POLICIES AND STANDARD

OPERATING PROCEDURE
PRIVATE / GENERAL WARD
Area Description

 The private ward is located at the fifth floor of the hospital. There are 9
rooms in the floor for admission of patients who do not have the San Juan
Health Card or those who waived their privilege to use the health card.
Other patients who require or choose admission to a single room are also
admitted in the Private ward.
 All patients regarding of age and cases ( Internal medicine, OB Gyne,
Pediatrics, Neonates, Surgery cases and EENT)are admitted at Private
Ward⁄ General Ward.
 For reservation of rooms for admission , refer to admitting section.
Admission
Procedure
 A) Direct to Room Admission

1. Patient/relative
makes arrangement with the
admitting section/information.
2. Admitting clerk or info calls the nurse’s station to
notify regarding admission.
3. Admitting clerk/utility accompanies patient to room
of choice.
 4. Nurse on duty to receive patient;
a. welcome and accompany patient to his/her room
b. make initial assessment and brief history taking
c. orient patient/relative to the environment, hospital rules
and regulations
d. inform ROD/ Attending physician of admission
e. carry-out doctor’s order, transcribe in kardex and
make necessary documentation
B. Admission from Emergency room

 1. ER staff/admitting clerk notifies the nurse’s station of

admission.
 2. ER nurse accompanies and endorses patient to the
floor nurse
 3. follow the above procedure for receiving patient
TRANSFER
A) To another hospital

1. Secure a written doctor’s order

2. Arrangement are done by patient’s relative and by
resident doctor on duty with the receiving hospital
3. Secure clinical abstract from ROD with Xerox copy of
the results of laboratory works, x-ray, etc
4. Secure clearance/discharge notice/SOA
5. Book ambulance conduction if patient or relative
desires.
B. To another room

 1. Ask patient/relative to make arrangement with the

clerk (info)regarding choice of the room
 2. inform ROD/AP
 3. inform the unit where the patient will be transferred to
prepare the room of choice
 3. secure transfer form with time and date
“
NO OUT ON PASS !

”
Abscond

Patients who are on “abscond precaution” are those :

a. with credit difficulties

b. who have an order for discharge but are unable to settle accounts
c. with pending court case or criminal charges
d. patient’s who insist to be discharged without doctor’s order
Precaution measures:
 a. notify the security guard and supervisor for proper identification
 b. inform ROD/AP
 c. record in kardex and endorse to incoming shift
Discharges

Patients are discharge after the following have been accomplished:

a. written doctor’s order
b. notification of other services/AP regarding discharge order
c. secure discharge notice form and checklist and tracking form
d. home instructions on medications, treatments, follow up check-up,
dietary instructions (if any), etc.
e. equipment’s , articles and linens are checked before pt. discharged
2. Nurse/admin aide accompanies patient to the hospital lobby
3. Chart must be properly completed. To include date and time of discharge
4. patient’s chart must be brought down to the medical record after
accomplished, received and signed in a logbook by medical record staff
For discharge against medical advice:
( DAMA)

 1. Notify doctor’s about patient/family’s desire to be

discharge and accomplish a written order for discharge
against medical advise
 2. Ask relative to make arrangement regarding
transportation of their choice.
 3. Follow procedure for discharging patient.
DEATHS

1. All deaths must be pronounced by a doctor.

2. Notify other referrals, nurse supervisor, laboratory and the
information
3. Accomplish expired notice form in triplicate form
4. Do routine post mortem care. Bring the cadaver to the morgue
with proper identification
(Name of the patient, date and time of death)
5. Instruct the relative to contact funeral parlor of their choice.
6. Release of the cadaver is done by laboratory department
Fetal deaths
Referrals

 1. Patient’s medical complaints and all abnormal

observations are referred first to the ROD
 2. In case of referral of the patient to another
department. The ROD of the particular department
should be notified first
UNIT FACILITIES, EQUIPMENT AND
SUPPLIES

1. Monthly/ yearly inventory is made by headnurse/senior

nurse
2. Losses and breakages are charge to the responsible
party (patient or staff)
3. Facilities and equipment that are either for
condemnation are surrendered to the CSR dept

*For repair – accomplish report form

 ENDORSEMENT

 Endorsement starts at 6am,2pm,10pm. If reliever is not yet in notify the

supervisor
 Patients endorsement must base on the kardex which includes:
patient’s name, chief complaints/s, working diagnosis,procedures to
be done,diet, medicines, IVfluids, abnormal laboratory results and
other procedures. Status of the patient should be endorse
Other matter to be endorsed.
- Announcement of meetings, notices and reminders
- All equipment and supplies in the nurse station such as e-cart ,etc
- All returnable items barrowed from other’s area or from patient
KARDEX

 It presents a clear profile of the patient, procedure

ordered, treatments, IVF and medications to be givern
 ROUNDS

 Observed professionalism during nursing rounds. Open and close doors gently and avoid
necessary noise.
 Show concern and interest in the patients by calling their names and listen attentively to
their complaints
 Check patients condition, IV sites, patency, drainage, operative site, comfortable position
of the patient, etc. Explain procedures to be done and give necessary instructions.
 Check for the cleanliness of the room, equipment used by the patient, return/remove
unnessary things in the room.
 Ensure patient’s safety :
-Provide siderails
- see to it that all electrical wires and outlet are in good condition
MEDICATIONS

 All medications given are entered in the medication sheet.

a. standing order sheet
b. PRN medication
c. stat doses
d. drugs used for skin test and procedure
e. all skin test – indicate time, reactions, ROD name who interpreted
the skin test
GUIDELINES IN RECEIVING AND
CARRYING OUT OF DOCTOR’S ORDER

 1. All orders for treatment and medication should be completely and

clearly stated in writing, dated and signed by the physician.
 2.When the doctors is not able to write down his/her orders while on
rounds, the nurses may jot down the orders, indicate if it is verbal order and
let the doctor sign the order.
 3. When the order through the telephone, the nurse writes the orders on
the physician order sheet, reads back the orders to the physician and
indicates that it is a telephone order. Let countersigned by the physician
on his/her next visit to the patient.
 4. Orders should be discontinued only upon the direction of the physician.
5. Nurses after carrying orders countersigned her full name and the date and time the order was
carried out.
6. Notify the doctor if there are orders that could not be carried out, like unavailable medicine or
equipment, specific test or procedure, uncooperative or refusal of the patient.
7. For any doubt or need further clarification of an order, Refer to the doctor who issued order
8. Guidelines in carrying out orders:
a. transcribed the orders in the kardex
b. make the medicine card/treatment card
c. transcribed in the standing order sheet
d. countersigned the order
e.check doctor’s order sheet including, cards,nurses’s notes and other related record on all
patients and see that no orders are omitted.
OTHER
GUIDELINES
 1. Accompany attending physician as much as possible
when he/she make rounds
 2. Assist AP with examinations and treatments and
have the equipment ready before AP arrives.
 3. Report condition and unusual observation of
patients.
PATIENT’S CHART

 Patient records are specific documents and are

necessary adjunts to good patient care. Therefore,
every effort must be made to make them accurate.
Concise and clear. Entries in the chart should be
expicity honest. Only the AP/ROD and other medical
staff to read it.
Patient’s record serves the following
purposes:

a. it is a permanent record for planning and coordinating

patient care
b. it serves as basis for any other important hospital activity
like pt. care, continuous monitoring activities,
utilization review,credentialization,education, risk
management, research etc
c. Legal document
Documentation
General Guidelines for
Documentation

1. write patients name and identifying data on every record page. Nurses
are responsible to filled out the data.
2. time and date all entries include day,month,year and exact time
3. make entries understood by all. It should be neat, legible, and concise
4. sign every entry you make- include your professional title
5. be specific
6. be objective
7. be complete and current. Record everything significant such as
patient’s problems.