AUDIT FINDINGS

MARCH 25, 2021

BY: MARGIE G. ROSARIO, JENNIFER ROSE F. MONJE, JOANNE

FRIANEZA, DANICA JOI MANANGAN
 OUT-PATIENT DEPARTMENT

 Mission and Vision of Unit

 Quality Policy and Quality Objective of Unit

 Disassembled Documents

 No portfolio
 TRIAGE AREA

 Classification as to urgency and

non-urgent of patient

 No portfolio
 EMERGENCY ROOM

 No portfolio
 Mission and Vision of Unit
 Timeliness in the Admission Logbook
(for traceability)
 ACCOUNTING SECTION

 No Calendar of Activity
 No Safety Protocol
 No Disaster Management Guidelines

 No Policy on Maintain/Retain of Documents

 BILLING SECTION

 Provide queue card to watcher

 No billing Policy
 Indicate start time in the logbook
 No safety protocol
 No Disaster Management Guidelines
 MEDICAL RECORDS OFFICE

 No Incident logbook
 No waiver for refusal to use father's
surname of newborn

 No proper labeling of charts

 No systematic arrangement of charts

 No schedule of unit disinfection

 PUBLIC ASSISTANCE DESK

 No Policy on Maintain/Retain of Documents

 Security of logbooks (no filing box/labels)

 CASHIER SECTION

 No reimbursement policy
 No copy of accounting auditing rules
and regulations

 No Policy on Maintain/Retain of Documents

 Memorandum Order of Continual Cashier

service during night duty
 PHILHEALTH SECTION

 Medical Case Rate not updated

 No incident logbook
 No logbook of refused to use philhealth

 No logbook of denied claims and RTH

 OB COMPLEX

 No minutes of the meeting

 Orderliness of logbook
 Mission and Vision of Unit
 CENTRAL SUPPLY
 Supply/Equipment logbook
(indicate date and name with signature of receiver
for condemned supplies)

 Preventive Maintenance Report

not submitted to Department Head

 Mission and Vision of Unit

 AMBULANCE

 Indicate the name of driver-on-duty in the Referral Logbook

 No safety protocol for Referral/Pick up of patient
 No minutes of the meeting
 Indicate start and end time of endorsement in the
Endorsement Logbook
 No schedule of ambulance disinfection
 Check completeness of Driver's trips logbook which show
time in and time out of the employee
 No incident report/Logbook
 Coaching and Mentoring Report
 Covid-19 protocol (PHO and Hospital Memo)
THANK
YOU!