ADMISSION 1. Pre-endorsement or patient transfer receiving call from er/or/icu/dialysis/ward 2.

. Endorsement (bedside) putting APs name outside the room putting name of patient inside the room nurse to nurse endorsement. receiving patients name, attending physician, complaint, final diagnosis, latest vs/nvs, diet, intravenous fluid, diagnostic tests(done, requested, for follow up), medications, treatment, contraption and special endorsements checking of chart completion introduction of nurse on duty to patient checking the Intravenous Fluid, tag, regulation, level and site reinstruction of diet, diagnostics, and special endorsement to patient orientation to environment and equipment 3. Writing to census log book draw the sign for admission room no. name age diagnosis time of patient transfer to room of choice 4. Putting patient name on census board and medication box patient name is in accordance to Attending physicians color 5. Checking the vital signs blood pressure temperature pulse rate respiratory rate pain scale nvs other complaint o if with abnormal findings, informing the Resident on duty/Attending physicians 6. Preparing the kardex Room no. date of admission name age sex weight attending physician referral and co-management chief complaint admitting diagnosis

 diet medications intravenous fluid intravenous fluid to follow side drips treatment contraptions special endorsements 7. Making medication administration card color in accordance to frequency room # patients name medication (generic, brand, dosage, route, frequency, dose) signature at the back of MAC 8. Prescribing medication prescription pad name of patient date age name of medicine and amount other supplies (syringes, needle, distilled water) 9. Securing signature from patient relative proceed to patients room and have the patient / immediate relative signed the prepared prescription pad for medication 10. Getting medication from pharmacy proceed to pharmacy and submit the prescription pad with information needed for prescribing medication. Wait for the pharmacist to prepare the medicines. If done, get the medicines and proceed to your respective Stations. 11. Putting chart to chart holder insert the chart to the chart holder with corresponding patients room number indicate patients name( color coded) APs name and referrals DOCTORS ON ROUNDS 1. Securing lab results/diagnostic films Before doctors do their rounds Call / follow up all laboratory/ diagnostic results needed 2. Discussing assessment and patients complaint Vital signs / NVS Pain scale Abdominal assessment Other related assessments 3. Accompanying doctor on patients room BP Apparatus Stethoscope

Thermometer Pen light Other tools needed for assessment Chart

CARRY OUT DOCTORS ORDER / COUNTERSIGNING OF DOCTORS ORDER Verify the order, if not sure / certain, ask ROD Follow / accomplish what is being ordered Below the order, just beside the doctors signature, indicate NOD Signature over printed name date carried out time carried out DIET instructing patient informing dietary updating diet card/list and kardex MEDICATION (carrying out doctors order) writing in / updating medication administration record making / updating medication administration card prescribing medication securing signature of relative getting medication to pharmacy endorsing to / informing primary nurse starting medication MEDICATION ADMINISTRATION

observe 10 R verify physicians order p.o.: by mouth

IM: intramuscular injection SC: subcutaneous injection IV: intravenous PR: per rectum SL: sublingual h.s.: at hour of sleep (bedtime) ac: before meals pc: after meals

q: every, ie, q 8 h means every 8 hours q.d.: every day b.i.d.: twice/day t.i.d.: three times/day q.i.d.: four times/day q.o.d.: every other day Skin test

preparing for ST taking medication history prior to ST skin testing proper evaluation of ST after 30 mins if with reaction: informing ROD/AP

IVF/SIDE DRIP writing in IVF administration form making prescription endorsing to treatment nurse securing signature from patient / relative getting ivf from pharmacy starting new line to new site if needed preparation of ivf and iv tag o name o Room no. o Bottle/side drip no. o iv name o incorporation o regulation o date started o time started o date to be consumed o time to be consumed o AP o NOD Hooking of IVF Regulating/titrating as ordered Proper documentation to ivf monitoring sheet DIAGNOSTIC PROCEDURE Requesting through HIMS Signed if with request Instructing patient for diagnostic procedure and providing needed material Preparing patient if needed o Requesting if with specimen

CONTRAPTION Informing patient Securing consent for procedure if needed Writing in administration card Endorsing to treatment nurse Making prescription Securing signature of patient or relative Getting materials from pharmacy Informing ROD if assistance is needed SPECIAL ENDORSEMENT Monitoring of urine output, nvs, etc. Proper documentation Referral for any abnormalities FOR

Securing specimen first Requesting procedure through HIMS Putting label on specimen bottle Writing in specimen log book Sending specimen to laboratory If result was released; relaying to ROD / AP

SURGERY/OTHER PROCEDURE Making proposal Sending proposal if for OR Securing consent Informing ROD/NOD/AP for CP Clearance/Assist/Anesthesiologist Preparing patient Requesting IW Transferring patient Endorsing patient

TRANSFERRING PATIENT TO HOSPITAL OF CHOICE/OUT ON PASS Informing AP, ROD and immediate head or supervisor on duty Securing statement of transfer from patient or immediate relative (have the patient / immediate relative signed) Ensure having registered nurse, doctor and ambulance for transfer Completing patients chart Securing clinical abstract Sending chart to billing Requesting photocopy of all laboratory Requesting diagnostic films if any Coordination c/o ROD Accompanying patient to hospital lobby/ambulance If with ok for discharge: o Instructing home medication if any o Instructing special endorsement to nurse conducting the transfer

o o o

Writing in census log book Requesting for IW Accompanying patient to hospital lobby/ambulance

PATIENT FOR DISCHARGE Verify doctors order for discharge Ensuring that final diagnosis was written Informing other AP Making home medication prescription Making home medication instruction Securing laboratory request form for follow up as ordered Completing patient chart Sending chart to billing o Chart should be written in the partial or discharge log book Providing medical certificate per request Requesting photocopy of all laboratories as ordered If with ok for discharge: o Instructing home meds and follow up o Giving of copy of documents requested to patient or relative o Writing in census log book o Requesting for IW o Accompanying patient to hospital lobby If cannot go home for some instances: o Inform attending physician / ROD o Giving prescription to relative o Making medication administration card for home meds o Instructing patient/relative for medication o Charting UPDATING KARDEX Verify / check doctors order Update kardex CLOSING CENSUS LOG BOOK Indicate the number of patient / last census Admission Discharge Expired Transferred ENDORSEMENT TO INCOMING DUTIES Census (PISO) ROD Kardex Special endorsements Equipment

ENDORSEMENT TO OTHER AREA Inform Attending Physician Informing the area Completing the chart Preparing the kardex Preparing patients medication, materials, medication administration card Requesting for IW Accompanying patient to room Putting APs name to patients room Endorsing patient to nurse on duty HAVING THE RELATIVE SIGN THE OXYGEN THERAPY SHEET Inform the relative that whenever the patient is in oxygen therapy, they need to sign such form Indicate to the form what time the oxygen therapy was started and how many litres/min are being given Bring the chart to patients room and have the patient sign the form Indicate NODs initial CHARGING OXYGEN HIMS Patients name Oxygen L/min Time INCOMING NURSES WILL HAVE THEIR ROUNDS Greeting and introduction of self Checking doctors name to each room Checking IVF, tag, level and site Physical assessment and complaints Reinstructing patient of diet, laboratory and diagnostic procedures and special endorsement Health teaching Checking for any contraptions SURGERY OR OB DOCTORS ON ROUNDS If for wound dressing o Preparing dressing cart and needed supplies o Assisting doctor in dressing o Cleaning the instrument o Charging used dressing materials AM SHIFT Prescribing IV medication for PM and NIGHT shift use

NIGHT SHIFT Prescribing oral medication for 24 hours shift and IV medications for AM shift Adding pages to patients chart and filling up patients information Doing 24 hours checking o Checking doctors order for the last 24 hours if carried out o Medication administration record o Iv monitoring sheet o Medication card o Laboratories if requested o Updating kardex REQUESTING MEDICAL CERTIFICATE Patient will request Purpose Diagnosis MEDICAL ABSTRACT Instruct that the patient will pay Php 200 for rush Php 50 for 7 - 10 days Provide relative with 2 pieces of news print / gray paper indicating medical abstract and the amount to be paid After payment, call medical records and inform them that the patient is requesting medical abstract. DIAGNOSTIC / LABORATORY EXAMINATION ECG Verify doctors order for procedure Request to HIMS Explain the procedure to patient The ECG technician will go to the patient 2D ECHO Verify doctors order for procedure Explain the procedure to patient Explain to relative that the procedure is cash basis Secure consent for procedure, signature over printed name Request to HIMS Once settled the staff on heart station will be the one to call on when the procedure will start Call IW when its time for the patient to undergo the procedure Accompany the patient to the Heart Station X-RAY Verify doctors order for procedure Request to HIMS Explain the procedure to patient The Rad Tech will call to the nurse station when the patient will undergo the procedure

Call IW when its time for the patient to undergo the procedure Accompany the patient to the X-ray Station

PATIENT PREPARATION FOR X-RAY PROCEDURE KUB-IVP PREPARATION 6:00 pm 4 tabs Dulcolax 6:30 pm 60 cc castor oil NPO KUB 6:00 pm 4 tabs Dulcolax 6:30 pm 60 cc castor oil NPO Barium Enema 6:00 pm 4 tabs Dulcolax 6:30 pm 60 cc castor oil NPO Upper GI series 6 hours NPO OTHERS Normal Creatinine

ULTRASOUND Verify doctors order for procedure

Request to HIMS Prepare the patient for the procedure (required diet if needed/ Full Bladder if applicable) The Ultrasound Tech will call to the nurse station when the patient will undergo the procedure Call IW when its time for the patient to undergo the procedure Accompany the patient to the Ultrasound Station

PATIENT PREPARATION FOR ULTRASOUND PROCEDURE Whole Abdomen Upper Abdomen Lower Abdomen PREPARATION NPO NPO Full Urinary Bladder Light meal HBTP/HBT Non-fatty foods Light meal KUBP/KUB Full Urinary Bladder Light meal Pelvic Full Urinary Bladder Light meal OTHERS

CT SCAN Verify doctors order for procedure Request to HIMS Explain the procedure to patient Inform the patient / relative that the procedure is cash basis Secure consent for procedure, signature over printed name Prepare the patient for the procedure (required diet if necessarynecessary) The CT Scan Tech will call to the nurse station when the patient will undergo the procedure Call IW when its time for the patient to undergo the procedure Accompany the patient to the CT Scan Station

PATIENT PREPARATION FOR CTSCAN

PROCEDURE Chest Whole Abdomen

PREPARATION 6 hours NPO 6:00 pm 4 tabs Dulcolax 6:30 pm 60 cc castor oil NPO

OTHERS Normal Creatinine Normal Creatinine

Upper Abdomen Lower Abdomen

6 hours NPO 6:00 pm 4 tabs Dulcolax 6:30 pm 60 cc castor oil NPO

Normal Creatinine Normal Creatinine

Cranial with Contrast

6 hours NPO

Normal Creatinine

BLOOD EXAMINATION Verify doctors order for procedure.

Request to HIMS including the ordered time of blood extraction (e.g. now, today, or the exact time) Explain the procedure to patient including the diet restriction (NPO) if there is. The laboratory technician will extract blood for blood exam. FECALYSIS Explain the procedure to patient. Provide a specimen bottle for the patient. Verify doctors order for procedure Request to HIMS. The nursing attendant/nurse on duty will forwarded specimen at the laboratory. URINALYSIS Explain the procedure to patient. Provide a specimen bottle for the patient. Verify doctors order for procedure Request to HIMS. The nursing attendant/nurse on duty will forwarded specimen at the laboratory. SPUTUM EXAM Explain the procedure to patient including the proper time of collection and preparation for catching the specimen. Provide a sterile specimen bottle for the patient. Verify doctors order for procedure Request to HIMS. The nursing attendant/nurse on duty will forwarded specimen at the laboratory. WOUND CS Attending physician will collect specimen from the patients wound. Secure consent if needed. Verify doctors order for procedure. Request to HIMS. The nursing attendant/nurse on duty will forwarded specimen at the laboratory. SENDING OUT OF LABORATORY EXAM Attending physician will collect specimen from the patients wound. Verify doctors order for procedure Request to HIMS. If for histopath, the nursing attendant/nurse on duty will forwarded specimen at the laboratory. If for blood exam, the laboratory technician will extract blood. The laboratory technician will inform the nurse on duty that the specimen will be sending out and possible release of the result.