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Republic of the Philippines Policies and Procedure Controller Copy

Province of South Cotabato STANDARD OPERATING PROCEDURE No
City of Koronadal (SOP) FOR AMBULANCE PROVIDER

Office of The City Health

Health Emergency Management
Cluster – Ambulance Transport
Document Page Document Name Effectivity Date
Number No Standard Operating Procedures January 1, 2022
HEMB-2 1 of 1 for Ambulance transport

I. POLICY STATEMENT
This manual provides Standard Operating Procedures (SOPs) for operating patient transport vehicles at
the City Health Office City of Koronadal South Cotabato. Standard Operating Procedures are a set of
written instructions that should be followed in every sphere of activity in order to achieve economy,
efficiency, effectiveness and uniformity.

II. BACKGROUND

The City Government of Koronadal in partnership with the City Health Office, Health Emergency
Management Service (HEMS Unit) and the City Disaster Risk Reduction management office (CDRRMO)
augment and collaborated to establish the Emergency Health Operation Center or (Op-Cen) located at
the City Health Office 2nd floor building Bonifacio Street Barangay Zone 4 Koronadal City. The EOC is
equipped with Ambulance and Patient Transport Vehicles, essential health commodities and trained
Emergency Response Team (EMT) for deployment 24/7.

Operating ambulance services will improve the accessibility, safety, and security of patients and is meant
to bridge the gap between the need for emergency response and timely transport of patients to
hospitals / outpatient clinics for diagnosis and treatment.
III. SCOPE
The primary function of an ambulance is emergency transportation of Maternity Lying-in
patients, accidents and other emergency health cases from the 27 Barangays of Koronadal
to the nearest Government of Private Hospitals, clinics and out-patient Primary care
Facilities

IV. GENERAL ATTRIBUTES & CONDUCT OF

PERSONNEL
1. Respect and Consideration

Ambulance Services personnel will treat all patients with respect and consideration regardless of their
race, color, sex, creed, culture, economic status and religious beliefs. There will be no discrimination on
the basis of race, sex, sexuality and sexual orientation.

2. Professional Execution

Both the driver and the attendant will ensure that the vehicle and related equipment are washed and
cleaned once daily and in between transportation of patients. The driver of the vehicle will check the
status of fuel, oxygen cylinder and other necessary equipment as per the checklist provided
(Annexure/SOP- 1) every morning as well as before leaving for a call. Both the driver and the attendant
will complete all paperwork related to ambulance operations in between calls and at the end of the day.

The cleaning of the vehicle, cleaning of equipment, completion of paperwork, and continuing
maintenance of the vehicle are absolutely necessary for the proper and timely functioning of ambulance
services.

3. Attendance

Both the driver and the attendant will be available for ambulance duty at any point in time to perform
the duty. It is the responsibility of the operating partner to ensure that regular attendance and
punctuality are maintained at all points in time.

4. Uniform

The Standard uniform code will be dark gray shirts and trousers. Both the driver and the attendant will
wear uniforms as specified above while on duty to promote professionalism and facilitate identification
as ambulance operations staff.

5. Physical Fitness
The Driver and the attendant will remain physically and mentally fit and sound so as to be able to
perform their duties at all times.

6. No Smoking Policy

Cigarette smoking and other vaping devices are strictly prohibited inside the ambulance vehicle

7. Communication Protocols

Proper communication protocols need to be maintained with the callers and patient parties.

Guidelines/Protocols for Communication:

Simple, direct, professional and courteous language will be used at all times.

When an ambulance is dispatched on the basis of a call the dispatcher will ensure that the ambulance is
responding to the correct address.

Contact with the dispatch (ambulance Nurse or attendant and Driver) will be maintained at all times.

Some commonly used Ambulance Operation terms are:

“Available” : ambulance is available to respond to a call.

“Proceeding” : ambulance is going or picking up patient
“Out of Service” : ambulance is not available to respond
“Received” : ambulance staff has received the information.
“engaging” : ambulance is en route to a call
“Status” : Find out the availability of ambulance
“On Site” : Ambulance has arrived at call location.
“On Board” : Ambulance is transporting the patient to a hospital. Must be followed
by hospital name.
“endorsed” : Ambulance has arrived and endorse the patient to hospital staff
“Pull-Out” : Ambulance Return to Base

V. CODE OF CONDUCT OF THE DRIVER/ATTENDANT

a. Will be cleanly dressed in uniform
b. Will be polite
c. Will be sympathetic
d. Will be punctual and on time
e. Will complete paperwork
f. Will check all operational details of the ambulance every morning and before leaving for
an assignment as per checklist (Annex1)
 g. At all times will drive the ambulance within permissible speed limits in busy/crowded
areas and intersections
h. Will not use the siren indiscriminately. Will use the Siren only while transporting patients.
i. Will not chew or smoke in front of patients and during transportation and inside the
ambulance when the ambulance is not running.
j. Will not consume alcohol during duty hours or should not have consumed alcohol 4 hours
prior to departure
k. Will not shout or use abusive language
l. Will not charge extra money from the relatives of the patients
m. Will not harass patients

VI. INFECTION CONTROL

a. use all protective gear for handling patients at all times
b. When the possibility of exposure to blood or other body fluid exists, gloves are
recommended. If hands accidentally become contaminated with blood, they should
be washed thoroughly as soon as possible.
c. When there is a risk of eye or mouth contamination (for example, the patient is
vomiting bloody material or there is arterial bleeding), protective eyewear and
masks are recommended.
d. Masks should be worn by the ambulance staff or patient for those infectious agents
transmitted by airborne diseases like Tuberculosis, Chicken Pox, Measles and the
like
e. Equipment should be thoroughly cleaned after each use.
f. All significant exposures shall be reported to the Supervisor/Coordinator/ CESU
immediately so that necessary action can be taken.

Significant exposure is defined as the following:

a. Any puncture of the skin by a needle or other sharp object that has had contact
with the patient’s blood or body fluids or with fluids infused into the patient.
b. Blood spattered onto mucous membranes (e.g., mouth or eyes).
c. Contamination of open skin (cuts, abrasions, blisters, open dermatitis) with blood,
saliva, amniotic fluid, etc.
VII. REQUEST FOR AMBULANCE SERVICES
The request for ambulance services will come to the Emergency Health Operation Center or (Op-Cen)
through telephone or in the form of a personal caller for transporting accident or Maternity Lying-in
patients and other emergency health cases (termed hereunder as normal emergency cases) as per the
guidelines mentioned below.

1. CHO AMBULANCE TRANSPORT GUIDELINES FOR NON-EMERGENCY ELECTIVE TRAVEL

Step 1. Write a letter of request approved by the City Mayor

step 2. Fill up the ambulance request form at the city health office

step 3. Patient case evaluation c/o ambulance Coordinator

step 4. Fill-up trip ticket and gas slip c/o driver on deck

step 5. Travel memorandum

2. PICK-UP AND TRANSPORTATION OF INJURED PATIENT/S

1. Before ‘proceeding” the driver will check the status of fuel, oxygen cylinder, and other
necessary equipment as per the ‘Check List’ provided to him (checklist details: Annex/SOP –
1).
2. The driver will take with him the ‘Call Record’ form. (Annex/SOP-2)
3. On reaching the pick-up point, the driver will ensure the safe shifting of the patient/s to the
ambulance on a stretcher, wherever required, with the help of the accompanying attendant.
4. The driver/attendant will ensure the use of oxygen cylinders/other lifesaving equipment by
the patients if required.

3. PICK-UP AND TRANSPORTATION OF PATIENT/S FROM RESIDENCE TO PRIVATE HOSPITALS/

CLINICS, PRIMARY CARE FACILITIES, OR BARANGAY HEALTH STATIONS

1. The Driver shall obtain a post facto approval in the Call Record Form from the
Ambulance Coordinator/District Health Physicians or City Health Officer who would
approve such movement after being satisfied with the same.

4. REQUEST FOR AMBULANCE SERVICES OVER THE TELEPHONE FOR TRANSPORTING EMERGENCY
CASES

1. Emergency Operator receives a phone call requesting ambulance services.

2. Details of the request will be noted in the ‘Request for Ambulance’ / Call Record form (Annex-2)
in duplicate. Full address and clear direction for the location of the patient supported by
important landmarks will also be noted down
3. The filled-in form should be signed by the Ambulance Coordinator or Medical Officer on duty or
any other person authorized by the City Health Officer before dispatch of the ambulance.
4. Thereafter, the original form is to be handed over to the driver of the ambulance immediately. a
copy of the form should be kept in the office file.

5. REQUEST FOR AMBULANCE SERVICES OVER THE TELEPHONE FOR TRANSPORTING ACCIDENT
EMERGENCY CASES

1. Emergency Operator will receive a phone call requesting ambulance services for transporting
accident cases.
2. Details of the request will be noted in the ‘Call Record’ form (Annex/SOP- 2) in duplicate. Clear
directions for locations of the accident victims supported by landmarks will also be noted down.
3. Thereafter, the original form is to be handed over to the driver of the Ambulance immediately. A
copy of the form should be kept in the office file.

6. PATIENT CARE REPORTS/ DOCUMENTATION

Documentation is one of the most important aspects of completing an ambulance call. Both
the call receiver as well as the driver of the ambulance must maintain and complete call
reports. Patient Care Reports are frequently referred to as Call Reports. The documentation
norm will be:

a. Complete report on each patient for any call (Annex/SOP- 2)

b. All call reports are recorded in duplicate as the call occurs and the duplicate copy is kept
in the office file.
c. All calls are to be registered in the Log Book after the completion of the call (Annex/SOP-
VIII.ROLES AND RESPONSIBILITIES OF THE CHO-
OPERATION CENTER
A. AMBULANCE SERVICE

1. The CHO-OPCEN will exclusively use the ambulance for carrying emergency and referral
of patients within the City of Koronadal to the nearest Government or Private Hospitals
or other related Health Facilities

2. The CHO-OPCEN will be responsible for providing ambulance services to patients who
are in need of the same on a round-the-clock basis

3. Emergency Operator will be in charge of the Daily check-in Operations, Requests and
Logbooks

4. The Emergency Operator or EMT staff will maintain a movement register/logbook,

(Annex/SOP-3) which will be kept and regularly updated by the driver of the ambulance,
indicating therein the distance covered and user charges realized from the patient or
his/her representative. The logbook will be regularly checked and signed by the
Ambulance Coordinator or Authorize Representative

5. Ambulance Drivers and Emergency Operators are on 24/7 duty rotation

6. Ambulance Drivers must Park the Ambulance Vehicles in the Proper Parking Area
provided by the CHO-OPCEN

7. Checking Refilling and Utilization of Medical supplies must be done Daily by the EO /
Driver and Nurse Attendant
.
B. HEMS OPERATION CENTER

1. Monitors all health and health-related events on a 24/7 basis, including all national
events, mass gatherings, and international events with potential impact to the
Philippines
2. Monitors all DOH implementation and response efforts to activation of Code Alerts
(White, Blue, Red)
3. Coordinates all health-related response efforts to major health emergencies and
disasters
4. Coordinates and monitors the mobilization of technical experts and all types of medical
teams needed in emergencies and disasters
5. Utilizes various information and communication technologies (ICT) in the
dissemination of early warning and other appropriate information to stakeholders and
the public
6. Ensures that communication equipment (e.g., radio, mobile phones) are at any time
available, functional and ready for use in emergencies and disasters
7. Ensures functionality and safekeeping as well as preventive maintenance of
equipment, vehicles and other utilities/facilities
8. Maintains a working environment conducive to the productivity of employees through
secure and well-maintained facilities.
9. Assists in the preparation of the Annual Procurement Plan, Operational Plan and Work
and Financial Plan
 Checklist Annex/SOP-1

Driving and Vehicle Operations

Before driving any ambulance, a driver must have the following documentation:

 Current, valid Driving License

 “Clean” Driving Record from the Department of Motor Vehicles (No Record of Reckless
Driving, not more than two moving violations in the past one year).

Vehicle

Vehicle documents required:

 Certificate of Registration

 Insurance Certificate

 Pollution Certificate

Operational Checklist
 Fuel
 Brake Oil
 Engine Oil
 Coolant
 Brake pad
 Battery

 Life-saving equipment/medical kit
 Stretcher in place
 Vehicle is clean
 Siren is working
 Itinerary trip ticket
 Blank Ambulance Request Form
 logbook
 Annex/SOP- 2

Request for Ambulance Form/Call Record

Date: Time:

Patient Name:

Caller Name:

Relationship with Patient:

Age of Patient: Sex of Patient:

Address:

Place of Pick Up:

(Including clear directions)
Important Landmarks:

Destination:

Complaint: Referral Doctor:

Signature of Call Receiver/Driver:

Authorization by Ambulance Coordinator or his/her representative:

 Annex/SOP- 3
Ambulance Logbook/Ambulance Movement Register

Date Start Patie Place Tim Place Time Time of End Signature of Checked
km. nt’s of e of Out Return to km. the driver of & signed
Name Pick \In Drop CHO the by the
Up ambulance EO/AC
 Annexure/SOP-4

Itinerary trip ticket

Name of Patient:

Sex: Age:
Date: Time:

Start km: Pick Up (km):

Drop (km):

Total Distance Travelled (km.):

Rate Per Kilometer:

Signature of recipient:

Signature of Patient/Patient Party:

 Annex/SOP- 5
MONTHLY REPORT

1. Name of the Ambulance: _________________________ 2. Vehicle plate No. _________________

3. Reporting Month: _________________________ 4. Date of Submission ___________

7. TOTAL NUMBER OF PATIENTS TRANSPORTED DURING THE MONTH

7-A. Type of patients transported 7-B. Details of transportation 7-C. Category of

Accident emergency cases Referred from BH/BHS/PCF patients transported

Delivery related cases Residence to BH/PCF/Clinic INDIGENT

Child related cases Residence to other govt. hospitals NON-PHIC

Other Emergency cases Residence to private hospitals Phil health

Others (specify)
Others (specify) Senior Citizen

Total Patients Total Patients Total Patients

8-A) Opening Kilometer on the first day of the month

8-B) Closing kilometer on the last day of the month
8-C) Total kilometers travelled during the month

9-A) Number of days the ambulance did not carry any patient
9-B) Reasons:

10-A) Number of times the ambulance used for some other purposes:
10-B) Reasons:

11. Problems encountered / Important case studies/ General comments:

 Noted By:
Prepared By: Checked By:
ATTY. ELIORDO U. OGENA
IAN ISAIAS R. RECLA RN VINCENT L. ENDE MD CITY MAYOR
HEMS COORDINATOR ACTING CITY HEALTH OFFICER