Policy

CAMP LAPULAPU STATION HOSPITAL MANUAL OF OPERATIONS

d Indicate final diagnosis date of evacuation and place to be evacuated opposite the patientrsquos name in the A and D book and drop from census

e Return borrowed items in the CSR

141c Transfer of Hospital (within Cebu) a When the patient needs extensive medicalsurgical

management beyond the capability of the hospital Ward Officer is responsible for completion of all data necessary for transfer to include preparation of Narrative Summary

b Ward master ward man on duty will forward Disposition Form to A amp D Section

c Narrative summary will go with the patient chart should remain in the hospital for future use filing and safekeeping

141d Discharge by Deatha When death occurs on the ward the nurse on duty shall

immediately notify the A amp D Section personnel on duty who should prepare the death certificate The last attending Medical Officer completes the diagnosis and other clinical requirements

b Post mortem care should be done before sending the cadaver to the morgue

c All belongings of the deceased shall be properly accounted for and turned over to the relatives properly receipted

d A death certificate shall be given to the immediate relatives who will accompany the cadaver to the funeral parlor

e Log patientrsquos final diagnosis datetime of death in the A and D book and census

142 Dependents1421Discharge procedure is the same as that of the military except that

they can be discharged on the day of disposition once clearance is obtained

1422For the patientrsquos who are discharged against medical advice the patient of legal age or his her parent and or relative are made to sign a certificate to the effect that the hospital shall not be responsible for anything that would happen to the patient after he leaves the hospital after the doctorrsquos order which is also signed by two (2) witnesses

143 Civilian 1431Civilian employees retired military personnel dependents of retired

military personnel pure civilian have the same discharge procedure as dependents

1432Nurse on Duty should prepare billing prior to discharge 1433Billing of Civilian patients will be done by the Finance Sergeant1434Obligations such as hospital charges shall be settled at the

Admission and Disposition (A amp D) Section before discharge 1435Civilian employee with Phil health form must accomplish the form

in order to obtain clearance from the A amp D Section Medicines medical supplies diagnostic examinations and days of hospitalization should be listed and forwarded to the A amp D Section with the patientrsquos chart

1436Dependents of retired military personnel - same as above1437Retired Military Personnel (RMP) - only mess is charge1438Pure civilian - same as the civilian employees

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CAMP LAPULAPU STATION HOSPITAL MANUAL OF OPERATIONS

1439Patient presents a duly accomplished clearance prior to the release of discharge order and receipt of payment to the nurse on duty

15 EMERGENCY ROOM POLICIES AND GUIDELINES

1 only emergency cases are entertained in the ER General consultations are referred to the OPD After office hours and on SaturdaySunday and Holiday consultations may be entertained upon the discretion of the OPD

2 patients must be referred to the MOD

3 NOD should obtain the patientrsquos chief complaint weight vital signs get gestational data (LMP ED BP FH FHT if the patient is an OBGYNE case) and other admitting notes

4 inform patient of the existing hospital policies and guidelines upon admission (visiting schedule rights responsibilities policies and regulations

5 provide watcherrsquos id and provide the admin on duty with the list of admitted patients

6 NOD must facilitate requisition of hospital number

7 MOD attends to the patients The nurse on duty assists the MOD in performing assessments

8 for admitted patients MOD writes order for the medical treatment and the ER nurse on duty immediately executes them

9 a signed consent must be obtained from the patients In case of minor or handicapped patients guardians must fill up the consent for them

10NOD should facilitate laboratory works

11 IVF insertion is done either by the PGI on dutyMOD or NOD

12NOD starts giving the medications available Drugs that require skin testing must be performed at the ER and this should be confirmed by the physician and recorded in the patientrsquos chart

13MODNOD gives initial health teachings to the client or significant others as needed

14NOD regulates the IVF of patients before transporting to the ward

15 if patient refuses admission she must inform the MOD and sign a waiver denouncing the hospital from any liabilities A thorough explanation by the MOD shall be afforded to the patient upon signing of the waiver

16 illiterate patientscompanion must be asked to have their thumb marks on the record

17all stocks medicines used by the patient must be replaced as soon as possible on or before the patient leaves the ER This will be done by the duty ER NCO

18only emergency cases are provided with ER stocks NOD gets the prescription and have these items replaced by the pharmacy andor CSR

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CAMP LAPULAPU STATION HOSPITAL MANUAL OF OPERATIONS

19ER NOD duty ER NCO will be held accountable for whatever lossesdeficiencies that may occur during hisher shift

20 inventory of all ER items is done every after shift by the NOD

21ER NCOIC must submit a monthly inventory report to the pharmacy and supply section for auditing purposes

22consultations are not entertained in the ER during office hours They are referred to the OPD

23communicableInfectious conditions which require isolation and cases other than OB-GYNEPedia are not accepted for admission but referred to other agencies after MOD has evaluated the patient The MOD should call and should be the one to make the call to the hospital where the patient is to be transferred to

24wounds of more than 24-hour duration are not entertained in te ER but in the OPD except on holidays Saturdays and Sundays

25 for invasive procedures a consent signed by the patient (if adult) companion andor guardian should be obtained before treatment or care is instituted

26should patient refuse she cannot be submitted to a particular treatment This should be properly documented on the patientrsquos record and have the patient sign a waiver for the refusal

27 for emergency cases where a patientrsquos life is in danger no consent is necessary However proper notation shall be made on the patientrsquos record by the physician and must be affirmed by a witness

28media is not allowed within the ER premises to avoid distortion in the management of patients

29dean on arrival (DOA) clients in ER cases are classified in the following categories

DOA Criteria0 vital signs ndash CPR done rarr failedNo death certificate shall be issuedER death ndash 0 vital signs rarr CPRrarr reviverarr died within 26 hoursHospital issue death certificateDOA and ER deaths should be marked on the patientrsquos record in bold

letters using ball pen

30all procedures performed in the ER shall be subjected to official charging which will be forwarded to the different branch of services where the patient belongs Only CENTCOM organic military personnel will be carried free of charge

15 POLICIES ON DO NOT RESUSCITATE (DNR)

151 Definition of Terms151a Resuscitation is a medical procedure which seeks to

restore cardiac andor respiratory function to individuals who have sustained a cardiac andor respiratory arrest

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CAMP LAPULAPU STATION HOSPITAL MANUAL OF OPERATIONS

151b Do Not Resuscitate (DNR) is a medical order to provide no resuscitation to individuals for

whom resuscitation is not warranted151c Cardiopulmonary resuscitation (CPR) is the

common term used to refer to resuscitation However the options available to treat very sick patients are broader than CPR as literally defined Other options include intensive care antibiotic therapy hydration and nutritional support Appropriate comfort care measures should be employed for all patients especially terminally ill patients

152 DNR Protocol

1521WILL suction the airway administer oxygen position for comfort splint or immobilize control bleeding provide pain medication provide emotional support and contact other appropriate health care providers and

1521WILL NOT administer chest compressions insert an artificial airway administer resuscitative drugs defibrillate or

cardiovert provide respiratory assistance (other than suctioning the airway and administering oxygen) initiate resuscitative IV or initiate cardiac monitoring

153 Types of DNR Orders

1531a DNR Comfort Care DNR Comfort Care orders activate the DNR Protocol at the time the order

is given DNR Comfort Care orders permit comfort care only both before and during a cardiac or respiratory arrest Resuscitative therapies will not be

administered prior to an arrest This order is generally regarded as appropriate for patients who have a terminal illness short life expectancy little chance of surviving CPR and a desire to let nature take its course in the face of an impending arrest

1531b DNR Comfort Care-ArrestDNR Comfort Care-Arrest orders activate the DNR Protocol at the time of a cardiac or respiratory arrest A cardiac arrest occurs when there is an absence of a palpable pulse A respiratory arrest occurs when there are no spontaneous respirations or there is agonal breathing Resuscitative therapies will be administered before an arrest but not during an arrest The term DNR (without additional wording) when recorded in the medical chart shall be considered a DNR Comfort Care-Arrest order

1531c DNR Specified All other DNR orders are DNR Specified orders DNR Specified orders modify the DNR Protocol in some respect either in treatment modalities or in the timing of the protocol activation

1531d Authority to Give a DNR Order Only a patients primary physician may give a DNR order The primary physician is generally the first physician listed on the patients data card Primary physicians may delegate to

STANDARD OPERATING MANUAL MEDICAL SERVICE 16

CAMP LAPULAPU STATION HOSPITAL MANUAL OF OPERATIONS

physician residents the authority to record a DNR order in the medical chart

1531e Patient Consent to a DNR Order

DNR is a medical order to be given only by authorized health care practitioners DNR orders generally should be given with the informed consent of the patient or the patientrsquos surrogate decision-maker Ideally the physician should sensitively discuss the DNR option with the patient while the patient is mentally competent However DNR orders are often considered for patients who are comatose or who otherwise lack decisional capacity with whom this discussion has not occurred or cannot occur

In cases when a patient lacks decisional capacity the DNR option should be considered in conjunction with the patients advance directives if known or should be discussed with a surrogate A surrogate may be designated by a patient as the attorney-in-fact in a Durable Power of Attorney for Health Care A surrogate may also be identified as the first available person(s) from the following list in order

f Spouseg Son of or daughter of legal age h Either parent i Brother or sister of legal age or j Guardian

In all cases the primary physician should discuss the DNR option with the patient if possible and the surrogate(s) if appropriate There is no obligation to offer or initiate CPR if resuscitation would be futile ie if resuscitation would not achieve its physiological objective would offer no benefit to the patient and would violate reasonable medical standards

154 Recording the DNR Order in the Medical Chart

The words DNR Comfort Care DNR Comfort Care-Arrest or DNR Specified should be recorded on the left-hand side of the medical chart (where advance directives are maintained) along with the date time rationale for the DNR order the names of the patient andor family members involved in the decision and a statement that the patient andor surrogate was fully informed about and consented to the DNR order If a DNR Specified order is recorded the modifications to the DNR Protocol should be specified in the medical chart as well as the desired timing of the activation of the modified Protocol

DNR decisions for inpatients should be transmitted clearly to those caring for the patients A DNR order should never result in the abandonment of a patient and steps should

155 Reassessment and Revocation of DNR Orders

The DNR order should be reassessed as part of the ongoing evaluation of an inpatient A DNR order should be affirmed modified or revoked only after a discussion between the primary physician and the patient if possible or the surrogate(s) if appropriate and the consent of the patient or surrogate DNR orders should be reassessed frequently and

STANDARD OPERATING MANUAL MEDICAL SERVICE 17

CAMP LAPULAPU STATION HOSPITAL MANUAL OF OPERATIONS

as conditions warrant Reassessments of DNR orders should be documented in the medical chart If a DNR order is changed from one of the three types of DNR orders to a different type the patients DNR bracelet should be replaced with a new bracelet containing the revised designation If a DNR order is revoked the DNR bracelet should be removed and destroyed A physician or other health care worker who feels that he or she cannot honor a patients DNR request may not prevent or delay the transfer of the patient to a physician or facility which will honor the DNR status

156 Invasive Procedures and Anesthesia Care

The administration of anesthesia necessarily involves some practices and procedures that might be viewed as resuscitation in other settings Prior to any inpatient or outpatient invasive procedure for which the policy requires the documentation of informed consent any existing DNR order should when possible be reviewed with the patient or the patients surrogate As a result of this review the status of the DNR order during the perioperative period should be affirmed clarified or modified based on the preferences of the patient Any clarifications or modifications should be documented in the medical chart along with a notation indicating if or when the original DNR order should be reinstated Concurrence on these issues by the primary physician the surgeon and the anesthesiologist is desirable The DNR bracelet should not be removed during the perioperative period even if the DNR order has been temporarily modified

157 Conflicts Between DNR Orders and Advance Directives

In the event of a conflict between one of the three types of DNR orders and an advance directive which has become effective because a person is unable to communicate and is terminally ill or permanently unconscious the instructions from the document (or person named as an Attorney-in-Fact) ranked higher in the following list shall prevail

a Living will of a person who is in a terminal condition or a permanent unconscious state

b Durable Power of Attorney for Health Care or an Attorney-in-Fact acting in accordance therewith of a person who is in a terminal condition or a permanent unconscious state

c DNR order d

16POLICIES ON PATIENTrsquoS DISCHARGE INSTRUCTION

161 The patient or his her legal guardian has the right to be informed by the physician or his her delegate ( nurse) of his her continuing health care requirements following discharge including instructions about

a Take home medicationsb Dietc Physical activityd Special instructions

- Signs to watch out for - When to bring the patient back to the physician- Instructions to follow in the event of untoward incidences

complications

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CAMP LAPULAPU STATION HOSPITAL MANUAL OF OPERATIONS

e Follow-up Check-upf All other pertinent information to promote health and well-being

162 At the end patientrsquos confinement he she is entitled to a brief written summary of the course of his her illness which shall include at least the history physical examination diagnosis medications surgical procedure ancillary and laboratory procedures and the plan of further treatment and which shall be provided by the attending physician

17 POLICIES ON DISCLOSURE OF PATIENTrsquoS INFORMATION

171 The privacy of the patients must be assured at all stages of his her treatment Similarly the patient has the right to be free from unwarranted public exposure EXCEPT in the following cases

a When his her mental or physical condition is in controversy and the appropriate court in its discretion orders him her to submit to a physical or mental examination by a physician

b When the public health and safety so demandc When the patient waives his her rights

172 Any health care provider or practitioner involved in the treatment of the patient and all those who have legitimate access to the patientrsquos record is not authorized to divulge any information to a third party who has no concern with the care and welfare of the patient without his Her consent EXCEPT

a When such disclosure will benefit public health and safetyb When it is in the interest of justice and upon the order of a competent

courtc When patients waives in writing the confidential nature of such

information d When it is needed for continued medical treatment or advancement of

medical science subject to de-identification of patient and shared medical confidentiality for those who have access to the information

1721 Informing the spouse or the family to the first degree of the patientrsquos medical condition may be allowed Provided that the patient of legal age have the right to choose on whom to inform

1722 In case the patient is not of legal age or is mentally incapacitated such information shall be given to the parents legal guardian or his her next of kin

18 ETHICAL CONSIDERATIONS IN THE ADMINISTRATION OF BLOOD

181 The physician should obtain the patients informed consent before administering blood products This includes explaining to the patient the relative benefits and risks of receiving and not receiving the blood product as well as any reasonably viable alternatives

182 Generally in emergency situations where treatment is necessary to preserve the life or health of the patient and consent is not available (because the patient is unconscious or otherwise unable to consent) the physician may administer blood products (and any other treatment) necessary to preserve the life or health of the patient This does not apply if

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