grp 1 personnel manual

1JGMMDH PERSONNEL MANUAL 2011

OREWORD

The nursing service is one of the units in the Hospital Structural Organization.

This unit deals with human beings who are sick, physically and mentally, people under

stress and problems, people with individual differences who want comfort and

understanding, to ease them with their pains and problems.

Human beings who are admitted or sick consultation in the hospital have different

personality traits or types, cultural values, political affinities and different disease. The

only thing common in them is the belief that they will be treated and will be recovered

from their diseases or illnesses.

The hospital environment is not a conducive place to stay, with different odors,

noises, agonies, emergencies and tragic incidents or tragedies. Being a witness of an

incident of a death of a co-patient in the ward is not a pleasant picture to look at and a

frightening incident for one who is also suffering from a disease, especially for those with

debilitating disease.

Yet, despite of these individual differences that exist in different hospital wards,

there are policies and procedures uniform to every individual and a useful tool a nurse can

use in dealing with her patients, to inform uniformity and orderliness of her work with

patients, and that can make her care to them useful and meaningful.

The Nursing Service Unit with the biggest manpower, component, is composed of

personnel though with the same health-related educational background and exposures, but

with different personality traits and behaviors, religion and political affinities.

Henceforth, this Nursing Service Manual was formulated to ensure uniformity,

continuity and smoothness of hospital unit operations, especially the Nursing Service

Unit.

F


TABLE OF CONTENTS

ACKNOWLEDGEMENT iFOREWORD 1

PART 1 PREFACE 4

JGMMDH Vision, Mission, Pillar of Success 5

A. Philosophy of Nursing Service 6

B. Objectives of the Nursing Service 6

C. Vision of the Nursing Service 6

D. Mission Statement of the Nursing Service 7

E. Organizational Structures 8

F. General Policies of the Nursing Service 10

PART 2 NURSING SERVICE DEPARTMENT 12

CHAPTER 1 THE NURSING SERVICE 14

CHAPTER 2 ORIENTATION PROGRAM 22

CHAPTER 3 IN-SERVICE STAFF DEVELOPMENT PROGRAMS 25

CHAPTER 4 NURSING PROCEDURES 33

CHAPTER 5 INTER-DEPARTMENTAL COORDINATION 52

CHAPTER 6 MONITORING STRATEGIES & NURSING AUDIT 56

CHAPTER 7 NURSING SERVICE PERSONNEL POLICIES 63

CHAPTER 8 EMPLOYEE PAY AND BENEFITS 71

CHAPTER 9 GRIEVANCE AND DISCIPLINARY PROCEDURES 80

APPENDIX A. SUBORDINATE RATER FORM (SRF) 91


PART 1


PREFACE

This manual is developed to provide the hospital staff and personnel of Joseph G.

Marañon Memorial District Hospital a comprehensive guide of the general information of

the organization’s goals and objectives, functions and responsibilities, standard policies

and procedures for the effective operations of the hospital and to promote efficiency and

to meet the rising expectations of its clientele and the public. It serves as a ready

reference to all hospital staff in the management and daily operations of their respective

unit or sections.

1


JOSEPH G. MARAÑON MEMORIAL DISTRICT HOSPITAL

Vision

To provide effective, quality and accessible health care services through an

efficient, self-sustaining department and highly competent employees.

Mission

Affirms its role in the delivery of effective and accessible health care services

Commits itself in the persistence of sustainable growth and development through

innovative generation of financial resources

Create an environment that promote excellence and professionalism among

service providers

Pillars of Success

1. Client satisfaction

2. Excellent service providers

3. Responsive administrative support

4. Sustainable revenue generation

5. Continuing personnel growth and development


NURSING SERVICE DEPARTMENT

A. Philosophy of the Nursing Service

1. Clients have the right to the best possible health care regardless of their race,

creed, sex, social status, capability to pay and political belief.

2. Medical interventions require the coordinated effort of all the various components

of the health care delivery system since health and illness are multi-causal.

3. An integrated health service (including the nursing service) should be adequately

operationalized to be responsive to the health needs of the clientele.

4. Nursing personnel should be adequately prepared to assume their various roles in

the promotion, maintenance and restoration of health.

B. Objectives of the Nursing Service

To improve the quality of patient care by:

1. Minimizing absences/tardiness.

2. Increasing awareness of their commitment and dedication towards work.

3. Establishing a harmonious working relationship with superiors, peer groups,

subordinates and other health team member.

4. Improving nurse-patient relationship.

5. Improving public relations with watchers and other members of the community.

C. Vision of the Nursing Service

Health as a right. Health for all Filipinos.


D. Mission Statement of the Nursing Service

The Nursing Service is primarily concerned with the provision of quality

patient care to all patients, by qualified and fully-equipped nursing service staff

and personnel, regardless of race, color, creed, sex, social, and economic status

and political beliefs, in order to promote, maintain and restore health.

E. Organizational Structure of the Nursing Service

Organizational charts are fundamental to effective administration in

dictating the lines of authority and responsibility, the major channels of formal

communication, and the inter departmental, as well as, the intra-departmental

relationships. For the systematic and effective administration of the Nursing

Service, the nursing department must be organized within the framework of the

hospital's objectives and sound organizational principles.


Chief of Hospital

Chief Nurse

Nurse Supervisor

Head Nurse

Staff Nurse

Administrative Officer Medical

Officer IV

Nursing Attendant

Nutritionist Cashier

Cook

Clerk

Driver

Utility Worker

Social Welfare Officer

Medical Records Officer

Security Guard

Supply Officer

Med. Tech.

Dental Aide

Dentist

Medical Officer III

Pharmacist

Medical & Ancillary Services

Administrative Services

Nursing Service

ORGANIZATIONAL STRUCTURE OF

JOSEPH G. MARAÑON MEMORIAL DISTRICT HOSPITAL

LEGEND:

Direct line of authority and responsibility

Coordinated relationship


ORGANIZATIONALSTRUCTURE

OF THE NURSING SERVICE

Nurse II (Ward Nurse)

Nurse II(OR /ER Nurse)

Chief of Hospital

Nurse III (Supervising Nurse)

Nurse I

Nursing Attendant


Chief Nurse (Nurse IV)

Nurse I

Nurse I

Nurse I


Nurse I

Nursing Attendant

Nurse I

Nurse I

Nurse I

Nursing Attendant

Nursing Attendant

Nursing Attendant

Nurse I

Nursing Attendant

Nurse I

Nurse I

Nurse I

Nursing Attendant

Nursing Attendant

Nursing Attendant

Nurse I

Nursing Attendant

Nurse I

Nurse I

Nurse I

Nursing Attendant

Nursing Attendant

Nursing Attendant


F. General Policies of the Nursing Service

1. All Nursing Service Personnel must attend the flag ceremony every Monday of

the week.

2. Time-in and time-out using the bandi-clock must be observed by each employee

before and after going on duty.

3. The nurse employee must wear their *prescribed uniform, complete with ID and a

nurse’s cap for female nurses assigned in the wards.

4. Reporting time for duty should be at least (15) fifteen minutes before the

start of shifting to have a proper endorsement of patient and wards from the

outgoing personnel.

5. Nursing service personnel on duty shall not leave their units without their

relievers.

6. All nursing employee must follow and strictly implement the hospital general

policies.

7. All nursing personnel must observe the patient’s rights at all times.

8. All nursing service personnel must inform the patient about his/her rights upon

admission.

9. All nursing service personnel will provide quality care to all patients with no

biases on age, race and beliefs of the patient.

10. All nursing service personnel must be an example of good manners and right

conduct in the hospital.

11. All nursing service personnel must observe the legal an ethical aspect of the

nursing profession at all times.

12. All nursing personnel shall provide health teachings when necessary.

13. Specific requirements:

a. Hair- No frizz bangs should not too long to touch eyelids. Long hair must be

swept to the back in a neat bun. No hair accessories (colored ribbons, clips)

b. Make up should be Light (day time).

c. Nails should be cut short and no dark colored polish allowed.

d. Jewelry- Only wrist watch, wedding ring if married and school ring are

allowed. Absolutely no chokers, anklets, fashion jewelry of any kind.


e. School pin, Name plate or Hospital ID should be worn at all times while on

duty.

*Prescribed Uniforms

For Females - Non transparent, non sheen, white material, Non tight fitting skirts

no open slits, Skirts must be level or below the knee not above the

knee, No embroidery no ruffles no frills\white pants are allowed

provided that blouse will cover buttocks.

For Males - Uniform must be non transparent non sheen white material, Clean

white shoes no rubber shoes, No earrings, Hair must short not to touch

collar

For Special areas like ER/OR- Monday, Wednesday, Friday, Sunday: Scrub suit

with logo (Royal Blue), Tuesday, Thursday, Saturday: : Scrub suit

with logo (Light brown)

For Nursing Attendants - Battle-green colored uniform, white shoes with clean

white socks, No rubber shoes


PART 2


NURSING SERVICE

DEPARTMENT

One of the largest manpower in an institution: the nursing service department

holds the greatest responsibility in the attainment of the institutions goals. Nurses are the

first liners in the provision of different health care services being offered.

With the variety of workload assigned to different departments, the nursing

service department holds the most vital and diverse responsibilities. From admission of

the patient to his/her discharge, to daily assessment, planning and implementation of

individualized care to patients, up to the spiritual and as well as the intellectual aspect of

the client, this is what we call the holistic approach unique to the nursing service

department.

In this chapter we will identify the different standard operating procedures being

practiced by our institution in the achievement of its goals. This chapter will equip you

with the basic knowledge of the how the nursing service machinery works under different

circumstances, how the nursing service department manages, controls and maintains its

quality nursing care and how it protects not only the patients’ rights but also the nursing

personnel.

2


CHAPTER 1 THE NURSING SERVICE

A nurse administrator is the one responsible in managing the entire nursing

workforce. He/she is assigned to spearhead all activities concerning the nursing

department. Among these tasks is the organization of the work schedules to avoid

understaffing, overstaffing, and conflicts.

The institution is a secondary level, government owned and funded, 50

bed-capacity, 3 story building. Composed of four nursing stations: station 1-

Medical wards and isolation wards, station 2-surgical wards, station 3-OB ward,

DR and private rooms, station 4-pedia ward and special areas such as OPD, NICU

and ER/OR.


A. Staff Shifting

All nursing service personnel will observe the following shifting

schedule:

7:00am- 3:00pm Morning shift

3:00pm-11:00pm Afternoon shift

11:00pm-7:00am Night Shift

The incoming staff must report 15min. before his/her shift to

receive proper and complete endorsement from the outgoing staff.

B. Staff Scheduling

Schedule of duties and off-duties are posted weekly every Friday

morning at the nursing service bulletin board. This is prepared 3 days

before the start of the schedule. Special requests should be submitted every

Wednesday from 8am to 5pm at the nursing service office.

The nursing service staff schedule is equally distributed for 3

shifting; from 7-3 shift will proceed to 3-11 shift the next day then 11-7

shift, this rotation is observed every week and is given two (2) days off

either in between the rotation or two consecutive off.

Exchange of duty schedules are permitted ONLY during

emergency situation or on valid reasons only.

Nursing service personnel should fill-up the prescribed form

properly when exchanging duty schedules. The said form shall then be

signed by the respective personnel and supervisors, before granting the

said exchange of duty or off duty.

Holiday off of nursing service personnel should be scheduled on

rotation basis except for supervisors. When exigency of the service

demands, supervisors are required to render duty on Saturday, Sundays

and Holidays, to answer the need.


All nursing service personnel are required strictly to check daily

their respective schedules of duty and off duty for any changes.

C. Job Description and Qualifications

CHIEF NURSE (Nurse IV) Job Description – also known as the

Nursing administrator and is the executive head of the Nursing Service.

1. Carries full administrative responsibility and authority for the entire

nursing service of the hospital.

2. Participates in formulating hospital policies, in developing and

evaluating programs and services

3. Assumes full authority and responsibility for development of nursing

service policies

4. Organize, directs, coordinates, and evaluates activities of the Nursing

Service Staff which allow for satisfaction and professional growth.

5. Provides means & methods by which nursing personnel can interpret

the goals & policies of hospital & nursing service to the patient & the

public.

6. Initiates and directs studies

7. Evaluates procedures for the improvement of nursing in relation to the

total care of patients

8. Directs planning and implementation of staff development programs

for different categories of nursing personnel.

9. Prepared with the supervisory staff budget proposal

10. Recruits and recommend personnel for appointment, promotion or

dismissal depending on staffing needs of the services.

CHIEF NURSE (Nurse IV) Qualifications

1. Be a registered nurse in the Philippines

2. Have at least 2 yrs. experience in general nursing service

administration & at least 5 years experience in supervisory or

managerial position in nursing

3. Possess a degree of Bachelor of Science in Nursing, with a Master’s

degree in Nursing


4. Be a member of good standing of the accredited professional

organization of nurses

NURSE SUPERVISOR (NURSE III) Job Description- under the

supervision of the Chief Nurse, he/she manages the nursing activities

(nursing care and services) in the ward or special areas.

1. Supervision of patient care

a. Checks the senior nurse’s plan of care and sees to it that they

are correctly and efficiently executed.

i. Keeps herself informed of the patient’s needs and

problems.

ii. Reinforces health instructions given to patients and

folks as the need arises.

iii. Verifies implementation of requests for referrals to

evaluate continuity of care.

iv. Serves as consultant and adviser of senior nurse in

developing, devising and adopting work techniques and

methods for the solution of problems related to patient

care.

2. Personnel management

a. Interprets standard operating procedures and policies, reviews

work performance of personnel to determine if it conforms to

recognized standards.

b. Plans programs and work of all the nursing personnel of the

unit.

c. Directs arrangements of schedule of work hours, off-duties,

vacation leaves, etc. of all nursing personnel in the unit.

d. Evaluates work accomplished by each nursing employee.

e. Prepare the plans for counseling of co-workers, individually

and especially to personnel with problems.

f. Renders harmonious relationships and self-discipline among

nursing personnel under supervision.


3. Helps in providing adequate and safe environment by guiding and

helping Head Nurses in providing and maintaining a safe, orderly and

clean environment for patient and personnel.

4. Helps in providing adequate supplies and equipment by:

a. Determining the needs for supplies and equipment based on

past experience and future plans for patient care.

b. Making proper representation to the administration the needs of

the department.

c. Coordinating with the specialty department (maintenance and

property) to meet the needs for supplies and equipment for the

department.

NURSE SUPERVISOR (NURSE III) Qualifications


2. Have at least 2 years experience in general nursing service

administration

3. Possess a degree of Bachelor of Science in Nursing, with at least 9

units in management and administration courses at the graduate

level



HEAD NURSE (NURSE II) Job Description- under the supervision of

the Nurse Supervisor, he/she manages the nursing activities (nursing care

and services) in a specific unit.

1. Conducts patient rounds and sees to it that all patients in her ward get

the necessary care.

2. Sees to it that all equipments are in order and properly kept and

supplies are available.

3. Makes weekly schedules and daily assignment of her staff.

4. Checks and countersigns recording done by staff nurses.

5. Sees to it that doctor’s orders are carried out properly and intelligently

by the staff.

6. Plans and supervises all nursing activities in her ward.


7. Evaluates performance of her staff every six months.

8. Coordinate ward activities in the administration of nursing service with

all other hospital services.

9. Directs and supervises activities of nonprofessional workers in the

ward.

10. Participates in the orientation of new staff.

11. Interprets hospital objectives and policies to staff, patients and their

folks.

12. Represents her ward in the nursing service meetings and other hospital

meetings when necessary.

13. Acts as supervising nurse when so delegated.

14. Renders direct nursing care if the unit is understaffed

15. Supervises cleanliness and orderliness of the ward.

HEAD NURSE (NURSE II) Qualifications


2. Have at least 2 years experience in general nursing service

administration

3. Possess a degree of Bachelor of Science in Nursing, with or

without units in management and administration courses at the

graduate level



STAFF NURSE (NURSE I) Job Description- Under supervision,

responsible for delivering nursing care to patient within an assigned area.

1. Gives direct nursing care.

2. Identifies nursing needs of patients.

3. Plans, gives and evaluates nursing care.

4. Admits patients.

5. Takes and records vital signs.

6. Observes medical asepsis.

7. Observes signs and symptoms, institutes remedial action when

appropriate and records these in the chart.


8. Reports observations to the physicians.

9. Observes and responds to patients’ emotional and spiritual needs.

10. Acts as liaison between patients and hospital personnel.

11. Interprets to the patient and his family their roles in promoting

successful therapy and rehabilitation.

12. Prepares patients for, and assists physicians with diagnostic therapeutic

procedures.

13. Carries out doctor’s legal orders.

14. Assists physicians when examining patients.

15. Performs irrigations, catheterizations and gives enemas and etc.

16. Administers and charts medications and patients’ reactions to

medications.

17. Instructs patients and families.

18. Sees to it that equipment receive proper care and maintenance.

19. Discharge patients.

20. Teaches and directs nonprofessional nursing personnel.

21. Makes and submits reports.

22. Makes rounds in the hospital and invalid wards.

23. Receives and endorses ward equipment and supplies.

24. Interprets hospital policies and procedures.

25. Gives health teachings.

26. Maintains good relationships with other hospital personnel.

27. Charts accurately medications and treatments given.

28. Attends meetings and conferences.

STAFF NURSE (NURSE I) Qualifications


2. Possess a degree of Bachelor of Science in Nursing.



NURSING ATTENDANT (NURSE AID) Job Description- Under

supervision, performs the following:


1. Checks and receives articles from outgoing aide.

2. Attends morning rounds with the ward nurses.

3. Assists in giving baths to ambulatory patients.

4. Feeds patients who cannot eat by themselves.

5. Give/performs simple treatments like perineal care, SS enema, refilling

of hot water bags and ice caps.

6. Measures fluid intake and output.

7. Takes and charts vital signs when delegated.

8. Provides specimen vials, collect urine and stool specimen and sends

them to the laboratory.

9. Answers patient’s call and delivers messages.

10. Shaves patients for surgery.

11. Maintains cleanliness and orderliness of the patient’s unit at all times.

12. Sees to it that all beds are complete with linen and pillows.

13. Tidy beds and bedside tables, counter, cabinets and bedside chairs.

14. Remove all used or discontinued equipment from patients areas and

cleans and returns them to the utility room.

15. Does other jobs as requested by the supervisors.

NURSING ATTENDANT (NURSE AID) Qualifications

1. Be a graduate of midwifery or 3rd year nursing student or at least 1 yr.

in health care service course

2. With good communication and interpersonal skills

3. Hardworking


CHAPTER 2 ORIENTATION PROGRAM

Orientation is designed to equip the new employee/s with the basic

organizational information to enable him/her to adapt to the work situation.


A. Policies

1. There shall be a prepared program for an orientation.

2. Orientation shall be a MUST to new employee/s.

3. Orientation shall be prepared and conducted to facilitate new personnel’s

adjustment.

4. Orientation shall be scheduled for at least one-week to enable new employee/s

to fully understand and comprehend the contents of the orientation.

5. Orientation shall be conducted in the conference room of the hospital.

6. Orientation shall be prepared by the training staff and the head of the three

service areas of the hospital.

7. Orientation shall cover three(3) aspects, namely:

7.1. Orientation to the hospital which include the following:

7.1.a. Mission, Vision, Objectives and Philosophy of the Hospital.

7.1.b. Organizational Structure and Composition.

7.1.c. Hospital set-up, and functions of different departments.

7.1.d. Personnel Policies in General

7.1.e. Ethics in Public Service

7.1.f. Government Service Insurance System

7.1.g. Tour to the hospital.

7.2. Orientation to Service Areas (Specific for each service area).

7.2.a. Objectives, Philosophy

7.2.b. Organization

7.2.c. Job Descriptions

7.2.c. Personnel Policies

7.3 Orientation to the Unit (Specific for each service area)

7.3.a. Physical Lay-out

7.3.b. Introduction to Members of the Health Team

7.3.c. Unit Policies

7.3.d. Job Descriptions

7.3.e. Standard Operating Manual


7.3.f. Records and Reports

7.3.g. Legal Limitations of Functions.

Note: Unit Policies of the Nursing Service include:

7.3.c.1 Admissions and Discharges

7.3.c.2 Transfers and Referrals

7.3.c.3 Death

7.3.c.4 Medication Policies

7.3.c.5 Narcotic Control

7.3.c.6 Doctors Orders

7.3.c.7 Medical and Nursing Records

7.3.c.8 Unit Equipments

B. Procedures

1. Orientation starts upon first (1st) day of assumption to duty.

2. The respective head of the service area where the new employee belongs, will

conduct the orientation tour of the hospital.

3. The new employee will be introduced to all hospital staff and personnel during

the tour.

4. The training staff of the hospital will present the general hospital policies, and

other components of the hospital through an LCD projector.

5. Each section head will be responsible in the presentation of his/her unit also

through a projector.

6. Presentation will be scheduled to facilitate full understanding of the contents

of the orientation.


CHAPTER 3 IN-SERVICE STAFF DEVELOPMENT PROGRAM

Every official and employee of the government is an asset or resource to

be valued, developed and harnessed so that they can perform better in the delivery

of basic nursing services to the public. Hence, as a government employee, ones

career and personal growth is the main concern of the nursing department.

All heads of departments are mandated by the Civil Service Commission

to establish a continuing program for human resource development for all agency

personnel at all levels. The agency head must also create an environment

conducive to the development of skills, talents and values for better public service,

thus the existence of the following in-service staff development programs.


Orientation Program

OBJECTIVE

To inform the new employees through activities and courses about the

nursing service department programs, procedures and operations as well as other

duties and responsibilities, terms and conditions of work. This is discussed

thoroughly in Chapter 2.

5’S And Productivity Training Program

OBJECTIVE

A 3 hour in-house training is conducted once a year to inform and increase

the knowledge and as well as improve the attitude of nurses regarding being

productive at work.

SUMMARY OF THE TRAINING PROGRAM

The aim of productivity movement is to make a better tomorrow for

everyone. In order to make your tomorrow better than today, you must make your

company more successful through effective use of resources, improving efficiency

and economic operation of the business.

For example, in improving productivity, if you put most emphasis on

rationalization of manufacturing process, JIT (just-in-time) is considered to be one

of the effective approaches. If you put most emphasis on rationalization of

maintenance of machineries and equipments, TPM (Total Productive

Maintenance) is reported as the most advanced approach. And if you put more

emphasis on improvement of quality of products and resources, TQC (Total

Quality Control) or TQM (Total Quality Management) is the appropriate

approach.

So many people tend to try and implement such sophisticated productivity

improvement technologies as JIT,TPM,TQC/TQM without knowing weakness of


their foundation or without strengthening the ground on which such technologies

can stand.

5’S provides the ground or foundation for such technologies. Not only

that, 5’S alone can be a very effective independent approach for improving

productivity at medium/smaller companies where human and financial resources

are limited.

Accordingly, it can be said that the road to productivity starts from 5’S and

through 5’S you can make highly productive company and highly productive

people.

What is 5’s?

“5’s” stands for Japanese works all starting with S. But in the Philippines

someone translated these Japanese words into 5 English words, also starting with

S.

Japanese English Brief Explanation

Seiri sort take-out unnecessary items

Seiton systematize arrange necessary items in good order for use

Seiso sweep clean your workplace

Seiketsu sanitize maintain high standard of house keeping

Shitsuke self discipline do things spontaneously without being told/

ordered

The nature and implication of each S need to be understood as follows:

Seiri (Sort)- is an action to identify and eliminate all unnecessary items from your

workplace.

Seiton (Systematize)- is an action to put every unnecessary item in good order.

Seiso (Sweep)- is also an action to clean your workplace thoroughly.

Seiketsu (Sanitize)- is a condition where high standard of good housekeeping is

maintained so that there is no dust and rust anywhere.

Shitsuke (self-discipline)- is a condition where all members practice the above 4’S

spontaneously and willingly as a way of life. Accordingly, it is a

culture.


4S can be practiced by order or by enforcement. But, such practice will be

only short-live. Therefore, to give a long life to 4S and to ensure that the level of

4S to make continuous improvement, it is essential to create such a corporate

culture where well disciplined people (management and employee together)

practices 4S autonomously, spontaneously and willingly. When you reached such

stage, then, you can say you are practicing 5S.

What can you gain from 5S?

1. It makes your workplace more pleasant

2. Makes your work more efficient

3. Improves your safety

4. Improves quality of your work and your products.

What can the company gain from 5S?

1. Increase production

2. Improves quality

3. Reduces cost

4. Makes delivery on time

5. Improves safety

6. Improves morale

All these contribute to productivity improvement of the company.

How to motivate people to practice 5S:

1. 5S evaluation sheets

2. Fixed point photography method

3. Starts departmental competition

Productivity is, above all, an attitude of mind. It seeks to continually

improve what already exists. It is based in the belief that one can do things better

today than yesterday and better tomorrow than today.


Breastfeeding Policy

OBJECTIVE

A seminar is conducted annually to inform and enhance the knowledge of

nurses regarding the breastfeeding policy of the Department of Health and in order

to maintain the baby friendly hospital title of the institution.

SUMMARY OF THE PROGRAM

General Objective of the Program: To promote and support RA 7600 known as

“Rooming-in” and Breastfeeding act of 1992” for the benefit of both mother and

baby.

Specific Objectives:

1. To provide first immunization to the newborn by giving colostrums

2. To promote mother-child bonding through immediate breastfeeding in

the delivery room.

3. To lessen expenses for both mothers and the hospital.

4. To reduce infant morbidity and mortality rates caused by diarrhea or

any form of disease and infections.

5. To foster confidence and compliance to mothers on breastfeeding

through information dissemination and health education by trained

hospital staff.

6. To promote lactation amenorrhea method (LAM) as a family planning

method.

7. To assist working mother in their breastfeeding problems and

difficulties by teaching them about breast milk banking.

Hospital breastfeeding policies, 10 steps to successful breastfeeding and

Responsibilities of the hospital staff relative to ED 51 (milk code) are discussed

thoroughly during the seminar.


Interpersonal and Psychosocial Development Programs

Spiritual Enhancement

OBJECTIVE: To promote and enhance the spiritual aspect of every employee.

SUMMARY OF THE PROGRAM:

Several activities comprise this enhancement program, and these are:

1. Mass every 1st Friday of the month

2. Morning prayer at 6:00am through the hospital public information sound

(PIS) system

3. 3:00 o’clock habit (prayer every 3:00pm through the PIS system)

4. 6:00 pm angelus (through the PIS system)

5. Nurses pray the nurse’s prayer before endorsement every shift.

Health Advocacy

OBJECTIVE: To hone the skills of inter-personal communication among nurses and

patients and at the same time to inform the patients about necessary

information regarding their health and the hospital.


Every shift, regular nurses conduct a health advocacy wherein each time the

nurses approach the patients they communicate with them their patients’ rights and the

hospital policies. They assess level of understanding through questions and reinforce

correct information and correct wrong information understood by the patients and their

folks. This is done every shift to continuously reinforce and evaluate understanding of the

patient regarding his condition and the hospital policies. Upon admission each patient


receives a booklet regarding hospital policies and patient’s rights, this is used by nurses as

visual aid and references during the health teaching.

Family Day and Christmas Party

OBJECTIVE: To promote camaraderie and unity among the personnel and their families.

SUMMARY OF THE ACTIVITY:

Conducted every 22nd of December along with the Hospital Christmas

Celebration, this whole day event is composed of several parlor games and door prizes.

And a luncheon of all employees sponsored through solicitations.

HATAW Healthy Lifestyle

OBJECTIVE: To promote camaraderie and provide physical fitness activities to the

employees.

SUMMARY OF THE ACTVITY:

Every Wednesday at 3:00pm, HATAW dance aerobics is held at the OPD and this

is open to all employees and even watchers. A video tape is played and anyone who is

willing to join can dance with the group.

Foundation Day Celebration

OBJECTIVE: To commemorate the founding of the hospital and to give back to the

people as a sign of gratitude, through this activity the moral values and

interpersonal skills of the employees are enhanced.


This is a whole day affair done every August 10. In the morning a number of

outreach programs such as feeding, free circumcision and check-up is done all sponsored


by the hospital. In the afternoon this is the employees’ affair wherein parlor games with

prizes are given and lunch sponsored through solicitations is enjoyed by all employees.

Beast in Christmas Decoration/ Cleanest Ward/ Best Waste Segregation Unit

OBJECTIVE: This is to promote the creativity aspect of the employees and as well as

enhance team cooperation among the staff per unit and to reinforce the

waste segregation program of the institution.

SUMMARY OF THE CONTEST:

This is done every December and the winning group is awarded during the

Christmas Party. The contest is judged by selected high ranked members of the institution

and the criteria for judging are prepared by the nursing service department.

Invitational Sportsfeast

OBJECTIVE: To provide a recreation time for employees to enjoy and have fun once in a

while and also to inculcate the spirit of sportsmanship and teamwork

among the employees.

SUMMARY:

During the GSIS day and Civil Service week of the City an invitational sportsfeast

is conducted and one of the participating teams is the Hospital, volunteers from each

departments are grouped to form a team for basketball and volleyball and other sports

activities. And they compete with other agencies in the City.

Medical Mission

OBJECTIVE: To extend the services offered by the hospital in far flung areas and to

promote the interpersonal skills of the nurses.


SUMMARY:

With the availability of funds, a medical mission is conducted once or twice a

year. Free check-up, circumcision, and feeding program compose the outreach program.

And health classes are given by nurses to the community.

CHAPTER 4 NURSING PROCEDURES

The nursing procedures being observed by the nurses during duty hours

will be reflected in this chapter. These nursing standard operating procedures were

formulated to serve as basis for evaluation and most importantly to guide the

nursing service personnel in the provision of the different nursing services being

offered by the institution in congruence to its objectives.


Qualities ALL Nursing Service Personnel MUST Have

Knowledge

• Good basic clinical knowledge and level of technical skills commensurate with

experience

• Has extensive theoretical knowledge of her area and applies her knowledge

• Has excellent awareness of hospital policies and reinforces same in practice

Demonstrates familiarity with the concepts of

Nursing quality assurance

Infection control

Nursing policies and procedures

Patient confidentiality and privacy

Attitude

• Expresses commitment to nursing and to excellence in provision pf patient care

• Readiness for new learning and challenges

• Readiness to accept guidance

• Ability to work as a member of team, and to contribute to ongoing team building

• Reports punctually on duty

• Observes the uniform code at all times

• Makes every effort to expand her clinical knowledge and skills, seeking out

available resources


• Seeks and welcomes criticism in order to improve performance, uses resources

personnel to evaluate results

• Demonstrates enthusiasm in updating self by reading new nursing literature and

compiling same for the use of the unit

• Shares new ideas and information with the rest of the staff or nurse

• Reinforces the unit philosophy and goals

• Demonstrates a positive attitude towards authority

• Demonstrate a “caring” attitude towards patient and family

• Makes efforts to establish positive nurse / patient and family relationship

• Integrates criticism to improve practice

• Interacts well with peers, senior nurse and subordinates

• identifies learning needs and seeks assistance

• Demonstrates commitment to nursing

• Seeks out opportunities for improving clinical knowledge and skills

Skills

• Acts as a resource person to other staff members

• Exercises a democratic approach to leadership in managing the unit when

assigned

• Organizes workload well and completes assignment even under difficult and

stressful circumstances

• Evaluate results of interventions and modifies nursing care plans

• Incorporates patient’s teaching needs into nursing care plan and utilize other

resources if necessary


• Implements an individualized program of teaching with patient and family

• Teaches the patient about effects of medications and their safe administration

• Charting reflects a comprehensive understanding of the patient’s status; efforts

are made to improve the quality of charting and to help others to do the same

• good delegator in emergencies, evaluates the outcome of the emergencies and

shares knowledge with other colleagues

• Based on knowledge of team members, skill and experience allocates

assignment so as to provide for their professional growth

• Is supportive and considerate to less experienced nurse when offering criticism,

offer positive suggestions for correction and improvement

• Plans assignments and experiences for new nurse which involve application of

new protocols and procedures

• Helps and direct new staff member with personal integration as well as with

professional responsibilities

• Takes a leading role in the development of unit standards. Actively participates

in follow up of audit recommendations.

• Attends conferences and workshops even in her own time

• Identifies resource person or persons

• Administers medication safely

• Demonstrates advance beginner skills in nursing process and care planning

• Document and signs off all nursing entries

• Performs all unit procedures independently

• Is skilled in given basic nursing care

• Is aware of the components of safe nursing care and exercise due care in

delivery of same.


Demonstrate basic skills in the use of:

Nurses notes

Flow chart

Incident reports

Standard Operating Procedure in the Ward

As a general rule:

1. The Chief Nurse, during her daily rounds, should be responsible for implementing

the policies and SOPs of the unit in the ward.

2. The Nursing Supervisor in their supervision is responsible for the follow-up of the

implementation and orientation of the newly admitted patients on hospital policies

in general and wards policies in particular. They are responsible in maintenance of

the following:

a. Cleanliness and orderliness of the different wards and private rooms,

especially all comfort rooms.

b. Adequate stocks of medical-surgical supplies, emergency drugs and IV fluids,

including patients’ chart forms for ward use.

3. There should strictly be no transferring of beds from obstetrics and isolation

rooms to other rooms to avoid cross contamination.

4. Schedule of visiting hours and meal distribution in the ward should strictly be

observed.

VISITING HOURS

AM------9:00 AM-11:00PM

PM-------3:00 PM-9:00PM

MEAL DISTRIBUTION

BREAKFAST---- 6:30 AM-7:30 AM

LUNCH ---------- 10:30 AM-11:30 AM

SUPPER---------- 4:30 PM -5:30 PM


5. Only one (1) watcher is allowed to stay with the patient. Additional watchers may

be granted if the patient’s conditions warrants.

6.

7. The nurse on duty is the officer-on-duty of the day during her shift.

Standard Operating Procedure upon Receiving Admission

1. From the ER, all admitted patients shall have the following:

a. Admission chart completely filled-up, charted by the admitting nurse. It

should be intact with the following forms:

a.1. Face sheet

a.2. Consent for admission

a.3. History Sheet

a.4. Physical Examination sheet

a.5 Progress notes

a.6. Laboratory sheet

a.7. Doctor’s order sheet

a.8. TPR sheet

a.9. Medication sheet

a.10. Nurse’s Notes

a.11. Discharge Summary

a.12. Intravenous Fluid Sheet

a.13. Labor Record (for OB cases)

a.14. Newborn Record ( for newborn)

a.15. Surgical Memorandum (if there is any minor surgical procedures

performed)

2. Transcribe the admission in the kardex, the medication in the medication sheet

and make medication cards.

3. Record the admission in the Logbook for daily floor census.

4. Nurse-on-duty informs the nursing attendant about the new admission.

5. In case of private room admission, the nursing attendant-on-duty performs the

following:

a. Cover the bed with the hospital bed sheet.


b. Label the bed with a bed tag corresponding to the patient’s identity.

c. Include the patient’s name in the station’s directory

d. Provide medication box for patient’s medications and specimen bottles for

any laboratory exam requiring as such.

e. Check from the nurse-on-duty pending laboratory exams to be performed

and make requests in the laboratory.

6. Bed pan and urinal are provided to patients requiring them to have “complete bed

rest” or those who cannot ambulate or weak.

7. In case of any borrowed items. Borrower’s slip should be provided, signed and

attached to patient’s records and items borrowed should be returned after using or

upon discharge.

8. All available medication should be started as soon as possible. Medicine not

started due to reasons beyond control should be endorsed to the next shift.

9. Available IV fluid should be labeled properly with the patient’s name.

Standard Operating Procedure upon Discharge

1. Patients for discharge should have a written order from physician-on-duty and

properly billed-out.

2. Going home instructions should be transcribed properly and completely in the

sheet.

3. A gate pass signed by the cashier should be presented to the nurse-on-duty. A

discharge slip will be signed by patients or relative.

4. The nursing attendant should checked any item borrowed by patient or relative

before discharge.

5. The nurse-on-duty should explain clearly and completely all going home

instructions

6. Patients who are discharged against medical advice should sign a discharged

against medical advice slip.

7. The condition and companion of the patient should be written in the nurse notes


8. All remaining medications should be return to patients upon discharge.

9. For transferred patients to other hospitals, in addition, the conveying vehicle

should also be stated in the nurses’ notes.

Standard Operating Procedure on

Assisting Diagnostic and Therapeutic Procedures

1. The nurse-on-duty should transcribe doctor’s order for a specific procedure.

2. The nurse-on-duty should inform the patients and relatives on the procedure

ordered.

3. Consent for the procedure ordered should be signed by the patients or

responsible relative on legal age.

4. The nurse-on-duty should verify if the patient had understood the doctor’s

explanation of the procedure and will answer questions if there is any.

5. The nurse-on-duty should:

a. Instruct the responsible watcher or relative completely and clearly as to

request on outside clinics.

b. Checks on Out-of –pass order of the attending physician in the doctor’s

order sheet.

c. Secure signatory of the patients or responsible relative before leaving.

d. Chart the time the patients has went out-on-pass, the condition when the

patient left the hospital, the conveying vehicle and the time the patients

went back.

6. Results of the examination should be referred to the attending physician or

resident on duty once available.


Standard Operating Procedures of the Nursing Service (Per Unit)

DELIVERY ROOM

1. All OB patients should go direct to labor room for preparation such as perineal

shaving and for labor watch.

2. Cleanliness should be done every shift by nursing attendant assigned especially

after delivery.

3. Ultraviolet rays should be done once a month in order for the area to be sterilized.

4. Only authorized personnel of the DR are allowed inside the delivery room

5. Birth certificates should filled up by DR personnel (Nurse/Nursing Attendant)

6. Nursing attendant should log the newborn at the ER log book right after the

delivery.

7. Inventory of medicines/ supplies should be charge to the patients immediately

after deliveries and should be forwarded to the Business Office, Pharmacy, and

CSR for charging and replacement.

8. Only authorized personnel of the DR are allowed inside the delivery room.

9. All personnel, students, and CI’s should wear prescribed attire (gown, cap, mask,

slippers) in order to maintain sterile aseptic technique.

10. Sleeping/loitering inside the DR is prohibited.

11. Medicines/ supplies not properly charged will be charge to the concern personnel

of that shift.

12. All medicines are for DR use only, except for emergency cases that some station

can borrow but they should have a borrower’s slip.

13. All new born babies must have wrist band for proper identification.

14. All instruments used must be cleansed, sterilized and returned to its proper place

every after use/ procedure done.



EMERGENCY ROOM

The succeeding policies and Procedures have following objectives:

1. ·To smoothen the operation of the Emergency Room in particular and of the

hospital in general.

2. To guide personnel, staff, volunteers, student affiliates and including the Patients.

3. To have coordinated works geared towards better service to those in need.

STANDARD OPERATING PROCEDURES

1. The Emergency Room is manned by E.R. Nurses for 24 hours. These nurses have

been trained in the Operating Room, so that they could relieve in the O.R. when

necessary.

2. The nurse duty makes -an immediate rough evaluation of the patient, whether the

patient is a case of:

a.) urgent emergency,

b.) emergency, but not urgent, and

c.) plain admission only, not emergency.

3. For urgent emergency cases, the Resident-on-Duty should be notified and come

immediately, while the NOD prepares the patient for my possible anticipated

procedures and treatments.

4. For emergency, but not urgent, the ROD is notified but not necessarily to rush to

come immediately while the NOD prepares the patient for any anticipated

procedures or treatments.

5. For plain admissions only, the NOD will refer to the usual SPOs.

6. In cases of2a and 2b, after all the rest of the SOPs will follow.

7. Complete data on the OPD and admission chart.

8. Take patient's vital signs and inform the Resident-on-Duty about the said

admission.

ADULTS: Temperature, Pulse Rate, Respiratory Rate, Blood Pressure, Weight

PEDIATRICS: Temperature, Cardiac Rate, Respiratory Rate, Weight

Additional data for OB patients:

LMP-Last menstrual Period


EDC-Expected Date of Confinement

FHB- Fetal Heart Beat

*take the number of pregnancies, deliveries, and abortion (if any) the patient had.

Example: G3PlA0

9. Carry out doctor's orders as Specified:

a) Inform Dietary Dept. as to the patient’s diet, in the slip provided for.

b) Make Laboratory, X-ray, and ECG and ultrasound request in proper request

form provided for. Inform the X-ray/laboratory personnel on duty as to

the stat examinations to be performed. For examinations to be performed

by outside, give request to the patient's folk with proper instructions.

c) Stat orders must be carried out immediately, unless medicine is not available

or procedure cannot be performed at that moment. Inform ROD whether it’s

performed or not. X-rays and ECGs are done before sending patient to the

wards.

d) For intravenous to be inserted and medicines to be used, prescribed IVF,

tubing, IVF needle and medicines to be purchased from. The hospital

Pharmacy, ER stocks are solely for emergency cases only and for use during

night time. PHILHEALTH patients may avail of any available stocks

anytime.

10. OPD charts of admitted patients must bear the RODS signature and diagnosis.

This should be placed inside a folder provided for, after recording in the ER and

admission logbooks.

11. Consent slip for admission/treatment must be signed by the patient, parents or

accompanying folks or persons authorized to do so. For refusal to receive

treatment or refusal for admission, a signed consent is required.

12. For surgical cases, provide one copy of the surgical memorandum, properly filled

up by the ROD and signed by the surgeon, and attach this to the patient's chart.

13. Every page of the chart must bear the patient's name and room assignment.

14. All equipments/supplies must be in their proper places, for easy

accessibility/location when needed.

15. No oxygen tank must be left empty. When it reaches 500 pounds or less, utility

workers must immediately replace it with a full tank.

16. Every shift must check for the completeness of the ER, ready to

accommodate patients anytime.


17. After every procedure, thoroughly clean the instruments and when necessary.

Sharps like scissors and suturing needles are not boiled. After cleaning, they are

placed directly inside the soaking pan provided for.

18. If the situation warrants, sterilization of instruments is done only after Lunch, to

minimize the electricity consumption.

19. For patients to be transferred to other hospitals or the patient's hospital of choice,

the ROD will make a referral slip in triplicate copies. The original copy will be

given to, the patient. The duplicate will be attached to the patient's chart and the

triplicate copy will be given to the ambulance driver (if using CDH ambulance)

for his own file. Patient's bill must be settled first, before transfer. It is then

recorded in the logbook for transfer.

20. Attach an anatomical diagram to the patient’s chart for every medico-legal case.

Make sure that the ROD has recorded it in the medico-legal logbook.

21. Minor surgeries of admitted patients are recorded in the Minor Operations

logbook provided for. Place "IN" before the patient's name which means that the

patient is an in-patient. This is also for easy taking of statistics at the end of the

month.

22. Consultation at the ER (after consultation hour at the OPD will be changed

P200.00 based on the Provincial Tax Ordinance.

23. Patients that need to be observed first whether to be admitted or not, are placed

under observation in the Observation Room. Doctors’ orders are carried out as

indicate. Hospital bill is settled before discharged.

24. DOA forms properly filled up will be issued to the relatives of the deceased with

instruction to claim Death Certificate form their respective health centres;

example: Cadiz City Health Office in case of Cadiz residents.

25. When admitting vaginal bleeding cases, shaving is done before sending patient to

the wards. For OB cases, shaving is done in the Delivery Room.

26. Charge slips are made for every supplies used, for chmgi.ng and replacement

purposes. These are forwarded to the CSR. Change slips for medicines and I.V.

fluids used are written on prescription pads and forwarded to the Pharmacy losses

will be charged to those who did not do the inventory or to those shift it was

lost/missing.

27. Stock medicines and I.V. fluid are for ER use only. No I.V. follow-ups and

medicines for ward use may be taken from ER, excerpt on Emergency cases.


28. Accommodate injections and dressing during week-end/holidays.

29. Observe the 5's of Good Housekeeping every shift.

30. When admitting patients for stat operations, pre-op shaving is done to operative

site, and the consent slip signed by the accompanying fo1ks.


OUT PATIENT DEPARTMENT (OPD)

POLICIES AND PROCEDURES

I. Schedule of consultations

1. Consultation time starts from 8:00- 11:30 AM and 1:00- 4:00PM. All out-

patient consultations after 4:00PM should be referred to the Emergency Room

for proper disposition.

2. Consultation days are Mondays to Fridays, except during holidays.

3. Prenatal check-up should be done every Wednesdays. Unusual manifestations

related to pregnancy may be attended to at anytime.

II. Dressings/Injections

1. Wound dressings are done in the morning.

2. Injections of Anti-tetanus and tetanus toxoids must be done in the morning.

a. Patient must have taken their meals prior to administration of any injected

medications

b. Temperature and blood pressure must be checked before doing any skin testing

c. If in doubt of the results of the skin test, call the Physician-in-charge for

appropriate appraisal of the skin tests result

d. Allow patient to remain and be well rested at the OPD for at least 30 min after

administering an injection. Instructions must be given to the patient to refer

any untoward reactions like dizziness, itchiness, chest pain/tightness, difficulty

of breathing, etc.

3. Injections must be administered preferably in the morning. Any other injections

maybe given in the afternoon, unless otherwise specified. Examples of these

injectables that could be given in the afternoon are tetanus toxoid and BID

doses of injectable antibiotics.


4. Referred patients for injections coming from other institutions/private clinics,

must have a referral slip from the referring agency/physician, which must then

be attached to the individual patient's chart.

5. Patients undergoing surgery in other institutions and coming in for removal of

sutures, must present a referral slip from his Attending Surgeon. The referral

slip must then be attached to the patient's chart.

III.Filling Up of OPD Chart.

1. The patients name must be written with family name first, first name next and

middle name written in full.

a. Maiden name of unwed mothers must be used.

b. Babies of unwed mothers may use the name of their Biological Father as

allowed under the new Family Code of the Philippines.

2. Unwed couples, living in or co-habiting, shall be reflected as "SINGLE" under

the item of Civil Status.

3. Blood pressure, Weight and Temperature should be routinely taken and

reflected in the records of all Adti.lt patients. In pediatric patients, Blood

pressure is only taken when indicated such as in shock, comatose or severely

dehydrated patients while Temperature should be routinely taken.

4. For patients who will undergo prenatal check up, check BP and weight. Ask for

the number of previous pregnancies, deliveries, and abortion the patient may

have had. Also ask for the last menstrual period and determine the expected

date confinement/delivery.

Example: G4P2Al LMP: Dec 2, 1998 EDC: Sept. 9, 1999.

IV. OPD Cases Scheduled For Surgery

1. Fill up the OPD Chart the usual way. Consultation slip for operation/treatment

must be signed by the patient or anyone authorized to do so.

2. Provide 1 copy of surgical memorandum properly filled up by the nurse on duty

and signed by the ROD. Attach copy in the patients chart.

3. On the patients chart, indicate on the left side the following:

a. skin prep time

b. time of surgery

c. amount of anesthesia.


4. Record all minor surgeries in the logbook provided for.

V. BABIES FOR NEWBORN SCREENING (NBS)

1. All babies delivered in the hospital will have a routine newborn screening

before discharge.

2. Newborn kit is available at the OPD. Physician on duty, OPD Nurse-in-charge

or midwife on duty wilt be the one to perform newborn screening.

3. All filter papers used for NBS must be air-dried for 4 hrs in the newborn screen

rack before being sent by courier New Born Screening Center Visayas for re-

evaluation.

4. All filter papers must be filled up correctly with the appropriate data and

information before being sent by courier to New Born Screening Center

Visayas for re-evaluation.

5. The OPD Nurse in charge will release all Newborn Screening results coming

from New Born Screening Center Visayas, at anytime as soon as they are

available, except on Saturdays and Sundays and holidays.

6. A skilled Medical Technologist will do confirmatory tests for G6PD in the

hospital laboratory. Three cubic centimetre (3cc) of blood is withdrawn from

the patient and placed in a 3cc EDTA test tube which is then put in a Coleman

container filled with ice.

7. The Coleman container is wrapped in paper and. properly labelled and together

with a properly filled up filter paper are sent to New Born Screening Center

Visayas. Confirmatory tests are done every Mondays and Wednesdays in the

morning to allow for the samples to be sent by courier in the afternoon of the

same day and be received at \ New Born Screening Center Visayas for

evaluation on Tuesdays and Thursdays.

VI. TB CASES

1. All patients diagnosed to have TB should be routinely weighed.

2. Requests for sputum examinations must be properly filled up and procedures

for getting sputum samples must be properly explained.

3. All admitted/hospitalized patients with positive (+) sputum examination results

and positive (+) chest x-ray results should be referred to OPD for appropriate

management.

VII. MISCELLANEOUS

1. When writing dates, it must be in words and not in numbers.


2. During consultations of children 5 years old and below, the mother /folks must

present the under 5 Clinic Growth Chart.

3. For prenatal patients, we issue home based mothers record (pink card).

Instruction is given that they must bring it along and present them every time

they have prenatal check up.

4. Attach an anatomical diagram to the patients chart for every medico legal cases.

Make sure that the ROD has recorded his findings in the Medico-Legal Log

book. Indicate in the chart the following:

a. Name of the incident (NOI)

b. Tune of the incident (TOI)

c. Date of the incident (DO I)

d. Place of the incident (POI)

5. All consultations, dressings, injections, minor surgeries, prenatal check-ups etc.

are recorded in the OPD logbook

6. The 24 hour census of the day is taken on the following day and recorded on 2

separate Forms then submitted to the record section at the end of the month.


OPERATING ROOM

POLICIES AND PROCEDURES

OBJECTIVES:

1. To maintain asepsis and cleanliness within the area.

2. To ensure patient safety during surgery.

3. To know individual duties and responsibilities and promote teamwork among

surgical team.

POLICIES

1. Street Wears are not allowed inside the main operating room

2. Eating inside the main operating room is strictly prohibited.

3. The Operating room staff nurse is ready at all times for any possible procedure.

4. Consent slip is properly signed by the patient or folk before any procedure is

done.


5. Complete patients chart including laboratory, xray, ultrasound results must go

with the patients to the operating room.

6. All operations are logged in at the operating room logbook provide for.

7. All specimens taken from the patients are saved and properly labeled with

instruction and request form.

8. Equipments and instruments taken or borrowed from the operating room their

should be a borrower’s slip duly signed by the borrower’s, operating rom staff and

supply officer as well

9. Inventory of stocks, supplies must be done every last Friday of the month, any

lost, OR nurse on duty is held responsible.

10. All scheduled elective cases shaving of patients according to the type of operation

should be done on 3-11 shift.

11. There must be a written notice from the ward nurse for any scheduled emergency

operations.

12. All post operative patients’ are directly endorsed to recovery room; stationlarea

will be the one to received as to the type of cases done.

Ex. Surgical cases – station II

Ob-Gyne cases – station III

13. All stat and scheduled operation done after duty hours E.R. nurses are scheduled

on all as follows:

a. 7-3 (3pm – 6pm)

b. 3-11 (11pm – 7am)

c. 11-7 (6pm – 11pm)

Note: all outgoing off duties will be the first and 2nd on call major

surgeries.

14. No scheduled operation during the week ends and holiday unless emergency.

15. Charge slips for supplies and medicines are made every other operations.

16. Any operation done, NOD will be responsible to write the case number in the

logbook provided.

17. O.R. stretcher should not be used outside the operating room.

18. Taking of pictures inside the operating room while operation is going on, is

strictly prohibited, unless for documentation on approval from the Chief of

Hospital is required.

19. Logbook should not be out from the operating room.


20. Utility workers assigned at the operating room should check the availability of

Oxygen tank at all times.

21. Cleanliness of the OR must be maintained.

22. Observe the 5’s of good housekeeping.

23. Observe proper segregation of waste.

PROCEDURES:

OR Nursing Attendant / Utility Worker:

Transfer patient to operating room.

Nursing Attendant / Utility Worker

Disinfect operating room with Lysol every after operation.

Circulating Nurse:

Open operating room pack.

Prepare the set-up for the particular operation.

Arrange the packs on top of the operating room table.

Open additional packs needed for the particular operation.

Scrub Nurse:

Continue setting up as needed. (In abnormal operations)

Prepare suturing set and sponges.

Circulating Nurse:

Count sponges, instrument and needles.

Scrub Nurse:

Recheck the counting.

Circulating Nurse:

Write on the blackboard the number of sponges, instruments and

needles.

Staff Nurse:

Count sponges, instruments and needles with the circulating nurse and

scrub nurse before the operation starts.

Circulating Nurse:

Receive patient and check chart to find it all pre-operative

requirements and administered.

Check operative site, sterilize skin and drape patient.


Place patient in prescribed position to protect nerves from undue

pressure.

Set instruments and supplies according to specified order and to type

of operation to be performed.

(In abdominal operation)

a. Counts sponges and instruments and dictate to circulating nurse.

b. Write on the blackboard the number of sponges and instruments to be

use.

c. Anticipate needs of scrub nurse.

Anesthesiologist:

Check medicines needed for the operation

Prescribe substitutes for medicines not available.

Check and recheck blood pressure every five minutes and record in the

anesthesia record.

Sterile Nurse:

Anticipates needs of surgeon during operation

(Before surgeon closes the operation(abdominal)

Circulating and Sterile Nurse:

Check and tally the number of instruments and sponges used.

Scrub Nurse:

Remove all straps, clean and cover patient.

Take patients to the recovery room

OR Nurse:

Suction patient if still unconscious

Check vital signs every five minutes and record in the chart

Call doctor for any unusual signs observed

Record in the chart all observations made

Place tissues removed in appropriate containers

Place label showing name of patient, surgeon and room number

o (When patient regains consciousness)

Call Nursing Attendant

Nursing Attendant/ Utility Worker:

Take patient to the ward.


CHAPTER 5 INTER-DEPARTMENTAL COORDINATION

The other function of the nursing service is to unite its various functions

with other departments in the institution. This is what we call coordination

function of the nursing service; this helps achieve the hospital’s goals for each

department complements the work of the other.


Coordination with the Professional Medical Staff

In patient care planning, regular meetings and dialogues between the medical and

nursing staff are necessary. Discussion should include finding mutually satisfactory

solutions to problems related to the delivery of patient care. Together, the medical and

nursing staff will establish working arrangements, policies and SOP’s for the benefit of

the patients.

Coordination with the Radiology and Laboratory Services

Standard Operating procedures include:

1. Radiology or laboratory personnel inform nurses regarding patient preparation for

a procedure/treatment/exam.

2. Gives time schedule or appointments of patients for special examinations to

facilitate completion of desired examination.

3. Properly informs or notifies the Nursing service upon completion of the

procedure/test/examination in order to transport the patient back to his/her room.

4. Informs and gives the results of the examination/test/procedure to the nurse.

Coordination with the Administrative Staff

The Chief Nurse coordinates with the Administrative Staff during the following

procedures:

1. Recruitment and selection of personnel

2. Promotion of personnel

3. Procurement of supplies and equipments

4. Budget preparation

5. Maintenance of equipment


The Senior Nurse/ staff nurses’ reports problems related to housekeeping, laundry,

linen, equipment damages to the chief nurse and the chief nurse coordinates with the

Administrative Service since this is under their department.

Coordination with the Medical Records Service

The medical record is in-charge of safeguarding, maintaining, updating and

processing medical records of each patient. The nursing service plays a vital role in

ensuring the safety, confidentiality, and completeness and correctness of the nursing

records of the patients.

The following procedures are observed:

1. Each patient entertained in the ER or OPD are documented in a log-book.

2. All charts of discharged patients are checked by the nurse supervisor for

completeness and correctness and then are forwarded to the Medical Records for

filing within 24 hours after discharge.

3. The attending Physician completes the chart after patient’s discharge. In case the

physician is unable to do so, it is the Medical Records personnel’s responsibility

to ascertain its completion.

4. To safeguard the confidentiality of the patient’s records, the chart is directly to the

medical records section by the nurse on duty and not by the relatives/folks of the

patient.

Coordination with the Dietary Service

The dietary service assumes the responsibility of providing food service to

patients, including meal distribution. The nursing service personnel ensures that patients

are served the correct diet, see to it that changes in patient’s diet are correctly conveyed to

the dietitians, including instructions and counseling for special diets.

Coordination with the Pharmacy

The use of generic drugs is strictly practiced.


The Senior Nurse ensures the completeness of stocks of medicines to meet the

Emergency needs of patients. Nurses are instructed to always write the generic name of

the drug and to inform the relatives/folks to purchase it in the hospital pharmacy. The

nursing service personnel check daily the emergency stocks to ensure completeness, no

over-stocking and no expired medicines.

Coordination with the Social Welfare Office

The nurse coordinates concerning the psycho-socio-economic problems of the

patients to the Social Welfare Office. Nurses make the necessary referrals for patients in

need of blood, medicine, financial and material assistance.


CHAPTER 6 MONITORING STRATEGIES

& NURSING SERVICE AUDIT

Nurse Administrators and other Nursing Heads are responsible in

controlling, maintaining and improving the standard and quality services of the

nursing department. In order to keep track of the performance of the nursing

service personnel nurse administrators have come up with the following

monitoring strategies.


Monthly Meetings

The Chief Nurse of the hospital conducts monthly meeting of nurses and nursing

attendants (including utility workers assigned in the nursing service to ensure the quality

of services provided by the personnel in accordance to the hospital’s policies and

procedures, nursing service objectives, mission and vision, and the job expected/ stated in

the job description of personnel.

The discussion evolves on the things that should be properly observed such as

attendance, SOPs in every stations, benefits, sanctions, and ways of improvements.

Monthly meeting is conducted every second Tuesday of the Month.

The Nursing Service Audit

This is composed of selected members, and they conduct an official examination

of nursing records, physical facilities and personnel involved in patient care for the

purpose of evaluation, verification and improvement. They function similar to a Quality

Assurance Committee. Nursing audit serves as a means of improving nursing care by

revealing existing deficiencies.

Composition of the Nursing Audit Committee

It consists of the following: Chairman a Nurse Supervisor, Co-chairman a Nurse

Supervisor, 4 Members each a Senior Nurse per unit and an Ex-Officio member the Chief

Nurse.

Selection of committee members is done on a rotation basis with overcalling of

tenure of service. Regular audit committee meetings are held at least twice (2x) a month.

However, special meetings may be called as the need arises. Minutes of the meetings are

kept on file by the Chairman.


Objectives of the Nursing Audit Committee

1. Review systematically the nursing records of hospital patients

2. Maintain the record of performance of each professional nurse or staff

3. Develop and improve the quality if nursing care and nursing notes

4. Develop a means to reveal areas of strengths and weaknesses in the hospital

services

5. Develop better cooperation/collaboration among nurses and member of the health

care team

6. Provide means for self-evaluation of nursing care

Functions of the Committee

1. Act as liaison between the Nursing Service and the health care team

2. Serves as a means of correcting shortcomings

3. Aid in establishing a cooperative spirit among the nursing personnel

4. Keep confidential all information obtains during audits.

Committee Activities

Reviews records of discharged patients from one unit one meeting at a time.

Tallies patient evaluation forms upon discharge. Suggests/recommends ways of

improving/correcting shortcomings identified in the audit.

Responsibilities of the Committee

All members have a free access to the evaluated records. The Chairman of the

committee informs the nurse his/her deficiencies and suggests ways or means by which


these may be improved. The deficiencies are recorded in the individual nurse’s files. A

follow-up is done a month after the meeting with the nurse.

Performance Appraisal

The Performance Evaluation Survey (PES) is used to evaluate the personnel’s’

performance. This is done to help an employee improve his/her work methods to ensure

the achievement of organizational goals. Each employee should be evaluated by the line

supervisor and vise versa.

It is conducted every six months, June and December of the year. The evaluation

process is a two way process, the one who evaluates (rater) should be evaluated by the

ratee as well. The only difference is the format of the PES form.

Peer evaluation, superior, subordinate and self-evaluation systems are practiced by

the institution. After evaluation all data gathered is collaborated and a general conclusion

and recommendation is formulated by the Nursing Audit Committee.

THE PERFORMANCE EVALUATION SYSTEM

All departments and agencies are required to have a performance evaluation

system which will:

1. Continuously foster improvement of employee performance and efficiency;

2. Enhance organizational effectiveness and productivity;

3. Provide an objective performance rating which shall serve as basis for incentives

and rewards, promotion, training and development, personnel actions and

administrative sanctions.

The Evaluation System must meet the following minimum requirements:

1. Identification of outputs and job-related behaviors of the position/function and the

corresponding performance standards which should be mutually agreed upon by

the supervisor and subordinates for a particular appraisal period.


2. Means by which employees are currently advised of their progress in

accomplishing assignments.

3. Opportunities for supervisors to make comments and recommendations regarding

employee’s strengths and weaknesses which may be instrumental in furthering a

career or identifying constraints that may impede one’s development.

4. Frequency of formal appraisal. Performance evaluations are done every six

months ending in June 30 and December 31 of every year. However, if the

organizational needs require a shorter or longer period, the minimum appraisal

period is at least 90 days or 3months. No appraisal period runs beyond one year.

Evaluation Principles:

1. For a worker's performance evaluation to be valid, it must be based on his/her job

description and performance standards.

2. An adequate and representative sampling of the nurses' behavior should be

observed in the process of evaluating performance. Care must be taken to evaluate

his/her usual or consistent behavior. Focusing on or magnifying an isolate distance

of either extremely capable or extremely inept behavior on the part of the nurse

should be avoided.

3. The nurse should be provided with a copy of his/her job description, “performance

standards and evaluation form to review prior to the scheduled evaluation

conference so that the nurse and his/her supervisor can discuss the evaluation from

the same frame of reference.

4. In documenting the employee's performance appraisal, the manager should

indicate clearly those areas in which the worker's performance is satisfactory and

those which need improvement. The supervisor should refer to specific instances

of the nurses' satisfactory and unsatisfactory behavior in order to clarify exactly

what types of changes are required in his/her performance.

5. If there is a need to improve the nurse's performance in several areas, the manager

should indicate which area(s) should be given priority by the nurse.

6. The evaluation interview should be scheduled at a time convenient for both the

nurse and the manager. It should be held in a pleasant surrounding and should

allow time for both parties to ask questions and discuss the evaluation at length.

Types of Performance Evaluation Tools Utilized by the Hospital


1. Performance Checklist

This consists of a list of performance criteria (one for each of the most

important tasks in the employee's job description) with corresponding blanks

wherein the evaluator is asked to indicate, "for each criterion whether the nurse

has or has not exhibited the desired behavior. Since the criteria are statements of

desired or approved behavior, a quick glance at the completed form reveals the

overall quality of the nurse's total work-performance.

2. Rating Scale

This includes a series of items representing different activities or tasks

included in the nurse's job description. The supervisor is asked to indicate the

quality of the nurse's performance for each activity by checking the appropriate

point on a numerical scale. Example: On a scale of 0 through 10, indicate the

degree of the nurse's manual skillfulness in handling surgical instruments and

supplies.

High 10 - Outstanding8 - Very Satisfactory6 - .Satisfactory4 -- Unsatisfactory

Low 2 – Poor

Other Strategies

FOR THE CHIEF NURSE

1.) Communicating effectively - Chief Nurses engage in both horizontal and

vertical communication at the unit level. They are seen as the pivotal point person,

or ‘go to’ person. They must master the art of assertive and persuasive

communication, as well as develop negotiation and listening skills.

2.) Building Team Synergy – Chief Nurses play a crucial role in the retention

and turnover of registered nurses. As team leaders, they set the tone for unit

performance by creating a culture which promotes staff effectiveness and

productivity, with the goal of coordinating all components of patient care.

FOR THE NURSE SUPERVISOR

1.) Maintain nursing staff job results by coaching, counseling, and disciplining

employees; planning, monitoring, and appraising job results.


3.) Maintain a cooperative relationship among health care teams by communicating

information; responding to requests; building rapport; participating in team

problem-solving methods.

FOR THE HEAD NURSE

1.) Patient teaching - The head nurse conduct health teaching to the patient to ensure

and answers some of the patients' queries.

2.) Evaluating and disciplining - Evaluates the performance of nursing personnel

through regular rounds in the ward

3.) Helps coordinate the clinical nursing staff - Coordinates, guides and direct the

development, implementation and evaluation of nursing regimen for patients

within a specific nursing unit

4.) Coordinate the nursing staff


CHAPTER 7NURSING SERVICE PERSONNEL POLICIES

These serves as the guidelines of the nursing service department from

selection to recruitment to appointment to promotion, termination and other legal

aspects concerning the government employee.


The personnel policies for hospital personnel under the new Ministry of Health are

governed by provision under Republic Act 2260 of the Civil Service Law and Rules and

Regulations Implementing the Labor Code of the Philippines, Administrative and

Department Orders. Within the provisions of these general policies, the nursing service

personnel policies are administered by the Chief Nurse under the supervision of the

Administration with freedom to establish its procedures and techniques which would

provide for their effective functioning and promote efficiency and improvement of

morale. It is incumbent upon nursing personnel to follow lines of authority to support

policies, to observe regulations to be loyal to the institutions and to give the hospital the

best of service of which they are capable. (Excerpt from the Nursing Administrative

Manual 2nd edition)

Recruitment, Selection for Appointment and Promotion

RECRUITMENT: It is the process of guiding an interested registered nurse an

available opening in nursing positions. Under Article VI, Sec. 23 (Civil Service Rules &

Laws) on recruitment and Selection of Employees-It states: "Opportunity for government

employment shall be open to all qualified citizens and positive efforts shall be exerted to

attract the best qualified to enter the service."

Nursing applicants should meet the following requirements:

1. Must be a Filipino citizen.

2. Must have graduated from an accredited school or college of nursing.

3. Must have passed the Nurse's Board Examination and licensed to practice

nursing in the Philippines by the Professional Regulation Commission, Board

of Nursing.

4. Must be a Civil Service Eligible by R.A. 1080.


5. Must be in good physical and mental condition.

6. Must have High Ethical Standards

SELECTION: Employees shall be selected on the basis of their fitness to

perform the duties and assume the responsibilities of the position whether in the

competitive and classified or in the non-competitive or unclassified service.

SCREENING COMMITTEE: For the purpose of selecting for appointment or

promotion of subordinate non-medical employees, the Screening Committee has been

created under Department Memorandum No. 106, s.1964 and organized under

Administrative order No.26, s. 1966 to compose the following offices:

Hospital Administrative Officer or Chief of Hospital-Chairman

Chief of Clinics or Supervising Resident- Member

Chief of Nursing Service- Member

Chief of Dietary Service – Member

Hospital Dentist- Member

The Chief of Hospital shall recommend to the Human Resource Management

(HRM) of the Province of Negros Occidental the proposed appointee as screened by the

Committee.

Employment Procedure for Nursing Personnel

1. Nursing Service Department (or Personnel Officer if there is any)

a. Accepts applications.

b. Administers entrance examination (IQ test, Nursing Aptitude Test

and Psychology test)

c. Makes appointments for interview. (Only examination passers will

proceed to the interview)

2. Screening Committee (composed of Chief Nurse as Chairman and Supervising

Nurse as members)

a. Evaluates general professional and personal qualification and experience of the

applicants.

b. Interviews and screens applicants.


c. Recommends acceptance or rejection of applicants to the Hospital Screening

Committee.

3. Administrative Officer in the absence of a Personnel Officer

a. Informs applicants who have satisfactorily met the requirements.

b. Informs applicants of other requirement papers for appointments and physical

health examination.

c. Prepares all application papers to be forwarded to the HRM.

APPOINTMENTS: All appointments to the position in the competitive or

classified service must be made in acceptance with the provisions of the Civil Service

Law and Rules and the Compensation and Position Classification Bureau. Appointments

should be prepared in the prescribed form, duly signed by their commanding officer: The

Provincial Governor, the Chief of Hospital, the Human Resource Officer of the Province

of Neg. Occ. This shall be submitted to the Civil Service Commission for approval.

Requirement for Appointment

(Papers shall be prepared in 6 copies)

1. Information sheet of the appointee.

2. Record of physical and medical examination of the appointee duly accompanied

by a physician.

3. Identification picture – passport size.

4. Assets and liabilities.

5. Certificate of eligibility under Republic Act 1080 as amended by Republic Act

1344.

6. Clearance from the National Bureau of Investigation; Philippine National Police

or Local Chief of Police.

7. A certificate of the Chief of Agency that the provisions on promotion and

nepotism have been observed and funds are available.

Processing of Appointment Papers

Appointment papers shall be coursed through the following agencies:


Flow process of appointment papers:

a. The Chief of Hospital.

b. The Civil Service Commission.

c. Human Resource Management Office.

Types of Appointments

Appointment in the Civil Service are either permanent or temporary.

a. Permanent Appointment

A permanent appointment is issued to a person who possesses the

appropriate Civil Service eligibility and have met the qualification

requirements prescribed to fill the position. A permanent appointment maybe

original or through transfer, promotion, demotion, re-employment or re-

instatement.

b. Temporary Appointment

A person who does not have appropriate civil service eligibility but

who possesses the other qualifications required to fill the position may be

given a temporary appointment. A temporary appointment shall not be more

than twelve (12) months and the appointee may be replaced any time a person

who possesses the appropriate civil service eligibility and other qualifications

for the position becomes immediately and actually available.

c. Substitute Appointment

It is a temporary appointment wherein an appointee replaces one who

is on leave for a definite period of time.

Terminologies

TRANSFER

A transfer is a movement from one position to another which is of equivalent rank, level

of salary, without breaking service and involving the issuance of an appointment. The

transfer maybe between hospitals to another or from one organizational unit to another in

the same agency. An employee who seeks appointment by transfer to another office shall

first secure permission from the head of agency or department where she is employed.


The permission to seek transfer to another office granted to the employee shall be valid

for another thirty (30) days from request of the employee. The head of the agency shall

not propose or make the appointment for the transfer of an employee to any department or

agency until the written consent of the head of the agency where the employee is

employed has been obtained

DETAIL

A detail is the movement of an employee from a department or an agency t o another

which is temporary in nature and does not require the issuance of an appointment. Detail

shall not be allowed outside of the original station more than three (3) months without the

consent of the employee concerned.

RE-ASSIGNMENT

It is the movement of an employee from the organization unit to another in the same

department or agency which does not involve a reduction in rank, status or salary and

does not require the issuance of an appointment.

RE-INSTATEMENT

A person who has been permanently appointed in the classified service and who has,

through no delinquency or misconduct been separated there from, upon the request of the

proper officer and the certification of the Civil Service Commissioner be reinstated to a

vacant position of a grade or class not higher than the one he has been separated from,

subject to the conditions provided by law or existing civil service rules.

RE-EMPLOYMENT

It is the re-appointment of a person who has been appointed permanently to a position in

the career service and who has been separated as a result of reduction of forced re-

organization.

Conditions of Employment

TENURE


Nursing personnel with civil service eligibility are given permanent positions after six

months of satisfactory service to the institution. They hold their appointments

permanently until such time when they are promoted to higher positions or transferred to

other offices, reassigned or separated from the service either on optional retirement or

reaching the automatic compulsory retirement age of 65.

SUBSISTENCE, QUARTERS AND LAUNDRY ALLOWANCE (Rep. Act 649)

The Secretary of Health and Head of other departments of the government which employ

nurses should give free quarters, and allowances and laundry to all nurses who are

employed in the institution or hospital.

EFFECTIVITY OF APPOINTMENT

Appointments shall become immediately effective upon the assumption of duties of the

appointees entitling them to receive all the corresponding salaries and benefits. Unless

otherwise provided by law, approval of appointments shall be a sufficient authority for

the payment of salaries to the appointees.

SALARIES

Wages are established on the basis of equal pay for equal work. To insure that the

individual employee's salary rate is consistent with the job requirement and job

performance, the Office of Compensation and Position Classification plans for various

occupation groups. Payroll deductions are made from the pay envelope as required by

law. The deductions include insurance, retirement premiums, withholding tax, PhilHealth,

and other authorized deductions as salary loans, policy loans and real estate loans.

Night shift differential, overtime pay and Holiday Pay is not observed in the institution.

Hazard pay equivalent to 25% f monthly basic salary is given to all employees with

salary grade 19 and below and 5% for those with salary grade 20 and above. Subsistence

allowance is also given to all regular employees and this is equivalent to 20% of their

monthly basic salary. Laundry allowance of Php125 per month is provided to all regular

employees.

Monthly salaries are given every first Friday of the month and deductions are reflected on

the pay slip.


TERMINATION OF EMPLOYMENT

(Resignation or Transfer)

The nursing employee seeking transfer to another agency or who voluntarily resigns from

the service should notify in writing such intention to the Chief of Hospital through the

Nursing Office at least one month prior to the affectivity of the resignation or transfer

date. This will give the Chief Nurse an ample time to make the necessary adjustment of

her staff and to secure a replacement as well as give the employee enough time to turn her

responsibilities without interruption. A clearance paper must accompany the application.

A statement of assets and liabilities should also be properly accomplished. An exit

interview with the Chief Nurse and her assistant is desirable for evaluation and to ensure

good relationships.


CHAPTER 8 PAY AND BENEFITS

Employee welfare and benefits help maintain and retain competent

personnel. Welfare and benefits program either augment regular salary or

indirectly improve socio economic conditions. Government employee benefits are

more generous.

Increased morale by way of salary has been enhanced with the

standardization (RA 6758) of government pay.


Leave Benefits

Granted to reward a regular employee for continuous services rendered in

the government. This is granted to enable one to rest and to recuperate as well as

to regain vigor and energy. As a whole leave laws are intended to promote

efficiency, general welfare and morale within the rank of government employees.

All employees of the government whether permanent or temporary, after 6

months of continuous and satisfactory service, is entitled to an annual 15 days

vacation and 15 days sick leave, with full pay. This leave is exclusive of

Saturdays, Sundays, and public holidays and without limitation as to the number

of days of vacation and sick leave that one may accumulate.

VACATION LEAVE

Vacation leave of absence is usually taken for personal reasons and

granted depending on the contingency and needs of the service. It aims to

provide rest and relaxation essential to your mental and physical health.

You are entitled to an annual vacation leave of 15 days with pay,

excluding Saturdays, Sundays and holidays with no limit on accumulation.

Application for vacation leave is filed five days in advance.

However, granting of vacation leave is discretionary on the part of the

nurse administrator and the chief of hospital.

An employee is required to go annually on vacation leave for a

minimum of five working days, which need not be successive. The

mandatory annual five-day vacation leave is forfeited if not taken during

the year. However in case where your scheduled leave has been cancelled

in the exigency of the service by the head of agency, the scheduled leave

not enjoyed will no longer be deducted from the total accumulated

vacation leave.

SICK LEAVE


Sick leave is taken on account of personal sickness of that of any

member of your immediate family which prevents you from reporting for

work. Immediate member of the family refers to any relative living under

the same roof and dependent upon the employee for support. You earn 15

days of annual sick leave with pay with no limit on accumulation.

All application for leave will be submitted five days before the

scheduled leave and must use the prescribed form. Application of sick

leave in excess of five days should be accompanied with proper medical

certificate

MATERNITY LEAVE

Maternity leave is granted to a female married/unmarried employee

in case of pregnancy. It is granted in order to extend to working mothers

some measure of financial support and to provide them a period of rest and

recuperation during periods of pre- and post-natal care.

Accordingly, women in the government service who have rendered

two (2) or more years of continuous service, in addition to the vacation and

sick leave granted to them are also entitled to maternity leave of sixty (60)

days with full pay to start on or before giving birth, depending on the

health of the mother; leave benefits of two (2) months for government

employee women who undergo surgery caused by gynecological disorders

and CS delivery.

For those who have rendered less than two (2) years of continuous

service, they may receive full pay for a number of days based on the ration

of 60 days to two (2) years of continuous service.

ABSENCE WIHTOUT LEAVE

Absences covering at least thirty (30) days without approved leave

is considered absence without leave (AWOL). If you are declared AWOL,

you will be dropped from the service. However, when the exigencies of

work require your service and you fail/refuse to return to the service, the

head of office may drop you from the service even prior to the expiration

of your 30 days leave.


PATERNITY LEAVE

Paternity leave of seven (7) days with full pay is given to a married

male employee under RA 8187. However, these leave can be availed of for

the first four deliveries of the legitimate spouse. Paternity leave can be

enjoyed on the days immediately before, during or after the child’s birth or

miscarriage of the legal spouse. This leave is non-cumulative and cannot

be converted into cash.

Government Office Hours

Government employees are required to render eight (8) hours of work a

day or a total of forty (40) hours a week, exclusive of time for lunch.

Government Service Insurance System (GSIS)

The GSIS of the Philippines was created under Commonwealth Act No.

186. It is a government owned/controlled corporation (GOCC) and partly engaged

in government financial institution (GFI) operations. Its purpose is to render

assistance as well as to provide life-time protection to the government employee

and his/her family, your heirs or beneficiaries, in the event of contingencies such

as retirement, disability or death. It also extends your privileges in terms of salary,

policy, emergency/calamity and housing loans.

Government employees are covered by GSIS on a compulsory basis.

GSIS BENEFITS

Retirement Benefits- separation from the service at the mandatory age of

65 years is called compulsory retirement. A retirement at any earlier age is

referred to as optional retirement. Both retirement schemes require a

minimum service rendered. RA No. 660 provides that if your reach the

compulsory retirement age of 65 and you have completed at least 15 years

of service, you will receive a lump sum payment of the equivalent monthly


pension for the first five years and thereafter, a monthly pension for as

long as you live. Moreover if you are 63 years old and have completed 16

years of service, you can also avail of the retirement benefits. Under RA

No. 660, you can also avail of an optional retirement at age 52 to 64 and

with 15-35 years of service. This is termed “magic 87” which means that

the sum of your age and the length of your service must be 87. Benefits

include a lump sum payment for the first five years and a lifetime monthly

pension thereafter.

Compulsory Life Insurance- permanent employees are entitled to an

automatic endowment insurance based on a certain criteria. The amount of

insurance is based on your insurance plan, age and salary. Benefits under

the insurance are maturity, death, accidental death, cash surrender value,

insurance loans, and dividends. Upon maturity of your life insurance, you

receive maturity benefits less any indebtedness therein.

Sickness Income Benefits- for non-working connected sickness or injury

which results in temporary total disability is available after you have

exhausted all your sickness leave credits but not earlier than the fourth day

of your sickness or injury. You cannot avail of the sickness income

benefits and sick leave pay simultaneously. Benefits of not less than four

(4) pesos nor more than twenty (20) a day can be availed of by you, if you

have paid at least six (6) monthly contribution in the twelve-month period

preceding your sickness or injury.

Death, Accidental Death and Burial Benefits- are received by your

beneficiaries if you die prior to the maturity of your policy. When your

death is accidental and occurred within 90 days after the accident, the

accidental death benefits are twice the value of your insurance. Moreover,

a burial expense of Php 6,000.00 can be claimed by your beneficiaries.

Survivorship Benefits- non-working connected deaths will be paid to

your primary and secondary beneficiaries. The basic survivorship pension


is equivalent to 50% of your basic monthly pension plus dependent

pension not exceeding 50% of your basic monthly pension.

Cash Surrender Value- is paid to you if you resign or is separated from

the service, provided that your insurance has been in force for one year. If

you are dismissed for causes, only half of the value will be paid.

Separation benefits are also available if you are below age 80 and was

separated from the service after less than 15 years of service. Cash

payment equivalent to 100% monthly compensation for each year of

service is paid to you at age 60. Your cash payment should not be less than

Php 500.00. If you have at least 15 yrs. of service and you are below age

60 when you were separated from the service, you are entitled to five (4)

years lump sum payable upon reaching age 60. You are also entitled to a

lifetime monthly pension upon expiration of the five-year period.

Loan Privileges- you can obtain insurance loans in the form of salary and

policy loan if you have been insured for at least one year.

Salary Loan- granted in the amount equivalent to one month salary

if you have been a member for 20 months or over, two month

salary loan if your membership is 40 months or over and three

month salary loan if membership is more than 60 months.

Payments are made in 12 monthly installments and you can renew

your loan after paying 6 monthly installments. Two or 3 month

salary loan is payable 24 monthly installments renewable after

paying 12 months installments.

Emergency Calamity Loan- if you are a victim of either typhoons,

floods or earthquakes or other calamities in a locality declared as a

calamity area by a Presidential Proclamation. A five month salary

loan is the maximum amount you can borrow.

Educational Loan- is available for the purpose of financing studies

of your children or upon certification of the Division


Superintendent of the DepEd. It is payable upon employment of the

grantee or after one year from graduation.

Fly-Now-Pay-Later Plan- you can avail a one month salary loan

for purposes of defraying your domestic travel expenses. Such loan

is payable within one year in twelve monthly installments through

salary deduction.

Housing Loan- can be secured through the National Home

Mortgage and Finance Corporation, EO No. 90 rationalize all

housing program of the government and offers this loan. The

amount of loan offered to you is based on the date of issue your

policy, your age at the time when your insurance was issued,

amount of your insurance, your salary and the endowment plan of

your insurance.

Pre-need Protection Programs

1. Stock Purchase Financing Program (SPFP) - is available for the

purpose of acquiring shares of stock as a form of investment.

2. Family Hospitalization ‘Plus’ Plan- this plan covers hospital rooms

and board, doctors, surgeons and anesthesiologists fees, x-ray,

medicines and laboratory fees not covered by Medicare benefits

plus automatic accident insurance benefits. This also covers spouse

and up to five children. A convenient premium payment is offered

under this plan through salary deduction.

3. College Education Assurance Plan- available for the purpose of

acquiring a trust fund to finance future college education of your

child or kin.

4. The Genesis Memorial Plan- this plan guarantees, in case of your

death, the rendition of proper memorial service, regardless of

prevailing cost in the future and/or giving out cash benefits to your

beneficiaries.


PhilHealth

Established in order to provide viable means of helping the employee pay

for adequate medical care. This health insurance program subsidizes your sickness

and those of other members who find themselves in sudden need of financial

assistance when hospitalized. The Philippine Health Care Insurance administers

the PhilHealth Program and the GSIS is one of the Administrators of the health

insurance funds from the government sector.

This Program covers room and board, medicines, x-ray, laboratory,

surgeon, doctor and anesthesiologist fees, operating room fee and allowance for

sterilization procedures. All salaried government employees including legal

dependents such as spouse and children below 21 years of age are covered by this

program.

If the illness or injury is work connected or related, the member can avail a

much higher benefit under the Employee Compensation Program.

Employee’s Compensation Benefits

Created under presidential Decree No. 626 is a tax-exempt compensation

program for employees and their dependents. Is aims to help you and your

dependents, in the event of employment-connected injury, sickness, disability or

death, so you can promptly receive meaningful and substantial income benefits,

medical and related services and rehabilitation services.

PAG-IBIG (Home Development Mutual Fund)

Pagtutulungan sa Kinabukasan: Ikaw, Bangko, Industriya at Gobyerno

(PAG-IBIG) fund is a provident savings fund and a housing credit system for

wage earners. The fund aims to provide employees with an integrated nationwide

savings and housing credit system. PAG-IBIG Membership is compulsory for all

GSIS members. As member you will enjoy the following benefits:


1. Provident Benefits- double or triple savings, dividend earnings,

probability of Savings and Government Guaranteed Savings.

2. Short-term Loan Programs

3. Expanded Housing Loan Program

Other Benefits

Clothing Allowance- an annual clothing allowance for office uniform is available,

but is subject to availability of funds.

Year-End Benefits- RA No. 6686 implemented by National Compensation

Circular No. 54, provides an annual year-end bonus equivalent to one month basic

salary also known as the ”Thirteenth Month” bonus and a cash gift of Php

1,000.00 to all government officials and employees, regardless of appointment

status. Such benefit is granted if you have rendered four (4) months of service

within the period of January 1 to October 31 in a given year. The year-end benefit

is given twice a year, that is half (50%) of the total amount is given in June (Mid-

Year Bonus) and the remaining half is given in December. Further, this year-end

benefits are exempted from taxation.

Anniversary Bonus- pursuant of AO No. 263 of the Office of the President,

government employees are entitled to an anniversary bonus of not more than Php

3,000.00. This is given regardless of employment status.


CHAPTER 9 GRIEVANCE & DISCIPLINARY PROCEDURE

The grievance machinery aims to resolve problems and conflicts at the

lowest levels of organization before it grows into unmanageable proportions that

may result in strike(s) or interruption of public service. Thus, it operates as a

safety valve to resolve complaints and dissatisfaction through a formal system of

adjustment of grievances.


In any organization, no complaint grievance is too small to be set aside because

this will undermine morale and effective performance.

An employee who feels dissatisfied, jealous or discontented will not be able to

carry out his/her duties and responsibilities affectively. A mechanism should be installed

to ensure that grievances of all employees are treated fairly, justly, and expeditiously by

management.

Grievance Committee

A group of representatives chosen from a labor union or from both labor and

management to consider and remedy workers' grievances.

Grievance Committee Principles

(a.) An employee/union may without resorting to formal grievance procedures, discuss

informally any problem relating to his conditions of employment with the

supervisor.

(b.)In presenting a complaint of grievance, the employee is assured freedom from

coercion, discrimination or reprisal and of a speedy and impartial settlement of

such complaint or grievance.

(c.) Complaints and/or grievances must be resolved at the lowest possible level in the

agency.

(d.)Grievance proceedings are not bound by formal legal rules and technicalities.

(e.) An employee has the right to appeal decisions on grievances to such competent

authorities.

(f.) A complaint or grievance is considered not only in relation to its alleged object,

but also in relation to the personal situation of the complainant.

Complaints and grievances may arise between the employee and the supervisor or

between the union and the management on any or all matters that cause employee

dissatisfaction.


Composition of the Grievance Committee

1. For complaints/Grievances existing between and among individual employee

and supervisor/ management:

(a) One member of top management for each representative to act as

chairman.

(b) One higher supervisor except the one being complained of.

(c) One member of the rank and file.

2. For complaints/Grievances existing between the management and recognized/

bargaining unit:

(a) One member of top management or its representative to act as chairman

(b) One higher supervisor.

(c) One member of the association.

Guidelines for the Grievance Committee

1. Scope:

a. The Grievance Committee shall consider only individual grievances of

specific nature of members of the Association/Agency and raised individually

by the concerned aggrieved employee.

b. The Grievance Committee shall not consider any grievance of general

applicability or of collective nature of raised collectively by more than one

employee.

c. An employee who is a member of the union may address a grievance as an

individual or as a union member.

2. Procedure, Periodicity and Attendance at Meetings:

a. The Grievance Committee will meet at least once a month.

b. At least three members of the Grievance Committee shall be present in a

meeting.


c. If a member of the Grievance Committee is connected with the grievance of

the aggrieved individual, the concerned member of the Grievance Committee

shall not participate in the deliberations regarding that individual's case.

d. If the aggrieved person happens to be a member of the Grievance Committee,

then he shall not participate in the deliberations as a member of the Committee

when his/her representation is being considered.

Grievance Procedures

Grievance procedures refer to the method of determining and finding the best way

to remedy the specific cause or causes of the complaint or grievance filed individually by

the aggrieved employee. At the first instance, the complaint or grievance should be settled

at the lowest rank, typically between an employee and immediate supervisor.

(a) Oral Discussion- a complaint is presented orally first to the employee’s

immediate supervisor who will, within three (3) days from the date of

presentation, inform the employee orally of his decision.

(b) Grievance in Writing- If the employee is not satisfied with the decision of

the immediate supervisor he/she may submit the grievance in writing through

the immediate supervisor, to the next higher officer of official. Within five

days from the date of receipt of the written grievance, the next higher official

will render a decision and inform the employee in writing through the

immediate supervisor.

(c) Appeal to the Agency Head- If the employee is not satisfied with prior

decisions concerning the grievance, he/she may submit, through proper

channels, the grievance in writing to the department or agency head, who may

refer it to a grievance committee constituted for the purpose.

If the supervisor is the subject of the complaint, the next higher level directly acts

on the complaint filed.

Any party dissatisfied with the decision/resolution of a case that went through the

grievance procedure in their agency may appeal the case to the Grievance Committee.


The Grievance Procedure also refers to settling complaints and grievance of

registered employees’ union or members arising out of conflicts or disputes involving

terms and conditions of employment:

1. The union files its grievance in writing with the head of the agency for decision.

2. Where the object of the grievance is top management, either or both parties may

request for conciliation mediation from the Grievance Committee.

3. If the dispute remains unresolved and irreconcilable after exhausting all the

available remedies of negotiation, conciliation and mediation.

The time limits for each step are set in the grievance procedure. Usually, it takes

five to ten days at each level to make a decision. This time limit hastens action on all

complaints and grievances.

Steps in the Grievance Process

A. INITIAL MEETING OF THE COMMITTEE

1. Reviewing of Grievance Process and Role of Committee Members and Chair

Grievance Process

Role of Committee Members

Conflicts of Interest

No Ex Parte Communications

2. Reviewing the Grievance Statement to Determine Jurisdiction

Is the grievance filed against a proper party?

Does the grievance state a grievable matter?

Was the grievance timely filed?

Has the grievant followed the preliminary steps requisite to filing the

grievance?

B. THE PRE-HEARING CONFERENCE

Conflicts of Interest

Jurisdictional Issues

Issues in Dispute

http://www.ncsu.edu/general_counsel/legal_topics/grievance_committee/grievance_committee_manual.php#Prehearing

http://www.ncsu.edu/general_counsel/legal_topics/grievance_committee/grievance_committee_manual.php#Orientation

http://www.ncsu.edu/general_counsel/legal_topics/grievance_committee/grievance_committee_manual.php#Steps


Agreed Upon Statement of Facts

Procedural Decisions

C. THE GRIEVANCE HEARING

Opening Statements

Presentation of Grievant's Case

Presentation of Respondent's Case

Closing Statements

D. DELIBERATIONS

Role of the Chair

Resolving Conflicts in Testimony

E. WRITING THE DECISION

Composition of the Grievance Committee

Process Followed by the Committee

Identification of the Parties

Statement of the Grievance

Findings of Fact

Recommendations

Minority Report

F. THE OFFICIAL RECORD

Grievance Statement and Respondent's Response

Correspondence

Transcript

Exhibits

Excluded Evidence

G. DISCHARGE OF THE COMMITTEE AND/OR FURTHER PROCEEDINGS

Disciplinary Procedures

http://www.ncsu.edu/general_counsel/legal_topics/grievance_committee/grievance_committee_manual.php#Discharge

http://www.ncsu.edu/general_counsel/legal_topics/grievance_committee/grievance_committee_manual.php#Record

http://www.ncsu.edu/general_counsel/legal_topics/grievance_committee/grievance_committee_manual.php#Decision

http://www.ncsu.edu/general_counsel/legal_topics/grievance_committee/grievance_committee_manual.php#Deliberations

http://www.ncsu.edu/general_counsel/legal_topics/grievance_committee/grievance_committee_manual.php#Hearing


The general policy on employee conduct and discipline in the civil service is ”No

employee in the civil service shall be removed or suspended except for cause as provided

by law and after due process”.

The power to discipline, investigate and decide matters involving disciplinary

action against an employee rests on the heads of departments. It is the nurse supervisor

along with the chief nurse who composes the disciplinary team.

Types of Offenses

Grave Offense- resulting to legal liabilities, a matter of life, punishment is dismissal on

the first offense.

Less Grave Offense- example is giving of medication errors, may result to suspension on

the first offense.

Light Offense- penalty, reprimand, suspension and dismissal for the 3rd offense.

Example of offenses: habitual absenteeism and tardiness, sexual harassment.

Disciplinary Procedures

For light and less grave offenses:

First offense- the unit head/ head nurse will call the attention of the employee who

committed the offense and reprimand him/her verbally.

Second offense- the employee must write an explanation letter addressed to the

Chief Nurse through the head nurse explaining the reason why

he/she committed the offense for the 2nd time.

Third offense- an incident report must be made and the matter will be forwarded

by the Chief Nurse to the grievance committee for management.

For grave offenses:

First offense- the employee must submit and incident report within 24Hours of the

incident to the Chief Nurse noted by the unit head, for

documentation purposes.

*any legal matters regarding the offense is handled by the administrative staff.


Recent policies on Administrative Offenses and Application of Penalties

Habitual absenteeism and tardiness

These are reclassified from light offense to grave offense. This is punishable by

suspension for six months and one day to one year, for the first offense, to a maximum of

dismissal for second offense. You will be considered habitually absent if you incur

unauthorized absences exceeding the allowable 2.5 days monthly leave credit under the

leave law for at least three months in a semester or at least three consecutive months

during the year.

This means that the maximum number of months you can exceed the 2.5 days

monthly leave credit limit in a single semester is two months to avoid being considered as

an offender of habitual absenteeism. Absences exceeding 2.5 days per month backed by

approved leave of absence do not constitute habitual absenteeism.

You will be considered habitually tardy if you incur tardiness, regardless the

number of minutes, ten (10) times a month for at least two (2) months in a semester or at

least two (2) consecutive months during the year. This means that if you have already

been tardy ten times in a month in a semester, the maximum number of tardiness you will

incur for the succeeding months is only nine (9) times so you will not be considered

habitual tardy. Further, you should not be late ten times in a month of July if you already

incurred ten times or more tardiness in June of the same year.

Sexual Harassment

If done by another employee or officer now constitutes a ground for disciplinary

action. It is a grave offense and subject to dismissal from the service according to CSC

Res. No. 94-2854 dated May 31, 1994.

Sexual harassment is series of incidents involving unwelcome sex advance,

requests for sexual favors or other verbal or physical conduct of sexual nature, made

directly, indirectly and implied when: (1) such conduct might reasonably be expected to

cause insecurity, discomfort, offense or humiliation to another person or group; (2)

submission to such conduct is made either implicitly or explicitly a condition of

employment or opportunity for training or grant scholarship; (3) submission to rejection


of such conduct is used as basis for any employment decision; (4) such conduct has the

purpose or the effect of interfering with a person’s work performance, or creating an

intimidating, hostile or offensive work environment.

You may be placed under preventive suspension while an investigation is going

on if the charge against you involves dishonesty, oppression or grave misconduct or

neglect in the performance of duty, or if there are reasons to believe that you are guilty of

charges that warrant your removal from the service.

Preventive suspension is not a punishment for misconduct in the office but

considered as preventive measure. It is not considered part of the actual penalty of

suspension imposed upon you, if found guilty.

You can be suspended for a period not exceeding ninety (90) days. After ninety

days you will be automatically reinstated even if the investigation has not been

terminated. But when the delay in the disposition of the case is due to your fault,

negligence or your petition, the period of delay will not be included on the accounting of

the 90 day calendar-day suspension.

Pursuant to Sec. 22 of Rule XIV of the Omnibus rules implementing Book V of

Executive Order No. 292, the following are administrative guidelines for the application

of penalties in administrative cases.

1st Offense 2nd Offense 3rd Offense

A. Grave Offenses

1. Gross Neglect of Duty

2. Grave Misconduct

3. Disgraceful and Immoral

Conduct

4. Inefficiency and

Incompetence in the

performance of official duties

Dismissal

Dismissal

Suspension6 mos.

and 1 day to 1 year

Suspension 6 mos.

and 1 day to 1 year

Dismissal

Dismissal


5. Gross insubordination

6. Falsification of official

documents

7. Receiving for personal use of

a fee, gift or valuables when

such gift is given in the hope

of expecting or receiving a

favour or better treatment or

committing acts punishable

under the anti-graft laws.

8. Disclosing or misusing

confidential or classified

information officially known

to him by reason of his office

and not mad available to the

public, to further his private

interests or give undue

advantage to anyone or to

prejudice the public interest.

B. Less Grave Offenses

1. Simple neglect of duty

2. Simple misconduct

3. Insubordination

Suspension 6 mos.

and 1 day to 1 year

dismissal

dismissal

Suspension 6mos.

and 1 day to 1 year

Suspension 1mo.and

1 day to 6 mos.

Suspension 1mo.and

1 day to 6 mos.

Dismissal

Dismissal

Dismissal

Dismissal

Dismissal

Dismissal


C. Light Offenses

1. Discourtesy in the course of

official duties

2. Refusal to render overtime

service

3. Disgraceful, immoral or

dishonest conduct prior to

entering the service

4. Failure to attend to anyone

who wants to avail of the

services of the department

Suspension 1mo.and

1 day to 6 mos.

Reprimand

Reprimand

Reprimand

Reprimand

Dismissal

Suspension

1-30 days

Suspension

1-30 days

Suspension

1-30 days

Suspension

1-30 days

Dismissal

Dismissal


APPENDIX A

Province of Negros Occidental

PEER EVALUATION SYSTEM

PES

SUBORDINATE RATER FORM

(SRF)

RATING PERIOD

NAME OF SUPERVISOR TO BE RATED

POSITION

OFFICE


INSTRUCTIONS

1. This form is used for evaluating the performance of your supervisor in this rating period. Please use pen or ball pen when accomplishing this form.

2. Please observe fairness and objectivity when rating your supervisor.

3. In rating your supervisor, check the box that most objectively represents his/her level of performance guided by the definitions of rating under each factor.

Please use the rating scale below:

High 10 - Outstanding8 - Very Satisfactory6 - .Satisfactory4 -- Unsatisfactory

Low 2 – Poor

4. After accomplishing this form, please affix your signature and submit this to your next higher supervisor.

FACTORS

PART I – PERFORMANCE

Accomplishment of Work

How would you assess the overall work accomplishment of your supervisor in relation to his/her performance targets?

10 Attains exceptional level of accomplishment; accomplishments exceed the targets by 30%.

8 Attains level of accomplishment more than adequate but falls short of being exceptional; accomplishments exceed the target by 15-29%.

6 Attains adequate level of accomplishment; meets targets as planned and exceeds it up to 14%.

4 Attains level of achievement less than adequate level but can be improved; meets only 51-99% of the targets.

PLEASE READ THE INSTRUCTIONS

CAREFULLY BEFORE ACCOMPLISHING

THIS FORM


2 Poor, accomplishment is below 50% of the target.

PART II - CRITICAL FACTORS

1. Management of Work

Please rate your supervisor’s demonstrated ability to plan and prioritize activities; assign work properly, set appropriate work standards, establish monitoring systems, streamline office operations and make prompt and sound decisions.

10 Exceptional8 More than adequate but falls short of being exceptional6 Adequate4 Less than adequate but can be improved2 Poor

2. Management of People

Please rate your supervisor in his/her ability to promote employee development, observe fairness and impartiality, maintain discipline, motivate staff' and give effective feedback on performance.

10 Exceptional8 More than adequate but falls short of being exceptional6 Adequate4 Less than adequate but can be improved2 Poor

3. Courtesy and Public Relations

In your observations, how would you rate your supervisor’s behaviour, manner of speech and actuations in dealing with the public/clientele?

10 Always goes all the way to make people comfortable and satisfied even under pressure and occupied with work.

8 Frequently goes out of the way even when occupied with work in giving assistance to the public

6 Normally or usually goes out of the way to assist the public

4 Occasionally assists the public at times, discourteous; shows lack of patience in dealing with the public


2 Most of the time discourteous; often times complained about due to inconsiderate attitude.

Punctuality and AttendancePlease rate the observed bet1avior of your supervisor in coming to the office on time or be present at work to complete assigned responsibilities.

10 Not more than 3 times tardy / under time and 4 days absent; stays in office even after office hours to complete assigned responsibilites at hand when needed all the time.

8 4 -6 times tardy/under time and 5-8 days absent; generally present when needed assistance to the public

6 7 – 10 times tardy/under time and 9 – 12 days absent normally present when needed.

4 11-15 times tardy/under time and 13-16 times absent; at times missing without informing staff about his/her whereabouts .

2 More than 15 times tardy and more than 16 days absent; leaving the workplace without notice and attending to unofficial matters rnost of the time.

COMMENTS AND RECOMMENDATIONS

Name and Signature of Rater

Position

Office/Division


Date

grp 1 personnel manual

Documents