operations in hospital
TRANSCRIPT
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U
8 47
M3 h
99
A MANUAL
OP R TIONS
FOR
SM LL
HOSPIT LS
Prepared
by
the
Committee to Develop a Manual of Operations for Small Hospitals
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Registration and Issuance of License to Operate
T LE OF CONTENTS
Minimum Standards for Primary Category
LICENSING REQUIREMENTS
PART HOSPITAL CONSTRUCTION
6
7
2
5
6
4
4
7
5
7
44
24
Page o
I
~ l l l I l I l l l l i l ~
ep rtmenl orHealth
D 4
H ~ 8 4 7 M 3 h
992 A manualof optmltlons for m hospitals
Nursing Service
Clinical and Ancillary Services
Administrative Service
Patient Care Facilities
Basic Service Facilities
Physical Plant Facilities
Permit to Construct
Basic Hospital Services
Classification
Category
Definition of Terms
LICENSING REQUIREMENTS
PART II HOSPITAL OPERATIONS
INTRODUCTION
FOREWORD
ACKNOWLEDGEMENTS
7
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APPENDICES
Office Order Creating the Committee to Develop a Manual of
Operations for Small Hospitals
Procedures 1 to 7
BLR Form 1: Application for Permit to Construct a Hospital
Letter to Hospital Owner Informing Approval of Permit to
Construct Expand or Renovate
BLR Form 4: Application for Registration and Issuance of
Renewal of License to Operate a Hospital
BLR Form 4 A: Statistical Report
BLR Form 4 B: List of Technical Equipment and Instruments
License
Medical Records Disposition Schedule
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It
is my hope that hospital managers and health workers make good
use of this carefully-crafted document designed to upgrade the quality of
hospital care for the millions of Filipinos who encounter the need for
treatment at these vital health facilities.
A critical facet in the nation s healthcare scheme is the system of
small hospitals scattered throughout the Philippines. These tacilities fill
a vital niche for specialized health services needed by small communities
in both urban and rural settings. Even as the government s thrusts on
Primary Health Care will greatly contribute to the prevention of disease
it is necessary to have in place well-equipped scphisticated health
facilities constantly prepared to respond to any contingency that may
arise.
SAN LAZAROOOMPOUND
RIZALAVENUE STA CRUZ
M NIL
PHIUPPINES
TEL
O
711 6 8
FOREWORD
Republic
of
the Philippines
eportment of Health
OFFI E OF
THE
SE RET RY
In this regard the Department of Health is mandated to support
these initiatives through establishing the appropriate conditions for small
hospitals to effectively function and serve their respective communities.
This
anual of
Operation for Small ospitals will assist owners.
administrators or operators of these
est blishments
in their
d ily
management and in maintaining the high standards set by government and
demanded by the populace. At the same time this manual will assist
operators in meeting the requirements on registration and licensure set by
tile government for these hospitals.
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JUA
~ S I
M.D.
Under ecretary of Health for
Hospital and Facilities Services
The pollcles. procedures and guidelines outlined in this manual will assist the
practicing hospital administrator in the day to day decision making process
necessary to operate an effective and efficient hospital. We urge the small-
hospital administrator to consult this manual as often as needed in order to
answer the many administrative questions which arise in the daily operation of
delivering quality patient care to a diverse opulation in need of hospital ser-
vices.
The Bureau of Licensing and Regulation of the Department of Health has
developed this
Manual of Operations for Small Hospitals
to serve as a guide to
hospital administrators of small hospitals especially those in rural areas. This
manual was developed during the period
1990 91
under the leadership and
direction of the former Undersecretary of Health for Standards and Regulation
Dr. Tomas
P
Maramba
Jr.
The information which follows is the work of a multi-
sectoral committee which received input and advice from a variety of sources
including the Philippine Hospital Association the Philippine College of Hospital
Administrators and the Private Hospital Association of the Philippines.
SANL Z RO OMPOUND
RIZAL AVENUE STA. CRUZ
MANILA PHILIPPINES
T l NO. 711 6080
FOREWORD
Republic
of
the Philippines
ep rtment of Health
OFFICE OF
THE SECRETARY
This manual is a revision and update of the
Manual of Information on Philip-
pine Hospital Licensure Standard uide for Philippine Hospital Services
originally issued by the Bureau of Medical Services in December 1965. The
contents of this manual refer to existing standards of the Department of Health
at the time of formulation and do not include any new standards after that date.
Consequently some of the items are for information only and the user will want
to check with the Department for any recent changes or additions. The
process of devolution will also bring about even more changes in the future
which will dictate new regulations and the development of new standards.
However we believe that the operating hospital administrator will find the infor-
mation contained in this manual of value and we have pushed for the publica-
tion of this manual at this time.
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KNOWLEDGMENTS
This anual Operations for Small ospitals was developed with the help
coordination and administrative support of various health agencies associa-
tions and individuals to cope with the changing community needs.
The Committee wishes to express sincerest thanks to Dr. Alfredo R. A.
Bengzon former Secretary of Health and to
Dr
Tomas
P
Maramba Jr.
former Undersecretary of Health for Standards and Regulation for their en-
couragement and wholehearted support in the preparation and finalization of
this manual during their term in office.
Several people were generous with their time and expertise; they deserve
much credit for their wisdom and sound advice but are not to be held account-
able for the end product:
Dr
Thelma N. Clemente President Philippine Hospi-
tal Association; Dr. Yolanda M. Mison Executive Director Philippine Hospital
Association; Marco Antonio C. Sto Tomas and Grace M. Valderama of the
Philippine Nurses Association; Ador A. Abueg and Ma. Theresa H. Gutierrez of
the Bureau of Food and Drugs; Agnette
P
Peralta of the Radiation Health Ser-
vice; Dr. Teresita R. Sanchez of the Philippine Academy of Family Physicians;
Dr. Ruben N. Caragay of the
U P
College of Public Health; Luis M. Ferrer of
the Hospital Infrastructure Services; Teresita G. Yambao of the DOH National
League of Nurses; Dr Amelia Fernandez of the Philippine Pediatric Society; Sr.
Paz T. Marfori D.C. of San Juan de Dios Hospital; Dr. Marietta Baccay of the
Bureau of Research and Laboratories; Velonia A. Corpus of the Nutrionist As-
sociatlon of the Philippines;
Dr
Narciso Navarro of the Private Hospital Associa-
tion of the Philippines; Dr Siopin Co of the Philippine Society of Hospital Phar-
macists; and Dr. Delfin Tan of the Philippine College of Hospital Administrators.
The Committee is likewise indebted to Dr. Primo V. Brillantes Jr. Chief of
Hospital III Jose
R
Reyes Memorial Medical Center for the use of their
facilities and resources.
Special thanks also go to the technical staff of the Hospital Operations and
Management Services for their valuable contributions in the making of the
Manual.
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astly to the Bureau of Licensing and Regulation staff who acted patiently as
secretariat typing the manuscript in its various phases of revision our
deepest thanks
R ZEN I R E
L
FUENTE
hairman
ommittee to evelop a Manual of
Operations for Small Hospitals
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INTRO U TION
The Bureau of Licensing and Regulation
BLR
was created by Ex
ecutive Order No. 119, which reorganized the Department of
Health to improve the licensing and regulation of health care
facilities and make the delivery of public service more efficient and
effective. The Bureau is mandated to:
Formulate policies and establish standards for the licens
ing and regulation of hospitals, clinics, and other health
facilities
Establish standards for health field offices
Provide consultative, training and advisory regulatory
functions over hospitals, clinics, and other health facilities.
Small
hospitals evolved in considerable number especially in far
flung areas when in the mid 70 s the Philippine Medical Care Corn
mission started the implementation of the Medicare Program.
Most of the small hospitals are run by physicians, nurses, phar
macists, or businessmen, many or most of whom have not taken
hospital administration. This often leads to problems in regula
tions.
This anual of Operations for Small ospitals intends therefore
to provide guidelines not only to help minimize problems on
registration, licensure, and operations of primary hospitals but,
more importantly, to educate the non-professional small hospital
manager.
EFINITION OF TERMS
ospital is defined by the Expert Committee on Organiza
tion of Medical Care of the World Health Organization
thus: the hospital, the function of which is to provide
for the population complete health care, both curative
and preventive and whose outpatient services reach out
to the family in its home environment; the hospital is also
a center for the training of health workers and for bioso
cial research.
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L SSIFI TION
linical
eneral Hospital - provides services for all kinds of ill
nesses, diseases, injuries, and deformities.
Special Hospital -
provides services for one particular
kind of illness/disease or health and medical care.
Examples:
Hospitals are classified in many ways, but the most commonly ac
cepted classifications are:
Clinical, that is, depending on the type of patients treated
According to ownership and control
Whether training and nontraining
Internal Medicine
Tuberculosis
Children Pediatric
Communicable Disease
Medicine
For the purpose of this manual, however, the term hospi-
tal as defined by Republic Act No. 4226, otherwise
known as the Hospital Licensure Law of the Philippines,
shall refer to a place devoted primarily to the main
tenance and operation of facilities for the diagnosis, treat
ment, and care of individuals suffering from illness, dis
ease
or deformity, or in need of obstetrical or other
medical and nursing care. The term hospital shall also
be construed as any institution, building, or place where
there are beds or cribs or bassinets for 24-hour use or
longer by patients in the treatment of diseases, diseased
condition, injuries, deformities, or abnormal physical and
mental states, maternity cases, and all institutions such
as those for convalescence, sanatorial or sanitariaI
cases, infirmities, nurseries, dispensaries, and such other
names by which they may be designated.
Small Hospital covers all primary category, general hospi
tals, usually with less than twenty beds and providing
basic services such as: Administrative Service, Clinical
Service, and Nursing
Service
rug Room - a room for storing emergency drugs only,
which could be dispensed by a doctor.
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overnment -
operated and maintained either partially or
wholly by the National, Provincial, Municipal, or City
Government or other political subdivision, board, or other
agency thereof.
Examples:
City
Municipal
Private or ongovernmental -
privately owned, estab
lished, and operated with funds raised, capital, or other
means by private individuals, associations, corporations,
religious organizations, firms, companies, or joint stock
associations.
Examples:
Missionary
Civic Organizations
Community
Private - nonprofit
Private - for profit
Surgery
Maternity
Chronic
Convalescent
wnership and ontrol
National
Regional
Provincial
Eye, Ear, Nose and Throat
Orthopedic, etc.
Office of the President
Department of Health
Department of National Defense
Armed Forces
Government Corporation
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Training Nontraining
Training a departmentalized hospital with accredited
residency training program in one or more specified
specialty or discipline.
ontraining
a nondepartmentalized hospital without ac-
credited residency training program.
C TEGORY
Hospitals have been categorized into primary secondary and ter-
tiary
v s
of health care according to service capabilities that
they offer.
rimary equipped with the service capabilities needed
to support licensed physicians rendering services in
Medicine Pediatrics Obstetrics and Minor Surgery.
Secondary equipped with the service capabilities
needed to support licensed physicians rendering ser-
vices in the fields of Medicine Pediatrics Obstetrics and
Gynecology General Surgery and Ancillary Services.
Tertiary a fully departmentalized hospital equipped with
the service capabilities needed to support certified medi-
cal specialists and other licensed physicians rendering
services in the fields of Medicine Pediatrics Obstetrics
and Gynecology Surgery their subspecialties and Ancil-
lary Services.
N U ST ND RDS FOR PRIM RY C TEGORY
Administrative Service
Clinical Services
General Medicine
General Pediatrics
Obstetrics
Minor Surgery
Nursing Service
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SIC HOSPIT L SERVICES
dministrative Service This shall attend to the admis-
sion disposition and discharge of patients including
financial transactions and other administrative aspects of
hospital operations such as the provision of food and
preservation of medical and administrative records.
Clinical and ncillary Services The physicians shall
render services in General Medicine Pediatrics
Obstetrics and Minor Surgery. Routine laboratory ser-
vices shall be available either within the hospital
premises or by affiliation.
Nursing Service This service shall be headed by a
registered nurse and shall provide professional nursing
care at all times.
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LICENSING REQUIREMENTS
Part I HOSPIT L CONSTRUCTION
As provided under the Hospital Licensure Act R A 4226 and its
implementing Rules and Regulations Administrative Order No. 68-
A series of
1989 ,
no hospital, whether government or private,
shall be constructed or renovated unless plans have been ap-
proved and a construction permit has been issued by the Bureau
of Licensing and Regulation, Department of Health. A permit to
construct is a requirement for an initial license to operate.
The following are the requirements to be fulfilled before a permit
to construct may be issued:
A letter of application from the owner addressed to the
Director, Bureau of Licensing and Regulation through the
Regional Health Director
Feasibility study
Floor plans of the physical plant of the proposed hospi-
tal, three copies in blueprint
An endorsement letter from the Regional Health Director
to the Director, Bureauof Licensing and Regulation.
The application shall be filed at the proper Regional Health Office
which shall endorse it to the Bureau of Licensing and Regulation.
It is important that all the above requirements are complied with.
Otherwise, the application shall be returned without action to the
owner through the Regional HealthOffice.
PERMIT TO CONSTRUCT
Any person, association, partnership, corporation, or government
entity desiring to construct, remodel, or repair a hospital building
shall file with the Bureau of Licensing and Regulation an applica-
tion for a construction permit using the prescribed form BLR
Form I which shall be accompanied by three copies of the floor
plans of the hospital plant proposed to be constructed,
remodeled, or repaired.
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The construction permit shall be issued by the Bureau of Licens-
ing and Regulation upon approval of the floor plans and payment
of the permit
f
Other building permits as required from other
government agencies shall be obtained.
Construction shall start within the time specified in the construc-
tion permit and shall follow the approved floor plan and specifica-
tions. A new construction permit is required if the original permit
was revoked due to violation of its terms and conditions or the
same expired before the construction could be started.
PHYSI L PL NT F ILITIES
hysical lant Any structure put to use to house or
provide direct services to patients shall conform with the
requirements prescribed by the Bureau of Licensing and
Regulation and those of local building codes applicable
thereto.
echanical and Structural Requirements New or
remodeled hospital facilities shall not be licensed by the
Bureau of Licensing and Regulation unless the following
requirements have been complied with :
Plans and Specifications
Construction of the new
building or floor remodeling shall not be undertaken
unless plans have been previously approved by the
Bureau of Licensing and Regulation. The floor plans
for any new hospital construction or any proposed
annex of an existing hospital and for remodeling pur-
poses which involve physical changes shall be sub-
mitted for approval. Said approval shall be obtained
from the licensing agency before construction work is
begun. Such floor plans shall be prepared by an ar-
chitect or a civil engineer who is licensed to practice
in the Philippines. Floor plans and specifications for
any new hospital or for changes in an existing hospi-
tal shall show that all necessary considerations have
been given to ensure proper functional relationship of
physical facilities.
General Requirements
In order that a permit to
construct a hospital may be issued the hospital plan
shall provide sufficient space as provided for in the re-
quirements.
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Walls floor, and ceilings of the hospital shall be of
sturdy materials, which shall permit frequent wash
ing, cleaning, and painting.
The hospital shall be adequately ventilated at all
times. Kitchens, bathrooms, and service rooms
shall be ventilated by properly constructed vents,
windows, or other mechanical means to prevent of
fensive odors from entering rooms of patients and
public corridors. Window screens shall be
provided for all other exterior openings whenever
necessary.
- Ventilation -
Provision shall be made for adequate
ventilation to ensure comfort and safety of patients
and personnel in every hospital.
Kitchen and toilets, service and utility and storage
rooms, and janitors closets and the like shall be
properly ventilated in compliance with requirements.
- lumbing -
All
parts of the plumbing system shall
comply with the existing rules and regulations
prescribed by the Office of the City or Provincial or
Municipal Building Official and other local plumbing
codes or ordinances.
- Water Supply System -
Each hospital shall use an
approved public water supply system whenever
avail-
able
The water service shall be adequate and water
supply shall be brought into the building free of cross
connections in accordance with the requirements
prescribed by the Office of the City or Provincial or
Municipal Building Official. If a private deep or shal
low well) water supply is provided, the requirement
prescribed by the Office of the City or Provincial Build
ing Official likewise shall be complied with.
- Sewage isposal System -
Hospital sewage shall be
discharged into an approved public sewerage system
where such system is available, otherwise, the
sewage shall be collected, treated, and disposed of in
an independent system septic tank type) which com
plies with requirements prescribed by the Office of the
City or Provincial or Municipal Building Official and
local ordinances and the Sanitation Code of the
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Philippines. Separate toilet facilities shall be main
tained for patients and personnel, male and female,
with a ratio of 8 to 10 patients/personnel for every
water closet. This shall be conveniently located in the
area served.
-
lectrical nstallations
- The installation of the electri
cal system and equipment shall comply with all local
ordinances relative thereto and with the National
Electrical Code, as well as those herein provided:
All equipment and installations shall be acceptable
as established by the Fire Department.
Emergency lighting shall be provided for exits,
stairs, patient corridors, emergency rooms and
similar areas as necessary for safe and efficient
patient care Emergency lighting shall be supplied
by an emergency generator or its equivalent.
All rooms and areas in the hospital shall be
provided with sufficient illumination to enable per
sonnel to properly carry out procedures per
formed therein.
- Solid Waste Management - All hospitals shall have a
program of solid waste management covering sorting,
storage, pre-treatment, collection, and disposal sys
tems.
All hospital infectious solid waste shall be
pretreated in any approved method before
storage, collection, and disposal.
Proper sorting of solid waste sharps, syringes,
linens, mattresses from isolation/infectious wards
must be done, segregating it from the general
waste.
Separate puncture-proof refuse containers proper
ly labelled and with covers must be assigned to
prevent any accident or contamination before dis
posal.
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Disposal shall be done either through burying, in
cineration or through city or other collecting agen
cy.
SIC SERVICE F CILITIES
Hospital basic service facilities shall include the following:
dministrative Service
Lobby with information counter
Admitting Office
Director s/Chief of Hospital s administrative office
Toilet facilities
Clinical and ncillary Services
Emergency Room
Examination/treatment Room
X-ray room optional)
Laboratory optional)
Emergency drug cabinets
Toilet facilities
Nursing Service
Nurses station with toilet facilities
Male ward
Female ward
Isolation ward
P TIENT C RE F CILITIES
All patient care areas and units shall be segregated from those
used by the public.
ursing nits - All nursing units shall have the following
facilities:
- Nurses Station Counter
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- Medicine Area
Fixed and locked narcotic storage facilities
Refrigerator for drugs
- Utility Facilities
Clean linen storage area
Soiled linen storage area
Lavatory
Sterilizing equipment
Treatment rea -
Area for patient treatment is re
quired in all hospitals.
Patient Rooms
- The design and equipment of patient
rooms shall be similar for all types of patients.
The maximum number of patient rooms planned for a
nursing unit shall depend on the type of patients to
be served and the plan of operation as well as other
matters.
The minimum amount of usable floor space required
shall be as follows:
For private rooms:
9 sq. m. per adult bed
7.5 sq. m. per crib or pediatric bassinet
For rooms with two or more beds:
7.5 sq. m. per adult bed or pediatric crib
4 sq. m. per pediatric bassinet
Note: It is recommended that the area and design
of the room be such as to provide 91 m. of usable
floor space.)
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Lavatories
Lavatories
shall
be in each patient s room or its adjoin
ing toilet room.
Any room used for isolation shall have a lavatory
within the room.
A lavatory
shall
be provided in toilet rooms used
by patients who give self care or which are used
for isolation.
One lavatory shall be provided for every eight beds.
Toilets -
These shall be required for rooms which do
not have adjoining ones. These shall be made avail-
able within 30.3 m.
1
feet distance from the far-
thest patient room served by such toilets. ,
Patient Bathing Facilities -
These shall be provided in
each patient unit according to the type of patients
served and procedures planned.
Janitor s Closet -
This shall be provided within the
nursing unit.
Storage Areas -
The space required depends on the
plan of operation. All nursing units shall have space
to store a reserve supply of linen and other things.
Corridors and service work areas shall not be used
for storage.
Personnel Toilets -
These shall be in or near each
nursing unit with adequate hand washing facilities.
Public Toilets -
These are required for nursing units
adjacent to public areas and shall have adequate
space and handwashing facilities.
Floor Waiting Area -
The desirability of this area is de
pendent on the plan of operation and size of the
hospital. In small hospitals this area may be com
bined with the lobby.
Gowning Area -
This is required in contagious nursing
units only.
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- It shall have an emergency drug cabinet.
Storage area Refrigerator, upright, reach-in
Bins for rice)
Receiving area Weighing scale, table model 10
kg.)
Food preparation area Utility table/work table
Hand sink
Chopping board
Garbage receptacle with cover
Kawa
30 -diameter), cast-iron
finish
10-gallon stock pot 2)
Top burners
2
Work tables
ink
2 compartments
13
Cooking area
tsolstion Facilities -
There shall be available isolation
facilities for patients who are known to have infectious,
communicable diseases, and for burn cases. The isola
tion facilities shall be provided with all utility and other
services required to carry out isolation techniques. Such
facilities shall be designated for isolation and shall be
available for use whenever necessary.
Emergency are Facilities -
Provisions shall be made for
an emergency room which may be combined with out
patient service.
- The emergency room shall be so equipped as to
provide whatever lifesaving measures may be needed
for the patients.
- It shall have a toilet with lavatory within or in close
proximity to it.
ietetic Service Facility -
For primary hospitals this ser
vice is not a requirement. A kitchen will suffice wherein
food for inpatients are prepared/dished out. However if
. the hospital opts to have one, the following shall be
provided:
Areas Equipment/Supplies
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- Screened windows and doors
Provisions shall be made for:
- Adequate ventilation
Chopping boards
Hood with filter and suction fan
Exhaust fan
Sink, 24 deep at least two
compartments)
Shelves/racks for pots and
pans drying and storage)
fus
receptacle with cover
Tray assembly area
Food carts screened, if not
metal made or finish)
Utility carts
Hand sink
Soiled dish table
Clean dish table
Utility rack for tray storage)
Garbage can with cover
Dishwashing area
Serving area
Pots and pans
_ eneral Service reas - There may be provided a
waiting area or room for patients awaiting service.
_ Laboratory Service -
This shall be provided through
affiliation with a nearby licensed laboratory. However,
if the hospital opts to provide such service within the
hospital premises, it has to obtain a license from the
Bureau of Research and Laboratories. A minimum of
18.5 - 20.9 sq. m. for exclusive washing and steriliz
ing area should be provided.
- Adequate drainage system
Facilities for ncillary iagnostic and Treatment Ser-
vices -
These are not included in the standards for
primary category hospitals. However, if the hospital opts
to have such services, they should be located con
venient to both inpatient and outpatient areas.
The following are required :
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- Radiological Service -
This shall be provided
through affiliation with a licensed x-ray facility.
However, if the hospital opts to provide such service
within its premises, it has to obtain a license from the
Bureau of Licensing and Regulation upon recommen
dation by the Radiation Health Service.
- Pharmacy Service -
In the absence of a pharmacy
service, an emergency drug cabinet kit shall be
provided. However if the hospital opts to provide
such service it has to obtain a license from the
Bureau of Food and Drugs and comply. with its re
quirements.
- Examination and Treatment Rooms -
All hospitals
shall at least have one all-purpose room for examina
tions, treatment, etc.
eneral Service acilities - Facilities for service units
may be provided and shall include the following:
Employee
F ~ i i t i e s - These may include a rest
room/lounge area with locker facilities and separate
toilets for female and male employees.
-
Laundry
-
Laundry facilities required in the hospital
will depend on whether hospital laundry is operated
within the hospital premises or commercial services
are utilized.
Housekeeping
This should include a
housekeeper s Office may be part of another ser
Vice
lavatory, storage room for supplies and equip
ment), and other facilities that may be required for the
type of service rendered. The amount of space
provided for this service shall depend on the person
nel assigned and the volume of work.
-
Maintenance
-
There should be a maintenance
shop/area in each hospital.
REGISTR TION ND ISSU N E OF LI ENSE TO
OPER TE
Section 4 of
A.A.
4226 provides that no hospital shall operate or
be opened to the pubtic unless it shall have been registered and
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a license for its operation shall be obtained from the Bureau of
Licensing and Regulation, Department of Health.
nitial icense to Operate
In the issuance of the initial license to operate, there are proces-
ses involved. First after completion of the hospital bUilding the
hospital owner shall accomplish and file R form NO.4 applica-
tion for Registration and Issuance of License to operate a hospi-
tal. Next, a written request for an ocular inspection of the finished
hospital shall be submitted to the Bureau of Licensing and
Regula-
tion authorities with the prescribed requirements please see
annex procedure and checklist no. 2 . The Regional Licensing Of-
ficer has to certify that the hospital is ready for inspection. Finally
the license shall be issued if the application has been found to be
meritorious and the licensure fee duly paid.
The license specifies its bed capacity as well as its classification
and kind of service/capabilities provided, and is not transferable.
Should there be a change in ownership, management, or name of
the hospital, the licensing agency shall be notified.
The license to operate a hospital shall be placed in a con-
spicuous place readily seen by the public.
Renewal of icense to Operate
The license to operate and maintain a hospital shall be renewed
annually and shall expire on the last day of December. A transfer
of location shall require an application for a new license.
Separate licenses are required for hospitals operating in separate
premises not in the same compound even if they are under the
same ownership or management.
To renew a license, the hospital owner accomplishes and files
R
form
No
between January 2 and March 3 of each year.
For the requirements please see annex checklist 3. There is a
penalty for renewal of licenses filed after March 31.
A provisional license shall be granted to hospitals for three to six
months pending full compliance with all the necessary require-
ments and standards governing their operations.
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LICENSING REQUIREMENTS
Part II HOSPITAL OPERATIONS
ADMINISTRATIVE SERVICE
The administration of the hospital is the responsibility of the
governing body, the Administrator, and Representatives of the
medical
st ff
The Governance
The governing body, owner, or board of trustees, is the top
authority responsible for the management and control of the en-
tire institution, including employment of a hospital administrator
and appointment of members of the medical staff. In the case of
the Department of Health, it shall be the responsibility of the
Secretary of Health or his duly authorized representative.
If the governing body is composed of more than one person, it
shall be organized as a corporate body to conduct hospital affairs.
The governing body assumes responsibility for the management
and control of the hospital. Evidence that the governing body is
assuming this responsibility shall be:
That a written set of goals and policies duly promulgated
and updated by the governing body is in the hands of
the Administrator updating means review and revision
as the need arises .
That the responsibility and authority of the hospital ad-
ministrator have been written and are known to persons
working in the hospital.
That the reports of hospital operations including services
provided and results thereof in the care of the patients,
are reviewed at least once a year by the governing body.
That provisions have been made to safeguard the assets
of the hospital to insure its continuing operation.
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That provisions have been made for the close relation-
ship between the hospital and the community and the
various health or welfare agencies.
The Medical Staff should review the medical records of patients.
It
should audit the medical care plans of the attending physicians
permitting only those that are acceptable.
The ospital dministrator
The Administrator/Director is responsible for planning organizing
directing coordinating and controlling hospital operations except
medical care. In the case of the Department of Health it is the
Director or Chief who is designated to carry out its policies. He
shall be expected under licensing rules and regulation to carry
out the responsibilities of the executive office which are listed as
follows:
Formulation and writing in clear statements of:
The goals or ends to be attained by the hospital
The goals or ends to be attained by each service in
terms of what the service is to produce its contribu-
tion to other services and its place in the total hospi-
tal program; and
Basic guides for attaining the established goals and
dissemination of goals.
Development with the assistance of hospital personnel
and the medical staff of a program of patient care and
hospital operation in line with the needs of patients
served.
Establishment and maintenance of an organizational
structure for the hospital which clearly defines the
authority and responsibilities of various positions and
their relationship and which should be communicated
reviewed and revised as the need arises.
Provision of an effective method of communication be-
tween the various elements in the hospital organization.
Maintenance of a written record of all business transac-
tions and patient services rendered and submission of
reports to the governing body. Effectiveness of hospital
operations
s ll
be measured in terms of the expected
results of patient care rendered.
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Development of long-range plans for the continuing im
provement of the hospital.
Provision of the administrative control of the entire hospi
tal during the absence of the hospital administrator.
Preservation and protection of patients and personnel
against hazards and contagious diseases including:
- The checking of all patients admitted as deemed
necessary by the medical staff to insure that con
tagious diseases are made known for appropriate
measures to prevent its spread and to eradicate it;
- Pre-employment and periodic physical and laboratory
examination are deemed necessary as well as daily
observation of all personnel having direct or indirect
contact with patients; and
- Development of policies on the administration treat
ment and diagnostic procedures in cooperation with
the medical
staff
Provision of orientation and follow-up training for all
hospital personnel.
Establishment and maintenance of a plan for emergency
operation of the hospital to provide for the safety and
well being of inpatient in case of fire explosion or other
disaster occurring within the hospital as well as for the
care of casualties.
dministrative olicies
Hospital personnel are expected to maintain proper
decorum at all times in their relationship with patients
relatives and with each other.
Management shall see to it that all employees are given
proper orientation and training in the performance of
their assigned work.
All employees are required to obey the lawful instructions
of their supervisors connected with the performance of
their duties.
Administration shall establish a system of
recr uitment
selection and placement of employees on the basis of
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fitness to perform the duties and responsibilities of the
position.
Management shall provide its personnel with reasonable
protection against unreasonable demands harassments
and physical harm.
The hospital management reserves the right to change
revise or amend hospital rules and regulations as the
need arises and any such changes or amendment there-
to shall become effective after proper dissemination to all
concerned.
Hospital administration is not responsible for any loss of
patients valuables.
Administration/management is tasked to direct and coor-
dinate the activities of the medical staff as well as all the
activities of the hospital to ensure efficient and judicious
delivery of hospital services based on its objectives.
Coordination and teamwork among hospital personnel
shall serve as a common approach to attain overall
goals and objectives.
The tasks of every employee shall be clearly spelled out
and mutually understood reasonably quantified and ac-
tual performance shall be regularly evaluated.
All patients shall immediately be attended to upon arrival
giving preference to emergency cases and/or seriously ill
patients.
Clinical and nursing care shall be made effective via the
following provisions:
_ Clear written hospital policies including reasonable
rates.
_ Emergency room logbooks and protocols treatment
and physical examination consent emergency room
and outpatient consultation forms.
_ Well understood and well written discharge advice
and instructions.
_ Forms for reporting/recording medico legal and report-
able diseases.
Complete and uniform in patient records.
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- Equipment and instruments to comply with the
Bureau of Licensing and Regulation requirement.
Management shall ensure maintenance of ade
quate facilities, equipment, and supplies necessary
for good patient care for the nursing unit.
Management shall provide an environment that is
conducive to the physical, spiritual, and emotional
well being of patients and personnel.
ietetic Unit
This unit is not a requirement. However, if the hospital opts to
have one, for hospitals less than 20 beds, the cook acts as
marketer/menu planner and is the informal leader in the dietetic
unit, under the direct supervision of the Administrator or Medical
Director, assisted by two food service workers
FSW
or utility
workers. While it may not be required that a nutritionist-dietitian
be employed in a 10- to 15-bed hospital, it is, however, recom
mended that such hospital must try to consult, coordinate, and
avail itself of the services of a nutritionist-dietitian in a nearby
secondary category hospital, through its networking system.
Policies
The food budget shall be sufficient to provide nutritionally
adequate and palatable diets, and food served shall be
regularly evaluated to meet these ends.
Personal hygiene and proper food handling practice of
dietetic personnel shall be such as to ensure that the
patients receive
safe,
clean, and wholesome food.
Pertinent safety practices, including the control of electri
cal, flammable, mechanical, and appropriate radiation
hazards must be observed.
The dietetic unit shall be designed and equipped to
facilitate the
safe,
sanitary, and timely provision of food
service to meet the nutritional needs of patients includ
ing garbage disposal, dishwashing and general cleaning,
transport of food .
The quality and appropriateness of nutritional care
provided by the dietetic unit shall be regularly reviewed
and evaluated.
ep rtment of ealth
1I11111 1I 1Ii II 11
21
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H l 8 4 ~ 3 1 h
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Meals shall be provided to patients in accordance with a
written order by the responsible medical practitioner. Ap
propriate dietetic information shall be recorded in the
patient s medical records by the nurse in charge.
The hospital should have a standard diet manual or
guide to be used by the medical staff in diet ordering
and the staff in fulfilling the diet orders.
ospital Maintenance Unit
The main function of this unit is to create a pleasant and comfort
able safe and clean physical environment for patients
employees medical staff and general public by maintaining and
servicing utilities such as light water power garbage system
and security. The hospital as a whole and its various parts in
cluding fixtures
w lls
floors ceilings and furnishings shall be
well-maintained.
oli ies
It shall have a space for repair and maintenance.
It shall have the required number of personnel depend
ing on the size and needs of the hospital. There shall be
a definite assignment of maintenance functions to
qualified personnel.
t shall plan and supervise security refuse collection and
disposal and insect and rodent control.
Provision shall be made for periodic inspection and
repair of hospital plant and equipment by qualified per
sonnel. Insofar as possible repair shall be made prior
to breakdown so that plant operation and patient care
shall not be jeopardized.
Instructions for operating and maintaining equipment
shall be made available to maintenance personnel.
Operating and maintenance record shall be kept and
analyzed periodically.
Hospital maintenance may be on contractual basis.
ousekeeping Unit
The housekeeping unit shall be responsible for the maintenance
of a clean and healthful environment within the hospital premises.
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t
shall ensure an environment conducive to the recovery of
patients The hospital including fixtures w lls floors ceiling and
furnishings shall be kept clean and free of vermin and rodents
The housekeeper together with the nursing staff may participate
in the formulation of hospital policies and guidelines to prevent
the occurrence of nosocomial infection
Policies
The hospital shall formulate standard procedures in the
sanitation and cleanliness of the different patient care
units
The assignment and scheduling of institutional
workers/janitors sh ll take into consideration the needs
of the patient care units for 24 hours
Janitorial cleaning supplies and equipment shall be
provided in sufficient amount and type required to ade-
quately care for the hospital
There shall be a definite assignment of housekeeping
functions preferably to one who has had institutional ex-
perience Such person shall provide immediate super-
vision over his/her staff
inen and aundry Unit
Every hospital has the responsibility of providing sufficient linen to
ensure the comfort of patients and safeguard them from infec-
tions and communicable diseases transmitted through linen The
minimum amount of linen required will vary with the number and
type of patients cared for the time required to process linen and
return to use and other factors
For small hospitals of less than 20 beds the standard manpower
complement includes one laundry worker The Nursing Service
has the added responsibility of providing these specific functions:
Determine the utilization processing life span of linen:
Develop a system to provide adequate and continuous
supply of linen required for patient care and other hospi-
tal units
Ensure efficient collection of soiled linen from and dis-
tribution of clean linen to the different units of the hospi-
tal
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Conduct periodic inventory of linen materials in wards
and in stock.
Project linen requirements yearly or as the need arises,
including budgetary requirements.
Change bed linen as often as necessary.
The minimum requirement of at least four sets of linen
per bed or bassinet shall always be made available.
CLINICAL AND ANCILLARY SERVICES
Clinical Service Patient Care
The primary role of the hospital is to care for the sick and injured.
Other important functions are subordinate although recognized as
part of the responsibility of the institution insofar as they con-
tribute directly or indirectly to patient care. The existence and
viability of the small hospital is dependent on the immediate com-
munity it serves.
The secondary role is to be a relevant link in a network of clinical
care and public health services either as a referring unit or an end
unit. As a referring unit, it refers to the next higher level facility
which is accessible within an hour away by usual means of
transportation). However, when a small hospital is so situated
geographically that the nearest higher level facility is more than an
hour for emergency and/or critical cases) to four hours for non
emergency and/or elective cases)
w y
it then assumes the role
and function of an end unit which would render the needed ser-
vices.
Comprehensive patient care shall essentially be com-
posed of the activities of the patient s physician and
hospital personnel to meet specific needs of the patient
for diagnosis, treatment, rehabilitation, disease preven-
tion, and personal care. Its purpose is to cure or al-
leviate the effects of disease, injury, or disorder and to
promote a positive state of health, restoring the patient
to constructive living in consideration of his disability as
well as abilities and capacities.
Patterns of hospital organization shall provide the neces-
sary mechanism for the promotion of unity of purpose
and efforts by physicians and hospital personnel. If
necessary, control measures shall be instituted to bring
about teamwork among them.
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The contents of a plan for patient care shall include the
following:
- Goals and objectives of care or what is to be ex
pected as a result of given care;
- Basic principles of care including several procedures
that the staff need to perform in carrying them out;
- Specific roles of each discipline and the means of
maintaining the necessary relationships between them
in giving care; and
- Means of determining and planning the care needs of
individual patients.
The small hospital has the following specific roles and functions:
To cater to the clinical care needs of the community it
serves.
- To render diagnostic and therapeutic services.
- To deliver emergency services to patients in terms of
evaluation/diagnosis/emergency room care and treat
ment and be able to either transfer admit or send
home patients after four to eight hours emergency
room stay at most.
To give 24-hour inpatient medical and nursing care
not ordinarily available for the following categories of
cases:
Cases which need one to seven days of confine
ment and general medical care.
Cases which need to be isolated and cared for by
a general practitioner or practitioner of family
medicine.
Cases which are very critical and cannot be trans
ferred.
Cases admitted during disasters.
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Cases which need to be transferred to the next
higher accessible facility within eight to twenty four
hours.
Cases which cannot be referred right away and
need to be clinically stabilized first.
To be a relevant part of a health care delivery system as
an end unit or as a referring unit.
To acquire competencies and provision for delivering
relevant primary care services.
To have written policies procedures records of its
delivered clinical services. This shall include patient
data in the emergency room/outpatient department
OPD , wards and laboratory. There shall be ad-
ministrative records for the purpose of determining
the nature and cost of patient services and for
monitoring feedback to management government
regulatory and professional bodies.
To have procedures and forms for communicating
with and relating to other parts of the network and the
community at large.
The medical staff is responsible for the quality of medical care
provided and for submitting reports on the quality of care
provided to the governing board of the hospital at frequent inter-
vals.
While the governing body of the hospital is the final
authority as regards the administrative aspects of hospi-
tal operation it must be recognized that all elements in
the hospital including the medical staff have important
contributions to make in the area of Administration and
should be accorded a voice.
The complexity of the modern hospital requires a team
approach concept in hospital administration and opera-
tion if the best patient care is to be provided. The wide
array of services and personnel required to meet the
needs of patients today necessitates that a program of
patient care be developed for the various categories of
patients cared for. .
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ncillary ervices
dmitting Service Unit
Provision shall be made for the admission of patients to
the hospital in accordance with their needs. and due
regard for their safety and well-being. Admitting person
nel shall not only get personal information on patients
but also on the nature and needs of other patients and
the services available in each nursing unit.
- Specific policies for the admitting service shall be as
follows:
Information about patients including an admitting
diagnosis clinical condition and their personal
characteristics shall be submitted to the admitting
service before or at the time of admission of
patients to the hospital. Physicians and nursing
service personnel shall recommend placement of
patients in the hospital in accordance with
patients needs and facilities available.
Admitting procedures shall be adapted to patients
needs. Patients shall be admitted in such a way
as to insure others against transmission of dis
e ses
Patients having or suspected of having com
municable diseases shall be assigned to beds in
such a place where transmission of diseases or in
fection of other patients or personnel could be
prevented. Any such transmission or infection
shall be promptly reported to the authorities con
cerned.
Mothers who deliver outside of the hospital s
obstetrical unit may however be admitted
provided that they are housed in a way as to
separate them from other patients.
Working arrangements with other services in the
same hospital shall be made to insure that all
patient s needs are properly met.
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Hospital rules and regulations and admitting proce-
dures shall be made available at all times for the
use or reference of personnel.
Admitting personnel shall be given orientation train-
ing and kept informed of policy or procedure chan-
ges affecting their work from time to time.
The discharge of hospital patients shall be as follows:
Patients shall be discharged only upon written
order of the attending physician.
The attending physician shall be required to enter
in the summary sheets his final diagnosis of the
given case with a brief summary and final
progress note and affixes his signature thereon.
When the discharge order. is duly signed by the
physician the nursing and admitting units shall be
promptly notified.
In case of death of a patient a statement to that
effect
s ll
be entered in the progress notes of the
chart including the final diagnosis and the cause
of death duly signed by attending physician. The
nurse in charge of the ward shall notify the admit-
ting unit prepare the body and inform the rela-
tives of the deceased patient.
Policies for clinical care are as follows:
There shall be competent medical and nursing
staff supported by adequate logistics to handle
routine outpatient and inpatient needs.
There shall be a 24 hour physician staff that can
provide diagnosis and appropriate treatment of
emergency cases.
edical ecords
is said that good medical records generally imply good
medical care. Inadequate medical records often reflect
poor medical care. For this reason the medical record
is selected as one of the yardsticks to be used in
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measuring the quality of medical care rendered by a
hospital and its medical staff.
They shall serve as basis for planning patient care
provide means of communication between physicians
and other professional groups contributing to patient
care furnish documentary evidence on the course of the
patient s illness and treatment and serve as basis for
review
study and evaluation of medical care rendered.
The function of the Medical Records Unit is to keep and
preserve all charts and records pertinent to the stay of
the patient in the hospital and to make the charts and
records easily available to authorized persons at all times.
For primary hospitals of less than 20 beds the standard
manpower complement includes at least one medical
records clerk. In some hospitals the medical records
clerk may be assigned other administrative functions.
- Functions of the Medical Records Unit
eceive classify analyze codify and file charts
and records of patients.
Keep and maintain all charts and records of treat
ment of patients and make them easily available
only to authorized persons.
Maintain and update patient s index death
registry and registry of admissions and dischar
ges. Accurate and complete medical records shall
be maintained on all patients from the time of ad
mission to the time of discharge. There should
be space for retrieval of records.
Prepare and issue medical birth and death certifi
cates.
Prepare periodically statistical reports of the hospi
tal as required.
- Policies
An accepted method shall be established within
each hospital for recording data. All records shall
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be part of the hospital records system. No medi
cal record
s ll
be permanently filed until it is com
. pleted.
The completion of the medical records shall be
the responsibility of the attending physician. Or
ders for treatment and all reports shall be legibly
entered into the medical record either in ink or
typewritten and signed by the physician. The com
pleted medical record including signature of attend
ing physician shall be forwarded to the records
area/room within 24 hours following the patient s
discharge from the hospital.
A trained medical records clerk or any other
responsible hospital employee shall be given the
responsibility for the proper custody supervision
filing and indexing of completed medical records
of all patients discharged from the hospital. He
will also prepare medical statistics and reports.
Medical records shall be made available for inspec
tion by any authorized representative of the
Bureau of Licensing and Regulation.
Confidential information obtained from medical
records shall be furnished only on the written
authority of the patient or executor of his estate or
his attending physician. Such authorization shall
be kept on file together with the patient s record.
All previous records shall be made available for
the use of the physician attending a readmission
case.
- Content of Medical Records - All medical records
shall contain the following information:
Identification data
Chief complaint
Present illness
History and physical examination - Only physicians
are competent to write or dictate medical histories
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and physical examinations. Nurses medical
records clerk or secretaries shall not be permitted
to take medical histories.
Provisional diagnosis - There shall be a provisional
or admitting diagnosis made on every patient at
the time of admission.
Clinical laboratory reports - The original signed
laboratory report shall be entered in the patient s
record. Duplicates are filed in the laboratory and
reports from laboratories outside the hospital shall
be acceptable in lieu of tests performed in the
hospital if the examination was performed in a
licensed laboratory. As the hospital shall be held li
able for the quality of laboratory work reported in
the medical record the hospital shall limit outside
laboratory work.
X-ray reports - The original report signed by the
radiologist shall be entered in the patient s record.
Consultations - Consultations shall imply an ex
amination of the patient and patient s record. The
consultation note shall be recorded and signed by
the consultant.
Medical and surgical treatment - All treatment pro
cedures shall be documented in the medical
record.
Progress notes - Progress notes give a chronologi
cal picture and basis of analysis of the clinical
course of a patient and shall be made at a fre
quency as determined by the condition of the
patient.
Final diagnosis - A definite final diagnosis shall be
written as part of the patient s records.
Nursing record - Nursing records on patient charts
shall include a graphic chart of vital signs such as
temperature pulse and respiration blood pressure
readings intake and output reports as indicated
medications and treatments given and nursing ob
servations or nursing notes.
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Discharge summary - A summary of the patient s
condition on discharge shall be required a
recapitulation of the patient s hospitalization.
Obstetrical records - All obstetrical records shall
in addition to other required records include
reports on the following:
Past obstetrical history of the patient s previous
pregnancy.
Admission of obstetrical examination describing
condition of mother and fetus.
Complete description of the progress of labor
includinq reasons for induction or operative pro
cedures if any signed by the attending
physician.
Anesthesia analgesia and medication given.
Signed report of a qualified obstetrical consult
ant when such service was obtained.
Names of assistants present during parturition.
Condition of infant one hour after delivery.
Progress notes including involution of the
uterus type of lochia and condition of breasts
and nipples.
Records of the newborn - Records of newborn in
fants are required to form part of patient s whole
medical record and shall include the following:
Date and time of birth birth weight and length
and period of gestation.
Parents name and address.
Description of complications of pregnancy or
delivery if any inclUding premature rupture of
membranes condition at birth such as color
quality of cry and method as well as duration
of resuscitation.
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{ Record of instillation into each eye at delivery
as prophylaxis.
{
Report of initial physical examination including
any abnormalities signed by the attending
physician.
{ Progress notes including weight and feeding
charts temperature number consistency
color of stools condition of eyes and umbilical
cord condition and color of skin and motor be-
havior.
{ Physical examination on discharge.
{ Recommendations and signature of attending
physician.
Forms
The Bureau of Licensing and Regulation shall
evaluate medical records on the basis of contents
and form that each hospital shall find useful and ac-
ceptable for their purpose.
A short form medical record which contains informa-
tion that will specifically identify the patient is accept-
able in certain treatment and diagnostic cases of a
minor nature which require less than 48 hours
hospitalization.
Ownership
The medical record is the property of the hospital and
shall be maintained for the benefit of the patient the
physician and the hospital itself. It shall be the
responsibility of the hospital to safeguard the informa-
tion on the record of each patient against loss
tampering or use by unauthorized persons.
Preservation of Medical Records
The medical records of hospital in patients shall be
kept for a reasonable length of time usually 25 years
for clinical and scientific purposes after discharge or
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death. Disposition thereof after the specified period
may be made pursuant to provision of law.
In hospitals where the use of medical records for
scientific purposes is limited and the rate of read-
missions is low as well as where the needs of
medical staff and patients are adequately met and
protected by retention of medical records for less
than 25 years a 10 year period of retention is con-
sidered minimum. After said period the same
may be disposed of pursuant to legal provisions
provided the hospital retains an index registry or
summary card of such basic information as iden-
tification data of patient date of admission and dis-
charge name or responsible physician and
record of diagnosis and operation.
Hospital Records
Each hospital shall maintain the following hospital
records:
Daily census
Register of admissions and discharges
Register of outpatients
Register of births
Register of deaths
Register of operations
Narcotic register and
Emergency room admissions.
Reports
llhospitals shall comply with laws ordinances rules
and regulations which provide for the registration of
births and deaths and the reporting of communicable
diseases.
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rivate
hospitals shall submit quarterly and annual
reports on patient statistics and hospital operations to
the Bureau of Licensing and Regulation on the
prescribed forms. On the other hand government
hospitals shall submit monthly and annual reports in
accordance with the existing Department of Health
rules
regulations or orders relative thereto.
Storage of Medical Records
Storage on open shelves is far preferable to the old
method of filing cabinets making records more easily
available and occupying less floor space.
mergency OPO Unit
Whether a hospital maintains an emergency unit or not
a plan for the reception and care of mass casualties
shall be required for all hospitals. If an emergency unit
is maintained the following shall be the guiding prin-
ciples:
There shall be a well organized emergency unit
headed by a competent licensed physician.
_ Facilities shall be provided to assure prompt diag-
nosis and emergency treatment.
A small observation room/area where patients can be
observed after emergency treatment may be provided.
There shall be adequate medical and nursing person-
nel available at all times for emergency service.
Adequate medical records on every patient shall be
taken and kept.
_ There shall be a written plan for the care of mass
casualties and which shall be coordinated with the in-
patient and outpatient services of the hospital.
_ The emergency operating area need not be so large
but it shall be provided with the equipment and instru-
ments required by the Bureau of Licensing and
Regulation.
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aboratory nit
As a general rule, in the evaluation of a patient s condi
tion, more so when examinations have to be done else
where, the patient or a responsible family member shall
be made aware and informed of the reasons, ad
vantages, and the cost of these examinations.
When a small hospital affiliates with another in the use of
its facilities, expertise, and ancillary services, a regular
monthly or quarterly) meeting between affiliating units
shall be held to tackle problems and work out improve
ments in the network.
Feedback relating to specific critical or problematic
cases shall be instantaneous and automatic whether by
telephone, messenger, personal, or other means of com
munication.
Basic pre-analytic specimen collection, transport, han
dling, and post-analytic recording, reporting, charging)
requirements shall be written and posted in the emergen
cy room/outpatient unit/ward and the physician s office.
The following shall be met whether examinations are
done in-house or referred out:
- Specimen container specification and labeling
- Request forms, duly signed
- Accompanying data
- Method and time of specimen collection and accep
tance by laboratory
- Amount of specimen required for each requested ex
amination
- Time and method of transport
- Temperature requirements
- Precautions against infections or hazards, and
- tes and charges
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Policies for emergency laboratory services
Policies for outpatient laboratory services
n Requests/results
outpatient, nonemergency
are sent out to affiliating
Surgical and nonsurgical abdominal condition HB
Hct, WBC differential indices)
Requirements shall be put in writing, or printed
and posted in the ward, emergency room/out
patient unit and in the doctor s room.
When adequacy of specimen cannot be assured
because of natural distance, weather) or human
factors, either the hospital staff or the patient him
self
if able, shall be instructed and made to go to
the affiliating hospital laboratory.
Waiting time for results shall be known to the
physician and the patient.
Specimen shall be collected and transported ac
cording to the requirements of the affiliate
laboratory pertaining to:
- When requests for
laboratory examinations
laboratories
n Specimen collection/ handling and transport
- Where there is no accessible higher level laboratory
facility within eight hours of total travel time, basic
laboratory services of a
level
determined by the
needs of the community and the expertise of the
physician shall then be set up. This laboratory
facility shall be maintained by the hospital or the corn
munity according to the rules and regulations relating
to the establishment and operations of clinical
laboratories.
- In-house or affiliate services shall be able to provide
the physician, within one hour, the laboratory support
or data needed for the initial or complete evaluation of:
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Response to emergency room care
Policies for inpatient laboratorv service
Degree and type of anemia/blood loss dehydration.
amoeba/non-amoeba
auses of diarrhea
fecalysis
This is not a requirement, however. A drug room will
suffice in which prepared drugs are stored. If the hospi
tal opts to have a pharmacy which serves only
- Laboratory services and their results, whether in
house or referred, shall be available at a four-hour in
terval during a 24-hour day.
- When the nearest affiliate laboratory is more than an
hour total waiting time away, the hospital or com
munity shall set up and maintain basic laboratory ser
vices for emergency care according to the rules and
regulations relating to the establishment and opera
tions of clinical laboratories.
Pediatric diarrhea - Hct, blood smear morphology,
stool examination, urine specific gravity, and
l:l HB, Hct, indices, blood smear, morphology,
urine specific gravity
Presence or absence of urinary tract infection
urinalysis, WBC count, differential count
l:l
Blood typing, cross matching
- When this is not possible, such a capability shall be
provided by the hospital or community and main
tained according to the rules and regulations relating
to the establishment and operations of clinical
laboratories.
harmacy nit
The pharmacy is the repository of drugs, chemicals,
pharmaceuticals, and narcotics in the hospital. The law
requires that only a licensed pharmacist shall com
pound prescriptions.
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inpatients the pharmacy shall be placed within the hospi-
tal premises convenient to the hospital personnel. it
serves both outpatients and inpatients it shall be easily
accessible to both and shall:
Ensure continuous supply of drugs and medicines of
quality standard to patients by maintaining adequate
quantities of stocks.
_
ill
out prescriptions and dispense drugs in accord-
ance with the laws pertinent thereto.
_ Distribute to the different units of the hospital routi-
nary drug supplies.
_ Request distribute and control the use of all drugs.
_ Maintain proper storage and preservation of drugs.
Maintain records files and reports on dangerous
drugs and other pharmaceuticals as required by law.
Serve as drug information center to all hospital per-
sonnel and patients.
Policies
Drugs and medicines used in hospitals for emergency
cases shall always be made available.
_ An official hospital formulary in generics based on
Department of Health Hospital Formulary shall be es-
tablished.
Prohibited drugs in vials shall be issued to inpatients
through the nurse on duty.
Records files and reports on dangerous drugs and
other pharmaceuticals shall be maintained in com-
pliance with government regulations.
_ There shall be a policy on paid drugs returned by
patients upon their discharge.
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- Expired and deteriorated drugs, fluids, etc. shall be
properly discarded in accordance with the policy on
deteriorated and expired drugs.
- In the sale of medicines, official receipts must be is
sued by the cash clerk or anyone designated to do
so if possible.
-
drug products delivered to the pharmacy shall be
subjected to random testing by the Bureau of Food
and Drugs.
- Drug products received shall not have less than 12
months interval between their delivery and their expiry
date.
A pharmacy unit shall provide for the following:
For the Outpatient Unit
- It shall maintain an inventory of basic generic, non
prohibited drugs and first-line antibiotics in oral
tablets/liquid , parenteral and suppository forms.
- It shall have on stock at level as dictated by its
budget and the usual demand drugs, supplies, or
agents that are not ordinarily available from regular
community outlets such as skin, eye, ear prepara
tions, and vaccines.
- It shall have adequate provisions for its usual load of
minor surgical procedures: instruments and con
sumabies such as sutures, anesthetics, antitetanus,
dressings and antibiotics.
For the Emergency Room
- Life-saving drugs and special pharmacologic agents
in sufficient stock to permit timely replacements from
the nearest pharmacy service.
Examples:
Cardiac/CNS stimulants, depressants, anticonvul
sants
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Sedatives/tranquilizers
Analeptics
Local anesthetics
Steroids
Coronary vasodilators
Anti-asthma agents - bronchodilators
Drugs for hypertension oral and parenteral)
Anti-ulcer drugs
Plasma expanders
Replacement water/electrolyte solution
Oxytoxics
- There shall be available stock of the following sup-
plies:
Intravenous infusion sets
Syringes
Masks
Sterile specimen containers
10 Formalin
Glass slides
Disinfectants
Splints
Ice bags, packs
Oxygen with gauge
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- There shall be at least a week s supply of basic
necessities and supplies in the event of natural or
man-made disasters such as floods,
fir
typhoons,
and earthquake which can lead to an emergency
situation affecting public health:
Water containers or jugs with potable or
chlorinated water
Disinfectants Lysol, Clorox)
Portable IV stands
Emergency bag with provisions
Medicine bag with prescriptions and medicines
Extra linens
Antitetanus serum
Kerosene lamps
Portable emergency lights
For Inpatient Service
- Medicines shall be available in sufficient quantity for
the duration of a patient s confinement.
- Routine immunization and other needs for normal
neonatal postpartum care shall be provided for by the
hospital.
adiology nit
This is not a requirement for a primary-category hospital;
however, if the hospital opts to provide one within the
hospital premises, the following guidelines shall be ob
served.
As a general rule, in the evaluation of a patient s condi
tion, more so when examinations have to be done else
where, the patient or a responsible family member shall
be made aware and informed of the reasons, ad
vantages, and the cost of these examinations.
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When a small hospital affiliates with another in the use of
its facilities, expertise, and ancillary services, a regular
monthly or quarterly) meeting between affiliating units
shall be held to tackle problems and work out improve
ments in the network.
Feedback relating to specific critical or problematic
cases shall be instantaneous and automatic whether by
telephone, messenger, personal, or other means of com
munication.
- Requests for X-ray shall be signed and shall include
the following information:
Patients n me age, sex, status, and address
Date of request, pertinent clinical data, and ex
amination requested
Tentative diagnosis
Clinical unit shall have written schedules including
required patient preparation and rates of x-ray pro
cedures.
- Follow-up examination requests shall include:
Date of last x-ray examination
Nature and result of the previous x-ray examina
tion being monitored.
Previous clinical findings if any
For Outpatients
- The hospital shall affiliate with a unit which is not
more than four hours away by usual means of
transportation.
- When the hospital decides to set up its own x-ray
facility, there shall be available corresponding man
power competencies and facilities to support such ad
ditional services. Only qualified personnel shall be al
lowed to operate the x-ray equipment.
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In house service may be set up at a
level
which will
depend on the needs of the community and com-
petence and skills of available manpower. Only
qualified personnel will be allowed to operate the x-
ray equipment.
For Inpatients
Patients requiring serial x ray for their diagnosis and
monitoring shall be referred out when no in house ser-
vice is available.
NURSING S RVI
Every hospital shall have a nursing service responsible for the
planning organizing directing and control of the service which
shall be capable of providing comprehensive quality nursing care.
l nning Planning shall be based on the type of agen-
cy the services it offers its philosophy and its objec-
tives. It shall be congruent with the overall development
plan of the hospital.
The nursing service shall have established policies stand-
ards and procedures to ensure conformity and consis-
tency with pre established regulations:
Approved personnel and nursing policies are in writ-
ing communicated and kept up to date.
Procedure manuals are available in each clinical area
which shall be reviewed/revised periodically.
A mechanism for assessing personnel performance
and quality of nursing care shall be developed and es-
tablished.
Policies procedures standards and evaluation sys-
tems are included in nursing personnel orientation.
Needs in each patient care area are assessed and
determined by the collective suggestion of nurses in
that re
Each care unit shall have a list of essential equipment
it is responsible for.
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Stock of basic emergency medicines shall be main-
tained in each area.
rganizing the ursing Service
The Chief Nurse or
his/her designate
s ll
be responsible for the organiza-
tion and administration of the Nursing Service. He/she
shall be directly responsible to the Chief of Hospital/Medi-
cal Director/Administrator.
rganizational structure depends on the category
of hospital. It shall establish a harmonious working
relationship with the other services of the hospital and
clearly defines the responsibilities for each level of
nursing personnel.
Staffing The Nursing Service shall develop and
maintain a staffing pattern that will meet the needs of
the patients and standards of the profession and as-
sure adequate provision of care at all times.
The number of nursing personnel shall be in accord-
ance with licensing requirements of the Bureau of
Licensing and Regulation Department of Health.
ob descriptions Job descriptions shall be clear
and in writing. The seven cardinal functions of a
professional nurse shall be followed:
Undertaking responsible nursing care and super-
vision of medical communicable psychiatric minor
surgical pediatric obstetric patients involving
management of nursing care requiring the ap-
plication of principles based upon the biological
psychological physical and social sciences.
Observation of symptoms of physical mental con-
ditions and needs requiring evaluation or applica-
tion of principles based upon the biologic physi-
cal and behavioral sciences.
Accurate reporting and recording of facts includ-
ing evaluation of the whole case.
Supervision of other personnel contributing to the
nursing care of patients.
Execution of nursing procedures and techniques.
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Direction and education to secure physical and
mental care.
Application and execution of written legal orders of
physicians concerning treatment and medications,
including the application of hypodermic and in
tramuscular injections.
_
u lific tions of nursing personnel
.: .,/ r
The chief nurse or his/her designate must be a
registered nurse, preferably a holder of a Bachelor
of Science degree in Nursing with at least one
year of experience and satisfactory performance.
The staff nurse shall be a registered nurse,
preferably a holder of a Bachelor of Science de
gree in Nursing.
Nursing attendants shall be at least a high school
graduate, preferably registered midwives.
irecting the Nursing Service - The Nursing Service shall
provide the mechanism whereby organizational goals
and objectives are achieved to the highest extent pos
si le
_ Directions must be reasonable, clear, and complete.
- Effective supervision shall be provided to ensure at
tainment of the nursing service objectives.
- Intra- and inter-departmental coordination shall be ob
served.
_ A staff development program shall be provided to en
hance nursing personnel s knowledge, skills, and at
titudes.
Orientation to introduce them to their new job
In-service education in specific areas to increase
knowledge and develop proper attitude.
Continuing education beyond the basic curriculum.
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