PASIG CITY CHILDREN’S HOSPITAL – CHILD’S HOPE

IN – PATIENT SERVICE WARD 1

PURPOSE
The In – patient service ward 1 is a charity ward which is dedicated to the care of children from birth up
to 18 years old.
GOAL
The PCCH – Child’s Hope is dedicated to deliver outstanding safe, compassionate care
OBJECTIVES
1. To provide skillful, intelligent, need- based comprehensive care to the children in health and
sickness.
2. To interpret the basic need of the children to their parents and family members and to guide
them in childcare.
3. To promote growth and development of children towards an optimum state of health for
functioning at the peak of their capacity in future.
4. Perform delegated task promptly, correctly, and safely.
5. Provide immediate care to newly admitted patients
6. Establishes collaborative relationship with colleagues and other members of the health care
team.
7. Appreciate the importance of rendering safe and prompt services to the patients.
8. The members of the team must make the parents feel that they are working in a collaborative
manner for the treatment of their child.
9. The staff should speak in the language which the parents and child can understand.
10. The staff must be willing to acknowledge the parents’ rights to the decision concerning their
children.
11. Learn how to manage multiple patients simultaneously and prioritize their care.
12. Learn how to handle problems and think of the best possible solution based on patients’
needs.

I. Organizational Chart
 II. IN –PATIENT SERVICE WARD 1 POLICIES AND PROCEDURES

OPERATIONAL POLICIES AND PROCEDURES

A. GENERAL POLICIES

1. All medical staff should run-through the standard policy mandated by the guidelines of the hospital
and based on the proper standard procedure.
2. Suitable and consistent documentation of all the legal documents regarding of every patient should
be secured and remain private within the medical team.

POLICIES AND PROCEDURES IN PATIENT’S ADMISSION

PURPOSE
To provide quality health care and smooth transition during patient’s admission.
SCOPE
It covers from the time the endorsing unit calls the receiving unit regarding patient admission up to the
documentation of admission.
POLICY
1. Admission from Emergency department and In-patient service ward II will be receive from 7am to
4:30pm and 7pm to 4:30am.
2. Admission from Out-patient department will be receive anytime.
3. Trans-in from Pediatric and Neonatal Intensive Care Unit will be receive from 7am to 4:30pm and
7pm to 4:30am, unless if there is a need for a vacant room in PICU for new admission.
PROCEDURE
1. Nurse-on-duty or personnel from the following areas informs admission, direct admission or trans-
in:
1.1 Emergency department
1.2 Out-patient department
1.3 Admitting section
1.4 Pediatric Intensive Care Unit
1.5 Neonatal Intensive Care Unit
1.6 In-patient Service Ward 2 department
2. Unit nurse receives call from Admitting Section for room assignment
3. Unit nurse prepares the room and bed
4. Unit nurse receives call first to receive information on patient admission, then second to give a go
signal on transfer of patient from the Department where the patient will come from
 5. Nurse perform bedside endorsement
6. Receiving nurse checks consent for admission
7. Receiving nurse checks patient’s condition and contraptions
8. Receiving nurse verifies and carries out physician’s order, regulates IVF and checks patency
9. Checks requisition from laboratory, radiology and pharmacy
10. Orients patient’s relatives on ward policies using Policies for Patient Watcher
11. Unit nurse accomplishes kardex and bed tag
12. Unit nurse documents patient care in patient’s chart and this transfer or admission to Census
Logbook

POLICIES AND PROCEDURES ABOUT CONSENT FORM

PURPOSE
To allow health care providers to do procedures and acquire necessary informations legally.
SCOPE
It covers all invasive procedures, operation and anesthesia.
POLICY
1. The consent form should be signed by the legal guardian of the patient who is at a legal age.
2. The consent is only valid for 24 hours from the date it was signed.
PROCEDURE
1. Consent for admission
- It must be accomplished by the endorsing unit before the patient is admitted at ward.
2. Consent for invasive procedures
- It should be explained well by the Hospitalist to patient’s legal guardian.
- Nurse-on-duty must also sign as the witness
3. Consent for Anesthesia
- It should be explained well by the anesthesiologist to patient’s legal guardian.
- Nurse-on-duty must also sign as the witness

POLICIES AND PROCEDURES ABOUT INCIDENT REPORT

PURPOSE
1. To identify patient harms and increase patient safety
 2. To document the exact details of the occurrence while they are fresh in the minds of those who
witnessed the event. This information may be useful in the future when dealing with liability issues
stemming from the incident.
SCOPE
The incident report involves all patients’ complaint, medical errors, medical device malfunctions, or anyone-
patient, staff member or visitor- is injured or involved in a situation with the potential for injury.
POLICY
The incident report should be completed at the time an incident occurs no matter how minor an injury is.
PROCEDURE
1. It should be:
1.1 Accurate
 All data must be clear and specific
 Provide more specific details of what you are referring to and avoid any vague statements that
may cause confusion
 Always proofread your report before submission to see errors that you might overlooked.
1.2 Factual
 It should be objective supported by facts
 Avoid including emotional, opinionated and biased statements.
 It should provide both sides of the story and should not favor one side
1.3 Complete
 Ensure that essential questions (what, where, when, why and how) are covered in the incident
report.
 Record not only the people who were injured and what caused the accident to happen, but also
include details such as people who witnessed and reported the incident.
 Anticipate what other significant details will be needed for any future study and investigation.
1.4 Graphic
 Photos, diagrams and illustrations should be included as supporting evidence.
1.5 Valid
 Upon completion those who were involved should sign off to testify and validate all the information
that was mentioned in the incident report.
 POLICIES AND PROCEDURES ABOUT DOCTOR’S ORDER SHEET
PURPOSE
To avoid mistakes or misinterpretations of orders and to prevent causing harm to our patients.
SCOPE
It includes all orders written and verbally ordered by the Physician.
POLICY
1. Doctors’ order should be written legibly and complete
2. Superimpositions and using of correction fluid/tape is not allowed
3. Doctors’ should have a signed with PRC number and signature above his/her name
4. Verbal orders should be signed within 24 hours from the date the order was made
PROCEDURE
1. Always write legibly, neatly and correctly.
2. Do not recycle the used medicine card
3. A new doctors’ order is a new medicine card
4. Do not revise/ rephrase what have written in the doctors’ order. Rewrite completely what have
written in the order.
5. If the nurse have any doubts regarding the medical order, he/she will clarify it with the attending
physician who made the order.
6. Always signed doctors’ orders with your complete name, PRC number, date, time and signature
after carrying it out.

POLICIES AND PROCEDURES ABOUT INFECTION CONTROL PRECAUTIONS

PURPOSE
To prevent the transmission and cross-infection of communicable diseases within the ward.
SCOPE
It covers all procedures and precautions that are needed to know by every nursing staffs with regards to
infection control preventions.
POLICY
All infectious cases should be properly coordinated both with the Hospitalist and Infection Control
Committee
PROCEDURES
Standard Precautions will be used with all patients whenever contact with blood or other body fluids are
anticipated.
The following categories of precautions will be used in addition to Standard Precautions:
 Airborne Precautions
 Droplet Precautions
 Contact Precautions

Types of Precautions:
1. Standard Precautions
a) Hand hygiene must be performed when entering and exiting the patient’s room. In addition
hand hygiene must be performed before and after touching the patient, the patient’s
belongings or the patient’s environment.
b) Gloves must be worn for touching blood and body fluids, mucous membranes, or non-intact
skin of all patients, and for handling items or surfaces soiled with blood or body fluids and
vascular access procedures. Gloves must be changed after contact with each patient and hand
hygiene must be performed after gloves are removed. Gloves must be changed between tasks
and procedures on the same patient if moving from a dirty site to a clean site.
c) Masks and protective eyewear (if noted necessarily) must be worn during procedures that are
likely to generate droplets of blood or other body fluids to prevent exposure of mucous
membranes of the mouth, nose, and eyes.
d) Impervious gowns must be worn during procedures that are likely to generate splashes of
blood or other body fluids. Discard or deposit gowns after each patient contact and perform
hand hygiene. Do not reuse gowns.
e) Sharps safety: used syringes, needles, and other such objects are to be placed in designated
biohazard containers at the point of use. Never recap, bend, break, or otherwise manipulate
any sharps type items. Never force additional sharps into an overflowing disposal container.
f) Health Teaching: patients, families, and visitors should be taught about the basic concepts of
standard precautions, hand hygiene, and other precautions needed depending on the patients’
cases.

2. Transmission-Based Precautions
a) Airborne Precautions
 Room: The door must be kept closed at all times. Contact Infection Control Committee
for further instructions.
 Notifications: Place Contact Precautions sign in patient’s kardex.
 Respiratory Protection: All personnel entering the room must wear either disposable
surgical mask or N-95 mask.
 Personal Protective Equipment (PPE): In addition to respiratory protection, wear
gowns and gloves only when indicated (e.g., concomitant contact precautions).
  Transport and procedures: Patient should remain in the room except for essential
therapeutic or diagnostic procedures. When out of the room, the patient must wear a
surgical mask. Notify receiving departments of required precautions.
 Cleaning: Once patient is discharged, terminal cleaning (three times wall-to-wall using
mild or strong solution) and fumigation will be done. Notify ICC for further instructions.
 Visitors: Limit visitors every visiting hours. Hand Hygiene is always required when
entering and exiting the room. Visitors should wear surgical mask while in the patient’s
room.

b) Droplet Precautions
 Room: The door does not need to be kept closed at all times. Contact Infection Control
Committee for further instructions.
 Notifications: Place Contact Precautions sign in patient’s kardex.
 Respiratory Protection: Surgical masks should be worn when entering the room.
 Personal Protective Equipment (PPE): In addition to respiratory protection, wear
gowns and gloves only when indicated (e.g., concomitant contact precautions).
 Transport and procedures: Patient should remain in the room except for essential
therapeutic or diagnostic procedures. When out of the room, the patient must wear a
surgical mask. Notify receiving departments of required precautions.
 Cleaning: Re-useable instruments should be thoroughly cleaned before using on
another patient using appropriate disinfectant. Routine cleaning should be done with
staff wearing the proper personal protective equipment (PPE).
 Visitors: Limit visitors every visiting hours. Hand Hygiene is always required when
entering and exiting the room. Visitors should wear surgical mask while in the patient’s
room.

c) Contact Precautions
 Room: Use a single room. Door does not need to remain closed. When a single room
is not available, place patient in a room with a patient who has the same
microorganism and no additional organisms. Consult with Infection Control Committee
before cohorting.
 Notifications: Place Contact Precautions sign in patient’s kardex.
 Personal Protective Equipment (PPE): Gown and gloves must be worn by all
personnel when entering the room. Gowns are not to be re-used. After use, place
gowns in dirty linen hamper.
 Patient Equipment: Patient must have their own thermometer. Blood pressure cuffs
and stethoscopes must be used and kept in room. No patient care items or equipment
can be shared with other patients until cleaned with an appropriate disinfectant.
 Transport and procedures: Patient should remain in the room except for essential
therapeutic or diagnostic procedures. Notify receiving departments of required
precautions. When transport is necessary, ensure that infected or colonized areas of
the patient's body are contained and covered. Remove and dispose of contaminated
PPE and perform hand hygiene prior to transporting patients. Take clean PPE and don
clean PPE to handle the patient at the transport destination.
  Cleaning: Re-useable instruments should be thoroughly cleaned with appropriate
disinfectant before using on another patient and when removed from room. Once
patient is discharged, terminal cleaning (three times wall-to-wall using mild or strong
solution) and fumigation will be done. Notify ICC for further instructions.
 Visitors: Visitors should wear gown and gloves when participating in patient care. Hand
hygiene is always required when entering and exiting the room.

POLICIES AND PROCEDURES ABOUT ROOM ALLOCATION

PURPOSE
To prevent the transmission and cross-infection of communicable diseases within the ward.
SCOPE
It covers procedures and operations about designating and allocating rooms based on patients’ cases.
POLICY
All infectious cases should be properly coordinated both with the Hospitalist and Infection Control
Committee.
PROCEDURES
A. DESIGNATING ROOM TO NEWLY ADMITTED PATIENTS
 Emergency Room and Out-Patient Department will inform the ward for admission.
Rooms for newly admitted patients will be based on their diagnosis, unless
coordinated with Hospitalist-on-duty and Infection Control Committee.
 The left wing (Oncology A, B, Hematology, Nephrology, Cardiology, Neurology,
Gastrology A, B, Adolescent, Miscellaneous and Isolation wards) is designated for
clean cases while the right wing (Pulmonology 1, 2, 3, 4, 5, Surgery A, B wards) is
designated for infectious cases.
B. ROOM ALLOCATION OF IN-PATIENTS
 Patients who have chest x-ray result which are not normal (e.g. pneumonia, with
consolidation, with primary Koch’s infection) will be transferred to infectious rooms at
the right wing as ordered by HOD.
 Patients with growth in their microbiology result will be allocated to a single room or to
a designated room with patients of the same laboratory result as per HOD orders or
ICC instructions.
 POLICIES AND PROCEDURES IN DISCHARGING PATIENTS

PURPOSE
To ensure the provision of effective and efficient care to the patients during their stay in the ward until
he/she will be discharged. And maintain optimum level of wellness at home.
SCOPE
From the time IPS1 Ward Nurse provided care to the patients until he/she goes home.
POLICY & PROCEDURE
1. Carry out the may go home order of the Hospitalist.
2. Inform patients’ relative regarding patient discharge
3. Inquire about their need for Medical Certificate and Clinical Abstract, if so asked the relative to go to
Medical records Section.
4. Asked patients’ relative if they have a Philhealth, if so let the hospitalist accomplished the CF2 and
CF4
5. Tag the patient as billed then inform the billing section right away.
6. Give the discharge slip to patients’ relative and advise them to go to Billing Section after 30 mins- 1
hour
7. Completion of clearance with statement of account will be presented by the patients’ relative to
Nurse-on-duty.
8. Explain patients’ home medication and follow-up check-up and let them sign the Discharge
Instruction Form
9. Instruct patients relative to answer the Survey form.
10. Remove any patients’ contraptions.
11. Document patient care and discharge.

POLICIES AND PROCEDURES IN HOME AGAINST MEDICAL ADVICE

PURPOSE
To ensure the provision of effective and efficient care to patients during their stay until the patient is
discharge
SCOPE
From the time IPS1 Ward Nurse provided care to the patients until he/she goes home.
POLICY
1. All patients discharged as HAMA are not allowed to use their Philhealth, if they have
2. They are not also allowed to seek for financial assistance in our Social Welfare Assistance
3. The hospitalist is not going to provide Home medical instructions.
PROCEDURE
1. Relative of patient verbalizes that she wants to discharge his/her patient on his/her on decision
2. Inform the Hospitalist-on-duty and let the doctor talk to patients’ relative regarding the consequences
of their decision
3. If the relative still wants to discharge the patient, let them sign at chart
4. Advice patient’s relative to settle bill.
5. Completion of clearance form with statement of account.
6. Remove patients’ contraptions.
7. Instruct patient’s relative to fill up survey form.
8. Document patients care and discharge.

POLICIES AND PROCEDURES IN TRANSFER TO HOSPITAL OF CHOICE

PURPOSE
To ensure the provision of effective and efficient care to the patients during their stay in the ward until
he/she will be transferred to other institution.
SCOPE
From the time IPS1 Ward Nurse provided care to the patients until patient’s transfer.
PROCEDURE
1. Routine Patient Care
 Perform complete endorsement every shift
 Assess patient’s condition and contraptions
 Carry out doctor’s order
 Regulate intravenous fluid
 Take and record Vital signs
 Properly administer medications
 Document patient’s care in nurses notes
2. Patient’s relative decides/needs to go be transferred
3. Inform patients attending physician
4. Attending physician discusses transfer patient and his/her relative
5. Attending physician accomplishes transfers/referral form
6. Accomplish trip ticket
7. Inform relative to go to information desk for the charge of trip ticket.
8. Tag patient as transferred in HIS
9. Inform billing section
 10. Advise patient’s relative to settle bill
11. Completion of clearance
12. Instruct patients relative to answer survey form.
13. A doctor and a nurse assists in transferring the patient to the hospital of choice.
14. Document patients care and transfer

POLICIES AND PROCEDURES ABOUT REFERRALS TO DIETARY, DENTAL, ENT,

OPTHALMOLOGIST AND PHYSICAL THERAPY
PURPOSE
To allow health care providers to establish a definitive plan of treatment to patients.
SCOPE
it covers all referrals to specialist services
PROCEDURE:
1. It must be accomplished by the Hospitalist with patient’s medical history
2. It must be endorsed to designated area
3. It should be properly logged in to incoming/outgoing logbook

POLICIES AND PROCEDURES REGARDING REQUEST FORMS TO RADIOLOGY,

LABORATORY AND DIAGNOSTIC

PURPOSE:
Request forms are essential communication tools used by hospitalist referring patients by Radiological,
Laboratory and Diagnostic investigations. It also indirectly helps to shorten the investigation time and
improve the quality of service offered to the patient.
SCOPE:
it covers all request forms to the radiology, laboratory and diagnostic.
PROCEDURE:
1. Radiology
  Procedure to be done should be properly explained and understood by the patient
 It should be properly accomplished by the Hospitalist with patient’s medical history
 Endorsed the request form to the radiology department
 Patient should be accompanied by the nurse-on-duty or Nurse assistant during the procedure
2. Laboratory
 It should be accomplished by the Hospitalist with name and signature
 Specimen should be properly secured with patent’s complete name
 Bring the request form to the laboratory with the specimen and should be properly logged in
Specimen logbook with receiver’s name and signature
3. Diagnostic
 It should be accomplished with name and signature of the Hospitalist
 Endorse the request form to the diagnostics
 Secure schedule

POLICIES AND PROCEDURES IN STOCKS MONITORING

PURPOSE:
To provide the necessary materials/ equipment that is needed for the procedure and in the Ward.
SCOPE:
To monitor the available stocks in the Ward
PROCEDURE:
1. Provide the checklist of available stocks in the Ward
2. List the materials that is used for the patient
3. Encode used materials for every patient as a Post charge