The Cure Medical Center: Rizza Mae G. Garma, RN

THE CURE MEDICAL CENTER
RIZZA MAE G. GARMA, RN
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VISSION:
To provide each patient with the world class- care, exceptional service and compassion
we would want for our loved one.
MISSION:
1. We care for patients as members of our family. We work to heal the sick, treat the
injured and prevent illness. We protect the trust of our community and employees, to
be a progressive, quality health care organization.
2. To enhance lives and preserve health by enabling access to a comprehensive, fully
integrated network of the highest quality and most affordable care, delivered with
kindness, integrity and respect.
PHILOSOPHY STATEMENT:
THE CURE Medical CENTER

“We Care for life. We Mean the Life of People”
OBJECTIVES:
1. THE CURE will promote and recognize the highest professional and ethical
standards, health service delivery achievements and innovative medical and
non-medical treatments for the betterment of patient.
2. THE CURE provide safe and therapeutic environment for all patients, staff and
visitors.
3. Promoting medical cooperation and referring hospital of nearby local hospital.
4. To provide opportunities for training and research in all aspects of Hospital
services Health Care Delivery System and Health Care Administration.
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ORGANIZATION STRUCTURE
“We Care for life. We Mean THE
the Life of People” CURE
MEDICAL
CENTER
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FLOOR PLAN
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Background:
Nursing is a vital service in any health care facility. In any setting, nurses provide non-
stop direct and care irrespective of holidays and emergencies. Without an effective Nursing
Service, patient care will suffer. It integrates all the hospital’s vital service. Nursing interfaces
with all other support services such as medical, dietary, dental, laboratory, pharmacy, medical
social services, housekeeping, maintenance, record-keeping, etc.
The nursing service is burdened with the expansion of the nurses’ functions, rapid
turnover, and the structure constraints within the healthcare facility, such as understaffing.
Despite all these constraints and problems, the Nursing service is still expected to render
quality service.
The integration of the promotive and preventive of health into curative and rehabilitative
services, calls for the reorientation of roles and functions of the health personnel.
I. INTRODUCTION
The numerous changes in the environment brought about by rapid advancement of
knowledge and technologies had let to the transformation of the nursing profession from a simple
pattern of bedside care in the hospital to expanded roles and function extended to the patients,
family and community.
As such, the Nursing service department of the hospital which aims to provide optimum
care for the patient and family by effectively interacting with the numerous medical and
technical personnel that gives the patient’s family and optimum opportunity to live and thrive.
II. PHILOSOPHY
The philosophy of the Nursing service is in line with the hospital’s belief regarding
patient care.
As such we believe that:
a. The goal of the Nursing is to provide high level of nursing care to patient and family in
the atmosphere of compassion and understanding and the attainment of realistic health
objectives.
b. The nurse as member of the health team must promote cooperative planning and
coordination of function of the nursing staff and support service in the delivery of care to patient
especially the preventive and promotive aspect.
c. Nurses participation in staff development progress, fostered leadership and clinical
competence geared towards improving patient care.
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d. Developing standard in recruiting qualified personnel and the effective utilization of

the nursing manpower are the essential nursing inputs in the health care delivery system of the
institution.
e. Meeting cost effective and cost efficient ensures for the general good.
III. OBJECTIVES
General Objectives:
To provide quality nursing care, including the promotive, preventive, curative and
rehabilitative aspect of care.
Specific Objectives:
1. Identify the total nursing needs of patient and family and participate in the promotive,
preventive, curative and rehabilitative aspect of care.
2. Coordinate and cooperate with the members of healthcare in reducing mortality and
morbidity rate.
3. Discuss the nursing care plan as it relates to the needs of the patient and family.
4. Updates knowledge in the current trends and issues in nursing care.
NURSING SERVICE POLICY
1. POLICY ON SCHEDULE OF DUTY:

a. Off duty shall be requested 5 days before the rotation.
b. Schedule of duty signed by Chief Nurse/Asst. Chief Nurse shall be
posted 2 days before the start of rotation.
c. Request form for the exchange/ change of duty shall be accomplished
8 hours prior to its affectivity; for staff nurses/midwives/nursing
attendants to be by the supervisors to be approved by Asst. Chief
Nurse.
d. Exchanging of duty is according to level/groupings
e. No notification for change of schedule will marked absent.
Note: staff nurses/midwives/nursing attendants are not allowed to
write any remarks on the schedule.
2. POLICY ON ATTENDANCE
Chief Nurse and Asssistant Chief Nurse
8:00am-4:00 pm daily except Saturday, Sunday and Holidays
Nurse III, Nurse II, Nurse I, Midwife I, Nursing Attendant
Morning Shift 8:00AM – 4:00 PM
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Afternoon Shift 4:00PM – 12:00MN

Night Shift 12:00MN – 8:00 AM
Note: Holidays are taken by schedule
OPD Staff
Monday – Friday 8:00 am- 12:00 noon – 1:00 – 4:00PM
Saturday 8:00 am – 12:00 noon
Except Sundays and Holidays
Note:
o Shifting may temporarily change to 12 hours if there is an exigency of
manpower.
o Nursing service Personnel shall render service to 40 hours per week
including meal time.
o They shall enjoy two days off duties per week or accumulated 8 days off
in a month.
o Holidays are enjoyed but not on the same day. It will be given per
schedule.
o Reporting to duty is 15 minutes before time
o Nursing staff shall log in log and out at the guard house.
o Three consecutive late (15-30 min) in a month means one day absent
o Sequence of shifting schedule shall be, morning to night to afternoon to
reliever each lasting to 10 days
3. POLICY ON TRANSFERRING TO OTHER NURSING

DEPARTMENT:
Shall inform/ notify the immediate supervisor in writing of the intention
and the desired area to be transferred.
Permanent staff: one month ahead of time
Casual/Contractual: fifteen (15) days ahead of time
4. POLICY ON UNIFORM
Chief Nurse, Assistant Chief Nurse, Supervisors/Head Nurses:
Morning shift white skirt with Blouse with stocking, cap,
nameplate, closed white shoes
Afternoon shift complete with uniform, nameplate, closed
white shoes
Night shift scrub suit, closed white shoes/white rubber
shoes, nameplate, NO using of slippers
Staff Nurses:
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Morning shift complete white uniform with cap,

nameplate, closed white shoes
Afternoon shift white uniform, nameplate, closed white
shoes
Night shift scrub suit, closed white shoes/white rubber
shoes, nameplate, NO using of slippers.
Operating Room, ICU, NICU Nurses:
Scrub suit with nameplate at the work area
White smock gown when going out.
Midwives, Nursing attendant

Gray or green Blouse and pants with nameplate, black
closed shoes
Note:
Hair must be intact/not touching the neckline (all shift)
Fine for income uniform P50.00/violation.
Frequent (3-5x) violation will mean disciplinary action-
forfeited off duty.
5. POLICY ON MEETING:
1. General Meeting- Quarterly (January, April, July, October-first Friday
of the month)
2. Nurse III and Nurse II- monthly (last Friday) and as needed.
3. Ward Meeting- as needed c/o supervisor in charge
Note:
Posted 5 days prior to schedule meeting.
Fine of P50.00 will be paid for every absence in meeting or
forfeiture of one day off.
6. POLICY ON VACATION, SICK LEAVE, ABSENCES AND

RESIGANATION:
1. Sick leave shall be filed upon reporting to duty. if more than five (5)
days shall be accompanied with a medical certificate. The nurse
supervisor shall be notified.
2. Vacation leave shall be applied (5 days) prior its effectively and must
be approved before one can avail the leave.
3. Resignation letter must be submitted in writing thirty (30 days) before
date of effectively and clearance must be accomplished.
4. Maternity leave: written application for maternity leave and clearance
must be accomplished two weeks before the expected date of delivery.
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5. A nursing Service Personnel who cannot report to duty has to inform

the supervisor on duty eight (8hrs) before the scheduled time of duty.
6. For every absence in scheduled duty, two days off will be forfeited and
an Incident Report (two copies) is required to be submitted within the
24 hours to Supervisor on duty.
NURSING STAFF RESPONSIBILITIES AND JOB DESCRIPTION:
NURSE III
1. Plans the program and workload of the Nursing Service Personnel within the
unit.
2. Provides leadership through planned conference with the Nursing personnel
under her supervision
3. Engage in decision making and supervision of all Nursing personnel.
4. Provides and maintains open communication network/channel information/
meetings with staff/ personnel to assess ward problems and condition.
5. Participates in the orientation of new nursing service employee.
6. Evaluates accomplishments of each nursing staff.
7. Submit monthly report to the Nursing Office.
8. Attends nursing development activities and participates in the Nursing
Education program.
9. Comply, monitor and participate actively in the Quality assurance Program
10. Monitor the teaching-training activities in the ward
11. Coordinate with other service regarding the needs of the patient to attain
quality nursing care.
12. Checks the general cleanliness of the assigned areas.
NURSE II
1. Evaluate capabilities of personnel and properly designates ward assignment
under his/her area of responsibility and supervision.
2. Ensures adequacy of facilities/supplies/equipment’s essentially pertinent to
quality patients care delivery system.
3. Receives endorsement from outgoing duty and coordinates delivery of the
nursing and non-nursing services relevant to patient’s needs.
4. Evaluates performance of his/her respective personnel with the coordination
of her respective senior nurse.
5. Attends and participates in the staff and personnel training and development
activities.
6. Supervises administration of drugs and treatment of the nursing personnel.
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7. Assist staff in identifying nursing problems/needs and cares,

planning/implementing and evaluating effectiveness of the intervention.
8. Promotes, establish and maintains good disciplines, rapport and effective
skills.
9. Prepares and submits report to the Nursing office.
10. Evaluates the accomplishment of the staff in his/her area.
11. Maintain ward/ nurses’ station cleanliness and orderliness.
NURSE I
1. Sponges patients and maintain personal hygiene of assigned patients
especially the critically ones.
2. Carries out the doctors’ order and endorsed properly.
3. Prepares administers and records oral and parenteral medications and patients
reactions.
4. Prepares set/equipment for diagnostic procedures and assist physician in
administering treatment.
5. Observes signs and symptoms, identifies nursing care, needs, instituted
appropriate intervention and specified in the nurses’ charting.
6. Admits and discharge patients.
7. Keep patient chart and nursing care plan properly updates, accurate and
informative of the patient’s condition.
8. Orients hospital policies/ward set up to newly admitted patients and gives
health information/teachings to discharging patients.
9. Measures intake and output, weight, abdominal and head circumference.
10. Performs nasogastric feeding/medications, changes abdominal and chest
drainage bottle system.
11. Properly delegate and supervises works of the nursing attendants and
orderliness.
12. Attends nursing development activities and participates in nursing education
program.
13. Collaborates with other health team members in the plan of care
14. Evaluates the accomplishments of the staffs in his/her area.
15. Check completeness of E-Cart.
16. Maintains ward/nurses’ station cleanliness and orderliness.
NURSING ATTENDANT
1. Helps maintain patients hygiene/comfort/change/stretched out patient’s linens
and beddings.
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2. Cleans bedside unit of patients and help maintain ward cleanliness and
orderliness. Participates in the explanation of hospital rules and plocies to
watchers/visitors.
3. Receives and endorses equipment, articles and linens.
4. Monitor and record vital signs, urine and stool.
5. Counts, collects and bring soiled linens to the laundry room.
6. Request ward supplies from CSSR.
7. Bring specimen to the laboratory.
8. Prepares/updates diet list.
9. Returns unused meds to the pharmacy.
10. Prepares bed and accomplished bed tags of the newly admitted patients.
11. Maintains ward/nurse’s station cleanliness and orderliness.
12. Performs discharge care.
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FORMS AND POLICIES

A. ARRANGEMENT OF IN-PATIENT CHART
PHILHEALTH CHART
1. Clinical Data Sheet
2. Consent for admission
o All consent, Release from responsibility
3. Physician Admitting History
4. Phil. Health Form 2
5. Phil. Health Form 3
6. TPR record sheet
7. Vital Signs monitoring Sheet
o FHT, I and O, Glasgow, Abdominal Girth monitoring
8. Laboratory result sheet
9. Doctors Order
10. Standing order sheet
o Insulin injection form
11. Intravenous fluid sheet
12. Nurses Notes
13. Discharge Summary
14. Discharge Notice
NON-PHILHEALTH CHART
1. Clinical Data Sheet
o All consent, Release from responsibility
3. Admitting History
4. TPR record sheet
5. Vital Signs monitoring Sheet
o FHT, I and O, Glasgow, Abdominal Girth monitoring
6. Laboratory result sheet
o CBG monitoring
o Radiologic result
o ECG result
7. Doctors Order
8. Standing order sheet
o Insulin injection form
9. Intravenous fluid sheet
10. Nurses Notes
11. Clinical Abstract
o All OR/DR forms, medical certificate
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o All referral forms

o Medico-legal forms
12. Home instruction
13. Linen Issuance form
14. Billing form
A. CLINICAL DATA SHEET

1. Must be completely filled up
2. Patients name to include the Family Name, Given name and Middle Name
3. Complete Address to include the house number, street name, “Purok”,
barangay, municipality and province
4. Nearest Relatives
Husband/wife---either
Children---------parents
Parent(widow)—children
5. Occupation
Pedia—child (newborn,infant),pupil, student
Retired/senior citizen/PWD---not applicable
6. Religion
Pedia-religion of parent
B. CONSENT FOR ADMISSION, SURGICAL AND INVASIVE PROCEDURE

To ensure that patients is informed by qualified personnel of their disease
condition, severity, prognosis, benefits and possible adverse effects of various
treatments, options and the likely cause of treatment before securing consent.
Procedure:
1. The patient/significant others shall be provided with complete information of the
procedure to be done including the intended outcome and the potential harm or effect.
2. The one who will give the consent must be legal capacity and who understood what
he/she is consenting.
3. For patient less than 18 years old, consent is secured from parents, guardians or
nearest relative.
Three exceptions to this ruling; an emergency situations where the consent of the
minor is sufficient, such as sexually transmitted disease and a court order or other
legal authorization has been obtained.
4. An emancipated minor (one who is married, pregnant, a parent or financially
independent) can give a valid consent to treatment.
5. Refusal to treatment or confinement shall be respected but the patient or
representative is ask to sign the waiver form.
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6. In cases of emergency where no one to give consent to a patient who is mentally or

physically incapable, action is taken by the physician to preserve the patient life.
Procedures requiring informed consent:
1. Hospitalization
2. Surgical Procedure
3. Invasive Procedure
Consent form

2. Consent for nursing procedures- blood transfusion, NGT insertion, IFC insertion
3. Consent for surgical and medical procedure—minor surgical procedure (paracentesis,
thoracentesis, umbilical catheter)
4. Consent for surgery/anesthesia (OR/DR use)
C. THE TPR SHEET CHARTING POLICY
The TPR sheet is the specific form provided for the recording of the temperature,
pulse, respiratory rate continuously monitored every four hours, round the clock,
likewise for the urine and stool recording ever end of the shift.
1. Temperature and respiratory rate must be recorded/graphed in black ink only

2. Pulse rate must always record/ graphed in red ink only.
3. All the vital signs of normal level provided at the left side must be enriched and
connected to the very start of the first graphing line using the proper ink prescribed
for each respective vital sign.
Normal Rates: Temperature: 37 degrees Celsius
Pulse rate: 100 beats per minute
Respiration: 30 cycles per minute
NOTE: TO INDICATE NORMAL RATE----- Neonates, PEDIA
4. All necessary data is provided for in the form must always be properly filled up and
updated (name, ward, bed number, dates/day of the month and etc.)
5. Any rechecked, latest temperature for febrile cases must be identified by connecting
the graph with the continuous line of dots either going up or going down along the
same column up to the right level that will indicate the latest.
6. For urine and stool monitoring, it should be indicated at 10:00 AM inclusive of all
shifts.
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D. VITAL SIGNS MONITORING SHEET
This form is the monitoring sheet prescribed for recording the patients’ blood
pressure, pulse rate, respiratory rate and temperature which usually taken care of
by the nursing staff at ordered interval.
1. Fill up all necessary data provided for in the form, with identified
patient room
2. Unusual vital signs shall be repeated after 15 minutes and should b
preferred at once to the resident physician on duty.
E. THE LABORATORY REQUEST AND RESULTS
1. All ordered laboratory examination should always be made with the

corresponding request thru Bizbox.
2. Patients with request for laboratory examination of urine or stool must be
provided with labeled specimen bottles and properly instructed for collection.
3. The Nursing Attendant is responsible in bringing the specimen to the
laboratory.
4. Laboratory examination to be done in specified time after the outgoing shift
must be properly endorsed to the incoming shift.
5. Laboratory request for any “STAT” examination must send at once to the
laboratory.
6. All laboratory result shall be referred immediately to the Resident on Duty.
7. Laboratory examination to be done outside the hospital shall be explained by
nurse to the family/watcher concerned.
F. INTRAVENOUS INFUSION FORM AND PROCEDURE
This form is used for recording all kinds of intravenous drip/blood transfusion.
1. The form should always be properly filled up with the necessary data.
2. All intravenous infusion must be recorded according to bottle number with the date
and time started.
3. All blood transfusion follows the same procedure except by writing the blood packs
serial number, instead of bottle number.
4. The intravenous fluid bottles numbering should not be affected by the follow up of
any kind of blood transfusion unless ordered interrupted or changed with a new kind
of IV fluid solution.
5. New bottle of intravenous fluid hooked after an interrupted fluid shall follow the
sequence of numbering.
6. Iv fluid with incorporation shall reflect in the parenteral sheet.
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7. Intravenous infusion shall be properly labeled by an IV tag with name of patient, date,
time started, number, kind, volume, incorporation, rate, time consumed with name
and signature of NOD.
8. Infiltrated IV infusion shall be reinserted at once especially those for hydration and
emergency infusion.
9. Shall always observe aseptic technique.
10. IV infusion with incorporation of Vitamin C shall be covered with carbon paper while
on infusion.
11. Shall check IV site for any sign of inflammation, swelling, tenderness and patency
from time to time.
12. IV fluid infusion for possible reinsertion must be properly kept sterile.
G. THE MEDICATION FORM/CARD AND POLICIES

The form is used in recording all medications and therapeutic treatment. The
medication card is prepared for all oral and parenteral medications/treatments. A
Guide in preparing and administering drug with correct and proper prescription.
PRESCRIPTION VERIFICATION
This aims to dvelop and maintain a system in verifying doctors order before drug
administration
POLICY
1. Read doctors order carefully and verify if not clearly understood.
2. Medication card must be clearly written and shall be verified on the physicians order.
3. Medication card should contain the strength, dose, route and frequency of
administration, ward and date at front of the medication card, then the name and
signature of the nurse at the back.
4. Check label of the medication.
5. Carefully examine the medicine for unusual changes. In such case, the drug should
not be administered.
6. The nurse accepting the verbal/telephone order shall record and read back the order
entirely to the prescribing physician at the time the order is given. Students are not
allowed to receive verbal orders.
TIMELY, SAFE, APPROPRIATE AND CONTROLLED MANNER IN DRUG

ADMINISTRATION
This aims to provide guidelines in a timely, appropriate and controlled manner in drug
administration to the right patient.
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POLICY
1. Administer the right drug
2. Administer the right drug to the right patient.
3. Administer the right dose.
4. Administer the right drug by the right route.
5. Administer the right drug at the right time
6. Document each drug you administer.
7. Teach your patient about the drugs he is receiving.
8. Verify if the patient has any drug allergies.
9. Be aware of potential drug-drug or drug-food reaction
10. Any error in medication should be reported immediately to the charge nurse.
11. The nurse who prepares the medication should be the one to administer.
12. Never leave the patient until medicines is taken or swallowed.
13. If any medication is refused or cannot be administered, refer to the physician.
PROCEDURE:
1. All drugs must be written in the medication sheet/medicine cards.

2. All drugs/therapeutic treatment with standing orders must be written down as
provided in the medication sheet with correct dates as ordered.
3. All medications and therapeutic treatment should always carry the description of the
medicines, right dosage, route, frequency or interval of administration.
4. Columns provided for the dates of daily medication must always be properly filled
up.
5. Medications and therapeutic treatment given/done each shift must be reflected on the
proper date and column by writing down the time for each medicine and encircle the
correct time and signed by the nurse who administered. Those which have not been
done or given must be reflected by not encircling the time and specify whether its
NPO or presc.
6. All single dose or ‘stat’ medication must be reflected at the nurse’s note and standing
order sheet.
7. Transcribe only present medication and treatment.
8. All discontinued, shifted, revised and completed medications/treatment cards must be
removed from the rock. New medication card must be made for the newly ordered
medication/therapeutic treatments.
9. Always make new medication card for the new ordered medicines, changes in dose,
frequency and have them transcribed in the standing order sheet.
10. Lost medication/treatment card must be replaced by a new card with the present date
and with the nurse signature at the back.
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11. Any medications which are out stock/not available within 24hrs must be referred to
the physician.
12. Medication for completion or any skin tested medications should be included in the
special endorsement.
13. Skin testing should be done and read after 30 mins. If in doubt refer it to the
physician.
14. Record only those medicines which you have administered. No one else to record for
someone else.
FREQUENCY TIME COLOR

OD (once a day) 8AM WHITE
BID (twice a day) 8AM------6PM GREEN
TID (Three times a day) 8AM---1PM----6PM BLUE
QID (four times a day) 8AM—1PM—4PM—8PM PINK
Q4H (every 4 hrs) 8AM-12NN-4PM-8PM-12MN-4AM GREEN
Q6H (every 6 hrs) 6AM-12NN-6PM-12MN ORANGE
Q8H (every 8 hrs) 8AM—4PM—12MN WHITE
Q12H (every 12 hours) TIME started the meds YELLOW
HS (hours of sleep) 9PM WHITE
PRN AS NEEDED RED
o Once the medicine is available it can be started at once, however on the

next dose it is discretion of the nurse on duty to make an adjustment of the
time or to follow the standard time administration of medication
o Two or more antibiotics can’t be administered at the same time. It must be
2 hours apart unless ordered by the physician to do so.
PATIENTS’ IDENTIFICATION
This aims to ensure that patients are correctly identified by the health care personnel prior
to drug administration.
POLICY
1. All patients must have wristband indicating the complete name of the patient. For
neonates, contain the surname and sex
Example: Garcia, Bb. Boy
2. Medicine cards are one of the identifiers before administration of medication.
3. Calling or asking the full name of the patient.
4. Bed tag
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Components;
a. Patients name
b. Age/sex
c. Date admitted
d. Chief complaints
PROPER DOCUMENTATION OF DRUG ADMINISTRATION
To ensure the safe, appropriate and accurate administration and handling of medications.
POLICY:
Drug administration is properly documented in the patient’s chart.
PROCEDURES:
1. Encircle the time the drug is administered in the medication sheet and countersign by
the one who administered.
Example:
INJECTABLES: 03-01-19 03-02-19
Cefuroxime 750mg 8 4 12 8
q8h ANST (-)
2. Write prescribed (presc.) to newly ordered meds not started within the shift.
INJECTABLES: 03-01-19
Cefuroxime 750mg Presc.
q8h ANST (-)
3. When medication is omitted for any reason, record the reason.
ORALS: 03-01-19 03-02-19

Ascorbic Acid tab
OD 8
FESO4 + FA cap 8 1 6
TID
INJECTABLES: 03-01-19 03-02-19
Cefuroxime 750mg
IVq8h ANST (-) 8 12 2
Amikacin 500mg IV
q12 ANST (-) 6 12
4. Once the drug is discontinued, resumed, shifted or changed in frequency, dose and
route, write discontinued, resumed, shifted or changed frequency, dose and the date.
ORALS: 03-01-19 03-02-19 03-03-19
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Ascorbic Acid tab

OD 8 8/discontinued 03-02-19
FESO4 + FA cap 8 1 6
TID
Cefixime 200mg tab
BID x 3 days 1 6
INJECTABLES: 03-01-19 03-02-19

Cefuroxime 750mg
IVq8h ANST (-) 8 12 2 8/shifted 03-02-19
Amikacin 500mg IV
q12 ANST (-) 12 12 12/ ↓frequency
Amikacin 500 mg
1V q24 12
5. In drugs that are ordered to be consumed, T/c chould be written in the medication
card and sheet followed by the date. Once the drug is consumed, write consumed and
date.
Example:
03-01-19 03-02-19 03-03-19 03-04-19
Cefuroxime
100mgIV q12 8 8 8 8 8/t/c 8 8consumed
ANST 03-04-19
6. If drugs is to be given for a number of doses more, write how many doses more on
the day it was ordered then write Last dose after the time of given date.
Example:
03-01-19 03-02-19 03-03-19 03-04-19
Cefuroxime
100mgIV q12 8 8 8 8/ 8L/D 3/3/19
ANST For 2 dose
more
Note: Code
NPO-including meds T/c- to consume

D/C-discontinued Presc. - Prescribed
OOP-out on pass L/D---- last dose
Cons.-consumed Disl. - Dislodged
SD- single dose
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DETECTING, REPORTING AND MONITORING ADVERSE EFFECTS OF

DRUGS
To establish a mechanism to ensure that adverse drug reactions are syatematically
reported and reviewed.
POLICY:
The staff giving direct care to the patient has the responsibility of reporting,
documenting and monitoring adverse drug reactions.
PROCEDURES:
1. Any suspected adverse drug reaction will be reported by the patient/ significant
others to the nurse on duty.
2. The nurse on duty shall assess the patient and notifies the physician on duty.
3. The physician on duty will examine the patient, order necessary interventions as
needed.
4. The nurse on duty will carry out the physicians order intelligently.
5. The nurse on duty will document fully any adverse drug reaction/s, time and
nature of reaction, time the physician notified, interventions taken and patient’s
response.
POLICIES IN TRANSCRIBING/CARRYING OUT THE DOCTOR’S ORDER
1. Check the doctor’s order and read the nurses notes of the admitting nurse in
Emergency Room (ER) to verify what orders had been carried out at once in the
ward.
2. Transcribe all continuing medications, therapeutic treatments in the medication
sheet reflecting the ate of order, the name of the drugs, its frequencies and routes,
dose etc.
3. All “stat’orders must be done at once with time and signature in the standing
order and at nurse’s notes.
4. Transcribe all important orders for endorsement at the Kardex.
5. After the doctor’s orders had been totally carried out, put slash, write ‘noted by’
and sign above complete name with time using color coded pen.
H. THE NURSES NOTES

The nurses notes is specifically the form being used by the nurses where in the
nurses chart down on their evaluations and observation of the progress, reactions
and responses of the patient towards the nursing administration of cares and
treatment from day to day activities.
POLICY
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1. Use standard pen colors when charting during each respective shift.
 8 hours shift
Black: for 8:00 am- 4:00pm shift
Blue: for 4:00 pm- 12:00mn shift
Red: for 12:00mn-8:00am shift
 12 hours shift
Black: AM shift
Red: PM shift
2. Nurses notes must be clear, specific and concise.
3. Do not use non-standard abbreviations.
4. Specific time of referral, visits of the doctors, special medications, treatment or
procedures done, intravenous infusions and unusual manifestation of sign and symptom
must always be recorded of the left side of the line.
5. Consent secured for any special/minor procedures to be done to the patient must be
documented.
6. Do not copy the doctor’s order when charting.
7. Do not patch or crash out any mistakes in the charting. Draw a single line on the mistakes
written and write at the top of mistake, “MISTAKEN ENTRY” to indicate the mistake
and affix the nurse’s signature.
8. The characteristics of patient’s secretions/discharges must always be noted down as its
amount, odor and color.
9. Note patient’s condition, state consciousness, IV fluids and other contraptions and time
when receiving, endorsing and discharging patient.
10. Nurse’s signature must always be affixed at the end of charting so as to indicate the
closing of the charting. Always sign your name legibly and without fail.
I. THE KARDEX POLICIES

The kardex is a device to facilitate in transcribing standing doctor’s order and to
instruct personnel on medications, diet, treatments, laboratory exams and
procedure. This must be accomplished by the nurse who made the admission and
should be updated every now and then by the nurse in charge.
POLICIES:
1. All kardex form shall be properly filled up in pencil.

2. Medications, treatment or laboratory procedures that need to be done on specified date or
time must noted for special endorsement.
3. In case of transfer of the patient to the other ward, the kardex together with themedication
cards and the patients chart should be all together. The kardex is voided in case the
patient is discharged.
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J. DISCHARGE PLAN FOR CONTINUITY OF CARE MANAGEMENT

To provide for home care management to all discharge patients fuly documented
to nurses notes and doctors order sheet.
POLICY:
All discharge plans should focus on management of care to a patient at home with
information drive regarding the continuity process of treatment and succeeding management of
care throughout patient basis.
PROCESS:
1. Verify Doctor’s order for discharge.

2. Inform patient and watchers about discharge order.
3. Advise patient/watcher to settle hospital bill.
 Philhealth
 Member-PHIC form duly accomplished, photocopy of membership ID
 Dependent- PHIC form duly accomplished, photocopy of membership ID, MDR
(spouse and children birth certificate
4. Secure the cooperation of the patient and relative by explaining the importance of the
following:
a. Take home medications based on doctor’s order.
b. Nutritious diet and other dietary measures in accordance to
patient’s illness.
c. Limitations of work activity while recovery stage.
d. Involve the relatives in health care process at home specially
for pediatric and geriatric patients.
e. Advised health home care tips.
f. Instruct date and place of follow-up and or referral to RHU if
needed.
VII. ENDORSEMENT POLICY
1. From admitting Section to Ward

a. The Nurse on Duty will accompany patient up to his/her bed.
b. Nurse to Nurse Endorsement. All verification must be done
during endorsement
2. From Ward to other Ward
a. Inform the concern ward at least 20 minutes prior to transfer
b. Nurse to Nurse endorsement. All verification must be done during
endorsement.
2.1 From Ward to ICU
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a. Inform ICU staff at least 30 min prior to transfer.

b. Nurse to nurse Endorsement. All verification must be
done during the endorsement.
3. Ward to OR
a. Pre-op checklist must be proper accomplished.
b. Size of cannula must be g20 or 18 for adult, g22 or 24 for pedia.
c. OB cases: Inform Obstretrician/ ROD prior to transfer to DR/LR
 Primi-6 cm
 Multi- 5 cm
4. OR to ward
Nurse to nurse endorsement. All verifications must be done during endorsement.
VIII. HOME AGAINST MEDICAL ADVICE
Note: if patient request to leave the hospital against medical advice. He/She shall be
declared on Home Against Medical Advice (HAMA)
1. Explain Consequences
a. Shall explain consequences of going home against medical advice
b. Shall note in the doctors order sheet that the patient/significant others requested
going home against medical advice.
2. Shall request the patient/significant others to sign a waiver the release from
responsibility form
IX. DEATH
1. Pronounce death by physician
Shall assess patient and shall be responsible in pronouncing death of patient.
2. Nurse/Nursing Attendant
Shall perform post-mortem care
3. Physician
Accomplished 4 copies death certificate
4. Shall discharge the patient in accordance to billing and cashier control procedure
5. Shall forward the Death certificate to Records section
X. ABSCONDED
Note: if patient cannot be found in the ward for 1 hour the patient shall be declared
absconded.
1. Shall inform physician that the patient absconded
2. Shall document the incident as follows;
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 Patient absconded
 Time of incident
3. Shall return unused medicine
4. Shall submit billing form and follow billing discharge process.
INFECTION CONTROL
Infection control is the discipline concerned with preventing, nosocomial or healthcare

associated infections, a practical discipline of epidemiology.
It addresses factors related to the spread of infections within the healthcare setting
(whether patient to patient from patients to staffs and from staff to patients or among staff) a
particular health care setting and management.
CONTENTS OF INFECTION CONTROL
a. Infection, control in healthcare facilities

3. Hand hygiene
4. Cleaning, disinfection and sterilization
5. Personal protective equipment
6. Antimicrobial surfaces
b. Vaccination of healthcare workers
c. Post exposure prophylaxis
d. Surveillance for emerging infections
e. Isolation
f. Outbreak investigation
g. Training in infection control and health care epidemiology
In infection control measures can be as simple as hand washing and as sophisticated as
high level disinfection of surgical instruments.
INFECTION CONTROL MEASURES
Apart from general hygienic practices and vaccination of staff of institution should also
adopt specific infection control measures against communicable disease.
1. STANDARD PRECAUTION
Standard precaution are based on the concepts that all blood, urine, feces, excretions,
saliva, vomitus, secretion from non-intact skin, wounds and mucous membrane should be
treated as potentially infections. Everyone should take appropriate protection measures
when coming into contact with them.
This includes:
1. Hand washing
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2. Respiratory hygienic cough measures

3. Use of personal protective equipment
4. Proper cleansing and disinfection of used or exposed articles
5. Prevention of sharp injury
6. Proper waste management
WEARING PPE STEP BY STEP:
1. Wash hands
2. Put on mask
3. Put on eye protection or face shield (if necessary) and disposable cap
4. Put on gown
5. Put on gloves
REMOVING PPE STEP BY STEP:
1. Remove gloves
2. Wash hands
3. Remove gowns
4. Wash hands
5. Remove disposable cap and eye protector/face shield reome mask
6. Wash hands again
CLEANSING AND DISINFECTION OF USED OR EXPOSED ARTICLES
1. Handling used or exposed instruments and articles should be done carefully as they may
become soiled by infectious agents.
2. Ensure used or exposed instruments and articles are cleaned thoroughly before storage on
subsequent use.
3. Cleanse all visible soil before disinfecting
4. Wipe items such as electronic equipment with alcohol since they can be damaged by
soaking in aqueous substance.
5. Ensures the disinfectant reaches all surfaces including internal surface.
6. Replace articles with disposable items when they cannot be cleansed or disinfected
properly.
SHARPS DISPOSAL AND PREVENTION OF SHARP INJURY:
1. Always take precautions to prevent sharps injury.

2. Use recapping devices when needed.
3. Dispose sharps directly into puncture-proof and spill-proof container which is labeled
with sharp Box and biohazard.
4. Seal sharps when it is 3/4full.
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5. Pack the sharp box in well-fastened clinical waste bag by using swan-neck, sealing
method with a warning signs “BEWARE OF SHARPS” for disposal.
CLINICAL WASTE DISPOSAL
1. Separate clinical waste used needles and gauze soaked with blood from domestic wastes.
2. Pack and label clinical waste properly in color coded bags with biohazard signs.
3. Wash hands thoroughly after handling clinical wastes.
4. Store clinical wastes securely before collected by licensed clinical waste collector.
5. Contact the clinical waste collector when there is substantial amount of clinical waste.
TRANSMISSION BASED PRECAUTION
Apart from standard precaution, when the infectious agent and its mode of transmissions
are known, specific precaution measures should be adopted. Some diseases can be transmitted by
more than one mode to prevent the spread of such diseases, combined preventive measures
should be considered.
1. CONTACT PRECAUTION
a. Practice hand hygiene strictly.
b. Wear PPE depending on the nature of contact
1. Gloves, apron, gown for lifting
2. Mask, gloves, apron for bed making
c. Cleanse or disinfect used items before subsequent use.
d. Increase the frequency of environmental cleansing and disinfect all frequently
touched surfaces with 1 in 49 diluted household bleach for 15-30 minutes
before rinsing with water and wiping dry.
2. DROPLET PRECAUTION
a. Let more fresh air in example open more windows or switch on exhaust fan
b. Practice hand hygiene strictly.
c. Advise persons with respiratory symptoms to wear mask to reduce spread of droplets
to surrounding areas.
d. educate and assist residents to maintain cough measures.
e. advise health care workers to wear when they are working within 2 meters from
infected person, or to wear mask, face shield and put gown for certain coughing or vomiting
induced procedures.
f. increase the frequency of environmental cleansing and disinfect all frequently touched
surfaces with 1 in 49 diluted household bleach and leave for 15-30 minutes before rinsing and
wiping dry.
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g. arrange a separate room for infected residents.

3. VISITORS
1. advise visitors to comply with infection control measures including:
a. perform hand hygiene before and after visit.
b. maintain cough manner.
c. beware of their own health conditions
d. wear surgical mask when having respiratory symptoms
2. Inform visitors when the institution is having outbreak and they should refrain from
visiting as advised by DOH.
In addition isolating people with specific communicable, disease urging visitors to
observe infection control rules and management high risk person with greater caution can
minimize the risk of communicable disease outbreak in an institution.
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The Cure Medical Center: Rizza Mae G. Garma, RN

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THE CURE MEDICAL CENTER

RIZZA MAE G. GARMA, RN