Module 2 Key policies

1. KEY POLICIES

2. Learning Objectives:
At the end of this module, the participant will be able to:
• Understand the basic policies being implemented at Regional
Orthopaedic Center as to service delivery, human resource and
material resource and infrastructural management.
• Identify the roles and responsibilities attached to every ROC nursing
staff.
• Determine strategies on how to function effectively as a nurse.

3. CASE MANAGEMENT

4. Admission
POLICIES:
1. All patients for Unit admission must be endorsed properly prior to
transfer.
2. All patients for Unit admission must have an admitting diagnosis and
must be completely recorded and endorsed to the nurse on duty.
3. All patients for Unit admission must be received properly from the ER or
other unit (if patient is ER-OR, or trans - in) at the bedside.
4. All Nursing Staff must follow the policies and standards operating
procedures on ward admission.
5. Nurse on Duty shall validate patient identity
6. All nursing staff must ensure the safety of the patient at all times
7. Nurse on Duty shall receive patient endorsement from respective
ER/Unit Nurse and ensures the completeness of patient’s chart

5. Policies on Admission
8. All Forms must be arranged in orders as follows:
1. Clinical Cover Sheet ( BMC-F-MED/HIMS-002)
2. Standing Order ( BMC-F-NSG-028)
3. IV Fluid Sheet ( BMC-F-NSG-052)
4. Treatment And Medication( BMC-F-NSG-030)
5. Laboratory Results ( BMC-F-NSG-014) and ECG Results ( BMC-F-
MED-0102)
6. Progress Notes/ Doctors Order Sheet Results ( BMC-F-NSG-002)
7. Nurses Progress Notes Results ( BMC-F-NSG-022)
8. Consent for Admission Results ( BMC-F-NSG-003)
9. Consent to Surgery and Procedures Results ( BMC-F-NSG-004)
10. ER Assessment Checklist Results ( BMC-F-NSG/ER-013)
11. TPR Sheet Results ( BMC-F-NSG-061)

6. Cont. Policies on Admission
9. Receiving nurse on duty validates if Attending Physician is notified
10. Admitting physician or newly admitted patient shall be followed
up before the end of the shift.
11. Receiving nurse validates all orders such as:
 All started medicines are documented.
 All diagnostic requests done are documented or if not had been
endorsed
 Checked and secured all the contraptions attached to patient.

7. PROCEDURES FOR ADMISSION
1. All ward nurses shall ensure that all patients are endorsed by ER
NURSE/UNIT NURSE.
2. Gives the appropriate care accordingly to the needs of the patients.
3. All patients are continuously monitored and evaluated.
4. All patients have a clear case disposition.
5. Validates patient identification.
6. Secures all contraptions
7. Nurse On Duty checks for the completeness of patient chart
8. Nurse On Duty process the patient’s data at Integrated Hospital
Operations and Management Information System (IHOMIS) in addition to
unit census, also request the patient diet.
9. Record patient data in the Admission Logbook ( BMC-LB-NSG/ ORT- 001).
10. Carries out doctor’s order and performs unit routines on admitting
patient. Transcribe the Doctor’s Order Sheet at the Kardex and make
medication card as follows.

8. DISCHARGE POLICIES
1. All Nursing Staff must ensure that all patients shall have a written
discharge order
2. All Nursing Staff must ensure that all unused medicine and
supplies are returned prior to processing of discharge
3. All Nursing Staff must adhere to the policies and standard
operating procedures on patient discharge.
4. If co manage by other services, final disposition for all services
must be obtained prior to processing the discharge.

9. DISCHARGE PROCEDURE
1. The Attending Physician decision to discharge the patient is made and
documented by the attending clinician.
 Nurses on duty facilitate the discharge order using the discharge checklist.
2. Nurse on duty carries out discharge order properly, ensures that
attending physician has written the final diagnosis, and other doctors to
whom the patient was referred is notified/listed in the discharge slip.
3. Ensures that the PTO’s, SMS and verbal orders are signed by the
Attending Physician.
4. Ensures that the doctor sign the forms in the chart such as Discharge
summary, History Record and other forms needed for completion.
5. Identifies and returns excess medicines and supplies to relatives to be
returned to the pharmacy and CSSU.
6. If the patient used Blood Product while admitted, a blood clearance form
( BMC-F-NSG-061) issue by the Blood Bank Unit must be secured.

10. Cont. Discharge Procedure
7. At Integrated Hospital Operations and Management Information System
(IHOMIS)., the Nurse on duty validates the completeness of entry at the
CF4, the final diagnosis written by the Doctor, and the Discharge
instruction. Charge all the supplies, provided nursing procedures to the
patient since the first day of confinement and tagged the patient’s
disposition.
8. Once Cleared to all unit, The nurse on duty or the nurse attendant
submit the Alagang Tagubilin Pinoy Discharge Summary ( BMC-F-MED-
001) , Checklist of Requirement for Pre discharged ( BMC-F-NSG-062),
Philhealth Slip ( BMC-F—FINBILL-004) at the Billing section for the
issuance of Statement of Account. For the pay patient, a copy of Consent
to pay ( BMC-F- MED/MSW-009) and list of Attending Physician will
added.

11. Cont. Discharge Procedure
9. The Final Statement of Account shall be received by the nurse or
nursing attendant-on-duty and presented to the patient. Payment
of fees shall be facilitated by the patient significant others
• For non-PhilHealth Member or PhilHealth Member with excess, the
nurse or nursing attendant shall coordinate with Medical Social
Service Section for financial assistance.
• For PhilHealth members classified as NBB, Claim Signature Form
shall be signed by patient or SO and shall be submitted to
PhilHealth Processing Unit by the nursing-attendant-on-duty.
10. Removes all contraptions.

12. Cont. Discharge Procedure
11. Gives discharge instruction to patient/family together with the
prescription and extra medicines to be taken at home instruct and
follow-up check-up.
12. Nurse on duty make arrangements for transport home where
necessary.
13. Nurse on duty /Nursing Attendant presents the discharge slip to
the guard on duty at the entrance area of the Main Lobby before
leaving the hospital.

13. Trans In
• refers to the transferring of patient’s service and management to unit
from other unit when care management is no longer indicated to patient
condition and case.

14. TRANS-IN POLICIES
1. There should be a written order from the doctor before
patient's transfer.
2. The receiving attending physician must acknowledge the
patient transfer prior to transport.
3. Inform the patient and relatives about the transfer unless in
emergency situation (in case there is a need for immediate
evacuation due to unforeseen events).
4. Review of Medication, Chart Entry and CF4 must complete
prior to transfer
5. Verify availability of the room before patient’s transfer.
6. The NOD should accompany the patient during transfer to
another unit.

15. PROCEDURES for TRANS-IN
1. The transferring unit must inform the receiving unit regarding patient’s
transfer.
2. The nurse attendant or the nurse on duty will prepare the room for
impending admission.
3. The transferring unit will endorse the patient case and file to the
receiving unit. At the same time the receiving unit will check the
completeness of patient chart
4. The following information must be endorsed to the ward NOD:
 Patient's data
 Medications, treatments, IV fluids
 Vital signs
 Special procedures done such as CT scan ultrasound and others.
 With or without oxygen inhalations
 Diet
 Post-operative patients
 Operative site. Wound dressing
 Activity in the ward

16. Cont. Procedures for Trans-in
5. Verify the time of transfer with the ward nurse.
6. Give due medications until the patient leaves the unit.
7. Transport patient to the specified ward. Give complete and accurate
endorsement.
8. At Integrated Hospital Operations and Management Information System
(IHOMIS)., the Nurse on duty update the patient’s record, the status of
the room and the patient’s diet, also, validates the completeness of
entry at the CF4.
9. The Nurse on duty will inform the admitting section to update and
change the patient’s type of service.
10. Complete the patient's data in the admission.

17. Trans Out
• a process wherein the patient service will be transferred to other unit
after the improvement of the condition of the patient and his compliance
to the Medical and Nursing Management.

18. POLICIES for Trans Out
1. There should be a written order from the doctor before patient's
transfer.
2. The receiving attending physician must acknowledge the patient
transfer prior to transport.
3. Inform the patient and relatives about the transfer unless in
emergency situation (in case there is a need for immediate
evacuation due to unforeseen events).
4. Review of Medication, Chart Entry and CF4 must complete prior to
transfer
5. Verify availability of the room before patient’s transfer.
6. The NOD should accompany the patient during transfer to another
unit.

19. Procedures on Trans Out
1. The transferring unit must inform the receiving unit regarding patient’s
transfer.
2. The nurse attendant or the nurse on duty will prepare the room for
impending admission.
3. The transferring unit will endorse the patient case and file to the
receiving unit. At the same time the receiving unit will check the
completeness of patient chart
4. The following information must be endorsed to the ward NOD:
 Patient's data
 Medications, treatments, IV fluids
 Vital signs
 Special procedures done such as CT scan ultrasound and others.
 With or without oxygen inhalations
 Diet
 Post-operative patients
 Operative site. Wound dressing
 Activity in the ward

20. Cont. Procedures on Trans Out
5. Verify the time of transfer with the ward nurse.
6. Give due medications until the patient leaves the unit.
7. Transport patient to the specified ward. Give complete and accurate
endorsement.
8. During transport:
– Ensure safety of patient at all times
– Lift patient into the patient compartment (head first).
– Secure patient for transport .
– Secure patient’s contraptions
– Provide patient comforts and privacy
9. At Integrated Hospital Operations and Management
Information System (IHOMIS)., the Nurse on duty update the
patient’s record and the status of the room also, validates the completeness
of entry at the CF4.

21. Pre- Operative Policies
1. The pre-operative checklist must be properly accomplished for patient
who will undergo surgery
2. Operative sites must be properly prepare, shaving may be done if hair
may interfere the operative site
3. Clearances for other services must be obtained prior to OR,
cardiopulmonary clearances for patient with ages 40 y/o and above and
for pedia ages 7 y/o and below must secure pedia clearance

22. PROCEDURES for PRE-OPERATIVE:
1. Carries out doctor’s and pre-op orders. If for clearances, informs the
attending about the status of stratification for procedure.
2. Secures patient’s consent.
3. Forward the accomplish Operating Room Notification (BMC-F-NSG-023)
and Coordinates the scheduled procedure to the Operating Room (OR)
Section.
4. Reviews pre – operative checklist ( BMC-F-NSG-015) for completeness
5. Ensures preparedness of patient for the procedure. Secure all
contraptions and materials needed.
6. Endorses patient completely and properly to the OR Nurse.
7. Ensures that a post operative bed is prepared and coordinates post op
equipment and supplies needed.

23. POLICIES ON POST- OPERATIVE
1. Receives patient at bedside and checks dressing and patency of
contraptions.
2. Checks patient’s level of consciousness and ensures vital signs is checked
and recorded per Doctor’s order.
3. Check the procedure done to patient and the presence of operative
technique
4. Check for the completeness of the chart
5. Assesses patients’ condition. Refers untoward manifestations observed
accordingly.

24. ROUTINE CARE
1. Patient care
2.Documentation
3. Security and safety protocols
4. Personnel safety
5. Environment safety
6. Linen and laundry
7. Emergency and fire safety
8. Waste management
9. Human resource management

25. Thank you