MAKILALA MEDICAL SPECIALISTS HOSPITAL, INC.

Document Control No.:Medical Records DepartmentVolume IV- Administrative Services

Title of this Document:Manual of Operations and

Procedures

Effective Date:September 1, 2009

Policy Control No.: Title of this Policy: No. of Pages Effective Date:

Submitted by:Medical Records In Charge

Reviewed by:Hospital Administrator

Authorized by:CEO/ President/Chairman

ARTICLE I: VISION, MISSION AND PURPOSE

Section 1. Vision

The Medical Records Department aims to support proper recording and to

develop progressive report all the years to come and to maintain confidentiality of

patient’s record.

Section 2. Mission

To serve AMSHI clients, by ensuring the safety and privacy of patient’s records.

And maintain a comprehensive recording of relevant information through time.

Section 3. Purpose

a. To maintain all medical records in accordance with the principles and

practices of efficient and effective medical record management.

b. To help in conducting a review of records for completeness and accuracy,

coding of diseases, operations, and special therapies according to

approved nomenclature and classification.

c. To maintain a comprehensive and up-to-date record for hospital patient to

ensure that all relevant information on each patient is collected, placed in

the record and filed accordingly.

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d. To produce statistical reports required by DOH and respective hospital

management through the compiled data.

e. To provide records, upon request, for patient’s attendance to OPD and the

wards.

f. To help in preparing periodic reports on morbidity, birth and death,

utilization of hospital beds, rate of bed occupancy, out-patient services

rendered, as well as compilation of statistical reports on type of surgery

performed and types of diseases treated.

ARTICLE II: ORGANIZATIONAL CHART

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BOARD OF DIRECTORS

CHIEF EXECUTIVE OFFICER

HOSPITAL ADMINISTRATOR

MEDICAL RECORDS CLERK

Section 1. MASTER STAFFING PLAN

Position DOHMinimum

Requirement

InternalManpower

Plan

ComplianceStatus

(FT if Full Time)

(PT if Part Time)

Remarks

Medical Records

Clerk1 1 1 FT

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Name of Department: Medical Records Department

General Policy:

1. The health facility appoints and allocates personnel who are suitably qualified, skilled and/ or experienced to provide the service and meet patients needs.

2. Each personnel is qualified, skilled and/or experienced to assume the responsibilities, authority, accountability and functions of the position.

3. Professional qualification are validated, including evidence of professional registration/license, where applicable, prior to employment.

4. An organized medical and nursing staff shall be responsible for the quality of patient care and for the ethical conduct and professional practices of its members.

ARTICLE III: DUTIES AND RESPONSIBILITIES

Officer In-charge

a. Received, checked and arrange patients chart.

b. Checks all patients chart for proper indexing and file it to permanent

shelves.

c. Checks and monitor patients charts returned and back to file.

d. Check discharge patients chart on general logbook and summary of daily

discharge patients.

e. Check discharged patient’s charts if completely filled-up by NOD with

date/time discharge, iv flow sheet, nurses notes and doctors order, etc.

f. Segregates complete and incomplete patients chart.

g. Makes daily list of incomplete chart for completion of doctors/ consultants

and nurses.

h. Checks returned patient chart and classify according to coding, recording

and filing.

i. Prepare Medical certificate and medical records as requested by patient for

personal claims/ follow check-up.

k. Prepare and process Birth Certificate and Death Certificate.

l. Entertains patients request, such as:

1. fill-up personal insurance claims

2. laboratory examination and results

3. Medical/ Clinical records

m. Retrieves and pull-out patients chart requested for the use of:

1. study purposes of doctors and students

2. HMO/ Insurance

3. Philhealth / DOH

4. MRD

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ARTICLE 3.a. Work Schedules and Meeting

The Officer In-charge must be in his post 8:00 am – 5:00 pm with

1 hour lunch break from 12:00 – 1:00 pm and 15 minutes break every

morning and afternoon.

Working day is from Monday – Sunday with 1 day off.

Regular meeting with NS and Administrative Department is scheduled at

least once a month for evaluation, updates and implementation of the

policies and procedures.

ARTICLE IV: POLICIES AND PROCEDURES

Section 1. Record Storage(Safe Keeping and Maintenance)

1. Proper Lighting

a. The light in the storage and filing area should be situated in between cabinets

and should run parallel with the arrangement of the cabinet.

b. Medical record in charge tend to work efficiently and effectively in well

lighted working areas.

2. Proper Ventilation

a. The important thing to consider in planning for a good medical record

layout is good ventilation, it is not only considered for health reasons but

also protection of records.

b. Filing and storage areas with very humid conditions also had bad effects

on the medical records, papers absorb moisture to some extent and this

could affect the quality of the record.

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3. Proper Temperature

It is fact that the temperature affects the performance of a person, it

shouldnot be too warm nor too cold, and conducive for working should be

provided.

4. Retention of records

a. Hospital Licensure Act, otherwise known as a Republic 4226, which

requires hospitals to maintain medical records for 10-25 years.

b. DOH came up with ministry Circular 77, series 1981 which further

qualifies the 25 year retention period for all hospitals under the DOH

regardless of its category/ classification.

4. 1. The medical record is also influenced by the following factors:

a. Activity/ Usage of DataThis can be assessed by determining the number the number of

requests for information from the records as well as the type of

information requested; it reflects the clinical value of the medical

record.

b. Available Space and Alternatives

1. Medical Record Service with small filing area must maintain a

secondary filing for inactive records.

2. Active records are usually maintained for (5) years after which

they are transferred to the inactive file until they reach the required

retention period.

c. Attitude

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The people involve in medical records influence record retention

(in terms of it’s used for patient care, clinical research, and

education).

Section 2. Disposal Schedule for Medical Records Service

Document type Disposal ScheduleAdmission and Discharge Retain permanentlyBirth Register Retain permanentlyCorrespondence Log Book for MRS Seven (7) years after date of the

last entry

Daily Census Report One (1) year after.Death certificate (file copy) Retain permanentlyDeath register Retain permanentlyDisease Operation Index Retain permanently ER Blotter/ER Register Retain permanently

In-patient Record

ADULTS * Teaching-training and Research,

And Provincial Hospitals 25 years * District/Community Hospitals 25 years

MINOR (All) until the child reaches the age of maturity (18) years plus an

additional 5 years * Psychiatric Hospital Retain permanently

Laboratory Report Copies If filed in the in-patient, retain as for in-patient record

Labor Room Register Retain permanentlyNumber Register Retain permanentlyOut-patient Records Retain as in-patient recordsOperating Room (OR) Register Retain permanently Master Patient Index/ Retain permanently

Patient Master Index

Research Request 10 years

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Subpoenas Retain as for in-patientIf no record Retain as for correspondence X-ray Result/Report

* If filed with the chart Retain as for in-patient record * If no Record Retain for 10 years

Section 3. Filing of Chart

Section 3.a. Purpose

For efficient and effective filings system to establish sequence to ensure the

rapid location and retrieval of records. An efficient filling system is vital

requirement .All records should be filed in one established sequence. A filing

area which will ensure the rapid location and retrieval of records must be

maintained.

Section 3.b. Policies

1. All patient charts should be checked properly by the Record in

charge before filing it to their permanent shelves, check the

following;

a. Final diagnosisb. ICD-10 codingc. Patient Index Cardd Report of Operation (if any)e. ECG reading (if any)f. Anesthesia record (if any)g. IV flow sheet completeh. Correct carry out of nurses notesi. complete checklists of patients chart.

2. All records of discharged patients should be filed in Alphabetical

order from A to Z.

3. All charts ready for filling should be stamp by MRD Head at the

right upper portion of Medical Examination Sheet or above the

date of admission with corresponding signature of MRD in charge.

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4. All Charts endorsed to MRD in charge should be in logbook or

make a hard copy list with signature of person endorsing the chart

for records purposes.

5. MRD in charge should monitor the in and out of patients chart.

Make a separate logbook for incoming charts received, and separate

logbook for pull out or borrowed charts. All transactions should be

properly documented in order to check the movement of patients chart.

6. No one is allowed to enter the records stockroom without the presence

or permission of the MRD in charge, because any loss of patient chart

in charge is the one liable or responsible.

Section 3.c. Different Methods in Numbering and Filing

a. Filing

1. ALPHABETICAL- all records of discharged patients are filed in

strict alphabetical order from A to Z. This is otherwise

known as the “dictionary arrangement” of filing.

2. NUMERICAL- all records are filed by their admission number.

3. BY YEAR - charts maybe filed alphabetically or numerically by

year or discharge.

b. Numbering

1. Serial Numbering - This method entails assigning a new register

number to each patient at time of admission. Charts

maybe filed separately under number as assigned or

together under the most recent number.

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2. Unit Numbering - This is the assignment of one number to a

patient on first admission using the same number of

subsequent admissions. All records of the patient

are kept on one jacket regardless of the number of

admissions of the patient.

MRD department plans for the future that each patient had their own patient index

card.

Section 4. Retrieval of Chart

a. PHIC office

PHIC office pull-out discharged charts 2 days after patients discharge for

their claims processing. Signed the daily discharge list prepared by MRD

staff for records purposes. Returned the charts borrowed 3 days after date

borrowed then counter check MRD in charge for checking of complete

charts returned.

b. HMO office

HMO Office pull-out discharged charts for claims processing purposes.

List all borrowed chart at logbook countersigned by HMO staff for record

purposes. Returned chart to MRD counter check by in charge for

checking of complete charts borrowed.

c. OPD clinic

ER nurse will call via intercom charts for pull-out for study purposes of

physicians for follow up check up of the patient. All borrowed chart by

OPD clinic should be in logbook counter signed by the person who

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received the chart. Returned the chart immediately at MRD, in charge will

note the logbook for the chart returned.

d. MRD in charge pull-out chart for personal insurance claims and patient

requesting for clinical summary, laboratory results, Xray, operating report,

etc.

1. For strict compliance, patients chart will not easily be

pulled-out by anybody unless it is needed by attending physician,

PHIC/DOH personnel and any other healthcare providers.

2. MRD agreed that chart retrieval for current charts is within

20-30 minutes, while on old charts year 2007and below, chart

retrieval is within 2 hours or more due to records at computer

corrupted and MRD will scan record at General logbook.

Section 4.1 Procedures in Retrieval of Chart

a. Authorized person must fill up borrowers slip form in MRD.

b. MRD in charge receives and verifies the borrowers slip.

c. MRD in charge shall pull out the patient’s record from its permanent

file.

d. Retrieve chart ready for release must be recorded in the logbook.

e. Insert the tracer card in the place where the record was pulled out to

easily locate its original post when returning the chart after.

f. For students who will conduct case study they must present a letter

from the school to be address to the Chief Nurse or Hospital

Administrator for approval and it will then follow the sequence of A to

E.

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Section 4.2 Important Factors for Easy Retrieval of Chart

1. Efficient and Effective Filing System

This is an important factor that makes retrieval easy because it is

adaptable to the type or records maintained. To be truly effective, it

needs to adapt the corresponding unit numbering system.

2. Time

Time element is very crucial in medical records. Retrieval should be

as quick as possible because the information that may be retrieved

from the chart might be affecting the patient’s life or death.

3. Monitoring of Chart Movement

Another important factor to consider in the efficient management of

medical records is the full knowledge of the movement of the records.

This is why the medical record department should maintain an

effective tracking or follow-up system. The use of such as system,

coupled with the full knowledge of the work-flow will help the

medical record staff control the records more effectively.

4. Good Physical Layout

For good physical layout, the medical record department should

consider flexibility and functionality. The arrangement of the

employees should follow the workflow, facilitate smooth flow of

paperwork, and improve coordination between employees. The

physical location of medical record department should be near the

OPD and ER as the activity rate of medical records is considered high

in these services.

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ARTICLE V: RECORDING AND RELEASING OF DOCUMENTS

IN-PATIENT

Section 1. Issuance of Medical Certificate

a. Patient must fill up request form provided by medical records.

b. For inpatient:

1. Patient should be discharge first at the nurse station before Medical

records can print a medical certificate.

2. Patient must present an official receipt from the cashier signifying

payment of medical certificate.

3. Medical records cannot print a Medical Certificate if patient still

admitted unless on case-to case basis or emergency case depending on

patients need.

c. All released medical certificate should be properly signed by attending

physician specially for our in-house consultants except for visiting

physician, patient have the option to choose if they will be the one to go to

doctors clinic for physicians signature or come back 2-3 days for

completion.

d. Medical Certificate should be release immediately within 10-20 minutes

depending on physician availability.

e. In case, attending physician is not available/ out of town, patient is

scheduled to comeback 2-3 days after date of requisition.

f. In case patient send a representative to get his/her medical certificate,

patient should make an authorization letter and bearer should present

Identification Card for verification and records purposes.

g. MRD in charge should explain to patient/ any representative the

confidentiality of patient’s record.

h. MRD in charge should logbook all patients request forms and released of

medical certificates.

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Section 2. Issuance of Medico - Legal Certificate

a. Fill –up request form as provided by medical records.

b. Requesting party should bring a copy of subpoena from court.

c. In the absence of subpoena, requesting party should bring a letter of

request from Police station or from the lawyer handling the case.

d. MRD in charge should inform attending physician regarding the request of

the patient.

e. Attending Physician should sign the Medico-Legal certificate in two (2)

copies, 1 for patient’s copy and the other 1 for MRD Records file.

f. MRD should attach the duplicate file to the request or letter for proper

record purposes.

g. Logbook all request/ and released medico-legal certificate.

h. File the duplicate file at the permanent file.

Section 3. Issuance of Medical Certificate with Vehicular Accident

Related Cases

a. Fill – up request form as provided by medical records.

b. If the patient is the one requesting for medical certificate, he/she can

immediately get medical certificate depending on the availability of

attending physician.

c. In case attending physician in not available, he/she advised to comeback

2-3 days after date of requisition or depending on when the attending

physician is available specially when AP is out of town

d. In case the third party is the one requesting the medical certificate, they

should submit a copy of Affidavit of Desistance.

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e. Medical Certificate should be in two (2) copies, one for the patient and

one for the medical records for proper records purposes.

f. Duplicate file should be filed, together with the copy of the Affidavit of

Desistance.

g. All request and released Medical Certificate should be in logbook for

records purposes and signed by patient/ representative for confirmation of

the released certificate.

Section 4. Issuance of Clinical Records with Insurance Claims

a. Fill-up request form as provided by medical records.

b. Classify or verify what he/she needed for the claim.

c. In case he/she needed clinical records, laboratory results/ operating

technique/report, he/she is advice to wait for 30 minutes to 1 hour or

advised to comeback for the next day depending on the availability of the

records needed.

d. In case of personal insurance claims for filled-up, they are advised to

comeback on 2-3 days or depending on the availability of the attending

physician.

Section 5. Issuance of Birth Certificate

a. DR Nurse will pick-up daily the newborn footprint at delivery room and

endorses it to MRD for issuance of MBFH (Mother Baby Friendly

Hospital certificate.

b. MRD in charge will give the parents a Birth Certificate Information

Sheet.

c. Information Sheet should be properly filled-up by parent with Signature

over printed name below noted by MRD in charge.

d. MRD in charge then will fill up the final Birth Certificate Form as

provided by National Statistic Office.

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e. Parent should check first the data encoded before signing the birth

certificate.

f. A certificate of confirmation should be properly filled-up and signed by

the parent of the baby for confirmation of records of the baby.

g. MRD in charge , is the one assigned to complete the forms with:

a. signature of OB-Gyne

b. receiving and processing at local civil registrar.

h. Parent must receive the Birth Certificate as soon as possible or before

discharged.

i. Original copy will be given to the parent and a duplicate file will be left to

the hospital for record purposes.

j. In case an error or changes in any data given after typing/printing birth

certificate, a corresponding charge of the form will be implemented.

k. For strict compliance, all released Birth Certificate must be complete and

received by the LCR.

l. All request and released certificates should be in logbook with

corresponding signature of any representative for records keeping

purposes.

Section 6. Issuance of Death Certificate

a. Requesting party should fill-up an Information Sheet.

b. They are advised to wait for at least 1-2 hours or comeback on the next

day, depending on the availability of the attending physician.

c. MRD in charge will fill up the data written on the information sheet at the

Death Certificate Form as provided by the NSO.

d. MRD in charge released the form to any representative with complete:

a. signature of attending physician

b. causes of death

e. A duplicate/photocopy of death certificate will be left for records

purposes.

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f. Families of the deceased will be the one to finished all the signatures

needed for the form, with the following:

a. funeral/ embalmer

b. city health officer

c. receiving at the local civil registrar

g. All request and released death certificate should be in logbook with

corresponding signature of any representative for records purposes.

ARTICLE VI: MEDICAL RECORDS MANAGEMENT SYSTEM

Medical Records – is a compilation of pertinent facts of patient’s life history including

past and present illness (es) and treatment(s) entered by health professionals contributing

to the patient care.

Section 1. Three Basic Principles of Medical Records

a. must be accurately written

b. properly filed

c. easily accessible

1. The basic principles involved in obtaining adequate medical

records and maintaining smoothly functioning medical records

department are similar in all hospital regardless of size.

2. The patient’s record should contain complete and accurate set of

information to facilitate effective patient’s care and it’s evaluation.

Entries into medical record are made only by duly authorized

person. All entries including alterations must be legible. Only

abbreviations and symbols approved by the Medical Record

Committee are to be used.

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3. Any person making an entry in the medical record must date and

sign his entry or properly authenticate the entry made. The

medical record is a legal document, so no form maybe detached

once it is filed with the charts. There should be no erasures of any

sort.

To correct:

a. Draw single line through the information to be corrected or

change.

b. Write an initial “M.E” for mistaken entry and affix initial

and date.

c. Write the correct entry near the information to be corrected.

Section 2. Important General Rules in Medical Records

a. No one is allowed to enter the records stockroom without the presence or

permission of the MDR in charge.

b. Patient’s chart will not easily be pulled out by anybody unless it is needed

by Attending Physician, PHIC/DOH personnel and any other healthcare

providers.

c. MRD agreed that chart retrieval for current charts is within 20-30 minutes.

d. For patients upon discharged, attending physician should immediately

write or give the final diagnosis of the patient.

e. ECG strips should be attached at the chart with complete reading.

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f. In case ECG strips had no reading upon discharge, MRD will forward the

chart to at OPD section for completion.

g. Operating report/technique if possible should be properly filled up and

attached at the patient’s chart before or upon discharge.

h. All discharged charts should be forwarded daily by NS Head nurse or the

head of the shift in the absence of the head nurse.

i. All discharged chart should be properly checked by NS head nurse or

supervisor before endorsing at MRD office.

j. NS will make a logbook for all patients endorsed to MRD and MRD will

also make separate logbook for records purposes and verification of chart

received.

k. Medical Records must be maintain the privacy, accuracy and prevent loss

and destruction of patient’s record.

l. All errors of patient identification data during admission must be notarized

and a joint affidavit should be presented to the Medical records Department

for changing of data.

Section 3. Various Forms for Medical Records

For the medical record of patient to be complete, it must include the

following forms, properly accomplished, signed and dated;

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1. Medical Examination Sheet - this form contains the;

a. Name of patient, address, age, date/time of admission and status and

patient number.

b. Admitting and final diagnosis, as well as description of any operation and

procedures performed.

c. History Sheet: - contains chief complaint, personal and family history

(past and present)

d. Past History records the previous operations and illness of the patient and

particularly those that might be related to the present illness.

e. Social History present facts about patient’s file and habits that might affect

his condition. If, for example, he has an allergic condition, it maybe

important to know his diet, the pets he own, the plants that grow around

his house, and the materials he comes in contact with at work and at home.

f. Family History records the diseases which members of the patient’s

immediate family have or have had. Most important are those that might

directly affect the patient either through heredity or contact.

g. Physical Examination Sheet - contains all pertinent (positive and

negative) findings and impressions.

2. Patient’s data sheet - includes patient’s personal data like name, address, age,

sex , birthday, fill up completely consent for admission, signed completely waiver

of loss, medication consent and hospital policy.

3. Laboratory Result Sheet - contains all results of all diagnostics, laboratory,

2D echo, CT scan, x-ray procedures and etc.

4. Vital Sign Sheet- contains name of patient with attending physician, date and

time of temperature, B.P, pulse, resp. Intake and output urine/hour with signature of

nurse on duty.

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5. TPR Sheet - contains name of patient, physician, room no. hospital no. and

complete graphic of patient.

6. IV Flow Sheet - records the IV fluids consumed by the patient with description

and no. of bottle consumed, rate, no. of hours, date/time started, signature of

NOD, date/time consumed/discontinued with signature of NOD.

7. Physicians Order - contains all doctors order.

8. Progress Note Sheet - includes doctors positive and negative observations and

comments. It gives a chronological picture of the clinical condition of a patient.

9. Medication Sheet - contains data of name of patient, room no. and hospital

no. Records all medicines given by NOD to patient with date ordered, name of

medicines & treatment, time given, signature of NOD and date/time discontinued

with signature of patient/representative at the right lower portion of the form.

10. Nurses Notes - contain the notes of all nurses who tended the patient. These

include their observations of the patient, the treatment given, the response to the

treatment, and unusual occurrence. The first page shall always contain a record of

checking the patient in the unit and recording his physical condition at the time.

The admission portion is completed when the patient first admitted to a particular

nursing unit; while the discharge portion if completed when the patient is

discharged from the unit. The discharged notes should include basic information

such as time of discharge with signature over printed name of NOD and condition

upon discharge.

11. Discharge Instruction Sheet - summarizes the significant findings and events

occurring during patient’s hospitalization, final diagnosis, date of discharge, home

medication with complete dosage, time and duration of intake, recommendation

and arrangement of future care (OPD follow-up treatment), special instructions (if

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any), NOD signature over printed name, signature over printed name of any

representative and name of attending physician

12 Anesthesia Report Sheet (if any)

13. Report of Operation Sheet - record and authenticate a pre-operative diagnosis

before surgery. The record should contain a report of all findings, a description of the

technique used, description of any “tissue” removed, and a post-operative diagnosis,

date of operation and signature of the surgeon.

14. Birth and Death Certificate , if either of these events occurred.

15. Other Sheets - OB-gyne History form, Physical Therapy Note form, consent for

operation(if any) and Trauma Form.

16. Consultation Reports - adequately record the consultant’s findings on physical

examination of the patient, as well as his opinion and recommendations.

17. Birth and Death Certificate , if either of these events occurred.

18. Other Sheets - Medication and treatment, vital sign sheet, graphic chart sheet,

referral form and ETC.

19. Information Sheet- for preparation of birth and death certificate. Patient must

fill up this sheet with correct and complete data.

ARTICLE VII: PHOTOCOPIER CONTROL SYSTEM

The Medical Records Department in charge shall also be the one

authorized to operate the photocopier machine. Daily checking of the machine status in

number pages should be done to monitor the movement of photocopy services.

Basic rules are the following:

a. All charged photocopies must pass through the approval of Hospital

administrator by submitting a filled up in charge slip.

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b. Indicate the person’s name requesting it, date, purpose and numbers of copies in

the charge slip.

c. Approved charged slip must be presented to MRD before it will be

performed by the in charge.

d. All sales from the photocopy service for the day must be remitted to the cashier

with corresponding official receipt.

e. Photocopier in charge must provide a logbook for all sales and charge photocopy

including the errors for proper control system.

f. This report must be verified by the accounting officer and with an actual checking

on the machine to confirm the accuracy of the report.

ARTICLE VIII: SERVICE STANDARDS

Antipas Medical Specialist hospital, Inc believes that the best way to give quality care to patient is by satisfying their needs. And begin this by caring for ourselves and each other. The way we treat each other within AMSHI sets the way on how we treat our patients and guests. We need to treat each other with courtesy, respect and kindness. All employees are therefore expected to pledge to provide and uphold the following service standards.

1. Smile

smile warmly and introduce yourself make eye contact welcome patients/customers in a friendly manner rudeness is never acceptable apologize for problems and inconvenience thank patients/customers for choosing our hospital

2. Telephone and Ramp Etiquette

when answering calls, identify your department and yourself ask callers “how may I help you” ask permission to place caller on hold

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allow patients and visitors the right of way in the ramp, stairs, hold door open for those trying to enter the room

politely ask others to wait for the next wheelchair or stretcher if transporting patients on beds.

always practice patient confidentiality including clinical discussions in the hallway, ramp and all public areas.

acknowledge with a nod or smile to patients/watchers guests.

3. Accident Free Environment

follows all policy and procedures for emergency claims report any hazardous or suspicious things / people to security guard

immediately use protective dress wear return all equipment to its proper place pick up and dispose of any litter you find clean up spills and debris immediately place any equipment or supplies on one side of the hallway in the patient care

units. keep exits clear

4. No Waiting

acceptable waiting time for a scheduled appointment is 30 minutes. For a non-scheduled visit, every effort will be made to see the patient within an hour.

apologize if there is a delay, offer to reschedule the appointment if possible. if delay is over an hour, update patient about their status at least every 30

minutes. update family members at least hourly while patient is still on procedure.

5. Dress Professionally

always wear NAME TAG keeping name clearly visible take pride in your personal appearance never chew gum or eat while interacting with patients or customers adhere to hospital and department specific dress code policy male employees are not allowed to wear earrings, body tattoos, body piercing female employees are to wear jewelleries appropriately

6. Address Patient’s Needs

address patient by name, ma’am , sir, nay, tay or any comforting name/address to patient.

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do not leave the floor until patients requests have been conveyed to appropriate nurse/attendant.

appropriate nurse must respond to patient call or request within 3 minutes. before leaving the patient, ask. “ is there anything else I can do for you”

ma’am / sir? check patients an hour before shift change to minimize patients requests

during endorsement. before leaving the floor for breaks or meals, notify patients of when you will

return, inform patient who will cover in your absence.

7. Respect Patients’ Privacy

always knock before entering a patient room interview patients’ in privacy, close curtains or doors when available. never discuss clinically related issues in a public area, or in the presence of

others. provide blanket, sheets, patient gown when patients are ambulating or in a

wheelchair or stretcher.

8. Direct Communication

if someone appears to need directions, offer help escort patients/customers to their destination, or get someone else to

immediately escort them provide explanation about patient care using understood and appropriate

language collaborate with physicians to reinforce the information provided to patients avoid technical or professional jargon

9. Speak positively

treat everyone like a VIP, because everyone is important smile warmly and introduce yourself by name and title extend a warm greeting use positive body language listen to what the patient/customer is saying and offer feedback if appropriate

speak positively about AMSHI to make our patients safe and confident.

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