Policy and Procedure

LUMBISRANCES GENERAL HOSPITAL
PHIC ACRED: No. H05010131 LIC No.: 05-058-13-020-H-2-2

DTI No.: 01264099 TIN No.: 109-018-258-000
TELEFAX: (052) 485-6209 EMAIL:lrgenhosp@yahoo.com
NATIONAL ROAD, BRGY. ILAOR SUR, OAS, ALBAY
POLICY AND PROCEDURE ON PERSONAL PROTECTIVE EQUIPMENT
Policy
Personal Protective Equipment (PPE) will be worn when there is reasonably anticipated exposure
to any patient’s blood, body substance, non-intact skin and mucous membrane. PPE will be worn
while providing care to patients with epidemiologically important microorganisms to reduce the
opportunity for transmission of pathogens.
Objective
The proper donning, wearing and removal of gloves, gowns, masks and eye protection can reduce
the risk of infection to both healthcare provider and patients.
PPE should be donned in the following order when all are required:
Mask/eye protector
Gown
Gloves
PPE should be removed in the following order:
Gloves
Gown
Mask/eye protector
Procedure
Gloves
 Donning:
a. Non-sterile, disposable gloves do not require any special technique for donning.
 Removal:
b. Gloves should be removed before mask or gown and discarded in a white bag (with
biohazard symbol).
c. Gloves should be removed to minimize aerosolization of glove powders and
microorganisms.
d. Remove gloves by hooking the thumb of the opposite hand inside the glove
and pulling the contaminated outer side in on itself.
e. Repeat this procedure with the other glove, touching only the inside of the
of the other glove.
f. Discard gloves in appropriate waste container.
g. Wash hands or use alcohol hand sanitizer.
Mask and Eye Wear
 Donning:
a. Mask and eye wear protection before donning, gown and gloves.
b. Masks are to be worn once.
c. Masks should be changed as soon as it becomes moist or wet.
d. Avoid handling mask before placing on your face.
e. Tie top strings at the back of the head, making sure the string pass over the ears.
f. Tie the lower strings of the mask at the back of the head at the neckline.
g. Do not remove mask from nose and mouth and permit it to dangle around the neck
h. If eye protection is not considered adequate eye protection.
i. Corrective lenses are not considered adequate eye protection.
 Removal:
a. Wash hands after removal of gloves (if worn).
b. Untie lower strings of mask first, then upper ones.
c. Remove mask, wrap strings around mask and discard in appropriate receptacle.
d. Remove eye protection. Reusable eye protection should be cleaned if soiled with
blood, body fluids, etc.
e. Wash hands after removal of mask and /or eye protection.
Gowns
Donning
a. Gowns should be full length and large enough to cover clothing adequately.
b. Select a gown and unfold it.
c. Put arms through the gown sleeves.
d. Adjust the gown on your shoulders.
e. Tie the neck ties.
f. Tie the waist belt.
Removal:
a. After gloves have been removed, untie the waist belt.
b. Wash hands.
c. Untie neck ties.
d. Remove the first sleeve of the gown by placing your forefinger under the cuff of the
sleeve and pull the sleeve down over hand without touching the outside of the gown.
e. Remove the other sleeve. With your hand inside the first sleeve, draw the second
sleeve down over your hand.
f. Slip out of the gown. Discard reusable gowns carefully in a soiled linen container
prior to leaving examination room. Discard a disposable gown in appropriate
receptacle.
g. Wash hands.
GENERAL PPE GUIDELINES

A. Always perform hand hygiene before handling and putting on any item of PPE.
B. Any damaged or broken pieces of re-usable PPE must be removed and replaced
immediately.
C. All items of PPE must be removed as soon as possible after completing the health care
procedure to avoid contaminating other surfaces.
D. All single use items of PPE must be discarded immediately after use, using the
appropriate waste management facilities.
E. Always perform hand hygiene immediately after removing and discarding any item of
PPE.
Responsibilities: Quality Assurance Committee and Infection Control Committee

Dissemination: This policy and procedure shall be disseminated through meetings and
Memos.
Person Responsible: Medical Officer/Staff Nurses
MELBA O. ALANO, RN, MAN EMMAN VALENCIANO, RM, RN, MD,

Chief Nurse Medical Director
DTI No.: 01264099 TIN No.: 109-018-258-000
NATIONAL ROAD, BRGY. ILAOR SUR, OAS, ALBAY
POLICY AND PROCEDURE FOR RECYCLING AND

SAFE REUSE OF ITEMS
OBJECTIVE
To practice safe reuse and recycling of items to minimize waste that can result savings in our
health care facility.
POLICY
LRGH shall institute a policy on recycling of materials and safe reuse of items that will help
minimize waste and contribute in environmental protection.
PROCEDURE AND GUIDELINES

1. Identification of all globally accepted reusable items including procdures that should be
used.
2. Safe reuse is an important practice in health care institution to minimize waste whenever
possible.
3. Reusable items may include equipment, instrument, glass, bottles and containers by
collecting after use and separate from reusable items, carefully washed and sterilized by
the DOH approved method such as autoclaving.
4. Plastic syringes and catheters should not be thermally or chemically sterilized for reused
but should be properly discarded.
5. Certain types of containers maybe reused provided that they are carefully washed and
disinfected.
6. Pressurized gas containers should be generally is sent to be refilled.
7. Containers that once held detergent or other liquid maybe reused as containers for sharp
waste provided that they are punctured proof and correctly and clearly marked on its
sides.
8. Used papers from Administrative Office can be used for packing instruments/items
medicine glass, vials, bottles can be reused as specimen bottles.
9. Syringes for non-infectious patients can be reuse for medicine measurement of paediatric
dropper.
10. IV plastic bottles can be reused as measuring of intake and output of urine or used for
storage condiments in dietary.
Reuse Procedure:
a. Vials can be reused to specimen bottles.
b. Papers from administrative offices can be used as wrapper for packing items/autoclaved
equipment for procedural usage.
Procedures on Recycling and reuse

 Medical and other equipment used in health care establishments maybe used provided
that it is designed for the purpose and withstand the sterilization process.
 Reusable items such as sharps, scalpels, glass bottles and containers are collected
separately from non-reusable items, carefully washed and sterilized based on DOH
approved method such as autoclaving.
 Plastic syringes and catheters should not be thermally or chemically sterilized or reused but
should be properly discarded.
 Certain types of container maybe reused provided that they are carefully washed
and disinfected.
 Pressurized gas containers, should generally be sent to specialized centers to be refilled.
 Containers that once held detergents or other acquired maybe reused as containers for
sharp waste provided that they are punctured proof and clearly and correctly marked on
all sides.
 Recycling of papers, metals, glass and plastic can result in savings for the health care
facility.
Dissemination
Policy to be disseminated to all hosp staff.
Monitoring
The Committee shall review and evaluate the procedures and revise as needed.
Persons responsible:
All hospital staff.
MELBA O. ALANO, RN, MAN

Chief Nurse
Noted by;
EMMAN VALENCIANO, RM, RN, MD.

Medical Director
DTI No.: 01264099 TIN No.: 109-018-258-000
POLICY ON RATIONAL ANTIMICROBIAL USE
Objective:
To have a standard operating procedure on the rational use of antimicrobials.
Policy:
LRGH policy to promote and adhere to the principles of rational antimicrobial use.
Indications for antimicrobial therapy:
1. Definitive therapy: This is proven bacterial infections. Antibiotics (read

antibacterial) are drugs to tackle bacteria and hence should be restricted for the
treatment of bacterial infections only. Based on the reports, a narrow spectrum,
least toxic, easy to administer and cheap drug should be prescribed.
2. Empirical Therapy:Empirical antibacterial therapy should be restricted to critical
cases, when time is inadequate for identification and isolation of the bacteria and
reasonably strong doubt of bacterial infection exists: systemic shock/sepsis
syndrome, immunocompromised patients with severe systemic infection, hectic
temperature, neutrophilic leukocytosis, raised ESR etc. In such situations, drugs that
cover the most probable infective agents should be used.
3. Prrophylactictheraphy: Antibacterial prophylaxis is administered to
susceptible patients to prevent specific infections that can cause definite
detrimental effect. These include antitubercular prophylaxis and prophylactic use of
antimicrobials in invasive medical procedures etc. In all these situations, only
narrow spectrum and specific drugs are used. It should be remembered that there
is NO single prophylaxis to “prevent all” possible bacterial infections.
Procedure:
The following strategies and procedures shall be the general guideline in the implementation of
the policy;
 Establishment of the Therapeutic Committee to set the standards and monitor
antimicrobial use.
 Development or Adoption of CPG and standard treatment guidelines for infectious diseases
based on antimicrobial resistance pattern.
 Limiting the antimicrobial prescribing to various levels like non-restricted, restricted and
very restricted.
 Prescription auditing of antimicrobial use.
 Improving diagnostic facility to clinicians to help prescribing appropriately
 Promoting surveillance of antimicrobial resistance
 Following good infection control practices.
Dissemination
This policy and procedures shall be given to all physicians and nurses in the hospital for guidance.
Persons responsible:
Medical Officers/Nurses

Chief Nurse
Approved by;
EMMAN VALENCIANO RM, RN, MD.

Medical Director
DTI No.: 01264099 TIN No.: 109-018-258-000
CLEANING AND DISINFECTION OF EQUIPMENT
Any piece of equipment used in providing patient care must be handled with care, s it may be
contaminated and have the potential to spread infection.
General principles to remember when handling contaminated (used) patient care equipment.
 It is important to avoid any contact between a used piece of equipment and the skin,
mucosa or clothing of the health care worker, including any handles of the equipment.
 The process of cleaning and disinfecting respiratory equipment frequently results in
sp[lashes which could potentially be contaminated.
When cleaning and disinfecting respiratory equipment the health-care worker should
Wear;
 Rubber gloves
 A gown and a rubber apron
 Face protection, such as a full face shield on an eye protection, such as a visor or goggles,
plus a face mask.
 Re-usable equipment must be cleaned with soap or detergent and water until all visible
signs of soiling are removed and must then be appropriately disinfected before the
equipment can be used on another patient.
 Appropriate reprocessing always includes thorough cleaning and may also include
disinfection or sterilization depending on the nature and intended use of the devise or
equipment.
 Any item designed for single use must be disposed of in an appropriate container or waste
receptacle immediately after use. This is essential to prevent any accidental contamination
of either another person or the environment.
Disinfectant use
The disinfectants available may vary from country to country. In disinfecting re-usable respiratory
therapy equipment a high level of disinfection is required. Generally, bleach provides a reasonable
level of chemical disinfection. The use of a chemical germicide, such as bleach or a physical
method such as autoclaving is usually sufficient. Cleaning should precede any high-level
disinfection activity.
When selecting the best method to conduct high-level disinfection, the following
factors should be taken into consideration:
 The piece of equipment to be disinfected,
 The composition of the piece of equipment and its intended use,
 The level of disinfection required; and
 The availability and capacity of services, physical facilities, organizational resources and
personnel.
The stages involved in reprocessing re-usable equipment are as follows;
1. Wash the piece of equipment with soap or detergent and water
2. Rinse
3. Disinfect
4. Rinse again if using chemicals to disinfect
5. Dry
6. Store
Essential points for cleaning and disinfecting equipment;
 Clean and disinfect all respiratory equipment between uses.
 Thoroughly clean respiratory and re-usable equipment prior to disinfection
 Health care workers must use PPE for cleaning and disinfection of respiratory equipment
 Keep clean and disinfected items dry and in individual packages.
MELBA O. ALANO RN, MAN

Chief Nurse
Noted by:

Medical Director
DTI No.: 01264099 TIN No.: 109-018-258-000
POLICIES AND PROCEDURES VERBAL/TELEPHONE

COMMUNICATIONS
Objectives:
On the onset of every case met in all sections verbal/telephone orders are seldom practiced
among our medical staff. To prevent any misunderstanding and miscommunications, we have
set some policies and procedures to follow regarding this matter.
POLICIES ISSUES:
The medical officer will authenticate/countersign telephone/verbal order to confirm their
accuracy.
Presentation of evidence:
a. Text messages
b. Telephone calls
c. Verbal Orders
PROCEDURE:
1. All medical staff orders for diagnosis and treatment shall be in writing. A verbal
order/telephone orders shall be considered to be in writing if dictated, faxed or texted
to a duly authorized person.
2. Verbal order/telephone orders can be accepted only by registered nurse.
3. Prior to the completion of the verbal/telephone orders, the person receiving the order
must repeat the entire order and obtain verification from the physician that the orders
are correct as repeated. Notation on the order MUST include the abbreviation -RAV- to
indicate that the order was REPEATED AND VERIFIED, and the person taking the order
must record their name, designation, date and time as well.
4. The medical staff member may then authenticate the verbal/telephone orders the
chart is open and the patient is in the hospital.
5. The authentication will consist of the members’ signature and the date that the
authentication is completed within 24 hours.
MONITORING:
The nurse on duty will check if the orders were carried out as expected within 24 hours.
DISSEMINATION:
1. Posting of written communication/memos to designated bulletin boards in all clinical sections.
2. Reiteration of memos and communication during meetings /conferences.
PERSONS RESPONSIBLE:
Medical Officer and Nursing staff

Chief Nurse

Medical Director
DTI No.: 01264099 TIN No.: 109-018-258-000
POLICY AND PROCEDURES FOR PATIENT ADMISSION, REFERRAL AND

REPORTING OF CASES
OBJECTIVE
To establish a standard procedure on patient admission, referral and reporting of communicable

diseases.
SCOPE:
1. General Policy
2. Medical staff
3. QAC/Infection Control Committee
PROCEDURE
1. The Committee shall develop a system on admission procedure and referral of cases. The
hospital shall adopt the policies stated in Patients Rights.
2. All communicable and reportable diseases shall be reported to the PHO for their
references and proper action. A record of the cases and reports shall be kept.
3. Referral of cases shall be handled with prompt action and professional manner. A referral
letter (3 copies) shall be accomplished by the ROD as soon as possible; all RL shall be
collected for further references.
RESPONSIBILITY
QAC/Infection Control Committee

Medical Staff

Chief Nurse
Noted by:

Medical Director
DTI No.: 01264099 TIN No.: 109-018-258-000
HAND HYGIENE
Hand hygiene before and after contact with every patient is among the most important means of
preventing the spread of infection.
 Wash hands with soap and running water when visibly dirty or contaminated with
proteinaceous material, they should be washed with soap and water.
 Use an alcohol-based product for routinely decontaminating hands, if hands are NOT
visibly soiled.
 DO NOT use alcohol-based hand products when hands are visibly soiled.

 blood or body fluids. In these cases, wash hands with soap and water and dry.
POINTS TO REMEMBER WHEN PERFORMING HAND HYGIENE
 When hands are visibly dirty or contaminated with proteinaceous material, they should be
washed with soap and water.
 If hands are NOT visibly soiled or contaminated, an alcohol based hand product for routine
decontamination of hands should be used.
 Ensure hands are dry before starting any activity.
PERFORM HAND HYGIENE:

Immediately:
 On arrival at work
Before:
 Direct contact with patient.
 Putting on gloves for performing clinical and invasive procedure (e.g.
administering intravascular injections, intravenous injections)
 Medication preparation
 Preparing handling, serving or eating food
 Feeding patient
 Leaving work
Before:
 Certain procedures on the same patient were soiling of hands is likely, to avoid
cross-contamination of body sites
After:
 Contact with patient
 Removal of other personal protective equipment
 Removal of gloves
 Contact with blood, body fluids, secretions, excretions, exudates from wounds,
and contaminated items
 Contact with items/ surface know or considered likely to be contaminated with
blood, body substances, or excretions (e.g. bedpans, urinals, wound dressings)
whether or not gloves are worn.
 Personal body functions such as using the toilet, wiping or blowing one’s nose.

Chief Nurse

Medical Director
DTI No.: 01264099 TIN No.: 109-018-258-000
CONTACT PRECAUTION
Transmission by contact is always a risk for healthcares workers; additional precautions should be
taken to avoid the risk of infection through direct contact.
Some common respiratory pathogens can be spread through the contamination of a patients
hand, the hands of a healthcare worker or an environmental surface.
Hands can transmit these diseases by having direct contact with a contaminated surface, followed
by contact with either another body surface such as conjunctiva or nasal mucosa or by
contaminating another intermediate area.
PRINCIPLES
Contact Precautions should be applied whenever providing care to a patient suspected or
confirmed of having a disease spread by contact with contaminated surfaces.
Ensure that any movement of patient into areas outside of their designated is kept to a minimum.
Ensure that any contact between patient s kept to a minimum.
KEY CONTACT PRECAUTIONS

 Use clean, unsterilized gloves and a disposable or re-usable gown whenever you have
direct contact with a patient.
 Remove safely the gloves and gown immediately following any contact with a patient.
Perform hand hygiene immediately after removing any item of PPE.
 Dedicate specific equipment for use with a single patient and ALWAYS clean and disinfect
shared equipment between patient uses.
 Avoid touching your face, eyes or mouth with either gloved or un-gloved hands as these
may be contaminated.
 Place patients in a single occupancy room whenever possible or alternatively with other
patients with the same diagnosis.

Chief Nurse

Medical Director
DTI No.: 01264099 TIN No.: 109-018-258-000
LINEN AND WASTE MANAGEMENT
POLICY
Handle both waste and used linen with care, wearing appropriate PPE and practicing regular hand
hygiene.
GENERAL PRINCIPLES
 All used linen and waste should be placed in bags or containers which are able to
withstand transportation without being damaged.
 Double bagging is not needed for used linen or waste.
LINEN
 Any solid matter on soiled linen should be removed and flushed down on a toilet. The
soiled linen should then be placed immediately into a laundry bag in the patient area.
 Used linen should be handled carefully to prevent contamination of surrounding surfaces
or people.
 Used linen should then be washed according to normal routines.
WASTE
 Waste should be classified, handled and disposed of according to local health authority
regulations and policies. Classifying waste is key to ensure it is handled correctly and
disposed of down the appropriate channel.
Examples of waste classification include:

 General waste – such as leftover meals, administrative rubbish;
 Clinical waste without sharp objects – such as material used during wound care;
 Clinical waste with sharp object – such as needles, blades
 Clinical waste with anatomic pieces – such as placenta
Heath- care workers should take care to avoid aerosolization of matter whenever handling and
disposing of the waste. This is especially important for faeces.
Health – care workers should wear disposable gloves whenever handling waste and should
perform hand hygiene immediately after removing the gloves.
Managing linen and waste

 Handle linen and waste with care
 Transport soiled linen and waste in closed containers or bags.
 Ensure safe handling and final treatment of waste, by classifying the waste ( this is utmost
importance) and using the containers or bags specified according to its classification.
 Health- care workers must use adequate PPE whenever handling soiled linen and waste.
Reuse Procedure:
a. Vials can be reused to specimen bottles.
b. Papers from administrative offices can be used as wrapper for packing items/autoclaved
equipment for procedural usage.
Procedures on Recycling and Reuse
a. Medical and other equipment used in health care establishment maybe used provided
that it is designed for the purpose and withstand the sterilization process.
b. Reusable items such as sharps, scalpels, glass bottles and containers are collected
separately from non-reusable items, carefully washed and sterilized based on DOH
approved method such as autoclaving.
c. Plastic syringes and catheters should not be thermally or chemically sterilized or reused but
should be properly discarded
d. Certain types of container maybe reused provided that they are carefully washed and
disinfected.
e. Pressurized gas containers, should generally be sent to specialized centers to be refilled.
f. Containers that once held detergents or other acquired maybe reused as containers for
sharp waste provided that they are punctured-proof and clearly and correctly marked on
all sides.
g. Recycling of papers, metals, glass and plastic can result in savings for the health care
facility.
DISSEMINATION:
Policy to be disseminated to all hospital staff.
MONITORING
The Committee shall review and evaluate the procedures and revise as needed.
All hospital staff
MELBA O. ALANO, RN, MAN.

Chief Nurse
Noted by:

Medical Director
DTI No.: 01264099 TIN No.: 109-018-258-000
POLICY AND PROCEDURE ON VERIFICATION OF

PRESCRIPTION AND ORDERS
PURPOSE/INTRODUCTION
Drugs can be administered by various routes, depending on the patient’s condition, the drug, and
the desired effect. The nurse must be able to prepare and administer drugs correctly using various
routes, keeping in mind the basic concepts of safe administration and those related to the special
routes. The nurse’s knowledge of the anatomy and physiology related to the organ being treated
and of the actions, usual dosage, desired effects of the drugs being administered are imperative
for safe practice.
POLICY DESCRIPTION
Prescription errors can and do occur. There are a number of easy steps you can help avoid these
errors. First make sure you understand the prescription fully, including what drug has been
prescribed as well as its generic and if, applicable, brand name. Ask your doctor to write legibly
and carefully check prescription refills and renewals.
GENERAL PRINCIPLES
Applies to all registered and IV therapist nurse for safe medication practice.
PROCEDURE:
1. Follow instruction carefully. It’s essential that you take the correct dose at the [proper time
intervals, avoid potential food and drug interactions.
2. Keep a log of your medicines and let your doctor know your drug and medical history. It’s a
good idea to review your medications with your primary – care doctor annually, including
both prescription and OTC drugs.
3. Try to have prescriptions filled at one pharmacy. The pharmacist will get to know you and
your medicines, and will be more likely to detect any possible prescription errors.
4. Store medicines properly, away from sunlight, heat and humidity. The bathroom medicine
cabinet, because of the humidity, closets away from the reach and sight of children is ideal.
5. Discard expired medicines. Prescription drugs should not be used past their expiration
date. Some drugs lose their potency with time; other outdated medicines, such as the
tetracycline antibiotics, may have dangerous side effects. Ask your Pharmacist to label your
prescription container with an expiration date, and regularly discard old medicines down
the toilet.
6. Don’t share prescription drugs or borrow them from others. What’s good for one person
may be harmful to another.
7. Don’t take medicines in the dark. You could take the wrong pill by accident. Read the label
carefully each time you take a drug to be sure you are getting the right medicine.
8. Keep emergency phone numbers handy. You should have the numbers of your doctor,
emergency medical services, and the nearest poison control center readily available in case
a medical emergency arises.
9. Don’t be afraid to ask questions. Understand your medicines as thoroughly as possible.
Why you are taking them, how and when they should be taken, and things to look out for.
People who ask questions are more satisfied with their medical care.
10. Alert your doctor to any side effects or changes in your patient condition. He or she may be
able to adjust your dosage or give you a substitute medication.
CLINICAL ALERT
If you assigned client receives new medication orders, double check the transcribed information
with the primary care providers order. This ensures client safety.
PARTS OF A PRESCRIPTION:
 Descriptive information about the client: name, address, and sometime age
 Date on which the prescription was written
 The Rx symbol, meaning take
 Medication name, dosage, and strength
 Route of administration
 Dispensing instructions for Pharmacist, for example, Dispense 30 capsules
 Direction for administration to be given the client, for example, one tablet with meals
 Physician signature
MONITORING
Prescription pad always available and properly fill up with correct information
DISSEMINATION
Section meetings
PERSON RESPONSIBLE
Medical Officers/Ward Nurses

Chief Nurse
Noted by;

Medical Director
DTI No.: 01264099 TIN No.: 109-018-258-000
NURSING SERVICE DEPARTMENT
VISION:
 QUALITY HEALTH CARE FOR ALL THE

CONSTITUENTS OF OAS & NEARBY
TOWNS.
MISSION:
 TO PROMOTE QUALITY OF HEALTH

AND PREVENTION OF DISEASES AND TO
PROVIDE THE MOST EFFECTIVE AND
EFFICIENT MEANS TO CARE FOR ALL
THE SICK CLIENTS OF OAS AND
NEARBY TOWNS.
DOCUMENTATION DO’S AND DON’T’S
DO’s DONT’s
 DO read what other provides  DON’T begin charting until

have written before providing you check the name d
care and before charting. identifying number on the
 DO time and date all entries. patient’s chart on each page.
 DO use flow sheet/checklist.  DON’T chart procedures or
Keep information on flow chart in advance.
sheet/checklist current. DO  DON’T clutter notes with
chart as you make repetitive or frequently
observations. changing data already charted
 DO write your own on the flow sheet/checklist.
observations and sign over  DON’T make or sign an entry
printed name. Sign and initial for someone else DON’T
every entry. change on entry because
 DO describe patient’s someone tell you to.
behavior. DO use direct  DON’T label a patient or show
patient quotes when bias.
appropriate.  DON’T try to cover up a
mistake or accident by
 DO be factual and
inaccuracy or omission.
complete. Record exactly
 DON’T “white out” or erase
what happens to patient an error.
and care given.  DON’T throw away notes
 DO draw a single line thru with an error on them.
an error mark this entry as  DON’T squeeze in a
“Mistaken” and sign your missed entry or “leave
name. space” for someone else
 DO use next available line who forgot to chart.
to chart DON’T write in the
 DO document patient’s margin.
current status and  DON’T use meaningless
response to medical care words and phrases, such
and treatments. as “good day” or “no
 DO write legibly. DO use complaints.”
standard chart forms.  DON’T use notebook,
 DO use only approved paper or pencil.
abbreviations.
LUMBIS RANCES GENERAL HOSPITAL

ILAOR SUR, OAS, ALBAY, 4505
MEDICAL STAFF ORDER/PROGRESS NOTES
DATE DOCTOR’S ORDER PROGRESS NOTES
NAME:_____________________________________AGE________SEX________

DTI No.: 01264099 TIN No.: 109-018-258-000
POLICIES AND PROCEDURES FOR CORRECTLY IDENTIFYING

PATIENTS BY THEIR CHART
OBJECTIVE:
To provide guidelines for positive identification of patients prior to initiation of any treatments and or
transport of the patient from area to another.
POLICY DESCRIPTION:
This policy includes correct patient identification as a patient safety priority to positively identifying
patient at all times and always before rendering services including administering meds or blood
products, taking blood samples, therapies, performing invasive and non-invasive procedures,
transporting of patients within the hospital and transfer or discharge to another facility.
RIGHTS AND RESPONSIBILITIES:

It is the responsibility of the medical and nursing personnel to ensure that all personnel are aware of and
for adherence to this policy.
DEFINITIONS:
1. Patient Identifiers – distinct pieces of information that are unique to the patient. Patients
first and last name are the priority identifier and will be used with other identifier such as
patient’s hospital number, date of birth, SSS number. A driver’s license can be utilized in
areas that don’t require an ID band.
2. LRGH

DTI No.: 01264099 TIN No.: 109-018-258-000
MINUTES OF MEETING
NAME OFNCOMMITTEE:
` DATE:
TIME STARTED:
TIME ADJOURNED:
ATTENDEES/ATTENDANCE:
AGENDA ISSUES AND DISCUSSION/AGREEMENT

CONCERN
DTI No.: 01264099 TIN No.: 109-018-258-000
POLICIES AND PROCEDURES IN INFORMING PATIENT FOR ANY

DELAY ON THE DELIVERY OF SERVICE
INTRODUCTION:
Delayed Surgical Operations were encountered in LRGH. Most common were economic or financial
problems of patients. Usually the anesthetic Medicines and supplies for operations were not available. In
addition for some cases was due to in availability of blood for patients who were anemic and on cases
with anticipated massive blood loss.
r
OBJECTIVE:
To minimize the delay on the delivery of service to patient especially in Operating Room.
POLICY STATEMENT:
All emergency operations should be operated within ten hours upon admission.
PROCEDURE:
1. The Ward Nurses refer the patient to ROD, then progress channeling to concerned person.
2. Explain the procedure to the patient and relative for them to participate in the preparation of supplies/
blood of the patient.
3. Clearly explain to them the SOP’s on prioritization of cases.
a. STAT cases – life threatening cases within 30 mins.
b. Emergency 1 – within 1 hour upon admission
c. Emergency 2 – within 2 hours upon admission
4. Ward nurse should coordinate with OR staff on available supplies in OR.
 Surgeon – The doctor who performs the surgical operation to surgical patients.
 Assistant Surgeon – The doctor who assist the surgeon in the operation.
 Anesthesiologist – Physician who provides a safe induction of anesthesia to operative cases.
 OR Nurse – Scrub/Circulating Nurse who prepares the sterile supplies, linens and instruments
and assists to the operation/procedure.
 Ward/DR nurse – Nurse who is responsible for the complete preparation of patient
preoperatively, this includes the informed consent, physical and psychological preparation.
SECTION CONCERNED: Ward and Operating Room

PERSON RESPONSIBLE: Ward and OR Nurses
MONITORING: Documentation or Supervisors Logbook
DISSEMINATION: Regular monthly meeting/orientation of new staff

Chief Nurse
Noted by;
EMMAN VALENCIANO, RM, RN, MD

.Medical Director

DTI No.: 01264099 TIN No.: 109-018-258-000
POLICY AND PROCEDURE ON PATIENT WAITING TIME
OBJECTIVE:
To provide a systematic quality service to our clients.
INTRODUCTION:
Based on our OPD Annual report 2020 we have an average of 5-10 patients daily coming from
different municipalities of Oas , Albay and other nearby town. Since we have a Resident on Duty
assigned in ER/OPD and Ward for 24 hours duty the patient can be seen and examined right away and
they don’t have to wait for a longer time. Aside from this, the length of time spent by the physician with
his/her clients varies with flexibility due to cases. Patients must know that OPD/ER is open 24 hours
PROCEDURES:
OUT PATIENT PROTOCOL
Follow these steps:
1. Consultation of patients –
“Secure patient record from the OPD/ER Nurse on duty. Hospital numbers are given to the
patient corresponding to their chart.
“Once your name has been called by the nurses, present OPD card, if you do not have an
OPD card, you may request to be issued one from the nurse on duty.
“Nurse fills up OPD chart and assess patients needs and records complaints.
2. Taking of Vital signs
“Nurse/Midwife/Nursing Aide will take the patients VS and records it on the patients chart.
3. Assist Patients
“The Nurse on duty calls patients name and guides patient to the ROD together with their
records.
4. General consultation and prescription of medication.
“Nurse assists doctor while examining patient.
“Doctor examines patient and prescribe medication.
“Nurse gives follow up instructions from the attending doctor.
5. Diagnosis tests
Patient undergoes diagnostic tests needed to determine the mode of treatment as requested
by the examining physician;
 Blood Test
 X-ray/ UTZ
 ECG
6. Minor Operations
“Minor Operations are scheduled by the Resident on duty.
“ Nurse checks patient’s records and OR logbook; advises patient on scheduled check up after a
week

Policy and Procedure

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LUMBISRANCES GENERAL HOSPITAL

PHIC ACRED: No. H05010131 LIC No.: 05-058-13-020-H-2-2