STAFF ID FILE L TOTAL L L COMMENTS
NUMBER COMP COMPL COMP COMP COMPL
A B C LIANC A B C IANCE A B C LIANC A B C LIANC A B C IANCE TOTAL
SUGGESTION
E E E
73 09-07-2023 maryann 31814 20169600 N/A N/A N/A N/A N/A N/A N/A N/A N/A 1 1 1 100% N/A N/A N/A 100% ADMISSION

74 10-07-2023 rachell 180270 1584673 N/A N/A N/A N/A N/A N/A N/A N/A N/A 1 1 1 100% N/A N/A N/A 100% VITAL SIGNS

75 10-07-2023 tin 180996 20147750 N/A N/A N/A N/A N/A N/A N/A N/A N/A 1 1 1 100% N/A N/A N/A 100% CTG

76 10-07-2023 sreeya 182010 2063934 N/A N/A N/A N/A N/A N/A N/A N/A N/A 1 1 1 100% N/A N/A N/A 100% IV FLUIDS ADMINISTRA
k.kailasam
77 11-07-2023 182151 1539638 N/A N/A N/A N/A N/A N/A 1 1 1 100% N/A N/A N/A N/A N/A N/A 100% MEDICATION

78 11-07-2023 s. 182262 20169856 N/A N/A N/A N/A N/A N/A N/A N/A N/A 1 1 1 100% N/A N/A N/A 100% BABY IDENTIFICATION

79 11-07-2023 s. 182262 20168566 N/A N/A N/A N/A N/A N/A N/A N/A N/A 1 1 1 100% N/A N/A N/A 100% TRANSFER PATIENT TO

80 13-07-2023 s. 182262 20170059 N/A N/A N/A N/A N/A N/A N/A N/A N/A 1 1 1 100% N/A N/A N/A 100% ADMISSION

81 13-07-2023 maryann 31814 1321806 N/A N/A N/A N/A N/A N/A N/A N/A N/A 1 1 1 100% N/A N/A N/A 100% VITAL SIGNS

82 14-07-2023 rachell 180270 20167725 N/A N/A N/A N/A N/A N/A N/A N/A N/A 1 1 1 100% N/A N/A N/A 100% CTG

83 14-07-2023 tin 180996 20048793 N/A N/A N/A N/A N/A N/A N/A N/A N/A 1 1 1 100% N/A N/A N/A 100% IV FLUIDS ADMINISTRA

84 15-07-2023 sreeya 182010 20143547 N/A N/A N/A N/A N/A N/A 1 1 1 100% N/A N/A N/A N/A N/A N/A 100% MEDICATION
k.kailasam
85 15-07-2023 182151 20170188 N/A N/A N/A N/A N/A N/A N/A N/A N/A 1 1 1 100% N/A N/A N/A 100% BABY IDENTIFICATION

86 15-07-2023 s. 182262 20150018 N/A N/A N/A N/A N/A N/A N/A N/A N/A 1 1 1 100% N/A N/A N/A 100% TRANSFER PATIENT TO

87 15-07-2023 s. 182262 20158730 N/A N/A N/A N/A N/A N/A N/A N/A N/A 1 1 1 100% N/A N/A N/A 100% ADMISSION

88 15-07-2023 maryann 31814 20168798 N/A N/A N/A N/A N/A N/A N/A N/A N/A 1 1 1 100% N/A N/A N/A 100% VITAL SIGNS

89 16-07-2023 rachell 180270 20050354 N/A N/A N/A N/A N/A N/A N/A N/A N/A 1 1 1 100% N/A N/A N/A 100% CTG

90 16-07-2023 s. 182262 20087138 N/A N/A N/A N/A N/A N/A N/A N/A N/A 1 1 1 100% N/A N/A N/A 100% IV FLUIDS ADMINISTRA

91 17-07-2023 s. 182262 1158127 N/A N/A N/A N/A N/A N/A 1 1 1 100% N/A N/A N/A N/A N/A N/A 100% MEDICATION

92 17-07-2023 maryann 31814 20139984 N/A N/A N/A N/A N/A N/A N/A N/A N/A 1 1 1 100% N/A N/A N/A 100% BABY IDENTIFICATION

93 17-06-2023 rachell 180270 1581484 N/A N/A N/A N/A N/A N/A N/A N/A N/A 1 1 1 100% N/A N/A N/A 100% TRANSFER PATIENT TO

94 17-06-2023 tin 180996 20011745 N/A N/A N/A N/A N/A N/A N/A N/A N/A 1 1 1 100% N/A N/A N/A 100% ADMISSION

95 18-07-2023 sreeya 182010 20170550 N/A N/A N/A N/A N/A N/A N/A N/A N/A 1 1 1 100% N/A N/A N/A 100% VITAL SIGNS
k.kailasam
96 18-07-2023 182151 1506424 N/A N/A N/A N/A N/A N/A N/A N/A N/A 1 1 1 100% N/A N/A N/A 100% CTG

Page 73 of 111
 DALLAH HOSPITAL - NAMAR
PERFORMANCE IMPROVEMENT IPSG 1
NURSING DEPARTMENT

DEPARTMENT/UNIT AUDITED: LABOR AND DELIVERY Review Period: 1-Aug-22

COMPLIANCE RATE WITH CORRECT PATIENT IDENTIFICATION

Activities: CRITERIAS:
1 Before taking blood and other specimen for clinical testing A. I.D. Band with three full names & medical record number
2 Before administering blood and blood products B. I.D. band matched with the medical record number.
3 Before drug administration C. Identify the patient by asking 3 full names & match with the I.D. Band.
4 Before any interaction to the patient, treatment and procedures
Before giving/delivering patient's
5 prescribed diet
KEY CODES: PRESENT/YES=1 ABSENT/NO=0 NOT APPLICABLE = N/A
1 2 3 4 5
PATIENT CRITERIAS TOTA CRITERIAS CRITERIAS
TOTA
CRITERIAS
TOTA
CRITERIAS TOTAL
REMARKS
NO. DATE STAFF ID FILE L TOTAL L L COMMENTS
NUMBER COMP COMPL COMP COMP COMPL
A B C LIANC A B C IANCE A B C LIANC A B C LIANC A B C IANCE TOTAL
SUGGESTION
E E E
97 19-07-2023 s. 182262 1259990 N/A N/A N/A N/A N/A N/A N/A N/A N/A 1 1 1 100% N/A N/A N/A 100% IV FLUIDS ADMINISTRA

98 19-07-2023 s. 182262 20015028 N/A N/A N/A N/A N/A N/A 1 1 1 100% N/A N/A N/A N/A N/A N/A 100% MEDICATION

99 maryann 31814 N/A N/A N/A N/A N/A N/A N/A N/A N/A 1 1 1 100% N/A N/A N/A 100% BABY IDENTIFICATION

100 rachell 180270 N/A N/A N/A N/A N/A N/A N/A N/A N/A 1 1 1 100% N/A N/A N/A 100% TRANSFER PATIENT TO

101 s. 182262 N/A N/A N/A N/A N/A N/A N/A N/A N/A 1 1 1 100% N/A N/A N/A 100% ADMISSION

102 s. 182262 N/A N/A N/A N/A N/A N/A N/A N/A N/A 1 1 1 100% N/A N/A N/A 100% VITAL SIGNS

103 maryann 31814 N/A N/A N/A N/A N/A N/A N/A N/A N/A 1 1 1 100% N/A N/A N/A 100% CTG

104 rachell 180270 N/A N/A N/A N/A N/A N/A N/A N/A N/A 1 1 1 100% N/A N/A N/A 100% IV FLUIDS ADMINISTRA

105 tin 180996 N/A N/A N/A N/A N/A N/A 1 1 1 100% N/A N/A N/A N/A N/A N/A 100% MEDICATION

106 sreeya 182010 N/A N/A N/A N/A N/A N/A N/A N/A N/A 1 1 1 100% N/A N/A N/A 100% BABY IDENTIFICATION
k.kailasam
107 182151 N/A N/A N/A N/A N/A N/A N/A N/A N/A 1 1 1 100% N/A N/A N/A 100% TRANSFER PATIENT TO

108 s. 182262 N/A N/A N/A N/A N/A N/A N/A N/A N/A 1 1 1 100% N/A N/A N/A 100% ADMISSION

109 s. 182262 N/A N/A N/A N/A N/A N/A N/A N/A N/A 1 1 1 100% N/A N/A N/A 100% VITAL SIGNS

110 maryann 31814 N/A N/A N/A N/A N/A N/A N/A N/A N/A 1 1 1 100% N/A N/A N/A 100% CTG

111 rachell 180270 N/A N/A N/A N/A N/A N/A N/A N/A N/A 1 1 1 100% N/A N/A N/A 100% IV FLUIDS ADMINISTRA

112 s. 182262 N/A N/A N/A N/A N/A N/A 1 1 1 100% N/A N/A N/A N/A N/A N/A 100% MEDICATION

113 s. 182262 N/A N/A N/A N/A N/A N/A N/A N/A N/A 1 1 1 100% N/A N/A N/A 100% BABY IDENTIFICATION

114 maryann 31814 N/A N/A N/A N/A N/A N/A N/A N/A N/A 1 1 1 100% N/A N/A N/A 100% TRANSFER PATIENT TO

115 rachell 180270 N/A N/A N/A N/A N/A N/A N/A N/A N/A 1 1 1 100% N/A N/A N/A 100% ADMISSION

116 tin 180996 N/A N/A N/A N/A N/A N/A N/A N/A N/A 1 1 1 100% N/A N/A N/A 100% VITAL SIGNS

117 sreeya 182010 N/A N/A N/A N/A N/A N/A N/A N/A N/A 1 1 1 100% N/A N/A N/A 100% CTG
k.kailasam
118 182151 N/A N/A N/A N/A N/A N/A N/A N/A N/A 1 1 1 100% N/A N/A N/A 100% IV FLUIDS ADMINISTRA

119 s. 182262 N/A N/A N/A N/A N/A N/A 1 1 1 100% N/A N/A N/A N/A N/A N/A 100% MEDICATION

120 s. 182262 N/A N/A N/A N/A N/A N/A N/A N/A N/A 1 1 1 100% N/A N/A N/A 100% BABY IDENTIFICATION

Page 74 of 111
 DALLAH HOSPITAL - NAMAR
PERFORMANCE IMPROVEMENT IPSG 1
NURSING DEPARTMENT

DEPARTMENT/UNIT AUDITED: LABOR AND DELIVERY Review Period: 1-Aug-22

COMPLIANCE RATE WITH CORRECT PATIENT IDENTIFICATION

Activities: CRITERIAS:
1 Before taking blood and other specimen for clinical testing A. I.D. Band with three full names & medical record number
2 Before administering blood and blood products B. I.D. band matched with the medical record number.
3 Before drug administration C. Identify the patient by asking 3 full names & match with the I.D. Band.
4 Before any interaction to the patient, treatment and procedures
Before giving/delivering patient's
5 prescribed diet
KEY CODES: PRESENT/YES=1 ABSENT/NO=0 NOT APPLICABLE = N/A
1 2 3 4 5
PATIENT CRITERIAS TOTA CRITERIAS CRITERIAS
TOTA
CRITERIAS
TOTA
CRITERIAS TOTAL
REMARKS
NO. DATE STAFF ID FILE L TOTAL L L COMMENTS
NUMBER COMP COMPL COMP COMP COMPL
A B C LIANC A B C IANCE A B C LIANC A B C LIANC A B C IANCE TOTAL
SUGGESTION
E E E
121 maryann 31814 N/A N/A N/A N/A N/A N/A N/A N/A N/A 1 1 1 100% 1 1 1 100% 100% Diet serve

122 rachell 180270 N/A N/A N/A N/A N/A N/A N/A N/A N/A 1 1 1 100% N/A N/A N/A 100% VITAL SIGNS

123 maryann 31814 N/A N/A N/A N/A N/A N/A N/A N/A N/A 1 1 1 100% N/A N/A N/A 100% CTG

124 rachell 180270 N/A N/A N/A N/A N/A N/A N/A N/A N/A 1 1 1 100% N/A N/A N/A 100% IV FLUIDS ADMINISTRA

125 tin 180996 N/A N/A N/A N/A N/A N/A 1 1 1 100% N/A N/A N/A N/A N/A N/A 100% MEDICATION

126 maryann 31814 N/A N/A N/A N/A N/A N/A N/A N/A N/A 1 1 1 100% N/A N/A N/A 100% BABY IDENTIFICATION
127 rachell 180270 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A 1 1 1 100% 100% Diet serve
128 tin 180996 N/A N/A N/A N/A N/A N/A N/A N/A N/A 1 1 1 100% N/A N/A N/A 100% CTG

TOTAL COMPLIANCE – EACH ### ### ### 100% 100% 100% 100% 100% 100% 100% 100% 100%
CRITERIA ###
TOTAL COMPLIANCE – ALL CRITERIA 0

YURAIDEL STEPHANIE
Audited by : AMPATUAN/OB GYNE AQUINO/ OB GYNE Date Submitted: July 30, 2023
(Name/ID #/Unit) (Name/ID #/Unit)
1st Data Collector 2ND Data Collector

Page 75 of 111
 DALLAH HOSPITAL - NAMAR
PERFORMANCE IMPROVEMENT HIGH ALERT
NURSING DEPARTMENT

DEPARTMENT/UNIT AUDITED: LABOR AND DELIVERY JULY 2023

COMPLIANCE ON SAFETY OF HIGH ALERT MEDICATION

Activities: CRITERIAS:
1 With each dose/injection A. Compare the label with product content in hand against the written order and MAR if it’s the first dose, or label and product content with for the
subsequence dose.
2 At the time of concentration changes.
B. The infusion pump setting will be also double check for correct rate of infusion on initiation time of infusing.
3 At the change of each shift or any transfer of care.
4 With any dose change. C. Documentation of the double check will be included on the MAR.
1 2 3 4
DATE
CRITERIAS CRITERIAS CRITERIAS CRITERIAS
REMARKS
(DAY/ PATIENT FILE TOTAL TOTAL TOTAL TOTAL
NO. MONTH/
STAFF ID
NUMBER
TOTAL COMMENTS
COMPLIA COMPLIAN COMPLIAN COMPLIAN
YEAR)
A B C NCE A B C CE A B C CE A B C CE
SUGGESTION

1 21-06-2023 tin 180996 20166323 1 N/A 1 100% N/A N/A N/A N/A N/A N/A N/A N/A N/A 100% PETHEDINE INJECTION

2 21-06-2023 tin 180996 20166323 1 N/A 1 100% N/A N/A N/A N/A N/A N/A N/A N/A N/A 100% SYNTO IM

3 21-06-2023 arlen 181258 20166323 N/A N/A N/A 1 1 1 100% N/A N/A N/A N/A N/A N/A 100% SYNTO INFUSION

4 21-06-2023 sreeya 182010 20166246 1 N/A 1 100% N/A N/A N/A N/A N/A N/A N/A N/A N/A 100% PETHEDINE INJECTION

5 k.kailasam 1 N/A 1 100% N/A N/A N/A N/A N/A N/A N/A N/A N/A 100% SYNTO IM
21-06-2023 182151 20166246
6 21-06-2023 s. 182262 20166246 N/A N/A N/A 1 1 1 100% N/A N/A N/A N/A N/A N/A 100% SYNTO INFUSION
maryann
7 21-06-2023 31814 20107437 1 N/A 1 100% N/A N/A N/A N/A N/A N/A N/A N/A N/A 100% PETHEDINE INJECTION

8 21-06-2023 rachell 180270 20107437 1 N/A 1 100% N/A N/A N/A N/A N/A N/A N/A N/A N/A 100% Syntocinon IM

9 21-06-2023 lyn 180273 20107437 N/A N/A N/A 1 1 1 100% N/A N/A N/A N/A N/A N/A 100% syntocinon infusion

10 22-06-2023 jally 180306 909193 1 N/A 1 100% N/A N/A N/A N/A N/A N/A N/A N/A N/A 100% Syntocinon IM

11 22-06-2023 mj 180410 909193 N/A N/A N/A 1 1 1 100% N/A N/A N/A N/A N/A N/A 100% syntocinon infusion

12 22-06-2023 jesica 180499 909193 1 N/A 1 100% N/A N/A N/A N/A N/A N/A N/A N/A N/A 100% Syntocinon IM

13 23-06-2023 tin 180996 1689973 N/A N/A N/A 1 1 1 100% N/A N/A N/A N/A N/A N/A 100% syntocinon infusion

14 23-06-2023 arlen 181258 1689973 1 N/A 1 100% N/A N/A N/A N/A N/A N/A N/A N/A N/A 100% Syntocinon IM

15 23-06-2023 sreeya 182010 1689973 N/A N/A N/A 1 1 1 100% N/A N/A N/A N/A N/A N/A 100% syntocinon infusion

16 k.kailasam N/A N/A N/A 1 1 1 100% N/A N/A N/A N/A N/A N/A 100% syntocinon infusion
24-06-2023 182151 20168227
17 24-06-2023 s. 182262 20168227 1 N/A 1 100% N/A N/A N/A N/A N/A N/A N/A N/A N/A 100% Syntocinon IM
maryann
18 24-06-2023 31814 20168227 N/A N/A N/A 1 1 1 100% N/A N/A N/A N/A N/A N/A 100% syntocinon infusion

19 k.kailasam 1 N/A 1 100% N/A N/A N/A N/A N/A N/A N/A N/A N/A 100% Syntocinon IM
24-06-2023 182151 20043602
20 24-06-2023 s. 182262 20043602 N/A N/A N/A 1 1 1 100% N/A N/A N/A N/A N/A N/A 100% syntocinon infusion
maryann
21 24-06-2023 31814 20043602 N/A N/A N/A 1 1 1 100% N/A N/A N/A N/A N/A N/A 100% syntocinon infusion

22 24-06-2023 rachell 180270 20083007 1 N/A 1 100% N/A N/A N/A N/A N/A N/A N/A N/A N/A 100% Syntocinon IM

23 24-06-2023 lyn 180273 20083007 N/A N/A N/A 1 1 1 100% N/A N/A N/A N/A N/A N/A 100% syntocinon infusion

24 24-06-2023 jally 180306 20083007 N/A N/A N/A 1 1 1 100% N/A N/A N/A N/A N/A N/A 100% syntocinon infusion

Page 76 of 111
 DALLAH HOSPITAL - NAMAR
PERFORMANCE IMPROVEMENT HIGH ALERT
NURSING DEPARTMENT

DEPARTMENT/UNIT AUDITED: LABOR AND DELIVERY JULY 2023

COMPLIANCE ON SAFETY OF HIGH ALERT MEDICATION

Activities: CRITERIAS:
1 With each dose/injection A. Compare the label with product content in hand against the written order and MAR if it’s the first dose, or label and product content with for the
subsequence dose.
2 At the time of concentration changes.
B. The infusion pump setting will be also double check for correct rate of infusion on initiation time of infusing.
3 At the change of each shift or any transfer of care.
4 With any dose change. C. Documentation of the double check will be included on the MAR.
1 2 3 4
DATE
CRITERIAS CRITERIAS CRITERIAS CRITERIAS
REMARKS
(DAY/ PATIENT FILE TOTAL TOTAL TOTAL TOTAL
NO. MONTH/
STAFF ID
NUMBER
TOTAL COMMENTS
COMPLIA COMPLIAN COMPLIAN COMPLIAN
YEAR)
A B C NCE A B C CE A B C CE A B C CE
SUGGESTION

25 24-06-2023 sreeya 182010 1691628 1 N/A 1 100% N/A N/A N/A N/A N/A N/A N/A N/A N/A 100% Syntocinon IM

26 k.kailasam N/A N/A N/A 1 1 1 100% N/A N/A N/A N/A N/A N/A 100% syntocinon infusion
24-06-2023 182151 1691628
27 24-06-2023 s. 182262 1691628 1 N/A 1 100% N/A N/A N/A N/A N/A N/A N/A N/A N/A 100% Syntocinon IM
maryann
28 24-06-2023 31814 20159448 N/A N/A N/A 1 1 1 100% N/A N/A N/A N/A N/A N/A 100% syntocinon infusion

29 k.kailasam N/A N/A N/A 1 1 1 100% N/A N/A N/A N/A N/A N/A 100% syntocinon infusion
24-06-2023 182151 20159448
30 24-06-2023 s. 182262 20159448 1 N/A 1 100% N/A N/A N/A N/A N/A N/A N/A N/A N/A 100% Syntocinon IM
maryann
31 24-06-2023 31814 20166153 N/A N/A N/A 1 1 1 100% N/A N/A N/A N/A N/A N/A 100% syntocinon infusion

32 24-06-2023 rachell 180270 20166153 N/A N/A N/A 1 1 1 100% N/A N/A N/A N/A N/A N/A 100% syntocinon infusion

33 24-06-2023 sreeya 182010 20166153 1 N/A 1 100% N/A N/A N/A N/A N/A N/A N/A N/A N/A 100% Syntocinon IM

34 k.kailasam N/A N/A N/A 1 1 1 100% N/A N/A N/A N/A N/A N/A 100% syntocinon infusion
25-06-2023 182151 20168304
35 25-06-2023 s. 182262 20168304 N/A N/A N/A 1 1 1 100% N/A N/A N/A N/A N/A N/A 100% syntocinon infusion
maryann
36 25-06-2023 31814 20168304 1 N/A 1 100% N/A N/A N/A N/A N/A N/A N/A N/A N/A 100% Syntocinon IM

37 k.kailasam N/A N/A N/A 1 1 1 100% N/A N/A N/A N/A N/A N/A 100% syntocinon infusion
25-06-2023 182151 1590774
38 25-06-2023 s. 182262 1590774 N/A N/A N/A 1 1 1 100% N/A N/A N/A N/A N/A N/A 100% syntocinon infusion
maryann
39 25-06-2023 31814 1590774 1 N/A 1 100% N/A N/A N/A N/A N/A N/A N/A N/A N/A 100% Syntocinon IM

40 25-06-2023 rachell 180270 20165224 N/A N/A N/A 1 1 1 100% N/A N/A N/A N/A N/A N/A 100% syntocinon infusion

41 25-06-2023 tin 180996 20165224 N/A N/A N/A 1 1 1 100% N/A N/A N/A N/A N/A N/A 100% syntocinon infusion

42 25-06-2023 sreeya 182010 20165224 1 N/A 1 100% N/A N/A N/A N/A N/A N/A N/A N/A N/A 100% Syntocinon IM

43 k.kailasam N/A N/A N/A 1 1 1 100% N/A N/A N/A N/A N/A N/A 100% syntocinon infusion
25-06-2023 182151 20168404
44 25-06-2023 s. 182262 20168404 N/A N/A N/A 1 1 1 100% N/A N/A N/A N/A N/A N/A 100% syntocinon infusion
maryann
45 25-06-2023 31814 20168404 1 N/A 1 100% N/A N/A N/A N/A N/A N/A N/A N/A N/A 100% Syntocinon IM

46 k.kailasam N/A N/A N/A 1 1 1 100% N/A N/A N/A N/A N/A N/A 100% syntocinon infusion
25-06-2023 182151 20168446
Page 77 of 111
 DALLAH HOSPITAL - NAMAR
PERFORMANCE IMPROVEMENT HIGH ALERT
NURSING DEPARTMENT

DEPARTMENT/UNIT AUDITED: LABOR AND DELIVERY JULY 2023

COMPLIANCE ON SAFETY OF HIGH ALERT MEDICATION

Activities: CRITERIAS:
1 With each dose/injection A. Compare the label with product content in hand against the written order and MAR if it’s the first dose, or label and product content with for the
subsequence dose.
2 At the time of concentration changes.
B. The infusion pump setting will be also double check for correct rate of infusion on initiation time of infusing.
3 At the change of each shift or any transfer of care.
4 With any dose change. C. Documentation of the double check will be included on the MAR.
1 2 3 4
DATE
CRITERIAS CRITERIAS CRITERIAS CRITERIAS
REMARKS
(DAY/ PATIENT FILE TOTAL TOTAL TOTAL TOTAL
NO. MONTH/
STAFF ID
NUMBER
TOTAL COMMENTS
COMPLIA COMPLIAN COMPLIAN COMPLIAN
YEAR)
A B C NCE A B C CE A B C CE A B C CE
SUGGESTION

47 26-06-2023 s. 182262 20168446 N/A N/A N/A 1 1 1 100% N/A N/A N/A N/A N/A N/A 100% syntocinon infusion
maryann
48 26-06-2023 31814 20168446 1 N/A 1 100% N/A N/A N/A N/A N/A N/A N/A N/A N/A 100% Syntocinon IM

49 26-06-2023 rachell 180270 20164836 N/A N/A N/A 1 1 1 100% N/A N/A N/A N/A N/A N/A 100% syntocinon infusion

50 26-06-2023 tin 180996 20164836 N/A N/A N/A 1 1 1 100% N/A N/A N/A N/A N/A N/A 100% syntocinon infusion

51 26-06-2023 s. 182262 20164836 1 N/A 1 100% N/A N/A N/A N/A N/A N/A N/A N/A N/A 100% Syntocinon IM
maryann
52 26-06-2023 31814 20168408 N/A N/A N/A 1 1 1 100% N/A N/A N/A N/A N/A N/A 100% syntocinon infusion

53 26-06-2023 rachell 180270 20168408 N/A N/A N/A 1 1 1 100% N/A N/A N/A N/A N/A N/A 100% syntocinon infusion

54 26-06-2023 tin 180996 20168408 1 N/A 1 100% N/A N/A N/A N/A N/A N/A N/A N/A N/A 100% Syntocinon IM

55 27-06-2023 sreeya 182010 20168550 N/A N/A N/A 1 1 1 100% N/A N/A N/A N/A N/A N/A 100% syntocinon infusion

56 k.kailasam N/A N/A N/A 1 1 1 100% N/A N/A N/A N/A N/A N/A 100% syntocinon infusion
27-06-2023 182151 20168550
57 27-06-2023 s. 182262 20168550 N/A N/A N/A 1 1 1 100% N/A N/A N/A N/A N/A N/A 100% syntocinon infusion

58 27-06-2023 s. 182262 20146329 1 N/A 1 100% N/A N/A N/A N/A N/A N/A N/A N/A N/A 100% Syntocinon IM
maryann
59 27-06-2023 31814 20146329 N/A N/A N/A 1 1 1 100% N/A N/A N/A N/A N/A N/A 100% syntocinon infusion

60 27-06-2023 rachell 180270 20146329 N/A N/A N/A 1 1 1 100% N/A N/A N/A N/A N/A N/A 100% syntocinon infusion

61 28-06-2023 tin 180996 1087603 1 N/A 1 100% N/A N/A N/A N/A N/A N/A N/A N/A N/A 100% Syntocinon IM

62 28-06-2023 sreeya 182010 1087603 N/A N/A N/A 1 1 1 100% N/A N/A N/A N/A N/A N/A 100% syntocinon infusion

63 k.kailasam N/A N/A N/A 1 1 1 100% N/A N/A N/A N/A N/A N/A 100% syntocinon infusion
28-06-2023 182151 1087603
64 28-06-2023 s. 182262 20168132 1 N/A 1 100% N/A N/A N/A N/A N/A N/A N/A N/A N/A 100% Syntocinon IM

65 28-06-2023 s. 182262 20168132 N/A N/A N/A 1 1 1 100% N/A N/A N/A N/A N/A N/A 100% syntocinon infusion
maryann
66 28-06-2023 31814 20168132 N/A N/A N/A 1 1 1 100% N/A N/A N/A N/A N/A N/A 100% syntocinon infusion

67 28-06-2023 rachell 180270 1160651 1 N/A 1 100% N/A N/A N/A N/A N/A N/A N/A N/A N/A 100% Syntocinon IM

68 28-06-2023 tin 180996 1160651 N/A N/A N/A 1 1 1 100% N/A N/A N/A N/A N/A N/A 100% syntocinon infusion

69 28-06-2023 sreeya 182010 1160651 N/A N/A N/A 1 1 1 100% N/A N/A N/A N/A N/A N/A 100% syntocinon infusion

70 k.kailasam 1 N/A 1 100% N/A N/A N/A N/A N/A N/A N/A N/A N/A 100% Syntocinon IM
28-06-2023 182151 20155257

Page 78 of 111
 DALLAH HOSPITAL - NAMAR
PERFORMANCE IMPROVEMENT HIGH ALERT
NURSING DEPARTMENT

DEPARTMENT/UNIT AUDITED: LABOR AND DELIVERY JULY 2023

COMPLIANCE ON SAFETY OF HIGH ALERT MEDICATION

Activities: CRITERIAS:
1 With each dose/injection A. Compare the label with product content in hand against the written order and MAR if it’s the first dose, or label and product content with for the
subsequence dose.
2 At the time of concentration changes.
B. The infusion pump setting will be also double check for correct rate of infusion on initiation time of infusing.
3 At the change of each shift or any transfer of care.
4 With any dose change. C. Documentation of the double check will be included on the MAR.
1 2 3 4
DATE
CRITERIAS CRITERIAS CRITERIAS CRITERIAS
REMARKS
(DAY/ PATIENT FILE TOTAL TOTAL TOTAL TOTAL
NO. MONTH/
STAFF ID
NUMBER
TOTAL COMMENTS
COMPLIA COMPLIAN COMPLIAN COMPLIAN
YEAR)
A B C NCE A B C CE A B C CE A B C CE
SUGGESTION

71 28-06-2023 s. 182262 20155257 N/A N/A N/A 1 1 1 100% N/A N/A N/A N/A N/A N/A 100% syntocinon infusion

72 28-06-2023 s. 182262 20155257 N/A N/A N/A 1 1 1 100% N/A N/A N/A N/A N/A N/A 100% syntocinon infusion
maryann
73 28-06-2023 31814 905061 1 N/A 1 100% N/A N/A N/A N/A N/A N/A N/A N/A N/A 100% Syntocinon IM

74 28-06-2023 rachell 180270 905061 N/A N/A N/A 1 1 1 100% N/A N/A N/A N/A N/A N/A 100% syntocinon infusion

75 28-06-2023 tin 180996 905061 N/A N/A N/A 1 1 1 100% N/A N/A N/A N/A N/A N/A 100% syntocinon infusion

76 29-06-2023 sreeya 182010 20136355 1 N/A 1 100% N/A N/A N/A N/A N/A N/A N/A N/A N/A 100% Syntocinon IM

77 k.kailasam N/A N/A N/A 1 1 1 100% N/A N/A N/A N/A N/A N/A 100% syntocinon infusion
29-06-2023 182151 20136355
78 29-06-2023 s. 182262 20136355 N/A N/A N/A 1 1 1 100% N/A N/A N/A N/A N/A N/A 100% syntocinon infusion

79 29-06-2023 s. 182262 20153841 1 N/A 1 100% N/A N/A N/A N/A N/A N/A N/A N/A N/A 100% Syntocinon IM

80 29-06-2023 s. 182262 20153841 N/A N/A N/A 1 1 1 100% N/A N/A N/A N/A N/A N/A 100% syntocinon infusion
maryann
81 29-06-2023 31814 20153841 N/A N/A N/A 1 1 1 100% N/A N/A N/A N/A N/A N/A 100% syntocinon infusion

82 29-06-2023 rachell 180270 20168542 1 N/A 1 100% N/A N/A N/A N/A N/A N/A N/A N/A N/A 100% Syntocinon IM

83 29-06-2023 tin 180996 20168542 N/A N/A N/A 1 1 1 100% N/A N/A N/A N/A N/A N/A 100% syntocinon infusion

84 29-06-2023 sreeya 182010 20168542 N/A N/A N/A 1 1 1 100% N/A N/A N/A N/A N/A N/A 100% syntocinon infusion

85 k.kailasam 1 N/A 1 100% N/A N/A N/A N/A N/A N/A N/A N/A N/A 100% Syntocinon IM
29-06-2023 182151 1328480
86 29-06-2023 s. 182262 1328480 N/A N/A N/A 1 1 1 100% N/A N/A N/A N/A N/A N/A 100% syntocinon infusion

87 29-06-2023 s. 182262 1328480 N/A N/A N/A 1 1 1 100% N/A N/A N/A N/A N/A N/A 100% syntocinon infusion
maryann
88 30-06-2023 31814 1340092 1 N/A 1 100% N/A N/A N/A N/A N/A N/A N/A N/A N/A 100% Syntocinon IM

89 30-06-2023 rachell 180270 1340092 N/A N/A N/A 1 1 1 100% N/A N/A N/A N/A N/A N/A 100% syntocinon infusion

90 30-06-2023 s. 182262 1340092 N/A N/A N/A 1 1 1 100% N/A N/A N/A N/A N/A N/A 100% syntocinon infusion

91 30-06-2023 s. 182262 20044018 1 N/A 1 100% N/A N/A N/A N/A N/A N/A N/A N/A N/A 100% Syntocinon IM
maryann
92 30-06-2023 31814 20044018 N/A N/A N/A 1 1 1 100% N/A N/A N/A N/A N/A N/A 100% syntocinon infusion

93 30-06-2023 rachell 180270 20044018 N/A N/A N/A 1 1 1 100% N/A N/A N/A N/A N/A N/A 100% syntocinon infusion

94 30-06-2023 tin 180996 20167655 1 N/A 1 100% N/A N/A N/A N/A N/A N/A N/A N/A N/A 100% Syntocinon IM

95 30-06-2023 sreeya 182010 20167655 N/A N/A N/A 1 1 1 100% N/A N/A N/A N/A N/A N/A 100% syntocinon infusion

Page 79 of 111
 DALLAH HOSPITAL - NAMAR
PERFORMANCE IMPROVEMENT HIGH ALERT
NURSING DEPARTMENT

DEPARTMENT/UNIT AUDITED: LABOR AND DELIVERY JULY 2023

COMPLIANCE ON SAFETY OF HIGH ALERT MEDICATION

Activities: CRITERIAS:
1 With each dose/injection A. Compare the label with product content in hand against the written order and MAR if it’s the first dose, or label and product content with for the
subsequence dose.
2 At the time of concentration changes.
B. The infusion pump setting will be also double check for correct rate of infusion on initiation time of infusing.
3 At the change of each shift or any transfer of care.
4 With any dose change. C. Documentation of the double check will be included on the MAR.
1 2 3 4
DATE
CRITERIAS CRITERIAS CRITERIAS CRITERIAS
REMARKS
(DAY/ PATIENT FILE TOTAL TOTAL TOTAL TOTAL
NO. MONTH/
STAFF ID
NUMBER
TOTAL COMMENTS
COMPLIA COMPLIAN COMPLIAN COMPLIAN
YEAR)
A B C NCE A B C CE A B C CE A B C CE
SUGGESTION

96 k.kailasam N/A N/A N/A 1 1 1 100% N/A N/A N/A N/A N/A N/A 100% syntocinon infusion
30-06-2023 182151 20167655
97 30-06-2023 s. 182262 20168725 1 N/A 1 100% N/A N/A N/A N/A N/A N/A N/A N/A N/A 100% Syntocinon IM

98 30-06-2023 s. 182262 20168725 N/A N/A N/A 1 1 1 100% N/A N/A N/A N/A N/A N/A 100% syntocinon infusion
maryann
99 30-06-2023 31814 20168725 N/A N/A N/A 1 1 1 100% N/A N/A N/A N/A N/A N/A 100% syntocinon infusion

100 30-06-2023 rachell 180270 20149320 1 N/A 1 100% N/A N/A N/A N/A N/A N/A N/A N/A N/A 100% Syntocinon IM

101 30-06-2023 s. 182262 20149320 N/A N/A N/A 1 1 1 100% N/A N/A N/A N/A N/A N/A 100% syntocinon infusion

102 30-06-2023 s. 182262 20149320 N/A N/A N/A 1 1 1 100% N/A N/A N/A N/A N/A N/A 100% syntocinon infusion
maryann
103 30-06-2023 31814 1358907 1 N/A 1 100% N/A N/A N/A N/A N/A N/A N/A N/A N/A 100% Syntocinon IM

104 30-06-2023 rachell 180270 1358907 N/A N/A N/A 1 1 1 100% N/A N/A N/A N/A N/A N/A 100% syntocinon infusion

105 30-06-2023 tin 180996 1358907 N/A N/A N/A 1 1 1 100% N/A N/A N/A N/A N/A N/A 100% syntocinon infusion

106 01-07-2023 sreeya 182010 20145320 1 N/A 1 100% N/A N/A N/A N/A N/A N/A N/A N/A N/A 100% Syntocinon IM

107 k.kailasam N/A N/A N/A 1 1 1 100% N/A N/A N/A N/A N/A N/A 100% syntocinon infusion
01-07-2023 182151 20145320
108 01-07-2023 s. 182262 20145320 N/A N/A N/A 1 1 1 100% N/A N/A N/A N/A N/A N/A 100% syntocinon infusion

109 01-07-2023 s. 182262 20168772 1 N/A 1 100% N/A N/A N/A N/A N/A N/A N/A N/A N/A 100% Syntocinon IM
maryann
110 01-07-2023 31814 20168772 N/A N/A N/A 1 1 1 100% N/A N/A N/A N/A N/A N/A 100% syntocinon infusion

111 01-07-2023 rachell 180270 20168772 N/A N/A N/A 1 1 1 100% N/A N/A N/A N/A N/A N/A 100% syntocinon infusion

112 01-07-2023 s. 182262 20168773 1 N/A 1 100% N/A N/A N/A N/A N/A N/A N/A N/A N/A 100% Syntocinon IM

113 01-07-2023 s. 182262 20168773 N/A N/A N/A 1 1 1 100% N/A N/A N/A N/A N/A N/A 100% syntocinon infusion
maryann
114 01-07-2023 31814 20168773 N/A N/A N/A 1 1 1 100% N/A N/A N/A N/A N/A N/A 100% syntocinon infusion

115 02-07-2023 rachell 180270 20148475 1 N/A 1 100% N/A N/A N/A N/A N/A N/A N/A N/A N/A 100% Syntocinon IM

116 02-07-2023 tin 180996 20148475 N/A N/A N/A 1 1 1 100% N/A N/A N/A N/A N/A N/A 100% syntocinon infusion

117 02-07-2023 sreeya 182010 20148475 N/A N/A N/A 1 1 1 100% N/A N/A N/A N/A N/A N/A 100% syntocinon infusion

118 k.kailasam 1 N/A 1 100% N/A N/A N/A N/A N/A N/A N/A N/A N/A 100% Syntocinon IM
02-07-2023 182151 1600274
119 02-07-2023 s. 182262 1600274 N/A N/A N/A 1 1 1 100% N/A N/A N/A N/A N/A N/A 100% syntocinon infusion

Page 80 of 111
 DALLAH HOSPITAL - NAMAR
PERFORMANCE IMPROVEMENT HIGH ALERT
NURSING DEPARTMENT

DEPARTMENT/UNIT AUDITED: LABOR AND DELIVERY JULY 2023

COMPLIANCE ON SAFETY OF HIGH ALERT MEDICATION

Activities: CRITERIAS:
1 With each dose/injection A. Compare the label with product content in hand against the written order and MAR if it’s the first dose, or label and product content with for the
subsequence dose.
2 At the time of concentration changes.
B. The infusion pump setting will be also double check for correct rate of infusion on initiation time of infusing.
3 At the change of each shift or any transfer of care.
4 With any dose change. C. Documentation of the double check will be included on the MAR.
1 2 3 4
DATE
CRITERIAS CRITERIAS CRITERIAS CRITERIAS
REMARKS
(DAY/ PATIENT FILE TOTAL TOTAL TOTAL TOTAL
NO. MONTH/
STAFF ID
NUMBER
TOTAL COMMENTS
COMPLIA COMPLIAN COMPLIAN COMPLIAN
YEAR)
A B C NCE A B C CE A B C CE A B C CE
SUGGESTION

120 02-07-2023 s. 182262 1600274 N/A N/A N/A 1 1 1 100% N/A N/A N/A N/A N/A N/A 100% syntocinon infusion
maryann
121 02-07-2023 31814 20146595 1 N/A 1 100% N/A N/A N/A N/A N/A N/A N/A N/A N/A 100% Syntocinon IM

122 02-07-2023 rachell 180270 20146595 N/A N/A N/A 1 1 1 100% N/A N/A N/A N/A N/A N/A 100% syntocinon infusion
maryann
123 02-07-2023 31814 20146595 N/A N/A N/A 1 1 1 100% N/A N/A N/A N/A N/A N/A 100% syntocinon infusion

124 02-07-2023 rachell 180270 20140995 1 N/A 1 100% N/A N/A N/A N/A N/A N/A N/A N/A N/A 100% Syntocinon IM

125 02-07-2023 tin 180996 20140995 N/A N/A N/A 1 1 1 100% N/A N/A N/A N/A N/A N/A 100% syntocinon infusion
maryann
126 02-07-2023 31814 20140995 N/A N/A N/A 1 1 1 100% N/A N/A N/A N/A N/A N/A 100% syntocinon infusion
127 02-07-2023 rachell 180270 47149 1 N/A 1 100% N/A N/A N/A N/A N/A N/A N/A N/A N/A 100% Syntocinon IM
128 02-07-2023 tin 180996 47149 N/A N/A N/A 1 1 1 100% N/A N/A N/A N/A N/A N/A 100% syntocinon infusion

TOTAL COMPLIANCE – EACH CRITERIA 100% NA 100% 100% 100% 100% 100% 100% NA NA NA NA NA NA NA
###
TOTAL COMPLIANCE – ALL CRITERIA 100%

YURAIDEL AMPATUAN/OB STEPHANIE AQUINO/

Audited by : GYNE OB GYNE July 30, 2023
(Name/ID #/Unit) (Name/ID #/Unit) DATE SUBMITTED
1st Data Collector 2ND Data Collector

Page 81 of 111
 DALLAH HOSPITAL - NAMAR HOME
PERFORMANCE IMPROVEMENT NURSING QUALITY
INDICATOR
NURSING DEPARTMENT

DEPARTMENT/UNIT AUDITED: LABOR AND DELIVERY REVIEW PERIOD: JULY 2023

COMPLIANCE WITH NON OR SURGICAL TIME OUT PROCEDURE

CRITERIAS:
6. Check equipment, instrument and any other special
1. Confirm that all team members have introduced themselves by name and role. requirements.
2. Correct patient identity 7. Patient specific concerns w discussed.
3. Correct side and site
4. Agreement on the procedure to be perform.
5. Display and checking of essential imaging is available.
KEY CODES: PRESENT/YES = 1 ABSENT/NO = 0 NOT APPLICABLE = N/A
DATE CRITERIAS
TOTAL
NO. PATIENT MR NUMBER COMPLIANCE COMMENTS
REVIEWED 1 2 3 4 5 6 7
1 NO CASE
2 ###
3 ###
4 ###
5 ###
6 ###
7 ###
8 ###
9 ###
10 ###
11 ###
12 ###
13 ###
14 ###
15 ###
16 ###
17 ###
18 ###

Page 82 of 111
 DALLAH HOSPITAL - NAMAR HOME
PERFORMANCE IMPROVEMENT NURSING QUALITY
INDICATOR
NURSING DEPARTMENT

DEPARTMENT/UNIT AUDITED: LABOR AND DELIVERY REVIEW PERIOD: JULY 2023

COMPLIANCE WITH NON OR SURGICAL TIME OUT PROCEDURE

CRITERIAS:
6. Check equipment, instrument and any other special
1. Confirm that all team members have introduced themselves by name and role. requirements.
2. Correct patient identity 7. Patient specific concerns w discussed.
3. Correct side and site
4. Agreement on the procedure to be perform.
5. Display and checking of essential imaging is available.
KEY CODES: PRESENT/YES = 1 ABSENT/NO = 0 NOT APPLICABLE = N/A
DATE CRITERIAS
TOTAL
NO. PATIENT MR NUMBER COMPLIANCE COMMENTS
REVIEWED 1 2 3 4 5 6 7
19 ###
20 ###
21 ###
22 ###
23 ###
24 ###
25 ###
26 ###
27 ###
28 ###
29 ###
30 ###
31 ###
32 ###
33 ###
34 ###
35 ###
36 ###

Page 83 of 111
 DALLAH HOSPITAL - NAMAR HOME
PERFORMANCE IMPROVEMENT NURSING QUALITY
INDICATOR
NURSING DEPARTMENT

DEPARTMENT/UNIT AUDITED: LABOR AND DELIVERY REVIEW PERIOD: JULY 2023

COMPLIANCE WITH NON OR SURGICAL TIME OUT PROCEDURE

CRITERIAS:
6. Check equipment, instrument and any other special
1. Confirm that all team members have introduced themselves by name and role. requirements.
2. Correct patient identity 7. Patient specific concerns w discussed.
3. Correct side and site
4. Agreement on the procedure to be perform.
5. Display and checking of essential imaging is available.
KEY CODES: PRESENT/YES = 1 ABSENT/NO = 0 NOT APPLICABLE = N/A
DATE CRITERIAS
TOTAL
NO. PATIENT MR NUMBER COMPLIANCE COMMENTS
REVIEWED 1 2 3 4 5 6 7
37 ###
38 ###
39 ###
40 ###
41 ###
42 ###
43 ###
44 ###
45 ###
46 ###
47 ###
48 ###
49 ###
50 ###
51 ###
52 ###
53 ###
54 ###

Page 84 of 111
 DALLAH HOSPITAL - NAMAR HOME
PERFORMANCE IMPROVEMENT NURSING QUALITY
INDICATOR
NURSING DEPARTMENT

DEPARTMENT/UNIT AUDITED: LABOR AND DELIVERY REVIEW PERIOD: JULY 2023

COMPLIANCE WITH NON OR SURGICAL TIME OUT PROCEDURE

CRITERIAS:
6. Check equipment, instrument and any other special
1. Confirm that all team members have introduced themselves by name and role. requirements.
2. Correct patient identity 7. Patient specific concerns w discussed.
3. Correct side and site
4. Agreement on the procedure to be perform.
5. Display and checking of essential imaging is available.
KEY CODES: PRESENT/YES = 1 ABSENT/NO = 0 NOT APPLICABLE = N/A
DATE CRITERIAS
TOTAL
NO. PATIENT MR NUMBER COMPLIANCE COMMENTS
REVIEWED 1 2 3 4 5 6 7
55 ###
56 ###
57 ###
58 ###
59 ###
60 ###
61 ###
62 ###
63 ###
64 ###
65 ###
66 ###
67 ###
68 ###
69 ###
70 ###
71 ###
72 ###

Page 85 of 111
 DALLAH HOSPITAL - NAMAR HOME
PERFORMANCE IMPROVEMENT NURSING QUALITY
INDICATOR
NURSING DEPARTMENT

DEPARTMENT/UNIT AUDITED: LABOR AND DELIVERY REVIEW PERIOD: JULY 2023

COMPLIANCE WITH NON OR SURGICAL TIME OUT PROCEDURE

CRITERIAS:
6. Check equipment, instrument and any other special
1. Confirm that all team members have introduced themselves by name and role. requirements.
2. Correct patient identity 7. Patient specific concerns w discussed.
3. Correct side and site
4. Agreement on the procedure to be perform.
5. Display and checking of essential imaging is available.
KEY CODES: PRESENT/YES = 1 ABSENT/NO = 0 NOT APPLICABLE = N/A
DATE CRITERIAS
TOTAL
NO. PATIENT MR NUMBER COMPLIANCE COMMENTS
REVIEWED 1 2 3 4 5 6 7
73 ###
74 ###
75 ###
76 ###
77 ###
78 ###
79 ###
80 ###
81 ###
82 ###
83 ###
84 ###
85 ###
86 ###
87 ###
88 ###
89 ###
90 ###

Page 86 of 111
 DALLAH HOSPITAL - NAMAR HOME
PERFORMANCE IMPROVEMENT NURSING QUALITY
INDICATOR
NURSING DEPARTMENT

DEPARTMENT/UNIT AUDITED: LABOR AND DELIVERY REVIEW PERIOD: JULY 2023

COMPLIANCE WITH NON OR SURGICAL TIME OUT PROCEDURE

CRITERIAS:
6. Check equipment, instrument and any other special
1. Confirm that all team members have introduced themselves by name and role. requirements.
2. Correct patient identity 7. Patient specific concerns w discussed.
3. Correct side and site
4. Agreement on the procedure to be perform.
5. Display and checking of essential imaging is available.
KEY CODES: PRESENT/YES = 1 ABSENT/NO = 0 NOT APPLICABLE = N/A
DATE CRITERIAS
TOTAL
NO. PATIENT MR NUMBER COMPLIANCE COMMENTS
REVIEWED 1 2 3 4 5 6 7
91 ###
92 ###
93 ###
94 ###
95 ###
96 ###
97 ###
98 ###
99 ###
100 ###
101 ###
102 ###
103 ###
104 ###
105 ###
106 ###
107 ###
108 ###

Page 87 of 111
 DALLAH HOSPITAL - NAMAR HOME
PERFORMANCE IMPROVEMENT NURSING QUALITY
INDICATOR
NURSING DEPARTMENT

DEPARTMENT/UNIT AUDITED: LABOR AND DELIVERY REVIEW PERIOD: JULY 2023

COMPLIANCE WITH NON OR SURGICAL TIME OUT PROCEDURE

CRITERIAS:
6. Check equipment, instrument and any other special
1. Confirm that all team members have introduced themselves by name and role. requirements.
2. Correct patient identity 7. Patient specific concerns w discussed.
3. Correct side and site
4. Agreement on the procedure to be perform.
5. Display and checking of essential imaging is available.
KEY CODES: PRESENT/YES = 1 ABSENT/NO = 0 NOT APPLICABLE = N/A
DATE CRITERIAS
TOTAL
NO. PATIENT MR NUMBER COMPLIANCE COMMENTS
REVIEWED 1 2 3 4 5 6 7
109 ###
110 ###
111 ###
112 ###
113 ###
114 ###
115 ###
116 ###
117 ###
118 ###
119 ###
120 ###
121 ###
122 ###
123 ###
124 ###
125 ###
126 ###

Page 88 of 111
 DALLAH HOSPITAL - NAMAR HOME
PERFORMANCE IMPROVEMENT NURSING QUALITY
INDICATOR
NURSING DEPARTMENT

DEPARTMENT/UNIT AUDITED: LABOR AND DELIVERY REVIEW PERIOD: JULY 2023

COMPLIANCE WITH NON OR SURGICAL TIME OUT PROCEDURE

CRITERIAS:
6. Check equipment, instrument and any other special
1. Confirm that all team members have introduced themselves by name and role. requirements.
2. Correct patient identity 7. Patient specific concerns w discussed.
3. Correct side and site
4. Agreement on the procedure to be perform.
5. Display and checking of essential imaging is available.
KEY CODES: PRESENT/YES = 1 ABSENT/NO = 0 NOT APPLICABLE = N/A
DATE CRITERIAS
TOTAL
NO. PATIENT MR NUMBER COMPLIANCE COMMENTS
REVIEWED 1 2 3 4 5 6 7
127 ###
128 ###
TOTAL COMPLIANCE – EACH CRITERIA NA NA NA NA NA NA NA
###
TOTAL COMPLIANCE – ALL CRITERIA

Audited by : YURAIDEL AMPATUAN/OB GYNE Date Submitted: 8/31/2023

(Name/ID #/Unit)
1st Data Collector
STEPHANIE AQUINO/ OB GYNE
(Name/ID #/Unit)
1st Data Collector

Page 89 of 111
 H
O
M HOME
E
IMPROVE EFFECTIVE COMMUNICATION
IPSG 2
Timeliness of Reporting Panic Result of Glucometer
DATA COLLECTION FORM
Unit/Area:LABOR AND DELIVERY Month & Year: JULY 2023

Panic Result of Glucometer

Date
Reporting Time ( PUT 1 OR 0)
No. Staff ID No. Patient File No.
Reviewed Remarks
Reported within 30 Reported more
minutes than 30 minutes

1 NO CASE
2 ###
3 ###
4 ###
5 ###
6 ###
7 ###
8 ###
9 ###
10 ###
11 ###
12 ###
13 ###
14 ###
15 ###
16 ###
17 ###
18 ###
19 ###
20 ###
21 ###
22 ###
23 ###
24 ###
25 ###
26 ###
27 ###
28 ###
29 ###
30 ###
31 ###
32 ###
33 ###
34 ###
35 ###

Page 90 GLUCO
 Panic Result of Glucometer
Date
Reporting Time ( PUT 1 OR 0)
No. Staff ID No. Patient File No.
Reviewed Remarks
Reported within 30 Reported more
minutes than 30 minutes
36 ###
37 ###
38 ###
39 ###
40 ###
41 ###
42 ###
43 ###
44 ###
45 ###
46 ###
47 ###
48 ###
49 ###
50 ###
51 ###
52 ###
53 ###
54 ###
55 ###
56 ###
57 ###
58 ###
59 ###
60 ###
61 ###
62 ###
63 ###
64 ###
65 ###
66 ###
67 ###
68 ###
69 ###
70 ###
71 ###
72 ###

Page 91 GLUCO
 Panic Result of Glucometer
Date
Reporting Time ( PUT 1 OR 0)
No. Staff ID No. Patient File No.
Reviewed Remarks
Reported within 30 Reported more
minutes than 30 minutes
84 ###
85 ###
86 ###
87 ###
88 ###
89 ###
90 ###
91 ###
92 ###
93 ###
94 ###
95 ###
96 ###
97 ###
98 ###
99 ###
100 ###
101 ###
102 ###
103 ###
104 ###
105 ###
106 ###
107 ###
108 ###
109 ###
110 ###
111 ###
112 ###
113 ###
114 ###
115 ###
116 ###
117 ###
118 ###
119 ###
120 ###
121 ###
122 ###
123 ###
124 ###

Page 92 GLUCO
 Panic Result of Glucometer
Date
Reporting Time ( PUT 1 OR 0)
No. Staff ID No. Patient File No.
Reviewed Remarks
Reported within 30 Reported more
minutes than 30 minutes
125 ###
126 ###
127 ###
128 ###
Audited by : YURAIDEL AMPATUAN/OB GYNE Date Submitted 9/7/2022
(Name/ID #/Unit)
1st Data Collector

STEPHANIE AQUINO/ OB GYNE

(Name/ID #/Unit)
2ND Data Collector

Page 93 GLUCO
 H
O
M HOME
E
GRAPHS
Nursing Department
Key Performance Improvement ATTENDANCE
Unit/AreaLABOR AND DELIVERY Review Period: JULY 2023

Percentage of newborns compliance with correct ID

When newborn is in the NURSERY/NICU the
When newborn is in the L&D the following following information is used to match baby to
information is used to match baby to mother. mother.
CRITERIAS: CRITERIAS:
1.Gender of the baby 1. Gender of the baby
2. Mother's full name 2. Mother's full name
3. Mother's file number 3. Baby file number
4. Date and Time of Delivery
KEY CODES: PRESENT/YES=1 ABSENT/NO=0 NOT APPLICABLE = N/A
Date Criteria Remarks
Staff ID Total
No. File No.
No. Reviewed 1 2 3 Compliance
4
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31

Page 94 CORRECT ID
 Percentage of newborns compliance with correct ID
When newborn is in the NURSERY/NICU the
When newborn is in the L&D the following following information is used to match baby to
information is used to match baby to mother. mother.
CRITERIAS: CRITERIAS:
1.Gender of the baby 1. Gender of the baby
2. Mother's full name 2. Mother's full name
3. Mother's file number 3. Baby file number
4. Date and Time of Delivery
KEY CODES: PRESENT/YES=1 ABSENT/NO=0 NOT APPLICABLE = N/A
Date Criteria Remarks
Staff ID Total
No. File No.
No. Reviewed 1 2 3 Compliance
4
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72

Page 95 CORRECT ID
 Percentage of newborns compliance with correct ID
When newborn is in the NURSERY/NICU the
When newborn is in the L&D the following following information is used to match baby to
information is used to match baby to mother. mother.
CRITERIAS: CRITERIAS:
1.Gender of the baby 1. Gender of the baby
2. Mother's full name 2. Mother's full name
3. Mother's file number 3. Baby file number
4. Date and Time of Delivery
KEY CODES: PRESENT/YES=1 ABSENT/NO=0 NOT APPLICABLE = N/A
Date Criteria Remarks
Staff ID Total
No. File No.
No. Reviewed 1 2 3 Compliance
4
73
74
75
76
77
78
79
80
81
82
83
84
85
86
87
88
89
90
91
92
93
94
95
96
97
98
99
100
101
102
103
104
105
106
107
108
109
110
111
112
113

Page 96 CORRECT ID
 Percentage of newborns compliance with correct ID
When newborn is in the NURSERY/NICU the
When newborn is in the L&D the following following information is used to match baby to
information is used to match baby to mother. mother.
CRITERIAS: CRITERIAS:
1.Gender of the baby 1. Gender of the baby
2. Mother's full name 2. Mother's full name
3. Mother's file number 3. Baby file number
4. Date and Time of Delivery
KEY CODES: PRESENT/YES=1 ABSENT/NO=0 NOT APPLICABLE = N/A
Date Criteria Remarks
Staff ID Total
No. File No.
No. Reviewed 1 2 3 Compliance
4
114
115
116
117
118
119
120
121
122
123
124
125
126
127
128
129
130
Total Compliance of each activities NA NA NA NA
Total Compliance of overall activities #DIV/0!

Audited by : THELMA BOYLES Date Submitted: 8/31/2023

(Name/ID #/Unit)
1st Data Collector

(Name/ID #/Unit)
2 Data Collector
ND

Page 97 CORRECT ID
NDANCE

Page 98 CORRECT ID
 H
O
M HOME
E
Nursing Department
IPSG 6
Unit/AreaLABOR AND DELIVERY Review Period: JULY 2023

Compliance with Fall Risk Assessment

Activities:
1. On Admission
2. On any transfer from one unit to another
3. Following any change of status
4. After a Fall
5. Every Shift
6. Every Out patient visit
KEY CODES: PRESENT/YES=1 ABSENT/NO=0 NOT APPLICABLE = N/A
Staff ID Date Activities Total Remarks
No. File No.
No. Reviewed 1 2 3 4 5 6 Compliance
tin
1 180996
tin 20166323 21-06-2023 1 N/A N/A N/A N/A N/A 100% On Admission
2 180996
arlen 20166323 21-06-2023 N/A N/A 1 N/A N/A N/A 100% Following any change of status
3 181258
sreeya 20166323 21-06-2023 1 N/A N/A N/A N/A N/A 100% On any transfer from one unit to
4 182010
k.kailasa 20166246 21-06-2023 1 N/A N/A N/A N/A N/A 100% On Admission
5 m 182151 20166246 21-06-2023 N/A N/A 1 N/A N/A N/A 100% Following any change of status
6 s. 182262
maryann 20166246 21-06-2023 N/A 1 N/A N/A N/A N/A 100% On any transfer from one unit to
7 31814
rachell 20107437 21-06-2023 N/A 1 N/A N/A N/A N/A 100% On any transfer from one unit to
8 180270
lyn 20107437 21-06-2023 N/A N/A N/A N/A 1 N/A 100% Every Shift
9 180273
jally 20107437 21-06-2023 1 N/A N/A N/A N/A N/A 100% On Admission
10 180306
mj 909193 22-06-2023 N/A N/A 1 N/A N/A N/A 100% Following any change of status
11 180410
jesica 909193 22-06-2023 1 N/A N/A N/A N/A N/A 100% On Admission
12 180499
tin 909193 22-06-2023 N/A N/A N/A N/A 1 N/A 100% Every Shift
13 180996
arlen 1689973 23-06-2023 N/A N/A 1 N/A N/A N/A 100% Following any change of status
14 181258
sreeya 1689973 23-06-2023 1 N/A N/A N/A N/A N/A 100% On Admission
15 182010
k.kailasa 1689973 23-06-2023 N/A N/A N/A N/A 1 N/A 100% Every Shift
16 m 182151 20168227 24-06-2023 N/A N/A 1 N/A N/A N/A 100% Following any change of status
17 s. 182262
maryann 20168227 24-06-2023 1 N/A N/A N/A N/A N/A 100% On Admission
18 31814
k.kailasa 20168227 24-06-2023 N/A N/A N/A N/A 1 N/A 100% Following any change of status
19 m 182151 20043602 24-06-2023 N/A N/A 1 N/A N/A N/A 100% On Admission
20 s. 182262
maryann 20043602 24-06-2023 1 N/A N/A N/A N/A N/A 100% Following any change of status
21 31814
rachell 20043602 24-06-2023 N/A N/A N/A N/A 1 N/A 100% On Admission
22 180270
lyn 20083007 24-06-2023 N/A N/A 1 N/A N/A N/A 100% Every Shift
23 180273
jally 20083007 24-06-2023 1 N/A N/A N/A N/A N/A 100% Following any change of status
24 180306
sreeya 20083007 24-06-2023 N/A N/A N/A N/A 1 N/A 100% On Admission
25 182010
k.kailasa 1691628 24-06-2023 N/A N/A 1 N/A N/A N/A 100% Every Shift
26 m 182151 1691628 24-06-2023 1 N/A N/A N/A N/A N/A 100% Following any change of status
27 s. 182262
maryann 1691628 24-06-2023 N/A N/A N/A N/A 1 N/A 100% On Admission
28 31814
k.kailasa 20159448 24-06-2023 N/A N/A 1 N/A N/A N/A 100% Every Shift
29 m 182151 20159448 24-06-2023 1 N/A N/A N/A N/A N/A 100% Following any change of status
30 s. 182262
maryann 20159448 24-06-2023 N/A N/A N/A N/A 1 N/A 100% On Admission
31 31814
rachell 20166153 24-06-2023 N/A N/A 1 N/A N/A N/A 100% Every Shift
32 180270
sreeya 20166153 24-06-2023 1 N/A N/A N/A N/A N/A 100% Following any change of status
33 182010
k.kailasa 20166153 24-06-2023 N/A N/A N/A N/A 1 N/A 100% On Admission
34 m 182151 20168304 25-06-2023 N/A N/A 1 N/A N/A N/A 100% Every Shift

Page 99 FALL RISK

 Compliance with Fall Risk Assessment
Activities:
1. On Admission
2. On any transfer from one unit to another
3. Following any change of status
4. After a Fall
5. Every Shift
6. Every Out patient visit
KEY CODES: PRESENT/YES=1 ABSENT/NO=0 NOT APPLICABLE = N/A
Staff ID Date Activities Total Remarks
No. File No.
No. Reviewed 1 2 3 4 5 6 Compliance
35 s. 182262
maryann 20168304 25-06-2023 1 N/A N/A N/A N/A N/A 100% Following any change of status
36 31814
k.kailasa 20168304 25-06-2023 N/A N/A N/A N/A 1 N/A 100% On Admission
37 m 182151 1590774 25-06-2023 N/A N/A 1 N/A N/A N/A 100% Every Shift
38 s. 182262
maryann 1590774 25-06-2023 1 N/A N/A N/A N/A N/A 100% Following any change of status
39 31814
rachell 1590774 25-06-2023 N/A N/A N/A N/A 1 N/A 100% On Admission
40 180270
tin 20165224 25-06-2023 N/A N/A 1 N/A N/A N/A 100% Every Shift
41 180996
sreeya 20165224 25-06-2023 1 N/A N/A N/A N/A N/A 100% Following any change of status
42 182010
k.kailasa 20165224 25-06-2023 N/A N/A N/A N/A 1 N/A 100% On Admission
43 m 182151 20168404 25-06-2023 N/A N/A 1 N/A N/A N/A 100% Every Shift
44 s. 182262
maryann 20168404 25-06-2023 1 N/A N/A N/A N/A N/A 100% Following any change of status
45 31814
k.kailasa 20168404 25-06-2023 N/A N/A N/A N/A 1 N/A 100% On Admission
46 m 182151 20168446 25-06-2023 N/A N/A 1 N/A N/A N/A 100% Every Shift
47 s. 182262
maryann 20168446 26-06-2023 1 N/A N/A N/A N/A N/A 100% Following any change of status
48 31814
rachell 20168446 26-06-2023 N/A N/A N/A N/A 1 N/A 100% On Admission
49 180270
tin 20164836 26-06-2023 N/A N/A 1 N/A N/A N/A 100% Every Shift
50 180996 20164836 26-06-2023 1 N/A N/A N/A N/A N/A 100% Following any change of status
51 s. 182262
maryann 20164836 26-06-2023 N/A N/A N/A N/A 1 N/A 100% On Admission
52 31814
rachell 20168408 26-06-2023 N/A N/A 1 N/A N/A N/A 100% Every Shift
53 180270
tin 20168408 26-06-2023 1 N/A N/A N/A N/A N/A 100% Following any change of status
54 180996
sreeya 20168408 26-06-2023 N/A N/A N/A N/A 1 N/A 100% On Admission
55 182010
k.kailasa 20168550 27-06-2023 N/A N/A 1 N/A N/A N/A 100% Every Shift
56 m 182151 20168550 27-06-2023 1 N/A N/A N/A N/A N/A 100% Following any change of status
57 s. 182262 20168550 27-06-2023 N/A N/A N/A N/A 1 N/A 100% On Admission
58 s. 182262
maryann 20146329 27-06-2023 N/A N/A 1 N/A N/A N/A 100% Every Shift
59 31814
rachell 20146329 27-06-2023 1 N/A N/A N/A N/A N/A 100% Following any change of status
60 180270
tin 20146329 27-06-2023 N/A N/A N/A N/A 1 N/A 100% On Admission
61 180996
sreeya 1087603 28-06-2023 N/A N/A 1 N/A N/A N/A 100% Every Shift
62 182010
k.kailasa 1087603 28-06-2023 1 N/A N/A N/A N/A N/A 100% Following any change of status
63 m 182151 1087603 28-06-2023 N/A N/A N/A N/A 1 N/A 100% On Admission
64 s. 182262 20168132 28-06-2023 N/A N/A 1 N/A N/A N/A 100% Every Shift
65 s. 182262
maryann 20168132 28-06-2023 1 N/A N/A N/A N/A N/A 100% Following any change of status
66 31814
rachell 20168132 28-06-2023 N/A N/A N/A N/A 1 N/A 100% On Admission
67 180270
tin 1160651 28-06-2023 N/A N/A 1 N/A N/A N/A 100% Every Shift
68 180996
sreeya 1160651 28-06-2023 1 N/A N/A N/A N/A N/A 100% Following any change of status
69 182010
k.kailasa 1160651 28-06-2023 N/A N/A N/A N/A 1 N/A 100% On Admission
70 m 182151 20155257 28-06-2023 N/A N/A 1 N/A N/A N/A 100% Every Shift
71 s. 182262 20155257 28-06-2023 1 N/A N/A N/A N/A N/A 100% Following any change of status
72 s. 182262
maryann 20155257 28-06-2023 N/A N/A N/A N/A 1 N/A 100% On Admission
73 31814
rachell 905061 28-06-2023 N/A N/A 1 N/A N/A N/A 100% Every Shift
74 180270
tin 905061 28-06-2023 1 N/A N/A N/A N/A N/A 100% Following any change of status
75 180996
sreeya 905061 28-06-2023 N/A N/A N/A N/A 1 N/A 100% On Admission
76 182010
k.kailasa 20136355 29-06-2023 N/A N/A 1 N/A N/A N/A 100% Every Shift
77 m 182151 20136355 29-06-2023 1 N/A N/A N/A N/A N/A 100% Following any change of status

Page 100 FALL RISK

 Compliance with Fall Risk Assessment
Activities:
1. On Admission
2. On any transfer from one unit to another
3. Following any change of status
4. After a Fall
5. Every Shift
6. Every Out patient visit
KEY CODES: PRESENT/YES=1 ABSENT/NO=0 NOT APPLICABLE = N/A
Staff ID Date Activities Total Remarks
No. File No.
No. Reviewed 1 2 3 4 5 6 Compliance
78 s. 182262 20136355 29-06-2023 N/A N/A N/A N/A 1 N/A 100% On Admission
79 s. 182262 20153841 29-06-2023 N/A N/A 1 N/A N/A N/A 100% Every Shift
80 s. 182262
maryann 20153841 29-06-2023 1 N/A N/A N/A N/A N/A 100% Following any change of status
81 31814
rachell 20153841 29-06-2023 N/A N/A N/A N/A 1 N/A 100% On Admission
82 180270
tin 20168542 29-06-2023 N/A N/A 1 N/A N/A N/A 100% Every Shift
83 180996
sreeya 20168542 29-06-2023 1 N/A N/A N/A N/A N/A 100% Following any change of status
84 182010
k.kailasa 20168542 29-06-2023 N/A N/A N/A N/A 1 N/A 100% On Admission
85 m 182151 1328480 29-06-2023 N/A N/A 1 N/A N/A N/A 100% Every Shift
86 s. 182262 1328480 29-06-2023 1 N/A N/A N/A N/A N/A 100% Following any change of status
87 s. 182262
maryann 1328480 29-06-2023 N/A N/A N/A N/A 1 N/A 100% On Admission
88 31814
rachell 1340092 30-06-2023 N/A N/A 1 N/A N/A N/A 100% Every Shift
89 180270 1340092 30-06-2023 1 N/A N/A N/A N/A N/A 100% Following any change of status
90 s. 182262 1340092 30-06-2023 N/A N/A N/A N/A 1 N/A 100% On Admission
91 s. 182262
maryann 20044018 30-06-2023 N/A N/A 1 N/A N/A N/A 100% Every Shift
92 31814
rachell 20044018 30-06-2023 1 N/A N/A N/A N/A N/A 100% Following any change of status
93 180270
tin 20044018 30-06-2023 N/A N/A N/A N/A 1 N/A 100% On Admission
94 180996
sreeya 20167655 30-06-2023 N/A N/A 1 N/A N/A N/A 100% Every Shift
95 182010
k.kailasa 20167655 30-06-2023 1 N/A N/A N/A N/A N/A 100% Following any change of status
96 m 182151 20167655 30-06-2023 N/A N/A N/A N/A 1 N/A 100% On Admission
97 s. 182262 20168725 30-06-2023 N/A N/A 1 N/A N/A N/A 100% Every Shift
98 s. 182262
maryann 20168725 30-06-2023 1 N/A N/A N/A N/A N/A 100% Following any change of status
99 31814
rachell 20168725 30-06-2023 N/A N/A N/A N/A 1 N/A 100% On Admission
100 180270 20149320 30-06-2023 N/A N/A 1 N/A N/A N/A 100% Every Shift
101 s. 182262 20149320 30-06-2023 1 N/A N/A N/A N/A N/A 100% Following any change of status
102 s. 182262
maryann 20149320 30-06-2023 N/A N/A N/A N/A 1 N/A 100% On Admission
103 31814
rachell 1358907 30-06-2023 N/A N/A 1 N/A N/A N/A 100% Every Shift
104 180270
tin 1358907 30-06-2023 1 N/A N/A N/A N/A N/A 100% Following any change of status
105 180996
sreeya 1358907 30-06-2023 N/A N/A N/A N/A 1 N/A 100% On Admission
106 182010
k.kailasa 20145320 01-07-2023 N/A N/A 1 N/A N/A N/A 100% Every Shift
107 m 182151 20145320 01-07-2023 1 N/A N/A N/A N/A N/A 100% Following any change of status
108 s. 182262 20145320 01-07-2023 N/A N/A N/A N/A 1 N/A 100% On Admission
109 s. 182262
maryann 20168772 01-07-2023 N/A N/A 1 N/A N/A N/A 100% Every Shift
110 31814
rachell 20168772 01-07-2023 1 N/A N/A N/A N/A N/A 100% Following any change of status
111 180270 20168772 01-07-2023 N/A N/A N/A N/A 1 N/A 100% On Admission
112 s. 182262 20168773 01-07-2023 N/A N/A 1 N/A N/A N/A 100% Every Shift
113 s. 182262 20168773 01-07-2023 1 N/A N/A N/A N/A N/A 100% Following any change of status

Page 101 FALL RISK

 Compliance with Fall Risk Assessment
Activities:
1. On Admission
2. On any transfer from one unit to another
3. Following any change of status
4. After a Fall
5. Every Shift
6. Every Out patient visit
KEY CODES: PRESENT/YES=1 ABSENT/NO=0 NOT APPLICABLE = N/A
Staff ID Date Activities Total Remarks
No. File No.
No. Reviewed 1 2 3 4 5 6 Compliance
maryann
114 31814
rachell 20168773 01-07-2023 N/A N/A N/A N/A 1 N/A 100% On Admission
115 180270
tin 20148475 02-07-2023 N/A N/A 1 N/A N/A N/A 100% Every Shift
116 180996
sreeya 20148475 02-07-2023 1 N/A N/A N/A N/A N/A 100% Following any change of status
117 182010
k.kailasa 20148475 02-07-2023 N/A N/A N/A N/A 1 N/A 100% On Admission
118 m 182151 1600274 02-07-2023 N/A N/A 1 N/A N/A N/A 100% Every Shift
119 s. 182262 1600274 02-07-2023 1 N/A N/A N/A N/A N/A 100% Following any change of status
120 s. 182262
maryann 1600274 02-07-2023 N/A N/A N/A N/A 1 N/A 100% On Admission
121 31814
rachell 20146595 02-07-2023 N/A N/A 1 N/A N/A N/A 100% Every Shift
122 180270
maryann 20146595 02-07-2023 1 N/A N/A N/A N/A N/A 100% Following any change of status
123 31814
rachell 20146595 02-07-2023 N/A N/A N/A N/A 1 N/A 100% On Admission
124 180270
tin 20140995 02-07-2023 N/A N/A 1 N/A N/A N/A 100% Every Shift
125 180996
maryann 20140995 02-07-2023 1 N/A N/A N/A N/A N/A 100% Following any change of status
126 31814
rachell 20140995 02-07-2023 N/A N/A N/A N/A 1 N/A 100% On Admission
127 180270
tin 47149 02-07-2023 N/A N/A 1 N/A N/A N/A 100% Every Shift
128 180996 47149 02-07-2023 1 N/A N/A N/A N/A N/A 100% Following any change of status
Total Compliance of each activities 100% 100% 100%
Total Compliance of overall activities 100%
YURAIDEL AMPATUAN/OB
Audited by : GYNE Date Submitted: 7/30/2023
(Name/ID #/Unit)
1st Data Collector

STEPHANIE AQUINO/ OB GYNE

(Name/ID #/Unit)
2ND Data Collector

Page 102 FALL RISK

 H
O
M
E
NURSING DEPARTMENT
NON OR TIME OUT MONITORING FORM
Unit/Area:LABOR AND DELIVERY MONTH& YEAR: JULY 2023

No. DATE Patient File No. PATIENT NAME PROCEDURE DONE Remarks

1 NO CASE

3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33

Page 103 NON OR

No. DATE Patient File No. PATIENT NAME PROCEDURE DONE Remarks

34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72

Page 104 NON OR

No. DATE Patient File No. PATIENT NAME PROCEDURE DONE Remarks

84
85
86
87
88
89
90
91
92
93
94
95
96
97
98
99
100
101
102
103
104
105
106
107
108
109
110
111 1111
112
113
114
115
116
117
118
119
120
121
122
123
124

Page 105 NON OR

 No. DATE Patient File No. PATIENT NAME PROCEDURE DONE Remarks

125
126
127
128

Audited by : THELMA BOYLES 31569/ L&D

(Name/ID #/Unit)
1st Data Collector

0
(Name/ID #/Unit)
2ND Data Collector

Page 106 NON OR

 SUCCESS RATE OF INSERTING IV CANNULA ON FIRST ATTEMPT SHEET

Unit/Area LABOR AND DELIVERY MONTH: JULY 2023

SUCCESFUL
CANNULATIO Staff name
N (1 OR 0) Witness Staff Name
No. Date FILE PATIENT NAME and ID No. Remarks
and ID No.
1ST 2ND who inserted
ATTEMP ATTEMP
T (1) T (0)
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
76
77
78
79
80
81
82
83
84
85
86
87
88
89
90
91
92
93
94
95
96
97
98
99
100
101
102
103
104
105
106
107
108
109
110
111
112
113
114
115
116
117
118
119
120
121
122
123
124
125
126
127
128
129
130
131
132
133
134
135
136
137
138
139
140
141
142
143
144
145
146
147
148
149
150
151
152
153
154
155
156
157
158
159
160
161
162
163
164
165
166
167
168
169
170
171
172
173
174
175
176
177
178
179
180
181
182
183
184
185
186
187
188
189
190
191
192
193
194
195
196
197
198
199
200
201
202
203
204
205
206
207
208
209
210
211
212
213
214
215
216
217
218
219
220
221
222
223
224
225
226
227
228
229
230
231
232
233
234
235
236
237
238
239
240
241
242
243
244
245
246
247
248
249
250
251
252
253
254
255
256
257
258
259
260
261
262
263
264
265
266
267
268
269
270
271
272
273
274
275
276
277
278
279
280
281
282
283
284
285
286
287
288
289
290
291
292
293
294
295
296
297
298
299
300
301
302
303
304
305
306
307
308
309
310
311
312
313
314
315
316
317
318
319
320
321
322
323
324
325
326
327
328
329
330
331
332
333
334
335
336
337
338
339
340
341
342
343
344
345
346
347
348
349
350
351
352
353
354
355
356
357
358
359
360
361
362
363
364
365
366
367
368
369
370
371
372
373
374
375
376
377
378
379
380
381
382
383
384
385
386
387
388
389
390
391
392
393
394
395
396
397
398
399
400
Audited by : THELMA BOYLES 31569/ L&D Date Submitted 8/31/2023
(Name/ID #/Unit)
1st Data Collector

0
(Name/ID #/Unit)
2ND Data Collector

Page 107 of 111

 H
O
M
E
IMPROVE EFFECTIVE COMMUNICATION (IPSG NO. 2)
Nursing SBAR Compliance Form
DATA COLLECTION FORM
Unit/Area: LABOR AND DELIVERY Month & Year: JULY 2023

SBAR Compliance Form (/)

No. Date Review Patient File No. Remarks
YES (1) NO (0)
1 21-06-2023 20166323 ###
2 21-06-2023 20166323 ###
3 21-06-2023 20166323 ###
4 21-06-2023 20166246 ###
5 21-06-2023 20166246 ###
6 21-06-2023 20166246 ###
7 21-06-2023 20107437 ###
8 21-06-2023 20107437 ###
9 21-06-2023 20107437 ###
10 22-06-2023 909193 ###
11 22-06-2023 909193 ###
12 22-06-2023 909193 ###
13 23-06-2023 1689973 ###
14 23-06-2023 1689973 ###
15 23-06-2023 1689973 ###
16 24-06-2023 20168227 ###
17 24-06-2023 20168227 ###
18 24-06-2023 20168227 ###
19 24-06-2023 20043602 ###
20 24-06-2023 20043602 ###
21 24-06-2023 20043602 ###
22 24-06-2023 20083007 ###
23 24-06-2023 20083007 ###
24 24-06-2023 20083007 ###
25 24-06-2023 1691628 ###
26 24-06-2023 1691628 ###
27 24-06-2023 1691628 ###
28 24-06-2023 20159448 ###
29 24-06-2023 20159448 ###
30 24-06-2023 20159448 ###
31 24-06-2023 20166153 ###
32 24-06-2023 20166153 ###
33 24-06-2023 20166153 ###
34 25-06-2023 20168304 ###
35 25-06-2023 20168304 ###

Page 108 SBAR

 SBAR Compliance Form (/)
No. Date Review Patient File No. Remarks
YES (1) NO (0)
36 25-06-2023 20168304 ###
37 25-06-2023 1590774 ###
38 25-06-2023 1590774 ###
39 25-06-2023 1590774 ###
40 25-06-2023 20165224 ###
41 25-06-2023 20165224 ###
42 25-06-2023 20165224 ###
43 25-06-2023 20168404 ###
44 25-06-2023 20168404 ###
45 25-06-2023 20168404 ###
46 25-06-2023 20168446 ###
47 26-06-2023 20168446 ###
48 26-06-2023 20168446 ###
49 26-06-2023 20164836 ###
50 26-06-2023 20164836 ###
51 26-06-2023 20164836 ###
52 26-06-2023 20168408 ###
53 26-06-2023 20168408 ###
54 26-06-2023 20168408 ###
55 27-06-2023 20168550 ###
56 27-06-2023 20168550 ###
57 27-06-2023 20168550 ###
58 27-06-2023 20146329 ###
59 27-06-2023 20146329 ###
60 27-06-2023 20146329 ###
61 28-06-2023 1087603 ###
62 28-06-2023 1087603 ###
63 28-06-2023 1087603 ###
64 28-06-2023 20168132 ###
65 28-06-2023 20168132 ###
66 28-06-2023 20168132 ###
67 28-06-2023 1160651 ###
68 28-06-2023 1160651 ###
69 28-06-2023 1160651 ###
70 28-06-2023 20155257 ###
71 28-06-2023 20155257 ###
72 28-06-2023 20155257 ###
73 28-06-2023 905061 ###
74 28-06-2023 905061 ###
75 28-06-2023 905061 ###
76 29-06-2023 20136355 ###
77 29-06-2023 20136355 ###
78 29-06-2023 20136355 ###
79 29-06-2023 20153841 ###
80 29-06-2023 20153841 ###
81 29-06-2023 20153841 ###
Page 109 SBAR
 SBAR Compliance Form (/)
No. Date Review Patient File No. Remarks
YES (1) NO (0)
82 29-06-2023 20168542 ###
83 29-06-2023 20168542 ###
84 29-06-2023 20168542 ###
85 29-06-2023 1328480 ###
86 29-06-2023 1328480 ###
87 29-06-2023 1328480 ###
88 30-06-2023 1340092 ###
89 30-06-2023 1340092 ###
90 30-06-2023 1340092 ###
91 30-06-2023 20044018 ###
92 30-06-2023 20044018 ###
93 30-06-2023 20044018 ###
94 30-06-2023 20167655 ###
95 30-06-2023 20167655 ###
96 30-06-2023 20167655 ###
97 30-06-2023 20168725 ###
98 30-06-2023 20168725 TRANSFER TO LEVEL
99 30-06-2023 20168725 SHIFT TO SHIFT
100 30-06-2023 20149320 SHIFT TO SHIFT
101 30-06-2023 20149320 TRANSFER TO LEVEL
102 30-06-2023 20149320 SHIFT TO SHIFT
103 30-06-2023 1358907 TRANSFER TO LEVEL
104 30-06-2023 1358907 SHIFT TO SHIFT
105 30-06-2023 1358907 TRANSFER TO LEVEL
106 01-07-2023 20145320 SHIFT TO SHIFT
107 01-07-2023 20145320 TRANSFER TO LEVEL
108 01-07-2023 20145320 TRANSFER TO LEVEL
109 01-07-2023 20168772 SHIFT TO SHIFT
110 01-07-2023 20168772 TRANSFER TO LEVEL
111 01-07-2023 20168772 SHIFT TO SHIFT
112 01-07-2023 20168773 TRANSFER TO LEVEL
113 01-07-2023 20168773 SHIFT TO SHIFT
114 01-07-2023 20168773 TRANSFER TO LEVEL
115 02-07-2023 20148475 SHIFT TO SHIFT
116 02-07-2023 20148475 TRANSFER TO LEVEL
117 02-07-2023 20148475 TRANSFER TO LEVEL
118 02-07-2023 1600274 SHIFT TO SHIFT
119 02-07-2023 1600274 TRANSFER TO LEVEL
120 02-07-2023 1600274 SHIFT TO SHIFT
121 02-07-2023 20146595 TRANSFER TO LEVEL
122 02-07-2023 20146595 ADMISSION
123 02-07-2023 20146595 SHIFT TO SHIFT
124 02-07-2023 20140995 TRANSFER TO LEVEL
125 02-07-2023 20140995 ADMISSION
126 02-07-2023 20140995 SHIFT TO SHIFT
127 02-07-2023 47149 TRANSFER TO LEVEL

Page 110 SBAR

 SBAR Compliance Form (/)
No. Date Review Patient File No. Remarks
YES (1) NO (0)
128 02-07-2023 47149 ADMISSION
SHIFT TO SHIFT
TRANSFER TO LEVEL

Audited by : YURAIDEL
AMPATUAN/OB GYNE DATE OF SUBMISSION: ADMISSION
(Name/ID #/Unit) SHIFT TO SHIFT

STEPHANIE AQUINO/ TRANSFER TO LEVEL

OB GYNE ADMISSION
(Name/ID #/Unit) SHIFT TO SHIFT
TRANSFER TO LEVEL
ADMISSION

Page 111 SBAR