DJPRH Processes and Procedures

General Santos City Hospital
Manual of
Processes and Procedures
PART I
PROCEDURES IN CLINICAL AND NURSING

MANAGEMENT
• OPD PROCEDURES
• ER PROCEDURES
• ADMISSION PROCEDURES
• WARD PROCEDURES
• PROCEDURES FOR PATIENTS NEEDING SURGERY
and OPERATING ROOM PROCEDURES
• LABOR ROOM/DELIVERY ROOM PROCEDURES
• OB WARD PROCEDURES
• LABORATORY PROCEDURES
• RADIOLOGY PROCEDURES
GSC HOSPITAL OPERATIONS PATIENT SUMMARY FLOW
A patient may enter the hospital system through the Out-Patient Department or the
Emergency Room. In these two units, the patient may be: (1) admitted to the wards (2)
referred to other health facilities, or (3) sent home. In the ward, the patient receives care
from doctors, nurses, and support units, such as: Pharmacy, Dietary, Central Supply Room,
Laboratory, Radiology, Medical Social Service, and Medical Records. Upon admission, the
1
patient is classified based on his/her ability to pay. Before a patient is discharged or referred
to another health facility, he/she must pass through the Billing Section and Cashier’s office to
settle his / her financial obligations to the hospital.
2
CHART NO. 1. HOSPITAL OPERATIONS: PATIENT SUMMARY FLOW
Patient Patient
comes to comes to
the OPD the ER
Admitting
Patient Classification
Ward work/ patient

care
Billing / Cashier
Disposition
Other Others,
health Home e.g.
facilities morgue
3
GENERAL FUNCTIONS OF GSC HOSPITAL SERVICES AND
UNITS
Services/Units Functions
PATIENT CARE
SERVICES
OUT PATIENT DEPARTMENT 1. Provides initial care to the patient and serves as
AND EMERGENCY ROOM entry point for patients requiring hospitalization.
NURSING SERVICE 2. Provides nursing care and management.
3. Administers medicines, performs procedures,
monitors, and records patient’s status,
coordinates with other health providers, and
implements nursing care plan.
MEDICAL SERVICE 4. Provides medical care, diagnosis, and
management of patient conditions.
DIETARY SERVICE 5. Provides nutritional care and management.
SUPPORT
SERVICES
LABORATORY UNIT 6. Collects specimens and performs laboratory
procedures and tests to confirm and/or
support clinical diagnosis
RADIOLOGY UNIT 7. Performs contrast and non-contrast radiological
Procedures.
PHARMACY SERVICE 8. Provides drugs, medicines, and other therapeutic
substances
MEDICAL SOCIALE 9. Performs social work interventions. Assesses
SERVIC patient’s social, emotional, and economic
conditions and provides appropriate
interventions.
ADMITTING UNIT 10. Facilitates the admission of patient for hospital
care.
LINEN AND LAUNDRY UNIT 11. Provides clean linen and linen materials.
HOUSEKEEPING UNIT 12. Provides a sanitary and therapeutic environment.
BILLING 13. Collects and summarizes charges and bills
patient for costs incurred for his/her care.
CASHIER 14. Collects payment.
MEDICAL RECORDS SERVICE 15. Processes and maintains all medical records.
ENGINEERING 16. Performs building and equipment maintenance
and repairs.
SECURITYSERVICES 17. Protects the hospital’s properties and maintains
general order.
CENTRAL SUPPLY ROOM 18. Prepares, sterilizes, and provides medical
supplies and materials to the different units.
ACCOUNTING 19. Produces financial reports to facilitate decision
making, provides information on the status of
the
hospital’s economic resources and financial
performance.
BUDGETING 20. Develops and monitors the hospital operational
plan and indicates the hospital Budget for each
activity.
4
OUT-PATIENT DEPARTMENT
Responsibility Actions
OPD CLERK 1. Determines whether patient is “old” or “new”.
1.1. If patient is “new”, issues new ID and card,
logspatient’s name in the OPD register, and
creates new chart.
1.2. If patient is a referral from other health facilities,
asks for the referral slip and attaches this to the
chart.
1.3. If patient is “old”, retrieves OPD Record [Form
no. 1] from file.
2. Advises patient regarding the use and care of the
card.
3. Forwards OPD record to the OPD Nurse.
OPD NURSE 4. Calls patient’s name and takes patient’s vital signs.
5. Notes findings on the OPD record, including chief
complaints and reason for consultation.
6. Refers patient to department/specialty concerned (if
applicable) and gives OPD record to the OPD
Physician.
7. Advises patient to wait for his/her name to be called.
OPD PHYSICIAN 8. Interviews patient, examines, evaluates, and
determines the medical care needed:
8.1. If the patient is for medical care,
givesprescriptions and instructions to the
patient.
8.2. If the patient is for diagnostic work-up, writes
order, fills-up request form [Form no. 2] and
forwards them to the OPD Nurse.
8.3. If patient is a medico-legal case, refers patient
to the proper authorities.
OPD NURSE 9. Facilitates request for diagnostic examination.
10. If needed, refers patient to the Medical Social
Service(MSS) using MSS OPD referral form [Form no.
3].
NURSE ATTENDANT 11. Directs patient/watcher to the Medical Social Worker
(MSW).
MEDICAL SOCIAL WORKER 12. Evaluates and classifies patient accordingly, and
refers patient to the Diagnostic Center Staff (please
see MSS procedures for classifying OPD
patients, pp. 100-101).
REVENUE CENTER STAFF 13. Receives request and issues charge slip [Form no.
(laboratory or radiology staff) 4]. Advises patient to pay to the Cashier. (please
see Laboratory Procedures for OPD Patient,
pp. 7072; Radiology Procedures for OPD
patients, pp.
87-88).
CASHIER 14. Receives payment and issues official receipt.
5
OPD PHYSICIAN 15. Upon receipt of the diagnostic result, evaluates
examination outcomes, completes the patient’s record,
prescribes medication, and provides instructions to the
patient.
15.1. If the patient is for confinement, accomplishes
Doctor’s Order Sheet (DOS) [Form no. 5) and
Admitting History Sheet [Forms no. 6 and 7]
and endorses these to the OPD Nurse.
15.2. If the patient is for referral to other health
facilities, prepares clinical summary [Form no.
8], accomplishes referral slip [Form no. 9] and
endorses other documents to the Nurse (See
Referral Procedures, pp. 50-51).
15.3. If patient has a notifiable disease, indicates
diagnosis or findings on the patient’s records.
15.4. If the patient needs dietary management,
refers patient to the Clinical Dietitian for diet
counseling [Form no.10).
NUTRITIONIST-DIETITIAN 16. Conducts diet counseling on the dietary requirements
of the patient and fills-up appropriate forms [Forms
no. 11, 12, 13].
OPD NURSE 17. Carries out doctor’s orders.
18. If for admission, informs the Admitting Staff
andforwards patient’s record to the Admitting Unit.
(See Admission Procedures, pp. 16-17).
19. If patient has a notifiable disease, enters patient’s
name on the Notifiable Diseases Register.
OPD PHYSICIAN 20. Reports to the Hospital Epidemiological Surveillance
Unit (HESU) the admitted patient with notifiable
disease.
HOSPITAL SURVEILLANCE UNIT 21. Informs City Epidemiological Surveillance Unit
NURSE (CESU) about admitted patient with notifiable disease.
CITY 21.1. Forwards result of the surveillance to the HESU.
EPIDEMIOLOGICAL
SURVEILLANCE UNIT (CESU)
HESU NURSE 21.2. Forwards the result of the surveillance to the

Attending Physician.
ATTENDING PHYSICIAN 21.3. Enters findings on the patient’s OPD Record.
OPD NURSE 22. Conducts health education activities.
NURSING ATTENDANT 23. Ushers patient to the pharmacy.
6
PHARMACIST 24. Receives prescription and dispenses the
medicines required by the patient and provides
counseling and drug information (please
seePharmacy Procedures - Filling up of
prescription for OPD patients, pp. 131-
132).
PHYSICIAN 25. Writes on the OPD records the observations,
diagnosis, and treatment rendered.
26. Endorses OPD record to the Nurse.
OPD NURSE/NURSING 27. Prepares daily summary of OPD patients
ATTENDANT attendedby the respective medical staff, with
corresponding diagnosis and disposition.
28. Forwards patients’ records and summary of
OPDcases attended to the OPD Records Unit or to
the Medical Records Officer (MRO) or designate.
OPD RECORDS CLERK OR 29. Enters OPD data in the OPD Register.
MEDICAL RECORDS 30. Prepares the summary of OPD cases, notifiable
OFFICER/DESIGNATE diseases, and other reports.
31. Files OPD records.
7
CHART NO. 2:OPD PROCEDURES
HESU CESU PHYSICIAN OPD NURSE OPD CLERK NURSE MSW DIAGNOSTIC CASHIER NUTRITIONIST-
ATTENDANT CENTER STAFF DIETITIAN
Start Here
8
CHART NO. 2:OPD PROCEDURES (continuation)
9
EMERGENCY ROOM
PROCEDURES
ER NURSE 1. Provides emergency nursing measures.
2. Obtains patient data, takes and records vital signs,
gives support measures, and refers patient to the
Physician on duty.
ER NURSE 2.1. If vital signs are absent, gives immediate
resuscitative measures while notifying the ER
Physician on duty.
ER PHYSICIAN 2.2. If resuscitative measures fails, pronounces
patient as ER Death or Dead on Arrival (DOA).
ER NURSE/NURSING 2.3. Gives post mortem care. (See Disposition of
ATTENDANT Cadaver pp. 63-64)
ER NURSE 3. Enters patient’s status and data on the ER register
including time of arrival, name of companion and
his/her relation to the patient.
ER PHYSICIAN 4. Examines, evaluates, and treats patient while taking
his/her health history and writes doctor’s orders for
medication and treatment [use Forms no. 5. 6 and 7].
4.1. If patient is a medico-legal case, informs proper
authority.
4.2. If patient is for admission, writes and signs
admitting orders.
4.3. If patient is for referral to other health facilities,
prepares referral documents [Forms no. 8 and 9]
4.4. If patient is not for admission, gives

prescriptions and instructions.
ER NURSE 5. Carries out doctor’s orders.
5.1. Enters patient’s data, including pertinent
findings and disposition on the ER register.
5.2. For stat orders, facilitates transport of patient to
concerned departments.
REVENUE CENTER STAFF 6. Receives request, performs the diagnostic procedure /
(Laboratory, X-ray, service, and issues charge slip [Form no. 4]:
Pharmacy staff) 6.1. For admitted patients, forwards charge slip to
the Billing Section.
6.2. For non-admitted patients, attaches charge slip
on the clearance slip and indicates total cost of
services rendered, supplies, drugs, and
medicines used on the clearance form.
6.3. If no 24-hour billing service, forwards charge
slip from the revenue centers to
the designated hospital staff.

10
DESIGNATED STAFF 7. Reviews charge slips.
8. Bills patient or watcher.
9. Issues a temporary receipt.
10. Instructs patient/watcher to return during office
hours to claim official receipt.
ER PHYSICIAN 11. Interprets results of diagnostic procedures, reviews,
and completes patient’s ER record.
ER NURSE 12. If patient has psycho-social or economic problems,
refers patient to the Medical Social Worker [Form no.
3].
13. If patient is for admission:
13.1. Advises patient/relative to proceed to
theAdmitting Unit. (Please see Admission
Procedures, pp. 14-15).
13.2. Carries out doctor’s orders and
accomplishesadmission record.
13.3. Endorses patient to the designated ward.
14. If patient is not for admission:
14.1. Conducts health education activities.
14.2. Gives charge slip and instructs patient
toproceed to the Cashier, or to the designated
staff if after office hours.
14.2.1. If patient is unable to pay, refers
patient to the Medical Social Worker
(MSW).
MEDICAL SOCIAL WORKER 15. Conducts crisis intervention and initial assessment.
16. Evaluates and classifies patient (please see
Medical Social Service, pp. 98-99).
CASHIER 17. Collects payment and issues official receipt.
ER UTILITY WORKER/ 18. Transports the patient to the designated ward.
ER NURSE ER NURSE indorses patient to ward nurse.
ER NURSE 19. Prepares ER summary according to department,
diagnosis, and disposition.
SENIOR HOUSE OFFICER 20. Checks and approves ER summary.
ER NURSE 21. Forwards ER records including summary to the
Medical Records Officer.
RECORDS OFFICER 22. Files ER records and consolidates ER cases.
11
CHART NO. 3: EMERGENCY ROOM PROCEDURES
PHYSICIAN ER ER REVENUE MSW CASHIER
STAFF NURSE CENTER STAFF
CHART NO. 3: EMERGENCY ROOM PROCEDURES (continuation)
SENIOR ER NURSE CASHIER MEDICAL RECORDS
HOUSE OFFICER OFFICER
(A)
(B)
Provides health education
(C)
Issues charge slip
Checks and approves ER

summary Prepares ER summary
Forwards ER records
including summary to the Consolidates ER records
Medical Records Officer
Files ER records
13
ADMISSION
PROCEDURES
ADMITTING STAFF 1. Fills-up demographic data on the Clinical Cover
Sheet (CCS) [Form no. 14] and Patient Information
Sheet (PIS) [Form no. 15] in duplicate.
2. Asks patient to sign consent for hospitalization.
3. Enters admission data in the admission register.
4. Refers patient/relative to the Medical Social
Workerfor classification.
5. Forwards CCS to the Medical Social Service (MSS).
6. Forwards the patient’s information sheet to the
Billing Section.
MEDICAL SOCIAL WORKER 7. Evaluates and classifies patient.
8. Indicates classification of patient on the CCS.
9. Forwards the CCS to the Admitting Section.
ADMITTING STAFF 10. Notifies nurses’ station/ward of new admission.
UTILITY WORKER 11. Transfers patient to the ward.
ER/OPD NURSE 12. Endorses patient and medical record to the Ward
Nurse.
WARD NURSE 13. Receives patient and medical record.
14
CHART NO. 4: ADMISSION PROCEDURES
15
WARD PROCEDURES
Admission to Ward (Upon notice of admission)
WARD NURSE 1. Prepares bed assignment, individual
patient’s supplies and materials needed
based on the information from the
Admitting Unit.
WARD NURSE/ NURSING 2. Prepares patient’s unit (bed, bed tags, bedside
ATTENDANT/ UTILITY table, drinking water, etc.).
WORKER
Upon Arrival of Patient in the Ward
WARD NURSE 1. Receives patient and medical records from
theOPD/ER Nurse.
2. Accompanies patient to his/her assigned unit.
3. Orients patient/companion about hospital
policiesand location of the different hospital
units.
4. Assesses patient’s condition and notes findings

onthe patient’s record.
5. Prepares nursing care plan for the patient.
6. Performs admission care and carries out doctor’s
orders.
7. Initiates implementation of medical
managementlike request for examination,
medication, treatment, and referrals.
8. Coordinates with other support services
likePharmacy, Dietary, Laboratory, Radiology,
and Medical Social Service for the needs and
requirements of the patient.
9. Discusses with patient / companion the medical
ornursing care plan and the extent of his / her
participation.
10. Checks patient’s record to ensure that consent
for medical/surgical intervention has been signed
by either the patient or duly authorized
representative.
11. Charts observations, measures, and
medicationsadministered to the patient [Forms
no. 16, 17, 18, 19 and 20].
12. Enters patient’s name in the daily ward census,
Kardex, and diet list.
16
WARD NURSE/NURSING 13. Updates ward directory.
ATTENDANT 14. Prepares diet list and forwards the same to the Dietary
Service.
WARD NURSE 15. Informs the Physician on duty of new admissions.
PHYSICIAN ON DUTY 16. Examines and evaluates newly admitted patient.
Givesfurther orders and makes notes in the patient’s
record.
17. Performs special procedures, if necessary.
18. Endorses all patients admitted to the incoming
physician on 24-hours duty.
Doctor’s Rounds
PHYSICIAN IN-CHARGE or 1. Performs regular/daily ward rounds with the medical
PHYSICIAN ON DUTY and nursing staff.
2. Interprets results of diagnostic procedures, writes
orders [Form no. 5] and progress notes [Form no.
21].
3. If necessary, refers patient to a consultant or to a
higher level hospital.
4. Endorses all admitted patients to the incoming
physician on 24-hours duty.
Ward Activities
WARD NURSE ON DUTY 1. Conducts ward assessment and takes note of patients
requiring special care for immediate or regular referral
to concerned service/department.
2. Reviews Kardex and analyzes nursing progress reports.
3. Prepares work plan, determines resources, and sets
priorities.
4. Requests for medical supplies from the CSR.
5. Provides nursing care and carries out medical
treatment.
6. Records patient care activities, observations,
medication, and treatment.
7. Refers patients to the Attending Physician whenever
necessary.
8. Discusses patient management with the Senior Nurse,
Supervising Nurse, or the Chief Nurse, (depending on
the availability of nursing personnel) and Attending
Physician.
20
9. Monitors patient’s status regularly.
10. Updates Kardex after every round and physician’s visit.
11. Fills up medication treatment form.
12. Carries out medication treatment orders.
13. Assists Physician in conducting ward procedures.
14. Prepares request for routine examinations and
sendsthem to the service/unit concerned (e.g.,
Laboratory [Form no. 2] and/or Radiology [Form no.
22]).
WARD NURSE ON DUTY/ HEAD 15. Patient for discharge: Informs Billing Section and
NURSE MSW and facilitates the accomplishment of
Clearance Certificate (CC) [Form no. 23] (see
Disposition of Patient, pp. 57-58; 61-62).
16. Patient for referral: Facilitates transfer of patient
(see Referral of patients, pp. 50-51).
SENIOR NURSE/SUPERVISING 17. Conducts regular and daily rounds and performs
NURSE the following:
17.1. Supervises nursing care provided by the
Ward Nurse.
17.2. Observes staff nurses to determine their
competency level.
17.3. Checks accuracy and utilization of ward
supplies and equipment.
17.4. Checks/counterchecks and updates ward
directory.
18. Assists Ward Nurse in carrying out patient care, if
necessary.
18.1. Discusses with ward nurses the nursing care
plan.
18.2. Discusses with the Attending Physician the
plan of care, diagnosis, and prognosis of
patient.
19. Decides on procedural and administrative matters
within the bounds of the nursing service policies
OUTGOING NURSE 20. Endorses to the incoming nurse the shift activities
21
INCOMING NURSE and special treatments and medications that need
to be carried out.
21. Makes rounds with the incoming nurse and
nursing attendant and introduces incoming shift to
newly-
admitted patients.
22. Endorses drugs and medicines to the incoming
nurse and signs out.
CHART NO. 5: WARD PROCEDURES
ATTENDING NURSE WARD NURSE NURSING OPD/ER OUTGOING/
PHYSICIAN SUPERVISOR ATTENDANT NURSE INCOMING
22
NURSE
23
PROCEDURES FOR PATIENT UNDERGOING SURGERY
1. ELECTIVE SURGERY
Pre-operative procedures
Responsibility Action
Before the operation
SURGEON 1. Explains the procedure to the patient and
hisfamily (how the operation will be performed
and the reason for performing the operation).
2. Obtains the informed consent [Form no. 24]
ofthe patient for the surgery (patient/relative is
asked to sign on the consent form).
3. Writes the order for surgery and the pre-
operative medicines in the physician’s order
sheet.
4. Prepares request for surgery [Form no. 25],
toinclude type of operation, anesthesia to be
used, names of surgeon and anesthesiologist,
and sends it to the Chief of Hospital (COH) or
Senior Resident for approval.
5. Informs the Nurse about the operation.
CHIEF OF HOSPITAL/ SURGICAL 6. Approves request and sends it back to the
DEPARTMENT HEAD/ (If the Admitting Nurse.
COH or Surg. Dept. Head are not
available, ADMIN OFFICER)
ADMITTING NURSE 7. Carries out doctor’s order for the operation.
8. Checks the patient’s record and ensures
thatinformed consent has been signed by the
patient or his/her nearest kin.
9. Forwards approved request for surgery to
theOperating Room (OR) Nurse.
OPERATING ROOM NURSE 10. Enters request in the OR logbook and informs the
Admitting Nurse of the schedule of operation.
SURGEON 11. Determines the schedule of operation.
ANESTHESIOLOGIST 12. Writes order for cardio-pulmonary (CP) clearance
in the patient’s medical chart.
ADMITTING NURSE 13. Forwards request for CP clearance [Form no. 26]
to the Medical Resident/Internist.
MEDICAL RESIDENT/INTERNIST 14. Examines and evaluates patient and issues
CPclearance.
15. Forwards CP clearance to the Admitting Nurse.
24
ADMITTING NURSE 16. Informs the Surgeon about the result of the CP
clearance.
SURGEON 17. Makes referral to the Anesthesiologist.
ADMITTING NURSE 18. Notifies / informs Anesthesiologist.
Before the Operation
ANESTHESIOLOGIST 1. Evaluates patient’s condition, reviews record,
andchecks pre-requisites [Form no. 27].
2. Reassures the patient and explains the type of
anesthesia that would be used, its effect and the
post-anesthetic period.
3. Prepares prescription for pre-operative
medication and anesthetic drugs needed. 4.
Discusses with the OR Nurse the need for a
successful and safe induction of anesthesia.
RESIDENT PHYSICIAN/ 5. Ensures that the following pre-operative
ANESTHESIOLOGIST/ requirements are complete:
ADMITTING NURSE/OR NURSE 5.1. Consent for surgery
5.2. CP clearance
5.3. Cross-matched blood, if needed
5.4. Pre-operative medications
5.5. Surgical checklist and other supplies
6. Prepares patient psychologically and spiritually,
and orients him/her on the procedures to be
performed.
OPERATING ROOM NURSE 7. Checks instruments, surgical supplies, and other
materials needed prior to surgery.
ADMITTING NURSE 8. Instructs patient on NPO (Nil Per Orem) starting
midnight before the operation.
8.1. Instructs watcher to strictly comply with
NPO order for the patient.
9. Notifies Dietary Service of the operation to be
performed on the patient.
NURSING ATTENDANT 10. Places a tag on the patient’s bed indicating the
schedule and kind of operation.
SUPERVISING NURSE/SENIOR 11. Reviews the pre-operative preparations made for
NURSE the patient.
25
ADMITTING NURSE/NURSE 12. Prepares patient.
ATTENDANT 12.1. Performs pre-operative procedures (e.g.,
enema) as needed.
12.2. Conducts preliminary preparation of the
operative site.
12.3. Reminds patient to maintain the pre-
operative order(s) (e.g. NPO).
12.4. Removes all nail polish and advises patient
on personal and oral hygiene.
12.5. Advises patient to remove all jewelry,
contact lenses, prosthetic teeth, etc. and
turn over these items to the patient’s
companion for safekeeping. If the patient
has no companion, the Admitting nurse
receives the items for safekeeping
supported by an acknowledgement receipt.
ADMITTING NURSE 13. Fills and signs checklist of pre-operative
preparations [Form no. 28].
SENIOR NURSE 14. Reviews and countersigns checklist and
endorses the same to the Admitting Nurse.
ADMITTING NURSE 15. Attaches checklist in the patient’s record.
Early Morning of the Operation Day
ADMITTING NURSE 1. Ensures that jewelry, contact lenses, prosthetic
teeth, etc. have been removed.
2. Gives cleansing enema, if ordered.
3. Inspects operative site and checks
completenessof pre-operative medications.
4. Re-checks the checklist of pre-operative
medications.
5. Takes and records vital signs: Blood Pressure
(BP)/Temperature/ Pulse Rate (PR) or Heart
Rate (HR)/ Respiratory Rate (RR) and the level
of consciousness, and records findings [Form
no. 29] 15 minutes before and after pre-
operative medications have been given.
NURSING ATTENDANT 6. Changes patient’s clothes into OR gown.
ADMITTING NURSE 7. Gives pre-operative medications as scheduled.
OR NURSING ATTENDANT/ 8. Wheels patient from the ward to the OR with the
UTILITY WORKER medical record and other needed medications
and supplies on hand.
ADMITTING NURSE 9. Endorses patient to the OR Nurse.
26
2. EMERGENCY SURGERY
2.1. Pre-operative procedures

SURGEON 1. Explains the procedure to the patient and
hisfamily (how the operation will be performed
and the reason for performing the operation).
2. Obtains the informed consent [Form no. 24]
ofthe patient for the surgery (patient/relative is
asked to sign in the consent form).
3. Writes the order for surgery and the pre-
operative medicines in the physician’s order
sheet.
4. Prepares request for surgery [Form no. 25],
toinclude type of operation, anesthesia to be
used, names of surgeon and anesthesiologist,
and sends it to the Chief of Hospital (COH) or
Senior Resident for approval.
5. Informs the Nurse about the operation.
CHIEF OF HOSPITAL/SENIOR 6. Approves request and returns the same to the
RESIDENT Admitting Nurse.
ADMITTING NURSE 7. Carries out doctor’s order for the operation.
8. Checks the patient’s record and ensures
thatinformed consent has been signed by the
patient or his/her nearest kin.
9. Forwards approved request for surgery to
theOperating Room (OR) Nurse.
OPERATING ROOM NURSE 10. Enters request in the OR logbook and
informs the Admitting Nurse of the schedule
of operation.
SURGEON 11. Determines the schedule after discussing it with
the OR Nurse.
ADMITTING NURSE 12. Notifies/informs Anesthesiologist.
27
ANESTHESIOLOGIST 1. Evaluates patient’s condition, reviews record,
andchecks pre-requisites [Form no. 27].
2. Prepares prescription for pre-operative
medication and anesthetic drugs needed.
3. Discusses with the OR Nurse the need for a
successful and safe induction of anesthesia.
RESIDENT PHYSICIAN/ 4. Ensures that the following pre-operative
ANESTHESIOLOGIST/ requirements are complete:
ADMITTING NURSE/OR 4.1. Consent for surgery
NURSE 4.2. Cross-matched blood, if needed
4.3. Pre-operative medications
4.4. Other supplies
5. Prepares patient psychologically and
spiritually,and orients him/her on the procedures
to be performed.
OPERATING ROOM NURSE 6. Checks instruments, surgical supplies, and other
materials needed prior to surgery.
ADMITTING NURSE 7. Instructs patient on NPO (Nil Per Orem)
7.1. Instructs watcher to strictly comply with
NPO order for the patient.
SUPERVISING NURSE/SENIOR 8. Reviews the pre-operative preparations made for
NURSE the patient.
ADMITTING NURSE/NURSE 9. Prepares patient.
ATTENDANT 9.1. Performs pre-operative procedures as
needed.
9.2. Conducts preliminary preparation of the
operative site.
9.3. Reminds patient to maintain the order of
NPO.
9.4. Removes all jewelry, contact lenses,
prosthetic teeth, etc. and turns over these
items to the patient’s companion for
safekeeping.
ADMITTING NURSE 10. Fills up and signs checklist of pre-operative
preparations [Form no. 28] and gives it to the
Senior Nurse.
SENIOR NURSE 11. Reviews and countersigns checklist and returns
it to the Admitting Nurse.
ADMITTING NURSE 12. Attaches checklist in the patient’s record.
28
13. Inspects operative site.
14. Takes and records vital signs: Blood Pressure
(BP)/Temperature/ Pulse Rate (PR) or Heart
Rate (HR)/ Respiratory Rate (RR) and the level
of consciousness, and records findings [Form
no. 29] 15 minutes before and after pre-
operative medications have been administered.
NURSING ATTENDANT 15. Changes patient’s clothes into OR gown.
ADMITTING NURSE 16. Gives pre-operative medications as scheduled.
OR NURSING ATTENDANT/ 17. Wheels patient from the ward to the OR with
the
UTILITY WORKER medical record and other needed medications
and supplies on hand.
ADMITTING NURSE 18. Endorses patient to the OR Nurse.
29
CHART NO. 6: PRE-OPERATIVE PROCEDURES
CHART NO. 7: EARLY MORNING OF THE OPERATION DAY
ADMITTING NURSE NURSING ATTENDANT OR NURSING ATTENDANT/ UTILITY

WORKER
Ensures that jewelry,

contact lenses,
prosthetic teeth, etc.
have been removed
from the patient
Gives cleansing enema, if

ordered
Inspects operative site and

checks completeness of pre-
operative medications
Re-checks the checklist of

pre-operative medications
Takes vital signs, level of

consciousness before and Changes patient’s clothes
after pre-operative to OR gown
medications
Refers patient to the Surgeon

if BP is high
Gives pre-operative
medications as scheduled
Transfers patient from the ward

to the OR with the chart and
other needed medications and
supplies
Endorses patient and

record to the OR nurse
32
2.2. Preparation of the Operating Room before Surgery
OR AIDE/UTILITY WORKER 1. Cleans and disinfects OR and OR table before use.
Checks that OR lights and airconditioners are
functioning effectively.
NURSING AIDE/NURSE/ 2. Re-checks availability of suction apparatus,
ANESTHESIOLOGIST anesthesia machine, oxygen, and other OR
equipment/supplies needed.
3. Re-checks if machines are functioning effectively.
CIRCULATING NURSE 4. Prepares OR pack for the particular operation.
5. Prepares set-up for the particular operation.
Immediate Pre-operation Period
SCRUB NURSE 1. Sets up the table for sterile instruments, suturing
sets, sponges, basin, etc.
CIRCULATING NURSE 2. Counts and writes on the board the number of
sponges, instruments, and needles on the table.
2.3. Maintenance of the Operating Room
SUPERVISING OR NURSE 1. Assures the readiness of the OR at all times
2. Approves requisition for supplies and materials.
3. Reviews inventory of supplies and endorses reports.
SENIOR OR NURSE 4. Maintains the sterility of the OR.
5. Ensures the availability of supplies and materials.
6. Schedules cases appropriately.
7. Submits monthly report.
8. Implements strict compliance to
ORpolicies/procedures.
9. Assists OR Nurse in difficult cases.
10. Requests for OR equipment, drugs, supplies,
andmaterials.
OR NURSE 11. Prepares OR packs for sterilization.
12. Checks condition of OR instruments.
13. Maintains proper storage and labeling of supplies
andinstruments.
14. Enforces prescribed level of disinfection and sterility.
OR AIDE/UTILITY WORKER 15. Cleans the OR before and after each use.
16. Gathers the used linens/scrub suits. Disinfects and
forwards the same to the Laundry Unit
17. Collects all used tubes, needles, clips,
syringes,gauze, IV bottles, etc., and disposes these
properly.
18. Sanitizes the OR table.
19. Autoclaves OR packs and keeps these in its proper
storage.
CHART NO. 8: PREPARATION OF THE OPERATING ROOM
33
ANESTHESIOLOGIST CIRCULATING NURSING SCRUB OR AIDE/ NURSE AIDE
NURSE UTILITYWORKER
Re-checks availability of suction apparatus, anesthesia

Cleans and disinfects
machine, oxygen and other OR equipment/supplies needed OR before use
Re-checks if machines are functioning effectively
Prepares OR pack
for the particular
operation
Sets up the table

Prepares set-up for for sterile
the particular instruments ,
operation suturing sets,
sponges, basin,
etc.
Counts and
writes on the
board the
number of
sponges,
instruments and
needles on the
table
2.4. Patient care in the Operating Room
34
CIRCULATING NURSE AND 1. Receives patient and checks if all the pre-operative
ANESTHESIOLOGIST requirements were given.
UTILITY WORKER 2. Transfers patient to the operating table.
ANESTHESIOLOGIST 3. Takes and records vital signs, checks patency of IV
fluid line, urethral catheter, and other gadgets
attached to the patient.
CIRCULATING NURSE 4. Checks if operative site have been properly shaved
and cleaned.
ANESTHESIOLOGIST/ 5. Places patient in the prescribed position to ensure
CIRCULATING NURSE safety and protect patient from trauma.
SCRUB NURSE 6. Performs scrubbing techniques, gowning,
andgloving.
7. Arranges instruments and supplies according to
thespecified order and type of operation to be
performed.
8. Counts sponges and instruments and informs
theCirculating Nurse of the total number.
CIRCULATING NURSE 9. Writes on the board the number of sponges
andinstruments to be used.
10. Assists and anticipates the needs of the Scrub
Nurse, Surgeon, and Anesthesiologist.
ANESTHESIOLOGIST 11. Inducts anesthesia.
12. Continuously monitors vital signs during
operationand properly records them in the
Anesthesia Record [Forms no. 30 and 31].
13. Updates surgeon on the status of the patient.
CIRCULATING/ SCRUB 14. Disinfects the skin/operative site.
NURSE
SURGEON/ASSISTANT 15. Performs aseptic scrubbing, gowning, and gloving.
SURGEON
SCRUB NURSE/SURGEON 16. Prepares operative area aseptically and drapes
patient.
SURGEON/ASSISTANT 17. Performs the operation.
SURGEON
SCRUB NURSE/ 18. Assists and anticipates the needs of the surgeon
CIRCULATING NURSE during operation.
Before the Surgeon Closes the Operative Site
SCRUB NURSE 1. Informs the surgical team as to the completeness of
instruments, sponges, and needles.
CIRCULATING NURSE AND 2. Confirms the completeness of instruments, sponges,
SCRUB NURSE and needles.
SURGEON/ASSISTANT 3. Closes operative site and applies top dressing.
SURGEON
CIRCULATING NURSE 4. Completes documentation and recording.
CHART NO. 9: PATIENT CARE IN THE OR
35
2.5. Post-operative procedures
Inside Operating Room (OR)
36
SCRUB NURSE 1. Cleans and keeps the patient dry.
2. Checks for undue pressure of contraptures.
3. Keeps patient safe and comfortable by providing
ablanket and using straps or bed railings.
NURSING ATTENDANT 4. Gathers and washes used instruments and abdominal
packs.
CIRCULATING NURSE 5. Removes all straps attached to the patient.
ANESTHESIOLOGIST 6. Takes and records vital signs until patient
conditionstabilizes.
7. Checks patency of IV fluid lines and
othercontraptures.
8. Accomplishes anesthesia record and post-operative
orders.
SURGEON 9. Accomplishes operating room record [Forms no. 32
and 33] and writes the surgical technique used.
CIRCULATING 10. Accompanied by the Anesthesiologist, wheels
patient
NURSE/UTILITY WORKER to the recovery room and transfers the patient to
the bed.
CIRCULATING NURSE 11. Endorses patient to the Recovery Room Nurse.
SCRUB NURSE 12. Collects, places, and labels specimen in a
container with 10% formalin solution (see
Histopath Examination, pp. 83-84).
UTILITY WORKER 13. Cleans and disinfects Operating Room.
Recovery Room (RR)
RECOVERY ROOM NURSE 1. Receives patient from the OR Nurse.
2. Monitors patient’s condition and records in the
chartall observations, nursing care, and interventions
made. [Forms no. 34 and 35].
3. Refers to the Physician when needed.
ANESTHESIOLOGIST 4. Monitors patient’s status and progress.
5. Orders patient’s transfer to the ward.
RECOVERY ROOM NURSE 6. Informs Admitting Nurse on the patient’s transfer to
the ward.
UTILITY WORKER AND 7. Transports patient to the ward.
RR
NURSE 8. Endorses patient and patient record to the Admitting
Nurse.
ADMITTING NURSE 9. Receives the patient and the patient’s record.
37
CHART NO. 10: POST-OPERATIVE PROCEDURES
SURGEON ANESTHESIOLOGIST CIRCULATING SCRUB NURSE NURSING UTILITY

NURSE ATTENDANT WORKER
Cleans and
keeps patient
Takes and records dry
vital signs
Checks for
Accomplishes Checks patency undue pressure
operating of IV fluid lines of contraptures
room and other
record/writes contraptures
surgical
technique
used Keeps patient
safe and
Accomplishes comfortable by
anesthesia record providing
and post- blanket and
operative orders using straps or
Removes all straps bed railings Gathers and
from the patient, brings used
takes and records instruments to
patient’s vital signs wash room &
washes them
(with utility worker)

Accompanied by the
Anesthesiologist,
conducts patient to the
recovery room and
transfers the patient to
bed
Collects, places
Endorses patient to the and labels Cleans
Recovery Room Nurse specimen in a and
container with disinfects
10% formalin OR
solution
38
CHART NO. 11: CARE IN THE RECOVERY ROOM
OLOGIST RECOVERY UTILITY ADMITTING

ROOM NURSE WORKER NURSE
Receives
endorsement
from the OR
nurse
Monitors & records

patient’s condition
Refers to the physician

when needed
tient’s status
ogress
ent’s transfer
e ward
Informs Admitting Nurse

of the patient’s transfer to
the ward
th
Receives the
patient and the
patient’s record
from the RR nurse
LABOR ROOM/DELIVERY ROOM PROCEDURES

1. Patient care in the Labor Room
39
OBSTETRIC NURSE 1. Receives patient with record and duly accomplished
consent form signed by the patient or responsible
party.
2. Prepares patient for internal examination (e.g.,
perineal flushing, shaving).
Note: May be performed by the Nursing Attendant
3. Informs the Resident on duty
RESIDENT ON DUTY 4. Assesses patient.
5. Orders routine laboratory examinations, etc.
OBSTETRIC NURSE/ WITH 6. Monitors and records patient’s condition including
RESIDENT ON DUTY vital signs, blood pressure, weight, fetal heart tone
(FHT), and progress of labor (interval and duration
of uterine contractions), and refers patient if
necessary [Forms no. 36 and 37].
OBSTETRICIAN/ 7. Assesses patient.
RESIDENT ON DUTY 8. For direct to labor room admission,
orderspreparation for delivery like enema, complete
blood count (CBC), clotting time/bleeding time
(CT/BT) urine examination, and blood for blood
transfusion, if needed.
9. Orders the transfer of the patient either to
theDelivery Room (DR) or Operating Room (OR), as
the case may be.
CHART NO. 12: PATIENT CARE IN THE LABOR ROOM
40
OB NURSE WITH RESIDENT ON DUTY OBSTETRICIAN/ ROD
Receives patient with record, with

duly accomplished consent form
signed by the patient or
responsible party
Assesses patient
Positions patient on the DR table and
informs Obstetrician on duty
For direct to labor room

admission, orders preparation
Monitors and records patient’s condition for delivery like enema, CBC,
including vital signs, blood pressure, CT/BT, urine examination, and
weight, FHT, progress of labor, and refers blood for blood transfusion, if
patient if necessary needed
Prepares patient for examination
Orders the transfer of the

patient to either the DR or
the OR, as the case may
be
41
2. Patient care in the Delivery Room
DR NURSING ATTENDANT 1. Disinfects DR before and after use.
(NA)/UTILITY WORKER
DR NURSE 2. Receives the patient from the labor room with
themedical record, medicines, and other supplies.
3. Prepares DR pack.
4. Prepares set-up for normal vaginal delivery.
5. Arranges, counts, and writes on the board the
number of sponges, instruments, and needles.
6. Prepares patient for delivery.
6.1. Disinfects perineal area.
6.2. Drapes patient with sterile linen.
7. Monitors patient’s vital signs and FHT.
8. Informs the Obstetrician when patient is ready to
deliver the baby.
OBSTETRICIAN/ 9. Attends to the delivery and assist the patient.
RESIDENT ON 10. Observes aseptic technique.
DUTY 11. Records the obstetrical intervention/management.
DR NURSE/MIDWIFE 12. Assists Obstetrician during the procedure, initiates
latching-on of baby immediately after delivery.
13. Prepares and attaches ID tags to
bothmother/patient and baby.
PEDIATRICIAN/ 14. Receives baby and suctions secretions from thebaby’s
RESIDENT ON DUTY) mouth.
15. Assesses baby’s status.
16. Performs initial newborn care and management (use
the Newborn Record) [Form no. 38].
17. For complicated cases, endorses baby to theNeonatal
Intensive Care Unit (NICU).
NOTE:
If pediatrician or Pediatric resident is not readily
available, the Obstetrician/OB rersident on duty
will assess the baby’s condition.
DR NURSE Performs perineal care.

OBSTETRICIAN/ RESIDENT Writes post-partum orders on patient’s record.
ON DUTY
37
Action
Carries out immediate post-delivery doctor’s orders.
Completes recording/charting [Form no. 39].
Logs information on the DR register.
Prepares two copies of the charge slips [Form no.
4] for drugs, medicines, and other supplies used
during delivery.
Forwards the first copy of the charge slip to the
Billing Section.
Retains the second copy for DR file.
Transports the mother and baby to the ward.
Endorses mother and baby to the Ward Nurse for

oming-in with:
• Checklist
• Medications
• Medical record
• Latest vital signs
38
CHART NO. 13: PATIENT CARE IN THE DELIVERY ROOM
PEDIATRICIAN OBSTETRICIAN DR NURSE MIDWIFE DR UTILITY DR
NURSING WORKER ATTENDANT
39
OBSTETRIC (OB) WARD PROCEDURES
RESPONSIBILITY ACTION
RD NURSE 1. Receives mother, baby, and medical records from
the Delivery Room (DR) Nurse.
2. Prepares pre-form of Birth Certificate (BC)
[COHtocopy of Form no. 40] and forwards the same
to the Senior Nurse.
3. The Senior Nurse reviews pre-form of BC for
completeness and instructs Nursing Attendant to
forward the same to the Medical Records Service
(MRS) for transcription to official form [Form no.
40]
(please see Medical Records procedures on
preparation of Birth Certificates, pp.
166167).
4. Carries out treatments and medications ordered by
the Attending Physician.
5. Advises mother to breastfeed newborn baby.
6. Monitors vital signs and reports any untoward
findings to the Attending Physician.
7. Documents observations and nursing care given
[Form no. 16].
8. Refers patients contemplating legal adoption of
their babies to the Medical Social Service (MSS)
(please see Medical Social Service
Procedures, p. 120).
9. Submits daily charges to the Billing Section.
10. Informs Dietary Service of new admission(s) from
the DR.
11. Educates nursing mothers on lactation management
and breastfeeding sustainability counseling through
proper nutrition.
RSING ATTENDANT 12. Performs perineal flushing.
TENDING PHYSICIAN 13. Performs perineal assessment and Internal
Examination (IE) before the patient is sent home.
14. Gives discharge orders and instructions.
RD NURSE 15. Submits additional charges to the Billing Section.
40
CHART NO. 14: OB WARD PROCEDURES
WARD N NURSE NURSING ATTENDANT ATTENDING
Receives mother, baby,

and medical records from
the DR Nurse
Carries out treatments and

medication orders, prepares BC.
Advises mother to breastfeed

baby
Performs perineal flushing

Performs ward activities,
documents observations, &
refers untoward findings to
Physician Performs perineal
assessment and IE
before the patient is
sent home
Reviews BC for completeness,
and forwards to MRS
Gives discharge orders

Refers patients contemplating and instructions
legal adoption to MSW
Submits daily charges to the

Billing Section
Informs Dietary Service of

new admission(s) from DR
Provides lactation counseling
Monitors and records vital

signs and refers to Physician
for unusual findings
Submits additional
charges to the Billing
Section
41
PHYSICIAN
PROCEDURES IN THE CENTRAL SUPPLY ROOM
1. Requisition of supplies
CSR HEAD 1. Monitors stock level of supplies.
1.1. For supplies below stock level, instructs
Central Supply Room (CSR) Nurse/Attendant
to prepare requisition.
2. Disseminates information on status of new
supplies,materials, and instruments.
MIDWIFE/NURSING 3. Prepares Requisition Issuance Slip (RIS) [Form no.
ATTENDANT (NA)/CSR 41] and forwards the same to the CSR Head/Chief
STAFF Nurse.
NOTE: For disinfectants, prepares and forwards request

slip [Form no. 42] to the CSR Head/Chief Nurse.
CSR HEAD/CHIEF NURSE 4. Signs RIS and forwards the same to the Supply
Officer. For disinfectants, signs request slip and
forwards the same to the Pharmacist.
PHARMACIST 5. Issues disinfectants requested by CSR like povidone
iodine 10%, isopropyl alcohol 70%, glutaraldehyde
2% and saponated cresol 50% through the request
slip.
SUPPLY OFFICER/ 6. Evaluates request and determines the stock level.
STOREKEEPER/DESIGNATE 7. Indicates quantity and items available/
withdrawablein the RIS.
8. Forwards RIS to the CSR Head/Chief Nurse.
CSR HEAD/CHIEF NURSE 9. Recommends approval of the RIS and forwards the
same to the Administrative Officer (AO).
ADMINISTRATIVE OFFICER 10. Reviews and initials RIS and forwards the same to
the Chief of Hospital (COH).
CHIEF OF HOSPITAL 11. Reviews and approves the RIS, and returns the same
to the Supply Officer.
SUPPLY OFFICER/ 12. Issues items requested to the CSR-designated
STOREKEEPER/DESIGNATE recipient.
NURSE/NURSING 13. Receives supplies and signs the RIS.
ATTENDANT (NA)/CSR 14. Enters items received in the stock card [Form no.
STAFF 43].
42
CHART NO. 15: CSR PROCEDURES: REQUISITION OF SUPPLIES
CHIEF OF ADMINISTRATIVE CHIEF NURSE CSR HEAD NURSE/NA PHARMACIST SUPPLY
43
2. Receiving and sterilization of used articles
WARD NURSING 1. Delivers used articles to the CSR (from clinical
ATTENDANT area).
CSR COUNTER 2. Receives and checks used articles.
CLERK/NURSING 3. Indicates missing items on the borrower’s slip.
ATTENDANT
BORROWER 4. Acknowledges missing items/ parts.
CSR COUNTER 5. Places articles inside the autoclave for disinfection.
CLERK/NURSING 6. Files borrower’s slip/logbook for the report
ATTENDANT/UTILITY preparation.
WORKER 7. Forwards articles to the designated washers.
NURSE ATTENDANT 8. Washes, dries, and packs articles.
CSR/ NURSE/ NURSING 9. Labels packs indicating the contents and the date
ATTENDANT ofsterilization.
10. Places articles in the autoclave for sterilization.
11. Sorts sterilized packed articles.
12. Informs units/end-users concerned that sterilized
articles are ready for use/withdrawal.
INFECTION CONTROL 13. Monitors observance of aseptic techniques and
COMMITTEE MEMBERS infection control measures.
CHART NO. 16: CSR PROCEDURES:
RECEIVING AND STERILIZATION OF USED ARTICLES
50
INFECTION CSR CSR CSR NURSE BORROWER WARD NURSING CONTROL
STAFF NURSING ATTENDANT
Delivers used
articles to the
CSR
Receives and checks used articles
Acknowledges
YES missing items,
Missing items? if any
NO
Places articles directly inside the

autoclave for disinfection
Files borrower’s slip for the report

preparation
Forwards items to the designated

washers
Washes, dries
and packs articles
Labels and
sterilizes packs,
and sorts
sterilized articles
Monitors
observance of Informs units/end-
aseptic users concerned that
techniques and sterilized articles are
infection control ready for
measures use/withdrawal
COM. MEMBERS ATTENDANT
51
3. Issuance of sterile articles
RESPONSIBILITY ACTION
CSR STAFF/ 1. Receives borrower’s slip (2 copies) duly signed by
MIDWIFE/NURSING the end-user/ borrower.
ATTENDANT 2. Prepares articles and supplies listed on theborrower’s
slip and places them on a tray/receptacle.
3. Checks items against the borrower’s slip and
signsclearance for release.
4. Issues articles to the borrower.
CSR COUNTER 5. Issues copy of slip to the borrower and files original
CLERK/PERSONNEL copy.
52
CHART NO. 17: CSR PROCEDURES: ISSUANCE OF STERILE ARTICLES
CSR STAFF CSR NURSING CSR NURSE WARD NURSING ATTENDANT

ATTENDANT/ BORROWER
Receives borrower’s slip
Prepares articles and supplies listed in

the borrower’s slip and places them in a
tray
Checks prepared
articles and supplies
Issues articles to the against those listed in
Ward Nursing the borrower’s slip and
Attendant or borrower clears release of said
items being borrowed
Checks items against the

borrower’s slip, signs,
Issues copy of
slip to the
borrower and
files original copy
53
4. Routine preparation of supplies for sterilization
CSR HEAD 1. Identifies supplies/instruments/packs for
sterilization.
CSR STAFF/ATTENDANT/ 2. Prepares and labels needed supplies and packs
them
UTILITY WORKER individually or in bulk, or wraps them in clean
paper.
3. Sterilizes items.
CSR NURSE 4. Checks sterilized supplies.
CSR CLERK/NURSING 5. Updates stock card.
ATTENDANT (NA)
CHART NO. 18: CSR PROCEDURES:
ROUTINE PREPARATION OF SUPPLIES FOR STERILIZATION
CSR HEAD CSR CLERK/NURSING CSR NURSE
ATTENDANT
Identifies
supplies/packs/
instruments for
sterilization
Prepares needed supplies and packs them individually

or in bulk, or wraps them in clean paper
Labels these packs and sterilizes items
Checks sterilized supplies
Updates stock
card
54
5. Articles
for to be condemned/disposed
NURSING ATTENDANT 1. Endorses items to the CSR.
CSR STAFF /NURSING 2. Receives and lists articles to
ATTENDANT becondemned/disposed.
3. Accomplishes and signs Return Slip [Form no. 44]
intwo copies (1 copy for Supply Officer and 1 copy
for CSR) and forwards the same to the Chief Nurse
for approval.
CHIEF NURSE 4. Approves the Return Slip and returns the same to
the CSR personnel.
CSR STAFF /NURSING 5. Returns items to the Supply Officer/Storekeeper for
ATTENDANT their eventual disposal (Please see Property and
Supply Procedures, pp. 232-233).
5. Updates stock card [Form no. 43].
6. Files return slip.
7. Updates inventory.
CHART NO. 19: CSR PROCEDURES: ARTICLES TO BE CONDEMNED/DISPOSED
CHIEF NURSE CSR STAFF/NURSING NURSING ATTENDANT ATTENDANT

Receives and lists articlesto be
condemned Endorses
items for
condemnation
to the CSR
Approves the return slip Accomplishes and signs return
and gives it back to the CSR slip and forwards to the Chief
staff Nurse
Returns items to Supply

Officer/Storekeeper for their Chart no.
eventual disposal 113, p. 233
Updates stock card
Files return slip
Updates Inventory
55
REFERRAL PROCEDURES
1. Referral of patient
1.1. To other health facilities

ATTENDING PHYSICIAN 1. Prepares clinical summary [Form no. 8] and
accomplishes referral slip [Form no. 9].
2. Seeks approval of referral from the Chief of
Hospital(COH) or Senior House Officer.
CHIEF OF 3. Approves referral.
HOSPITAL/SENIOR HOUSE
OFFICER
ATTENDING PHYSICIAN 4. Coordinates with the doctor in the referral facility.
WARD NURSE/NURSING 5. Facilitates patient discharge.(See Issuance of
ATTENDANT Clearance Certificates, pp. 61-62)
6. If from OPD/ER, advises relatives/companion to
proceed to the Billing Section for payment of used
medicines and supplies (see Billing procedures
for patients from OPD, pp. 201-202).
7. Coordinates with the Medical Social Worker on the
referral.
MEDICAL SOCIAL WORKER 8. Provides patient and family counseling regarding the
psycho-social impact of the transfer.
9. Prepares case summary [Form no. 45] and referral
letter.
10. Identifies other problems that might affect the
referral.
11. Provides assistance to facilitate transfer.
NURSE 12. Coordinates with the hospital transportation service
for ambulance.
NURSE/ATTENDING 13. Accompanies patient to the referral facility.
PHYSICIAN
CHART NO. 20: REFERRAL PROCEDURES: TO OTHER HEALTH FACILITIES
56
COH/SENIOR ATTENDING NURSE NURSING MEDICAL
HOUSE RESIDENT PHYSICIAN ATTENDANT SOCIAL WORKER
Prepares clinical
summary and
accomplishes
referral slip
Seeks approval of
referral from COH or
senior house officer
Approves referral
Coordinates with the Provides patient and

doctor in the referral family counseling
facility regarding the
Facilitates patient’s release transfer
from the hospital:
• If from the ward,
facilitates the discharge
• If from OPD/ER, instructs
relatives/companion to go Prepares case
to the billing section for summary & referral
payment of used letter
medicines and supplies
Identifies other
Coordinates with the MSW problems that might
regarding the referral
affect referral
If necessary,
arranges for
ambulance
Accompanies patient to
referral facility
1.2. To other departments within the hospital

57
ATTENDING PHYSICIAN 1. Accomplishes inter-departmental slip or referral slip
within the hospital [Form no. 26].
2. Attaches laboratory and x-ray results and
provisional diagnosis.
3. Seeks approval of referral from the Senior
House Officer.
SENIOR 4. Approves referral.
HOUSE OFFICER
WARD NURSE 5. Sends referral slip to the Physician concerned.
RECEIVING PHYSICIAN 6. Examines patient and evaluates together with
theAttending Physician.
7. Documents assessment on the patient’s
medicalrecord.
58
CHART NO. 21: REFERRAL PROCEDURES:
TO OTHER DEPARTMENTS WITHIN THE HOSPITAL
SENIOR HOUSE ATTENDING RECEIVING NURSE

OFFICER PHYSICIAN PHYSICIAN
Accomplishes
Inter-departmental
referral slip
Attaches laboratory
and x-ray results and
provisional diagnosis
Approves referral Seeks approval of

referral from Chief of
Hospital (COH) or
Senior House Officer
Sends referral slip to
the physician
concerned
Examines patient and
evaluates together with
the attending referring
physician
Documents
assessment in the
patient’s medical
record
2. Networking for specialized equipment/procedures

ATTENDING PHYSICIAN 1. Prepares inter-agency referral form [Form no. 9] and
gives this to the Nurse.
NURSE 2. Receives and forwards the referral form to the Medical
Social Worker.
59
MEDICAL SOCIAL WORKER 3. Completes the requirements for referral and
preparessocial case study [Form no. 45].
4. Coordinates with the referral facility about
theexpenses and schedule.
5. Orients and prepares the family about the expenses.
6. Sources out funds for those who cannot fully
affordthe procedure.
7. Informs the Nurse of the schedule.
NURSE 8. If necessary, coordinates with the hospital
transportation service for ambulance.
PHYSICIAN/NURSE 9. If necessary, accompanies patient to the referral
facility.
PATIENT’S RELATIVE 10. If referral is for laboratory procedures, transports the
specimen to the referral facility.
60
CHART NO. 22: REFERRAL PROCEDURES: NETWORKING FOR SPECIALIZED
EQUIPMENT/PROCEDURES
PHYSICIAN NURSE MEDICAL SOCIAL PATIENT’S WORKER RELATIVE
Prepares inter-
agency referral
form and gives
this to the nurse
Receives and Completes the
forwards the requirements for referral
referral form to and prepares social case
the Medical study
Social Worker
Coordinates with the

referral facility about the
expenses and schedule
Orients and prepares the

family about the expenses
Sources out funds for

those who cannot fully
afford the procedure
Informs the nurse of the

schedule
Need to
NO Brings
transport specimen
patient?
to referral
facility
YES
Coordinates
with the
hospital
transportation
service for
ambulance, if
necessary
Accompanies patient to the

referral facility
61
3. Accepting referral from other facilities
CHIEF OF 1. Accepts referrals.
HOSPITAL/SENIOR
HOUSE OFFICER 2. Endorses the request to the concerned service or unit.
SERVICE/UNIT STAFF 3. Prepares charge slip [Form no. 4].
CASHIER 4. Accepts payment and issues official receipt.
SERVICE/UNIT STAFF 5. Performs requested procedure and reads result.
6. Types/writes result in an official form.
7. Releases result to the requesting physician,
throughthe patient or relative.
CHART NO. 23: REFERRAL PROCEDURES: ACCEPTING REFERRAL FROM
OTHER
FACILITIES
COH/SENIOR SERVICE/UNIT CASHIER

HOUSE OFFICER STAFF
Accepts referrals
Accepts payment and

Prepares charge slip issues official receipt
Endorses the
request to the Performs requested
concerned service procedure and reads result
or unit
Types/writes result in an
official form
Releases result through

the patient or relative
4. Refusing Patient referral from other facilities

CHIEF OF 1. Examines reason for referral
HOSPITAL/SENIOR
HOUSE OFFICER 2. Determines whether cause of referral is not appropriate
or the hospital has no capabilities to accept the referral.
SERVICE/UNIT STAFF 3. Informs conducting officer of the non-acceptance.
4. Makes appropriate arrangements.
62
DISPOSITION OF PATIENT
1. Discharge of patient
ATTENDING PHYSICIAN 1. Examines and evaluates patient and indicates in
thepatient’s medical record the order for discharge.
2. Writes discharge instructions and prescriptions needed
for home treatment [Form no. 6].
3. Completes diagnosis (ICD 10 Classification) on
thepatient’s record and forwards the same to the
Ward Nurse.
WARD NURSE 4. Informs Medical Social Service (MSS) of all indigent
patients for discharge planning.
MEDICAL SOCIAL WORKER 5. Visits and discusses discharge plan with the patient
(please see MSS procedures, pp. 110-111).
WARD NURSE 6. Reviews patient’s medical record for completeness.
7. Gives discharge instructions and health education
tothe patient and informs him/her of the date of
follow-up/check-up.
8. Prepares Clearance Certificate (CC) [Form no. 23]
and discharge notice [Form no. 46]. (See
Issuance of Clearance Certificate, this
chapter, pp. 6162).
9. Notifies Pharmacist regarding patients to
bedischarged and directs patient/watcher to the
Pharmacy to return unused drugs.
PHARMACIST 10. Dispenses take home medicines, if any, to the
patient and provides drug information and
counseling.
11. Prepares a list of returned medicines
usingpharmacy charge slip [Form no. 4].
11.1. Forwards charge slip to the Billing Section
(please see Billing procedures for in-patients,
pp. 203-204).
NURSING ATTENDANT 12. Ensures that all equipment/items previously issued
to the patient have been returned.
PATIENT/COMPANION 13. Presents duly accomplished CC and official receipt to
the Ward Nurse.
63
WARD NURSE 14. Discharges patient.
15. Cancels name of patient in the diet list and
patient’sdirectory both in the ward and Information
Unit.
16. Informs Dietary Service of the discharged patients.
17. Returns CC to the patient to be presented to
thedesignated hospital staff as pass.
64
CHART NO. 24: DISPOSITION OF PATIENT: DISCHARGE
65
ATTENDING WARD NURSE NURSING PHARMACIST MEDICAL PATIENT
2. Patient going Home Against Medical Advice (HAMA)

PATIENT/RELATIVE 1. Requests discharge against medical advice.
WARD NURSE 2. Refers request to Attending Physician.
66
ATTENDING 3. Advises patient/relative on the implications
PHYSICIAN/RESIDENT-ON- andconsequences of going home against medical
DUTY advice (HAMA) [Form 47].
4. Indicates HAMA on patient’s record.
5. Refers patient to the Medical Social Service (MSS)
forcounseling.
MEDICAL SOCIALWORKER 6. Counsels patient about the consequences
ofdischarging against medical advice.
7. Coordinates with the Attending Physician and Ward
Nurse.
WARD NURSE 8. Explains the HAMA form to the patient, fills it up, and
requests patient/relative to sign.
PATIENT/RELATIVE 9. Signs HAMA form.
WARD NURSE 10. Reviews HAMA form and medical record
forcompleteness.
11. Ensures that all hospital bills are settled
12. Prepares Clearance Certificate and discharge
notice[Forms no. 23 and 46] (please see Issuance
of Clearance Certificate, this chapter, pp. 61-
62).
13. Directs patient/watcher to the Pharmacy to
returnunused drugs.
PHARMACIST 14. Prepares a list for returned medicines using
pharmacy charge slip [Form no. 4].
14.1. Forwards charge slip to the Billing Section
(please see Billing procedures for
inpatients, pp. 203-204).
NURSING ATTENDANT 15. Ensures that all equipment/items previously issued to
the patient have been returned.
PATIENT/COMPANION 16. Presents duly accomplished CC and official receipt to
the Ward Nurse.
WARD NURSE 17. Discharges patient.
18. Cancels name of patient in the diet list and patient’s
directory both in the ward and Information Unit.
19. Informs Dietary Service of the discharged patients.
20. Returns CC to the patient to be presented to
thedesignated hospital staff as pass.
CHART NO. 25: DISPOSITION OF PATIENT: HOME AGAINST MEDICAL ADVISE
67
ATTENDING WARD NURSE NURSING PHARMACIST MEDICAL PATIENT
PHYSICIAN ATTENDANT SOCIAL WORKER
Advises Refers
Requests
patient/ request to HAMA
relative on attending
implications physician
and
consequences
of HAMA Counsels
patient about
the
consequences
Indicates of HAMA &
HAMA on coordinates
patient’s with the
chart & refers attending
patient to Fills up HAMA physician &
MSS for form and ward nurse
counseling requests
patient/relative Signs HAMA
to sign form
Reviews HAMA form

and chart for
completeness &
prepares CC and
discharge notice
Prepares a list of
returned
Directs patient/watcher medicines using
to the Pharmacy to Pharmacy charge
return unused drugs slip and
forwards this to
the Billing Section
Ensures that all
equipment/
items
previously
i ssued to the
p atient are
returned
Presents duly
accomplished
Discharges patient,
CC and official
cancels name in diet list receipt to the
and directory and Ward Nurse
informs Dietary Service
Gives back CC to
be presented to
the designated
hospital staff as
pass
3. Issuance of clearance certificate

68
PHYSICIAN 1. Writes discharge orders and forwards them to the
Ward Nurse.
WARD NURSE 2. Checks patient’s record for the physician’s
dischargeinstructions.
3. Prepares three copies of the Clearance
Certificate[Form no. 23].
4. Instructs patient/companion to secure clearance
withthe other units concerned, namely, Radiology,
Laboratory, Pharmacy and Central Supply Room
(CSR).
REVENUE CENTER STAFF 5. Checks for unbilled charges.
6. Prepares charge slips for unbilled accounts,
writesthe amount on the CC, and attaches the
charge slips [Form no. 4] on the clearance
certificate.
7. Initials in appropriate space of the CC and
instructspatient to proceed to the Billing Section.
BILLING SECTION 8. Checks patient’s jacket [Form no. 48] and
preparesStatement of Account [Form no. 49]
according to MSS classification.
9. Initials the CC and instructs patient/companion
topay to the Cashier. If patient cannot pay,
instructs patient to go to MSS.
MEDICAL SOCIAL WORKER 10. Re-evaluates patient and sources out funds to
cover hospital expenses.
11. Refers patient back to the Billing Section.
BILLING 12. Bills patient and instructs patient to proceed to the
Cashier.
CASHIER 13. Receives payment and indicates official
receiptnumber in the CC.
14. Issues official receipt to the patient/companion and
signs CC.
15. Instructs patient/companion to forward CC to
theWard Nurse.
NURSING ATTENDANT 16. Checks if all equipment/items previously issued to
patient have been returned.
WARD NURSE 17. Checks if CC have been properly accomplished.
18. Signs in appropriate space.
19. Gives final instructions to patients/relatives
regardinghome care, medication, and check-up
schedule.
20. Issues the CC to the patient/companion.
69
CHART NO. 26: DISPOSITION OF PATIENT: ISSUANCE OF CLEARANCE CERTIFICATE
PHYSICIAN WARD NURSE NURSING REVENUE CENTER BILLING CASHIER MEDICAL SOCIAL
ATTENDANT STAFF SECTION WORKER
Writes discharge
orders and
forwards them
to the Ward
Nurse
Checks unbilled
Bills patient and
charges, prepares Re-evaluates
instructs patient NO
Checks patient’s record for charge slips for unbilled Able to patient and
to go to the
discharge instructions and accounts, writes the pay? sources out
physician’s signature Cashier
amount on the CC and funds
attaches the charge
slips on the CC
YES
Prepares three copies of CC &
instructs patient/
companion to secure Initials in appropriate Receives
clearance with the other units space of the CC and payment and
concerned instructs patient to indicates official
proceed to the Billing receipt number
Section in the CC &
Checks if Clearance Certificate Checks if all gives OR and
have been properly equipment/ CC to the
accomplished items patient/
previously companion and
issued to signs CC
patient have
Signs in appropriate space been returned
Gives final instructions to Instructs

patients/relatives re: home patient/companion
care, medication, and check- to forward Clearance
up schedule Certificate to the
Ward Nurse
Issues CC to the patient/

companion
62
DISPOSITION OF CADAVER
1. Preparation of cadaver in the ward

NURSING ATTENDANT 1. Removes contraptions.
2. Provides post-mortem care.
3. Prepares three cadaver tags.
NURSE ON DUTY 4. Endorses personal belongings of the deceased to
therelative/watcher.
5. If unidentified, deposits personal belongings of
thedeceased to the property custodian/supplies officer
and documents receipt of such items.
6. Prepares cadaver’s clearance.
SENIOR HOUSE OFFICER 6.1 Informs proper authority of unidentified cadaver.
NURSE ON DUTY 7. Notifies Medical Social Worker of unidentified
cadaver.
MEDICAL SOCIAL WORKER 8. Exerts all efforts to locate family of unidentified
cadaver.
8.1 Checks all personal belongings together with
theProperty Custodian to get a clue on patient’s
identity.
8.2 Coordinates with the media - radio, print, and
television.
PHYSICIAN ON DUTY 9. Prepares Death Certificate (DC) [Form no. 50] and
asks a relative to sign as informant (please see
Medical Records Procedures, pp. 168-169).
UTILITY WORKER 10. Transports cadaver with the duly accomplished
Death Certificate and medical records to the morgue
for safekeeping until cadaver is claimed.
10.1 For unidentified/abandoned cadavers,
coordinates with the MSS for appropriate
action.
MEDICAL SOCIAL WORKER 10.2 Arranges for safekeeping or pauper’s burial.
72
SENIOR HOUSE NURSE ON DUTY WARD
OFFICER
CHART NO. 27: MSW PHYSICIAN ON DUTY NURSING UTILITY ATTENDANT WORKER
DISPOSITION OF
CADAVER:
PREPARATION OF
CADAVER IN THE
2. Receiving in the morgue
MORGUE ATTENDANT 1. Receives cadaver with the Death Certificate [Form
no. 50] and medical records, and logs receipt in the
register.
2. Files and maintains the confidentiality of the
medicalrecords in the appropriate area.
3. Keeps and maintains cadaver until it is claimed.
CHART NO. 28: DISPOSITION OF CADAVER: RECEIVING IN THE MORGUE
MORGUE ATTENDANT
Receives cadaver with the

Death Certificate and medical
records and logs receipt in
the register
Files and maintains the

confidentiality of the medical
records in the appropriate
area
Keeps and maintains cadaver

until it is claimed
74
3. Release of cadaver to the claimant
CLAIMANT 1. Requests for release papers (Disposition of the
cadaver) [Form no. 51] at the Information Unit.
INFORMATION CLERK 2. Interviews claimant to establish identity
(claimantmust be next of kin or executor/guardian).
3. Gives release documents to the claimant and
directshim/her to see the Morgue Attendant.
CLAIMANT 4. Presents the release paper to the Morgue Attendant.
MORGUE ATTENDANT 5. Receives notice of release of cadaver from
theclaimant.
6. Ensures that claimant has appropriate vehicle to
transport the cadaver.
7. Releases cadaver to the claimant and indicates in
thelogbook the date and time of release, the name
of the claimant, and ensures that no hospital
property is carried with the cadaver (e.g., hospital
linen).
8. Asks claimant to sign over his/her printed
ortypewritten name.
CLAIMANT 9. Receives cadaver and countersigns in the logbook.
MORGUE ATTENDANT 10. Forwards release documents, Death Certificate and
medical records to the Medical Records Service
(MRS). If after office hours, forwards these
documents to the Information Unit.
INFORMATION CLERK 11. Forwards medical records and other documents to
the Medical Records Unit.
RECORDS CLERK 12. Files all documents.
CHART NO. 29: DISPOSITION OF PATIENT: RELEASE OF CADAVER TO THE
CLAIMANT
75
4. Conducting autopsy examination (when applicable)
76
ATTENDING PHYSICIAN 1. Requests the family for an autopsy examination
of the deceased and explains the need for such
examination.
WARD NURSE 2. Prepares and secures consent of the
patient’srelative for autopsy examination [Form no.
52].
NOTE: If patient’s relative does not approve of the

autopsy, asks him/her to sign Refusal to Consent to
Autopsy [Form no. 53].
3. Endorses consent and request to the laboratory.

LABORATORY STAFF 4. Informs Pathologist.
MORGUE ATTENDANT 5. Takes cadaver to the autopsy room.
PATHOLOGIST 6. Performs autopsy on the cadaver.
7. Prepares autopsy report [Form 54], forwards a
copyto the Attending Physician and keeps a file
copy.
ATTENDING PHYSICIAN 8. Explains autopsy report to the family of the
deceased.
AUTOPSY ATTENDANT 9. Endorses cadaver to the morgue.
10. Forwards autopsy result to the Medical
RecordsService.
RECORDS CLERK 11. Attaches the autopsy report on the patient’s
medical records.
77
CHART NO. 30: DISPOSITION OF CADAVER: CONDUCTING AUTOPSY EXAMINATION
ATTENDING PATHOLOGIST WARD NURSE LABORATORY MORGUE AUTOPSY RECORDS STAFF ATTENDANT
ATTENDANT CLERK
Requests the Prepares & secures

family for an consent of the
autopsy patient’s relative
examination for the autopsy
Takes
Endorses consent Informs cadaver to
and request to the pathologist the autopsy
laboratory room
Performs autopsy
of the cadaver
Prepares autopsy
report
Forwards report to
Explains autopsy attending physician
report to the Endorses cadaver
family of the
to the morgue
deceased
Attaches the
Forwards autopsy autopsy report
result to Medical on patient’s
Records Service medical records
69
LABORATORY PROCEDURES
1. Laboratory examination for OPD Patient
LABORATORY STAFF 1. Receives request(s) [Form no. 2],
acceptsspecimen(s), and records them in the
logbook.
2. Sorts out request(s) as to Stat, Referral or
SpecialProcedure:
a. For stat request/s - locates patient for specimen
collection.
b. For referral to other facilities - notifies Attending
Physician, patient, or relatives.
c. For special procedure/s - notifies Attending
Physician, instructs patient or relatives and
schedules specimen collection.
d. For referral from other facilities,
reviewsrequirements.
MEDICAL TECHNOLOGIST 3. Performs requested laboratory procedure(s)
andreads result(s).
4. Types or writes result(s) in an official
laboratoryresult form and signs in the result form.
LABORATORY HEAD 5. Reviews laboratory result/s and signs on the result
form.
NOTE: If repeat or additional examination is needed,
notifies Attending Physician, instructs patient or relatives
and schedules specimen collection.
LABORATORY STAFF/ 6. Records the result(s) and files the request.
MEDICAL TECHNOLOGIST 7. Prepares charge slip [Form no. 4]:
a. If pay patient, instructs him/her to proceed to
theCashier.
b. If patient cannot pay, instructs him/her toproceed
to the Medical Social Worker for classification.
8. Enters transaction in the Income Proof Sheet (IPS)
[Form no. 55].

MEDICAL SOCIAL WORKER 10. Evaluates and classifies patient, and issues
Indigency Certification [Form no. 56] to fully indigent
patients (please see Medical Social Service
procedures, pp. 100-101).
70
Action
11. Presents official receipt or Indigency Certification to
the laboratory staff.
12. Transcribes official receipt number or
attachesIndigency Certification to the request form.
13. Submits results to the Physician or OPD Nurse.
NOTE: If patient is a referral from another facility,
releases result to the requesting Physician
through the patient/relative (See Referral
Procedures, p. 56)
14. Accepts results and signs in the laboratory
releasinglogbook.
15. Attaches result to the patient’s medical records.
71
CHART NO. 31: LABORATORY PROCEDURES: LABORATORY EXAMINATION FOR OPD PATIENT
LABORATORY
LABORATORY CASHIER MSW
72
2.
Laboratory examination for ER Patient
LABORATORY STAFF 1. Receives request(s) [Form no. 2],
acceptsspecimen(s), and records them in the
logbook.
2. Sorts out request(s) as to Stat, Referral or
SpecialProcedure:
a. For stat request/s - locates patient for
specimen collection.
b. For referral - notifies Attending Physician,
patient, or relatives.
c. For special procedure/s - notifies Attending
Physician, instructs patient or relatives, and
schedules specimen collection.
andreads result.
4. Types or writes result(s) in an official
laboratoryresult form and signs the same.
LABORATORY HEAD 5. Reviews laboratory result/s and signs on the result
form.
NOTE:If repeat or additional examination is needed,
notifies Attending Physician, instructs patient or
relatives, and schedules specimen collection.
LABORATORY STAFF/ 6. Records the result(s) and files the request.
MEDICAL TECHNOLOGIST 7. Prepares two copies of the charge slip [Form no. 4]
(please see ER procedures #6.1 to 6.3, p.
10). Submits the first copy to the Billing Section
and files the second copy.
8. Enters transaction in the IPS [Form no. 55].
LABORATORY STAFF 9. Submits official laboratory result to the Attending
Physician or ER Nurse.
ATTENDING PHYSICIAN/ ER 10. Accepts result(s) and signs laboratory releasing
NURSE logbook.
11. Attaches result(s) to the patient’s medical records.
CHART NO. 32: LABORATORY PROCEDURES: LABORATORY
EXAMINATION FOR ER PATIENT
84
PHYSICIAN/ LABORATORY MEDICAL LABORATORY
ER NURSE HEAD TECHNOLOGIST STAFF
Reviews laboratory Performs Receives

result/s and signs the laboratory request(s),
result form procedure as accepts
requested and specimen(s),
reads result and records
them in the
logbook
If repeat or Types/writes result
additional in an official
examination is laboratory request
needed notifies form and signs
attending Sorts out
physician, request(s) as to
instructs patient Stat, Referral or
or relatives Special Procedure
Records result and files request
Prepares charge slip in duplicate
Attaches result to
the patient’s
medical records
3. Laboratory examination for in-patient

85
LABORATORY STAFF/ 1. Receives request(s) [Form no. 2],
MEDICAL TECHNOLOGIST acceptsspecimen(s), and records these in the
register.
2. Sorts out request(s) as to Routine/Stat/Referral
orSpecial Procedure:
a. For routine request(s) - schedules specimen
collection and notifies the Nurse.
b. For stat request(s) - locates patient for
specimen collection.
c. For referral - notifies Attending Physician,
patient, or relatives.
d. For Special Procedure(s) - notifies Attending
Physician or Ward Nurse and gives instructions
for any special preparation prior to specimen
collection.
andreads result(s).
4. Types or writes result(s) in an official laboratory
result form and signs the same.
LABORATORY HEAD 5. Reviews laboratory result(s) and signs on the result
form.
NOTE: If repeat or additional examination is needed,
notifies Attending Physician or Ward Nurse and
schedules another specimen collection.
LABORATORY STAFF/ 6. Records result(s) and files requests.
MEDICAL TECHNOLOGIST 7. Prepares two copies of the charge slip [Form no.
4],submits the first copy to the Billing Section and
retains/files the second copy (please see Billing
procedures, pp. 201-202).
BILLING SECTION 9. Posts laboratory charges to in-patients’ ledger card
and files charge slip [Form no. 4] in the patient’s
jacket [Form no. 48].
LABORATORY STAFF 10. Submits official laboratory result(s) to the Attending
Physician or Ward Nurse.
ATTENDING PHYSICIAN/ 11. Accepts results and signs laboratory
WARD NURSE releasinglogbook.
12. Attaches result in the patient’s medical records.
13. If patient has already been discharged, forwards
laboratory result to the Medical Records Section
(MRS).
MEDICAL RECORDS 14. Attaches results to the patient’s medical records.
SERVICE
86
CHART NO. 33: LABORATORY PROCEDURES: LABORATORY EXAMINATION FORIN-PATIENTS
PHYSICIAN/ LABORATORY MEDICAL LABORATORY BILLING MEDICAL RECORDS

76
4. Blood cross-matching and other related procedures 4.1. Blood cross-
matching
LABORATORY STAFF/ 1. Receives request(s) [Form no. 2], accepts
MEDICAL TECHNOLOGIST specimen(s) and records them in the register. Sorts
2. out request(s) as to Routine/Stat/Referral or Special
Procedure
a. For routine request(s) - schedules specimen
collection.
b. For stat request(s) - locates patient for specimen
collection.
c. For referral - notifies Attending Physician, patient,
or relatives.
MEDICAL TECHNOLOGIST 3. Performs requested laboratory procedure(s):
a. If blood unit is available, inspects whether
thephysical characteristics of the blood units are
suitable for transfusion and cross-matches the
same with the patient’s blood.
b. If blood unit is not available, notifies
AttendingPhysician or relatives and coordinates
with the Medical Social Worker.
c. If hospital is capable of blood collection
fromdonors, donors are bled.
d. If hospital is not capable of blood collection
fromblood donors, donors are referred to other
blood banks or to the Red Cross for blood units
needed.
4. Reads and interprets blood cross-matching result:
a. If compatible, types or writes two copies of the
result in an official laboratory result form [Form
no. 57] and signs the same.
b. If not compatible, notifies Attending Physician,
patient, or relatives to bring volunteer blood
donors; coordinates with other blood bank or Red
Cross for blood units needed.
c. Refers result to the Laboratory Head.
LABORATORY HEAD 5. Reviews laboratory result and signs the result form.
NOTE:If repeat or additional examination is needed,
notifies Attending Physician, instructs patient or relative,
and schedules another specimen collection.
77
Action
6. Records result, files request, and keeps blood
underproper storage.
7. Prepares two copies of the charge slip [Form no.
4],submits original copy to the Billing Section and
files second copy (Please see Billing
Procedures, pp. 203-204).
9. Submits original copy of blood cross-matching
result to the Attending Physician or Ward/ER
Nurse, and files second copy.
10. Accepts results and signs laboratory releasing
logbook.
78
CHART NO. 34: LABORATORY PROCEDURES: BLOOD CROSS-MATCHING
PHYSICIAN LABORATORY MEDICAL LABORATORY
WARD / ER NURSE HEAD TECHNOLOGIST STAFF
Receives request(s),
accepts specimen(s)
and records them in
Reviews laboratory
the register
result/s and signs the
result form
Performs Sorts out

laboratory request(s) as to
procedure as Routine, Stat,
If repeat or requested and Referral or
additional reads result Special Procedure
examination is
needed, notifies
attending Reads and
physician & interprets cross-
instructs patient matching results
or relatives and
relatives
Records result and files request
Prepares charge slip in duplicate, submits the irst

f
copy to the Billing Section and retains the second
copy as file
Accepts results
and signs
laboratory Submits original copy of cross-matching result to
releasing the attending physician or ward nurse
logbook
Attaches
result to
the
patient’s
record
79
4.2. Release of donor’s blood
LABORATORY STAFF/ 1. Receives request for blood [Form no. 58 for Adultand
MEDICAL TECHNOLOGIST Form no. 59 for Pediatric patient].
2. Retrieves second copy of cross-matching result from
the file for validation.
3. Gets corresponding blood unit from the storage.
4. Reviews compatibility of data on both blood unit and
cross-matching result form.
5. Inspects whether the physical characteristics of the
blood units are suitable for transfusion.
6. Releases/issues compatible blood units.
7. Gives instructions to the receiving staff on the
properhandling and transport of blood units.
NURSING ATTENDANT 8. Signs the Blood Bank releasing logbook.
(NA)/WARD NURSE 9. Notifies the Attending Physician of the receipt of
blood unit(s).
CHART NO. 35: LABORATORY PROCEDURES: RELEASE OF DONOR’S BLOOD
MEDICAL LABORATORY NURSING

TECHNOLOGIST STAFF ATTENDANT
Receives request for blood Signs the Blood Bank releasing logbook
Notifies the attending

Retrieves second copy of cross-matching result physician
from file for validation
Gets corresponding blood unit and reviews

compatibility of data,
Inspects blood & releases/issues compatible

blood units
Gives instructions to receiving staff on proper

handling and transport of blood units
80
4.3. Blood transfusion procedures
NURSING ATTENDANT 1. Prepares blood transfusion set.
(NA)/WARD NURSE 2. Notifies patient or relatives about the transfusion.
3. Secures consent from the patient agreeing to a blood
transfusion [Form no. 24].
4. If patient does not give consent, asks him/her
(orrepresentative) to sign on the Refusal to Permit
Blood Transfusion Form [Form no. 60].
ATTENDING PHYSICIAN 5. Reviews compatibility of data in both blood unit
andcross-matching result form.
6. Inspects blood units for physical characteristics to
ensure that it is suitable for blood transfusion.
7. Initiates/performs blood transfusion on the patient.
8. Closely monitors patient for the first 15 to 30 minutes
for any untoward reactions to the transfusion.
WARD NURSE 9. Monitors patient for any untoward reactions.
NOTE: If untoward reactions occur, stops transfusion

immediately, notifies the Physician, takes vital signs and
records them properly.
10. Notes untoward reactions in the patient’s

medicalrecords.
ATTENDING PHYSICIAN 11. If there are any untoward reactions,
institutesappropriate actions immediately.
12. Fills and signs two copies of the Transfusion
ReactionForm [Form no. 61]; attaches original copy
to the patient’s medical records, and attaches the
second copy to the blood unit in question.
WARD NURSE 13. Submits signed Transfusion Reaction Form and
returns the blood unit in question to the laboratory
for further study.
14. If no untoward reactions occurred,
recordstransfusion in the patient’s medical records.
81
CHART NO. 36: LABORATORY PROCEDURES:
BLOOD TRANSFUSION PROCEDURES
PHYSICIAN WARD NURSE NURSING ATTENDANT
Prepares blood transfusion set
Notifies patient or relatives about the blood transfusion & secures consent
for the same
Reviews compatibility of data in

both blood unit and cross-
YES
matching result form, & Patient gives consent?
inspects blood uni ts
Performs blood transfusion on NO

the patient
Ask patient/representative to sign the Refusal to Permit
Blood Transfusion form & inform the Physician
Closely monitors patient for the
first 15 to 30 minutes for any
untoward reactions to the
transfusion Monitors patient for any
untoward reactions
Reactions NO
occurred?
YES
Stops transfusion
immediately, notifies the
Institutes appropriate actions
physician, gets vital signs
immediately
and notes reaction in
patient’s record
Fills and signs Transfusion

Reaction Form in duplicate
copies; attaches original copy Submits signed
to the patient’s medical Transfusion Reaction
records, and attaches the Form and returns the
second copy to the blood unit blood unit in question
in question to the laboratory for
further studies
Records
transfusion in the
patient’s medical
records
82
5. Histopath examination
SURGEON/RESIDENT 1. Writes order in the patient’s record.
PHYSICIAN 2. Notifies Resident Physician/Nurse.
3. Transcribes and signs order in a
Histopathologyrequest form [Form no. 62].
NURSE/OR STAFF 4. Places specimen in a suitable container with 10%
formalin, and labels the container properly.
5. Endorses request form(s) and/or specimen(s)
tothe laboratory.
LABORATORY STAFF 6. Receives request(s), accepts specimen(s), and
records these in the logbook.
NOTE: If laboratory is not capable of doing
histopath procedure, specimen is for “Referral”
(please see Referral procedures, pp. 54-55).
PATHOLOGIST 7. Performs gross examination on the specimen.
LABORATORY STAFF 8. Assists the Pathologist in performing the histopath
examination.
9. Writes down gross description of the
surgicalspecimen.
10. Processes the specimen (blocking, cutting,
staining,and mounting).
11. Refers specimen for reading/interpretation.
PATHOLOGIST 12. Performs microscopic examination on the
processed specimen.
LABORATORY STAFF 13. Types/transcribes two copies of the
surgical/histopathology report in an official result
form (original copy to be attached to the
patient’s record and the duplicate copy for file)
[Form no.
63].
PATHOLOGIST 14. Reviews and signs official histopath report.
MEDICAL TECHNOLOGIST 15. Records result and files request.
4] submits the original copy to the Billing Section
(please see Billing Procedures, pp. 203-
204) and attaches the second copy to the result
form.
BILLING SECTION 18. Files charge slip in the patient’s jacket [Form no.
48].
LABORATORY STAFF 19. Submits official laboratory result to the Attending
Physician or Ward Nurse.
20. If referral is from other facilities, gives result
topatient/relative.
AUTHORIZED STAFF 21. Accepts results and signs laboratory
releasinglogbook.
83
CHART NO. 37: LABORATORY PROCEDURES: HISTOPATH EXAMINATION
SURGEON RESIDENT PHYSICIAN/ PATHOLOGIST LABORATORY MEDICAL BILLING AUTHORIZED PATIENT/
NURSE/OR STAFF STAFF TECHNOLOGIST STAFF STAFF RELATIVE
Writes order Transcribes order, places Receives

& notifies specimen in a suitable request(s), Records result
container wi th 10% formalin,
resident accepts and files
and labels container properly
physician/ specimen(s), request
nurse Performs gross and records
examination on these in the
Endorses request form(s) the specimen logbook
and/or specimen(s) to the Prepares
laboratory charge slip in
duplicate,
Assists the copies and
pathologist, writes submits the
down gross original copy to
description, the Billing
Performs microscopic processes the Section and
examination on the specimen and attaches the
processed specimen refers specimen for second copy to
reading the result form
Transcribes
histopathology
report Enters
transaction in Files
the IPS charge
Reviews and signs
slip in the
official Histopath report
patient’s
Submits official jacket
result to physician Accepts results and signs
or nurse. If referral laboratory releasing
from other hospital, logbook
submits result to
the patient/relative
Attaches
result to
patient’s
record
84
6. Screening of volunteer blood donors
NURSING ATTENDANT 1. Welcomes potential blood donors.
BLOOD DONORS 2. Registers or fills-in Blood Donor Registration
Form/Record [Form no. 64].
MEDICAL TECHNOLOGIST 3. Interviews blood donors, takes vital signs and
medicalhistory.
4. Notifies Medical Officer for physical examination
andpre-donation counseling.
MEDICAL OFFICER 5. Decides whether potential donor is suitable/acceptable
for blood donation or not.
a. If suitable/accepted for blood donation,
securesdonor’s consent.
b. If deferred, provides counseling.
6. Signs donor record form [Form no. 64].
BLOOD BANK STAFF/ 7. Prepares materials for blood collection.
MEDICAL TECHNOLOGIST 8. Performs phlebotomy/blood collection.
9. Monitors blood donor for 15 to 30 minutes during and
after blood collection.
10. Provides post-donation counseling and post-donation
care.
11. Labels blood bags/units appropriately.
12. Refers blood bags to other blood service facilities
forblood testing of five transmissible diseases
(hepatitis B, syphilis, malaria, HIV infection/AIDS and
hepatitis C).
85
CHART NO. 38: LABORATORY PROCEDURES: SCREENING OF VOLUNTEER BLOOD
DONORS
MEDICAL BLOOD BANK MEDICAL NURSE NURSING BLOOD
OFFICER STAFF TECHNOLOGIST ATTENDANT DONORS
Welcomes Fills-in
potential Blood
blood Donor
donors Registration
Decides whether Interviews blood Form/
donor is suitable / donors, gets vital signs Record
acceptable for and medical history
blood donation or
not
a.If accepted
for blood Notifies Medical Officer
donation, for physical examination
secures and pre-donation
consent. counseling
b. If deferred,
provides
counseling
Prepares materials for blood collection

Signs donor
record form
Performs phlebotomy/blood collection &

monitors blood donor during collection
Provides post-donation counseling and

post-donation care
Labels blood bags/unit appropriately
Refers blood bags to other

blood service facilities for blood
testing of five transmissible
diseases (hepatitis B, syphilis,
malaria, HIV infection/AIDS,
and hepatitis C).
86
RADIOLOGY PROCEDURES
1. Conducting radiographic examinations for OPD patients
OPD PHYSICIAN 1. Prepares and signs request for examination [Form
no. 22].
OPD NURSE/NURSING 2. Instructs the patient to proceed to the x-ray room
ATTENDANT for the examination.
PATIENT 3. Presents request to the x-ray Clerk/Radiologic
Technologist.
RADIOLOGIC 4. Receives request and records it in the logbook.
TECHNOLOGIST 5. If patient requires special procedures, schedules
patient for examination:
5.1. Indicates in the registry card the date
thepatient is scheduled to return for the
special procedures.
5.2. Gives advice on the required preparations.
5.3. Notifies Radiologist about the scheduled
special procedure.
6. If patient is for routine x-ray procedure:
6.1. Enters patient’s name, procedure, and
otherdata on the x-ray register.
7. Prepares charge slip [Form no. 4]:
a. If pay patient, instructs him/her to proceed to
theCashier.
b. If patient cannot pay, instructs him/her to
proceed to the Medical Social Worker for
classification.
MEDICAL SOCIAL WORKER 8. Evaluates and classifies patient, and issues
Indigency Certification [Form no. 56] to fully
indigent patients (please see Medical Social
Service procedures, pp. 100-101).
RADIOLOGIC 10. Performs specified examination(s).
TECHNOLOGIST
NOTE: The requesting physician may make the initial
reading of the radiograph, to be confirmed by the
Radiologist (please see Getting Official Result,
this chapter, pp. 93-94)
11. Informs patient of scheduled release of result.

12. Releases result and keeps a file copy.
87
CHART NO. 39: RADIOGRAPHIC PROCEDURES: RADIOGRAPHIC EXAMINATIONS FOR OPD PATIENTS
OPD PHYSICIAN OPD NURSE NURSING RADIOLOGIC CASHIER MEDICAL PATIENT
ATENDANT TECHNOLOGIST SOCIAL WORKER COMPANION
Prepares and signs

request for examination Receives request and
records it in the logbook Present request
to the x-ray
Instructs the patient to proceed Clerk/Radiology
to the x-ray room for an Technologist
examination
NO For routine
exam?
YES
Enters patient’s name in Evaluates and
the x-ray register classifies
Receives patient and
payment issues
Schedules special certification to
procedure and issues
official fully indigent
receipt patients
Prepares charge slip and

refers patient to MSW, if
needed
Performs examination(s)
and files request(s)
Informs patient of
scheduled release of
result
Releases result
88
2. Conducting radiographic examinations for ER patients
PHYSICIAN 1. Prepares and signs request for x-ray examination
[Form no. 22].
NURSE-ON-DUTY 2. Informs X-ray Unit of the examination to be
performed.
ER STAFF 3. Accompanies patient with request on hand to the
xray room.
RADIOLOGIC 4. Performs examination and notifies the ER Physician
TECHNOLOGIST when the radiographs would be available.
4] please see ER procedures # 6.1-6.3, p.
10).
Submits one copy to the billing section and files
the other copy.
6. Enters transaction in the Income Proof Sheet (IPS)
[Form no. 55].
ER PHYSICIAN / 7. Wet reads the radiographs and gives impression of
RADIOLOGIST the findings.
89
CHART NO. 40: RADIOGRAPHIC PROCEDURES:
RADIOGRAPHIC EXAMINATIONS FOR ER PATIENTS
ER PHYSICIANRADIOLOGIST NURSE ER RADIOLOGIC STAFF TECHNOLOGIST
Prepares and Informs X-ray

signs request Unit of the
for x-ray examination to
examination be performed
Brings patient Performs

& request to examination and
x-ray room notifies the ER
Wet reads the radiographs physician when the
and gives impression of the radiographs would
findings be available
Prepares charge slip
Enters
transaction in
the Income
Proof Sheet
90
3. Conducting radiographic examinations for in-patients
PHYSICIAN 1. Prepares and signs request for x-ray [Form no. 22].
WARD NURSE 2. Coordinates with the X-ray Unit for scheduling.
NURSING ATTENDANT 3. Records request on the logbook.
(NA)
RADIOLOGIC 4. Logs request on the X-ray room register.
TECHNOLOGIST 5. Notifies Ward Nurse of the patient’s schedule and
gives advice on the necessary preparations for
special radiological procedures using contrast
agent.
WARD NURSE 6. Notifies Physician about the schedule and lists
preparations needed for the special radiographic
examination.
PHYSICIAN 7. Indicates on the patient’s record the preparation
required prior to the scheduled x-ray procedure.
UTILITY 8. Accompanies patient with doctor’s request on hand
WORKER/NURSING
ATTENDANT (NA) to the x-ray unit.
RADIOLOGIC 9. Receives request and records the same on the
TECHNOLOGIST logbook.
10. Performs x-ray examination.
RADIOLOGIST 11. Performs official reading of the radiographic
examination [Form no. 66] (please see
subsection 4, this chapter, pp. 93-94).
RADIOLOGIC 12. Forwards result to the Ward Nurse.
TECHNOLOGIST 13. Accomplishes IPS [Form no. 55] and prepares
charge slip [Form no. 4] and forwards the same to
the Billing Section.
BILLING STAFF 14. Inserts charge slip in the patient’s jacket [Form
no. 48] (please see Billing Procedures, pp.
203204).
WARD NURSE 15. Attaches result to the patient’s record and forwards
Or informs the same to the Physician.
91
CHART NO. 41: RADIOGRAPHIC PROCEDURES: RADIOGRAPHIC EXAMINATIONS FOR IN-PATIENTS
PHYSICIAN RADIOLOGIST WARD NURSE RADIOLOGIC NURSING UTILITY TECHNOLOGIST ATENDANT WORKER
Prepares and Coordinates with

signs request x-ray unit for Records
for x-ray scheduling request in the
Logs request on the X-ray logbook
room register
Writes on the
patient’s chart the Notifies ward nurse of the
preparation patient’s schedule
required prior to
scheduled x-ray Takes
procedure Notifies NO doctor’s
physician about Special request and
the schedule procedures? patient to
and list of the x-ray
preparations unit
required YES
Gives advice on the

preparations to be made for
special radiographic procedures
Receives request, records it in

Performs official the logbook & performs x-ray
reading of the x-ray examination
examination
Forwards result to the Ward
Nurse
Attaches result Accomplishes IPS,

in patient’s prepares charge slip &
record forwards it to the Billing
Section
92
4. Official reading and release of x-ray results
RADIOLOGIC 1. Takes radiographic film with request to the
TECHNOLOGIST Radiologist.
RADIOLOGIST 2. Reads, interprets, and writes down the findings.
X-RAY PERSONNEL 3. Types findings on the X-ray Result Form [Form
no. 65] (3 copies) and submits the same to the
Radiologist.
RADIOLOGIST 4. Reviews result, signs, and forwards the same to the
X-ray personnel.
X-RAY PERSONNEL 5. Forwards a copy of the result to the requesting unit.
One copy is attached to the patient’s medical record,
while another copy is filed. A third copy is given to
the patient, if requested by the latter.
6. Fills up the Daily Report Form.
93
CHART NO. 42: RADIOGRAPHIC PROCEDURES: OFFICIAL READING

AND RELEASE OF X-RAY RESULTS
RADIOLOGIC RADIOLOGIST X-RAY PERSONNEL
TECHNOLOGIST
Takes radiographic film

with request to the
Radiologist
Reads, interprets, and writes Types findings on X -ray Result

down the findings Form (3 copies) and submits it
to the Radiologist
Reviews the results, signs and

forwards it to the X-ray
personnel
Forwards a copy of the result to

the requesting unit:
• Attaches original to
patient’s MR
• Files second copy
• Gives third cop y to the
patient (if requested)
Fills up the Daily

Report Form
94
5. Performing ultrasonography
REQUESTING/ATTENDING 1. Prepares and signs request for ultrasonography
PHYSICIAN [Form no. 22].
NURSING ATTENDANT/ 2. Brings accomplished request form to the Radiology
NURSE Unit.
RADIOLOGIC 3. Receives, records, and files request.
TECHNOLOGIST 4. For OPD/In-patient:
4.1 Schedules the date/time of ultrasound
procedure.
4.2 Gives advice on preparations prior to the
procedure.
4.3 Notifies Ultrasonologist regarding the
schedule.
4.4 For OPD patient: advises patient to return
on scheduled date and time of the
ultrasonography.
4.5 For in-patient: Accompanies patient to the
ultrasonography room.
ULTRASONOLOGIST 5. Prepares patient and performs the procedure.
6. Reads and interprets the results.
RADIOLOGIC 7. Types results and submits the same to the
TECHNOLOGIST Ultrasonologist.
ULTRASONOLOGIST 8. Reviews and signs the official ultrasonography result
[Form no. 65].
RADIOLOGIC 9. Files results and sends the same to the ward or to
TECHNOLOGIST the requesting Physician.
10. Prepares and forwards charge slip [Form no. 4]
tothe Billing Section.
BILLING STAFF 12. Receives charge slips and bills patient (please see
Billing Procedures, p. 201-204).
95
CHART NO. 43: RADIOLOGIC PROCEDURES: PERFORMING ULTRASONOGRAPHY
ATTENDI
NG ULTRAS
PHYSICIAN TECHNOLOGIST ATTENDANT
Prepares and Brings accomplished request

signs request for form to the Radiology Unit
ultrasonography
Receives, records
and files request
Schedules the
procedure, gives
advice on the
preparations prior to
the procedure
Notifies the
Ultrasonologist
NO
In patient?
YES
Brings patient to
Prepares patient ultrasonography
and performs the room
procedure
Advises patient to
come back on
schedule of
Reads and interprets ultrasound
the results
Types results,
sends it t o the
ward or to the
requesting
physician, and files
a copy
Prepares and
forwards charge
slip to the Billing
Section, and
records in IPS
Charts no. 98 and

99, pp. 202 & 204
96
PART II
• MEDICAL SOCIAL SERVICE
• PHARMACY SERVICE
• DIETARY SERVICE
• MEDICAL RECORDS SERVICE • ADMINISTRATIVE
SERVICE
97
MEDICAL SOCIAL SERVICE (MSS) PROCEDURES

1. Summary of case management process
HOSPITAL STAFF 1. Refers patient to MSW for assistance [Form no. 3 if
from OPD/ER or Form no. 70 if from ward].
PATIENT/RELATIVE 2. Applies for assistance from the MSW.
MEDICAL SOCIAL WORKER 3. Conducts intake interview to determine
patient’seligibility for MSS assistance.
4. Assesses patient’s level of psycho-social functioning
as affected by illness, treatment, or vice versa. This
includes identifying patient’s strengths and
weaknesses.
MEDICAL SOCIAL WORKER 5. Facilitates agreement on problems to work on.
AND PATIENT/ RELATIVE 6. Conducts intervention planning.
7. Implements the agreed plans (casework, group work
or community organizing).
8. Conducts reassessment of patient’s situation.
MEDICAL SOCIAL WORKER 9. Monitors the implementation of plans.
10. Evaluates the outcome of intervention.
a. If goals are achieved, terminates the service.
b. If goals are not achieved, re-start at conducting
intervention planning.
98
CHART NO. 44: MEDICAL SOCIAL SERVICE:
SUMMARY OF CASE MANAGEMENT PROCESS
HOSPITAL STAFF MEDICAL SOCIAL PATIENT/ RELATIVE

WORKER
Conducts intake interview
Refers patient to to determine patient’s Applies for
MSW for eligibility for MSS assistance
assistance assistance
Eligible for NO
assistance
YES
Assesses patient’s level of

psycho-social functioning
Facilitate agreement on problems to work on
Conduct intervention planning
Implement the agreed plans
Conduct reassessment of patient’s situation
Monitor the implementation

of plans
Evaluates outcome of
intervention
NO Were the
goals
achieved?
YES
Termination
99
2. Classification of out-patient
OPD NURSE/M.D. 1. Prepares referral [Form no. 2] and forwards the same
to the Medical Social Service (MSS).
MEDICAL SOCIAL WORKER 2. Facilitates contract signing [Form no. 66].
(MSW) 3. Evaluates and classifies the referred patient using
thehospital approved protocol based on Administrative
Order No. 51-A, s. 2001 or other issuance as guide for
classifying patients.
4. Registers new patient in the general logbook.
4.1. If patient is not covered by the hospital-
approved protocol, makes appropriate
recommendation to the Chief of Hospital
(COH).
CHIEF OF HOSPITAL 4.2. Receives and/or approves recommendation.
4.3. Informs MSW of the approved action.
MEDICAL SOCIAL WORKER 5. Informs patient and/or relative of the
approvedaction.
6. Issues or revalidates service card [Form no. 67]. 7.
Stamps charge slip (Form no. 4) with classification
and indicates discount.
PATIENT/RELATIVE 8. Brings charge slip to the Cashier.
CASHIER 9. Receives charge slip and collects payment, if there
is any, and issues an official receipt to the patient
and/or relative.
100
CHART NO. 45: MEDICAL SOCIAL SERVICE: CLASSIFICATION OF OUT-PATIENT
CHIEF OF OPD NURSE MEDICAL SOCIAL WORKER CASHIER PATIENT HOSPITAL
Prepares and
Facilitates contract
forwards to MSS
signing
NO
Evaluates and Is patient covered by
classifies patient hospital-approved
protocol?
Registers in the YES

general logbook Brings charge
Informs patient and/or
slip to cashier
relative of the
approved action
Receives and Makes appropriate
approves recommendation to
recommendation the COH
Issues or revalidates Receives and

service card collects payments
Informs MSW of
approved action
Stamps charge slip

Issues official
receipt
3. Classification of ER patient
ER NURSE 1. Informs MSW about patient/family with
psychologicaland social problems.
2. Fills up referral slip [Form no. 3] and forwards
thesame to the MSS.
MEDICAL SOCIAL WORKER 3. Receives referral, provides crisis intervention, and if
necessary, performs advocacy role for the patient.
4. Facilitates contract signing [Form no. 66] to avail
ofMSS assistance.
5. Interviews patient (if conscious) or relative/family and
accomplishes Intake Sheet [Form no. 68].
6. Registers the new patient in the MSS general logbook.
7. Classifies patient based on hospital approved
protocol(A.O. No. 51-A, s. 2001) or other issuance.
7.1. If not covered by the hospital-approved
protocol, forwards recommendation to the
COH for approval.
CHIEF OF HOSPITAL 7.2. Receives and approves recommendation.
7.3. Informs MSW of approved recommendation.
MEDICAL SOCIAL WORKER 8. Informs the patient/family and ER staff of theapproved
action.
9. Issues or revalidates service card.
10. Makes proper endorsement to the different
services/units concerned using the Assessment and
Referral Report Form [Form no. 69].
PATIENT/RELATIVE 11. Assumes responsibility for treatment
/hospitalization in accordance with the approved
action.
MEDICAL SOCIAL WORKER 12. Taps resources for other needs of the patient.
13. Documents all activities and files them accordingly.
CHART NO 46: MEDICAL SOCIAL SERVICE: CLASSIFICATION OF ER PATIENT
CHIEF OF ER NURSE MEDICAL SOCIAL PATIENT/RELATIVE
HOSPITAL WORKER
Receives referral, provides

Provides all crisis intervention
necessary and
available medical
assistance
Facilitates signing of
contract
Informs MSW about

patient/family with Interviews patient/relative
psychological and social and accomplishes Intake
problems Sheet
Registers new patient on the

Fills up referral slip to general logbook
MSS
Classifies patient
Receives and NO
approves Is patient
Makes appropriate
covered by
recommendation recommendation protocol?
YES
Informs MSW of
approved
Informs the patient/family and
recommendation ER staff of the approved
action
Revalidate or issue service

card
Assumes
responsibility
Makes proper endorsement to for patient’s
different services concerned hospitalization
Taps resources for other

needs of patients
Documents all activities
Files documents
4. Classification of in-patient
ADMITTING UNIT 1. Forwards list of admitted patient to MSS.
STAFF/DESIGNATE 2. Forwards Clinical Cover Sheet (CCS) [Form no. 14] to
MSS.
MEDICAL SOCIAL WORKER 3. Determines if patient is “new” or “old”.
a. If patient is “new”, facilitates signing of
contract[Form no. 66] and conducts intake
interview using Intake Sheet [Form no. 68].
b. If “old” patient, retrieves and updates record.
4. Classifies patient according to hospital-approved
protocol which is based on A.O. No. 51-A, s. 2001
(or other issuance) and indicates classification on
the CCS.
5. Accomplishes assessment and referral report (Form
no. 69) and forwards it to the Billing Section.
6. Provides patient/relative orientation on the
following:
• Hospital policies
• Available social services
• Scope and limitations of hospital
assistance 7. Registers new patient in the
general logbook.
7.1. If patient is not covered by the
hospital- approved protocol, make
appropriate recommendation to the
COH.
CHIEF OF HOSPITAL 7.2. Reviews and approves recommendation.
7.3. Informs MSW of the approved action.
MEDICAL SOCIAL WORKER 8. Issues or revalidates service card.
PATIENT/RELATIVE 9. Returns CCS to the admitting unit staff.
CHART NO. 47: MEDICAL SOCIAL SERVICE: CLASSIFICATION OF IN-PATIENT
CHIEF OF MEDICAL SOCIAL ADMITTING STAFF PATIENT/RELATIVE

HOSPITAL WORKER
Forwards list of
admitted patient
and CCS to MSS
Is patient
new?
NO YES
Retrieves and Facilitates signing

updates old record of contract
Classifies patient and indicates

in the CCS
Accomplishes Form no. 69 and

forwards it to the Billing Section
Orients patient on hospital

policies, etc.
Registers in general logbook
Makes
appropriate NO Is patient
recommendation covered by
to COH hospital
protocol?
Reviews and
approves YES
recommendation
Returns CCS
Issues or revalidates to the
Admitting
Informs MSW of
Unit staff
approved action
5. Social casework process for hospital patients
PATIENT/RELATIVE 1. Applies for assistance.
ATTENDING 2. Refers patient to the MSS.
PHYSICIAN/NURSE/OTHER
HEALTH PROFESSIONALS NOTE: Fills up MSS referral slip [Form 70], and
forwards/sends the same to the MSS.
MEDICAL SOCIAL WORKER 3. Identifies patient as high risk needing social work
services.
4. Identifies presenting problems.
5. Confers with Attending Physician or Nurse about the
medical/health condition and status of the patient.
6. Gathers information, analyzes them, including an
estimate of the client’s coping strength and limitations
at the present time and the inter-relationship of
medical/health status and social situation.
6.1. Establishes rapport.
6.2. Schedules a series of interviews with
patient/family.
6.3. Interviews patient /family members.
MEDICAL SOCIAL WORKER 7. Conducts intervention planning:
AND PATIENT/RELATIVE 7.1. Sets mutual goals.
7.2. Identifies specific tasks for the MSW, patient/or
other health professional.
8. Implements the plan:
8.1. Selects appropriate social services (concrete
services, networking, home visitation).
8.2. Uses clinical social work techniques (counseling,
behavioral contracting, etc.).
MEDICAL SOCIAL WORKER 9. Prepares profile [Form no. 71] or progress notes
[Form no. 72] and inserts these in the patient’s
medical record for ready reference by referring
physician and other members of the health team.
Succeeding activities should be entered in the
progress notes accordingly.
10. Collaborates with other health professionals.
MEDICAL SOCIAL WORKER/ 11. Continues engagement.
PATIENT/OTHER HEALTH 11.1. Interaction of MSW, patient and/or other health
PROFESSIONALS professional aimed toward goal achievement. 11.2.
Ongoing monitoring, assessment and
reassessment.
MEDICAL SOCIAL WORKER/ 12. Evaluates on the basis of the following:
PATIENT a. If goals are being achieved, terminates the care.
b. If not, plans and implements alternative activities.
c. Terminates service after successful intervention.
CHART NO. 48: MEDICAL SOCIAL SERVICE: SOCIAL CASEWORK PROCESS
FOR HOSPITAL PATIENTS
MEDICAL SOCIAL PATIENTS
WORKER
Identifies patient as high

Refers patients to MSS
risk needing social work Applies for assistance
services
Identifies presenting problem
Confers with attending physician or

nurse about the medical/health
condition and status of the patient
Gathers information and analyzes

data including an estimate of the
client’s coping strength and
limitations
Conducts intervention planning
Implements plan
Prepares profile/progress notes and

inserts in the patient’s medical
record
Collaborates with other health

professionals
Continues engagement, monitoring and re

-assessment
Evaluates the process
NO
Were the goals achieved?
YES
Termination
ATTENDING PHYSICIAN/ NURSE/ OTHER HEALTH PROFESSIONAL

6. Managing referrals from other agencies in the community
REFERRING AGENCY STAFF 1. Writes referral letter addressed to the COH or
Administrative Officer (AO) and attaches Social Case
Summary to support the referral.
CHIEF OF HOSPITAL/ 2. Receives and endorses referral to the MSW.
ADMINISTRATIVE OFFICER
MEDICAL SOCIAL WORKER 3. Receives referral and determines if the hospital
canprovide patient’s request.
3.1. Consults other health personnel.
3.2. If not, counsels and refers patient back to
thereferring agency.
3.3. If yes, conducts intake interview to classify patient
[Form no. 68].
4. Performs necessary casework intervention
andestablishes a continuing working relationship with
the referring agency.
5. Documents all casework proceedings and files these
accordingly.
6. Provides feedback to COH/AO and to the referring
agency on the actions taken.
CHART NO. 49: MEDICAL SOCIAL SERVICE: MANAGING REFERRALS FROM OTHER AGENCIES
IN THE COMMUNITY
COH/AO MEDICAL SOCIAL REFERRING AGENCY
WORKER
Writes referral
Receives and endorses letter and attaches
referral to MSW Social Case
Summary
Receives referral and
determines if the hospital can
provide patient’s request
YES Can hospital

grant request?
NO
Counsels and refers patient

back to referring agency
Conducts intake interviews
Classifies patient
Performs necessary casework

intervention
Establishes continuing
working relationship with
referring agency
Documents casework
proceedings
Provides feedback to
COH/AO and referring
agency about actions
taken
7. Discharge planning
BILLING STAFF 1. Provides periodic update of patient’s bill.
MEDICAL SOCIAL 2. Orients the patient/relative about their bill
WORKER andcoverage of MSS assistance.
3. Motivates family to prepare counterpart/share.
4. Identifies other problems that may delay patient’s
discharge.
5. If patient manifests difficulty in paying their
counterpart:
5.1. Recommends for additional discount to the COH.
5.2. Recommends for provision of funds fromsponsor.
CHIEF OF HOSPITAL 6. Approves recommendation.

7. Informs MSW of approved action.
MEDICAL SOCIAL 8. Endorses to the Billing Section the patient’s
WORKER discount/ negotiated counterpart using the
Assessment and Referral Report [Form no. 69].
CHART NO. 50: MEDICAL SOCIAL SERVICE: DISCHARGE PLANNING
CHIEF OF HOSPITAL MEDICAL SOCIAL WORKER BILLING STAFF
Orients the patient/relative about Provides periodic

their bill and coverage of MSS update of patient’s bill
assistance
Motivates family to prepare

counterpart
Identifies other problems that may

delay patient’s discharge
Patient NO
manifests
difficulty in
paying?
YES
Recommends additional
discount to the COH
Approves recommendation
Informs MSW of approved

action
Endorses to the Billing

Section the patient’s
discount or negotiated
counterpart
8. Social group work process
MEDICAL SOCIAL WORKER 1. Reviews cases and identifies patients/families needing
group work intervention.
2. Groups patients according to their common needs or
situations.
3. Plans and programs appropriate activities based on:
• Stage of group development.
• Healthy behavior to be encouraged.
• Factors such as age, developmental levels, physical
capacities, motor skills, endurance,
interests, attention spans, social skills, etc.
4. Makes a periodic program for group work activities and
forwards the same to the COH/AO for approval.
CHIEF OF HOSPITAL/ 5.
Approves program for implementation by the MSW.
ADMINISTRATIVE OFFICER 6. Provides administrative support.
MEDICAL SOCIAL WORKER 7. Invites participants to the group activity.
8. Conducts group work sessions:
• Support group session
• Briefing on hospital policies, rules and regulations,
public and human relations
• Values education/re-orientation
• Play therapy
• Stress debriefing
• Livelihood program
• Health education and family planning
• Blood donation
• Family counseling
9. Documents observations needed for assessment and
diagnosis.
10. Prepares monthly report of group work activity [Form
no. 73].
11. Consolidates group work activities and incorporates this
in the Statistical Report [Form no. 74].
CHART NO. 51: MEDICAL SOCIAL SERVICE: SOCIAL GROUPWORK PROCESS
CHIEF OF HOSPITAL/ MEDICAL SOCIAL WORKER ADMINISTRATIVE OFICER
Reviews cases and identifies

patients/ families for group work
intervention
Groups patients according to their common needs

or situations
Plans appropriate group activities
Makes periodic program for group activities
Approves program for

implementation Forwards plans of activities to COH for approval
Provides administrative Invites participants to the group activity

support
Conducts group work sessions
Documents observations needed for assessment

and diagnosis
Makes monthly report of group work activity
Consolidates group work

activities and incorporates it in
Statistical Report
9. Community organization focus on linkages

NON-GOVERNMENT 1. Gives donations, assistance or voluntary services.
ORGANIZATION (NGO),
GOVERNMENT
ORGANIZATION (GO),
PHILANTHROPIC FAMILIES
AND INDIVIDUALS
MEDICAL SOCIAL WORKER 2. Compiles listing of community resources (NGOs, GOs,
philanthropic families and individuals/volunteers) for
ready reference.
3. Provides formal and informal recognition to these
community resources for their assistance and
donations.
4. Establishes ongoing linkages and coordinates with
these community resources.
CHIEF OF HOSPITAL 5. Assigns appropriate staff/hospital unit for
safekeeping of said donations.
MEDICAL SOCIAL WORKER 6. Based on casework findings, refers deserving
patients to any of these community resources
which could meet their needs.
NGO, GO, PHILANTHROPIC 7. Reviews and approves requests.
FAMILIES AND
INDIVIDUALS
PATIENT/RELATIVE 8. Receives donation/assistance and informs social
worker of the outcome of the referral and the
assistance received.
MEDICAL SOCIAL WORKER 9. Documents all activities emanating from GOs, NGOs,
philanthropic individuals and volunteers coordinating
with the hospital [Form no. 75].
10. Consolidates reports of said activities in the Statistical
Report [Form no. 74] for submission to the COH/AO
and inclusion in the hospital’s accomplishment report.
Submits
11. report to the COH/AO and NGOs/GOs, philanthropic
families/individuals.
CHIEF OF HOSPITAL/ 12. Receives report.
NGOs, GOs, 13. Receives utilization report.
PHILANTHROPIC FAMILIES
AND INDIVIDUALS
COMMUNITY ORGANIZATION FOCUS ON LINKAGES
CHIEF OF MEDICAL SOCIAL NGO, GO, PHILANTHROPIC PATIENT

HOSPITAL WORKER FAMILIES AND INDIVIDUALS
Gives donations or
Compiles listing of
assistance
community resources
Provides informal or
formal recognition
Establishes ongoing
linkages
Assigns
appropriate
service for
safekeeping
of donations
Refers deserving patients Reviews and approves Receives

to any of these resources request donations/
assistance &
informs MSW of
the outcome
Documents activities
Consolidates report of
such activities into the
statistical report
Submits report to COH/AO

and NGO/GO philanthropic
families/individuals
Receives report Receives utilization

report of
donations
10. Community
organizing focus on community outreach
MEDICAL SOCIAL WORKER 1. Identifies high-risk communities needing medical
social work intervention through:
• case review
• social analysis through focus group discussion with
the patients from identified community.
2. Proposes community outreach program to COH/AO.
CHIEF OF HOSPITAL/ 3. Reviews and approves proposal.
ADMINISTRATIVE OFFICER 4. Provides the necessary administrative support.
MEDICAL SOCIAL WORKER 5. Coordinates with formal or informal leaders of the
community about the proposed outreach activity.
6. Identifies the core group members.
MEDICAL SOCIAL WORKER 7. Conducts focus group discussion on:
AND CORE GROUP • Members’ reflection and study of their
MEMBERS predicament
• Relation of members’ predicament to the problems
facing the whole nation.
MEDICAL SOCIAL WORKER 8. Motivates the group members to formalize
membership in the group.
MEDICAL SOCIAL WORKER 9. Facilitates mapping out of action plan.
AND CORE GROUP 10. Implements action plan.
MEMBERS
NOTE:Chooses appropriate social work intervention to
strengthen community outreach.
11. Monitors the implementation of the action plan.

12. Evaluates outcome of the action plan
a. If goals are not achieved, maps out new
actionplan.
b. If goals are achieved, facilitates planning of
newdirections towards a sustained and self-reliant
organization.
MEDICAL SOCIAL WORKER 13. Documents activities [Form no. 76].
CHART NO. 53:
MEDICAL SOCIAL SERVICE: COMMUNITY ORGANIZING FOCUS ON COMMUNITY OUTREACH
CHIEF OF HOSPITAL/ MEDICAL SOCIAL CORE GROUP
ADMINISTRATIVE OFFICER WORKER MEMBERS
Identifies high risk

communities needing Medical
Social Work intervention
Reviews and
approves Makes proposal for community outreach
program
proposal
Coordinates with the formal/informal

Provides leader in the community
necessary
administrative
support
Identifies core group members
Conducts focus group discussion
Motivates members to formalize group
Facilitates mapping out of action plan
Implements plan of action
Monitors implementation and evaluate outcome
NO Were goals
achieved?
YES
Facilitates planning of new directions towards a sustained and self-reliant

organization
Documents activities
11. Management of victims of abuse
PHYSICIAN 1. Investigates all cases that indicate possible abuse.
2. Provides the necessary treatment.
3. Once the existence of abuse is established,
referspatient to the MSW.
MEDICAL SOCIAL WORKER 4. Conducts data gathering while providing safety
andcomfort to the victim.
5. Establishes a relationship with the victim.
6. Provides information and practical assistance to the
victim.
7. Reports the abuse to the municipal
socialworker/Department of Social Welfare and
Development (DSWD).
DEPARTMENT OF SOCIAL 8. Visits the patient within 48 hours and

WELFARE AND providesappropriate services.
DEVELOPMENT (DSWD) 9. Maintains coordination.
STAFF AND MSW/HEALTH
PERSONNEL
MEDICAL SOCIAL WORKER 10. Records all activities and files them accordingly.
CHART NO. 54: MEDICAL SOCIAL SERVICE: MANAGEMENT OF VICTIMS OF ABUSE
CIAN MEDICAL SOCIAL WORKER DSWD AND
OTHER HEALTH PERSONNEL
all cases
Conducts data gathering while
possible
providing safety and comfort to the
e
victim
Establishes a relationship with the

of victim
e?
Provides information and practical

assistance
necessary
ment
Visits the patien t and provides

Reports the abuse to the
the appropriate service(s)
Municipal Social Worker/ DSWD
nt to the MSW
Maintains coordination
MS service
Records all activities
Files documentation
12. Management of abandoned and neglected children

PHYSICIAN/NUTRITIONIST/ 1. Refers all abandoned and neglected children to the
NURSE/OTHER HEALTH MSW.
PROFESSIONAL
MEDICAL SOCIAL WORKER 2. Conducts data gathering.
3. Reports the cases to DSWD/Municipal Social Worker.
4. Visits patient and provides appropriate services.
DEPARTMENT OF SOCIAL 5. Maintains coordination.
WELFARE AND
DEVELOPMENT STAFF
/CITY SOCIAL
WELFARE AND
DEVELOPMENT (CSWD)
STAFF
MEDICAL SOCIAL WORKER 6. Provides intensive social casework.
7. Prepares documentation.
CHART NO. 55: MEDICAL SOCIAL SERVICE: MANAGEMENT OF ABANDONED AND
PHYSICIAN/NUTRITIONIST/ DSWD/MSWD NURSE/OTHER HEALTH PROFESSIONAL
NEGLECTED CHILDREN
Refers all
abandoned and Conducts data gathering
neglected children
to the MSW
Reports the cases to DSWD/Municipal

Social Worker
Visits patient and provide appropriate Maintains

services coordination
Provides intensive social casework
Prepares documentation
MEDICAL SOCIAL
WORKER
13. Management of elderly patients
PHYSICIAN 1. Evaluates elderly patient and provides necessary
treatment.
2. Refers elderly patient to the MSS.
MEDICAL SOCIAL WORKER 3. Prioritizes patient for intervention.
4. Conducts intake to:
• Determine validity of patient’s identification card.
• Assess level of patient’s psychosocial functioning
with special focus on ruling out abuse or neglect
cases.
5. Orients patient on the benefits and limitations of their
entitlement.
a. If found eligible, facilitates necessary treatments.
b. If found not eligible, gives 20% discount
andprovides counseling.
c. If patient is a Philippine Health
InsuranceCorporation (PHIC or PhilHealth)
member or dependent, refers patient to the
Billing/PhilHealth Section.
6. Provides appropriate social work intervention.
7. Documents and reports all services rendered to the
senior citizens and furnishes a copy to the COH and
the National Center for Health Facility Development
(NCHFD) - MSW adviser for consolidation and
feedback to the Office of Senior Citizen’s Affairs
(OSCA).
BILLING/PHILHEALTH 8. Ensures that PhilHealth benefits are utilized before

other entitlements are used.
MANAGEMENT OF ELDERLY PATIENTS
PHYSICIAN MEDICAL SOCIAL WORKER BILLING/PHILHEALTH STAFF
Evaluates Prioritizes patient for intervention

patient and
provides
necessary
Conducts intake interview
treatment
Orients patient on the benefits

and limitation of their entitlement
Refers patient to
MSS
NO Is patient
eligible?
YES
Facilitates necessary treatments
Allows 20% discount and

provides counseling
NO Philhealth
member/
dependent?
YES Ensures that

Philhealth benefits
Refers to Billing/Philhealth are utilized before
Section other entitlements
are used
Provides appropriate social

work intervention
Documents and reports all

services rendered to the
senior citizens
Furnishes a copy of report

to the COH and the NCHFD
MSW adviser
PHARMACY SERVICE PROCEDURES
1. Submission of required drugs and medicines for annual drug procurement plan
(ADPP)
DEPARTMENT 1. Reviews the previous year’s performance as to: •
HEADS/MEDICAL STAFF Number of patients served - OPD, ER and in patient
• Patient Classification- pay, with health insurance
(PHIC member), charity
• Type of cases served
• Other hospital utilization rates and statistics •
Previous budget allocation
2. Forecasts the medicines and drugs required for the
incoming year.
3. Lists drugs and medicines needed by the respective
departments and submits this to the Pharmacy and
Therapeutics Committee (PTC) for evaluation.
PHARMACY AND 4. Reviews and evaluates listings submitted by the

THERAPEUTICS COMMITTEE different department heads.
MEMBERS 5. Verifies whether listed drug classifications are
included in the Hospital Drug Formulary, based on
the Philippine National Drug Formulary (PNDF).
a. If drugs in the list are included in the Hospital
Drug Formulary, PTC approves and endorses
list to the Senior Pharmacist for consolidation,
indicating therapeutic classifications, drugs in
generic nomenclature, with complete
specifications and packaging.
b. If there are drugs not included in the Hospital
Drug Formulary, the PTC chairman notifies the
department concerned.
DEPARTMENT HEAD 6. Justifies inclusion of “new” drug to the Hospital Drug
CONCERNED Formulary.
PHARMACY AND a. If not approved by PTC, drug listed shall be
THERAPEUTICS COMMITTEE deleted.
MEMBERS b. If approved by PTC, updates listing of
HospitalDrug Formulary and notifies all
department heads.
123
y Action
7. Consolidates drug and medicine requirements
indicating therapeutic classifications, drugs in
generic nomenclature with complete specifications,
quantity and estimated cost.
8. Forwards consolidated list to the PTC chairman
forendorsement and recommendation to the Chief of
Hospital (COH).
9. Recommends approval of list and forwards this to the
COH.
10. Approves list and forwards the same to the Supply
Officer.
11. Prepares official Annual Procurement Plan (APP)
[Form no. 77] for drugs and medicines and submits
the same to the COH for endorsement to the CITY
MAYOR for approval.
12. Recommends and endorses the annual procurement

for drugs and medicines.
13. Approves ADPP and endorses this to the COH for

dissemination.
14. Files approved ADPP.
124
CHART NO. 57: PHARMACY: SUBMISSION OF REQUIRED DRUGS AND MEDICINES FOR ANNUAL DRUG PROCUREMENT
PLAN
125
2. Regular requisition and procurement of drugs and medicines
PHARMACIST 1. Determines stock level and prepares list of
neededdrugs and medicines if stock is below re-
order point.
2. Prepares Supplies Availability Inquiry (SAI) [Form no.
41] and forwards the same to the Accounting
Division.
ACCOUNTANT 3. Receives SAI and determines availability of drugs and
medicines requested and forwards the same to the
Pharmacist.
PHARMACIST 4. If drug(s) and medicine(s) is available, prepares RIS
(Requisition Issue Slip) and forwards the same to the
Property Section.
SUPPLY OFFICER 5. Issues drug(s) and medicine(s) requested according
to the quantity indicated in the RIS.
PHARMACIST 6. If drug(s) and medicine(s) requested is not available,
prepares purchase request (PR).
7. Certifies that drugs requested are listed in the PNDF.
8. Forwards PR to the Administrative Officer (AO) forreview
and initial.
ADMINISTRATIVE OFFICER 9. Receives, reviews, and signs initials in the
requisition portion of the PR, and forwards the
same to the Chief of Medical Professional Staff.
CHIEF OF MEDICAL 10. Receives, reviews, and signs in the requisition
PROFESSIONAL STAFF portion of the PR, and forwards the same to the
COH.
CHIEF OF HOSPITAL 11. Receives, reviews and signs in the approval portion
of the PR, and forwards the same to the Supply
Officer.
SUPPLY OFFICER 12. Receives PR and prepares action documents and
processes them accordingly.
NOTE:As a general rule, reordering point should be at 50% stock level.
126
CHART NO. 58: PHARMACY: REGULAR REQUISITION AND PROCUREMENT OF DRUGS AND MEDICINES
CHIIEF OF CHIEF, MEDICAL ADMIN. PHARMACIST ACCOUNTANT SUPPLY HOSPITAL PROFESSIONAL OFFICER
OFFICER
Determines stock level and
prepares list of needed drugs
and medicines
Receives, reviews
Receives, reviews Receives, and initials PR
and approves PR reviews, and and forwards this
and forwards this signs PR and to the Chief,
to the Supply forwards this to Prepares Supplies Availability Determines
Medical
Officer the COH Inquiry (SAI) and forwards it to availability of
Professional Staff
the Accounting Division drugs/medicines
requested and
forwards it to the
pharmacy
NO
Prepares Purchase Issues drug(s) and
Request (PR), Is the drug / medicine(s) requested
certifies that medicine according to the
drugs are listed in available? quantity indicated in
PNDF, and the RIS.
forwards PR to AO
YES
Prepares Request
Issuance Slip (RIS) and
forwards to property
section
Receives RIS and

prepares action
documents and
processes them
accordingly
STAFF
127
3. Acceptance of deliveries, storage, and preservation of drugs and medicines
SUPPLY OFFICER 1. Receives deliveries in the presence of the
Pharmacist, COA representative, and an Inspection
Committee member of the agency.
CITY INSPECTION 2. Inspects that deliveries conforms to quantity and
COMMITTEE MEMBER AND specifications.
HOSPITAL PHARMACIST 3. Takes random samples and forwards them to the
Bureau of Food and Drugs (BFAD) for testing.
4. Prepares inspection report [Form no. 79],
attachesBFAD test result and forwards these to the
Supply Officer (please see Property and Supply
Procedures, pp. 220 for further steps).
SUPPLY OFFICER 5. Issues drugs and medicines to the Pharmacist.
PHARMACIST 6. Receives drugs and medicines for proper storage,
preservation and records them in the Drug Stock
Card [Form no. 43] and Stock Ledger Card.
CHART NO. 59: PHARMACY: ACCEPTANCE OF DELIVERIES, STORAGE,
AND PRESERVATION OF DRUGS AND MEDICINES
CITY INSPECTION PHARMACIST SUPPLY COMMITTEE MEMBER OFFICER
Inspect deliveries as to quantity and specifications Receives deliveries

in the presence of
the Pharmacist,
representative of
COA, and agency
Takes random samples and forwards them to BFAD for testing Inspection
Committee
member
Prepares inspection report, attaches BFAD test resultand

forwards this to the Supply Officer
Issues drugs and

medicines to the
Pharmacist
Receives drugs and

medicines for proper
storage, preservation and
records them in the
Drug Stock Card and
Stock Ledger Card
149
PHYSICIAN 1. Prescribes generic drugs/medicines needed by the
patient.
NOTE: One drug, one prescription policy is applied.
Quantity of medicines prescribed should be good
for 24 hours only.
NURSING ATTENDANT (NA) 2. Presents prescription signed by the Attending
Physician to the Pharmacist.
PHARMACIST 3. If drugs and medicines are not available, instructs
NAaccordingly.
4. If drugs and medicines are available:
4.1 Fills up prescription with proper label such
aspatient’s name, generic name of the drug,
dosage strength, direction for use and name of
Pharmacist, and dispenses the medicines to the
NA.
4.2 Notes price and asks NA to inform the
patient/client of the cost.
5. Prepares pre-numbered charge slips [Form no. 4] and
forwards them to the Billing Clerk to be included in the
patient’s jacket [Form no. 48].
6. Records drugs and medicines dispensed and
filesprescription. If drug is regulated, records patient’s
name and quantity of drugs dispensed in the Narcotics
Record Book.
NOTE: All prescriptions should be properly
accomplished with patient’s name, ward,
classification, drug in generic nomenclature
and duly signed by a Physician (hospital staff).
4. Filling-up of prescriptions for in-patients
150
Note: For dangerous drugs, follow procedures as per the Dangerous Drugs Act and
Generics Act.
CHART NO. 60: PHARMACY: FILLING-UP OF PRESCRIPTIONS FOR IN-PATIENTS
PHYSICIAN PHARMACIST NURSING ATTENDANT
151
Presents prescription signed
Prescribes by the attending physician to
drugs/medicines in the Pharmacist
generics needed by
the patient
Drugs
YES
available?
NO
Instructs Nursing
Aide accordingly
Fills up prescription with

proper label and
dispenses the medicines
to Nursing Aide
Notes price and asks NA

to inform the
patient/client of the cost
Prepares pre-numbered
charge slips and
forwards them to the
Billing clerk
Records drugs and

medicines dispensed and
files prescription. If
regulated, records in the
Narcotic Record Book
152
5. Filling up of prescriptions for out-patient
PHYSICIAN 1. Prescribes in generic nomenclature the medicines
needed by the patient. One drug, one prescription
policy is applied.
PATIENT/CLIENT 2. Presents prescription duly signed by a Physician to
the Pharmacist.
PHARMACIST 3. If medicine is not available, instructs patient, andinforms
Physician of alternative drugs available in the pharmacy.
4. If medicine is available, prepares charge slips and
instructs the patient/client to pay to the Cashier.
5. If patient cannot afford to pay, refers the patient tothe
MSW.
MEDICAL SOCIAL WORKER 6. Evaluates and classifies patient/client and makes the
necessary recommendation(please see Medical
Social procedures, pp. 100-101 for further
steps).
CASHIER 7. Receives payment and issues official receipt to the
patient/client.
PATIENT/CLIENT 8. Presents official receipt or Indigency Certification
[Form no. 56] and prescription to the pharmacist.
PHARMACIST. 9. Indicates official receipt number or notes
patient’sIndigency Certification on the prescription
and fills up the same.
10. Dispenses medicine to the patient/client with
properlabel.
11. Provides patient counseling on the required dosage
and frequency of medication.
12. Records medicines issued and files the prescription.
13. For indigent patient, records the amount of
themedicine in the Indigency Record Book.
Note: For dangerous drugs, follow procedures as per the Dangerous Drugs Act and Generics
Act.
153
CHART NO. 61: PHARMACY: FILLING UP OF PRESCRIPTIONS FOR OUT-
PATIENT
132
6. Requisition of emergency drugs
ER NURSE 1. Informs ER unit head as to stock level of
emergency drugs.
ER UNIT HEAD 2. Prepares listing of drugs including quantity and
(PHYSICIAN) estimated cost and forwards the same to the
Pharmacist.
PHARMACIST 3.
Prepares RIS [Form no. 41] for the purchase of
emergency drugs (please see Property and
Supply Procedures on emergency purchase,
pp.
216-219)
CHART NO. 62: PHARMACY: REQUISITION OF EMERGENCY DRUGS
ER UNIT HEAD ER NURSE PHARMACIST (PHYSICIAN)

Prepares listing of drugs
including quantity and Informs ER unit head
estimated cost and forwards as to stock level of
it to the Pharmacist emergency drugs
Prepares RIS for

purchase of emergency
drugs
Chart no.
104
p.215
133
7. Requisition of disinfectants
CENTRAL SUPPLY ROOM 1. Checks stock level and availability of supplies.
HEAD
NOTE: For supplies below 50% stock level, instructs
Central Supply Room (CSR) Nurse/Attendant to prepare
requisition.
NURSE/NURSING 2. Prepares request slip [Form no. 42] and forwards the
ATTENDANT/CSR STAFF same to the CSR Head/Chief Nurse.
CSR HEAD/CHIEF NURSE 3. Signs request slip and forwards the same to the
Pharmacist.
PHARMACIST 4. Checks the stock availability of disinfectants.
a. If disinfectant is not available, informs the
ChiefNurse/CSR Head.
b. If disinfectant is available, issues disinfectantwith
proper labeling.
5. Records disinfectant issued and files the request slip.
6. Prepares Pharmacy Monthly Report of Issuance ofDrugs
and Medicines [Form no. 80], and accomplishes
summary Report of Issuance and Balance of Drugs and
Medicines [Form no. 81]
134
CHART NO. 63: PHARMACY: REQUISITION OF DISINFECTANTS
CHIEF NURSE CSR HEAD CSR NURSE/NA PHARMACIST

STAFF
Checks stock Prepares

level and request slip
availability of
supplies
Signs request slip
Checks availability of
disinfectant in stock
Disinfectant YES
available
NO
Informs the
Chief
Nurse/CSR
Head
Records disinfectant
issued and files the
request slip
Prepares
pharmacy
monthly report
135
8. Unit Dose Drug Distribution System (UDDDS)
PHYSICIAN 1. Prescribes drugs utilizing Physician’s Drug Order (PDO)
sheet [Form no. 82].
WARD NURSE 2. Checks completeness of PDO.
NURSING ATTENDANT 3. Forwards PDO to the Pharmacy.
SENIOR PHARMACIST 4. Transcribes PDO in the individual patient drug profile
(PDP) [Form no. 83].
4.1. Reviews patient census - admissions and
discharges.
4.2. Fills patient drug cassette.
5. Endorses drugs and medicines to the patient/relative in
the presence of the ward nurse.
6. Notifies patient/relative of the availability and non
availability of drugs.
7. Provides patient counseling.
8. Checks for used/unused drugs and medicines. Unused
drugs are deleted from the patient’s drug profile.
9. Prepares charge slips [Form no. 4] and forwards the
same to the Billing Section.
WARD NURSE 10. Administers drugs and medicines to the patient.
158
CHART NO. 64: PHARMACY: UNIT DOSE DRUG DISTRIBUTION SYSTEM
PHYSICIAN WARD NURSE SENIOR NURSING

PHARMACIST ATTENDANT
Prescribes drugs Checks

completeness of Forwards PDO to
utilizing physician’s the Pharmacy
drug order (PDO) PDO
sheet
Transcribes PDO in
the PDP
• Review patient
census
• Fills patient dru g
cassette
Endorses drugs and

medicines to the
patient/relative in the
presence of the
nurse
Notifies
patient/relative of
the availability and
non-availability of
drugs
Provides patient
counseling
Checks for
used/unused drugs
and medicines,
unused drugs are
deleted from
patient’s drug profile
Administers
Prepares charge slips
drugs and
medicines to and forwards them to
the patient the Billing Section
159
9. Disposal of expired or damaged drugs and medicines
PHARMACIST 1. Conducts drug inventory and separates expired or
damaged drugs and medicines.
2. Notifies Supply Officer.
SUPPLY OFFICER/ 3. Prepares Waste Material Report (WMR) [Form no.
STOREKEEPER/DESIGNATE 84], to include generic nomenclature, specifications,
quantity, and values.
4. Signs and submits WMR to the AO.
ADMINISTRATIVE OFFICER 5. Reviews, verifies, and recommends approval of WMR
to the COH.
CHIEF OF HOSPITAL 6. Approves and signs WMR and forwards it to Supply
Officer/Storekeeper for appropriate action.
SUPPLY OFFICER/ 7. Forwards documents to the General Services Officer
STOREKEEPER/ (GSO).
DESIGNATE NOTE: The processing of disposal of expired or
damaged drugs and medicines are done at the
GSO or GSCH office.
ACCOUNTING DIVISION 8. Forwards WMR and journal voucher for the dropping
of drugs and medicines to the COH.
CHIEF OF HOSPITAL 9. Forwards documents to Supply Officer/Storekeeper.
SUPPLY OFFICER/ 10. Forwards WMR and other documents to the
STOREKEEPER/DESIGNATE Pharmacist.
PHARMACIST 11. Drops from the records the quantity and value of
disposed drugs and medicines.
160
CHART NO. 65: PHARMACY: DISPOSAL OF EXPIRED OR DAMAGED DRUGS AND MEDICINES
HIEF OF ADMINISTRATIVE PHARMACIST SUPPLY OFFICER/ ACCOUNTING
OSPITAL OFFICER STOREKEEPER DIVISION
Conducts drug
inventory and Prepares Waste Material
separates Report (WMR), to
expired or include generic
damaged drugs nomenclature,
and medicines specifications, quantity
and values
Signs and submits WMR

Notifies Supply to the AO
Officer
proves and
gns WMR Reviews,
d forwards verifies and
to Supply recommends
Officer/ approval of Forwards
orekeeper WMR to the WMR and
for COH journal
ppropriate Forwards documents voucher for
action to General Services the dropping
Office of drugs and
medicines to
Forwards the COH
cuments to
Supply
Forwards WMR and other
Officer/
documents to the
orekeeper Pharmacist
Drops from the

records the
quantity and
value of disposed
drugs and
medicines
161
DIETARY SERVICE
1. Diet prescription at the time of admission

Responsibility Activities
PHYSICIAN 1. Writes diet prescription for the patient on
theDoctor’s Order Sheet [Form no. 5]
2. Forwards the medical record to the Ward Nurse.
NURSE 3. Informs the Dietary Service about the
patient’sadmission and prescribed diet [Form no.
85].
4. Notifies Dietary Service of change of diet if there
areany, and patients who are scheduled for
operation and discharge [Form no. 86].
DIETITIAN 5. Checks if diet orders are included in the diet
list[Form no. 87].
6. Includes new diet orders in the food
productionorder sheet [Forms no. 88 and 89].
7. Forwards the food production order sheet to
thecook.
140
CHART NO. 66: DIETARY SERVICE: DIET PRESCRIPTION AT THE TIME OF
ADMISSION
PHYSICIAN NURSE DIETITIAN
Writes diet
prescription for Informs the Dietary Service on
the patient in the the patient’s admission and
Doctors Order prescribed diet
Sheet
Notifies Dietary Service of

change of diet if any, and Checks if diet orders are
Forwards the patient chart patients who are scheduled for included in the diet list
to the ward nurse operation and discharge
Includes new diet orders

in the food production
order sheet
Forwards the
food production
order sheet to
the cook
2. Menu planning
DIETITIAN 1. Prepares cycle menu for the week [Forms no. 90
and 91] based on the existing subsistence policies,
budget, and food seasonability.
2. Submits cycle menu plan to the Administrative
Officer (AO)/Chief of Hospital (COH) for approval.
CHIEF OF 3. Reviews and approves weekly menu plan and
HOSPITAL/ADMINISTRATIVE returns the same to the Dietitian.
OFFICER
DIETITIAN 4. Posts approved cycle menu on the bulletin board for
the guidance of the dietary personnel.
CHART NO. 67: DIETARY SERVICE: MENU PLANNING
163
CHIEF OF HOSPITAL/ DIETITIAN ADMINISTRATIVE OFFICER
Prepares cycle menu for the

week, based on the existing
subsistence policies, budget, and
food seasonability
Reviews and approves weekly menu

plan and returns the same to the Submits cycle menu plan to the administrative
Dietitian officer/chief of hospital for approval
Posts approved cycle menu on

the bulletin board for the
guidance of the dietary
personnel
3. Food procurement (open market purchase)

DIETITIAN 1. Checks any left over cooked/uncooked foodstuff and
food stock inventory.
2. Checks menu for the day.
3. Checks patient census [Form no. 92].
4. Determines requirement for various types of diet.
5. Prepares procurement list or market order
form[Form no.93], and forwards the same to the AO
for initial.
ADMINISTRATIVE OFFICER 6. Reviews and initials procurement list for open
market and forwards list to the COH.
CHIEF OF HOSPITAL 7. Reviews and approves procurement list and
forwards the same to the Dietitian.
DIETITIAN 8. Instructs Food Service Worker (FSW) or assigned
buyer to do the marketing.
ASSIGNED FOOD BUYER 9. Purchases food items listed in the market order
form.
Note: Each item purchased must be supported by an
official receipt for liquidation purposes.
CHART NO. 68: DIETARY SERVICE: FOOD PROCUREMENT
164
CHIEF OF ADMINISTRATIVE DIETITIAN ASSIGNED
HOSPITAL OFFICER FOOD BUYER
Checks any left over
foodstuff and food stock
inventory
Checks menu for the day and patient

census
Determines requirement for various

Reviews and Reviews and types of diet
approves initials
procurement procurement
list and list for open
Prepares procurement list or market
rwards this to market and Purchases
order form and forwards to AO for
the Dietitian forwards this food items
to the COH initial
listed in the
market
Instructs food service worker or order form
assigned buyer to do marketing
4. Receiving and storage of food items

INSPECTION COMMITTEE 1. Upon arrival of the purchased foodstuff, checks all
CHAIRMAN/ DESIGNATE items according to specification and quantity
required as indicated in the procurement list.
DIETITIAN 2. Lists all items on the Statement of Daily
MarketPurchases (SDMP) [Form no. 94].
3. Presents the SDMP to the inspection
committeechairman for signature.
INSPECTION COMMITTEE 4. Reviews and signs SDMP.
CHAIRMAN/ DESIGNATE
DIETITIAN 5. Turns over food items to the assigned dietary
personnel.
ASSIGNED DIETARY 6. Brings perishable food items to the preparation area
PERSONNEL/COOK/FOOD and stores the non-perishable food in its proper
SERVICE WORKER places.
DIETITIAN 7. Prepares Disbursement Voucher (DV) [Form no. 95]
and forwards the same to the AO.
ADMINISTRATIVE OFFICER 8. Reviews reimbursement voucher, initials it, and
forwards the same to the COH for signature.
165
CHART NO. 69: DIETARY SERVICE:
RECEIVING AND STORAGE OF FOOD ITEMS
ADMINISTRATIVE INSPECTION COMMITTEE DIETITIAN ASSIGNED DIETARY

OFFICER CHAIRMAN/ DESIGNATE PERSONNEL/COOK/FSW
Upon arrival of the

purchased
foodstuff, checks
all items as
indicated in the
Lists all items on the
procurement list
Statement of Daily Market
Purchases (SDMP)
Reviews and signs Presents the SDMP to the

SDMP inspection committee
chairman for signature
Brings perishable food

Turns over food items to the items to the preparation
assigned dietary personnel area and stores non-
perishable food in proper
Reviews places
reimbursement
voucher, initials Prepares reimbursement
it and forwards voucher and forwards it to
said voucher to the AO
the COH for
signature
5. Food preparation
DIETITIAN 1. Determines number of patients and the type of
diet to be served based on the diet list.
2. Determines the equivalent quantity of food to
beprepared or cooked.
3. Instructs the cook/food service worker on
thequantity of food and the menu to be prepared
[Form no. 96] [Form 97] (in case there is a
cafeteria service or special function).
COOK 4. Prepares requisition of all items needed for
cooking [Form no. 98].
COOK/ FOOD SERVICE 5. Prepares and cooks the food for the day.
WORKER
CHART NO. 70: DIETARY SERVICE: FOOD PREPARATION
166
DIETITIAN COOK FOOD SERVICE
WORKER
Determines number
of patients and the
type of diet to be
served based on the
diet list
Determines the equivalent

quantity of food to be prepared
or cooked
Instructs the cook/food Prepares requisitions of

service worker on the quantity all items needed for
of food and the menu to be cooking
prepared
Prepares and cooks the food for the day
167
6. Food distribution
DIETITIAN 1. Prepares color-coded diet tags.
FOOD SERVICE WORKER/ 2. Transfers cooked food to the distribution area.
UTILITY WORKER 3. Prepares food tray for dishing out.
DIETITIAN 4. Supervises dishing out and apportioning of
cooked food on the patient trays.
COOK/ FOOD SERVICE 5. Dishes out cooked food items on patients’ trays
WORKER using the diet tags as guide.
FOOD SERVICE WORKER/ 6. Classifies and groups food trays by wards.
UTILITY WORKER 7. Loads dished out trays to the respective
conveyors.
DIETITIAN 8. Checks loaded food trays according to the diet,
orders, or prescriptions of patients in the diet
list.
FOOD SERVICE WORKER 9. Distributes food trays to the patients.
DIETITIAN 10. Conducts ward rounds and supervises the
distribution of food trays.
FOOD SERVICE WORKER 11. After mealtime, collects and returns used food
trays to the Dietary Service.
12. Washes and sanitizes food trays in preparation
forthe next service.
168
CHART NO. 71: DIETARY SERVICE: FOOD DISTRIBUTION
DIETITIAN COOK FOOD SERVICE UTILITY WORKER WORKER
Prepares color- Transfers cooked food to the distribution

coded diet tags area and prepares food tray for dishing out
Supervises dishing
out and apportioning
of cooked food on
the patient trays Does the dishing out of cooked food items on
patients’ trays
Classifies and group food trays by wards
Checks loaded food

trays according to
the diet orders or Loads dished out trays to the respective
prescriptions conveyors
Distributes food trays

to the patients
Conducts ward
rounds and
supervises food tray
distribution
After mealtime,
collects and returns
used food trays to
the Dietary Service
Washes and
sanitizes food trays
for the next service
169
7. Dishwashing, housekeeping and garbage disposal
FOOD SERVICE WORKER 1. Cleans and washes all cooking equipment
andutensils used in food preparation.
2. Cleans the work areas to make it ready for next
use.
3. Mops the floors and cleans the surroundings of the
Dietary premises.
4. Discards garbage daily and cleans receptacles
thoroughly.
5. Keeps garbage cans intact with covers.
DIETITIAN 6. Inspects Dietary premises to check compliance with
dishwashing, housekeeping, and garbage disposal
standards before closing time.
CHART NO. 72: DIETARY SERVICE:
DISHWASHING, HOUSEKEEPING AND GARBAGE DISPOSAL
FOOD SERVICE WORKER DIETITIAN
Cleans and washes all cooking

equipment and utensils used in food
preparation
Cleans the work areas to make it free from

grease and moist and ready for next use
Mops the floors and cleans the surroundings of

the Dietary premises
Inspects Dietary premises to

check compliance with
Discards garbage daily and cleans receptacles dishwashing, housekeeping
thoroughly and garbage disposal
standards
Keeps garbage cans intact with covers
170
8. Clinical activities monitoring
DIETITIAN 1. Makes rounds to supervise food distribution. 2.
Visits patients for diet compliance, food
preferences, acceptance, and conducts health
education.
3. Checks if the diet prescribed conforms to
thediagnosis.
4. Talks with the doctor if diet does not conformto
diagnosis.
5. Prepares therapeutic and special diet.
6. Accomplishes daily subsistence record
ofpersonnel and patients being served.
7. Submits dietary report to the Medical
Recordsfor statistical reports.
8. Submits dietary report to the Administrative
Officer.
171
MEDICAL RECORDS SERVICE PROCEDURES
1. Processing of medical records received for file
WARD NURSE 1. Submits Medical Records (MR) of discharged patients
of the previous day with corresponding Floor Census
Report (FCR) [Form no. 99] to the Medical Records
Service (MRS).
MEDICAL RECORDS 2. Checks all medical records received against the list of
OFFICER/MEDICAL discharges as reflected in the daily census report.
RECORDS CLERK 3. Signs duplicate copy of the FCR and returns the
same to the Ward Nurse.
4. Rearranges the records according to the
standardformat.
5. Analyzes data in the patient’s medical
records(please see Analysis of Medical
Records, pp.
155-156).
STAFF OF WARD/CLINICAL 6. Reviews incomplete medical record.

UNIT CONCERNED 6.1. Upon receipt of incomplete medical record
withattached deficiency slip, completes required
data and signs the same.
6.2. Returns completed medical record to the MRS.
MEDICAL RECORDS CLERK 6.3. Receives medical records and forwards the
same to the MRO for analysis.
MEDICAL RECORDS 7. Collects statistical data.

OFFICER 8. Codes diseases and operations using the
prescribedcode tools (please see Coding of
Diseases, pp.
157-158).
8.1. Performs analysis of the portion of the medical
records to be coded.
8.2. Assigns International Classification of Diseases
(ICD) code.
9. Collects clinical data for inclusion in the statistical
report.
MEDICAL RECORDS CLERK 10. Prepares the folder and inserts the coded medical
records.
11. Pre-sorts medical records numerically.
12. Files medical records using the terminal digit filing.
151
CHART NO. 73: FLOWCHART OF PROCEDURES: MEDICAL RECORDS - PROCESSING OF MEDICAL RECORDS
WARD NURSE MEDICAL RECORDS CLERK WARD STAFF MEDICAL RECORDS OFFICER
2. Preparation of hospital census report
NURSE SUPERVISOR 1. Prepares and submits Floor Census Report (FCR)
[Form no. 99] and medical records of discharged
patient to the Medical Records Service first working
hour (8:00 in the morning).
MEDICAL RECORDS CLERK 2. Checks medical records against list of discharges
(MRC) onthe FCR.
3. Acknowledges receipt of the duplicate copy of the
FCR.
4. Collates FCR into the 24-hour census report.
5. Enters data in the discharge record and statistical
analysis sheet.
6. Enters report in the worksheet for the monthly report.
7. Prepares 4 copies of the hospital daily census report
[Form no. 99].
MEDICAL RECORDS OFFICER 8. Reviews and authenticates the 24-hour census

(MRO) report.
MEDICAL RECORDS CLERK 9. Furnishes the Chief of Hospital (COH) with a copy
through the Senior House Officer, the Chief Nurse,
and Administrative Officer (AO).
10. Files one copy of the 24-hour census report.
CHART 74: FLOWCHART OF PROCEDURES: MEDICAL RECORDS -
PREPARATION OF HOSPITAL CENSUS REPORT
NURSE SUPERVISOR MEDICAL RECORDS OFFICER MEDICAL RECORDS

CLERK
Prepares and
submits Floor Checks medical records
Census against list of discharges
Report (FCR) on the floor census report
and medical
records
Acknowledges receipt of
the duplicate copy of FCR
Collates FCR into 24-hour

census report
Review and authenticates

the 24-hour census report
Enters data into the
discharge record and
statistical analysis sheet
Prepares hospital daily

census report
Furnishes copy to the COH

through the Senior House
Officer, the Chief Nurse
and AO
Files one copy of

the 24-hour census
report
3. Analysis of medical records

MEDICAL RECORDS CLERK 1. Receives the assembled medical records.
2. Performs quantitative and qualitative analysis on the
medical records.
2.1. Checks all forms required by the case.
2.2. Checks every page of the medical
record forthe patient’s name and hospitals number.
3. Checks to confirm whether the order were carried
out by:
3.1. Verifying from the nurses’ notes whether the
orders were carried out or not.
3.2. If carried out, checks for all corresponding
result/report.
3.3. If not, checks whether the nurses’ notes stated
why orders were not carried out.
4. Checks if all pages were properly filled up.
5. Accounts that tests, treatments, and observations are
reflected in the record.
6. Checks that all reports of treatments and
medications, examinations, and evaluation are dated
and signed by the person who made the report.
7. Checks if all orders were dated and signed.
8. Checks if the authorization/consent was dated and
signed by the patient or his/her nearest kin in the
presence of a witness whose signature should also
appear in the authorization/consent.
9. Checks if there is a corresponding form/consent for
surgical and special intervention.
10. Checks if spelling of names and hospital number are
correct and written on every page of the medical
record.
11. Sorts out complete from incomplete medical records.
11.1. For incomplete medical records, returns it
withdeficiency slip to the concerned staff/unit
for completion.
11.2. Forwards completed medical record for coding
and indexing and collation of hospital
statistical report to the MRO.
MEDICAL RECORDS OFFICER 13. Compiles statistical data and statistical report.
CHART NO. 75: FLOWCHART OF PROCEDURES:
MEDICAL RECORDS - ANALYSIS OF MEDICAL RECORDS
MEDICAL RECORDS CLERK MEDICAL RECORDS OFFICER
Receives and performs

quantitative and qualitative
analysis
Checks all forms required by case
Checks each page for patient’s

name and hospital number
Checks to confirm whether the

orders were carried out
Checks all pages if properly filled-

up
Checks whether all entries are

dated and signed
Checks for required consents
Checks for correct spelling of
Compiles statistical
data into Statistical
Report
Prepares record of incomplete
Medical Records
Forwards collected data to MRO

4. Coding and indexing of diseases and operations
MEDICAL RECORDS CLERK 1. Forwards analyzed medical records to the MRO.
ICD-10 CODER (NURSE II/I)/ 2. Receives and analyzes portions of the medical recordsto
MEDICAL RECORDS OFFICER be coded.
3. Checks completeness of the diagnostic statement.
NOTE: Performs coding of diseases and operation using ICD

10.
4. Performs coding of diseases:

4.1. Analyzes and identifies the main, principal,
andprimary diagnosis from the alternative,
secondary diagnosis, and other diagnostic
statements.
4.2. Identifies the lead term.
4.3. Locates the lead term from the ICD 10
alphabetical index (volume 3).
NOTE: If possible, exhaust all efforts to account for all the
words in the diagnostic statement in the coding tool.
4.4. Notes the code number from the alphabetical
index (Volume 3) and checks it on the tabular list
(Volume 1).
NOTE:Read and be guided by the “notes”, inclusion and
exclusion terms that appear on each chapter and blocks to
be able to come up with a more sensible code for the
condition being coded.
4.5. Writes the sensible code from the tabular list on
the appropriate space parallel to the
diagnostic statement on the face sheet of
the medical record.
MEDICAL RECORDS CLERK 5. Indexes coded data:
5.1. Prepares the disease index.
5.2. Takes note of the required data reflected on the
disease index and transfers it from the medical
records to the disease index.
5.3. Files the disease index according to the disease
codes.
NOTE: Code and index operations/procedures following the
steps in the coding of diseases using the International
Classification of Procedures in Medicine (ICPM).
MEDICAL RECORDS - CODING OF DISEASE
MEDICAL RECORDS CLERK MEDICAL RECORDS OFFICER
Forwards
analyzed Receives and analyzes part to be
medical records coded
to the coder
Checks completeness of
Diagnostic statement
Performs coding and indexing
Identifies main, principal, primary

Prepares disease box diagnosis from secondary, other
diagnosis
Identifies lead terms and locates

in volume 3
Transfer coded data into
the disease index
Writes sensible code from Vol. III

of ICD and write parallel to
diagnostic statement on the face
sheet
Files disease index
using disease code
(ICD)
5. Preparation of statistical report

WARD NURSE 1. Forwards the daily floor census report to the MRC.
MEDICAL RECORDS CLERK 2. Receives and checks the floor census report and
medical records of discharged patients.
MEDICAL RECORDS OFFICER 3. Collates the floor census report into the 24-hour
hospital census report form [Form no.99].
4. Enters report in the worksheet for the monthly report.
5. Collates all the in-patients’ clinical data, causes of
death and discharges, and operation performed from
different indexes.
6. Collects consolidated data from the different
sections(pharmacy, laboratory, radiology, dietary, and
others) at the end of each month.
7. Computes for the required hospital indicators based
on the standard formulae.
MEDICAL RECORDS CLERK 8. Prepares the statistical report.

MEDICAL RECORDS OFFICER 9. Reviews and affixes initials on the hospital
statisticalreport.
10. Forwards the report to the AO for review and initial.
ADMINISTRATIVE OFFICER 11. Reviews and affixes initials on the statistical
report and forwards the same to the COH for
review and signature.
CHIEF OF HOSPITAL 12. Reviews and signs statistical report and returns the
same to the MR Clerk.
MEDICAL RECORDS CLERK 13. Prepares transmittal letter and submits a copy to
the City Health Officer (CHO), endorsing a copy of
the report to the City Health Office.
CITY HEALTH 14. Receives and consolidates statistical report into the
OFFICE STAFF CITY Statistical Report.
MEDICAL RECORDS CLERK 15. Retains a file copy of the report.
MEDICAL RECORDS - PREPARATION OF STATISTICAL REPORT
MEDICAL MEDICAL
WARD RECORDS RECORDS
CHO COH AO NURSE

REQUESTING 1. Submits duly accomplished request form to the
PARTY/BORROWER Records Clerk [Form no. 100].
MEDICAL RECORDS OFFICER 2. Verifies the identity of the borrower.
MEDICAL RECORDS CLERK 3. Checks hospital number from the Master PatientIndex
(MPI) card.
4. Retrieves medical records from the file.
5. Records in the logbook, and releases medical records to
the authorized borrower.
AUTHORIZED BORROWER 6. Acknowledges and signs the logbook.
6. Retrieval of patient’s medical record for authorized borrowers
Submits duly
Checks hospital Verifies identity of accomplished
number borrower request form
Retrieves medical
records from file
Accomplishes the Acknowledges

tracking system receipt of
borrowed records
NOTE: The hospital should have a policy regarding borrowing of patients’ records
specifying who are authorized to borrow.
MEDICAL RECORDS - RETRIEVAL OF PATIENT’S RECORDS
FOR AUTHORIZED BORROWERS
MEDICAL RECORDS MEDICAL RECORDS REQUESTING PARTY / CLERK OFFICER

BORROWER
7. Issuance of medical and medico-legal certificate
PATIENT / AUTHORIZED 1. Requests for the issuance of medical and /or medico-
PARTY legal certificate.
MEDICAL RECORDS CLERK 2. Interviews patient to establish identity and to
knowthe reason for the request.
3. Requires the patient to accomplish the request form.
PATIENT / AUTHORIZED 4. Submits written request for Medical Certificate.
PARTY 5. Submits written request for medico-legal from the
Chief of Police or other authorities signed by the
head of the agency.
NOTE: If the requesting party is the patient himself, a
request from the police or authorized party is not
necessary.
MEDICAL RECORDS CLERK 6. Receives written request for medical and / or medico-
legal certificate from an authorized party.
MEDICAL RECORDS 7. Verifies name of patient from the Master Patient
OFFICER Index (MPI) file, checks the hospital number and
retrieves medical record from the file.
MEDICAL RECORDS CLERK 8. Seeks clearance from the Attending Physician.
ATTENDING PHYSICIAN 9. Gives clearance.
MEDICAL RECORDS CLERK 10. Prepares two copies of the charge slip [Form no. 4]
and instructs the requesting party to pay the fee to
the Cashier.
REQUESTING PARTY 11. Pays medical and / or medico-legal fee.
NOTE: If patient is unable to pay, advises patient to
proceed to the MSS.
MEDICAL SOCIAL WORKER 13. Evaluates and classifies patient (please see
Medical Social Service Procedures, pp.
100105)
MEDICAL RECORDS CLERK 14. Prepares 3 copies of the Medical and / or
Medicolegal Certificate [Form no. 101].
15. Forwards certificate and medical record to
theAttending Physician for review and signature.
ATTENDING PHYSICIAN 16. Reviews and signs Medical and / or Medico-Legal
Certificate and returns it to the Medical Records
Service.
MEDICAL RECORDS 17. Affixes hospital seal on the certificate.
OFFICER
MEDICAL RECORDS CLERK 18. Requests for the official receipt.
REQUESTING PARTY 19. Presents official receipt to the Medical Records Clerk.
MEDICAL RECORDS CLERK 20. Records in the logbook indicating the official receipt
number.
21. Asks requesting party to sign, and releases the
certificate (original and first duplicate).
REQUESTING PARTY 22. Receives certificate (original and first duplicate copy)
and signs in the logbook.
MEDICAL RECORDS CLERK 23. Retains the third duplicate copy for file and
attaches it to the patient’s medical record.
CHART NO. 79: ISSUANCE OF MEDICAL AND MEDICO-LEGAL CERTIFICATE
PATIENT / MEDICAL RECORDS MEDICAL RECORDS CLERK ATTENDING CASHIER MEDICAL

CHART NO. 79: ISSUANCE OF MEDICAL AND MEDICO-LEGAL CERTIFICATE (Continuation)
TIENT / MEDICAL RECORDS CLERK ATTENDING MEDICAL

HORIZED CLERK PHYSICIAN RECORDS
ARTY OFFICER
Prepares 3 copies
A of the Medical and
/ or Medico-legal
Certificate [Form Reviews and signs Affixes hospital seal on
no. 101] Medical and / or the certificate
Medico-Legal
Certificate and returns
Forwards it to the Medical
certificate and Records Service
medical record to
the Attending
Physician for
review and Requests for the official
signature receipt
ts official receipt
Medical Records
Clerk
Records in the logbook
indicating the official
receipt number
eives certificate
ginal and first Asks requesting party
cate copy) and to sign, and releases
in the logbook the certificate (original
and duplicate)
Retains the third duplicate

copy for file and attaches it to
the patient’s medical record
8. Preparation of Birth Certificate
DR / OR NURSE 1. Interviews patient and verifies whether patient is
literate or not.
PARENT 1.1. If literate, fills up the Birth Certificate (BC) draft
form [Photocopy of Form no. 40] and certifies
the accuracy and completeness of data by
signing the official form.
DR / OR NURSE 1.2. If patient is illiterate, assists / fills up draft
form of Birth Certificate (BC) and forwards
the same to the Supervising Nurse.
2. Verifies the accuracy of data entry.

SUPERVISING NURSE 3. Reviews entries in the draft form and affixes his / her
initials.
4. Endorses accomplished forms to the Medical Records
Clerk for transcription in the official form.
MEDICAL RECORDS CLERK 5. Transcribes data from the pre-form or draft form into
the official form [Form no. 40] (4 copies), and
forwards the same to the DR / OR Nurse.
DR / OR NURSE 6. Checks and signs the official BC and forwards the
same to the Attending Physician.
ATTENDING PHYSICIAN 7. Receives, reviews, and signs official BC and forwards
the same to the Medical Records Clerk.
MEDICAL RECORDS CLERK 8. Prepares transmittal letter and forwards the same to
the Medical Records Officer.
MEDICAL RECORDS OFFICER 9. Signs transmittal letter and returns the same to the
Medical Records Clerk.
MEDICAL RECORDS CLERK 10. Logs transmittal and BCs, retains one copy and
attaches it to the medical records.
11. Forwards BCs and transmittal letter to the Local Civil
Registrar (LCR).
12. Accomplishes the Birth Register.
13. Files official copy of the transmittal letter and BC.
MEDICAL RECORDS-PREPARATION OF BIRTH CERTIFICATE
ATTENDI
NG
DR/OR NURSE SUPERVISING MEDICAL MEDICAL PARENT PHYSICIAN NURSE

RECORDS RECORDS OFFICER CLERK
9. Issuance of Death Certificate

NURSE ON DUTY 1. Interviews the nearest kin of the deceased.
2. Fills and signs official form [Form no. 50] of
DeathCertificate (DC) (5 copies).
PATIENT’S RELATIVE 3. Signs official form (5 copies) as informant.
ATTENDING PHYSICIAN 4. Completes medical certification portion of the DC and
returns the same to the Nurse.
NURSE ON DUTY 5. Checks the completeness of data entry and forwards
official DC to the MRS.
MEDICAL RECORDS CLERK 6. Receives and records DC in the register.
MEDICAL RECORDS 7. Checks, reviews, and validates data entered on the
OFFICER patient’s DC.
PATIENT’S RELATIVE 8. Presents clearance certificate to the Medical Records
Clerk.
MEDICAL RECORDS 9. Establishes identity of the requesting party.
OFFICER
MEDICAL RECORDS CLERK 10. Releases four (4) copies of the DC to the nearest
kin of the deceased and retains one copy as official
file.
11. Advises patient’s relative to register the DC at the
LCR.
12. Retains duplicate copy of the DC.
PATIENT’S RELATIVE 13. Acknowledges acceptance of four (4) copies of the
DC and signs in the logbook.
MEDICAL RECORDS CLERK 14. Attaches DC to the patient’s medical records.
15. Files the medical certificate in the permanent
filingarea.
CHART NUMBER 81: FLOWCHART OF PROCEDURES: MEDICAL RECORDS-ISSUANCE OF DEATH CERTIFICATE
URSE ON DUTY MEDICAL RECORDS CLERK MEDICAL RECORDS PATIENT’S

OFFICER RELATIVE
Interviews
Informant
s-up and signs Signs official form

official death as informant
certificate
Receives and Checks, reviews & Presents clearance

records in death validates data certificate
register
Checks
mpleteness of
data entry Advises relative to Releases 4 copies Establishes identity
register at LCR to relative & of requesting party
retains one copy
Acknowledges
wards official DC acceptance &
to MRS signs the logbook
Attaches duplicate copy of death
certificate to medical record
Files medical record

10. Release of clinical information to insurance verifier
INSURANCE VERIFIER 1. Presents waiver to the Medical Records Clerk.
MEDICAL RECORDS CLERK 2. Receives waiver from the authorized insurance
verifier.
MEDICAL RECORDS OFFICER 3. Interviews and establishes the identity of the
insurance verifier.
MEDICAL RECORDS CLERK 4. Retrieves medical records from file.
5. Authenticates signature on the waiver.
6. Informs Attending Physician of the request using form
no. 102.
ATTENDING PHYSICIAN 7. Determines whether or not the information may be
released and advises the Medical Records Clerk
accordingly.
MEDICAL RECORDS CLERK 8. Upon clearance, prepares the charge slip [Form no.
4] and advises insurance verifier to pay the
required verification and duplication fees to the
hospital Cashier.
INSURANCE VERIFIER 9. Pays corresponding fees to the Cashier.
CASHIER 10. Receives payment and issues official receipt (OR).
MEDICAL RECORDS CLERK 11. Upon presentation of the OR by the insurance
verifier, COHtocopies requested portion of the
medical records and / or allows verifier to go over
the medical records, if requested.
12. Forwards COHtocopied portion to the Medical
Records Officer for authentication.
MEDICAL RECORDS OFFICER 13. Authenticates COHtocopy, affixes hospital seal, and
returns the same to the Medical Records Clerk.
MEDICAL RECORDS CLERK 14. Records in the official logbook, and releases
COHtocopied information to the insurance verifier or
other authorized requesting party.
15. Requests insurance verifier to acknowledge the
receipt of the information.
INSURANCE VERIFIER 16. Acknowledges receipt of information by signing in
the logbook.
MEDICAL RECORDS CLERK 17. Files waiver / request in the patient’s medical
records.
CHART NUMBER 82: FLOWCHART OF PROCEDURES:
MEDICAL RECORDS-RELEASE OF INFORMATION TO INSURANCE VERIFIER
ATTENDING MEDICAL RECORDS INSURANCE CASHIER
PHYSICIAN RECORDS CLERK VERIFIER
OFFICER
Presents waiver
to MR clerk
Receives waiver
Interviews/ident
ify insurance
verifier
Retrieves MR
Determines
whether
information Authenticates
may be patient’s signature
released
Informs attending
physician
NO Prepares charge slip

Release & advises insurance
Information verifier to pay fee at
cashier
YES
Advises Pays fee Receives payment
requesting party
Authenticates COHtocopies Issues Official

COHtocopies requested records Receipt
Acknowledges
Records & releases receipt of
COHtocopies to documents
insurance verifier
Files waiver with MR
11. Disposal of valueless medical records

MEDICAL RECORDS OFFICER 1. Initiates the disposal of valueless medical records.
2. Prepares notice to dispose of records and
forwards notice to the AO.
ADMINISTRATIVE OFFICER 3. Notes request to dispose of records.
4. Endorses request to the COH for approval.
CHIEF OF HOSPITAL 5. Signs and approves request.
6. Sends back request to the AO.
ADMINISTRATIVE OFFICER 7. Sends back request to the Medical Records Officer
MEDICAL RECORDS OFFICER 8. Mails request to dispose of valueless medical

records addressed to the Records Management
and Archives Office (RMAO) through the National
Center for Health Facility Development (NCHFD)
of the Department of Health (DOH).
9. Instructs Medical Records Clerk to cull
outvalueless records.
MEDICAL RECORDS CLERK 10. Culls out and accounts records for disposal.
NATIONAL CENTER FOR 11. Receives, notes, and endorses request to RMAO.
HEALTH FACILITY
DEVELOPMENT
RECORDS MANAGEMENT AND 12. Receives, evaluates, and assigns a
ARCHIVES OFFICE STAFF representativeto examine records for disposal.
13. Issues authority to dispose valueless records.
14. Recommends manner of disposal and sends it to
the COH.
CHIEF OF HOSPITAL 15. Receives and executes recommendation of RMAO
through the AO and witnessed by the COH
representative and RMAO.
ADMINISTRATIVE OFFICER 16. Disposes off valueless records based on
therecommendations of the RMAO.
17. Prepares certificate of disposal and sends originalto
RMAO.
18. Sends / forwards one copy of the certificate to the
MRO.
MEDICAL RECORDS CLERK 19. Files one copy of disposal document / record.
CHART NUMBER 83: FLOWCHART OF PROCEDURES:
MEDICAL RECORDS-DISPOSAL OF VALUELESS MEDICAL RECORDS
NCHFD-DOH RMAO COH AO MR OFFICER MR CLERK

12. Requisition of supplies and materials for purchase
MEDICAL RECORDS CLERK 1. Checks supplies and determines which items
arebelow the 50% inventory level.
2. Prepares Purchase Request (PR) [Form no. 103]
forall requested supplies.
3. Forwards requests to the MRO.
MEDICAL RECORDS 4. Reviews and countersigns PR and returns the same
OFFICER to the MR Clerk.
MEDICAL RECORDS CLERK 5. Forwards PR to the AO for signature.
ADMINISTRATIVE OFFICER 6. Reviews, evaluates, and signs the PR, and returns
7. Forwards PR to the COH for approval.
CHIEF OF HOSPITAL 8. Reviews and approves the PR, and returns the same
to the AO.
ADMINSTRATIVE OFFICER 9. Forwards approved PR to the Supply Officer.
SUPPLY OFFICER
10. Receives PR and forwards the same to the General
Services Officer (GSO) for procurement (See
Property and Supply Procedures for more
details, p. 212-217)
MEDICAL RECORDS - REQUISITION OF SUPPLIES AND MATERIALS FOR
PURCHASE
CHIEF ADMINISTRATIVE SUPPLY MEDICAL MEDICAL

OF OFFICER OFFICER RECORDS RECORDS
HOSPITAL OFFICER CLERK
Checks supplies and

sees which items are
below the 50%
inventory
Prepares Purchases
Request (PR) for all
requested supplies
Reviews and Forwards request to

countersigns PR MRO
& returns it to
Reviews and MR clerk
approves PR
and returns it to
AO
Reviews and Forwards PR to AO
countersigns PR & for signature
forwards to COH
for approval
Forwards approved PR
to the Supply Officer
Receives PR
and forwards it
to GSO for
procurement
ADMINISTRATIVE SERVICE PROCEDURES
1. Budgeting
1.1 Budget Preparation

ADMINISTRATIVE OFFICER 1. Arranges budget meeting with the Chief of Hospital
(AO) (COH) and unit heads.
2. Gives instructions on the details of the budget call.
3. Requests unit heads to submit their respective
operational plans.
UNIT HEADS 4. Submits operational plans based on specific
objectives including justifications for proposals
to the Administrative Officer (AO).
ADMINISTRATIVE OFFICER 5. Discusses plans and proposals with the respective
unit heads to ensure conformity with the hospital’s
objectives and targets.
UNIT HEADS 6. Prepares and submits final plans and proposals to
the AO.
ADMINISTRATIVE OFFICER 7. Reviews hospital plans and proposals submitted by
/
BUDGET OFFICER / the unit heads.
DESIGNATE 8. Consolidates and accomplishes budget preparation
forms.
ADMINISTRATIVE OFFICER 9. Recommends approval and forwards the same to
the COH.
CHIEF OF HOSPITAL 10. Reviews and approves the hospital budget
proposals and returns the same to the AO.
ADMINISTRATIVE OFFICER 11. Gets file copy and submits to the Budget Office .
CHIEF OF HOSPITAL 12. Attends scheduled budget hearing called by LFC

and the Sangguniang Panglungsod (SP) to defend
hospital budget proposals.
CITY BUDGET 13. Finalizes annual budget after budget deliberation of
OFFICE SP.
176
CHART NO. 85: ADMINISTRATIVE PROCEDURES: BUDGET PREPARATION
CITY CHIEF OF UNIT HEADS ADMINISTRATIVE/BUDGET OFFICER/ BUDGET OFFICE

HOSPITAL OFFICER DESIGNATE
Arranges
budget with
the COH and
Unit Heads
Gives instructions on
Budget Call
Submits plans Requests Unit Heads to

of operations submit their respective
plans of operations
Discusses plans and

proposals with the
Prepares and respective Unit Heads
submits final
plans &
proposals to AO
Reviews hospital plans and proposals
Consolidates and accomplishes budget

Reviews and preparation forms
approves
Hospital
Budget Recommends approval and
proposals and forwards it to the COH
returns it to
AO
Gets file copy and
submits to the Office of
the City Mayor
Finalizes annual Attends scheduled

budget after budget budget hearings
deliberation of SP
177
1.2 Preparation of the Work and Financial Plan
BUDGET OFFICER / OR 1. Prepares Work and Financial Plan (WFP) for the
DESIGNATE hospital using the appropriate budget form.
2. Forwards WFP to the AO for review.
ADMINISTRATIVE OFFICER 3. Initials the WFP and forwards the same to the COH.
CHIEF OF HOSPITAL 4. Reviews and signs the WFP and returns the same to
the Budget Officer or AO.
BUDGET OFFICER /
5. Submits WFP to the City Mayor for appropriate action.
CHART NO. 86: ADMINISTRATIVE PROCEDURES: PREPARATION OF THE WORK AND
FINANCIAL PLAN
CHIEF OF HOSPITAL ADMINISTRATIVE OFFICER BUDGET OFFICER
Prepares Work and

Financial Plan (WFP) for
the hospital
Reviews and signs

the WFP and returns
it to the Budget Initials the WFP and forwards it Forwards it to the AO for
Officer or AO to the COH review
Submits WFP to the City Mayor for

appropriate action
178
2. Collection for Regular Hospital Financial Transaction
COLLECTING CLERK OR 1. Receives cash or check payments.
DESIGNATE 2. Issues official receipt of cash / check payments
topatient.
3. Records the checks received in the logbook.
4. Cash counts collections made until the cut-off
time (3:00 p.m.)
5. Endorses collection to the Cashier for recording
andsafekeeping.
6. Enters official receipts issued during the day in
thecashbook.
CASHIER OR DESIGNATE 7. Prepares and signs daily statement of
collectionsand accountable forms, otherwise
known as City Form (PF) 96A [Form no. 104] for
the following:
• 1 Accounting
• 1 Treasurer Officer
• 1 COA
• 1 File
8. Reconciles and remits cash collection together
with PF 96A and a duplicate copy of the official
receipt.
9. Records amount remitted in the cashbook.
10. Files triplicate copy of the official receipt,
togetherwith the fourth copy of PF 96A.
179
CHART NO 87: ADMINISTRATIVE PROCEDURES: COLLECTION FOR REGULAR HOSPITAL
COLLECTING
CLERK OR
DESIGNATE
TRANSACTION
CASHIER OR DESIGNATE
Receives cash or check
payments
Prepares and signs daily statement
of collections and accountable forms
in 4 copies
Issues official receipts

Reconciles and remits cash collectio n
together with PF 96A and duplicate
Records the check received in the
copy of official receipt
logbook
Cash counts collections made until

cut-off time (3:00 pm)
Records amount remitted in the
cashbook
Endorses collections to Cashier
Enters official receipts issued during

the day in the cashbook Files triplicate copy of the official
receipt, together with the 4th copy
of PF 96A
180
3. Collection of Reimbursement from Philippine Health Insurance Corporation (PHIC)
PHILHEALTH OFFICER 1. Receives checks from the Philippine Health
Insurance Corporation (PHIC or PhilHealth).
2. Forwards PhilHealth check to the Billing Clerk.
BILLING CLERK 3. Checks with the routing slips if claimant was really
a patient of the hospital and reconciles the amount
stated in the claim.
4. Records checks in the logbook for PhilHealth
patients.
5. Records and acknowledges receipt of checks.
6. Forwards checks to the Collecting Officer or
designate.
COLLECTING OFFICER 7. Reviews check payments from PhilHealth.
8. Issues official receipt.
9. Records the checks received in the logbook.
10. Forwards PhilHealth checks pertaining to
professional fees to the COH for endorsement.
CHIEF OF HOSPITAL 11. Endorses checks and returns these to the Collecting
Officer.
COLLECTING OFFICER 12. Enters official receipts issued during the day in the
cashbook.
13. Prepares and signs 4 copies of the Daily Statement
of Collections and Accountable Forms (PF 96A)
[Form no. 104] for the following:
• 1 Accounting
• 1 Treasurer Officer
• 1 COA
• 1 File
14. Reconciles and remits collection together with PF
96A and a duplicate copy of the OR.
15. Records the amount remitted in the cashbook. Files
16. triplicate copy of official receipts, together with
fourth copy of PF 96A.
181
CHART NO. 88: ADMINISTRATIVE PROCEDURES: COLLECTIONS OF REIMBURSEMENT
FROM PHILHEALTH
PHILHEALTH OFFICER CHIEF OF HOSPITAL BILLING CLERK COLLECTING

OFFICER
Receives checks Reviews and check payments
from PhilHealth from PhilHealth
Checks the routing slips

if claimant was really a Issues official receipts
patient of the hospital
and reconciles the
Forwards PhilHealth checks to Billing amount in claim
Clerk
Records the checks received in
the logbook
Records checks in the
logbook for PhilHealth
patients Forwards PhilHealth
checks pertaining to
professional fees to COH
for endorsement
Records and
acknowledges receipt of
checks
Endorses
checks and
returns to the
Collecting
Clerk Enters official receipts issued during
the day in the cashbook
Prepares and signs daily

Statement of Collections
and Accountable forms (PF
96A) in 4 copies
Remits collection together with PF 96A and duplicate

copy of official receipts
Records amount remitted in the cashbook
Files triplicate copy of official

th
receipt, together with 4 copy
of PF96A
182
4. Processing of Claims for Payment
CLERK 1. Prepares payroll and vouchers, and checks
completeness of supporting papers.
2. Records these in the logbook and forwards payroll
and vouchers to the Bookkeeper.
BOOKKEEPER 3. Prepares ALOBS [Form no. 105].
4. Submits the ALOBS together with the supporting
papers to the Accountant or Designate.
ACCOUNTANT OR 5. Reviews documents. Ensures that computations are
DESIGNATE correct and all supporting papers are complete.
6. Posts on the subsidiary ledger for control and
monitoring purposes.
7. Assigns control number and forwards the payroll
and voucher together with the supporting
documents to the AO.
ADMINISTRATIVE OFFICER 8. Reviews and evaluates the payroll and voucher and
affixes initials.
9. Forwards these to the COH.
CHIEF OF HOSPITAL 10. Signs payroll, voucher, and other supporting
documents, and submits these to the Cityl
Budget Office (CBO) through the Liaison Officer or
Designate.
CITY BUDGET 11. Acts on the payroll, voucher, and other documents
OFFICE and forwards these to the Treasurer’s Office and
other offices for processing.
A. For Payroll
CASHIER OR DESIGNATE 12. Once the payroll is approved, prepares cash
advance check.
13. Forwards to City Accounting, Treasurer’s Office
and other offices concerned for processing.
CITY TREASURER’S 14. Issues checks for cash advance.
OFFICE
CASHIER OR DESIGNATE 15. Encashes checks and pays employees.
B. For Payment to other Creditors
CITY TREASURER’S 16. Prepares and issues checks for payment to
OFFICE creditors.
185
CHART NO. 90: ADMINISTRATIVE PROCEDURES: PROCESSING OF CLAIMS FOR PAYMENT
CITY CITY CHIEF OF ADMINISTRATIVE ACCOUNTANT BOOKEEPER CASHIER CLERK/
TREASURER BUDGET OFFICER HOS PITAL OFFICER DESIGNATE
Reviews Prepares
Acts on the Signs payroll, Reviews and documents ALOBS
payroll, voucher voucher & evaluates the Prepares
and other other payroll and payroll and
documents and supporting voucher, voucher and
forwards these documents affixes initials Post on the Submits the checks
documents to and submits and forwards subsidiary ALOBS completeness
the Treasurer’s to the PBO to COH ledger together with of
Office and other through the the supporting
offices for Liaison Officer supporting papers
processing papers to the
Assigns
Accountant or
control
designate
number and
forwards Records in
documents to the logbook
Once the and forwards
AO
payroll is payroll and
NO YES approved,
For voucher to
prepares cash the
Payroll?
advance Bookkeeper
check
Issues check
for cash
advance
Forwards to
the Prov.
Acctng,
Prepares and Treas. Off. &
issues checks other offices
for payment to concerned for
creditors processing
Encashes check
and pays
employees
186
5. Reports and other documents received for entry in the book of accounts (with
sub-allotment)
CLERK 1. Receives reports and other documents to be
recorded in the Book of Accounts.
2. Forwards report to the Bookkeeper.
BOOKKEEPER 3. Enters transactions in the journal voucher /
generaljournal.
4. Posts on the general ledger entries made in
thegeneral journal.
5. Maintains subsidiary ledgers.
CHAPTER 91: ADMINISTRATIVE PROCEDURES: REPORTS AND OTHER
DOCUMENTS
RECEIVED FOR ENTRY IN THE BOOK OF ACCOUNTS
(with sub-allotment)
BOOKEEPER CLERK
Journalizes transactions
in the journal Receives reports and
voucher/general journal other documents to be
recorded in the Book of
Accounts
Posts on the general

ledger entries made in
the general journal
Forwards report to the Bookkeeper
Maintains
subsidiary ledger
187
6. Preparation of reports (with sub-allotment)
BOOKKEEPER / CLERK 1. Prepares trial balance and other financial
reportsrequired by the City Accounting Office
and the Commission on Audit (COA).
2. Verifies accuracy of the footing with the
generalledger.
3. Initials the reports prepared.
4. Forwards reports to the COH.
CHIEF OF HOSPITAL 5. Reviews and signs the documents.
BOOKKEEPER 6. Prepares transmittal letter.
7. Distributes reports to the agencies concerned.
CHART NO 92: ADMINISTRATIVE PROCEDURES: PREPARATION OF REPORTS
(with sub-allotment)
CHIEF OF HOSPITAL BOOKEEPER CLERK
Reviews and
Prepares Trial Balance and
signs the
other financial reports
documents
Verifies accuracy of the footing with the

general ledger
Initials the reports and forward report to

the COH
Prepares
transmittal letter
Distributes reports to
the agencies
concerned
188
7. Request for the release of monthly allotment
PREPARATION OF DOCUMENTS IN THE HOSPITAL
BOOKKEEPER / CLERK 1. Prepares Disbursement Voucher (DV) [Form no.
95] based on the Advice of Allotment forwarded by
the CITY Budget Office.
2. Forwards DV to the COH.
CHIEF OF HOSPITAL (COH) 3. Signs DV and forwards the same to the Bookkeeper.
BOOKKEEPER 4. Forwards DV to the CITY Budget Office (PBO).
CITY BUDGET OFFICE
CLERK 5. Receives and controls DV.
6. Forwards DV to the CITY Budget Officer.
CITY BUDGET 7. Signs the DV and forwards the same to the Clerk for
OFFICER release.
CLERK 8. Releases DV to the Bookkeeper.
BOOKKEEPER (HOSPITAL 9. Signs the release logbook.
PERSONNEL) 10. Forwards DV to the CITY Accounting Office for
processing.
CITY ACCOUNTING 11. Receives and enters DV in the logbook.
OFFICE 12. Forwards DV to the Internal Control Unit for
preauditing.
INTERNAL CONTROL UNIT 13. Reviews / pre-audits DV in accordance with the
auditing rules and regulations.
14. Initials DV and forwards the same to the
AccountingClerk for indexing.
15. Writes journal entries in the DV.
BOOKKEEPER 16. Records transaction in the journal and forwards DV
to the Clerk for indexing.
CLERK 17. Indexes and initials DV.
18. Forwards DV to the CITY Accountant.
CITY ACCOUNTANT 19. Signs DV and forwards the same to the
Bookkeeper.
BOOKKEEPER (HOSPITAL) 20. Brings DV to the City Mayor’s Office.
CITY MAYOR’S OFFICE
CLERK 21. Receives and enters DV in the logbook.
22. Forwards DV to the City Mayor or the
CITY Administrator in his absence for approval.
CITY MAYOR 23. Signs DV and forwards the same to the Clerk for
release.
BOOKKEEPER / CLERK 24. Signs the release logbook and forwards DV to the
CITY Treasurer’s Office.
CITY TREASURER’S OFFICE
CLERK 25. Receives and logs-in DV.
26. Forwards DV to another clerk for indexing.
27. Indexes DV and forwards the same to the CITY
Treasurer for approval.
189
Action
28. Signs DV and forwards the same to the Cashier
or
check preparation.
29. Prepares check for signature of the CITY

Treasurer or the Assistant Treasurer.
30. Signs check.
31. Brings check to the City Mayor or the CITY

Administrator for counter-signature.
32. Forwards signed check to the CITY
Accounting Office for the preparation of the
Check Advice, and for submission to the
depository bank for check acceptance.
CCOUNTING OFFICE
33. Prepares Advice and forwards the same to the
Bookkeeper for his/ her signature and verification.
34. Signs Advice and forwards the same to the
CITY Accountant for approval.
35. Releases signed check together with the Advice to
the CITY Treasury Office for final release.
36. Receives signed check.
37. Upon return to the hospital, turns over the check
to the Cashier for deposit to the depository bank.
190
CHART NO. 93: ADMINISTRATIVE PROCEDURES: REQUEST FOR THE
RELEASE OF MONTHLY ALLOTMENT
PREPARATION IN THE HOSPITAL
CHIEF OF HOSPITAL BOOKKEEPER CLERK
Prepares Disbursement Voucher

based on the Advice of Allotment
forwarded by the CITY Budget
Office
Forwards Disbursement Voucher to the COH

Signs DV and forwards the same to the
Bookkeeper
Forwards DV to the PBO
215
AT THE CITY BUDGET OFFICE
CITY INTERNAL CLERK BOOKKEEPER BOOKEEPER

ACCOUNTING CONTROL (HOSPITAL)
OFFICE OFFICE
AT THE CITY MAYOR’S OFFICE

216
CITY MAYOR BOOKKEEPER CLERK
Receives and enters

DV in the logbook
Forwards DV to the CITY

Signs DV and forwards to Clerk for City Mayor or the CITY
release Administrator in his absence for
approval
Signs the release logbook and forwards DV

to the CITY Treasurer’s Office
217
AT THE CITY TREASURER’S OFFICE
PROV. TREASURER BOOKEEPER CASHIER CLERK OR ASSISTANT
Signs DV and forwards DV to Receives and logs

the cashier for check in DV
preparation
Forwards DV to another
clerk for indexing
Indexes DV and forwards

Prepares check
to the CITY Treasurer
for signature of
for approval
the CITY
Treasurer or the
Signs checks Assistant
Treasurer
Brings check to the
City Mayor
or CITY
Administrator for
signature
Forwards signed check

to the CITY
Accounting Office for
preparation of check
advice
194
AT THE CITY ACCOUNTING OFFICE
BOOKEEPER CLERK BOOKEEPER
Prepares advice and

forwards it to the
Bookkeeper for
signature and
verification
Signs Advice and forwards

it to the CITY
Accountant for approval
Releases signed check together

with the Advice to the CITY
treasury Office for final release Received signed check
Turns over the check

to the Cashier for
Deposit to the
depository bank
195
8. Remittances
BOOKKEEPER / CLERK 1. Prepares voucher for the remittance of GSIS
premium, Medicare, Pag-ibig, withholding tax, loan
installments, etc.
2. Forwards voucher to the AO.
3. Reviews and signs voucher.
BOOKKEEPER 4. Enters transactions in the journal.
5. Certifies availability of funds and forwards to
theAO.
ADMINISTRATIVE 6. Reviews and initializes voucher and forwards the
OFFICER same to the COH.
CHIEF OF HOSPITAL 7. Signs the voucher and forwards the same to the
Cashier.
CASHIER 8. Prepares check and signs those within his/
herauthority.
9. Forwards the check to the COH.
CHIEF OF HOSPITAL 10. Signs or countersigns the check.
CHART NO. 94: ADMINISTRATIVE PROCEDURES: REMITTANCES
( with sub-allotment)
CHIEF OF ADMINISTRATIVE CASHIER BOOKEEPER CLERK

HOSPITAL OFFICER
Signs the Prepares voucher

voucher and Reviews and for the remittance
forwards it initial voucher of GSIS premium
to the and forwards it etc.
Cashier to COH
Journalizes
transactions
Certifies
availability of
funds and
Prepares check and forwards to the
signs those within his AO
authority and
forwards check to the
Signs or COH
countersigns
the check
196
9. Linen and Laundry Procedures
9.1 Collection of soiled linen

LINEN PERSONNEL 1. Collects, sorts, and counts linens.
2. Records number of sorted linens in the
collectionlogbook.
WARD PERSONNEL 3. Signs logbook and indicates the date of collection.
LINEN PERSONNEL 4. Places collected linens in bags and endorses these
to the Laundry Unit.
LAUNDRY WORKER 5. Counts and tallies the number of soiled linens
received with the collection logbook.
CHART NO. 95: LINEN AND LAUNDRY: COLLECTION OF SOILED LINEN
LINEN PERSONNEL WARD PERSONNEL LAUNDRY WORKER
Collects, sorts
and counts
linen
Signs logbook and

Records number of indicates the date of
sorted linen in the collection
collection logbook
Places the collected linen

bags and endorses them
to the laundry
Counts and
tallies the
number of
soiled linen
received with
the collection
logbook
197
9.2 Preparations and Distribution of Clean Linens to Ward
LAUNDRY WORKER 1. Forwards clean linens to the linen room.
LINEN PERSONNEL 2. Receives, sorts, counts, and records linens in the
logbook.
3. Segregates torn or damaged linens for repair
orrecycling.
4. Fills out distribution logbook based on the
requestsof the units.
5. Forwards distribution logbook to the Linen Head
forsignature.
LINEN HEAD 6. Reviews and signs distribution logbook.
LINEN PERSONNEL 7. Reports receipt of clean linens by the ward
personnel to the Linen Head and presents
logbook for checking.
LINEN HEAD 8. Checks for accuracy and completeness of recording.
LINEN PERSONNEL 9. Files logbook in the designated area.
198
CHART NO. 96: LINEN AND LAUNDRY: PREPARATION AND
DISTRIBUTION OF CLEAN LINEN TO WARD
LINEN HEAD LINEN PERSONNEL LAUNDRY WORKER
Receives, sorts, counts, Forwards clean

and records linen in the linen to the
logbook linen room
Segregates torn or
damaged linen for repair or
recycling
Fills-out distribution
logbook based on the
requests of the units
Reviews and signs Forwards distribution

distribution logbook logbook to the linen head
for signature
Reports receipt of clean

linen by the ward personnel
to the linen head and
presents logbook for
checking
Checks for accuracy

and completeness of
recording
Files logbook in the

designated area
199
9.3 Repair and disposal of linens
LINEN HEAD 1. Sorts and inspects torn linens.
2. Counts and segregates reparable from
irreparablelinens.
LINEN PERSONNEL 3. Records reparable linens in the logbook and
endorses them to the sewing / repair room.
SEAMSTRESS / TAILOR 4. Receives and repairs torn linens.
5. Records repaired linens and endorses these to
thelinen personnel.
For Irreparable Linen:
LINEN PERSONNEL 6. Prepares list of linens to be disposed and sends
them to the Supply Unit for disposal.
SUPPLY UNIT 7. Accomplishes Report of Waste Materials form
and endorses the same to the concerned
signatories.
8. Disposes linen accordingly (please see
Property and Supply Procedures - Disposal
of government property, pp 232 -233).
CHART NO. 97: LINEN AND LAUNDRY: REPAIR AND DISPOSAL OF LINEN
Receives and
Records repair torn Accomplishes
reparable linen in linen. report of waste
the logbook and materials form and
endorses them to endorses it to the
the concerned
signatories
Sewing/Repair
Room
Records
repaired linen
and endorses
them to the
linen personnel
Chart No.
113, p.
233
LINEN HEAD LINEN
PERSONNEL Prepares list of
SEAMSTRESS/ linen to be
SUPPLY disposed and
sends them to
the Supply
Sorts and
unit for
inspects
Disposal
torn linen
Counts and
segregates
reparable from
irreparable linen
Y
Reparable?
TAILOR UNIT
200
HOSPITAL BILLING PROCEDURES

1. Billing of patient
1.1. For out-patients

REVENUE CENTERS 1. Prepares charge slips [Form no. 4].
(LABORATORY, RADIOLOGY, 2. Informs patient of the cost, indicates the same in
PHARMACY) STAFF thecharge slip and instructs patient to pay to the
Cashier.
NOTE: If patient is unable to pay all or part of the cost,
refers patient to the Medical Social Service (MSS).
MEDICAL SOCIAL WORKER 3. Evaluates and classifies patient (please see
Medical Social Service procedures, pp. 98-99).
CASHIER/COLLECTING 4. Receives payment, issues official receipt, and directs
CLERK/DESIGNATE the patients to the revenue centers.
5. Records payment in the cashbook.
PATIENT 6. Presents official receipt or Certificate of Indigency
[Form no. 56] (for indigent patients) to the revenue
centers concerned.
REVENUE CENTERS STAFF 7. Summarizes the services rendered for the day in the
Income Proof Sheet (IPS) [Form no. 55].
201
CHART NO. 98: BILLING PROCEDURES FOR OUT-PATIENTS
REVENUE CENTER MEDICAL SOCIAL CASHIER/COLLECTING PATIENT

STAFF SERVICE CLERK
Prepares charge slip
Informs patient of the cost,

indicates it in the charge slip
and instructs patient to pay
to the cashier
Patient can YES Receives payment and

issues official receipt and
pay? directs the patients to
Evaluates and the revenue centers
NO
classifies
patient
Presents
official receipt
or Certificate
Records payment in the of Indigency
cashbook (for indigent
patients) to
the revenue
centers
concerned
Summarizes the
services rendered for
the day in the Income
Proof Sheet
227
1.2. For in-patients
ADMITTING STAFF 1. Notifies Billing Section of admissions for the day.
BILLING 2. Prepares jacket [Form no. 48] and ledger card for
CLERK/DESIGNATE each admitted patient.
REVENUE CENTERS STAFF 3. Submits charge slips [Form no. 4] or notice of
services rendered to the Billing Section.
BILLING CLERK 4. Records and files daily, all charge slips inside
patient’s jacket and ledger card.
PATIENT 5. Upon order of discharge, presents discharge slip to
the Billing Clerk.
BILLING CLERK 6. Retrieves jacket and ledger card and prepares 3
copies of the Statement of Accounts (SA) [Form
no. 49] for patients not covered by Philippine
Health Insurance Corporation (PHIC or PhilHealth),
and 4 copies for patients covered by PHIC or other
insurance company.
a. For Class A (full paying) patients, directs
patientsto the Cashier for payment of bills.
b. For class B to D, refers patient to the MSS
todetermine patient’s share of the
hospitalization cost.
c. For PHIC members/dependent - deducts costs
chargeable against insurance and directs
patients
to the Cashier for payment of remaining balance.
7. Presents SA to the patient or relative for payment
tothe Cashier.
PATIENT 8. Forwards SA to the Cashier and pays the
corresponding fees.
CASHIER 9. Receives payment and issues official receipt to the
patient/companion.
10. Affixes to the SA the official receipt number. SA
shall be distributed as follows:
Pay Patient
1 copy (original) - patient
1 copy - billing
1 copy - accounting
PHIC Patients
1 copy (original) - PHIC
1 copy - patient
1 copy - billing
1 copy - accounting
BILLING CLERK 11. Files duplicate copy of SA.
CHART NO. 99: BILLING PROCEDURES FOR IN-PATIENTS
228
ADMITTING BILLING REVENUE CENTERS CASHIER PATIENT STAFF
CLERK STAFF
Notifies Prepares Submits charge Upon

Billing Section jacket and slips or notice of discharge,
of admissions ledger card services rendered presents
for the day for each to the Billing discharge slip
patient Section to the Billing
Clerk
Records and
files daily all
charge slips
inside patient’s
jacket and
ledger card
Retrieves jacket
and ledger card
and prepares
the Statement
of Accounts
Forwards
Presents Statement of
Statement of Account to
Accounts to the Cashier and
patient pays
corresponding
fees
Receives payment
and issues official
receipt to the
patient/
companion
Affixes to the
Files duplicate copy of Statement of
Statement of Account Accounts the
official receipt
number
2. Processing of claims under Philippine Health Insurance Corporation (PHIC)

PATIENT/COMPANION 1. Submits to the Billing Clerk the required PHIC
documents and supporting papers to avail health
insurance.
229
PHIC BILLING CLERK 2. Receives and checks if the forms have been signed
by the employer or his/her authorized
representative.
3. Fills-up PHIC Form 1 [Form no. 106] and checks
completeness of the supporting papers by referring
to the PHIC Guidelines.
4. Fills-up PHIC Form 2 [Form no. 107].
5. Prepares SA and certification of medicines issued
and laboratory services rendered and attaches these
to PHIC Form 2.
6. Sends papers to the Attending Physician
forsignature.
ATTENDING PHYSICIAN 7. Fills-up the final diagnosis portion of PHIC Form 2
and indicates the services rendered.
8. Signs and forwards the same to the Billing Clerk.
PHIC BILLING CLERK 9. Prepares transmittal letter with PHIC Form 2 and
other supporting documents to be forwarded to the
Chief of Hospital (COH) or designate for approval.
CHIEF OF HOSPITAL/ 10. Signs PHIC Form 2 and transmittal letter.
DESIGNATE
BILLING CLERK 11. Gets file copy, records it in the logbook and delivers
PHIC Form 2 together with the transmittal letter and
other supporting documents to the addressee.
CHART NO. 100: PROCESSING OF CLAIMS UNDER PHIC
230
CHIEF OF ATTENDING PHIC BILLING PATIENT/
HOSPITAL PHYSICIAN CLERK COMPANION
Receives and checks if

forms have been signed by Submits to the
the employer or his/her Billing Clerk
authorized representative the required
PHIC
documents
and supporting
Fills-up PHIC Form 1 and papers
Fills-up the final checks completeness of the
diagnosis portion supporting papers
of PHIC Form 2
and indicates the
services rendered Fills-up PHIC Form 2
(Medicare Claim for
Payment)
Signs PHIC Signs and

Form 2 and forwards it to the Prepares Statement of
transmittal billing clerk Account and Certification of
letter Medicines Issued and
laboratory services rendered
and attaches it to PHIC
Form 2
Sends papers to the

Attending Physician for
signature
Prepares transmittal letter

with PHIC Form 2 and other
supporting documents to be
forwarded to the COH or
designate for approval
Gets file copy,

records it in the
logbook and
delivers PHIC Form
2 toget her with the
transmittal letter
and other
supporting
documents to the
Addressee
231
PROCEDURES IN THE PROPERTY AND
SUPPLY OFFICE
1. Preparation of the Annual Procurement Plan (APP)
CITY MAYOR 1. Requires Heads of Department or offices to
submit to General Services Officer or Local
Treasurer, procurement plan of their supply
requirement for the ensuing fiscal year.
END-USER/UNIT OR SECTION HEAD 2. Identifies the needs of the unit/section for
the succeeding year.
2.1 Collates requisitions made the
previousyear.
2.2 If there are new activities, makes a
projection on items needed.
3. Sums up supply requirements and adds
10%increment.
4. Submit the list of needed items to the
Supply Officer/Storekeeper/designate stating
the quantity and specifications.
SUPPLY 5. Reviews and collates all data submitted bythe
OFFICER/STOREKEEPER/DESIGNATE different sections/units.
6. Determines the cost based on the latest
purchase price, if price is available.
7. Pro-rates quantity of each item into
quarterly allocation based on previous
consumption.
8. Prepares consolidated draft of the
APP(Form No. 77)
9. Submits draft of APP to the Administrative
Officer (AO).
ADMINISTRATIVE OFFICER 10. Reviews, evaluates, notes and revises,
ifnecessary, the APP based on the proposed
budget.
11. Presents the reviewed and corrected APP to
the different section/unit heads.
END-USER/UNIT OR SECTION HEAD 12. If necessary, revises APP to conform with
the proposed budget, and forwards the
same to the supply
officer/storekeeper/designate.
SUPPLY 13. Finalizes the APP and forwards it to the AO.
OFFICER/STOREKEEPER/DESIGNATE
207
ADMINISTRATIVE OFFICER 14. Initials APP and submits the same to the
Chief of Hospital for approval.
232
CHIEF OF HOSPITAL 15. Reviews and approves APP for inclusion
inthe hospital budget proposal.
16. Submits the annual budget together with
the APP to the City Mayor through the Local
Finance Committee or to the General
Services Officer (GSO).
CITY MAYOR 17. Approves the APP for the ensuing year.
CHART NO. 101: PREPARATION OF APP
LOCAL CHIEF END USER / UNIT / SUPPLY OFFICER / AO COH

EXECUTIVE SECTION HEADS STOREKEEPER / DESIGNATE
Requires
department
heads to submit Identifies needs and Reviews and collates Reviews, evaluates Reviews and
procurement submits list data submitted APP based on approves APP for
plan for ensuing proposed budget inclusion in hospital
fiscal year budget proposal
Determines cost
based on latest Presents reviewed & Submits annual
purchase price corrected APP to budget with APP to
diff. unit heads the City Mayor
Prepares
consolidated APP
draft & submits to
AO
Revises APP to Finalizes APP & Initials APP &

Approves APP conform with forwards to AO submits to COH.
for ensuing proposed budget &
year forwards to supply
officer
209
2. Annu
al Procurement Plan (With Approved Budget)
ADMINISTRATIVE OFFICER 1. Forwards to the Supply
Officer/Storekeeper/designate and
EndUsers/Unit/Section Heads the approved
budget ceiling
END-USER/UNIT OR SECTION 2. Revises the APP to conform to the approved
HEADS budget, if necessary, and submits the same to
the Supply Officer/Storekeeper/designate.
SUPPLY OFFICER 3. Consolidates and finalizes the APP and
submits the same to the AO for initial.
ADMINISTRATIVE OFFICER 4. Prepares transmittal letter and initials the
APP, then forwards the same to the COH for
approval.
CHIEF OF HOSPITAL 5. Reviews and signs transmittal letter and
forwards the same to the AO.
AO 6. Submits copies of APP to the Office of the
Mayor for distribution to the GSO and other
offices concerned.
7. Furnishes the Bids and Awards
Committee(BAC) and the sections concerned
with a copy of the approved APP.
235
CHART NO. 102: ANNUAL PROCUREMENT PLAN (With Approved Budget)
/ UNIT / SUPPLY OFFICER AO COH

DS
Forwards to supply
officer / end-user
the approved
budget ceiling
o Consolidates & Reviews & signs

ved finalizes APP & submits transmittal letter &
s to to AO for initials forwards to AO
Prepares transmittal letter

& initials APP & f orwards
the same to CM for
approval
Submits copies of APP to

the office of the CM
for distribution
Furnishes the BAC

& section
concerned with
copy of the
approved APP
211
3. Requisition from stock (regular)
END-USER/SECTION/UNIT 1. Determines supplies needed and prepares
(SAI) and forwards to Accounting Division
ACCOUNTING DIVISION 2. Verifies stock records, advises requisitioning
unit/end-users.
END-USER 3. Prepares RIS and forwards the same to the
Property/Supply Section.
SUPPLY OFFICER/STOREKEEPER 4. Initials RIS and forwards the same to the AO.
ADMINISTRATIVE OFFICER 5. Reviews and initials RIS then forwards the
same to the COH for approval
CHIEF OF HOSPITAL 6. Reviews and approves RIS for issuance.
SUPPLY OFFICER/STOREKEEPER 7. Issues supplies and materials requested by
section heads/end-users.
END-USERS/UNIT OR SECTION 8. Receives and signs the RIS to acknowledge
HEAD receipt of the supplies and materials.
SUPPLY OFFICER/STOREKEEPER 9. Enters supplies issued on bin and stock
cardsand files the same.
10. Provides the Accounting Division with a copy
of the RIS for the purpose of updating stock
balances.
237
CHART NO. 103: REQUISITION FROM STOCK (Regular)
ACCOUNTING DIVISION END-USER / UNIT / SECTION SUPPLY OFFICER / AO COH

STOREKEEPER
Determines supplies
needed & prepares
SAI & forwards to
accounting unit
Initials RIS & forwards
Verifies stock records Reviews & initials RIS & Reviews & approves
and advises end-user to AO
forwards to COH RIS for issuance
for approval
Prepares RIS and forwards Issues supplies /

the same to the supply materials requested
section
Receives & signs RIS to Enters supplies issued on

acknowledge receipt of bin and stock cards and
supplies / materials files the same
Provides
accounting unit
with a copy of RIS
213
4. Purchase of supplies to be carried on stock
END-USER/SECTION/UNIT 1. Determines supplies needed and prepares
(SAI) accordingly and forwards the same
to the Accounting Unit
ACCOUNTING DIVISION/UNIT 2. Verifies stock records and advises
requisitioning unit/end-user.
END-USER/UNIT OR SECTION 3. Prepares purchase request for items to be
HEAD procured. Indicate itemized quantity of
supplies or property needed and complete
description as to kind, quality, estimated
cost, and the balance on hand.
SUPPLY OFFICER 4. Attaches Stock Position Sheet for any single
commodity requisition above P1,000.
HEAD OF OFFICE OR 5. Certifies the necessity of the requisition for
DEPARTMENT official use and specifies the project / activity
where the supplies would be used.
LOCAL BUDGET OFFICER/LOCAL 6. Issues Certification for (ALOBS) that
ACCOUNTANT/LOCAL TREASURER appropriation exist and that an estimated
amount / funds has been obligated for the
purpose.
CITY MAYOR 7. Approves requisitions, provided that the
supplies are listed or included in the APP
8. Exercises the function of acquiring all the
CITY GENERAL SERVICES necessary supplies for the
OFFICER city.
239
CHART NO. 104: PURCHASE OF SUPPLIES TO BE CARRIED ON STOCK
END-USER / UNIT /SUPPLY OFFICER / HEAD OF OFFICE LOCAL BUDGET LCE OFFICE
SECTION HEAD STOREKEEPER OR DEPARTMENT OFFICER / OF THE
ACCOUNTANT / GSO
TREASURER
Determines
supplies needed
& prepares &
forwards SAI to Certifies the Issues Approves
accounting unit necessity for Certification for requisitions, Exercises the
Attaches stock official use (ALOBS) of the provided function of
position sheet specifying the existence of that acquiring all
for single project/activity funds supplies are necessary
commodity where the supplies appropriated for listed or supplies
requisitions would be used the purpose included in
above P1,000 the APP
Prepares Purchase
equest and forwards to
supply officer
215
4.1. Requisition through Emergency Purchase
END-USER/SECTION/UNIT 1. Determines supplies needed, prepares (SAI)
and forwards the same to the Accounting
Unit
ACCOUNTING DIVISION 2. Verifies if requested items are included in the
approved APP. If not included, requests
enduser to prepare justification why
procurement is of such urgency and prepares
supplemental APP.
3. Verifies stock records and advises
requisitioning unit/end-user
END-USER/SECTION/UNIT 4. Prepares PR with complete specifications and the
attached justification.
ACCOUNTING DIVISION 5. Issues ALOBS and forwards the same to the
AO.
ADMINISTRATIVE OFFICER 6. Evaluates and initials certification and
forwards the same to the COH for
approval.
COH 7. Evaluates and approves certification for
emergency purchase, signs PR and forwards
PR to the Supply Officer.
SUPPLY OFFICER 8. Facilitates procurement of the item(s).
9. Receives items purchased.
INSPECTION COMMITTEE 10. Verifies and inspects items delivered for
MEMBERS conformity to specifications and
reasonableness of prices and
prepares inspection report.
SUPPLY OFFICER 11. Prepares Certificate of Acceptance and RIS.
END-USER 12. Acknowledges receipt of items and signs RIS
and Certificate of Acceptance.
SUPPLY OFFICER 13. Records in the stock card the receipt and
issuance of the supply and files the RIS.
242
CHART NO. 105: REQUISITION THROUGH EMERGENCY PURCHASE
IVISION END USER / SECTION/ AO CHO SUPPLY INSPECTION

UNIT OFFICER COMMITTEE
MEMBERS
Facilitates
Evaluates and
Determines procurement
initials
supplies needed of the item
certification and Evaluates and
and prepares forwards the approves
(SAI) and same to the certification for
forwards to COH/COH/OIC emergency
Accounting Unit for approval purchase, signs Verifies and
PR and forwards Receives inspects items
to the Supply items delivered for
Officer purchased conformity to
Requests end-user specifications
Prepares PR with and
to prepare complete
justification why reasonableness
specifications and
procurement is of of prices and
the attached
such urgency and prepares
justification
amends APP Prepares inspection
Certificate of report
Acceptance
and RIS
Records the
receipt and
Acknowledges issuance of
receipt of items and
supplies and files
signs RIS and
the RIS
Certificate of 217
Acceptance
4.2. Preparation of report for emergency purchase
SUPPLY OFFICER / STOREKEEPER 1. Prepares confirmation report and report of
/ DESIGNATE utilization [Form no. 110] not later than 3
days upon the expiration of the 15 days
from the date of delivery and forward the
same to the end-user.
END USER / UNIT OR SECTION 2. Signs utilization and confirmation reports and
HEADS forwards these documents to the AO.
ADMINISTRATIVE OFFICER 3. Receives and initials confirmation and utilization
reports and forwards these to the
COH.
CHIEF OF HOSPITAL 4. Reviews and signs the reports and forwards
these to the Supply Officer / Storekeeper /
designate.
SUPPLY OFFICER / STOREKEEPER / 5. Forwards approved copy of utilization
DESIGNATE reportto the local Commission on Audit (COA)
and all members of the Committee on
Awards.
6. Attaches a copy on the Disbursement
Voucher[Form no. 95].
244
CHART NO. 106: PREPARATION OF REPORT FOR EMERGENCY PURCHASE
SUPPLY OFFICER / STOREKEEPER END USER / UNIT OR ADMINISTRATIVE OFFICER CHIEF OF HOSPITAL / DESIGNATE
SECTION HEADS
Prepares
confirmation and
utilization reports Signs utilization and Receives and initials Reviews and signs the
and forwards these confirmation reports and confirmation and utilization reports and forwards these
to the end-user forwards these to the AO reports and forwards these to the Supply Officer /
to the COH Storekeeper / designate
Forwards approved copy of

utilization report to the
local Commission on Audit
(COA) and all members of
the Committee on Awards
Attaches a copy
on the
Disbursement
Voucher
219
5. Delivery, inspection, and acceptance
SUPPLY OFFICER 1. Receives and inspects items delivered, as to
quantity, and signs DR.
2. Informs inspection committee of the delivery
INSPECTION COMMITTEE 3. Inspects delivered items in the presence
MEMBERS ofthe Storekeeper for conformity to quantity,
quality, cost, and specifications.
a. Items should be properly marked. For
rejected items, suppliers should be
properly informed in writing.
b. For drugs and medicines,
randomsamples should be taken and
forwarded to the Bureau of Food and
Drugs (BFAD) for testing.
4. Prepares and signs inspection report.
SUPPLY OFFICER / STOREKEEPER / 5. Prepares certificate of acceptance,
DESIGNATE andattaches the same to the inspection
report.
6. Records items received in the Supply
StockCard and Bin Card [Form no. 43].
7. Furnishes the COA / Inspection Committee /
ICU with a copy of the inspection report
within 24 hours upon acceptance by end
user.
246
CHART NO. 107: DELIVERY, INSPECTION, AND ACCEPTANCE
SUPPLY OFFICER INSPECTION COMMITTEE MEMBERS SUPPLY OFFICER / STOREKEEPER / DESIGNATE
Receives and
Inspects delivered items in Prepares certificate of
inspects items for conformity to quantity, acceptance, and attaches
delivered, and
quality, cost and the same to the inspection
signs DR
specifications report
Informs inspection
committee of the delivery Records items received in
the Supply Stock and Bin
Prepares and signs Cards
inspection report
Furnishes the
COA / Inspection
Committee / ICU
with a copy of the
inspection report
within 24 hours
221
6. Procedures in maintaining a Bin Card and a Stock Card ( for all supplies and
materials)
Supply Officer / Storekeeper / 1. Prepares a Stock Card and Bin Card for
Designate everysupply kept in stock.
2. Indicates in the card the complete description
of the supply including the date of acquisition,
cost of supply, the name of supplier and all
receipts and issuances. (Records all receipts,
issuances and balances on the stock card).
NOTE: The Stock Card and Bin Card is an
instrument to guard against overstocking and
serves as a guide in preparing the APP and the
Inventory Report of Supplies and Materials.
249
CHART NO. 108: PROCEDURES IN MAINTAINING A BIN CARD AND A STOCK CARD ( FOR ALL SUPPLIES AND MATERIALS)
SUPPLY OFFICER / STOREKEEPER / DESIGNATE
Indicates in the card the

complete description of the
Prepares a Stock Card supply including the date of
and Bin Card for every acquisition, cost of supply,
supply kept in stock the name of supplier and
all receipts and issuances
(Records all receipts,
issuances and balances on
the stock card)
250
7. Procedures in maintaining an equipment ledger card (for all sections handling
supplies and materials)
SUPPLY OFFICER / 1. Prepares equipment ledger card [Form
STOREKEEPER no.111] for each equipment received.
/ DESIGNATE / END-USER 2. Indicates in the card the following:
CONCERNED completedescription of the equipment
including the date of acquisition, property
number, cost of equipment, and to whom
issued.
3. Records all repairs performed and
partsreplaced on the equipment.
NOTE: The equipment ledger card serves as
a guide for the repair of the equipment and
facilitates physical inventory.
251
CHART NO. 109: PROCEDURES IN MAINTAINING AN EQUIPMENT LEDGER CARD (FOR ALL SECTIONS HANDLING SUPPLIES
AND MATERIALS)
SUPPLY OFFICER / STOREKEEPER / DESIGNATE / END-USER CONCERNED
Indicates in the card the complete

Prepares equipment description of the equipment Records all repairs
ledger card [Form no. including the date of acquisition, performed and parts
111] for each property number, cost of replaced on the
equipment received equipment, and to whom issued. equipment.
252
8. Payment of deliveries
SUPPLY OFFICER 1. Prepares Disbursement Voucher [Form no.
/STOREKEEPER 95] and attaches all pertinent supporting
papers (inspection report, acceptance,
abstract quotation, etc.).
2. Forwards documents to the AO.
ADMINISTRATIVE OFFICER 3. Reviews voucher and affixes initials to
signifypropriety of the transaction.
4. Forwards complete papers to theCOH.
5. Reviews and signs Box A of the voucher and

COH forwards the same to the GSO through the
Liaison Officer.
226
CHART NO. 110: PAYMENT OF DELIVERIES
SUPPLY OFFICER /STOREKEEPER ADMINISTRATIVE OFFICER

CITY HEALTH OFFICER / COH
/ OFFICER-IN-
CHARGE
Prepares Disbursement
Voucher [Form no. 95] Reviews voucher and affixes
initials to signify propriety of the Reviews and signs Box
and attaches all
transaction A of the voucher and
pertinent supporting
forwards the same to
papers (inspection
the GSO through the
report, acceptance,
Liaison Officer
abstract quotation, etc.)
Forwards complete papers to the

COH/COH/OIC.
Forwards documents to the AO
254
2
5
5
9.
Inventory
HOSPITAL INVENTORY 1. Conducts annual physical inventory of
COMMITTEE MEMBERS equipment and semi-annual physical inventory
of supplies and materials.
2. Prepares an inventory report [Form no. 112]
and submits the same to the AO for review.
SUPPLY OFFICER / STOREKEEPER 3. Updates Memorandum Receipt (MR) [Form
/ DESIGNATE no. 113], if necessary. (MRs should be
renewed every three years).
4. Compares inventory listing of equipment on
the property cards against the equipment
subsidiary ledger cards.
ADMINISTRATIVE OFFICER 5. Reviews and initials inventory report of
equipment, supplies, and materials, and
forwards the same to the COH for approval.
CHIEF OF HOSPITAL 6. Reviews and approves inventory report and
forwards the same to the Storekeeper for
distribution to the different offices concerned.
STOREKEEPER 7. Distributes copies of the inventory report to
the City Mayor’s Office through the GSO and
to the CITY COA, and keeps a file copy for
record purposes.
256
CHART NO. 111: INVENTORY
HOSPITAL INVENTORY SUPPLY OFFICER / ADMINISTRATIVE COH STOREKEEPER

COMMITTEE MEMBERS STOREKEEPER / DESIGNATE OFFICER
Conducts annual
physical inventory Updates Memorandum Reviews and initials Reviews and
of equipment and Receipt (MR) [Form inventory report of approves
semi-annual no. 113], if necessary. equipment, and inventory report
physical inventory, (MRs should be forwards the same and forwards the
supplies, and renewed every three to the COH for same to the
materials years) approval Storekeeper for
distribution to the
different offices
concerned
Compares inventory
listing of equipment on
the property cards
Prepares an inventory
against the equipment
report [Form no. 112] and Distributes copies of
subsidiary ledger cards
submits the same to the the inventory report
AO for review to City Mayor’s Office
through the GSO and
to the CITY COA,
and keeps a file copy
for record purposes
229
10. Repair of
Equipment
ACCOUNTABLE OFFICER 1. Reports and requests inspection of
unserviceable equipment.
2. Attaches to the report a copy of the
Memorandum Receipt (MR).
SUPPLY 3. Checks the Equipment Ledger Card for the
OFFICER/STOREKEEPER/DESIGNATE following:
a. If equipment is still within the warranty
period, contact the supplier.
b. If not, prepares (3) copies of the
Requestfor Pre-Repair Inspection and the
RIS for Repair
4. Indicates the complete description of the
equipment (serial number, model, etc.)
5. Forwards documents to the Engineering or
Maintenance Section.
BIO-EQUIPMENT Checks the equipment.
ENGINEERING/MAINTENANCE Indicates in the Request for Pre-Repair
SECTION Inspection Form the following:
• Nature and scope of work to be done •
Parts to be replaced.
• State whether said scope of work can be
done in-house or for outside job.
Initials Request for Pre-Repair Inspection
Report and forwards the same to the Supply
8. Officer.
SUPPLY OFFICER 9. Reviews and initials RIS and Request for Pre-
Repair Inspection Report and forwards these
to the AO for initial.
ADMINISTRATIVE OFFICER 10. Reviews and initials RIS and Request for
PreRepair Inspection Report and forwards to
the COH/COH/OIC for approval/signature.
COH 11. Reviews/signs/approves RIS and Request for
Pre-Repair Inspection Report and forwards to
the SO.
SUPPLY OFFICER 12. Assigns control number.
13. Records in the logbook, retain a file copy and
forwards these documents to the GSO.
259
CHART NO. 112: REPAIR OF
EQUIPMENT
ACCOUNTABLE OFFICER SUPPLY OFFICER/ BIO-EQUIPMENT
STOREKEEPER/ ENGINEERING
DESIGNATE /MAINTENANCE
SECTIO
N
Reports and
requests
inspection of Checks the Equipment Reviews and Reviews and Reviews/signs/app
unserviceable initials RIS and initials RIS and roves RIS and
Ledger Card Checks the
equipment equipment Request for Pre- Request for Pre- Request for Pre-
Repair Inspection Repair Inspection Repair Inspection
Report and Report and Report and
forwards to the forwards to the forwards to the
AO for initial COH/COH/OIC for SO
Indicates the complete Indicates in the Request approval/signature
Attaches a copy of
description of the for Pre-Repair
the Memorandum
equipment (serial Inspection Form the
Receipt (MR)
number, model, etc.) folowilng:
a. Nature and scope
of work to be
done
b. Parts to be Assigns control
Forwards documents to replaced. number
the Engineering or c. State whether
Maintenance Section said scope of
work can be done
in-house or for
outside job
Records in the
logbook, retains
a file copy and
forwards these
Initials Request for documents to
Pre-Repair Inspection the GSO
Report and forwards to
the Supply Officer
SUPPLY OFFICER AO COH

231
11. Disposal of Government Property
End-User/Section Heads 1. Reports/returns unserviceable
equipment and instruments, and other
semi-expendable supplies and
materials to the Storekeeper.
2. Attaches copy of the
MemorandumReceipt (MR).
Supply Officer/Storekeeper 3. Receives returned equipment and
other semi-expendable supplies and
materials.
4. Prepares request for repair/inspection
of the equipment.
CITY Engineering Office Staff 5. Inspects the equipment and makes
appropriate report.
Supply Officer/Storekeeper 6. If equipment is for repair, please see
Procedure for Repair of Equipment.
7. If equipment is for disposal, prepares
Waste Materials Report (WMR) of
unserviceable and obsolete equipment
and semi-expendable supplies and
materials, and forwards it to the AO for
review.
8. Prepares report of inspection and
appraisal of unserviceable and obsolete
(IIA report) equipment and submits the
same to AO for review and initial.
Administrative Officer 9. Reviews and initials the WMR and IIA
Report and prepares transmittal letter.
10. Forwards documents to the COH
forapproval.
Chief of Hospital 11. Reviews and approves documents and
forwards these to the GSO through the
Liaison Officer.
NOTE: The process of disposing
unserviceable and obsolete equipment
and semi-expendable supplies and
materials are performed at the CITY
government’s office.
General Services Officer 12. Forwards IIA report and journal
voucher for the dropping of equipment
to the COH.
Chief of Hospital 13. Receives documents and forwards to
the Supply Officer/Storekeeper.
Supply Officer/Storekeeper 14. Cancels MR issued to concerned user.
15. Adjusts inventory records.
263
CHART NO. 113: DISPOSAL OF GOVERNMENT PROPERTY
END-USER/ SUPPLY OFFICER/STOREKEEPER CITY AO COH GSO SECTION HEADS ENGINEERING

OFFICE STAFF
Receives Prepares
returned request for
equipment repair/inspecti Inspects the Reviews and Reviews and Forwards IIA
and other on of the equipment initials the WMR approves report and
Reports/returns semi- equipment and makes and IIA Report documents and journal voucher
unserviceable expendable appropriate and prepares forwards these for the dropping
equipment and supplies and report transmittal to the GSO of equipment to
letter through the the COH
instruments, materials
and other semi- Liaison Officer
expendable
supplies and Prepares Waste
materials to the Materials Report Disposal Eqpt. for Forwards
Storekeeper (WMR) of repair of
unserviceable and documents to
disposal? the COH for Receives
obsolete documents and
equipment and If equipment is for approval
forwards to the
semi-expendable repair, please see Repair Supply Officer/
supplies and Procedure for Repair Storekeeper
materials, and of Equipment
Attaches copy of the forwards it to the
Memorandum AO for review
Receipt (MR)
Prepares report of inspectionand appraisal of

unserviceable and obsolete (IIA report)
equipment and submits the same to AO for
review and initial
Adjusts Cancels MR issued to

inventory concerned user
records
233
12.
Clearance from property accountability
EMPLOYEE 1. Prepares and presents duly
accomplished clearance form [Form no.
116] to the Storekeeper.
2. Returns property under his
accountability, if any.
STOREKEEPER 3. Checks and verifies the files of
the employee concerned on
property accountability.
4. Checks and verifies returned property as
to specification as stated in the MR.
5. Cancels MR issued pertaining to the
returned property.
6. Signs clearance and forwards the same
to the Chief of Service.
CHIEF OF SERVICE 7. Reviews and recommends approval of
the clearance to the COH.
8. Approves clearance.
CHIEF OF HOSPITAL
266
CHART NO. 114: CLEARANCE FROM PROPERTY ACCOUNTABILITY
EMPLOYEE STOREKEEPER CHIEF OF SERVICE COH

OFFICER-IN-CHARGE
Checks and verifies
Prepares and
the files of the
presents duly employee concerned Reviews and
accomplished
on property recommends Approves
clearance form
accountability approval of the clearance
[Form no. 116] clearance to the
to the COH
Storekeeper
Checks and verifies

returned property as
to specification as
Returns property stated in the MR
under his
accountability, if any
Cancels MR issued
pertaining to the
returned property
Signs clearance and

forwards the same
to the Chief of
Service
235
Procedures in maintaining an Equipment Ledger Card (for all equipment)
Supply Officer /Storekeeper/Designate 1. Prepares Equipment Ledger Care
foreach equipment
received/purchased.
2. Indicates in the card the following:
• complete description of the
equipment
• the date of acquisition
• property number
• cost of equipment
• name of supplier
• estimated useful life
• warranty period
• to whom the equipment is issued
(Accountable Officer)
3. Records all maintenance services
andrepairs performed and parts
replaced on the equipment.
NOTE: The Equipment Ledger Card
serves as a guide for the
maintenance/repair of the equipment and
facilitates the annual physical inventory.
270
III. OTHER
OFFICE/ASDMINISTRATIVE
PROCESSES AND PROCEDURES
- CORRESPONDENCE, RECORDS MANAGEMENT & ARCHIVING
- TMS-PMS
- FACILITATION OF OPERATIONS REVIEW, MEETINGS AND
TRAININGS
- PREPARATION AND TRANSMITTAL OF FORMS
- MONITORING OF EMPLOYEES BEHAVIOR
- LEAVE ADMINISTRATION
- EMPLOYEES COMPENSATIONS, CLAIMS AND BENEFITS
- PERSONNEL MANAGEMENT
272
RepublicofthePhilippines
GENERALSANTOSCITYHOSPITAL
GeneralSantosCity
MAJORPROCESS
Correspondence/RecordsManagement
andArchiving
DOCUMENTRECEIVING
1.1A.AIll/JOreviewscompletenessofattachment
,.
1.2A.A111/JOreceivetheincoming
communications
',
1.3A.AIll/JOrecordtologbooktheincoming
communications
,.
1.4A.AIll/JOencodesdocumentstracking
databasetheincomingcommunications
1.5A.AIll/JOattachfilled-uptracerslip
,r
1.6A.AIll/JOforwardsdocumentstoDepartment
Head
MAJOR PROCESS
Correspondence/Records Management and Archiving
DOCUMENT ACTION
2.1 Department Head acts / notes the documents
2.2 AO collects noted documents from department

heads
2.3 AO forwards documents to designated

personnel
DOCUMENT DRAFTING
3.1 Department Head/Asst. Dept/Admin officer

drafts communications
3.2 DH/ADH/AO reviews drafted.
MAJOR PROCESS
Correspondence/Records Management and Archiving
DOCUMENT ENCODING
4.1 AA encodes & prints draft communication to DC

for review
4.2 Review draft & communication and returns to

AA for corrections if any
4.3 AA IV encodes corrections and print then

forward to DC for initials
4.4 DC initials communications and returns to AA

IV for Department Heads signature
DOCUMENT SIGNING
5.1 AA 1-4 submits communications to DH for

signatories
5.2 DH signs documents and returns to AA
MAJOR PROCESS
Correspondence/Records Management and
Archiving
DOCUMENT SORTING
6.1 AA identifies documents for routing delivery filing
DOCUMENT DISPATCHING
7.1 AA forwards to messenger for deliveries
7.2 Messenger delivers docs and have stamped

received by concerned dept agency
7.3 Messenger returns to AO II copy of documents
MAJOR PROCESS
Correspondence/Records Management
and Archiving
DOCUMENT FILING
8.1 AO II files documents to assigned folder

DOCUMENT RETRIEVAL / RE FILING
9.1 AO II retrieves documents for reference and re-

file
DOCUMENT ARCHIVAL
10.1 AO II segregates active inactive files
10.2 AO II transfer to separate records room

inactive files
10.3 AO II retains active files accessible to working

place
MAJOR PROCESS
TMS-PMS DATA
GENERATION
If Manual:
1. Collect manual DTR from concerned personnel duly signed by the

supervisor
If Fingerscan:
1 .Payroll clerk submits USB to TMS/PMS for data

generation
2 .Payroll clerk gets USB
3 .Payroll clerk prints data
DATA VERIFICATION
1. Payroll clerk verify approved leave, LWOP and payroll deduction
DATA ENCODING
1. Payroll clerk encodes data verified

MAJOR PROCESS TMS-PMS
SUBMISSION OF FINAL DTR/PAYROLL
1.Payroll clerk submits USD to TMS
2.Payroll clerk gets USB for printing
3.Payroll clerk prints final DTR/Payroll
4.Payroll clerk give final DTR to concerned

employees for signature
5.Payroll clerk collect DTR
6.Payroll clerk submits final DTR/payroll with

signature documents for DH/ADH signature
MAJOR PROCESS
Facilitation of Operations Review,
Meeting, and Trainings
1.AO coordinates with DH the schedule date of
Operations Review/Meetings/Trainings
2.Prepare letter address to HR on the schedule Operations

Review (with program)
3.Prepare training design
4.Prepare agenda
5.Prepare facilities and materials needed
6.Secretariat to take note reports of (in every

division) for final consolidation of report
(documentor)
MAJOR PROCESS
Preparation and Transmittal of Forms
(BIR, GSIS, PHILHEALTH, PAGIBIG..Etc.)
1.Fill-up forms
2.Facilitates signature of employees
3.Submit to agency concerned

MAJOR PROCESS
Monitoring of Employees’ Behavior
A. Events
1.Prepares attendance sheet
2.Requires employees to sign (if attended

)
3.AO confirms DH/ADH noted
4.Submit attendance sheet to HRMDO
B. During Office Hours

MAJOR PROCESS
1.AO prepares monitoring form
2.AO conducts surprise monitoring during work

hours
3.If employee is not on his/her station/ AO checks

locator slip
4.Absent locator slip, AO makes report for DH for

consumption
Leave Administration
1.AA Gather information from employee who

applies for leave
2.AA prepare leave application
3.Submit to admin countersign
4.DH approves
5.Submit leave application for approval (CMO, HR )
MAJOR PROCESS
Employee’s compensation, claims and
benefits
1.Receives draft payroll from PMS
2.Checks and reviews entries in the payroll
3.Returns draft payroll to PMS for final copy
4.Receives final copy of the payroll including

attachments
5.Initials and delivers to DH/ADH for signature
6.Forward payroll to CBO for processing

MAJOR PROCESS
Personnel Management
Competency Enhancement
1.AO remind / urge each division to submit division

training plan
2.Receives Division Training Plan
3.Admin to collate and consolidates DTP
4.Submit to DH for comments / recommendations
5.Finalized DTP
6.Finalized DTP submit to HR
MAJOR PROCESS General Services Maintenace

1.Repair and Maintenance of Equipment, Vehicles
and Facilities
1.1 AO conducts inventory of equipment, vehicles and

facilities
2.AO prepares inventory/status report (cleaning,

repair, return)
3.AO schedules regular cleaning of equipment,

vehicles and facilities
4.AO informs GSO re-repair of equipment vehicle,

facilities thru phone call / letter depending on
urgency
5.AO Acts on the Pre-inspection report
6.AO prepares PR and other related documents

according to GSO report
7.AO monitors / facilitates payment for repair

DJPRH Processes and Procedures

Uploaded by

Document Information

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

DJPRH Processes and Procedures

Uploaded by

Copyright:

Available Formats

General Santos City Hospital

PROCEDURES IN CLINICAL AND NURSING

Ward work/ patient

HESU NURSE 21.2. Forwards the result of the surveillance to the

4.4. If patient is not for admission, gives

the designated hospital staff.

Checks and approves ER

4. Assesses patient’s condition and notes findings

2.1. Pre-operative procedures

ADMITTING NURSE NURSING ATTENDANT OR NURSING ATTENDANT/ UTILITY

Ensures that jewelry,

Gives cleansing enema, if

Inspects operative site and

Re-checks the checklist of

Takes vital signs, level of

Refers patient to the Surgeon

Transfers patient from the ward

Endorses patient and

Re-checks availability of suction apparatus, anesthesia

Re-checks if machines are functioning effectively

Sets up the table

2.4. Patient care in the Operating Room

SURGEON ANESTHESIOLOGIST CIRCULATING SCRUB NURSE NURSING UTILITY

(with utility worker)

OLOGIST RECOVERY UTILITY ADMITTING

Monitors & records

Refers to the physician

Informs Admitting Nurse

LABOR ROOM/DELIVERY ROOM PROCEDURES

Receives patient with record, with

For direct to labor room

Prepares patient for examination

Orders the transfer of the

DR NURSE Performs perineal care.

Endorses mother and baby to the Ward Nurse for

Receives mother, baby,

Carries out treatments and

Advises mother to breastfeed

Performs perineal flushing

Gives discharge orders

Submits daily charges to the

Informs Dietary Service of

Provides lactation counseling

Monitors and records vital

NOTE: For disinfectants, prepares and forwards request

Receives and checks used articles

Places articles directly inside the

Files borrower’s slip for the report

Forwards items to the designated

COM. MEMBERS ATTENDANT

CSR STAFF CSR NURSING CSR NURSE WARD NURSING ATTENDANT

Receives borrower’s slip

Prepares articles and supplies listed in

Checks items against the

CSR HEAD CSR CLERK/NURSING CSR NURSE

Prepares needed supplies and packs them individually

Labels these packs and sterilizes items

Checks sterilized supplies

CHIEF NURSE CSR STAFF/NURSING NURSING ATTENDANT ATTENDANT

Returns items to Supply

Updates stock card

Files return slip

1.1. To other health facilities

Coordinates with the Provides patient and