Dmer Manual 2017

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Department of Medical Education and Research

Rules and Regulations Governing Training Programs and the Conduct of
Internship, Residency, Fellowship and Other Medical Trainees of the USTH
TABLE OF CONTENTS
1 The University of Santo Tomas Hospital .............................................................. 3

2 Organizational Structure ....................................................................................... 4
3 Definition of Hospital Trainees .............................................................................. 7
4 Description of the Training Programs ................................................................... 8
5 Objectives of Training Programs ........................................................................ 10
6 Standard Content of Training Manuals .............................................................. 10
7 Pre-requisites for Admission as a Trainee ......................................................... 12
8 Call Rooms ......................................................................................................... 14
9 Rules and Regulations-Generalities ................................................................. 144
10 Professional Code of Conduct............................................................................ 15
11 Intellectual Dishonesty ........................................................................................ 15
12 Uniform and Proper Attire ................................................................................... 19
13 Sexual Harassment ............................................................................................ 21
14 The General Chain of Command: ...................................................................... 25
15 Relationship with the Nursing Staff..................................................................... 26
16 Duties and Assignments ..................................................................................... 26
17 General Medical Care ......................................................................................... 31
18 The UST Hospital Emergency Room Service.................................................... 33
19 Medico-Legal Policy Statement and Procedures ............................................... 36
20 Charts and Record Keeping ............................................................................... 37
21 Key Persons Responsible for Chart Completion ............................................... 41
22 Use of Patient’s Records in Conferences .......................................................... 41
23 Attendance and Leave of Absence .................................................................... 41
24 Evaluation of Interns, Residents and Fellows in Training .................................. 44
25 Research ............................................................................................................. 46
26 Outcomes of Training Programs ........................................................................ 46
27 Extension, Retention, Termination from Training............................................... 47
28 Clearance for Promotion or Graduation and Issuance of Certificates ............... 48
29 Most Outstanding Trainee (“White Coat Award”) ............................................... 48
30 Anonymous Complaints or Letters ..................................................................... 49
31 Violations and Grounds for Disciplinary Action .................................................. 50
USTH HANDBOOK ON POSTGRADUATE TRAINING VER5, FORM1C

UPDATED ON DECEMBER 2017
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32 Appeals and Automatic Reviews of Investigations ............................................ 52

33 Ethical Guidelines for Medical Practice ............................................................. 52
34 TABLE: Violations/ Grounds for Disciplinary Action........................................... 52
7. Pre-requisites for Admission as a Trainee ................................................... 55
8. Call Rooms ................................................................................................... 55
9. Rules and Regulations-Generalities............................................................... 56
10. Professional Code of Conduct...................................................................... 57
Unprofessional Conduct .............................................................................. 57
11. Intellectual Dishonesty .................................................................................. 61
12. Uniform and Proper Attire ............................................................................. 61
13. Sexual Harassment ...................................................................................... 62
14. General Chain of Command ........................................................................ 62
16. Duties and Assignments............................................................................... 62
General Duties .............................................................................................. 62
Chief Residents/Chief Fellow ....................................................................... 63
Teaching Assignments ................................................................................. 63
Assignments to Other Institutions and Outside Rotations .......................... 64
Other Activities Outside of UST Hospital...................................................... 64
17. General Medical Care................................................................................... 64
18. The UST Hospital Emergency Room Service ............................................. 65
19. Medico-Legal Policy Statement and Procedures........................................ 66
20. Charts and Record Keeping ......................................................................... 66
23 Attendance and Leave of Absence .............................................................. 67
24 Ethical Guidelines for Medical Practice ....................................................... 67
Glossary ................................................................................................................. 68

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Rules and Regulations Governing the Conduct of Internship, Residency

and Fellowship Trainees
1 The University of Santo Tomas Hospital

1.1 The University of Santo Tomas Hospital is a level III, tertiary care center within the
campus of the University of Santo Tomas, the oldest University in Asia, and is located in
the heart of Manila. The University is known as a premier institution of learning in the
Philippines. The University of Santo Tomas Hospital is the teaching hospital of the
University of Santo Tomas Faculty of Medicine and Surgery.
1.2 Organizational Structure

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2 Department of Medical Education and Research

2.1 Department of Medical Education and Research is mandated to oversee, coordinate and
monitor ALL aspects of training including the trainees’ performance and the status of
training programs in the University of Santo Tomas Hospital.
2.2 Department of Medical Education and Research is directly under and answerable only to
the Medical Director. Department of Medical Education and Research is the first office
applying trainees should go to for processing. Likewise, it is the last office that clears
trainees and issues certificates of completion of training to graduating trainees. NO
DEPARTMENT, SECTION, UNIT OR ANY OTHER OFFICE CAN ISSUE ANY TYPE OF
CERTIFICATE OF TRAINING OR ITS KIND THAT BEARS THE NAME AND/OR LOGO
OF THE UST HOSPITAL OR ANY OF ITS UNITS, DEPARTMENTS OR SECTIONS.
2.3 Department of Medical Education and Research is directly handled by the Chairman (See
Organizational Chart). The Chairman of the Department of Medical Education and
Research is assisted by the following:
2.3.1 Fellowship Training Coordinator
2.3.1.1 He/she is the person that is directly responsible in the coordination and smooth flow of training in the
various fellowship training programs in different Departments and Sections.
2.3.1.2 He/she reviews fellowship training programs and sees to it that there are no duplications; accreditations
are current and training programs are complete.
2.3.1.3 He/she functions also as the liaison officer between the fellow-trainees, Departments or Sections and
Department of Medical Education and Research.
2.3.2 Residency Training Coordinator
2.3.2.1 The person that is directly responsible in the coordination and smooth flow of training in the various
Residency training programs in different Departments.
2.3.2.2 He/she reviews residency training programs and sees to it that there are no duplications; accreditations
are current and training programs are complete.
2.3.2.3 He/she functions as the liaison officer between the resident-trainees or Departments and Department of
Medical Education and Research.
2.3.3 Internship Training Coordinator
2.3.3.1 The person that is directly responsible in the coordination and smooth flows of training of interns in the
different Departments.
2.3.3.2 He/she reviews the internship training program and sees to it that it adheres to the stipulations of the
APMC.
2.3.3.3 He/she reviews the qualifications of intern applicants and coordinates with the different Departments on
the training aspects of interns.
2.3.3.4 He/she functions as the liaison officer between the interns or Departments and Department of Medical
Education and Research.
2.3.4 Coordinator for Continuing Medical Education (CME), Clerkship and External Affairs
2.3.4.1 He/she coordinates with the Clinical Programs Director in overseeing the hospital and clinical rotations of
clerks (4th year medical students) of the Faculty of Medicine and Surgery. The clerkship program is
directly under and handled by the Office of the Clinical Programs Director (Clerkship Office) of the Faculty
of Medicine and Surgery. All matters pertaining to hospital training of clerks are handled and settled

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together by the Clinical Programs Director and Department of Medical Education and Research thru the
coordinator for Continuing Medical Education (CME), Clerkship and External Affairs. ALL CLERKS ARE
SUBJECT TO THE RULES AND REGULATIONS OF THE HOSPITAL AND OF THE VARIOUS
DEPARTMENTS THAT THEY ROTATE IN.
2.3.4.2 He/she is the person that is directly responsible in tracking and coordinating all Continuing Medical
Education (CME) related events in the different Departments with Department of Medical Education and
Research.
2.3.4.3 He/she is the person that is directly responsible in tracking and coordinating Departmental/Sectional
projects that require the participation of non- UST Hospital organizations or personnel (e.g. UST Medical
Alumni of America, Governmental organization).
2.3.4.4 He/she ensures that Department of Medical Education and Research and the Office of the Medical
Director is notified and kept current of all CME and related training activities of each Department/Section.
2.3.5 The Hospital Postgraduate Training Committees
2.3.5.1 The Hospital Postgraduate Training Committees shall meet at least once every two (2) months or as the
need arises. The Hospital Postgraduate Training Committees are composed of the following:
2.3.5.1.1 The Resident and Fellowship Training Committee (RFTO)
2.3.5.1.2 The Internship Training Committee (ITC)
2.3.5.2 The Functions and Composition of the Residency and Fellowship Training Committee (RFTO)
2.3.5.2.1 This committee supervises the conduct of the Residency and Fellowship Training
Programs of the various Departments of the Hospital. The Resident and Fellowship Training
Committee shall be composed of the following
2.3.5.2.1.1 The Chairman of the Department of Medical Education and Research as Chairman;
2.3.5.2.1.2 The Fellowship Training Coordinator, Residency Training Coordinator, and the
Coordinator for Continuing Medical Education (CME), Clerkship and External Affairs
and;
2.3.5.2.1.3 The Residency and Fellowship Training Officers of the different Departments
2.3.5.2.2 The Functions of the RFTO are the following:
2.3.5.2.2.1 To review the training programs for trainees regularly, in coordination with the
Chairmen of the Departments, and recommend such changes as may be necessary
for improvement.
2.3.5.2.2.2 To review the Rules and Regulations governing the conduct of trainees regularly and
recommend such changes as may be necessary for improvement.
2.3.5.2.2.3 To assist the Medical Director in formulating guidelines, policies and procedures for
admission into the training programs and for other matters related to training.
2.3.5.2.2.4 To review, deliberate and give recommendations on any question, query or concerns
of Departments or Sections regarding training, rules and regulations and sanctions in
general or specifically concerning a trainee. Department of Medical Education and
Research may also convene the RFTO at any time to inform and discuss with the
Departments and trainees issues deemed important.
2.3.5.3 The Functions and Composition of the Internship Training Committee
2.3.5.3.1 This committee supervises the conduct of the Internship Training Program of the Hospital.
The Internship Training Committee shall be composed of the following
2.3.5.3.1.1 The Chairman of the Department of Medical Education and Research as Chairman;
2.3.5.3.1.2 The Internship Training Coordinator

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2.3.5.3.1.3 The Consultant Internship Supervisors of the different Departments

2.3.5.3.2 The Internship Training Committee shall have the following functions:
2.3.5.3.2.1 To review the training programs for trainees regularly, in coordination with the
Chairmen of the Departments, and recommend such changes as may be necessary
for improvement.
2.3.5.3.2.2 To review the Rules and Regulations governing the conduct of trainees regularly and
recommend such changes as may be necessary for improvement.
2.3.5.3.2.3 To assist the Medical Director in formulating guidelines, policies and procedures for
admission into the training programs and for other matters related to training.
2.3.6 The Residency/Fellowship Training Officer of the Department/Section
2.3.6.1 The Residency and/or Fellowship Training Officer, under the authority of the Chairman of the Department,
Chairman the Residency and/or Fellowship Training Committee of each Department/Section. The
Chairman of the Residency and/or Fellowship Training Committee of the Department/Section appoints the
other members of its’ Committee. The functions of the Departmental Residency and Fellowship Training
Committee are as follows:
2.3.6.1.1 To develop, refine and supervise the implementation of the training programs of their
respective Department/Section
2.3.6.1.2 To provide direct supervision of the trainees in the Department/Section
2.3.6.1.3 To regularly evaluate the performance of trainees in the Department/Section
2.3.6.1.4 To regularly evaluate the training program of the Department/Section as it relates to the
demands of the times and the needs of the specialty
2.3.6.2 It is preferable that the Residency and/or Fellowship Training Officer(s) of the Departments be active staff
members of the Hospital.
2.3.6.3 The Residency and/or Fellowship Training Officer(s) of the Departments act as liaison officers between
Department of Medical Education and Research and the Department Chairpersons. During the Hospital
Postgraduate Training Committee meetings, they act as the direct representative of the Department
chairpersons and hence are required to report to the chair on the matters taken up during the meeting.
Likewise, he/she is tasked to cascade important notices and information down the line to ensure that all
trainees are well informed.
2.3.7 Consultant Internship Supervisors
2.3.7.1 The consultant assigned by the Department to assess, develop and/or revise the internship training
program of the Department. He/she regularly evaluates the training program of the Department as it
relates to the demands of the times.
2.3.7.2 The consultant assigned by the Department that directly supervises the implementation of the Internship
training program in their respective departments.
2.3.7.3 The consultant assigned by the Department tasked to evaluate the performance of interns in the
Department. He/she may ask the help of other colleagues and/or trainees in the formulation of evaluation
tools and their implementation.
2.3.7.4 It is preferable that the Consultant Internship Supervisor of the Departments be an active staff member of
the Hospital.
2.3.7.5 The Consultant Internship Supervisor of the Department act as liaison officer between Department of
Medical Education and Research and the Department Chairpersons. During the Hospital Postgraduate
Training Committee meetings, they act as the direct representative of the Department chairpersons and
hence are required to report to the chair on the matters taken up during the meeting. Likewise, he/she is
tasked to cascade important notices and information down the line to ensure that all interns are well
informed.

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2.3.7.6 The Department may assign a Resident trainee (known as the Resident Intern Monitor) to assist the
Consultant Internship Supervisor in monitoring the performance of interns in their respective departments.
3 Definition of Hospital Trainees

3.1 Hospital trainees in this document refer to observers, interns, residents, pre-residents,
fellows and pre-fellows unless otherwise stipulated
3.2 Affiliate Trainees – medical students, student nurses, rehab interns etc. with direct
involvement in hospital function and activities.
3.3 Observers- a graduate or a student of a Philippine medical school or international
equivalent; or (b) is licensed as a physician of the Philippines, or possesses an
international equivalent;
3.4 Interns - A recent graduate of Medicine from an accredited Medical School who is under-
board. He/she is a medical trainee fulfilling his/her 2nd year training in clinics under the
one-year rotating internship-training program in the UST Hospital.
3.5 Residents – Licensed physicians pursuing a desired specialty-training program.
3.6 Fellows – Licensed, specialist doctors pursuing sub-specialty training.
3.7 Pre-Residents and Pre-Fellows:
3.7.1 Pre-Residents or Pre-Fellows are resident or fellow applicants undergoing a limited
period of evaluation in the concerned departments/sections. This limited period of
evaluation is used by the department/section to determine whether the Pre-Residents or
Pre-Fellows can be accepted into their respective training programs.
3.7.2 All pre-residents and pre-fellows must first apply for training at Department of Medical
Education and Research and complete the requirements of the office before they can
start their pre-residency or pre-fellowship in the hospital.
3.7.3 Pre-Residents and Pre-Fellows can only function under the direct supervision of bona
fide residents/fellows and/or attending consultant. They cannot make rounds alone or
write orders or notes in the chart. Pre-Residents and Pre-Fellows names or signatures
should not appear in the chart or in any formal Hospital form.
3.7.4 Pre-Residents and Pre-Fellows are also directly governed by the Rules and Regulations
Governing the Conduct of Trainees in the UST Hospital. All rules and regulations apply
to Pre-Residents and Pre-Fellows as modified by the provisions above.
3.7.5 The Hospital on many occasions receives requests from foreign medical graduates to
train as residents or fellows. The Hospital encourages and supports this endeavor and
may grant such applications on a case to case basis subject to the following rules and
regulations:
3.7.5.1 All foreign applicants must be graduates of medical institutions that are recognized by and/or have
bilateral agreements or memorandum of agreements with the Hospital.
3.7.5.2 All foreign applicants must first apply to Department of Medical Education and Research for such
privilege. The concerned Department or Section will then be notified. The said Department or Section
must evaluate and endorse the applicant before they can be accepted.

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3.7.5.3 All foreign applicants are subject to and must follow the rules, regulations and policies of the UST Hospital
as well as the rules and regulations of the Department/Section they are applying to for training.
3.7.5.4 All foreign applicants must be allowed to train in the Philippines by pertinent laws of the Philippines and
rules and regulations promulgated by the Department of Health (DOH) and the Philippine Regulations
Commission (PRC).
4 Description of the Training Programs

4.1 Internship Training Program
4.1.1 The Internship Training Program offered by the Hospital is a training program designed
to provide trainees who have recently graduated from accredited medical schools the
necessary clinical exposure to the various fields in medicine and surgery prior to
Residency. It is a 1 year clinical program accredited by the Association of Philippine
Medical Colleges Foundation Inc. (APMC) and is composed of regulated rotations in the
various fields of medicine and surgery. The program is designed to provide the trainee a
broad and holistic view, knowledge and experience in medicine and surgery.
4.2 Residency Training Programs
4.2.1 The Residency Training Programs offered by the Hospital are post-graduate training
programs in various fields of Medicine and Surgery available to any Filipino applicant
who has passed the Medical Board Exam and has been recognized by the Philippine
Regulations Commission (PRC) as a licensed physician. The Clinical Departments
consist of the Medical and Surgical Specialties. The duration of the training programs
varies according to the Specialty. The various Specialty Boards in the Philippines
accredit these training programs.
4.2.2 Foreigners may be accommodated as long as they do not displace a Filipino applicant,
as provided for in the constitution, and following the other rules and specifications
stipulated herein applicable to foreign trainees.
4.3 Fellowship Training Programs
4.3.1 The Fellowship Training Programs are post-residency training programs in the various
subspecialties of Medicine and Surgery. These are available to any qualified Filipino
doctor. The various Sub-specialty Boards in the Philippines accredit these training
programs.
4.3.2 Foreigners may be accommodated as long as they do not displace a Filipino applicant,
as provided for in the constitution, and following the other rules and specifications
stipulated herein applicable to foreign trainees.
4.4 Observer Program
4.4.1 The Hospital on many occasions receives requests from students or graduates of other
institutions to rotate in the hospital and to observe hospital procedures, teachings,
rounds, treatment etc. as part of their continuing medical education. The Hospital
encourages and supports this endeavor and grants “observer” status to the applicants
subject to the following rules and regulations:
4.4.1.1 All applicants (both local and foreign) WITHOUT A VALID MEDICAL LICENSE wishing to rotate in the
hospital must first pass thru the Clinical Director’s Office (Clerk’s Office) of the faculty of Medicine and

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Surgery for endorsement. They must then submit the endorsement to Department of Medical Education
and Research and complete the requirements of the office before observer status can be granted.
4.4.1.2 All Philippine and Foreign Medical Graduates WITH VALID MEDICAL LICENSES wishing to observe in
the hospital in certain departments for special procedures, treatments etc. must first apply to Department
of Medical Education and Research for such privilege. The concerned Department or Section will then be
notified. The said Department or Section must endorse or accept the applicant before they can be
observers.
4.4.1.3 All Observers are subject to and must follow the rules and regulations of the UST Hospital.
4.4.1.4 Observers are not authorized to handle, treat or question patients. They are there to observe and learn
the various procedures / proceedings being performed in the Hospital.
4.4.1.5 Observers are not authorized to write in the chart, give orders or place notes in any form in any part of the
patient chart or any other official hospital forms.
4.4.1.6 Maximum continuous time for observation is two consecutive months unless otherwise specified by
Department of Medical Education and Research or the Office of the Medical Director.
4.4.1.7 An observer must wear his/her identification card at all times while in the UST Hospital premises.
Department of Medical Education and Research issues the identification card.
4.4.1.8 All observers must carry a letter of introduction given by Department of Medical Education and Research
to be presented to the consultant(s) or Department Chairman and Section Chief that he/she wishes to
observe in.
4.5 International Affiliation for Limited Rotation
4.5.1 The Hospital on many occasions receives “hands-on” training related requests from local
or foreign medical practitioners on a limited rotation basis. This is part of the training
program of many foreign trainees under their elective rotations. Local or foreign medical
practitioners use this as part of their CME. The Hospital encourages and supports this
endeavor and allows these local or foreign nationals to observe hospital procedures,
teachings, rounds, treatment etc. as part of their continuing medical education subject to
the existing rules and regulation and those that may be formulated from time to time
including the following:
4.5.1.1 All Philippine and Foreign Medical Graduates wishing to rotate and have “hands-on” experience in the
hospital in certain departments in the hospital MUST HAVE A VALID MEDICAL LICENSE TO PRACTICE
MEDICINE IN THE COUNTRY.
4.5.1.2 All Philippine and Foreign Medical Graduates wishing to rotate in the hospital must first apply to
Department of Medical Education and Research for such privilege. The concerned Department or
Section will then be notified. The said Department or Section must endorse or accept the applicant before
they can start their rotation.
4.5.1.3 All foreign applicants must be allowed to train in the Philippines by pertinent laws of the Philippines and
rules and regulations promulgated by the Department of Health (DOH) and the Philippine Regulations
Commission (PRC). All Philippine and Foreign Medical Graduates and/or foreign practicing physicians
are subject to and must follow the rules and regulations of the UST Hospital.
4.5.1.4 All Philippine and Foreign Medical Graduates wishing to rotate in the hospital can only function under the
direct supervision of bona fide residents/fellows and/or attending consultant. The Maximum continuous
time for any rotation is two consecutive months unless otherwise specified by Department of Medical
Education and Research or the Office of the Medical Director.
4.5.1.5 Philippine and Foreign Medical Graduates and/or foreign practicing physicians must wear his/her
identification card at all times while in the UST Hospital premises. Department of Medical Education and
Research issues the identification card.

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4.5.1.6 Philippine and Foreign Medical Graduates and/or foreign practicing physicians must carry a letter of
introduction given by Department of Medical Education and Research to be presented to the consultant(s)
or Department Chairman and Section Chief that he/she wishes to rotate in.
5 Objectives of Training Programs

5.1 Internship Training Objectives
5.1.1 The Intern graduate shall be able to perform the following at the end of the program:
5.1.1.1 The graduate trainee shall have the necessary skills and knowledge so that they become eligible to take
and pass the Philippine Licensure Examinations.
5.1.1.2 The graduate trainee shall be provided with the necessary experience and knowledge for him/her to
decide what type of specialty he/she would like to pursue.
5.2 Residency and Fellowship Training Objectives
5.2.1 The Resident and Fellow graduate shall be able to perform the following at the end of
the program:
5.2.1.1 The graduate trainee shall be able to render quality health care to all sectors of the society including the
marginalized group.
5.2.1.2 The graduate trainee shall be able to professionally provide excellent, competent & skillful service in the
various specialties and subspecialties of medicine and surgery.
5.2.1.3 The graduate trainee shall be able to effectively share knowledge & expertise in the various specialties
and subspecialties of medicine and surgery to undergraduate & graduate trainees.
5.2.1.4 The graduate trainee shall be able to effectively conduct quality research in the various specialties and
subspecialties of medicine and surgery.
5.2.2 These objectives are in consonance with the three-fold thrust of the University Of Santo
Tomas Hospital, which are: Service, Education and Research.
6 Standard Content of Training Manuals

6.1 All Training Programs should be reviewed and updated at least every 5 years or as
frequent as necessary to accommodate and reflect the most current state of progress.
This job is necessarily done by the Department’s Training Committee under the
Department Chair supervision.
6.2 The following are the minimum information that must be included in the training program
manual. This list is by no means comprehensive and Departments or Sections may add
to this list depending on their need and field of specialty:
6.2.1 A Copy of the Accreditation Certificate or Letter
6.2.2 General information of the program including the vision-mission statement(s)
6.2.3 Narrative: Program Summary/Curriculum Outline
6.2.3.1 Program Description (Describe the following):
6.2.3.1.1 Program design
6.2.3.1.2 Total duration
6.2.3.1.3 Total number of trainees to include trainee-to-patient ratio

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6.2.3.1.4 General training goals of the Department/Section

6.2.3.1.5 Pre-requisites for admission (Before entering the program, what should the person know,
accomplished, finished. State if there is a competitive exam and/or interview and the need for
pre-residency or pre-fellowship)
6.2.4 Program Administration
6.2.4.1 Describe in narrative form the administrative structure of the program. Also include the organizational
chart of the Department/Section as it relates to training and CME. Including a list of the names of the
following:
6.2.4.2 Program Director
6.2.4.3 Department/Section Chief
6.2.4.4 Key Faculty Members, Training Committee members
6.2.5 Key administrative support (Enumerate, describe the following including the selection
process and criteria)
6.2.5.1 Overall Chairman of Training Committee(s)
6.2.5.2 Training Committee(s) and its members
6.2.5.3 Centralized contact number and E-mail address
6.2.6 Facilities and Resources
6.2.6.1 Describe the facilities and resources available to trainees including trainer to trainee ratio, availability and
diversity of patient population, library facilities, on-call rooms, laboratories, offices, computers etc.
6.2.7 Educational Program (Describe the following)
6.2.7.1 Overall program goals
6.2.7.1.1 What kind of trainees do you require
6.2.7.1.2 What are the entry qualifications into the program and for promotion from one level to the
next level
6.2.7.1.3 What are the exit qualifications for trainees to be eligible for graduation from the program
6.2.7.2 Clinical Evaluation
6.2.7.2.1 Enumerate the General and learning objectives of the clinical experience for each year of
training. These must conform to the core competencies as directed by the specialty boards.
6.2.7.3 List each major rotation(s) including:
6.2.7.3.1 Objectives for each major rotation or level of training with respect to knowledge, skills and
other attributes required of trainees and the method(s) of evaluation of each objective
6.2.7.4 Describe the Methodology of teaching (e.g. 1 on 1 coaching etc.)
6.2.7.5 Supervisory guidelines: Describe how supervision will be provided during the clinical training component
6.2.7.6 Rotation Schedule: List the required rotations and elective rotation(s).
6.2.8 Didactic Education
6.2.8.1 List the Goals of the Didactic Education. What are their purposes? What materials will be covered?
6.2.8.2 List names of conferences, rounds etc. available including its frequency
6.2.9 Research/Scholarly Activities
6.2.9.1 Goals of research programs/scholarly activities/ research lectures

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6.2.9.2 Process for selection of topic, mentor and research methodology

6.2.9.3 Process of Data and Protocol review and monitoring
6.2.9.4 Process of Scientific output generation and presentation
6.2.9.5 Include the number of research required before graduation and the type(s) of research (e.g. prospective,
retrospective, case reports, meta-analysis etc)
6.2.10 Criteria and process of choosing the following:
6.2.10.1 Chief Resident
6.2.10.2 Chief Fellow
6.2.11 Criteria used and documentation process for the white coat award(s)
6.2.12 Evaluation (Provide Department of Medical Education and Research the numerical and
non-numerical parameters and values) to include the evaluation method/tool(s) for the
following:
6.2.12.1 Evaluation tool for promotion, retention, termination and/or graduation
6.2.12.2 Criteria for promotion, retention, termination and/or graduation
6.2.12.3 Peer evaluation mechanism (i.e. trainee-to-trainee evaluation)
6.2.12.4 Faculty/Trainer evaluation of trainee
6.2.12.5 Program evaluation by Faculty, Trainers and trainees
6.2.13 Participating Institutions
6.2.13.1 List the institution(s), duration of rotation and the supervising faculty where the trainee will rotate covered
by an MOA (Submit a copy of any valid memorandum of agreement to Department of Medical Education
and Research).
6.2.14 Rules and Regulations with the corresponding violation and disciplinary actions specific
for the Department / Section
7 Pre-requisites for Admission as a Trainee

7.1 ALL PROSPECTIVE TRAINEES MUST FIRST APPLY FOR TRAINING AT
DEPARTMENT OF MEDICAL EDUCATION AND RESEARCH AND COMPLETE THE
REQUIREMENTS OF THE OFFICE BEFORE THEIR APPLICATION CAN BE
PROCESSED. All prospective residents and fellows must be evaluated, meet the
minimum entry competencies required by the training program and be recommended for
acceptance by the Department or Section that they are applying for in training.
7.2 ALL TRAINEES RECOMMENDED FOR TRAINING AT USTH must sign the HOSPITAL
WAIVER AND INDEMNIFICATION FORMS.
7.3 All residents and fellows are appointed or accepted in their respective training programs
on a yearly basis. ALL ARE REQUIRED TO SIGN A MEMORANDUM OF AGREEMENT
WITH THE HOSPITAL EVERY YEAR BEFORE THEY CAN FORMALLY START OR
CONTINUE THEIR TRAINING. NON-COMPLIANCE WITH THIS PROVISION (NOT
SIGNING THE MOA) AUTOMATICALLY MEANS THAT THE TRAINEE HAS NO
AGREEMENT WITH THE HOSPITAL OR HAS WITHDRAWN FROM TRAINING. As
such, all residents and fellows who have not signed the MOA or have not completed the

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requirements of Department of Medical Education and Research are considered dropped

from the list of qualified trainees of the UST Hospital, their training terminated and will be
asked to stop and desist from acting or performing the functions of a trainee.
7.4 Department of Medical Education and Research directly evaluates applicants for
INTERNSHIP MATCHING and acceptance in coordination with the Association of
Philippine Medical Colleges Foundation, Inc.
7.5 All trainees are required to pass the Basic Life Support (BLS) and Advanced Cardiac Life
Support (ACLS) seminars that are conducted by the hospital or to present an equivalent
certificate given by an accredited BLS and ACLS provider. Department of Medical
Education and Research reserves the right to accept or deny certificates given by other
BLS-ACLS provider. Furthermore, All Trainees are required to update their BLS and
ACLS Certification every two (2) years. ALL TRAINEES NEED TO BE CERTIFIED OR
RECERTIFIED IN BLS AND ACLS BEFORE THEY CAN BE ACCEPTED FOR
TRAINING OR CONSIDERED FOR PROMOTION TO THE NEXT LEVEL OR FOR
GRADUATION. Trainees in Pediatrics may present an updated equivalent certification,
the Pediatric Advanced Life Support (PALS) to comply with this requirement.
Recertification for Trainees in Pediatrics is every two (2) years or as stipulated by their
subspecialty boards.
7.6 ALL TRAINEES (Interns, Residents and Fellows) must be vaccinated with Hepatitis A and
B, MMR and Varicella before they are officially accepted in any training program in this
Hospital. Trainees are required to submit proof of vaccination.
7.7 All trainees are required to read and be familiar with the CHIC manual for the prevention
or spreading of various communicable diseases as well as on guidelines concerning
“accidents” while on hospital duty.
7.8 All FOREIGN APPLICANTS must pass thru the Department of Medical Education and
Research and complete the added requirements for foreign medical graduates. After
completing all requirements of Department of Medical Education and Research (including
pre-residency or pre-fellowship) and acceptance by the Department, all foreign medical
graduates must procure a letter from Department of Medical Education and Research
addressed to the finance director for them to place a Cash Bond (implemented 2006). A
cash bond for all accepted foreign nationals (the amount and mode of payment is
determined by the Office of the Medical Director and Finance Director) is mandatory and
will be refunded after completion of training minus expenses incurred during his/her
training period. This bond may outright be forfeited in favor of the UST Hospital when the
trainee fails to comply with all the terms stipulated in the contract entered between the
foreign trainee and the UST Hospital.
7.9 All foreign trainees must provide Department of Medical Education and Research Office of
the following additional requirements:
7.9.1 NBI Clearance for non-citizen.
7.9.2 Police Clearance from port of origin authenticated by the Philippine Consulate.
7.9.3 Show the True copy of applicant’s passport showing admission status and update stay.
7.9.4 Submit a Photocopy of the passport showing admission status and update stay.

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7.9.5 Any other requirements that may be promulgated from time to time
8 Call Rooms
8.1 Call rooms are provided by the hospital for all trainees as a place of rest and education
while the trainee is on duty. These call rooms are functional way-stations for all trainees
and must not be treated as a dormitory or personal room by any trainee. Users of these
call rooms should be guided by the following general rules (see below) and other rules
that may be promulgated from time to time.
8.1.1 Call rooms are to be used by the INTERNS, RESIDENTS and FELLOWS – ON - DUTY
at any given time
8.1.2 Call rooms are available for the 24 hour on-duty interns/residents/fellows to sleep study
and refresh themselves when they can. Those not on 24 hour duty should refrain from
sleeping in the call room
8.1.3 The Chief Resident and Chief Fellow must provide the 24 hour DUTY Schedule of the
month at least two-weeks before the expected month to the dormitory matron and
8.1.4 Lockers in the call room are to be used only for clothes/things to be worn on the following
day by the trainees on duty. NO VALUABLE MATERIALS OR EQUIPMENT MAY BE
STORED IN THE LOCKER. The hospital assumes no liability for any lost items
8.1.5 ABSOLUTELY NO EATING, SMOKING, LITTERING, OR DRINKING ALCOHOLIC
AND NON-ALCOHOLIC BEVERAGES, INSIDE THE CALL ROOM. Personal belonging
must be stowed properly in the designated areas
8.1.6 It is the responsibility of the interns/residents/fellows to maintain the CLEANLINESS of
the beds and room after use
8.1.7 EXERCISE GOOD JUDGEMENT. Behavior beyond the accepted social standards
while inside the call room will not be tolerated. This includes the use of inappropriate
language, behavior etc and these may be ground for sanctions including
restriction/banning the use of call rooms by erring trainees and/or sanctions on conduct
unbecoming of a professional
9 Rules and Regulations-Generalities

9.1 The following rules and regulations below apply to all trainees accepted into Internship
and the various Residency and Fellowship training programs of the University of Santo
Tomas Hospital, including those trainees who receive funding from other sources as well
as foreign medical graduates who have been accepted for training at the University of
Santo Tomas Hospital.
9.2 ALL TRAINEES SHOULD BE AWARE OF ALL THE RULES AND REGULATIONS OF
THE HOSPITAL, INCLUDING THOSE PRESCRIBED BY HIS/HER DEPARTMENT,
AND OTHER UNITS OF THE HOSPITAL. IGNORANCE OF THESE RULES AND
REGULATIONS IS NOT AN EXCUSE FOR VIOLATIONS AND SUBSEQUENT
SANCTIONS WILL BE IMPOSED.

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9.3 All Trainees are subject to any additional policies, rules and regulations that may be
promulgated by the Hospital Administration. New policies, rules and regulations and their
dates of effectivity may be imposed as needed.
9.4 All Interns, Residents, and Fellows accepted into the training programs of the University of
Santo Tomas Hospital are regarded as trainees. The Labor Code enacted by the
Republic of the Philippines does not apply to Interns, Residents, and Fellows; they are
considered trainees and not employees of the Hospital. However, the Hospital does its
best to provide adequate working conditions for its trainees.
9.5 He/She shall not exhibit lewd and/or violent behavior towards authorities, colleagues and
subordinates. All trainees must give respect to all, especially people in authority.
Disrespect for authority or to any person in authority will be grounds for disciplinary action.
9.6 All Trainees shall handle equipment or other properties belonging to the Department,
Section and/or the Hospital with care. Destruction of any hospital property will be
investigated in a case to case basis and the trainee may be held liable for carelessness or
recklessness. Theft or willful destruction of Department/Hospital properties constitutes a
violation of this provision.
9.7 All Trainees are responsible to all the consultants, Training Officer, the Chairman of the
Department, the Chairman of Department of Medical Education and Research and to the
Medical Director. He/She shall obey reasonable orders and the rules and regulations of
the Hospital, Department and Units. Refusal to obey rules and regulations as well as
refusal to carry out orders made by a Consultant or Officer of the Department or higher
Hospital authorities shall constitute among other things, Insubordination (See Glossary).
10 Professional Code of Conduct

10.1 All Trainees must follow the general norms of conduct of a Catholic Physician. They shall
conduct themselves with proper decorum at all times abiding by the general norms of
conduct of a Professional in the medical field. Failure to abide by this code of conduct or
commission of any provision provided below may be grounds for disciplinary action
including outright termination of training and expulsion from the Hospital.
10.2 All Trainees who undertake Training at the University of Santo Tomas Hospital must not
be employed in other institutions/companies. During his/her training, he/she shall not
engage in private practice within or outside the Hospital premises.
10.3 A Resident or Fellow accepted for training is responsible for the periodic renewal of his/her
license to practice Medicine in the Republic of the Philippines as well as other licenses or
requirements as may be required by law or by the policies, rules and regulations of the
Hospital.
10.4 ABSOLUTELY NO SMOKING TOBACCO, GAMBLING OR DRINKING ALCOHOLIC
BEVERAGES WITHIN THE HOSPITAL PREMISES
10.5 All Trainees cannot and should not ingest/smoke/use or unlawfully possess prohibited
drugs or entice others to use prohibited drugs, engage in gambling activities within the
Hospital premises and shall not smoke cigarettes in the University or he/she will be
subject to sanctions as provided.

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10.6 The Following Conduct, Acts, Or Conditions Constitute Unprofessional Conduct For Any
License Holder Or Applicant Under The Jurisdiction Of The UST Hospital:
10.6.1 The commission of any act involving moral turpitude, dishonesty, or corruption relating to
the practice of the person’s profession, whether the act constitutes a crime or not. If the
act constitutes a crime, conviction in a criminal proceeding is not a condition precedent to
disciplinary action. Upon such a conviction, however, the judgment and sentence is
conclusive evidence at the ensuing disciplinary hearing of the guilt of the license holder
or applicant of the crime described in the indictment or information, and of the person’s
violation of the statute on which it is based. For the purposes of this section, conviction
includes all instances in which a plea of guilty or “nolo contendere” is the basis for the
conviction and all proceedings in which the sentence has been deferred or suspended.
10.6.2 Misrepresentation or concealment of a material fact in obtaining a license or in
reinstatement thereof;
10.6.3 All advertising which is false, fraudulent, or misleading;
10.6.4 Incompetence, negligence, or malpractice which results in injury to a patient or which
create an unreasonable risk that a patient may be harmed. The use of a nontraditional
treatment by itself shall not constitute unprofessional conduct, provided that it does not
result in injury to a patient or create an unreasonable risk that a patient may be harmed;
10.6.5 Suspension, revocation, or restriction of the individual’s license to practice any health
care profession by competent authority in any state, federal, or foreign jurisdiction, a
certified copy of the order, stipulation, or agreement being conclusive evidence of the
revocation, suspension, or restriction;
10.6.6 The possession, use, prescription for use, or distribution of controlled substances or
legend drugs in any way other than for legitimate or therapeutic purposes; diversion of
controlled substances or legend drugs; the violation of any drug law; or prescribing
controlled substances for oneself;
10.6.7 Violation of any state or federal statute or administrative rule regulating the profession in
question, including any statute or rule defining or establishing standards of patient care
or professional conduct or practice;
10.6.8 Failure to cooperate with the disciplining authority by:
10.6.8.1 Not furnishing any papers or documents;
10.6.8.2 Not furnishing in writing a full and complete explanation covering the matter contained in the complaint
filed with the disciplining authority;
10.6.8.3 Not responding to subpoenas issued by the disciplining authority, whether or not the recipient of the
subpoena is the accused in the proceeding; or
10.6.8.4 Not providing reasonable and timely access for authorized representatives of the disciplining authority
seeking to perform practice reviews at facilities utilized by the license holder;
10.6.9 Failure to comply with an order issued by the disciplining authority or a stipulation for
informal disposition entered into with the disciplining authority;
10.6.10 Aiding or abetting an unlicensed person to practice when a license is required;
10.6.11 Violations of rules established by any health agency;

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10.6.12 Practice beyond the scope of practice as defined by law or rule;

10.6.13 Misrepresentation or fraud in any aspect of the conduct of the business or profession
including forgery/falsification or misrepresentation of documents;
10.6.14 Failure to adequately supervise auxiliary staff to the extent that the consumer’s health
or safety is at risk;
10.6.15 Engaging in a profession involving contact with the public while suffering from a
contagious or infectious disease involving serious risk to public health;
10.6.16 Promotion for personal gain of any unnecessary or inefficacious drug, device,
treatment, procedure, or service;
10.6.17 Conviction of any gross misdemeanor or felony relating to the practice of the person’s
profession. For the purposes of this subsection, conviction includes all instances in
which a plea of guilty or “nolo contendere” is the basis for conviction and all proceedings
in which the sentence has been deferred or suspended.
10.6.18 The procuring, or aiding or abetting in procuring, a criminal abortion;
10.6.19 The offering, undertaking, or agreeing to cure or treat disease by a secret method,
procedure, treatment, or medicine, or the treating, operating, or prescribing for any health
condition by a method, means, or procedure which the licensee refuses to divulge upon
demand of the disciplining authority;
10.6.20 The willful betrayal of a practitioner-patient privilege as recognized by law;
10.6.21 Interference with an investigation or disciplinary proceeding by willful misrepresentation
of facts before the disciplining authority or its authorized representative, or by the use of
threats or harassment against any patient or witness to prevent them from providing
evidence in a disciplinary proceeding or any other legal action, or by the use of financial
inducements to any patient or witness to prevent or attempt to prevent him or her from
providing evidence in a disciplinary proceeding;
10.6.22 Abuse of a client or patient, or sexual contact with a client or patient;
10.6.23 Acceptance of more than a nominal gratuity, hospitality, or subsidy offered by a
representative or vendor of medical or health-related products or services intended for
patients, in contemplation of a sale or for use in research publishable in professional
journals, where a conflict of interest is presented, as defined by rules of the disciplining
authority, in consultation with the department, based on recognized professional ethical
standards.
10.7 Verbal Abuse defined as the intentional use of inappropriate and unacceptable or profane
language with the purpose to demean, degrade or humiliate a colleague or subordinate.
11 Intellectual Dishonesty
11.1 The Nature of Academic/Intellectual Dishonesty [A standard definition of academic
dishonesty has been provided by Kibler, Nuss, Paterson, and Pavela (1988)]. The
Following Constitute Intellectual Dishonesty for any Trainee of The UST Hospital

PAGE 18 OF 69
11.2 Academic/Intellectual dishonesty usually refers to forms of cheating and plagiarism which
result in students/trainees giving or receiving unauthorized assistance in an academic
exercise or receiving credit for work which is not their own.
11.3 The following are specific forms of academic dishonesty:
11.3.1 Cheating - intentionally using or attempting to use unauthorized materials, information, or
study aids in any academic exercise. The term academic exercise includes all forms of
work submitted for credit or hours.
11.3.2 Cheating also includes: unauthorized multiple submissions, altering or interfering with
grading, lying to improve a grade, altering graded work, unauthorized removal of tests
from classroom or office, and forging signatures on academic documents.
11.3.3 Fabrication - intentional and unauthorized falsification or invention of any information or
citation in an academic exercise.
11.3.4 Facilitating academic dishonesty - intentionally or knowingly helping or attempting to help
another to violate a provision of the institutional code of academic integrity.
11.3.5 Plagiarism - the deliberate adoption or reproduction of ideas or words or statements of
another person as one's own without acknowledgment.
11.3.6 Plagiarism includes the following: copying of one person's work by another and claiming
it as his or her own, false presentation of one's self as the author or creator of a work,
falsely taking credit for another person's unique methods of treatment or expression,
falsely representing one's self as the source of ideas or expression, or the presentation
of someone else's language, ideas or works without giving that person due credit. It is
not limited to written works. For example, one could plagiarize music composition,
photographs, works of art, choreography, computer programs or any other unique
creative effort.
11.4 This page was developed by Alejandro Gomez, B.A. Psychology, 1997. Academic
dishonesty may also be demonstrated by one of the following:
11.4.1 AIDING AND ABETTING a trainee in any form of dishonest practice.
11.4.2 BRIBERY - paying or offering inducements to another person to obtain an advance copy
of an unseen examination or test paper or to obtain a copy of a coursework assignment
in advance of its distribution to the students concerned.
11.4.3 COLLUSION - the representation of a piece of unauthorized group work as the work of a
single candidate.
11.4.4 COMMISSIONING another person to complete an assignment that is then submitted as
your own work.
11.4.5 COMPUTER FRAUD - the use of the material of another person stored on a hard or
floppy disk as if it were your own.
11.4.6 DUPLICATION - the inclusion of coursework of any material that is identical or similar to
material which has already been submitted for any other assessment within the
University or elsewhere e.g. submitting the same piece of coursework for two different
modules.

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11.4.7 FALSE DECLARATIONS in order to receive special consideration by Examinations

Boards.
11.4.8 FALSIFICATION OF DATA - the presentation of data in projects, laboratory reports, etc.
based on work purported to have been carried out by the student which have been
invented by the student or altered or copied or obtained by other unfair means.
12 Uniform and Proper Attire

12.1 All Trainees shall wear the prescribed uniform at all times during his/her tour of duty and
during any official function of the University of Santo Tomas Hospital and Faculty of
Medicine and Surgery
OFFICIAL WHITE BLAZER FOR TRAINEES (JANUARY 1, 2006)
All trainees’ (residents, fellows and interns) white blazer must have the following
specifications:
• Full name (nick names/pseudo names must not be used), abbreviation must be
avoided. If a trainee has a long name, make use of the most recognize first name.
Below trainee’s name is the Department/Section. All must be printed in capital
letters, embroidered in dark blue and placed above the left breast pocket;
• Below the department must be UST Hospital logo; centered.
• Department patch, if any, shall be put on left upper arm.
• All trainees are reminded that they should be in casual business attire defined as:
1. Males: Long or short sleeves polo. Matching tie (optional).
2. Females: Any colored blouse with collar; Non-transparent or “no see-thru”;
No plunging neckline, sleeves or sleeve-less are allowed. White Skirts, the
shortest length is at most 1 inch above the knee, no mini-skirts. Female
trainees may wear white, non-see-thru trousers when on 24-hour duty.
12.2 Please be guided on the proper use of scrub suits and dresses. The purpose of this
section is to provide a consistent policy for wearing scrub suits and the official white
blazer.
12.2.1 Trainees Appearance
12.2.1.1 Trainees are expected to dress in a manner appropriate for a medical practitioner in a
hospital atmosphere. Uniforms will be worn at all times. All items of clothing must be
clean, in good repair and in good fit.
12.2.2 Dress Code
12.2.2.1 Interns, Residents and Fellows may wear the attached prescribed scrubs as an
alternative to wearing the casual semi-business attire provided that they all wear the
prescribed white blazer or smock gown on top of the scrubs at all times when within the
UST hospital premises.
12.2.3 General Guidelines

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12.2.3.1 A trainee must change to the prescribed clean scrubs of a unit before re-entering any sterile restricted
area.
12.2.3.2 Personnel from other departments observed wearing prescribed scrubs for House Staff should be
reported to their immediate supervisor for appropriate action because this is exclusive for House Staff
members only for proper identification.
12.2.3.3 If any trainee is seen in the hospital premises doing patient care without the prescribed white blazer,
he/she is subject to appropriate disciplinary action.
12.2.3.4 No cross dressing i.e. upper scrub and white pants or vice versa
12.2.4 The following items are NOT suitable:
12.2.4.1 Crocs, clogs, sandals, rubber shoes, slip on type or variants of such
12.2.4.2 earrings which are larger than a quarter
12.2.4.3 baggy style pants, maong pants, clothing which shows skin at the midriff, waist, or hips
12.2.4.4 undershirts worn as an outer garment
12.2.4.5 tank tops, spaghetti strap tops, Umbro style shorts and lycra shorts
12.2.4.6 Other clothing that distracts attention
FOR ALL TRAINEES (Interns, Residents AND Fellows): NO SANDALS, SLIPPERS,

CLOGS, SLIP-ON TYPE or variants of such, NO RUBBER SHOES, NO JEANS OR
“MAONG” PANTS OR SHORTS ARE ALLOWED AT ANY TIME. DECENT UNDERWEAR
A MUST (Defined as underwear that DOES NOT incite undue attention or distraction.)
12.3 Identification Card

12.3.1 ALL TRAINEES ARE REQUIRED TO WEAR HIS/HER IDENTIFICATION CARD
AT ALL TIMES.
12.3.2 The Hospital Identification card is the property of the University of Santo Tomas
Hospital and is validated to the period of training defined in the Training Program
under which the trainee has been accepted.
12.3.3 Possession, alteration, use or attempted use of an ID card for the purpose of
identification or to receive services, by anyone other than the person whose
name, ID number and photo appear on the card is considered unauthorized use
of the ID card. The offender will be subject to appropriate penalties and
confiscation of the ID card by Department of Medical Education and Research.
12.3.4 The UST Hospital ID Card is separate and distinct from the Faculty of Medicine
and Surgery ID Card. They are not interchangeable.
12.3.5 It is the trainee’s responsibility to report a lost or stolen identification card to
Department of Medical Education and Research at the 6th Floor, Clinical Division,
UST Hospital. A fee will be charged to replace lost, stolen or damaged cards.
12.3.6 Current Address: To avoid missing important communications from Department
of Medical Education and Research, it is the trainee’s responsibility to keep the
Department of Medical Education and Research informed of his/her current local

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and permanent addresses. Communications mailed to either address of record

will be deemed to be adequate notice.
12.3.7 ID card shall be surrendered upon termination of service at Department of
13 Sexual Harassment
13.1 All Trainees shall not engage in activities constituting violations of the Sexual
Harassment Act of 1995 (See Below).
REPUBLIC ACT NO. 7877 (Anti Sexual Harassment Act of 1995)

AN ACT DECLARING SEXUAL HARASSMENT UNLAWFUL IN THE EMPLOYMENT, EDUCATION OR
TRAINING ENVIRONMENT, AND FOR OTHER PURPOSES
SECTION 1: Title. - This Act shall be known as the “Anti-Sexual Harassment Act of 1995.”
SECTION 2: Declaration of Policy. - The State shall value the dignity of every individual, enhance the
development of its human resources, guarantee full respect for human rights, and uphold the dignity of
workers, employees, applicants for employment, students or those undergoing training, instruction or
education. Towards this end, all forms of sexual harassment in the employment, education or training
environment are hereby declared unlawful.
SECTION 3: Work, Education or Training-related Sexual Harassment Defined. - Work, education or
training-related sexual harassment is committed by an employer, employee, manager, supervisor, agent of
the employer, teacher, instructor, professor, coach, trainor, or any other person who, having authority,
influence or moral ascendancy over another in a work or training or education environment, demands,
requests or otherwise requires any sexual favor from the other, regardless of whether the demand, request
or requirement for submission is accepted by the object of said Act.
In a work-related or employment environment, sexual harassment is committed when:
The sexual favor is made as a condition in the hiring or in the employment, re-employment or continued
employment of said individual, or in granting said individual favorable compensation, terms, conditions,
promotions, or privileges; or the refusal to grant the sexual favor results in limiting, segregating or classifying
the employee which in any way would discriminate, deprive or diminish employment opportunities or
otherwise adversely affect said employee;
The above acts would impair the employee’s rights or privileges under existing labor laws; or
The above acts would result in an intimidating, hostile, or offensive environment for the employee.
In an education or training environment, sexual harassment is committed:
Against one who is under the care, custody or supervision of the offender;
Against one whose education, training, apprenticeship or tutorship is entrusted to the offender;
When the sexual favor is made a condition to the giving of a passing grade, or the granting of honors and
scholarships or the payment of a stipend, allowance or other benefits, privileges, or considerations; or
When the sexual advances result in an intimidating, hostile or offensive environment for the student, trainee
or apprentice.
Any person who directs or induces another to commit any act of sexual harassment as herein defined, or
who cooperates in the commission thereof by another without which it would not have been committed,
shall also be held liable under this Act.

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SECTION 4: Duty of the Employer or Chairman of Office in a Work-related, Education or Trainings

Environment. - It shall be the duty of the employer or the Chairman of the work-related, educational or
training environment or institution, to prevent or deter the commission of acts of sexual harassment and to
provide the procedures for the resolution, settlement or prosecution of acts of sexual harassment. Towards
this end, the employer or Chairman of office shall:
Promulgate appropriate rules and regulations in consultation with and jointly approved by the employees or
students or trainees, through their duly designated representatives, prescribing the procedure for the
investigation of sexual harassment cases and the administrative sanctions therefore.
Administrative sanctions shall not be a bar to prosecution in the proper courts for unlawful acts of sexual
harassment.
The said rules and regulations issued pursuant to this subsection (a) shall include, among others,
guidelines on proper decorum in the workplace and educational or training institutions.
Create a committee on decorum and investigation of cases on sexual harassment. The committee shall
conduct meetings, as the case may be, with officers and employees, teachers, instructors, professors,
coaches, trainors and students or trainees to increase understanding and prevent incidents of sexual
harassment. It shall also conduct the investigation of alleged cases constituting sexual harassment.
In the case of a work-related environment, the committee shall be composed of at least one (1)
representative each from the management, the union, if any, the employees from the supervisory rank, and
from the rank and file employees.
In the case of the educational or training institution, the committee shall be composed of at least one (1)
representative from the administration, the trainors, teachers, instructors, professors or coaches and
students or trainees, as the case may be.
The employer or Chairman of office, educational or training institution shall disseminate or post a copy of
this Act for the information of all concerned.
SECTION 5: Liability of the Employer, Chairman of Office, Educational or Training Institution. - The
employer or Chairman of office, educational or training institution shall be solidarily liable for damages
arising from the acts of sexual harassment committed in the employment, education or training environment
if the employer or Chairman of office, educational or training institution is informed of such acts by the
offended party and no immediate action is taken thereon.
SECTION 6: Independent Action for Damages. - Nothing in this Act shall preclude the victim of work,
education or training-related sexual harassment from instituting a separate and independent action for
damages and other affirmative relief.
SECTION 7: Penalties. - Any person who violates the provisions of this Act shall, upon conviction, be
penalized by imprisonment of not less than one (1) month nor more than six (6) months, or a fine of not less
than Ten thousand pesos (P10,000) nor more than Twenty thousand pesos (P20,000), or both such fine
and imprisonment at the discretion of the court.
Any action arising from the violation of the provisions of this Act shall prescribe in three (3) years.
SECTION 8: Separability Clause. - If any portion or provision of this Act is declared void or
unconstitutional, the remaining portions or provisions hereof shall not be affected by such declaration.
SECTION 9: Repealing Clause. - All laws, decrees, orders, rules and regulations, other issuances, or
parts thereof inconsistent with the provisions of this Act are hereby repealed or modified accordingly.
SECTION 10: Effectivity Clause. - This Act shall take effect fifteen (15) days after its complete publication
in at least two (2) national newspapers of general circulation.
Approved: February 14, 1995
13.2 The Department of Medical Education and Research is committed to maintaining

an environment which respects the dignity of all individuals. Accordingly, the

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DMER will not tolerate any sexual harassment by trainees, trainers or patients. The
DMER is promulgating this guide to reaffirm its opposition to sexual harassment
and to emphasize that learning and training opportunities must not be interfered
with by sexual harassment.
13.3 The purposes of this guideline include:
13.3.1 Preventing sexual harassment
13.3.2 Prohibiting sexual harassment
13.3.3 Encouraging good faith complaints if sexual harassment has occurred
13.3.4 Providing mechanisms and options for addressing and resolving complaints of
sexual harassment
13.4 The DMER will take prompt corrective action against any sexual harassment by
trainees or involving its’ trainee. This is designed to encourage persons who
believe that they have been sexually harassed to bring the conduct to the attention
of DMER so that the people of DMER can take prompt corrective action.
13.5 If the complainant is a student of the Faculty of Medicine and Surgery (which
includes Clerks assigned to the hospital), he/she may start the process by
complaining to the Dean of the Faculty of Medicine And Surgery or, the Director of
Clinical Programs of the Faculty of Medicine And Surgery or, the Chairman of
DMER who will then inform and work together to ferret out the truth and investigate
the complaint according to the mechanism herein described.
13.6 Department of Medical Education and Research can initiate an investigation on
any written or verbal complaint or incident that it receives, or at any time when it
deems it necessary.
13.7 The DMER reserves the right to continue investigation into the allegations with, or
without, the complainant's cooperation.
13.8 If the informant/complainant wishes CONFIDENTIALITY, he/she may ask for a
confidential meeting with the Chairman of DMER by informing the DMER
Secretary or by calling the DMER Office at +632-731-3001 local 2246.
13.9 If a hospital trainee (intern, resident or fellow) is involved, The Chairman of DMER
will assign the case to the proper investigating body which shall be convened by
the DMER. This process will determine the validity of the complaint and
recommend appropriate disciplinary action, if warranted.
13.10The investigating body shall be composed of the following:
13.10.1 Chairman of DMER which acts as the chairperson and moderates the
investigation and meetings, The Medical Director, the appropriate DMER
Coordinator (i.e., coordinator for residency, fellowship or internship), the legal
representative of the hospital, and if medical clerks are involved, the Director of
Clinical Programs shall be called upon to be part of the investigating body, as well
as other such persons or bodies that the Chairman of DMER chooses to help in
the investigation.

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13.10.2 A report of the incident shall be submitted to the Chairperson of the investigating
body for investigation and appropriate action. It will be kept in the permanent file
of the trainee at the DMER. It shall contain the following information.
13.10.2.1 Date and time of the incident
13.10.2.2 Place of incident, if applicable
13.10.2.3 A written narrative of the incident from the involved person(s) with dates and signatures
13.10.2.4 Complainant’s name and signature
13.10.3 The investigating body shall do the complete investigation of the incident report
or complaint against a trainee. The investigative process includes but is not
limited to the following:
13.10.3.1 The investigative arm shall notify all the accused trainee(s) and should obtain a written and
signed narrative of all those directly or indirectly involved in said incident or complaint. The
discretion is given to the investigating arm whether to involve peripheral personalities or issues.
13.10.3.2 The investigating body shall in all instances, make sure that the complainant is shielded from any
influence or pressure that may be brought to bear , either directly or indirectly, by the “accused” or
any of associates of the accused on the complainant. This may include but is not limited to
preventive suspension, reassignment of the complainant or the accused to other duties/places
during the time of investigation. The accused and any of his/her close associates that may
influence or pressure the complainant (i.e., fraternity members etc.) shall be directed not to have
any contact whatsoever with the complainant and cannot be present within 100 feet from the
complainant. Violation of this procedure will be dealt with harshly and may include termination of
those involved.
13.10.3.3 The investigating body should summon witnesses to ascertain the facts surrounding the incident
or to verify facts about the case. This may entail interviewing patients, consultants, nurses,
trainees, or other hospital personnel. All interviews that the investigative arm deem necessary
should be documented; all those interviewed should also be asked to submit their written and
signed narrative of the incident.
13.10.3.4 The investigating body should look into aggravating or mitigating factors and other such factors
that led to the incident or complaint.
13.10.3.5 The investigating body forms its conclusions of the case and creates its’ conclusions and written
recommendations including recommendations concerning severity of sanction, improvements in
system so that such incidents are not repeated etc
13.10.3.6 The investigating body shall inform the complainant and the accused of its findings, conclusions
and recommendations in writing.
13.10.4 The office of the Medical Director thru DMER shall impose the
recommendations, sanctions and corrective measures. As this already
involves the highest offices of the hospital with regards to trainees, the
decision is final.
13.11 Complaints regarding trainers or consultant staff involved other than a hospital
trainee will be transferred to the appropriate person/office for action.

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14 The General Chain of Command:

14.1 The chain of command should always be followed as protocol in terms of
informing, referring and managing cases. From the highest to the lowest in the
chain of command are: The Medical Director > DMER Chairman > Department
Chair > Section Chief > Dept or Section Training Committee Chairman > Pertinent
Dept or Section Training Officer > Attending Consultant > Pertinent Referral
Consultant > Pertinent Chief or Senior Fellow on duty > Chief Resident > Most
Senior Resident on duty > Intern > Clerks. Allowances can be made in cases of
extreme emergency such as natural disasters or calamities, terrorist activities,
violent national upheavals etc. wherein the top people should immediately be
informed. The flow of information should be from top to bottom and bottom to top
as well as sideways (nurses, aides, security, hospital personnel that have need to
know basis).
14.2 The Interns shall supervise the medical clerks assigned to his/her area of
responsibility. He/she is tasked to monitor their attendance and supervise the work
assigned to them. Interns have authority over the Clerks.
14.3 The Resident handles the pre-residents, interns and medical clerks assigned to
his/her area of responsibility. The Resident is tasked to monitor their attendance
and supervise the work assigned to them. Residents have authority over the
Interns and Clerks and pre-Residents.
14.4 The Fellow handles the pre-fellows, residents and pre-residents of all levels of
training assigned to the service, Unit or Section of the Department. The Fellow is
tasked to monitor, teach and supervise the work of the pre-fellows, residents and
pre-residents in their particular service, Unit or Section of the Department. Fellows
have authority over the pre-fellows, residents and pre-residents and other trainees
that are working or rotating in their particular service.
14.5 The Training Officer and/or the Consultant assigned or in-charge of the Ward/Unit
in general, handles the Fellows and other trainees that participate in the care of
patients in these areas or in the proper function of these areas. However, Fellows
are by nature trainees in sub-specialty fields and therefore are directly supervised
by the Fellowship Training Officer and other consultants of the Specialty where the
Fellows are training. In areas of conflict or diverging opinions, the Fellowship
Training Officer and/or other consultants of the Specialty where the Fellows are
training have direct staff authority over their respective Fellow trainees.
14.6 Conflicts or confusion on the proper roles, responsibilities and functions of trainees
that may arise with regards patient care should be resolved at the level of the
training consultants. If resolution cannot be obtained at this level, the chiefs of
sections or the chairpersons of the Departments involved are to resolve the issue.
14.7 Department of Medical Education and Research supervises the Department’s
administrative and training roles as they pertain directly to the Trainees. This
includes but is not limited to the review of sanctions imposed by Departments if an
appeal for reconsideration is elevated, automatic review of sanctions requiring
USTH HANDBOOK ON POSTGRADUATE TRAINING VER4, FORM1A

UPDATED ON NOVEMBER 2008
PAGE 26 OF 69
termination, training relationships with other institutions, review of old or new

training programs, etc. Department of Medical Education and Research with the
Office of the Medical Director can be called upon to resolve Administrative and
Training issues that may arise within and between Departments if such issues
cannot be resolved at the Departmental level.
15 Relationship with the Nursing Staff

15.1 The Professional relationship of a fellow, resident, intern or clerk with the nursing
staff is one of partnership with mutual respect and trust for both professions. All
must double check each other in areas of patient care especially taking care of
giving the correct medicine to the right patient in the correct manner. All trainees
can learn from each other as well as from the nursing staff for the benefit of the
patient. Therefore, the relationship is that of harmonious cooperation with the
ultimate goal of providing efficient health care delivery at the lowest cost, shortest
time with the patient’s rights, safety, well-being and satisfaction guaranteed.
15.2 Any complaints to or about any activity or action by or from any nursing staff
personnel should be directed to the Chairman of Office ofDepartment of Medical
Education and Research in writing. Such complaints must include the date, time,
the incident, names of people involved, and the circumstances surrounding the
incident. If there is more than one complainant, separate reports are to be
submitted with the name of the complainant clearly printed, his/her designation in
the hospital and signed. Such complaints will be elevated to the medical director
who in turn shall take the matter up with the Nursing Directress.
16 Duties and Assignments

16.1 General Duties:
16.1.1 All Trainees are required to report for work daily at 7:00 a.m. and may leave work
at 5:00 p.m. daily from Monday to Friday, except when they are on 24-hour duty,
in which case he/she continues to work even outside office hours. On Saturdays,
work hours are from 7:00 a.m. to 12:00 noon and on Sundays, from 8:00 a.m. to
12:00 noon. Schedules for holidays shall be announced by Department of
Medical Education and Research. All Trainees are required to report
PROMPTLY to their places of assignment. Prior to leaving the hospital, all
Trainees shall ensure that all matters pertaining to the care of critically ill patients
under his care are completed or appropriately endorsed. The Department may
require that Trainees report earlier or later than 7:00 a.m., as necessary for
endorsements and other duties or concerns as the need arises.
16.1.2 All trainees are required to follow the official UST time. The UST bundy clocks
and biometric kiosks is adjusted in accordance with the Pacific Standard Time
(PST) as disseminated by PAGASA Time Service Unit. All machines dealing with
time should follow the official UST official time which is regularly calibrated every
Wednesday afternoon.

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16.1.3 Twenty-four hour duties start at 7:00 a.m. of the duty day up to 7:00 a.m. of the
following day. No Trainee may leave and go off-duty earlier than 12:00 noon of
the following regular working day unless specifically granted by Department of
16.1.4 Trainees on duty shall be physically present at all times and all Trainees-on-call
shall be available for contact at all times. Trainees found out-of-post shall be
sanctioned appropriately (See Glossary).
16.1.5 Trainees shall follow the “Rounds, Endorse and Leave” Policy during Holidays
(announced or unannounced) and during unforeseen events that may lead to the
cancellation of regular working hours. During these times, the Medical Team in-
charge of the ward patients shall report to make rounds, evaluate each
patient and make the necessary physician’s orders. The resident-in-charge
may decide as to the time of the rounds. He/she may opt to convene the team at
6 a.m. and if all orders have been carried out and endorsements made to the
team on 24-hour duty, those not on 24-hour duties may leave early. All out-
patient consults shall be handled at the Emergency Medicine Department. The
“No Skeleton Force Policy” means that we shall not tolerate that only those
on 24-hour duty report for work during holidays. This is not in keeping with
quality patient care as it is the medical team in-charge of the patient who can truly
assess and address all the needs of the patient. This is also in keeping with the
“one-hospital” policy that emphasizes the same standards for Private and Clinical
Division patients.
16.1.6 Resident trainees are required to go on ambulance call at various times during
his/her training. The Chairman of the Department of Medical Education and
Research shall determine the frequency and actual dates of ambulance
assignment. Ambulance residents shall respond promptly to ambulance calls.
16.1.7 Substitution of duties shall be applied for in writing stating the reason(s) for the
request, the duty dates and times and the name(s) and rank(s) of the trainees
who will substitute for the requesting trainee. The Training Officer of the
Department or Section MUST APPROVE this request. Department of Medical
Education and Research must be furnished a copy of the approval at least forty-
eight (48) hours prior to the intended dates.
16.1.8 The Chairman of Department of Medical Education and Research may assign
Trainees to render reasonable special duties aside from duties relevant to
medical care of patients in the Hospital. In cases of emergent situations like
natural disasters, the Chairman of Department of Medical Education and
Research may recall Trainees who are off-duty or request Trainees going off-duty
to stay in the hospital to attend to patients admitted into Hospital.
16.1.9 All trainees are required to attend all functions, conferences, meetings that the
Hospital Administration or Department of Medical Education and Research
requires.
16.1.10 No Trainee shall act as a preceptoree for any consultant in the Hospital (See
Glossary).

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16.2 The Chief Resident/Fellow

16.2.1 The chief resident or chief fellow is appointed or chosen by the
Department/Section based on several criteria agreed upon by the Hospital
Training Committee. Some criteria may be added by the Department or Section
peculiar to the training of that Department or Section.
16.2.2 The following are the general duties of the chief resident or chief fellow (see
below). Other duties may be imposed by the Department or Section arising from
differences and peculiarities of the training program or as the need arises
16.2.3 The chief resident and chief fellow must provide Department of Medical
Education and Research the list of trainees on 24-hour duty, ambulance duty
roster and OPD duty roster at the latest two (2) weeks before the onset of duty of
the incoming trainees
16.2.4 The chief resident and chief fellow must provide the nurse’s stations of the entire
hospital (both pay and clinical) of the list of trainees on 24-hour at the latest two
(2) weeks before the onset of duty of the incoming trainees together with the
contact number and cell phones of these trainees
16.2.5 The chief resident and chief fellow must provide Department of Medical
Education and Research and the Emergency Room of both the Pay (TR) and
Clinical Division (ER) of the Hospital the list of trainees on second-call for the TR
and ER
16.2.6 The chief resident and chief fellow is ultimately responsible for the proper
safekeeping and compilation of all logbooks of his/her respective Department /
Section. These include logbooks on absences, tardiness, procedures done by
trainees etc.
16.2.7 The chief resident and chief fellow is ultimately responsible for the proper staffing
of the wards in cases where manpower needs to be redistributed as in cases of
absences etc
16.2.8 The Chief Resident and the Chief Fellow of each service is required to prepare
monthly reports of the activities of the Service. At the end of the tenure of the
Chief Resident or the Chief Fellow, he/she is required to submit an Annual
Report (year-end report) to the Chairperson of the Department and a copy
to DMER. The Chief Resident or the Chief Fellow shall not be awarded a
Certificate of Graduation until after submission of the Annual Report and
clearance from Department of Medical Education and Research.
16.3 Teaching Assignments
16.3.1 As a teaching hospital, the UST Hospital requires that all trainees shall be subject
to reasonable teaching assignments that his/her Department or Section requires
of him/her.
16.3.2 Residents are likewise tasked to teach their subordinates about the cases they
are handling. These subordinates include pre-residents, interns and clerks. Such
teaching sessions may be made at the bedside with all parties acting
professionally and with the consent of the patient. Most teachings or discussions

PAGE 29 OF 69
should be made away from the patient; out of hearing range unless direct
physical examination of the patient is needed to corroborate or document findings
of clinical relevance.
16.3.3 Fellows in the various subspecialties are also required to assist in the training of
their subordinates through didactic teachings of recent advances in their
respective subspecialties as well as in the application of new concepts and
principles during their daily rounds under the guidance of their respective
consultants.
16.3.4 In the course of teaching medicine, Consultants and Trainees do not look at or
use patients as subjects of clinical or scientific curiosity. The patient’s human
dignity must always be preserved and respected. The rights, safety, and well-
being of the patients are the most important considerations and should prevail
over interests of science and society (from the Principles of ICH Good Clinical
Practice)
16.4 Assignments to Other Institutions and Outside Rotations
16.4.1 All training activities should be held within the Hospital when the facilities of the
Hospital allow such training. In cases where the facilities of the Hospital are
insufficient to provide training integral to the completion of the Residency and
Fellowship Training Program, the Resident or Fellow may be assigned to rotate in
another institution which may provide such training only if there is an official
linkage or arrangement existing between that institution and the University
of Santo Tomas Hospital through a Memorandum of Agreement (MOA).
Assignments to other institutions and their MOA are subject to deliberation by
Department of Medical Education and Research, whose recommendations shall
be submitted to the Medical Director for final approval.
16.4.2 A MOA must cover training relationships with other institutions that require
trainees to rotate in other institutions. It is the responsibility of the Department
or Section to create the MOA with the other institution. The MOA however,
must be submitted to Department of Medical Education and Research for review
or comments. The MOA is then submitted to the Office of the Medical Director for
final approval.
16.4.3 The maximum duration of any outside rotation for any trainee is three (3)
consecutive months. This may be served in staggered basis depending on the
evolving needs of the Department and training.
16.4.4 The Hospital frowns on agreements with consortium. A Consortium is defined as
an agreement between three (3) or more institutions for purposes of training
interns, residents or fellows. Although the Hospital is not totally averse from
having such agreements, these types of agreements must pass thru rigid scrutiny
by Department of Medical Education and Research and the Medical Director and
may take time. At the present, it is better to develop individual MOA with distinct
institutions for purposes of training interns, residents or fellows.
16.4.5 The rules and regulations regarding attendance also apply during outside
rotations. The trainee’s attendance may be checked periodically by the

PAGE 30 OF 69
Department’s Residency Training Committee or by Department of Medical

Education and Research.
16.4.6 During his/her assignment or rotation to another institution, a Resident or Fellow
may still be required by the Department to go on 24-hours duty at the University
of Santo Tomas Hospital if deemed necessary.
16.4.7 All trainees who leave the premises of the Hospital for rotations in other
institutions must inform Department of Medical Education and Research of such a
rotation. All trainees on outside rotations should fill out the proper documents
necessary which are available at Department of Medical Education and
Research. These documents must be submitted at the latest, one (1) week
before the planned rotation. Non-compliance with this directive means that the
trainee(s) is/are outside of the UST Hospital without permission and the trainee(s)
shall be considered, among others, as Out of Post or AWOL (See Glossary).
16.5 Other Activities Outside of UST Hospital
16.5.1 All training activities should be held within the Hospital when the facilities of the
Hospital allow such training. However, there are some training programs that
require trainees to participate in activities outside the Hospital and this
participation is integral to the completion of the Residency and/or Fellowship
Training Program (example: Philippine College of Physicians (PCP) requiring
resident and fellow trainees in Medicine to attend the annual PCP meetings etc.).
The Hospital recognizes this need and allows this as long as the following
mechanism is observed:
16.5.1.1 All trainees who leave the premises of the Hospital for these types of activities must first inform
Department of Medical Education and Research of such an activity.
16.5.1.2 All trainees must fill out the proper documents necessary which are available at Department of
Medical Education and Research. These documents must be submitted not less than one (1)
week before the planned activity. These include providing the office the names of trainees
involved in these activities; the nature of the activity; the place, dates and times of the activity and
the names of the substitute trainees who will take over while they are away from the hospital.
16.5.1.3 Non-compliance with this directive means that the trainee(s) is/are outside of the UST Hospital
without permission and the trainee(s) shall be considered, among others, as Out of Post.
16.5.2 Other activities outside of the Hospital may be asked of our trainees that may
include humanitarian assistance, for personal and/or religious reasons, and other
services (example: Medical Missions, Calamity assistance, Retreats etc.). The
Medical mission is an effort on the part of health professionals to organize,
support and provide voluntary humanitarian medical services to the needy. In this
regard, the Hospital supports these types of efforts. However, all our trainees
(fellows, residents, interns and clerks) must realize that joining such missions are
not part of their training and is purely on VOLUNTARY basis and upon the
discretion of the Departments concerned. Therefore all trainees who have been
approved by their Departments to join such missions must first apply and fill out a
waiver that this University Hospital, its administrators, officers, directors and
employees are released from any liabilities that may result from death or injuries
that may befall him/her in connection with the mission. The waiver is available at

PAGE 31 OF 69
the Office of the Assistant Medical Director for Training. The Hospital allows this
as long as the following is understood and observed:
16.5.2.1 Participation in such events is purely voluntary.
16.5.2.2 All volunteer trainees who leave the premises of the Hospital for these types of activities must first
inform Department of Medical Education and Research of such an activity.
16.5.2.3 All volunteer trainees must fill out the proper documents necessary which are available at
Department of Medical Education and Research and submit these documents not less than one
(1) week before the planned activity to Department of Medical Education and Research. These
documents should include the invitation letter from the sponsoring agency, the names of trainees
involved in these activities; the nature of the activity; the place, dates and times of the activity and
the names of the substitute trainees who will take over while they are away from the hospital.
16.5.2.4 Non-compliance with this directive means that the trainee(s) is/are outside of the UST Hospital
without permission and the trainee(s) shall be considered, among others, as Out of Post.
16.5.2.5 Department of Medical Education and Research reserves the right to allow or deny the
participation of its trainees in such occasions.
16.6 Violation(s) of any provision in section 10, 11, 13, 18, 19, 20, 21, 22, and 23 shall
be broadly considered, among others, as Negligence or Dereliction of duties (See
Glossary).
17 General Medical Care

17.1 All Trainees shall render appropriate medical care to all patients admitted under
his/her care whether inpatient or outpatient at all times, and to all other patients
he/she is called to attend to during his/her tour of duty in the Hospital.
17.2 It is the duty of the trainee to know all admissions, referrals and critically ill or
serious patients during his term of duty. Needless to say, trainees are entrusted to
regularly make rounds to know new admissions, referrals or patient status.
Electronic communications are set up to facilitate this demand (i.e. cell phones,
land lines, paging system etc.) but trainees are not to rely solely on these
mechanisms. In this line, the nursing staff is likewise responsible for notifying the
medical team of admissions, referrals or changes in patient status. The medical
team here refers to the pertinent nursing team, interns, residents, fellows and
consultants taking care of the patient.
17.3 All Trainees are required to make regular, daily clinical rounds on all their patients
and as frequent as necessary. In such rounds, trainees assess the current clinical
condition of the patient, the impact of recent interventions and institute remedial or
long term care for the patient using the best available evidence or best clinical
practice that is available.
17.4 All Trainees shall provide follow-up care to all his/her patients.
17.5 All trainees are required to update their consultants regularly on the condition of
any of their patients. They must inform their consultants on any intervention that
was done, that is needed, or about any change in the clinical condition of the
patient or any laboratory result that requires immediate decision or response. All
pertinent trainees must inform any and all consultants of any admission or

PAGE 32 OF 69
emergency about any patient to discuss the patient’s condition and the plans for
treatment so that proper care and patient needs can be addressed immediately,
treatment be instituted at the earliest and most opportune time and referral(s) for
further specialized care can be made with utmost dispatch. Note that Nurses are
only mandated to notify all consultants of any admission, referral, or
transfer. The trainee must talk to the consultant about the patient’s case and
treatment options. These shall all be reflected in the appropriate areas of the
chart.
17.6 All trainees are required to provide life saving measures to any patient in need and
should call for “code blue” if the situation requires. After stabilizing the patient, the
appropriate seniors and consultant(s) should be apprised of the case. If the
consultant cannot be reached, then the trainee should inform the next authority on
line (See Above: Chain of Command).
17.7 All trainees are required to answer all calls and/or referrals within a reasonable
time.
17.8 All Trainees shall write Staff Progress notes on all patients under his/her care daily,
or as the patient’s condition changes. All Trainees must at all times document all
findings and clinical data when they see a patient or talk with their consultants.
He/She shall write the subjective complaints, his/her findings, assessment of the
situation, and plans for the management of the case, both diagnostic and
therapeutic.
17.9 All communication, agreements, diagnostic and therapeutic plans, and recent
clinical findings must be written in the staff progress notes sheet (not in the
physician’s orders sheet). ALL PHYSICIAN’S ORDERS MUST BE WRITTEN IN
THE PHYSICIAN’S ORDERS SHEET (POS). THE NURSES WILL FOLLOW
ONLY ORDERS IN THE POS.
17.10All trainees should be diplomatic to all the relatives of the patient. Information to be
divulged to patient’s relatives should be coordinated and have the consent of the
attending physician. No Trainee is allowed to divulge sensitive clinical information
about a patient’s case (Principle of Patient’s Privacy) to anybody unless cleared,
coordinated and with the consent of all attending physicians. For cases where the
attending physician is not available, the trainee should refer to the next line of
authority in the chain of command. Likewise, all trainees are held responsible for
the loss of vital information or surgical or biopsy specimen(s) obtained from
patients. In this regard, (i.e. loss of specimen etc. is the responsibility of the intern
and resident and as such ALL are held responsible).
17.11Upon discharge of the patient, the trainee together with the attending physician or
at the instructions of the attending physician should orient and explain to the
patient his or her medication, next visit, what are the needed medical precautions
and other necessary medical advice that the patient needs to know. These should
be duly logged in the chart indicating that such instructions were given and
understood by the patient and/or responsible kin or caretaker. This log MUST BE
SIGNED by the patient or responsible next of kin

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17.12Some of our trainees (Residents and Fellows) are being requested by some of our
Consultant Staff Members to accompany patients back home and even to the
provinces when discharged. Department of Medical Education and Research
would like to clarify certain issues germane to this particular practice. Although
these requests are done from the point of view of humanitarian and altruistic
motives, the office wishes to remind everyone concerned that this is not part of the
trainees’ job description unless specifically authorized by the Hospital (i.e.
ambulance conduction). Therefore, any trainee who accepts such request from
any Hospital Consultant Staff Members does so purely on a VOLUNTARY basis.
It is the Policy of the Hospital that trainees who accept such requests do so at their
own peril and that they need to sign a waiver from this office. The Hospital
assumes no responsibility or liability for any event that may result from this action.
Indeed, the consultant staff member who requests this “favor” from our trainees
assumes all responsibility and liabilities in the course of the Trainees
accommodating his request. THEREFORE, THE TRAINEE MUST PRESENT
SUCH A REQUEST IN WRITING DULY SIGNED BY THE TRAINEE AND
REQUESTING PHYSICIAN AND SUBMIT THIS TO DEPARTMENT OF
MEDICAL EDUCATION AND RESEARCH. IT SHOULD INCLUDE THE NAME
OF THE PATIENT, DESTINATION AND MODE OF TRAVEL. Failure to do so
would constitute a violation of the Rules Governing the Conduct of Trainees such
as being. Furthermore, the time spent by the trainee will be credited to his/her
leave of absence.
17.13As a general rule, all trainees with the consultant in charge are required to talk to
the patient and/or the responsible relative(s) before and after any procedure to be
done especially if the procedure is an invasive procedure. In many cases, the
consultant may not be present; in such cases, the trainees should proceed with life
saving procedures as long as they are adequately trained and under the
supervision of a senior but the trainee(s) is/are REQUIRED to update the
consultant. Trainees are required to apprise the patient and/or the
responsible relative/companion of the nature of the procedure, the benefits
and the risks of the procedure, and the possible complications of the
procedure. This must be documented in the chart by filling out the proper
informed consent form and letting the patient and/or responsible
relative/companion sign the form stating that complete explanation was
performed.
18 The UST Hospital Emergency Room Service

18.1 All trainees rotate in the emergency rooms in both the private and clinical divisions
of the hospital. The schedule of emergency room rotation for the year for interns,
residents and fellows must be submitted by the Department and/or section to
Department of Medical Education and Research not later than one (1) month prior
to the next incoming year.
18.2 If the concerned Departments or Sections fail to submit their roster or list of
trainees for emergency room duty, Department of Medical Education and

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Research reserves the right to assign any trainee to be on duty in the emergency
room.
18.3 All trainees rotating in the emergency room are directly under Department of
Medical Education and Research and the Medical Director. All trainees still report
to their respective Departments/Sections for patient triage, care and management
following the guidelines set below (see below). For administrative problems and
especially for possible medico-legal conditions, trainees are directed to
inform, consult, and coordinate immediately with the Department Chair or
Training Officer, Chairman ofDepartment of Medical Education and
Research and the Medical Director.
18.4 Emergency Cases:
18.4.1 All trainees are required to follow the rules and guidelines of the USTH
Emergency Room Service for emergency care services (See The USTH
Emergency Room Service (EMS) manual for more details).
18.4.2 All Trainees shall attend promptly to all emergency cases and referrals.
18.4.3 All Trainees are required to render assistance during emergencies when
requested, regardless of whether or not the case belongs to his/her service.
18.4.4 All Trainees must have an adequate working knowledge of emergency
procedures regardless of their specialty. ALL TRAINEES NEED TO BE
CERTIFIED OR RECERTIFIED IN BLS AND ACLS OR PALS BEFORE THEY
CAN BE CONSIDERED FOR PROMOTION TO THE NEXT LEVEL OR FOR
GRADUATION (See Pre-Requisites for All Trainees).
18.5 Non-Emergency Cases (See The USTH Emergency Room Service (EMS)
manual for more details).
18.5.1 All Trainees called to attend to a patient shall do so promptly. Fellows shall
likewise see all admissions that pertain to their specialty training. He/She shall
note the date and time the call was received. He/She shall write his findings, the
date and time they were noted and the measures taken in the Staff Progress
Notes sheet of the chart. At the Pay and Clinical Division, he/she shall give only
the orders necessary for initial attention and notify the Attending Physician. A
notation of whether or not the Attending Physician was contacted should also be
made. He/She shall continue giving the Attending Physician updates on the
patient’s condition and the progress made with regards to the diagnosis and
treatment. He/She may give additional orders if the Attending Physician is not
available. The intern, resident and fellow shall communicate and discuss among
themselves and with the appropriate attending physician all aspects of the
patient’s care, especially in the diagnostic work-up and the giving of therapy. .
He/She shall continue giving the Attending Physician updates on the patient’s
condition and the progress made with regards to the diagnosis and treatment.
18.5.2 All communication, agreements, diagnostic and therapeutic plans, and recent
clinical findings SHALL BE WRITTEN IN THE STAFF PROGRESS NOTES
SHEET (NOT IN THE PHYSICIAN’S ORDERS SHEET). ALL PHYSICIAN’S

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ORDERS SHALL BE WRITTEN IN THE PHYSICIAN’S ORDERS SHEET (POS).

THE NURSES WILL FOLLOW ONLY ORDERS IN THE POS.
18.5.3 If the patient seeking admission does not have an Attending Physician, the
patient shall be admitted under the care of the “Consultant of the Month”, who
shall be notified immediately of the patient’s admission, by the appropriate ROD.
An updated list of the “Consultants of the Month” shall be available in the
Emergency Rooms. If the consultant of the month is not available, then the
patient shall be admitted under the care of the preceding or next consultant of the
month, whoever is available and so forth. Channeling of patients is strictly
prohibited. If the patient requests for a physician based on personal preferences
other than the one on-deck, it shall be written on the Admitting Form as requested
and signed by the patient. (See Glossary)
18.5.4 Orders must be personally written in the Physician’s Order Sheet by the resident
attending to the patient. When writing order(s), All Trainees should indicate the
date and time the order was made. The Trainee must sign the corresponding
order(s) and his/her name should be printed legibly below the signature. No
Trainee may order any medication or procedure for the patient through the
telephone, SMS, phone-text.
18.5.5 Trainees are NOT ALLOWED TO INSERT NEW ORDERS IN BETWEEN
ORDERS THAT HAVE ALREADY BEEN WRITTEN IN THE PHYSICIAN’S
ORDERS SHEET AND CARRIED OUT BY THE NURSING STAFF. New orders
shall be written below the latest order that has been carried out duly signed, by
the trainee(s) with the corresponding time and date. ALL NEW ORDERS MUST
BE ENDORSED TO THE NURSING STAFF (NOTIFY THE NURSE ON DUTY
FOR ANY NEW ORDERS THAT HAVE BEEN WRITTEN).
18.5.6 Trainees shall not deface the POS by erasing any order thru the use of “white-out
materials” or by “blackening”, or by totally erasing any previous order. ANY
ERROR IN WRITING IN THE PHYSICIAN’S ORDERS SHEET SHALL BE
CORRECTED BY SIMPLY WRITING A SINGLE LINE ACROSS THE
WRITTEN ERROR. The Trainee(s) shall alert the nursing staff or the nurse on
duty of the error and endorse the correct orders. Correct orders are written
immediately below the error that has been struck-out.
18.5.7 All Trainees shall ensure that all doctor’s orders are carried out. In cases when
there is a delay or the order was not carried out, the reasons for these should be
written in the Staff Progress Notes sheet of the patient’s chart.
18.5.8 The Fellow or Resident shall personally make all requests for laboratory and
ancillary procedures necessary for the diagnosis and treatment of the patient’s
condition. He/She may delegate this responsibility to the Medical Intern or the
Medical Clerk under his/her direct supervision.
18.5.9 The Trainees in charge of a ward shall see all patients admitted under his/her
care at least once daily and make rounds with the Attending Physician. In
addition, he/she shall visit patients who are in critical condition as often as the

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situation demands. He/She shall make rounds with the Medical Clerks at least
once daily.
18.5.10 Residents or Fellows shall perform venipuncture on ALL pediatric cases and on
adult patients anticipated to have problems with venipuncture (See Below).
It is the policy of the Hospital that only licensed trainees can perform arterial punctures and these
are Residents and Fellows. Interns may be given this opportunity only under the strict supervision
of a licensed trainee (resident and/or fellow). Trainees cannot delegate this procedure to the
medical technologist of our laboratories. As such, all trainees must be cognizant of the
requirements by the Laboratories for certain arterial punctures i.e. type of collecting tube,
heparinized or not, etc. Knowing the exact requirements beforehand should prevent the spoiling of
the blood sample.
The med tech phlebotomist of our laboratory, residents and fellows may perform venipunctures.
Interns may do so but it must be under the direct supervision of a resident and/or fellow. Again, to
prevent spoiling of blood specimens, all trainees must be cognizant of the requirements of
Laboratory for particular blood sample to be drawn i.e. storage tube, red top, EDTA needed, etc.
19 Medico-Legal Policy Statement and Procedures

19.1 All Trainees must know the guidelines that cover Medico - Legal cases. The
Resident and/or Fellow in charge of a case known or suspected to be of medico-
legal nature shall notify the Attending Consultant and Medico-Legal Officer during
or after attendance to the medico-legal case and following the prescribed
procedures and filling out the appropriate forms (See below).
19.2 No trainee is allowed to accept any subpoena on his/her own volition. It is the
policy of the hospital that all legal issues and communications be delivered and
accepted only by the persons in the Medico-legal Department. In cases where a
subpoena is issued, all trainees should direct the legal officers to the Medico-legal
Department. In cases where the medico-legal team is not available, these legal
matters should be directed and accepted by the Office of the Medical Director.
19.3 In all instances of legal communication, forensic cases, or legal issues which
concerns or involves trainees, the office of DMER, Medico-legal Department and
the Office of the Medical Director should be informed in writing.
POLICY STATEMENT ON MEDICO - LEGAL CASES:

Patients, who are seen at the University of Santo Tomas Hospital who fall under “Forensic Cases”, will
be provided with the best health care available in the hospital under an Attending Physician (AMD) who
is responsible for the delivery of treatment including referrals, completion of records and
documentation. Likewise, the AMD acts as the expert witness if the patient will file a complaint against
the alleged perpetuator of the crime.
The latter function of the AMD may be delegated to a medico-legal practitioner, only if the AMD so
desires. Since this is a delegated duty, it is incumbent upon the AMD to decide if the services of a
Medico-legal practitioner are needed. Likewise, since the Medico-legal practitioner will represent the
AMD, the AMD has the right to choose the Medico-legal practitioner who will represent him.
1. GENERAL GUIDELINES

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1.A. Documentation of all pertinent data should be done by the ER physician/service resident
on duty using pertinent forms available.
1.B. An attending physician will be assigned for the purpose of follow-up if applicable.
1.C. If the patient needs a medical certificate, he may be referred to the Medico-legal
consultant of the day upon approval of the attending physician.
1.D. If a forensic report will be issued by the medico-legal consultant, a professional fee will
be separately charged appropriate for the service rendered.
1.E. For the clinical division, the patient will be automatically referred to the medico-legal
consultant of the day. Forensic reports are only issued per patient’s request and only
then can professional fees be collected.
2. FOR IN-PATIENTS
2.A. The AMD should be informed immediately about the admission and a clarification are
made if a medico-legal practitioner is required. If so, who?
2.B. The name of the medico-legal practitioner must appear on the patient’s chart as one of
the attending physicians.
3. PATIENTS CONSIDERED AS FORENSIC CASES
3.A. Unidentified victims.
3.B. Persons pronounced as dead on arrival (DOA).
3.C. Deaths under the following circumstances:
3.C.1. Deaths occurring less than 24 hours from admission when the clinical cause of
death could not be determined.
3.C.2. Unexpected death especially when the deceased was in apparent good health.
3.C.3. Death as result of violence, accident, suicide, or poisoning.
3.C.4. Death due to natural disease but with associated physical injuries and/or
suspicion of foul play.
3.D. Cases of sexual assault, alcoholism and drug related incidents
3.E. Cases of physical injuries under the following circumstances:
3.E.1. Physical injuries brought about by physical violence (e.g. vehicular accident; stab
wounds; gunshot wounds, etc.).
3.E.2. Physical injury brought about by electrocution, chemical or thermal incidents.
3.E.3. All physical injuries caused by asphyxia.
3.E.4. Physical injuries due to accident, suicide and/or homicide.
19.3.1 All medico-legal cases must be communicated to the Department’s /Section’s

Training Officer and Chair, Department of Medical Education and Research and
the Office of the Medical Director as soon as possible.
20 Charts and Record Keeping

20.1 This section pertains to charts or patient’s records in the pay division, clinical
division and in the Out Patient Department (OPD)

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20.2 The responsibility of record keeping and completeness of the patient’s chart start
with the intern and ascends upwards to the attending consultant. Command
responsibility in this regard should be exercised.
20.3 In particular, The Resident-directly-in-charge of the patient has full responsibility
that all records including laboratories, progress notes, histories etc. are
accomplished and placed in the patient’s chart. The chart of the patient must be
properly completed when the patient is discharged and the completed chart must
be submitted to the Records Department within 72 hours after the patient’s
discharge. Residents with incomplete or unaccomplished charts face penalties
and sanctions according to hospital policy and rules (See below).
Resident trainees are directed to complete the charts as prescribed in our rules and
regulations. The following scheme will be followed:
The Medical Records Department shall provide Department of Medical Education
and Research monitoring reports of incomplete charts every quarter.
Inclusive Months Inventory report would be released on
January to March April 15

April to June July 15
July to September October 15
October to December January 15
The Medical Records Department will give the inventory report to this Office on or
before the specified schedule. If in case the date falls on a weekend, the report will
be given a day earlier.
All residents are required to have a zero balance especially before going on leave.
Non-compliance would mean that every 10 charts unaccomplished is equivalent to
a Sunday duty as well as stipend and Hospital Benefits would be withheld until such
charts are completed.
Upon completion of deficient charts, the trainee must fill-out a record of completion
form. The Form (Record of Completion) is provided and is available at Department
of Medical Education and Research.
This Record of Completion must be submitted to the DMER Office for appropriate
action (201 file and payroll).
20.4 The Residents shall ensure that the history of the patient admitted be
accomplished by the Intern, in the Private Division and by the Medical Clerk and/or
Intern at the Clinical Division within 24 hours of the patient’s admission. The policy
on patient DISCHARGE SUMMARY is as follows:
20.4.1 It is the duty of the Attending Physician/Fellows/Residents to prescribed
discharge medications. In case of multidisciplinary problems, each specific
section/discipline should prescribe their own discharge medications which must
be written in the Physician’s Order Sheet (POS). The Attending
Physician/Fellows/Residents are the ones to personally write the discharge
prescriptions and to explain them to patients.

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20.4.2 The responsible intern documents the Discharge Summary. This is read and
corrected by the discharging resident physician at the time of the patient’s
discharge. Note that the responsible intern refers to the intern who at the time of
discharge is on duty regardless of he/she has just started rotating in the
department/section.
20.4.3 Documentation is due on the day of a planned discharge, and within 24 hours
following an unplanned discharge.
20.5 The Resident has the responsibility to complete the PhilHealth form and the
Discharge summary sheet with the correct diagnosis of patients in the Pay
Division. The diagnosis written by the Resident in the PhilHealth form and
discharge summary sheet must be cleared and verified by the attending
consultant. The senior residents of each Department have the duty to oversee the
junior residents in this task and to make sure that these forms are properly
completed (See below).
A. Discharge Summary Sheets
The PhilHealth requires this form for patients to avail of PhilHealth reimbursements.
The records section and patients have a hard time accomplishing this requirement if
the discharge summary sheets are not complete. To facilitate claims and to
complete records, it will now be the policy of this office to require Residents to fill out
the discharge summary sheets. Furthermore, it will be the duty of the Senior
Residents of each Department to make sure that these discharge summary sheets
are accomplished when the patient is discharged. The exact mechanism will be left
to the Department as to how best to do this. This duty is for BOTH CLINICAL and
PRIVATE DIVISION. However, it is the Duty of each consultant to sign the forms.
PhilHealth does not recognize signatures for “other consultants i.e. per signing”. If
the consultant disagrees with what is written, he/she should make his/her own in a
new form and incorporate it in the chart. To avoid duplication and waste of time, it is
suggested that residents and consultants work together from the beginning to
create the summary sheet.
B. PhilHealth Forms
Many patients currently are requesting their attending physicians to fill out
PhilHealth claim forms. Also, many of our medical staff are not reimbursed by
PhilHealth for services rendered. The main reason why this happens is that the
PhilHealth forms are not promptly and properly filled out. Many forms are filled out
with non-PhilHealth accredited diagnosis (ICD-10) and there appears to be some
confusion on how to place the amount in the PhilHealth claim form. To address this
particular concern, Department of Medical Education and Research requires that
Senior Residents fill out this PhilHealth claim form in terms of diagnosis. This
should ensure that the diagnosis will be ICD-10 compatible. The amount is left to
the attending to fill out properly. The Residents should therefore ask all patients to
produce the PhilHealth claim form as soon as possible. This way, our Senior
Residents are also trained on how to manage this particular paper work which they
will need to do once they graduate and start to practice.
20.6 Physician’s Order Sheet
20.6.1.1 When the Resident/Fellow makes a direct order without the knowledge of the AMD there is
no need to write the phrase “for Dr. _____ (name of AMD) in the POS. It is the duty of the
Resident/ Fellow ordering n the POS to inform the AMD ASAP of his actions to be noted in
the progress notes.

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20.6.1.2 When an order is placed in the presence of the AMD, the AMD must sign the
order immediately after it has been made.
20.7 All Trainees are required to update records on admissions, discharges of patients
under his care as well as to keep records of referrals to the service he is rotating in,
in files, logbooks or any form as may be adopted by the Department.
20.8 The Resident and Fellow assisting at operations must ensure that forms pertinent
to the operation are properly filled out immediately after surgery especially the
surgical technique(s) form and incorporate these forms in the patient’s chart. If no
resident or fellow has been called to assist, the surgeon who performed the
operation shall complete the Operating Rooms forms immediately after surgery
especially the surgical technique(s) form and incorporate these forms in the
patient’s chart.
20.9 All Trainees must ensure that all charts and forms of patients under his/her care
are complete prior to discharge of the patient. These shall include the final
diagnosis, discharge summary and the signature of the Attending Physician. The
discharge summary sheet may be filled out by the intern in charge of the patient in
terms of history and course in the ward. However, the final diagnosis, medications,
special instructions are the sole responsibility of the Resident in charge of the
patient. The Resident must review, correct and make sure that the discharge
summary sheet is in order and confirmed and signed by the attending physician
20.10The Resident and Fellow shall make sure that the completed charts are submitted
to the Medical Records Section of the Hospital within seventy-two hours after
discharge.
20.11The completeness, safety and credibility of patient’s charts/records at the out-
patient department are also the concern of all trainees and attending consultants
and should be treated with the same concern and vigor as charts of admitted
patients. Of note, the following (see below) are recurring violations that must
be recognized and avoided.
20.11.1 Trainees failure to correctly note down the patients registration ID number
20.11.2 Trainees failure to clearly print out their names and legibly sign on top of their
printed names after each patient visit
20.11.3 Failure of trainees to place the date and time that a patient consulted
20.11.4 Failure of trainees to indicate the disposition and diagnosis of the patient after
each visit
20.11.5 Failure of trainees to properly fill out the daily master list at the OPD and not
signing the daily master list
20.11.6 PhilHealth acknowledges the use of TRODATs in the POS. Trainees must
make sure that the Front and Back Page of the POS is stamped before affixing
their signatures.

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20.12In the chart, each order of consultants should have a double line to signify that it
has been carried by the nurses.
20.13Trainees and consultants cannot write after the double line of an order. They must
give a new order below previous written orders.
20.14All borrowed charts (i.e., the original chart, not the photocopy) must be returned to
the Medical Records Department within the time specified by the Medical Records
Department.
20.15 Lost chart should be reconstructed by the responsible Resident within 15 days.
21 Key Person Responsible for Chart Completion

21.1 Clinical Division: Final Diagnosis and Signature is the responsibility of the
Attending Medical Doctor; Rest of the Chart (i.e. progress notes, discharge orders,
operative report. etc.) are the responsibilities of Residents and Fellows in-charge
21.2 Private Division: Final Diagnosis and Signature is the responsibility of the
Attending Medical Doctor; Rest of the Chart (i.e. progress notes, discharge orders,
operative report. etc.) are the responsibilities of Residents and Fellows in-charge
21.3 HMO Patients: Final Diagnosis and Signature is the responsibility of the HMO
Coordinator; Rest of the Chart (i.e. progress notes, discharge orders, operative
report. etc.) are the responsibilities of Residents and Fellows in-charge
22 Use of Patient’s Records in Conferences

22.1 The following procedure on borrowing charts (see below) by trainees applies only
for the purposes of mortality/morbidity, grand-rounds, audits and Clinico-
Pathologic-Radiologic Conferences
22.1.1 A trainee is allowed to borrow the patient’s record(s) three (3) days before the
scheduled activity from the Medical Records Department.
22.1.2 All borrowed charts or patient’s records must be returned on or before 4:00 pm on
the day of the said activity
22.1.3 When charts are to be taken out of the records department for any of the above
mentioned activities, an accompanying letter of request must be submitted to the
records department. This letter should include (1) the purpose (e.g. audit, etc.),
(2) Date of event/activity and (3) Name(s) of patient(s) records that are to be
borrowed. The CHAIRMAN OR TRAINING OFFICER OF THE DEPARTMENT
MUST SIGN THIS LETTER OF REQUEST
22.1.4 The Chairman or Training Officer of the Department together with the Trainee
becomes responsible and accountable for the borrowed patient’s chart/records
23 Attendance and Leave of Absence

23.1 An intern must have attended and be physically present in 80% of the days
required in his/her rotation otherwise, the intern is considered as having insufficient

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attendance and not having satisfactorily completed his/her training rotation in that
Department (example: Rotation of 2 weeks or 14 days in a Department; Only 20%
absences allowed. Therefore 20% of 14 is about 3 days absence allowed. The
trainee must have attended 11 days to be considered as having rotated thru that
Department). An absence of more than the days allowed as stipulated prevents
the intern from graduating unless he/she makes up for his/her deficiencies and this
may require repeat service rotation. All make-ups are to be accomplished at the
end of the training year. The certificate of Completion of Internship will only be
given when the intern has successfully made up all his/her deficiencies. The intern
must secure clearance from all Departments that he/she has deficiencies and
present this clearance(s) to Department of Medical Education and Research to
obtain his/her certificate of Completion of Internship.
23.2 An intern that has been absent more than 20% of the days required for his/her
ENTIRE INTERNSHIP TRAINING YEAR is considered not to have finished
internship and cannot be awarded a certificate of completion unless he/she makes
up for his/her deficiencies. All repeat service rotations are to be done after the end
of the training year. The certificate of Completion of Internship will only be given
when the intern has successfully made up all his/her deficiencies that may require
repeat service rotation. The intern must secure clearance from all Departments
that he/she has made up for all his/her deficiencies and present this clearance(s) to
Department of Medical Education and Research to obtain his/her certificate of
Completion of Internship.
23.3 Interns are not allowed any leave of absence unless specifically granted by
Department of Medical Education and Research for special reasons.
23.4 Residents and Fellows must be cognizant of the definitions applied to Attendance
and Leave(s) of absence (see below). He/she may also apply for leave of absence
in any of the categories listed:
23.5 All Resident and Fellow trainees are required to complete at least 10 months of
attendance of their yearly activities inclusive of all leaves and absences that they
may accrue before being considered for promotion/graduation otherwise, the
trainee is considered as having insufficient attendance and has not satisfactorily
completed his/her training. Such trainees may be asked by the Department to
leave the training program or to repeat the level he/she has not satisfactorily
completed. If the trainee wishes to repeat, he/she needs to reapply to the
Department and is subject to the normal procedure for application and acceptance
by the Department and Department of Medical Education and Research.
23.6 All Trainees are required to file an official leave of absence in Department of
Medical Education and Research at least one (1) week prior to the expected date
whenever the trainee plans to avail of any Leave privileges. Likewise, all trainees
need to file and fill out the necessary documents when he/she is to leave the
premises of the hospital during duty/office hours for any event, whether official or
unofficial (i.e. part of a rotation, attending a meeting outside, retreats, etc.).
23.7 Upon filling out the necessary forms and submitting them to Department of Medical
Education and Research, it is the trainee’s responsibility to find out if his/her

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request for the leave has been granted by Department of Medical Education and
Research. It is Department of Medical Education and Research that HAS THE
FINAL SAY whether a trainee’s request is granted or denied. Failure to comply
with this requirements constitute grounds for disciplinary action and the
trainee shall be considered, among others, as being out of Post.
23.8 All trainees applying for any type of leave of absence should get clearance from
the Medical Records Department at least two days prior to the scheduled leave of
absence. All trainees are expected to have a zero backlog or a maximum of five
(5) unfinished patient’s charts before going on leave.
23.9 Types of Leaves of Absences
23.9.1 Applications for any type of leave of absence will only be entertained if there is no
unfinished or unreturned patient’s charts. Clearance from the Medical Records
must be obtained.
23.9.2 Academic Leave: This Type Of Leave Is Optional And Must Be Applied For
and Endorsed by the Department Chairman and Training Officer.
Department of Medical Education and Research and the Office of the Medical
Director determines whether the trainee will be granted this type of leave. The
trainee must apply for this type of Leave thru the Department. The Department
must officially endorse this type of leave and submit their endorsement to
Department of Medical Education and Research for action. The endorsement
should contain all of the following: (a) reason(s) for the leave, (b) destination and
event(s) (i.e. international congress etc.) where the leave is to be used, (c) place
where trainee is to stay, (d) exact number of days required for the leave, (e)
expected financial outlay including travel and lodging expenses, (f) contact
persons and numbers while trainee is on leave. All Applications Should Be
Submitted At Least Three (3) Weeks Before The Expected Leave. NO
APPLICATION WILL BE PROCESSED IF THE ABOVE REQUIREMENTS ARE
NOT FULFILLED.
23.9.2.1 A total of two (2) calendar weeks a year is given as a privilege in recognition of academic
achievement(s) such as the honor of presenting a research paper in an international forum or
participating in a foreign meeting etc. Department of Medical Education and Research, taking
into account circumstances unique to the applicant and with the recommendation of the
Department, determines the amount or duration of the leave. The trainee is required to give a
written report to the Office of what he/she did during the leave and to “Echo” the salient / new
information to the concerned parties as determined by Department of Medical Education and
Research in an appropriate forum for CME purposes.
23.9.3 Paternity Leave: Composed of one (1) week leave after the wife’s delivery.
23.9.4 Maternity Leave: Composed of two (2) weeks leave before and two (2) weeks
leave after delivery.
23.9.5 Sick Leave: Composed of a total of two (2) calendar weeks for each year
23.9.6 Vacation Leave: Composed of two (2) calendar weeks for each year
23.9.7 Maximum duration of continuous days on leave shall be 30 consecutive days.
Violation of this rule is ground for repeating the year level unless such leave had

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the prior approval of Chairman of the Department and Department of Medical

Education and Research (DMER).
23.9.8 A Resident or Fellow can apply for vacation leave only after the third month of the
first year of training. Vacation leaves should be arranged with the Department
and approved by the Chairman of the Department and the Chairman of
Department of Medical Education and Research. [No vacation leave or
academic leave of absence on the last fifteen (15) days of December is
allowed].
23.9.9 A Resident or Fellow shall report for work on the day after his approved leave of
absence. Extensions of the leave of absence are not permitted unless a written
application has been made at least three days prior to termination of the leave of
absence, which has been approved by the Chairman of Department of Medical
Education and Research. Unauthorized extensions of the leave of absence
constitute grounds for disciplinary action, which may involve cancellation or
termination of residency or fellowship training or other measures as may be
imposed by Department of Medical Education and Research.
23.9.10 A graduating Resident or Fellow is not permitted to apply for or undertake a
leave of absence during the last month of his final year (Terminal Leave) without
endorsing to the incoming chief resident and being fully cleared by Department of
Medical Education and Research (See Glossary).
23.9.11 A trainee can only avail of his or her vacation leave on the scheduled date
agreed upon. Otherwise, leaves which are not taken during the year are forfeited.
23.9.12 A trainee may not be allowed to go on leave if the Hospital, Department or the
Section he or she is reporting to is in critical need of his or her services to respond
to patient care.
23.9.13 A Resident or Fellow who is absent from work shall inform his Chief Resident of
his absence and the reasons for such. A Resident or Fellow who incurs an
absence due to illness of should submit a medical certificate signed by an
Attending Physician at the UST Hospital to the Chairman of the Department or his
designate and to the Chairman of Department of Medical Education and
Research.
23.9.14 All Departments/Sections are required to have a logbook of attendances and
absences for each trainee to include attendance in conferences, meetings etc.
that the Department / Section requires. Documentation of tardiness and
absences for each trainee is mandatory. The trainee must sign in the logbook
and the logbook must be countersigned by the training officer and the
Department Chairman. Logbooks of attendances on conferences or outside
rotations are also required for all trainees in all departments/sections.
Department of Medical Education and Research reserves the right to examine
any or all logbooks of any or all trainees in any or all Departments at any time.

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24 Evaluation of Interns, Residents and Fellows in Training

24.1 Methods of Evaluation
24.1.1 The Trainees may be evaluated by any of the various methods that the
Department/Section wishes to adapt. Evaluation should be made at several
times during the year, preferably on a quarterly basis. Department of Medical
Education and Research REQUIRES THAT ALL TRAINEES MUST HAVE AT
LEAST TWO (2) EVALUATIONS – A MID-YEAR EVALUATION AND A YEAR-
END EVALUATION. No trainee can be promoted or graduated without these two
(2) evaluations. Evaluation forms must be submitted to Department of Medical
Education and Research before the trainee can be promoted or graduated. All
trainees must be made aware of the results of these evaluations using a standard
form that can be obtained from Department of Medical Education and Research.
24.1.2 Department of Medical Education and Research sends out general forms of
evaluation for all trainees. These forms must be filled out and submitted to the
office for the mid-year and year-end evaluations. Different Departments/Sections
however can add to this general form other evaluation parameters unique to their
training to come out with a better evaluation of the trainee. These methods of
evaluation may include but is not limited to the following:
24.1.2.1 Consultants’ evaluations of medical knowledge, skills, patient care, attitudes, record keeping and
academic excellence
24.1.2.2 Written examinations or in-house society examinations
24.1.2.3 Oral examinations or oral presentations
24.1.2.4 Practical examinations
24.1.2.5 Completed research work
24.1.2.6 Skills evaluation
24.1.2.7 Attitudes, behavior, tardiness, number of incident reports etc.
24.1.3 For purposes of classifying and tracking a trainees’ performance, the following
criteria below may be used by the Department or Section in categorizing the
trainee. This may be of help in choosing a leader or a chief resident/fellow or as a
basis for endorsing a trainee for the white coat award.
24.1.3.1 The Advanced Level (96-100%) reflects superior performance. Advanced work indicates an in
depth understanding of disease processes and their diagnostic and treatment options as well as
exemplary display of the skills needed for their specialty training.
24.1.3.2 The Proficient Level (86-95%) reflects satisfactory performance. Proficient work indicates a
solid understanding of disease processes and their diagnostic and treatment options as well as
adequate display of the skills needed for their specialty training
24.1.3.3 The Basic Level (75-85%) reflects marginal overall performance satisfying the minimum
requirements needed for the level of training. Basic work indicates partial understanding and
limited display of the skills expected of a trainee. This work approaches satisfactory performance
but has not been reached. There is need for additional instructional opportunities and/or
increased commitment to achieve the proficient level.
24.1.3.4 The Below Basic Level (below 75%) reflects inadequate overall performance. Below basic
work indicates little understanding and minimal display of the skills expected of a trainee. There is

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major need for additional instructional opportunities and/or increased commitment to achieve the
proficient level.
24.1.4 The methods of evaluation and the assigned values adopted by the Department
shall be communicated to Department of Medical Education and Research. ALL
TRAINEES ARE REQUIRED TO HAVE A MINIMUM WEIGHTED AVERAGE
OF 75% TO QUALIFY FOR PROMOTION OR GRADUATION. This weighted
average may change in time depending on the decisions arrived at during
meetings with the Hospital Postgraduate Training Committees and the Office of
the Medical Director.
24.1.5 The Trainees shall be given information about these evaluations at least every six
(6) months.
25 Research
25.1 Department of Medical Education and Research requires that all Residents and
Fellows to author or co-author and submit at least one (1) prospective research
project to the satisfaction of the Department or Section before they can graduate
from the training program.
25.2 Different Departments and sections have other research requirements that the
trainee must be aware of and must also fulfill as part of their training.
25.3 For trainees involved in clinical trials, it is understood that the trainee(s) listed below
will be working with the principal investigator in the study as trainee(s), and that
their participation in the study is considered part of their training. As such, they are
not entitled to receive any remuneration for their work, except as reimbursement
for travel and incidental expenses.
26 Outcomes of Training Programs

26.1 Outcomes of Internship Training
26.1.1 An Intern may graduate from the program if he/she has accomplished the
following requirements:
26.1.1.1 The Intern has satisfactorily completed the requirements set forth by the Association of Philippine
Medical Colleges Foundation Inc. (APMC) for internship training.
26.1.1.2 The intern has complied with the rules and regulations of the University of Santo Tomas Hospital.
26.1.1.3 The intern has rotated thru and has been given a passing grade by all required Departments.
26.1.1.4 The Intern has made up for all deficiencies that he/she may have accrued during the training
year.
26.1.2 After satisfactory completion of all the requisites enumerated, Department of
Medical Education and Research may recommend the intern for graduation from
the training program. Recommendations of Department of Medical Education
and Research are then forwarded to the Office of the Medical Director for final
disposition

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26.1.3 The final outcome desired for Interns is that they become eligible to take and
pass the Philippine Licensure Examinations.
26.2 Outcomes of Residency and Fellowship Training
26.2.1 A Resident or Fellow may be promoted to the next level of residency or fellowship
if he/she has accomplished the following requirements:
26.2.1.1 The Resident or Fellow has satisfactorily completed the Department’s requirements for training at
a particular level of residency or fellowship.
26.2.1.2 The resident or fellow has complied with the rules and regulations of the University of Santo
Tomas Hospital regarding residency or fellowship training.
26.2.1.3 The resident or fellow has made up for all deficiencies that he/she may have accrued during the
training year.
26.2.1.4 After satisfactory completion of the requisite number of years of residency or fellowship training, a
resident or fellow may be recommended for graduation from the training program.
26.3 The final outcome desired for Resident Trainees is that they become eligible to
take and pass their respective specialty board exams. The final outcome desired
for Fellow Trainees is that they become eligible to take and pass their respective
sub-specialty board exams.
27 Extension, Retention, Termination from Training

27.1 It is the policy of the hospital that trainees are either promoted to the next level or
extended for not more than 1 month (30 days) to complete deficiencies including
research paper submission. No trainee can be retained at the same level for
another year. Such trainees are automatically terminated from training because of
not completing all the requirements for that year level or because of unsatisfactory
performance.
27.2 A Resident or Fellow may be retained in the same level of residency or fellowship
training only for a maximum of one (1) month (30 days) without pay ONLY for
completion of research requirements. At the end of this period, a decision shall be
made for his promotion, graduation or termination from residency or fellowship
training.
27.3 Extensions for reasons other than completion of research papers must be served
after the trainee’s full training period. For a graduating trainee, extension for 30
days is given to serve the sanctions of his/her offenses that were accrued during
his/her training period. The sanctions must be completed in 30 days together with
the submission of the research paper for the trainee to be granted a certificate of
completion.
27.4 A Resident’s or Fellow’s training may be terminated if he/she has not complied with
the Department’s requirements for completion of residency or fellowship or has
committed a violation of sufficient magnitude as to warrant termination from the
residency or fellowship training program. Any resident or fellow who has accrued
more than one (1) month (30 days) extensions as disciplinary sanctions from
various offenses at any point in time of his or her training may be considered for
termination.

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27.5 For graduating Residents and Fellows, they are allowed 3 years to complete and
submit their research paper requirements before they can be cleared by the
hospital and be issued a certificate of completion. IF THE TRAINEE DOES NOT
SUBMIT THE REQUIRED RESEARCH OUTPUT AFTER 3 YEARS, THE
TRAINEE’S PREVIOUS TRAINING PERIOD IS CONSIDERED NULL AND VOID
AND THEREFORE MUST REAPPLY TO REPEAT HIS ENTIRE TRAINING
PERIOD TO GET ANY CERTIFICATE OF COMPLETION.
27.6 The Residency and Fellowship Training Committee of each Department, with the
approval of the Chairman, determines whether a trainee may be promoted or
terminated using their respective criteria.
27.7 The Department’s Residency or Fellowship Training Committee shall submit all
recommendations regarding favorable or unfavorable evaluations including
promotions, extensions and terminations to Department of Medical Education and
Research for further deliberation. Recommendations of Department of Medical
Education and Research are then forwarded to the Office of the Medical Director
no later than the 15th of December of each year for final disposition.
28 Clearance for Promotion or Graduation and Issuance of

Certificates
28.1 Department of Medical Education and Research must clear all trainees before they
can be promoted or graduate. Issuance of any certificate of completion of training
will only be done after clearance by the Office and must come from Department of
Medical Education and Research. DEPARTMENTS OR SECTIONS ARE NOT
AUTHORIZED TO ISSUE ANY TYPE OF CERTIFICATE OF COMPLETION OF
TRAINING IN THE HOSPITAL.
28.2 In particular, the Residents or Fellows must get clearances from Department of
Medical Education and Research, the Medical Records Department and the
Department of Radiological Sciences as well as other Departments before they
can be issued any type of certificate of completion or graduation from a training
program.
29 Most Outstanding Trainee (“White Coat Award”)

29.1 The “White Coat Award” for excellence shall be presented to individual(s), who in
the judgment of a Panel of Judges have demonstrated exemplary service and
performance in academics, unblemished behavior befitting that and honoring the
medical profession, as well as in service to patients, hospital and the community.
29.2 Eligibility for the award – any UST Hospital House Staff trainee who fits the
following definition (see below) is eligible for the award:
29.2.1 Currently a graduating intern, resident and/or fellow-in-training
29.2.2 No violation of any rules and regulations of the hospital
29.3 Award winners receive

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29.3.1 Cash award

29.3.2 Recognition on stage during graduation
29.3.3 For interns – assured Residency slot in USTH of his or her choice
29.3.4 For residents – assured Fellowship slot in USTH of his or her chosen field
29.4 Nomination Requirements/Information
29.4.1 Department of Medical Education and Research shall put out a call for
nominations. Each Department / Section is allowed one (1) nomination for
Interns category, Residents category, Fellows Category
29.4.2 The nomination is submitted using the appropriate form provided by Department
of Medical Education and Research and must include all pertinent documents
and proofs plus a nomination letter from the Department’s / Section’s Training
Committee along with the nominee’s curriculum vitae with recent ID picture not
more than 6 months old (Documentation needed i.e., Department chair / TO
attesting to the fact in writing; certificates; official scores of exam(s); proof of
publication or presentation of a scientific output, etc.).
29.4.3 All nominations are submitted to Department of Medical Education and Research
for evaluation by a panel of judges created by the Chairman of Department of
29.4.4 The panel of judges recommends one candidate to the Chairman of Department
of Medical Education and Research for review who then submits their
recommendation to the Medical Director for approval
29.4.5 The panel of judges shall be composed of 3-5 members of the Postgraduate
Training Committee appointed by the Chairman of Department of Medical
Education and Research. One to two allied staff members of the hospital (e.g.
Nurses etc) may be asked by the Chairman of Department of Medical Education
and Research to be part of the Steering Committee
29.4.6 The CRITERIA for judging white coat nominees are created by Department of
Medical Education and Research but the panel of judges may modify these as
they see fit to best judge the candidates
30 Anonymous Complaints or Letters

30.1 As policy, Department of Medical Education and Research does not recognize any
allegations written anonymously against anybody.
30.2 If a person has any complaint against any trainee or consultant which they wish to
tell in private, they may set an appointment with the Chairman of Department of
Medical Education and Research or any of its coordinators for interns, residents,
fellows or external affairs at any time. This may be done directly or thru the
secretary

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30.3 All meetings or complaints of this nature are considered PRIVATE AND WILL BE
HELD IN STRICT CONFIDENTIALITY. APPROPRIATE ACTION(S) WILL
DEPEND ON THE MERITS OF THE CASE / COMPLAINT.
31 Violations and Grounds for Disciplinary Action

31.1 The following actions/lack of action in the list below (See Table) constitutes
violations of rules and regulations governing the conduct of resident and fellowship
trainees at the University of Santo Tomas Hospital. The list cannot be complete as
rules and regulations together with their violations and sanctions are continuously
being reviewed and revised to meet the ever-changing needs of our times. In
general, trainees are expected to conduct themselves in a professional manner,
with utmost decorum and to follow the norms of a conduct of a professional. Any
deviation from these norms of professionalism cannot be tolerated and is
construed broadly as conduct unbecoming of a professional.
31.2 All acts/lack of action, which constitute violations of these rules and regulations
shall be properly documented. A report of the incident shall be submitted to the
Chairperson of the Department for investigation and appropriate action. It will be
kept in the permanent file of the resident in the Department. It shall contain the
following information.
31.2.1 Date and time of the incident
31.2.2 Place of incident, if applicable
31.2.3 A written narrative of the incident from the involved trainees with dates and
signatures
31.2.4 Complainant’s name and signature
31.2.5 A notation by the Residency Training Officer of the Department
31.2.6 A notation by the Chairperson of the Department
31.3 Department of Medical Education and Research can initiate an investigation on
any complaint or incident that it receives or when it deems it necessary.
31.4 The appropriate Department shall do the complete investigation of the incident
report or complaint against a trainee. The Residency or Fellowship Training
Committee of the Department is usually tasked to perform this duty. However, the
Chair of the Department has the prerogative to create an ad hoc committee to
investigate such incidents or complaints. The investigative process includes but is
not limited to the following:
31.4.1 The investigative arm shall notify all the accused trainee(s) and should obtain a
written and signed narrative of all those directly or indirectly involved in said
incident or complaint – Form available at Department of Medical Education and
Research (CCVRF-1). The discretion is given to the investigating arm whether to
involve peripheral personalities or issues.
31.4.2 The investigative arm shall determine whether there is enough evidence or a
“prima-facie” case to warrant a formal investigation. If the investigative arm

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determines that there is enough evidence or a “prima-facie” case to warrant a

formal investigation, it shall notify the trainee(s) concerned about the complaint(s)
and the investigation – Form available at Department of Medical Education and
Research (CCVRF-2). This shall constitute the beginnings of due process.
31.4.3 The investigative arm should summon witnesses to ascertain the facts
surrounding the incident or to verify facts about the case. This may entail
interviewing patients, consultants, nurses, trainees, or other hospital personnel.
All interviews that the investigative arm deem necessary should be documented;
all those interviewed should also be asked to submit their written and signed
narrative of the incident.
31.4.4 The investigative arm should look into aggravating or mitigating factors and other
such factors that led to the incident or complaint.
31.4.5 The investigative arm forms its conclusions of the case and creates its’ written
recommendations including recommendations concerning severity of sanction,
improvements in system so that such incidents are not repeated etc. – Form
available at Department of Medical Education and Research (CCVRF-3).
31.4.6 The investigating arm submits its written recommendations to the Chair of the
Department together with ALL PERTINENT DOCUMENTS.
31.4.7 The Chair approves the recommendations or consults the investigating arm to
form the final resolution of the case.
31.4.8 The investigating arm, together with the training officer and the Chair of the
Department shall inform the erring trainee(s) of its findings, conclusions and
recommendations in writing.
31.5 The erring trainee(s) shall be informed of the conclusion(s) and decision(s) of the
Department’s investigation; the violation(s) that were incurred and the sanction(s)
imposed. If the trainee agrees with the decision, he/she signs his/her acceptance
in the investigation report (Form available at the Office of DEPARTMENT OF
MEDICAL EDUCATION AND RESEARCH – CCVRF-3). The Department sends a
copy of its resolution to Department of Medical Education and Research. It is the
duty of the Department to implement the sanctions that it deems fit.
Department of Medical Education and Research requires all Departments to
submit a written report about the offense and whether the sanction has been
implemented to the satisfaction of the Department signed by the Chair and
Training Office (Form available at DEPARTMENT OF MEDICAL EDUCATION
AND RESEARCH – CCVRF-4).
31.6 If the trainee disagrees with the Department’s decision(s), he/she has the right to
appeal the case to Department of Medical Education and Research for arbitration.
31.7 The Chairperson of the Department has the option to elevate the matter to
Department of Medical Education and Research if the course of disciplinary action
remains unclear. Department of Medical Education and Research shall then
investigate and resolve such issues. However, if sanctions are required, the
Department shall implement the recommended sanctions and shall inform
Department of Medical Education and Research when the sanction has been

PAGE 52 OF 69
satisfactorily completed (Form available at DEPARTMENT OF MEDICAL

EDUCATION AND RESEARCH – CCVRF-4 AND ccvrf-5).
32 Appeals and Automatic Reviews of Investigations

32.1 Appeals for review of investigations made at the Departmental level shall be
elevated by the concerned party to Department of Medical Education and
Research submitting all the available documents surrounding the appeal. As such,
the Department involved should furnish Department of Medical Education and
Research a COMPLETE SET OF ALL DOCUMENTS PERTAINING TO THE
CASE UNDER APPEAL OR REVIEW. THIS SHOULD INCLUDE ALL
DEPOSITIONS, INTERVIEWS, WRITTEN NARRATIVES OF ALL WITNESSES
OR PERSONALITIES THAT THE DEPARTMENT INVESTIGATED OR USED TO
INVESTIGATE THE INCIDENT UNDER APPEAL TOGETHER WITH THE
CONCLUSIONS, RECOMMENDATIONS AND SANCTIONS GIVEN.
32.2 Department of Medical Education and Research generally makes its’
recommendations based on all submitted documents. The Office of DMER is not
tasked to redo the investigation nor is it obliged to interview witnesses or
personalities associated with the incident. The Office of DMER shall form its own
conclusions and recommendations based on the submitted documents by the
Department. However, this does not preclude the office from inviting personalities
involved to clarify certain issues, to shed more light on the incident or to do another
investigation.
32.3 Review for arbitration on issues of violations and sanctions imposed may be
elevated to Department of Medical Education and Research only on the following
grounds listed below otherwise, these matters are settled at the Departmental level
and all records are kept within the Department. Department of Medical Education
and Research should be furnished a copy of the resolution of the case on an erring
trainee for filing (Form available at DMER). Department of Medical Education
and Research intercedes when:
32.3.1 The accused trainee disagrees with the Department’s decision(s) and he/she
appeals the case to Department of Medical Education and Research for
arbitration.
32.3.2 When the sanction imposed by the Department is termination, the Department’s
recommendation is automatically and immediately elevated to Department of
Medical Education and Research for review. In such cases, the Department
automatically submits to the Office of DMER all pertinent documentation
concerning the case.
32.3.3 When the Chairperson of the Department elects to elevate the matter to the
Chairman of Department of Medical Education and Research, if after due
process and exhaustive investigation the course of disciplinary action still remains
unclear.
32.3.4 The accused trainee makes an appeal thru the following mechanism.

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32.3.4.1 The accused trainee writes a formal letter of appeal to Department of Medical Education and
Research. The formal letter should include his/her reasons or grounds for appeal.
32.3.4.2 The accused trainee(s) submits the formal letter of appeal to Department of Medical Education
and Research with an attached copy of the Department’s resolution of his/her case and the
sanction(s) being imposed.
32.3.4.3 The Department is informed of the appeal and all records of the case including all documentation
of the investigation are forwarded to the Office of the DMER.
32.3.5 The sanctions of the Department are held in abeyance and the accused trainee
continues his/her appropriate role in the Department pending the resolution of
his/her appeal.
32.3.6 All appeals must be submitted within the 15days upon receipt of the sanction,
otherwise will be considered effective.
32.4 After receipt of the Appeal or request for review, the Chairman of Department of
Medical Education and Research shall submit the matter to the other members of
Department of Medical Education and Research (Coordinator of Residency,
Coordinator of Fellowship, Coordinator of Internship and Coordinator for External
Affairs) for consideration and action. The members of the Office of the DMER may
elect to submit the appeal to the Hospital Fact Finding Committee (an ad hoc
committee created by the Chairman of the Office of DMER and composed of the
appropriate member of the Office of the DMER and 5 members of the Hospital
Postgraduate Training Committee) for final arbitration.
32.5 If the case warrants termination, the case is automatically submitted by the
Chairman of DMER either to the other members of Department of Medical
Education and Research (Chair of Residency, Chair of Fellowship, Chair of
Internship and Chair for External Affairs) or to the Hospital Fact Finding Committee
(an ad hoc committee created by the Chairman of the Office of DMER and
composed of the appropriate member of the Office of the DMER and 5 members of
the Hospital Postgraduate Training Committee) for final arbitration.
32.6 The written recommendations of the Committees involved are then submitted to
the Office of the Medical Director for final approval. The Office of the Medical
Director shall inform the Office of the DMER, the Chair of the Department involved,
and the trainee involved of the FINAL resolution of the case.
32.7 The Chairman and the Training Committee Members of the Department shall be
held responsible for all other grounds for disciplinary actions and the
implementation of the required sanctions. The Department shall furnish
Department of Medical Education and Research of all the investigation of the
incident for the trainee(s)’ 201 file.
32.8 If the sanction is extension, the extension period of a resident shall be
automatically carried over after graduation as an extension of his/her residency or
fellowship training unless his/her residency or fellowship training is otherwise
terminated by reason of other or additional causes (Note that extension is only for 1
month. Sanctions equivalent to more than 1 month extension automatically means
termination).

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33 Ethical Guidelines for Medical Practice

PAGE 55 OF 69
34 TABLE: Violations/ Grounds for Disciplinary Action
Violation First Offense Second Offense Third Offense
7. Pre-requisites for Admission as a Trainee
7.1 Failure to complete all required documents as

TERMINATION OF TRAINING
requisites for admission
7.2 Not signing of MOA TERMINATION OF TRAINING
7.4 No valid certificate for or Not passing the BLS, Non-promotion;
ACLS or PALS TERMINATION OF TRAINING
7.8 No Cash Bond (Foreigner) Reprimand Termination of Training
8. Call Rooms
8.1.2. Sleeping in call rooms when not on 24-hour Banned from using call room
Reprimand Extension for 7 days w/o pay
duty for 7 days
Banned from using call room Banned from using call room Banned from using call room for
8.1.5. Smoking, Littering, Or Drinking Alcoholic for 7 days + For Smoking or for 7 days + For Smoking or 30 days + For Smoking or
And Non-Alcoholic Beverages drinking alcohol = refer to drinking alcohol = refer to drinking alcohol = refer to
specific violation specific violation specific violation
Banned from using call room for
Banned from using call room
8.1.6. Non-hygienic use of call room Reprimand 7 days + Extension for 7 days
for 7 days
w/o pay
NOTE: A 4TH OFFENSE OF THE SAME NATURE (unless otherwise stipulated) = TERMINATION
NOTE: OFFENSES ARE CUMULATIVE especially if they fall in the same category; Trainees need only be warned once (documented), any
offense thereafter, even if the offense is different, warrants citation of a second offense with the corresponding sanction.

PAGE 56 OF 69

From Reprimand and Warning From 7 days extension without From 30 days extension without
8.1.7. Unprofessional conduct while inside the call
to Termination depending on pay to Termination depending pay to Termination depending on
room
the gravity of the offense on the gravity of the offense the gravity of the offense
9. Rules and Regulations-Generalities
9.2 Willful transgression of existing hospital rules

and regulations
9.5 Lewd and/or violent behavior towards patients,
colleagues and subordinates; Willful and blatant
disrespect of authority or to any person in
authority
Termination of training and
9.6 Theft and/or Intentional destruction of Hospital
return of property or payment of
property
an equivalent amount
Trainee is liable to pay an
9.6 Destruction of Hospital property due to
equivalent amount to be
carelessness and/or recklessness
determined by the Hospital
Extension for fifteen (15) days Extension for thirty (30) days
9.7 Insubordination Termination of training
without pay without pay

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10. Professional Code of Conduct
10.2 Engaging in private practice of Medicine Extension For Thirty (30) Days
within or outside of Hospital premises W/O Pay
10.3 Loss of license to practice Medicine in the

Republic of the Philippines
10.4. Smoking Tobacco Or Drinking Alcoholic Extension For Thirty (30) Days
Beverages W/O Pay
Extension For Thirty (30) Days
10.4 Gambling Within Hospital Premises TERMINATION OF TRAINING
W/O Pay
THIRTY (30) DAYS
10.5 Ingestion/smoking/use or unlawful
EXTENSION w/o PAY WITH
possession of prohibited drugs or enticing others TERMINATION OF TRAINING
COUNSELLING AND
to use prohibited drugs in the University
REHABILITATION
Unprofessional Conduct
10.6.1 Acts involving moral turpitude, dishonesty

or corruption in the profession whether such is a TERMINATION
crime or not
10.6.2 Misrepresentation or concealment of a
material fact in obtaining a license or in TERMINATION
reinstatement thereof
10.6.3 All advertising which is false, fraudulent, or
TERMINATION
misleading;

PAGE 58 OF 69

10.6.4 Incompetence, negligence, or malpractice
From Reprimand with warning
which results in injury to a patient or which create
up to Termination depending on TERMINATION
an unreasonable risk that a patient may be
the gravity of the offense
harmed
10.6.5 Suspension, revocation, or restriction of the
individual’s license to practice any health care
profession by competent authority in any state,
federal, or foreign jurisdiction, a certified copy of TERMINATION
the order, stipulation, or agreement being
conclusive evidence of the revocation,
suspension, or restriction;
10.6.6 The possession, use, prescription for use,
or distribution of controlled substances or legend
drugs in any way other than for legitimate or
therapeutic purposes; diversion of controlled TERMINATION
substances or legend drugs; the violation of any
drug law; or prescribing controlled substances for
oneself other than for purely medical purposes
10.6.7 Violation of any state or federal statute or
administrative rule regulating the profession in
question, including any statute or rule defining or TERMINATION
establishing standards of patient care or
professional conduct or practice;
10.6.8 Failure to cooperate with the disciplining
TERMINATION
authority (11.6.8.1 – 11.6.8.4):

PAGE 59 OF 69

10.6.9 Failure to comply with an order issued by
the disciplining authority or a stipulation for
15 days Extension without pay TERMINATION
informal disposition entered into with the
disciplining authority;
10.6.10 Aiding or abetting an unlicensed person to
TERMINATION
practice when a license is required;
10.6.11 Violations of rules established by any
health agency;
10.6.12 Practice beyond the scope of practice as
defined by law or rule;
11.6.13 Misrepresentation or fraud in any aspect
of the conduct of the business or profession
including forgery/falsification or misrepresentation
of documents;*
10.6.14 Failure to adequately supervise auxiliary
staff to the extent that the consumer’s health or Reprimand and Warning TERMINATION
safety is at risk;
10.6.15 Engaging in a profession involving contact
with the public while suffering from a contagious
Reprimand and Warning 30 days Extension without pay TERMINATION
or infectious disease involving serious risk to
public health;
10.6.16 Promotion for personal gain of any
unnecessary or inefficacious drug, device, TERMINATION
treatment, procedure, or service;
*Any portion of a patient’s chart, research papers, certificates, memorandum, MOA, contracts, etc.

PAGE 60 OF 69

10.6.17 Conviction of any gross misdemeanor or
felony relating to the practice of the person’s
profession. For the purposes of this subsection,
conviction includes all instances in which a plea of TERMINATION
guilty or “nolo contendere” is the basis for
conviction and all proceedings in which the
sentence has been deferred or suspended.
10.6.18 The procuring, or aiding or abetting in
TERMINATION
procuring, a criminal abortion;
10.6.19 The offering, undertaking, or agreeing to
cure or treat disease by a secret method,
procedure, treatment, or medicine, or the treating,
operating, or prescribing for any health condition TERMINATION
by a method, means, or procedure which the
licensee refuses to divulge upon demand of the
disciplining authority;
10.6.20 The willful betrayal of a practitioner-patient
TERMINATION
privilege as recognized by law;
10.6.21 Interference with an investigation or
disciplinary proceeding by willful
misrepresentation of facts before the disciplining
authority or its authorized representative, or by the
use of threats or harassment against any patient
or witness to prevent them from providing TERMINATION
evidence in a disciplinary proceeding or any other
legal action, or by the use of financial
inducements to any patient or witness to prevent
or attempt to prevent him or her from providing
evidence in a disciplinary proceeding;

PAGE 61 OF 69

10.6.22 Abuse of a client or patient, or sexual
TERMINATION
contact with a client or patient;
10.6.23 Acceptance of more than a nominal
gratuity, hospitality, or subsidy offered by a
representative or vendor of medical or health-
related products or services intended for patients,
in contemplation of a sale or for use in research
30 days extension without pay TERMINATION
publishable in professional journals, where a
conflict of interest is presented, as defined by
rules of the disciplining authority, in consultation
with the department, based on recognized
professional ethical standards.
10.7 Verbal abuse 7 days extension without pay 30 days extension without pay Termination of training
11. Intellectual Dishonesty
Maximum of 30 days extension

11. Any violation without pay with written apology Termination of training
depending on gravity
12. Uniform and Proper Attire
Extension For Seven (7) Days Extension For Fifteen (15) Days
12.1 – 12.2 Not wearing of prescribed uniform Reprimand
W/O Pay W/O Pay
12.2 Not wearing of ID card Reprimand
W/O Pay W/O Pay

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13. Sexual Harassment
Extension for fifteen (15) days

13 Sexual Harassment (violation of any provision) w/o pay or outright termination Termination
14. General Chain of Command
14.1 – 14.5 Violation of these provisions Reprimand
W/O Pay W/O Pay
16 Duties and Assignments
16.1. General Duties
Extension for seven (7) days Extension for thirty (30) days w/o
16.1.1 & 16.1.2 Habitual Tardiness (see glossary) Reprimand
without pay pay
EXTENSION FOR THIRTY
16.1.4 Out-of-post (see glossary) TERMINATION OF TRAINING
(30) DAYS W/O PAY
16.1.5. Non-observance of “Rounds, Endorse, Extension for seven (7) days Extension for thirty (30) days
Termination of training
and Leave Policy” without pay w/o pay
16.1.6 Non-observance or refusal to go on Extension for seven (7) days Extension for thirty (30) days
ambulance duty without pay w/o pay
Extension for three (3) days w/o Extension for fifteen (15) days
16.1.7 Unauthorized substitution of duties Reprimand
pay w/o pay

PAGE 63 OF 69

16.1.8. Refusal or failure to render reasonable
special duties as directed by Department of
Medical Education and Research or the Hospital
administration
16.1.9 Non-attendance or tardiness in
Reprimand 7 days extension without pay 15 days extension without pay
conferences, functions or meetings required
16.1.10 Preceptoree (see glossary) Termination of training
16.2 Chief Residents/Chief Fellow
16.2.3 Non-submission of 24 Hour duty roster,

Chief Resident becomes on-
ambulance duty, OPD duty roster for each month Reprimand
deck until roster is submitted
to concerned dept/unit
16.2.5 Non-submission of TR/ER duty roster for Chief Resident becomes on-
Reprimand
each month deck until roster is submitted
16.2.7 Disregard of Hospital manpower staffing
Reprimand 7 days extension without pay 15 days extension without pay
responsibility
16.2.8 Non-submission of year-end report No certificate of completion
16.3 Teaching Assignments
16.3.1-16.3.3 Violation of these provisions Reprimand
W/O Pay W/O Pay
Extension For Seven (30) Days

16.3.4- Violation of this provision Reprimand Termination
W/O Pay

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16.4 Assignments to Other Institutions and Outside Rotations
16.4.1 Unauthorized performance, rotation or duty Extension for seven (7) days
Reprimand Termination of training
in other hospitals, clinics not covered by MOA w/o pay
Extension for 7 days without Extension for 15 days without
16.4.4 Attendance (refer to General duties) Reprimand
pay pay
16.4.6 Non-submission of application for outside
affiliation (refer to out-of-post and/or AWOL)
16.5 Other Activities Outside of UST Hospital
Unauthorized participation in activities outside of

UST Hospital (17.5.1 – 17.5.2)
(refer to out-of-post and/or AWOL)
16.6 Negligence/dereliction of duties (see Extension for seven (7) days Extension for thirty (30) days
glossary) without pay w/o pay
17. General Medical Care
From reprimand to thirty (30)

17.2 Failure to notify/consult the AP of any
days extension w/o pay Termination
admission/orders concerning patient care
From reprimand to thirty (30)
17.6 Failure to give assistance during
days extension w/o pay Termination
emergencies

PAGE 65 OF 69

17.7 Failure to respond to a call within a EXTENSION FOR SEVEN (7) EXTENSION FOR THIRTY
reasonable span of time DAYS W/O PAY (30) DAYS W/O PAY
EXTENSION FOR SEVEN (7) EXTENSION FOR FIFTEEN
17.8 Failure to write staff/progress notes REPRIMAND
DAYS W/O PAY (15) DAYS W/O PAY
17.9 All communication, agreements, diagnostic
and therapeutic plans, and recent clinical findings
must be written in the staff progress notes sheet EXTENSION FOR SEVEN (7) EXTENSION FOR FIFTEEN
REPRIMAND
(not in the physician’s orders sheet). ALL DAYS W/O PAY (15) DAYS W/O PAY
PHYSICIAN’S ORDERS MUST BE WRITTEN IN
THE PHYSICIAN’S ORDERS SHEET (POS).
17.10 Inappropriate handling of
confidential/sensitive clinical information for EXTENSION FOR FIFTEEN EXTENSION FOR THIRTY
TERMINATION
patient’s privacy or the loss of vital information or (15) DAYS W/O PAY (30) DAYS W/O PAY
surgical or biopsy specimen(s)
17.11 Failure to give discharge instructions to EXTENSION FOR FIFTEEN EXTENSION FOR THIRTY (30)
REPRIMAND
patients (15) DAYS W/O PAY DAYS W/O PAY
17.12 Unauthorized travel outside of UST Hospital
EXTENSION FOR FIFTEEN EXTENSION FOR THIRTY
for patient management upon discharge (refer to TERMINATION
(15) DAYS W/O PAY (30) DAYS W/O PAY
out-of-post and/or AWOL)
17.13 Failure to talk to the patient and/or the
EXTENSION FOR FIFTEEN EXTENSION FOR THIRTY
responsible relative(s) before any procedures TERMINATION
(15) DAYS W/O PAY (30) DAYS W/O PAY
and/or no signing informed consent form
18. The UST Hospital Emergency Room Service

EXTENSION FOR SEVEN (7)
18.5.3 Channeling of patients REPRIMAND TERMINATION OF TRAINING
DAYS W/O PAY
18.5.7 Failure to carry out the orders of the EXTENSION FOR SEVEN (7) EXTENSION FOR THIRTY
Attending Physician DAYS W/O PAY (30) DAYS W/O PAY
18.5.8 Failure to write and sign requests for EXTENSION FOR SEVEN (7) EXTENSION FOR THIRTY (30)
REPRIMAND
ancillary procedures or laboratory examinations DAYS W/O PAY DAYS W/O PAY
NOTE: A 4TH OFFENSE OF THE SAME NATURE (unless otherwise stipulated) = TERMINATION. NOTE: OFFENSES ARE CUMULATIVE especially if they fall in the same category;
Trainees need only be warned once (documented), any offense thereafter, even if the offense is different, warrants citation of a second offense with the corresponding sanction.

PAGE 66 OF 69
19. Medico-Legal Policy Statement and Procedures
19. Failure to follow prescribed procedure for EXTENSION FOR SEVEN (7) EXTENSION FOR THIRTY
medico-legal cases DAYS W/O PAY (30) DAYS W/O PAY
20. Charts and Record Keeping
20.4-21.7 Failure to complete forms pertinent to EXTENSION FOR SEVEN (7) EXTENSION FOR FIFTEEN
REPRIMAND
an operation. DAYS W/O PAY (15) DAYS W/O PAY
EXTENSION FOR SEVEN (7) EXTENSION FOR FIFTEEN

REPRIMAND with application
DAYS W/O PAY with (15) DAYS W/O PAY with
20.8 Failure to complete chart of patient upon of sanctions stipulated in memo
application of sanctions application of sanctions
discharge. concerning Unaccomplished
stipulated in memo concerning stipulated in memo concerning
Charts
Unaccomplished Charts Unaccomplished Charts
EXTENSION FOR SEVEN (7) EXTENSION FOR FIFTEEN EXTENSION FOR FIFTEEN
20.14 Failure to return borrowed charts/imaging DAYS with application of (15) DAYS W/O PAY with (30) DAYS W/O PAY with
studies within the time specified by the sanctions stipulated in memo application of sanctions application of sanctions
Department concerning Unaccomplished stipulated in memo concerning stipulated in memo concerning
Charts Unaccomplished Charts Unaccomplished Charts
RECONSTRUCT CHART RECONSTRUCT CHART
RECONSTRUCT CHART
20.15 Lost chart/imaging studies EXTENSION FOR 15 DAYS EXTENSION FOR 30 DAYS
W/O PAY W/O PAY

PAGE 67 OF 69
23 Attendance and Leave of Absence
NON - ISSUANCE OF
CERTIFICATE OF
COMPLETION OF
23.9.10 Terminal leave (See Glossary 33.2)
RESIDENCY/FELLOWSHIP
TRAINING OR CERTIFICATE
OF GRADUATION
33.2 Absence without leave (AWOL)
(See Glossary)
EXTENSION FOR THIRTY
33.14 Unexcused absence REPRIMAND AND MAKE UP TERMINATION OF TRAINING
(30) DAYS W/O PAY
24. Bioethics

PAGE 68 OF 69
Glossary
34.1 AWOL or absent without leave – defined as a trainee being absent from duty for fifteen
continuous days without authorization
34.2 CHANNELING OF PATIENTS – defined as the willful and intentional diversion of
patients to physicians other than the Consultants of the month.
34.3 DERELICTION OF DUTY – defined as willfully or negligently failing to perform
assigned duties or performing them in a culpably inefficient manner.
34.4 HABITUAL TARDINESS – defined as being late for three (3) of seven (7) days or five
(5) of thirty (30) days.
34.5 INSUBORDINATION – defined as willful disobedience; a valid ground for termination
of trainees who would willfully refuse or disobey reasonable rules and regulations
approved and adopted by a Department/Section/Unit, and made known to those
whose compliance is required.
34.5.1 “Insubordination” is one of the just causes or valid grounds provided under Article
282 of the Labor Code for the termination of an employment. In the case of Gold City
Integrated Port Services, Inc. vs NLRC (G.R. No. 86000, Sept. 1990), the Supreme
Court held that for insubordination or willful disobedience to be a valid ground for
dismissal, the following must be present:
34.5.1.1 The employee’s conduct must have been willful or intentional, the willfulness being characterized by a
“wrongful and perverse attitude”, and
34.5.1.2 The order violated must have been reasonable, lawful, made known to the employee and must
pertain to the duties which he had been engaged to discharge.
34.5.1.3 By analogy, insubordination or willful disobedience of trainees applies to those who would willfully
refuse or disobey reasonable rules and regulations approved and adopted by a unit and made known
to those whose compliance is required.
34.6 INTELLECTUAL DISHONESTY – refers to forms of cheating and plagiarism which
result in trainees giving or receiving unauthorized assistance in an academic exercise
or receiving credit for work which is not their own. It includes fabrication, facilitating
academic dishonesty and plagiarism. See Text for comprehensive definition.
34.7 LEWD BEHAVIOR – defined as incidents such as indecent exposure, voyeurism,
indecent or unlawful sexual advances (to include immoral behavior definition but to
draw a line between personal/private affair and public concern)
34.8 NEGLIGENCE - The failure to exercise the care, prudence, or attention to duties which
the interests of the patient require to be exercised by a prudent and reasonable person
under the circumstances.
34.9 OUT-OF-POST – refers to being out of the area of responsibility without reason or
permission from the training officer, without proper endorsement to a co-resident/fellow
and without the knowledge of senior resident/fellow on-duty (ROD). A trainee leaving
his/her post must have permission AND known by the senior ROD/fellow AND must
properly endorse to a co-trainee.

PAGE 69 OF 69
34.10PLAGIARISM - defined as the representation of another person’s work, without the

acknowledgement of the source, as the trainee’s own for the purpose of satisfying
formal assessment requirements.
34.11PRECEPTOREE – defined as a trainee who is assigned only to one consultant,
attending to his patients admitted at the USTH and/or other hospitals or consulting at
his/her clinic for more than two (2) months in a year.
34.12TERMINAL LEAVE – defined as leave of absence in the last 15 days prior to
graduation/end of training.
34.13UNEXCUSED ABSENCE – defined as absence without just cause and without
informing the Chief Resident or Training Officer.
34.14VIOLENT BEHAVIOR – Defined as the willful infliction of physical injury towards
patients, colleagues, superiors, subordinates or other person


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PAGE 1 OF 69

Department of Medical Education and Research

1 The University of Santo Tomas Hospital .............................................................. 3

USTH HANDBOOK ON POSTGRADUATE TRAINING VER5, FORM1C

32 Appeals and Automatic Reviews of Investigations ............................................ 52

USTH HANDBOOK ON POSTGRADUATE TRAINING VER5, FORM1C

Department of Medical Education and Research

Rules and Regulations Governing the Conduct of Internship, Residency

1 The University of Santo Tomas Hospital

USTH HANDBOOK ON POSTGRADUATE TRAINING VER5, FORM1C

2 Department of Medical Education and Research

USTH HANDBOOK ON POSTGRADUATE TRAINING VER5, FORM1C

USTH HANDBOOK ON POSTGRADUATE TRAINING VER5, FORM1C

2.3.5.3.1.3 The Consultant Internship Supervisors of the different Departments

USTH HANDBOOK ON POSTGRADUATE TRAINING VER5, FORM1C

3 Definition of Hospital Trainees

USTH HANDBOOK ON POSTGRADUATE TRAINING VER5, FORM1C

4 Description of the Training Programs

USTH HANDBOOK ON POSTGRADUATE TRAINING VER5, FORM1C

USTH HANDBOOK ON POSTGRADUATE TRAINING VER5, FORM1C

5 Objectives of Training Programs

6 Standard Content of Training Manuals

USTH HANDBOOK ON POSTGRADUATE TRAINING VER5, FORM1C

6.2.3.1.4 General training goals of the Department/Section

USTH HANDBOOK ON POSTGRADUATE TRAINING VER5, FORM1C

6.2.9.2 Process for selection of topic, mentor and research methodology

7 Pre-requisites for Admission as a Trainee

USTH HANDBOOK ON POSTGRADUATE TRAINING VER5, FORM1C

requirements of Department of Medical Education and Research are considered dropped

USTH HANDBOOK ON POSTGRADUATE TRAINING VER5, FORM1C

9 Rules and Regulations-Generalities

USTH HANDBOOK ON POSTGRADUATE TRAINING VER5, FORM1C

10 Professional Code of Conduct

USTH HANDBOOK ON POSTGRADUATE TRAINING VER5, FORM1C

USTH HANDBOOK ON POSTGRADUATE TRAINING VER5, FORM1C

10.6.12 Practice beyond the scope of practice as defined by law or rule;

USTH HANDBOOK ON POSTGRADUATE TRAINING VER5, FORM1C

USTH HANDBOOK ON POSTGRADUATE TRAINING VER5, FORM1C

11.4.7 FALSE DECLARATIONS in order to receive special consideration by Examinations

12 Uniform and Proper Attire

OFFICIAL WHITE BLAZER FOR TRAINEES (JANUARY 1, 2006)

USTH HANDBOOK ON POSTGRADUATE TRAINING VER5, FORM1C

FOR ALL TRAINEES (Interns, Residents AND Fellows): NO SANDALS, SLIPPERS,

12.3 Identification Card

USTH HANDBOOK ON POSTGRADUATE TRAINING VER5, FORM1C

and permanent addresses. Communications mailed to either address of record

REPUBLIC ACT NO. 7877 (Anti Sexual Harassment Act of 1995)

USTH HANDBOOK ON POSTGRADUATE TRAINING VER5, FORM1C

SECTION 4: Duty of the Employer or Chairman of Office in a Work-related, Education or Trainings

13.2 The Department of Medical Education and Research is committed to maintaining

USTH HANDBOOK ON POSTGRADUATE TRAINING VER5, FORM1C

USTH HANDBOOK ON POSTGRADUATE TRAINING VER5, FORM1C

USTH HANDBOOK ON POSTGRADUATE TRAINING VER5, FORM1C

14 The General Chain of Command:

USTH HANDBOOK ON POSTGRADUATE TRAINING VER4, FORM1A

termination, training relationships with other institutions, review of old or new

15 Relationship with the Nursing Staff

16 Duties and Assignments

USTH HANDBOOK ON POSTGRADUATE TRAINING VER4, FORM1A

USTH HANDBOOK ON POSTGRADUATE TRAINING VER4, FORM1A

16.2 The Chief Resident/Fellow

USTH HANDBOOK ON POSTGRADUATE TRAINING VER4, FORM1A

USTH HANDBOOK ON POSTGRADUATE TRAINING VER4, FORM1A