Policies and Procedures on Conducting Initial Assessment inEfficient and Systematic Manner Responsible Party: Medical / Nursing Service

Department Regulatory / Standard Reference: PHIC Benchbook Section: OPD/ER, LR/DR Policy No. _________ Date Issued: ________ PURPOSE / INTRODUCTION:Nursing assessment must be done in a systematic manner based onnursing model. Initially it starts from the nursing process which starts fromnursing assessment in which the nurse shall carryout complete and holisticnursing assessment of every patients needs, regardless of the reason theyencounter. Assessment includes physical examination, nursing history,psychological and social examination.POLICY DESCRIPTION:The hospital nursing administrator shall be responsible in assigning 87

appropriate professionals to perform and coordinate sequence patientassessment to client to reduce waste and unnecessary repetition.Medical and nursing assessment shall be responsible in documentation inthe patients medical or nursing records, which can be accessed by all membersof the health care team.DEFINITION:Nursing assessment- is the gathering of information about patientsphysiological, psychological and spiritual status.Nursing process chronologically composed in order the assessment,planning, intervention and lastly the evaluation.RIGHTS AND RESPONSIBILITY:All Nursing Staff are responsible in gathering the patient history, physically,psychologically, sociologically and spiritually.The responsibility encompasses promotion of health, prevention of illness,alleviation of suffering and restoration of health.ETHICAL PRINCIPLE:All nurses recognize the primary responsibility to preserve health at allcost.PROCEDURES:1.Record the observations and measurement of signs and symptoms observed. 2. Document assessment using nursing assessment tools.3.Identify the patients nursing problems thru taking a nursing history.4.Taking psychological and social examination that includes:1.clients perception2.emotional health3.social health4.physical health5.spiritual health6.intellectual health

5.

Some technique used may include inspection, palpation, auscultation andpercussion in addition to the v/s of temp., BP, PR, RR, further examination of body system such as cardiovascular or musculoskeletal system.6.Taking a nursing history prior to PE, allows a nurse to establish rapport withthe patient and family.Elements of history includes:. health status. course of present illness including symptoms. current mgt. of illness. past medical history including familys medical history. social history. perception of illnessMONITORING:Decrease incidence of unnecessary repetitionDecrease incidence of morbidity/ mortality caseIncrease quality work productivity

POLICIES AND PROCEDURE FOR RESOLVING ETHICAL ISSUESARISING FROM PATIENT CARE OR REPORTS OR RECORDS ORRESOLUTION OF ETHICAL DELIMA ARISING IN THE COURSE OFPROVIDING CARE POLICY DESCRIPTION: Ethical dilemma occurs when there are conflicting moral claims. A situation thatrequires an individual to make a choice between two equally unfavorablealternatives. 2.The decision made often has often to be defended against those who disagree withit. 3.Documentation help in resolving ethical issues thereby meeting the professional& legal standards. 4.Documentation provides a clear picture of the status of the client, the actions of the nurse, and the clients outcomes. 5.Nursing documentation clearly describes an assessment of the clients healthstatus, nursing interventions on clients outcomes, a care plan or health planreflecting the needs and goals of the client; needed changes to the care plan,information reported to a physician and advocacy undertaken by the nurse on behalf of the client.6.Within the nurse-client relationship, the nurse must apply nursing knowledge,skills and judgment according to professional standards.7. The nurse documentation may be used as evidence in legal proceedings such aslaw suits, coroners, inquests, and disciplinary hearings trough professionalregulatory bodies. In court law, the clients health record serves as legal record of the case or service provider. Nursing care and the documentation of that care will be measured according to the standard of a reasonable and prudent nurse withsimilar education and experience in a similar situation 8. The chief nurse may investigate or collect data from the chart and to theconcerned staff. The chief nurse may also ask questions from clients satisfactionof care provided by the concerned staff to resolved the issues.PROCEDURE:1.There shall be a written complaint.2.The complaint must be noted by the head nurse and supervisor of the area.3.The head nurse will issue memo within 24hrs.4.Incident report by the person concern ( student, CI, Staff nurse) to be submitted tothe department head

POLICIES AND PROCEDURES IN IDENTIFYING CLINICAL SERVICESTHAT WILL BEST ADDRESS PATIENTS CLINICAL NEEDS Responsible Party: All Clinical Department Heads Regulatory /Standards References: PHIC Benchbook Section: ER/OPD, General Ward, DR/OR, Laboratory, Pharmacy, TransportServices Policy No.:___________ Date Issued: ___________ INTRODUCTION:To provide quality health services in every client the available clinicalservices with respect to appropriate patients/clients clinical needs.To determine and prioritize the clients needs upon entry and identifying theappropriate clinical services that will best address to patient/ clients needs.POLICY:The hospital shall provide the highest level of care to ensure patientstriaging in determining and prioritizing patients clinical needs.The hospital shall provide the immediate quality output of requesteddiagnostic and laboratory results for quality health care services. These includes the presence of skilled and well trained health care professionals, the presence of transport services ( ambulance) and the referral system.The hospital shall have a system wide approach in dissemination of IECmaterials for the clinical services available.RIGHTS AND RESPONSIBILITIES:All staff shall follow policies and procedures in determining and prioritizing patients clinical needs and in identifying the clinical services that will bestaddress to patients clinical needs.GUIDING PRINCIPLE/ ETHICAL PRINCIPLE:There shall be a system wide coordinated program to orient every staff theavailability of clinical services.PROCEDURES:The hospital staff shall undergo orientation and knowledgeable of patient triaging as to what clinical services/facilities available inthe hospital that will best address to patients needs. ( e.g.Obstetrician - for OB cases; Internal Medicine - for Medical cases;Surgeon for Surgery cases, etc.).Brochures, IEC printed materials shall be available and posted at theentry point of the hospital and to other areas likeOPD/ER/Admitting Section.Individual client or group of clients maybe instructed for anyscheduled laboratory screening , healthy lifestyle seminar, healtheducation and counseling especially DM clients, HPN, FamilyPlanning, etc.Monitoring logbook shall be used for recording and evaluating the progress of the status of the client on her/his next session or visit

OLICIES AND PROCEDURES FOR CORRECTLY IDENTIFYING PATIENTSBY THEIR CHART Responsible Party:

Nursing Service / Medical Record Section Regulatory / Standard Reference: PHIC Benchbook Section: OPD/ER, DR, General Ward Policy Number: _________ PURPOSE / INTRODUCTION:To provide easy, safe and correct identification of patients using the color coded patients chart.To provide a mechanism which identifies patient according to the clinical needs,manifestations being presented.POLICY: 1. All charts shall have a corresponding color coding either by doctors specialty or bycase / room services as per institutional policy and that is readily accessible toauthorized personnel.2.All health care providers / newly hired personals shall be informed of the approvedcolor coded identification of patients by their charts.PROCEDURES:1.DADPFH color coding in identifying by their patients charts were as follows:Surgical BlueOB/Gyne - Green Medicine WhitePedia / NB Pink Isolation Red 2. Color coded in-patients charts were sorted out at Medical Record Section beforesafekeeping to easier access of retrieval.MONITORING:1.Decreases the incidence of medication error.2.Increases the work productivity of the staff.DISSEMINATION: 1. Memos2.Hospital Order REFERENCE:Existing Hospital Operational Protocol

Policies and Procedures for Evaluation of Professionals who Administer Drugs Regulatory/Standard Reference: Phic Bench book Section : E.R./O.P.D.,L.R./D.R., and Ward Nurses Policy No.________ Date Issued______ PURPOSE/INTRODUCTION :Evaluation of professionals who administer drugs is always done at the end of training and supervision during hands on procedures. This is to gauge the knowledge, skills,values of professional during enhancement program as the framework for providing safe practice. POLICY DECRIPTION :The Nursing service shall employ mechanisms for measuring & correcting performance of activities in order to assure that organizational objectives and plans areaccomplished. RIGHTS AND RESPONSIBILITIES :The Nursing Service administration shall be responsible in evaluating personnel performance appraisal and evaluation of professionals who administer drugs DEFINITION: Evaluation- it is the process of gauging the performed procedures after series of written exams, deductive reasoning, and practicum. PROCEDURES: 1.Pre & Post test2.Demo and return demo based from cognitive, affective, psychomotor domain3.Practicum after satisfactory passing the 1-3 procedures.4.Professional nurses with potential skills and got the passing rate will berecommended by the nursing service and permitted to administer medications

5.Evaluation toolPerformance 30%Character/attitude-70%Total100%MONITORING:EvaluationUpdates of Training (IV Therapy ) & certificates DISSEMINATION: Nursing PolicyMemosOrientationContinuing Education REFERENCES:

Nursing Manual DOHStandard of Safe PracticesANSAP Inc. 1999

Policies and procedures for Supervision of Professionals who Administer Drugs Regulatory/Standard Reference : Phic Benchbook Section: E.R. /O.P.D. Nurses, Ward Nurses, L.R./ D.R. Nurses Policy: ____________ Date issued: _______

PURPOSE/ INTRODUCTION: The Nursing Intravenous Standards was established as a guide for those who areto be supervised in the administration of drugs and will be practicing intravenous nursing. basedon the experience of the trainers and coordinators, it was noted that Intravenous (IV) Therapy isfast becoming a nursing specialty. The practice is constantly changing and developing. It is notintended to dictate or limit new concepts and technological advances. Its objectives includes thethree behavioral domains; cognitive, affective and psychomotor.POLICY DESCRIPTION:The hospital Nursing Service Administration shall establish Standard Operating policies and procedures to ensure safe I.V. therapy practice, and drug administration, to protectthe patients by maximizing benefits and to protect the practice Registered professional I.V. Nurses. The I.V. policies and procedures shall be written and continiously updated andreviewed as necessary.RIGHTS AND RESPONSIBILITIES:All nurses are responsible to ensure the safety of all clients/patients receivingdrugs, parenterals and I.V therapy. Nursing Service Administration shall be responsible for the governance developand implement policies and procedures based on the standards of nursing administration nursing practice on patient care. It shall also provide updated policies and procedures and clear directivefor nursing personnel at different levels of their functions and responsibilities to patient care.ETHICO-MORAL & LEGAL ACCOUNTABILITIES The Nursing Services Department has an established framework for ethico-moral& legal decision making in the clinical areas, and conforms with the applicable statutory laws,rules and regulations.DEFINITION:Cognitive Domain- intellectual discussions.Affective Domain- attitudes, attendance and active participation.Psychomotor Domain- skills as validated by training instructors/supervisorsPROCEDURES:The basis of safe nursing practice covers legally the carrying out of orders prescribed a duly registered physician; proficiency in all aspects of I.V. therapyadministration/drug administration validated in clinical judgment & practice; Ten(10) Rsand observation of aseptic techniques and hospital waste management.MONITORING:One on One

supervision of preceptors to professional administering drugs.Monitoring Logbooks for EvaluationDISSEMINATION:Memos Nursing PolicyOrientationContinuing Education

itle: Policies on Decontamination, Disinfection, Sterilization, Disinfectants for SpecificMedical Equipment/Items and Area Responsible Party: All Personnel in Clinical Division and Special Areas Section: OPD/E.R., L.R./D.R., Ward Nurses, and CSR Personnel Regulatory / Standard References: Phic Bench book/ ICC Manual Policy No.___________ Date issued__________ PURPOSE / INTRODUCTION:Everyday there is an enormous amount of equipment used throughout trust whichneeds to be handled safely and decontaminated prior to re-use. DADPFH has the duty to ensurethat all re-usable equipment are cleaned and sterilized to make it safe for re-use, storage, repair and maintenance or inspection.POLICY DESCRIPTION:The policy provides guidelines for the recognition of clean and soiled equipmentand guidelines for storage or treatment after use including the area.The policy states that all instruments, medical equipments and soiled linens shall be free from debris blood by soaking with Sodium Hypochloride with water for 5-10 minutes prior to cleaning, disinfection/sterilization.RIGHTS AND RESPONSIBILITIES:All personnel in Clinical Division and special areas has a responsibility to carry out decontamination on any piece of equipment they have used.DEFINITION:Cleaning-is the removal organic and inorganic material from objects and surfaces.This is normally accomplished by using detergents or enzymatic products.Thorough cleaning is necessary before disinfection andsterilization because inorganic and organic materials that remain on thesurface of the instruments interfere with the effectiveness of these processes.Decontamination-is the use of physical or chemical means to remove, inactive,or destroy microorganisms on a surface or item so that there are noinfections and the surface or item is rendered safe for handling use or disposal. The selection and use of cleaning equipment, chemicals andexposure times suggested by the device manufacturer should generallyfollowed to prevent damage to the items.Disinfection- is a process that reduces the number of microorganism ( with theexception of bacterial spores) on inanimate objects. This is done most often by use of an approved hospital detergent/disinfectant or chemical sterilant. a.)

High level disinfection- includes pasteurization or use of Denonex 53 plus. All microbial life ( except spores) is destroyed. Items that touchmucous membranes should receive high level disinfection. i.e. flexibleendoscopes, laryngoscopes and other similar instruments.( semi- criticalitems). b.) Intermediate level disinfection utilizes hospital grade disinfectant, anEPA- approved tuberculocidal cleaner/ disinfectant. Items that touchmucous membranes or skin that is not intact should receive intermediatelevel disinfection. i.e. thermometer, hydrotherapy tanks.c.) Low level disinfection-process that will inactivate most vegetative bacteria, some fungi, some viruses, but can not be relied upon toinactivate resistant microorganisms.(e.g. mycobacteria or bacterialspores) and is used for items that touch intact skin i.e. stethoscopes, beds,whirlpools, & equipment that is non-invasive to patients.( noncriticalitems).Antisepsis- inhibits the growth of microorganism on living tissue (e.g. skin preparation before vascular line insertion or other invasive procedure) lcohol, chlorhexidine gluconate and iodophors, i.e. betadine are the mostfrequently used solution for antiseptics. Germicidal chemicals used for antiseptics are not generally adequate for decontaminating environmentalsurfaces.Sterilization- is the complete destruction of all microbial life. It is accomplished byeither physical or chemical process such as steam under pressure, dry heat,ETO gas, and liquid chemicals. All items that enter sterile tissue or thevascular system must be sterile i.e. implants, scalpels , needles, surgicalinstruments etc.MONITORING:Twice a year ICC Monitoring & Surveillance TeamDISSEMINATION:MeetingBulletinWard ManualHospital MemoOrientationREFERENCE:ICC ManualExisting Hospital Policy