GENA FAMILY PLANNING

& MATERNITY CLINIC

GENERAL STANDARD OPERATING PROCEDURES

Page

Content

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2
3
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5

Title Page
Outpatient Consultations
Antepartum Care Policy and Procedures
Procedure in Performing Prenatal Check-up
Admission Cases: Labor, Delivery, Immediate Postpartum and

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10
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12
13
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15

Newborn Care
Spontaneous Vaginal Delivery and EINC Policy and Procedures
Postpartum Care Policy and Procedures
Procedures on Early Detection of High Risk Pregnancies
Transfer/ Referral Policies and Procedures
Policies and Procedures of Infection Control
Health Care Waste Management Policies and Procedures
Preventive Maintenance Program for Equipment
Medical/Obstetrical Records Policy and Procedures.
Pest and Vermin Control Policy
Policies and Procedures in Handling Complaints, Reporting and

16

Analysis of Incidents and Adverse Events

Policies and Procedures on Philhealth and Non-Philhealth

GENA FAMILY
PLANNING &
MATERNITY CLINIC

CLINIC STANDARD
OPERATING PROCEDURES
AND POLICIES
GENA FAMILY PLANNING AND MATERNITY CLINIC
#15 Don Julian St., Doa Pilar Village, Sasa, Davao City

CLINIC STATISTICAL DATA

2015

TOTAL PRENATAL

TOTAL DELIVERY

TOTAL LIVE BIRTH

JANUARY
FEBRUARY
MARCH
APRIL
MAY
JUNE
JULY
AUGUST
SEPTEMBER
OCTOBER
NOVEMBER
DECEMBER

TOTAL NUMBER OF MATERNAL DEATH: ____

TOTAL NUMBER OF NEONATAL DEATH: ____
TOTAL NUMBER OF PATIENTS REFERRED: MOTHER ____
BABY

____

PREPARED BY:
RUFFA JANE B. RIVAS
MEDICAL CLERK
GENA FAMILY PLANNING AND MATERNITY CLINIC
#15 Don Julian St., Doa Pilar Village, Sasa, Davao City

CLINIC STATISTICAL DATA

2015

TOTAL IUD

TOTAL
INJECTABLE

TOTAL PILLS

JANUARY
FEBRUARY
MARCH
APRIL
MAY
JUNE
JULY
AUGUST
SEPTEMBER
OCTOBER
NOVEMBER
DECEMBER

PREPARED BY:
RUFFA JANE B. RIVAS
MEDICAL CLERK

Immunization and Other Preventive Measures

Tetanus Toxoid Immunization

TOTAL
CONDOM

Below is the schedule of tetanus toxoid (TT) immunization.

Dosage

Given

Period of Protection

1st dose

As early as possible
during pregnancy
1 month after the 1st dose

None

2nd dose
3rd dose
4th dose
5th dose

At least 6 months after the

2nd dose
At least 1 year after the 3rd
dose
At least 1 year after the 4th
dose

3 years after the first dose

5 years
10 years
lifetime

Provide TT vaccination as needed based on the womans immunization status.

Iron/Foliate
Give 60 mg iron and 400 mcg foliate to be taken by mouth once daily for
three months.

PAGTUGOT ALANG SA ADMISYON UG PAGPA-EKSAMIN

Ako, _______________________ nga gidala sa Gena Family Planning and

Pangalan sa pasyente

Maternity Clinic, pinaagi niining kasulatan nagahatag sa akong pagtugot sa

admisyon, eksaminasyon, ug pagpatambal sa nahisgutan nga pasyente, sumala sa
katakus ug pagdumala sa mga personnel sa Gena Family Planning and Maternity
Clinic. Dugang pa niini, ang Gena Family Planning and Maternity Clinic ug ang
iyang staff gawasnon sa tanang obligasyon o tulubagon alang sa bisan unsang
mahitabo nga nagresulta gikan sa gihimong serbisyo medikal alang sa pasyente
sulod sa Gena Family Planning and Maternity Clinic.
Dugang pa niini akong nabasa ug hugot na nasabtan ang tanang nakasulat ug
wala ko gipugos o gigamitan og pwersa aron ko mupirma.

Pirma ____________________

Petsa(date) ____________________

Signature over printed name

Testigo ___________________

Petsa(date) ____________________

Signature over printed name

POLICIES AND PROCEDURES IN HANDLING COMPLAINTS,

REPORTING AND ANALYSIS OF INCIDENTS, AND ADVERSE EVENTS

GENA FAMILY PLANNING AND MATERNITY CLINIC encourages patient and family
feedback about their experiences while at the clinic. By obtaining feedback from patients and
families, the clinic can identify opportunities to improve its processes, thereby enhancing patient
and family satisfaction.

PURPOSE:
To provide patients and their families with a mechanism for communicating a concern or
complaint and to ensure that appropriate action is taken in regard to this information.
PROCEDURE:
1. All patients who are admitted to the clinic will be informed of their right, which will include
information in regard to the communication process for registering a concern or complaint. A
patient or family member may express a concern or complaint regarding any aspect of care or
treatment to any member of the clinics staff. This may be communicated verbally or in writing.
Verbal Complaints: If the complaint is made verbally, the person to who the complaint is made
will record detailed information, including, without limitation.

Patient name
Complainant name
Date of complaint
Description of the concern/issue
Date of the concern/issue
Requested action
Telephone number and/or address, depending on preferred method of response

Written Complaints will serve as the primary documentation. If additional information is

needed, the person primarily responsible for answering the complaint will contact the
complainant to obtain the additional information.
Clinic Staff Complaints: If the complaint is in regard to a member of the clinics staff, the
complaint documentation will be forwarded to the clinic manager for processing. If additional
help is needed, the manager will contact his/her supervisor (Back up OB) (CHO/MHO) to assist
in the review, appropriate action to be taken, or the response.

PREVENTIVE MAINTENANCE PROGRAM FOR EQUIPMENT

GENA FAMILY PLANNING AND MATERNITY CLINIC prepares and implements

comprehensive preventive/corrective/rehabilative maintenance program of biomedical, electronic
and communication equipment, electrical, mechanical, structural, civil works, physical plant,
motor vehicles and other health care equipment/devices.

POLICIES:
1. The provision of safe and functional facilities, healthcare equipment/devices, motor
vehicles and continuous supply/service of utilities shall be assured for delivery of quality
patient care.
2. Compliance to the local, national, international codes, standards and regulations on the
construction,

operation

and

maintenance

of

facilities,

utilities,

healthcare

equipment/devices and motor vehicles shall be strictly observed.

3. Implementation of the comprehensive manual of policies and procedures based on DOH
standards shall be followed.
4. Technical support and assistance shall be provided in the implementation of healthcare
waste management, energy conservation, sanitation, and environmental programs.
5. Networking shall be established with other healthcare facilities and agencies for further
linkages.

PEST AND VERMIN CONTROL POLICY

GENA FAMILY PLANNING AND MATERNITY CLINIC utility in charge provides and
maintains clean, safe and sanitary facilities and environment for clinic personnel, patients and
clients.
POLICIES:
1. Provision and maintenance of safe, pleasant, clean and green environment in all areas
shall be assured for quality healthcare delivery.
2. Housekeeping and cleaning protocols shall be strictly observed.
3. Implementation of Healthcare Waste Management Program shall be carried out.
4. Proper cleaning methods, infection control standards and supplies/equipment/tools
management shall be strictly followed.
5. Appropriate personnel protective equipment (PPE) shall be provided.
6. Prevention and eradication of rodents, pests, vectors and other vermin shall be
implemented regularly. (ONCE A WEEK)
7. Safe and proper handling of equipment, materials, and chemicals used for cleaning and
disinfecting shall be continuously emphasized.
8. Proper storage of housekeeping carts/ tools shall be observed.

ANTEPARTUM CARE POLICY AND PROCEDURES

GENA FAMILY PLANNING AND MATERNITY CLINIC will provide quality pre-natal
services such as 4 pre-natal visits, pregnant women should be seen and examine by a physician,
seen and examine by a dentist, provision of iron supplementation, laboratory examinations

(blood typing, urinalysis and hemoglobin determination), provide breastfeeding counseling and
family planning, thereby improve maternal health.
PURPOSE:
To provide pregnant mothers with quality pre-natal services following the World Health and
Department of Health standards.
PROCEDURE:
1. Greet Client as she enters the clinic.
2. Ask client what you can do for her.
3. Ask if she is a new client/patient or a return client/patient.\
For new client/patient:
a.) Prepare a clinical record.
b.) Get the demographic data and record in the appropriate space in the clinical
record.
c.) Take the client/patients weight, height, and vital signs and write them down in the
clinical record.
For return clients/patients:

4.
5.
6.

7.
8.

a.) Retrieve clinical record from file. Record retrieval should take no longer than three
minutes.
b.) Take the weight, height, and vital signs, and write them down in the clinical
record.
Ask the client to have a seat and wait for her name to be called if there is another client
being attented to or if there are other clients waiting.
If there are no other clients in the clinic, bring her and her record to the consultation room
where privacy and confidentiality can be observed.
The midwife or service provider takes the clientss medical and obstetrical history,
conducts a physical examination, requests appropriate laboratory procedures and writes
down all findings in the clinical record.
Provide services as appropriate, including necessary instructions and follow-up schedule.
Refer client to back-up doctor or to a higher level facility for complications or for
services not available in the facility using the two-way referral form.

GENA FAMILY PLANNING AND MATERNITY CLINIC

#15 Don Julian St., Doa Pilar Village, Sasa, Davao City

CERTIFICATION
This is to certify that GENA FAMILY PLANNING AND MATERNITY
CLINIC, a birthing facility duly organized and existing under and by
virtue of the laws of the Philippines, does not perform permanent
sterilization procedures such as Bilateral Tubal Ligation (BTL) and
Vasectomy.

This Certification is being issued for whatever legal purpose this may
serve best.
GENA B. RIVAS, R.M
Provider
PRC ID NO. 0119948
SUBSCRIBED AND SWORN to before me, this _________________
at Sasa, Davao City, Philippines

GENA FAMILY PLANNING AND MATERNITY CLINIC

#15 Don Julian St., Doa Pilar Village, Sasa, Davao City

CERTIFICATION
This is to certify that GENA FAMILY PLANNING AND MATERNITY
CLINIC, a birthing facility duly organized and existing under and by
virtue of the laws of the Philippines, does not perform DILATATION and
CUTTERAGE;

This Certification is being issued for whatever legal purpose this may
serve best.
GENA B. RIVAS, R.M
Provider
PRC ID NO. 0119948
SUBSCRIBED AND SWORN to before me, this _________________
at Sasa, Davao City, Philippines

4. Inform client that you are about to inject.

5. Needles should not be recapped. However, if recapping is necessary, follow the one hand
technique.
D. PROCEDURES OF USED INSTRUMENTS

1. Decontamination immediately after using instruments on clients or patients, soak the

instruments in 0.5% chlorine solution for 10 minutes.
2. Cleaning rinse and wash the instruments with detergent and water.
3. Sterilization or high-level disinfection
4. Drying
5. Packing
6. Use or store.

APPLICATION FOR
LICENSE TO OPERATE

APPLICATION FOR
LICENSE TO OPERATE

PTC

PTC

PRC

PRC

SIGNAGES

SIGNAGES