National Center for Mental Health

QUALITY MANAGEMENT TEAM

ISO DOCUMENTATION
(As of January 2017)

TABLE OF CONTENTS

I. QUALITY MANAGEMENT SYSTEM

 OVERVIEW
 PURPOSE
II. SCOPE OF QUALITY MANAGEMENT SYSTEM
III. QUALITY POLICY
IV. BUSINESS PROCESS
V. STRATEGIC AND OPERATIONS PLANNING
VI. QMS DOCUMENTATION STRUCTURE
VII. LIST OF APPROVED MANUALS
VIII. LIST OF APPROVED PROCEDURES
IX. LIST OF APPROVED GUIDELINES
X. LIST OF APPROVED WORK INSTRUCTIONS
XI. LIST OF HOSPITAL FORMS
XII. LIST OF NON-HOSPITAL FORMS

TOTAL NUMBER OF PROCEDURES 182

TOTAL NUMBER OF GUIDELINES 77
TOTAL NUMBER OF WORK INSTRUCTIONS 170
TOTAL NUMBER HOSPITAL FORMS 182
TOTAL NUMBER NON-HOSPITAL FORMS 546

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 I. QUALITY MANAGEMENT SYSTEM
OVERVIEW
This quality manual has been created primarily for National Center for Mental Health to describe the
hospital’s Quality Management System which is based on:
1. Formal operational procedures, work instructions, guidelines;
2. Assigned responsibilities; and
3. Reference documentation.
The operation and maintenance of the overall system is the responsibility of the designated Quality
Management Representative (QMR), who is responsible to the Medical Center Chief for the QMS’ effective
implementation and control

PURPOSE
This quality manual is documented and compiled in order, but not limited to:
1. Provide a clear statement of the quality policy and the methods by which quality is attained;
2. Establish a concise reference manual of standardized practices and procedures of the hospital;
3. Provide a reference against which current practices and proposed improvements can be factually
assessed;
4. Supply a document which can explain to client and other government agencies, the policies employed to
achieve and maintain quality standards;
5. Identify and designate personnel who will be responsible for ensuring that standards are maintained;
6. Maintain standardized practices despite employee movement.

II. SCOPE OF QUALITY MANAGEMENT SYSTEM

National Center for Mental Health’s Quality Management System is established and
implemented for the following processes:
“Psychiatric Specialty Hospital Operations Services”
(Hospital, Community, Nursing, Administrative and Finance Support Services)

III. QUALITY POLICY

Globally accepted, the National Center for Mental Health
is committed to provide responsive and comprehensive mental
health services that will promote a healthy nation.

We nurture a team of competent, compassionate and empowered staff

through continuous education, training and provision of equal
opportunity for professional growth and development.

We continuously provide safe environment and state-of-the art facilities and equipment
that are acceptable, accessible and affordable to the clients we serve.

We go beyond our clients’ expectations:

“We CARE, We EMPOWER, We EXCEL”

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 IV. BUSINESS PROCESS
The business process map of
National Center for Mental Health
follows the Plan-Do-Check-Act
(PDCA) framework. It reflects how
the various process groups of the
hospital are interlinked with one
another in order to translate clients’
requirements into quality services
that will satisfy not only the
identified patients but other stake
holders as well. With the long and
medium term goals set by the
hospital’s top management, the
organization utilizes this information
as input to annual strategic
planning. The strategic planning
process ensures that the each
division must set their key
performance indicators and targets
which are aligned to the overall
targets of the hospital.

The CORE processes are those that directly relate to the patients’ requirements. These include among others the
various processes in Hospital, Community and Nursing Services.
The SUPPORT processes on the other hand, are those that directly provide services to the core groups such as
Administrative, Hospital (Ancillary) and Finance Services
The REVIEW and IMPROVEMENT processes include internal audit, key performance indicators monitoring, and
management review. Whatever issues identified in these review activities are effectively addressed through
corrective and preventive action in order to permanently address the root causes of the problems.
The hospital’s main goal is not only to satisfy patients’ requirements but also to exceed their expectations. The
information/feedback relating to patients’ perception, as to whether their health needs have been met, are regularly
and closely monitored and analyzed.
In NCMH, we use the “process approach” to emphasize the importance of:
a) the understanding and meeting of patients’ health-related requirements,
b) the need to consider processes in terms of added value,
c) obtaining results of process performance and effectiveness, and
d) Continual improvement of processes based on objective measurements.

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 V. STRATEGIC AND OPERATIONS PLANNING

The organization’s ultimate goal is to exceed clients’ satisfaction, thus all clients’ feedback,
suggestions and complaints are carefully considered and depended upon for identifying
current problems and opportunities for improvements. The hospital ensures that clients’
needs and expectations are met through conformity, dependability, availability of necessary
supplies & equipment and safe delivery of services.
The hospital has established a Quality Policy that is aligned and consistent to the stated
organizational vision and mission. The said quality statements are communicated all across
the organization and are regularly reviewed for continuing suitability.
An annual strategic planning is being conducted to establish, review and revise hospital
objectives that are cascaded down to all services, sections and units. Each service has also
developed its own Key Performance Indicators.

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 VI. QMS DOCUMENTATION STRUCTURE
NCMH’s QMS is structured into 4 levels as described below:

st
1 Level – The Quality Manual is the highest level of QMS documentation. It defines the hospital’s quality policy,
objectives and process interactions as outlined in the Business Process map. Policy statements are
ways by which the hospital carries out the business within its various functions and activities. These are
defined further in respective SIPOC diagrams. This quality manual also states in clear terms the
commitment of NCMH’s management to deliver uncompromised quality hospital services.
nd
2 Level – The Procedure Manual describes the manner on how various activities of the hospital are carried out.
Documented procedures are referenced from NCMH’s business process map and SIPOC diagrams.
rd
3 Level – Support Document Manual may include, but not limited to, guidelines, work instructions, specifications,
externally generated executive orders, department orders, administrative orders.
4th Level – Quality Records are special type of documents which indicates full compliance with the requirements of
the documented QMS.

CONFIDENTIALITY AND DISTRIBUTION

This quality manual is treated confidential. It should not be removed from the premises without prior written
authorization from the QMR and the Medical Center Chief.
This manual along with procedures and support documents manual are made available in an electronic format and
hardcopies. Printing, copying and communicating a part or its entire contents are strictly prohibited. It is the
responsibility of the Document Controller to ensure that all manuals installed per workstations are updated and
authorized.

AMENDMENTS / REVISION:
Suggestions for amendments, revision, deletion or addition to the policies described in this Quality Manual shall be
done in writing and addressed to the Quality Management Representative for consideration and inclusion in the
manual. A re-issue of this Quality Manual will only be effected when:
1. There is a change in the scope of the certification,
2. If a certain section in this manual reached ten (10) revisions,
3. There is a change in the Management Structure which resulted to change in directions and priorities;
4. Improvement or changes in the Business Process;
5. Introduction of new scope of services;
6. Upon the written instruction of the Medical Center Chief.

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 VII. LIST OF APPROVED MANUALS
1. Quality Manual
2. Hospital Service Procedure Manual
3. Hospital Service Support Document Manual
4. Community Service Procedure Manual
5. Community Service Support Document Manual
6. Nursing Service Procedure Manual
7. Nursing Service Support Document Manual
8. Administrative Service Procedure Manual
9. Administrative Service Support Document Manual
10. Finance Service Procedure Manual
11. Finance Service Support Document Manual
12. Medical and Surgical Section Procedure Manual
13. Medical and Surgical Section Support Document Manual
14. Pavilion Manual
15. Psychiatric Residency Training Manual
16. Nursing Education and Training Section Manual
17. Infection Control Committee Manual
18. Nursing Residency Training Program Manual
19. Section Manual
20. Hospital Forms Compendium
21. Non-Hospital Forms Compendium

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 VIII. LIST OF APPROVED PROCEDURES
MANDATORY PROCEDURES
1. Procedure for Control of External Document
2. Procedure for Control of Non-Conforming Products and Services
3. Procedure for Control of Quality Records
4. Procedure for Corrective and Preventive Action
5. Procedure for Document Control and Distribution
6. Procedure for Document Preparation, Addition, Amendment, Deletion, and Approval
7. Procedure for Internal Quality Audit
8. Procedure for Management Review
9. Procedure for Monitoring and Measurement Process
HOSPITAL SERVICE
Activity Therapy Section
10. Procedure for Occupational Therapy
11. Procedure for Physical Rehabilitation
12. Procedure for Vocational Rehabilitation/ Livelihood Programs
13. Procedures on Provision of Other Related Patient Services
Anatomic Laboratory Section
14. Procedure for Anatomic Laboratory
15. Procedure for Histopathology Section
16. Procedure for Receiving and Proper Storage of Cadaver
17. Procedure for Releasing of Cadaver
18. Procedure for Screening for Drug Testing Section
Clinical Laboratory Section
19. Procedure for Clinical Laboratory Examination
Dental Section
20. Procedure for Dental Treatment for Charity/Out-Patient
21. Procedure for Dental Treatment for Charity/In-Patient
Psychological Section
22. Procedure for Psychological Evaluation
23. Procedure for Psychological Assessment for Hospital Service (OPS- Child & Adolescent)
24. Procedure for Psychological Assessment for Hospital Service
25. Procedure for Psychological Assessment for Community Service (Pavilion II- OPS)
26. Procedure for Psychological Assessment for HRAC
27. Procedure for Psychological Assessment for Community Service (ACIS-DDU)
28. Procedure for Psychological Assessment for Community Service (Women and Child Protection Unit)
29. Procedure for Psychological Assessment for Hospital Service (In-Patient)
30. Procedure for Psychological Assessment for Hospital Service (Pavilion 4- OPS)
31. Procedure for Psychological Assessment for Hospital Service (ACIS- Child and Adolescent)
Radiology Section
32. Procedure for X-Ray and Ultrasound
COMMUNITY SERVICE
33. Procedure for Handling Women and Child Protection Unit Cases
34. Procedure for Handling Patient at Out-Patient Section
35. Procedure for Admitting Patients at Out-Patient Section
36. Procedure for Handling Patients at Psychiatric ER
37. Procedure for Public Health Unit
38. Procedure for Specialty Clinic
39. Procedure for Implementation of the Point of Care Enrollment Program for Hospital Sponsored Members
NURSING SERVICE
40. Procedure for Patient Care Management at Pavilion
41. Procedure for Admission at Forensic Pavilion
42. Procedure for Safe Medication Administration

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 43.Procedure for Handling Missing Patient
44.Procedure for Handling Death
45.Procedure for Home Conduction
46.Procedure for Job Placement
ADMINISTRATIVE SERVICE
Dietary Section
47. Procedure for Diet Counseling
48. Procedure for Food Distribution
49. Procedure for Menu Plan and Menu Census
50. Procedure for Preparation and Production of Procedure for Foodstuff
51. Procedure for Foodstuff Against Petty Cash Fund
52. Procedure for Purchasing based on Annual Procurement
53. Procedure for Requisition of Supplies
54. Procedure on Receiving Foodstuffs
Engineering Section
55. Procedure for Calibration of Equipment
56. Procedure for Corrective Maintenance (Work Referrals)
57. Procedure for Health Care Waste Management
58. Procedure for Job Order Request
59. Procedure for Preventive Maintenance of Equipment
60. Procedure for Rehabilitative Maintenance Program
61. Procedure for Preventive Maintenance of Equipment and Facilities
Laundry Section
62. Procedure for Collection, Washing and Delivery
Legal Section
63. Procedure for Filing Administrative Complaint
64. Procedure for Conducting Formal Investigation
65. Procedure for Review of Government Contract
Linen Section
66. Procedure for Requisition of Linen/Patient Uniform
67. Procedure for Requisition for Purchase of Linen Materials
68. Procedure for Requisition of Cloth Intended for Sewing
69. Procedure for Requisition of Linen/ Linen Material
Material Management Section
70. Procedure for Auction Sale of Unserviceable Materials and Equipment
71. Procedure for Endorsement of Accountabilities
72. Procedure for Direct Issuance of Supplies to Specific End-User
73. Procedure for Issuance of Equipment
74. Procedure for Issuance of Gate Pass for Personal Items by the Owner/Supplier to be brought out of the
Hospital
75. Procedure for Issuance of Gate Pass for Items Requested to be brought-out of the Hospital for Repair
76. Procedure for Issuance of Inventory Custodial Slip Form
77. Procedure for Receipt, Recording and Preparation of Waste Material Report
78. Procedure for Receipt of Deliveries
79. Procedure for Relief from Property Accountability
80. Procedure for Requisition and Issuance of Available Supplies for General Use
81. Procedure for Requisition and Repair of Equipment, Charge against Petty Cash (Spare Parts)
82. Procedure for Requisition for Repair of Equipment, Charge against Petty Cash
83. Procedure for Return of Unserviceable Equipment/Small Inventory Items
Medical Records Section
84. Procedure for Medical Records Completion
85. Procedure for Coding and Indexing Diseases
86. Procedure for Preparation of Statistical Reports
87. Procedure for Filing Medical Records
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88. Procedure for Medical Records Retention and Disposition
89. Procedure for Releasing Information
90. Procedure for Medical Records Access
91. Procedure for Issuance of Official Documents
92. Procedure for Security of Medical Records
93. Procedure for Loss, Damages, and Destruction of Medical Records
94. Procedure for Borrowing and Returning of Medical Records
95. Procedure for Misfile of Medical Records
96. Procedure for Accomplishing Certificate of Live Birth
97. Procedure for Accomplishing Death Certificate
98. Procedure for Handling / Attending Court Appearances
Medical Social Service Section
99. Procedure for Job Placement
100. Procedure for Social Service Family Health Teaching
101. Procedure for Social Service Family Day
102. Procedure for Inter-Agency Referral
103. Procedure for Classification of Patients
104. Procedure for Follow-up of Court Cases
105. Procedure for Social Service Family Meeting
106. Procedure for Home Visit(Court Case)
107. Procedure for Home Conduction
108. Procedure for Social Service Discharge Planning
109. Procedure for Social Work Student Training Program
110. Procedure for Social Case History/Anamnesis
111. Procedure for Identification of Relatives/Claimant
112. Procedure for Transfer of Custody
113. Procedure for Availment of Medical Social Service Assistance
114. Procedure for Philhealth-Hospital Sponsored Member
115. Procedure for Hospital Donation
Personnel Section
116. Procedure for Hiring and Screening
117. Procedure for Payroll Preparation
118. Procedure for Preparation of Voucher
Pharmacy Section
119. Procedure for Storage of Medicines
120. Procedure for Disposal of Expired, Damaged, and Rejected Stocks
121. Procedure for Returning of Damaged, Expired and Rejected Medicines
122. Procedure for Dispensing of Prescription Drugs
123. Procedure for Public Inventory
Procurement Section
124. Procedure for Requisition and Procurement for Drugs and Medicines Consignment
125. Procedure for Requisition and Procurement of Supplies and Equipment thru Direct Contracting
126. Procedure for Requisition and Procurement of Supplies and Equipment thru Job Order
127. Procedure for Requisition and Procurement of Supplies and Equipment thru Public Bidding/Negotiation
(Based on Annual Procurement Plan)
128. Procedure for Requisition and Procurement of Supplies and Equipment thru Shopping
129. Procedure for Supplier Accreditation
130. Procedure for Supplier Evaluation and Re- Evaluation
Security Section
131. Procedure for Handling Crimes Committed Inside the Hospital Compound
132. Procedure for Suspicious Cause of Patient’s Death
133. Procedure for Handling Demonstration
134. Procedure for Handling Disturbance Caused by Patient outside the Pavilion
135. Procedure for Handling Escapee

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 136. Procedure for Handling Fire Incidents
137. Procedure for Handling Mob/Riot inside the Pavilion
138. Procedure for Reception of Visitors of NCMH Officials
139. Procedure for Handling Confiscated Dangerous and Prohibited Substance/ Drugs
140. Procedure for Ingress- Engress Control
Transport Section
141. Proper Operation of Hospital Vehicle
142. Requesting for Use of Hospital Vehicles
FINANCE SERVICE
Accounting Section
143. Procedure for Processing Purchase Orders
144. Procedure for Monitoring Availability of Funds
145. Procedure for Preparation of Disbursement Vouchers
146. Procedure for Payment of Disbursement Vouchers
147. Procedure for Recording Collection and Deposit
148. Procedure for Recording Non-Cash Transactions Covering Billing of Debtor
149. Procedure for Recording Non-Cash Transactions Covering Receipts / Purchases
150. Procedure for Recording Non-Cash Transactions Covering Issuance of Supplies
151. Procedure for Recording Non-Cash Transactions Covering Liquidation of Cash Advance
152. Procedure for Billing of First and Re-Admission of Pay Patient
153. Procedure for Billing of Pay Patients (Continuous Long-Term Confinement)
154. Procedure for Issuance of Out-on-Pass Clearance
155. Procedure for Home Conduction of Patients with Past Due Accounts
156. Procedure for Processing of Patients Account Refund
157. Procedure for Billing/Discharging Patient from ACIS, Charity and Infirmary Ward (Service Ward)
158. Procedure for PhilHealth Billing, Recording, Claim and Reimbursement
159. Procedure for Billing of Canteen Concessionaire and Other Lessee
160. Procedure for Billing of Affiliates
Budget Section
161. Procedure for Preparation of Budget Execution Documents
162. Procedure for Preparation of Physical Report of Operation
163. Procedure for Preparation of Budget Estimates
164. Procedure for Preparation of Quarterly Financial Report of Operation / COA Quarterly Report
165. Procedure for Recording of Allotment and Obligation
166. Procedure for Preparation of Statement, Allotment, Obligations and Balances
Cashier Section
167. Procedure for Disbursement by Check
168. Procedure for Payment by Expanded MDPS for LDDA/Ps
169. Procedure for Payment by Cash
170. Procedure for Report of Accountability
171. Procedure for Report of Stale Checks
172. Procedure for Cash and Check Collection
MEDICAL AND SURGICAL SECTION
173. Procedure for Consultation at OPD Infirmary Pavilion
174. Procedure for Admission at Ward Infirmary Pavilion
175. Procedure for Patient Management at ICU Infirmary Pavilion
176. Procedure for Operating Room Management
177. Procedure for Handling Patients at TB-DOTS
178. Procedure for Handling MDR-TB Patient
179. Procedure for Patient Care Management at Ward Infirmary Pavilion
180. Procedure for Discharging Patients
181. Procedure for Patient Care Management at E.R. Infirmary Pavilion
NURSING EDUCATION AND TRAINING SECTION
182. Procedure for Application for Contract of Affiliation
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 IX. LIST OF APPROVED GUIDELINES
MANDATORY GUIDELINES
1. GL for Process Traceability Matrix
2. GL for Implementing of Red Tag
HOSPITAL SERVICE
Psychological Section
3. GL for Psychologist
4. GL for HRAC (Neuro- Psychiatric Screening)
5. GL for Educational Tour, Interview with Psychologist and Case Study
6. GL for Training
7. GL for Practicum
8. GL for Seminar and Workshop
Radiology Section
9. GL for Monitoring Badge Using OSL Dosimeter
COMMUNITY SERVICE
10. GL for Admission at ACIS
11. GL for Admission of Female Patient
12. GL for Discharge at ACIS
13. GL for Patient Management in ACIS
14. GL for Watchers in ACIS
15. GL for Research Patients in ACIS
16. GL for Drug Detoxification – Rehabilitation Unit
17. GL for ECT Preparation
18. GL for Home Against medical Advice
19. GL for Mental Status Examination
20. GL for Out Patient Section – Pay Lane
21. GL for Out Patient Section – Service Lane
22. GL for Public Health Unit
23. GL for Rapid Neuroleptization
24. GL for Refused Admission
25. GL for Restraints and Seclusion
26. GL for Specialty Clinic
NURSING SERVICE
27. GL for Consultation at OPD Forensic Pavilion
28. GL for Discharging Patient at Forensic Pavilion
29. GL for Endorsement Procedure
30. GL for Safeguarding of Keys
31. GL for Patient Census
32. GL for Referrals
ADMINISTRATIVE SERVICE
Dietary Section
33. GL for Personnel Sanitation
34. GL for Safe Food Handling and Serving Practices
35. GL for Personnel Sanitation
Laundry Section
36. GL for Request of Pavilion/Offices for Special Laundry
37. GL for Collection of Solid Linens/Patient’s Uniform from Different Pavilion, Wards and Offices
Legal Section
38. GL for Preparation of Motion, Manifestation, Compliances and other Court Pleading
Linen Section
39. GL for Requisition of Linen/Patient’s Uniform
40. GL for Condemning of Linens
41. GL for Losses of Linens/Patient’s Uniform
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 Medical Records Section
42. GL for Releasing of Birth Certificate
43. GL for Releasing Death Certificate
44. GL for Use of Patient’s Medical Records for Research and Conferences
45. GL for Use of Symbols Abbreviations and Acronyms
Medical Social Service Section
46. GL for Classification of Patients
47. GL for Home Conduction of Charity Patients
Personnel Section
48. GL for Submission and Pick-up of Official Document from Different Agency
Pharmacy Section
49. GL for Returning of Medicines
Security Section
50. GL for After-Disaster Operations
51. GL for Application and Use of NCMH Facilities
52. GL for Conducting an Inspection
53. GL for Conducting Rounds
54. GL for Escorting Court Case Patients
55. GL for Internal Screening of Guard Applicants
56. GL for Handling Untoward Incidents/Violation of Security Related Hospital Policies
57. GL for Visits of Government Officials and VIPs
FINANCE SERVICE
Accounting Section
58. GL for Conduct of Physical Count of Inventory
59. GL for Acceptance of PCSO Guarantee Letter / GMA Pledge Form
Cashier Section
60. GL for Reporting of Collections and Deposits
61. GL for Maintaining Vault Security
MEDICAL AND SURGICAL SECTION
62. GL for Cleaning, Sterilization and maintenance of Surgical Instruments
63. GL for Cleaning, Disinfection and Sterilization of Reusable Medical Devices
64. GL for Discharge and Transfer-Out from Infirmary Pavilion
65. GL for Loading Sterilizer
66. GL for Operating Room Fire Evacuation Plan
67. GL for Packing of Instruments, Gowns and Linens
68. GL for Physical Assessment
69. GL for Proper Handling of Specimen
NURSING EDUCATION AND TRAINING SECTION
70. GL for Nursing Students Affiliation Program
71. GL for Preceptorship Orientation Training Program for Clinical Instructors on Mental Health and Psychiatric
Nursing
72. GL for Nursing Documentation and Recording on Patient’s Chart
INFECTION CONTROL COMMITTEE
73. Guidelines for Infection Control in the Dietary Section
74. Guidelines for Infection Control for Laboratory Section
75. Guidelines for Infection Control in OR/DR/NICU/NURSERY
76. Guidelines for Infection Control for Radiology Section
77. Guidelines for Infection Control in the Ward

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 X. LIST OF APPROVED WORK INSTRUCTIONS
HOSPITAL SERVICE
Activity Therapy Section
1. WI for Administration of Electrical Stimulator (ES)
2. WI for Administration of Hot Moist Pack (HMP)
3. WI for Administration of Infrared Radiation
4. WI for Administration of Therapeutic Ultrasound
5. WI for Administration of Transcutaneous Electrical Nerve Stimulator (TENS)
6. WI for Conducting an Occupational Therapy Activity
7. WI for Administration of Paraffin Wax Bath
Anatomic Laboratory Section
8. WI for Autopsy
9. WI for Fluid Cytology and Cell Block
10. WI for Frozen Section
11. WI for H and E Staining
12. WI for Microtomy
13. WI for Papanicolao Staining
14. WI for Proficiency Testing (PT)
15. WI for Screening Drug Test
16. WI for Tissue Embedding
17. WI for Tissue Processing
Clinical Laboratory Section
18. WI for Acid Fast Bacilli Smear and Staining
19. WI for Alanine Aminotransferase (ALT/SGPT) (Semi
20. WI for Automated Chemistry Analyzer)
21. WI for Albumin (Bromcresol Green) (Semi Automated
22. WI for Chemistry Analyzer)
23. WI for Alkaline Phosphatase (ALP/DEA) (Semi Automated Chemistry Analyzer)
24. WI for Aspartate Aminotransferase (AST/SGOT) (Semi
25. WI for Automated Chemistry Analyzer)
26. WI for Benedict’s Solution (Urine Sugar Test)
27. WI for Bleeding Time (Duke’s Method)
28. WI for Blood Banking (ABO Typing – Gel Technique)
29. WI for Blood Banking (ABO Typing – Reverse Typing)
30. WI for Blood Banking (ABO Typing – Tube Method)
31. WI for Blood Banking (Cross Matching – Gel Technique)
32. WI for Blood Banking (Cross Matching – Tube Method)
33. WI for Body Fluids Cell Count
34. WI for Pregnancy Test
35. WI for Routine Urinalysis
36. WI for Clotting Time using Dale and Laidlaw’s Capillary Clotting Time (Modified)
37. WI for Environmental Culture Swabbing
38. WI for Erythrocyte Sedimentation Rate using ESR Machine
39. WI for Exton’s Sulfosalicylic Acid Test (Urine Protein Test)
40. WI for Albumin (Fully Automated Chemistry Analyzer)
41. WI for Blood Urea Nitrogen (Fully Automated Chemistry Analyzer)
42. WI for ALT (SGPT) Alanine Transaminase (Fully Automated Chemistry Analyzer)
43. WI for Alkaline Phosphatase (Fully Automated Chemistry Analyzer)
44. WI for Cholesterol (Fully Automated Chemistry Analyzer)
45. WI for High Density Lipoprotein (Fully Automated Chemistry Analyzer)
46. WI for Low Density Lipoprotein (Fully Automated Chemistry Analyzer)
47. WI for Triglycerides (Fully Automated Chemistry Analyzer)
48. WI for Uric Acid (Fully Automated Chemistry Analyzer)
49. WI for AST (SGOT) Aspartate Transaminase (Fully Automated Chemistry Analyzer)
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50. WI for Total Bilirubin (Fully Automated Chemistry Analyzer)
51. WI for Creatinine (Fully Automated Chemistry Analyzer)
52. WI for Direct Bilirubin (Fully Automated Chemistry Analyzer)
53. WI for Glucose (Fully Automated Chemistry Analyzer)
54. WI for Running of Complete Blood Count using Fully Automated Hematology Analyzer
55. WI for Running of Controls in Complete Blood Count using Fully Automated Hematology Analyzer
56. WI for Running Prediluted Blood Samples using Fully Automated Hematology Analyzer
57. WI for Total Protein (Fully Automated Chemistry Analyzer)
58. WI for Gram Staining
59. WI for Hemoglobin A1c
60. WI for Indirect Platelet Count
61. WI for KOH (Potassium Hydroxide) Preparation
62. WI for Malarial Smear (Thick and Thin Smear)
63. WI for White Blood Cell Count (Manual Count)
64. WI for Erythrocyte Sedimentation Rate (ESR) Manual Method
65. WI for Microbiology
66. WI for Obtaining Blood Specimen for Culture
67. WI for Obtaining Gram Positive and Gram Negative Smear
68. WI for Obtaining Specimen for Fungal Infection
69. WI for Obtaining Sputum Specimen for Culture
70. WI for Obtaining Stool Specimen for Culture
71. WI for Obtaining Throat Swab Specimen for Culture
72. WI for Obtaining Urine Specimen for Culture
73. WI for Obtaining Wound Discharge Specimen for Culture
74. WI for Routine Fecalysis
75. WI for Peripheral Blood Smear
76. WI for Bilirubin (Diazotized Sulfanilic) (Semi Automated Chemistry Analyzer)
77. WI for Cholesterol HDL Direct (Semi Automated Chemistry Analyzer)
78. WI for Cholesterol LDL Direct (Semi Automated Chemistry Analyzer)
79. WI for Cholesterol Oxidase/ Peroxidase (Semi Automated Chemistry Analyzer)
80. WI for Creatinine Kinase MB (CK MB) (Semi Automated Chemistry Analyzer)
81. WI for Creatinine Kinase (CK Total) (Semi Automated Chemistry Analyzer)
82. WI for Creatinine (Alkaline Picrate) (Semi Automated Chemistry Analyzer)
83. WI for Glucose Oxidase/ Peroxidase (Semi Automated Chemistry Analyzer)
84. WI for Total Protein (Semi Automated Chemistry Analyzer)
85. WI for Triglycerides (Glycerol Phosphate Oxidase/ Peroxidase) (Semi Automated Chemistry Analyzer)
86. WI for Urea/ BUN-UV (Urease/ Glutamate Dehydrogenase) (Semi Automated Chemistry Analyzer)
87. WI for Uric Acid (Uricase/ Peroxidase) (Semi Automated Chemistry Analyzer)
88. WI for Serology (ONE STEP DENGUE NS1)
89. WI for Serology (Rapid Dengue Combo Test (IgG+IgM)
90. WI for Serology (One Step Cardiac Troponin I (cTnI) Test kit)
91. WI for Serology (TYPHI DOT RAPID)
92. WI for Serology (HBsAG Screening)
93. WI for Serology (HIV 1 & 2 Screening)
94. WI for Serology (One Step Anti-TP (Treponeme Pallidum/Syphilis) Test)
95. WI for Sodium, Potassium and Lithium Assay (Electrolyte Analyzer)
Dental Section
96. WI for Oral Examination
97. WI for Oral Prophylaxis
98. WI for Tooth Extraction
Radiology Section
99. WI for Routine X-Ray Procedures (Analog and Digital)
100. WI for Special X-Ray Procedures (Analog and Digital)
101. WI for Ultrasound
102. WI for Special X-Ray (Computed Radiography System)

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 103. WI for Routine X-Ray (Computed Radiography System)
COMMUNITY SERVICE
104. WI for Out Patient Service Registration
NURSING SERVICE
105. WI for Administering a Subcutaneous Injection
106. WI for Administering Intramuscular Injection
107. WI for Administering Intradermal Injection
108. WI for Administering Otic Instillation
109. WI for Administration of Oral Medication
110. WI for Applying Restraints
111. WI for Hand washing
112. WI for Implementing Seizure Precautions
113. WI for Measuring Oxygen Saturation
114. WI for Obtaining a Capillary Blood Specimen to Measure a Blood Glucose
115. WI for Positioning of Patient
116. WI for Post Mortem Care
117. WI for Preparing Medications from Ampules and Vials
118. WI for Transfer of Patient
119. WI for Wound Irrigation
120. WI for Electroconvulsive Therapy
FINANCE SERVICE
Accounting Section
121. WI for Recording Non-Cash Transactions Covering Depreciation of PPE
122. WI for Remitting Taxes Thru ETRA and EFPS
123. WI for Journal Entry Voucher Preparation on ENGAS
124. WI for Approval of JEV on ENGAS
125. WI for Preparation of Financial Report
126. WI for Generating Aging of Receivables and Payables
ADMINISTRATIVE SERVICE
Laundry Section
127. WI for Washing Machine Operation
128. WI for Extractor Machine Operation
129. WI for Dryer Machine Operation
Linen Section
130. WI for Making an Apron
Medical Records Section
131. WI for Analysis of Medical Records TITLE
132. WI for Archiving of Medical Records
133. WI for Medical Records Information Unit
134. WI for Preparation of Master Patient Indexes
135. WI for Medical Library
136. WI for Preparation of Medical Records upon Admission
137. WI for Medical Records Creation
138. WI for Completion of Medical Records
139. WI for Handling Telephone Inquiries
Personnel Section
140. WI for Application of New ID
141. WI for Service Record Application
142. WI for Hospital Order and Memorandum Preparation
143. WI for Loan Application
Pharmacy Section
144. WI for Requisition and Inspection of Drugs and Medicine
Transport Section
145. WI for Corrective Maintenance of Hospital Vehicles

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 146. WI for Preventive Maintenance of Hospital Vehicles with Three (3) Months Utility and/or every 1000-
Kilometer Reading
MEDICAL AND SURGICAL SECTION
147. WI for Administering an Enema
148. WI for Administering IV Medications Using IV Push
149. WI for Administering a Tube Feeding
150. WI for Administering Otic Medication and Otic Instillation
151. WI for Administering Oxygen by Cannula or Face Mask
152. WI for Blood Transfusion
153. WI for Discontinuing Intravenous Infusion
154. WI for Counting of Instruments, Needles and Sponges
155. WI for Donning and Removing Personal Protective Equipment (Gloves, Gown, Mask, Eyewear)
156. WI for Donning and Removing Sterile Gloves (Open Method)
157. WI for Draping
158. WI for Establishing and Maintaining a Sterile Field
159. WI for Giving and Removing a Bedpan
160. WI for Gowning and Gloving the Surgeon
161. WI for Gowning
162. WI for Inserting and Removing a Nasogastric Tube
163. WI for Oropharyngeal, Nasopharyngeal, & Nasotracheal Suctioning
164. WI for Skin Preparation of Patient
165. WI for Starting an Intravenous Infusion
166. WI for Surgical Hand Scrubbing
167. WI for Hand Rubbing with Alcohol-Based Solution
168. WI for Pre-Surgical Hand Asepsis
169. WI for Tracheostomy or Endotracheal Tube WI for Suctioning
170. WI for Urinary Catheterization

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 XI. LIST OF APPROVED HOSPITAL FORMS
NCMH FORM
FORM NAME
#
HOSP- 1 Emergency Room Record
HOSP- 2 Admission and Discharge Record
HOSP- 2A Patient’s Sociological Data
HOSP- 3 Terms and Condition of Admission (Service Pavilion)
HOSP- 3A Contract for Confinement and Treatment
HOSP- 3B Contract for Confinement and Treatment (Philhealth Pav. 6)
HOSP- 4 Consent to Confinement and Treatment
HOSP- 4A Consent to the Administration of Electro-Convulsive Therapy (ECT)
Refusal to Consent to the Administration of Electro-Convulsive Therapy
HOSP- 4B
(ECT)
HOSP- 4C Consent to Prohibited Drug Screening Test
HOSP- 4D Consent to Treatment for Substance Use
HOSP- 4E Informed Consent to Surgery, Anesthesia, or Other Procedures
HOSP- 4F Consent to Involvement in Clinical Trials (Therapeutic)
HOSP- 4G Consent to Autopsy
HOSP- 4H Refusal to Autopsy
HOSP- 4I Responsibilities of Patient-Family
HOSP- 4J Rights of Patients
HOSP- 5 Admission and Consultation Slip
HOSP- 6 Patient’s Identification
HOSP- 6A Patient’s Identifying Marks
HOSP- 7 Admission Notes (ER)
HOSP- 7A Admission Notes (Physician in Charge)
HOSP- 7B Consultation Notes
HOSP- 7C ER Referral
HOSP- 8 Physical and Neurological Examination
HOSP- 8A Physical Examination (Infirmary)
HOSP- 8B Medical History
HOSP- 8C Medical Intern/Clerk Physical and Neurological Examination
HOSP- 8D Medical Intern/Clerk Medical History
HOSP- 9 Progress Notes
HOSP- 10 Clinical Summary/Discharge Summary
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HOSP- 10A Discharge Summary (Infirmary)
HOSP- 10B Medical Intern/Clerk Clinical Summary/Discharge Summary
HOSP- 11 Laboratory Request Form
HOSP- 11A Urinalysis Result
HOSP- 11B Fecalysis Result
HOSP- 11C Crossmatching Result
HOSP- 11D CBC Result
HOSP- 11E Miscellaneous Form
HOSP- 11F Serology (Thypidot)
HOSP- 11G Serology (HIV)
HOSP-11H Serology (Syphilis)
HOSP- 11I Serology (Dengue)
HOSP- 11J Serology (HBsAg)
HOSP- 11K Microbiology (Antimicrobial sensitivity)
HOSP- 11L Microbiology
HOSP- 11M Clinical Chemistry (HbA1C)
HOSP-11N Clinical Chemistry (Electrolytes)
HOSP- 11O Clinical Chemistry (CK MB)
HOSP- 11P Clinical Chemistry (Blood Chemistry)
HOSP- 11Q Hematology
HOSP- 11R Request for Pathologic Consultation
HOSP- 11S Autopsy Report
HOSP- 11T Papsmear Result Form
HOSP-11U Cytopathology Report
HOSP- 11V Surgical Pathology Report
HOSP- 11W Histopathology Request Form
HOSP- 11X Histopathology Result
HOSP- 12 X-Ray Request/Ultrasound Request Form
HOSP-12A X-Ray Result
HOSP- 12B Ultrasound Result
HOSP- 12C Electrocardiogram Tracing
HOSP- 12D Electrocardiogram Report
HOSP- 12E CP Clearance Form

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HOSP- 13 Psychological Report
HOSP- 14 Medical Social Service Intake Survey Sheet (Eligibility Form)
HOSP- 14A Medical Social Service Notice of Schedule of Visit
HOSP- 14B Medical Social Service Questionnaire
HOSP- 14C Medical Social Service Questionnaire (Cover Letter)
HOSP- 14D Contract for Placement of Patient
HOSP- 14E Social Worker’s Notes
HOSP- 14F Medical Social Service - Interview Letter
HOSP- 14G Medical Social Service - Police Investigation Report
HOSP- 14H Medical Social Service - Referral Slip
HOSP- 14I Medical Social Service - Case Status Verification
HOSP- 14J Medical Social Service - Discharge Letter
HOSP- 14K Mutual Agreement for Escorted Patients
HOSP- 14L Medical Social Service – Closing Summary
HOSP- 14M Social Case Summary
HOSP- 14N Checklist of Requirements
HOSP- 14O Medical Social Service- Medical Social Worker Letter
HOSP- 14P Certificate of Indigency
HOSP- 14Q Fund Utilization
HOSP- 14R Acknowledgement
HOSP- 14S Donors and Donation Report
HOSP- 14T Donors and Distribution Report
HOSP- 14U Payment in Kind report
Activity Therapy Section - Comprehensive Occupational Therapy
HOSP- 15
Evaluation Scale
HOSP- 15A Activity Therapy Section - Activities of Daily Living Questionnaire
HOSP- 15B Activity Therapy Section - Occupational Therapy Notes
HOSP- 15C Activity Therapy Section - Occupational Therapy Initial Evaluation Interview
HOSP- 15D Activity Therapy Section - Physical Therapy Evaluation
Activity Therapy Section - Pre-Vocational Evaluation of Rehabilitation
HOSP- 15E
Potential
HOSP- 15F Activity Therapy Section - Referral for Occupational Therapy
HOSP- 15G Activity Therapy Section – Occupational Therapy Priority Checklist
Activity Therapy Section – Personal Grooming Unit Daily Accomplishment
HOSP- 15H
Report
HOSP- 15I Activity Therapy Section - Personal Grooming Unit Individual Monthly
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 Accomplishment Report

HOSP- 15J Activity Therapy Section – Physical Rehabilitation

HOSP- 15K Activity Therapy Section – Physical Therapy Notes
HOSP- 16 Dental Health Record
HOSP- 17 Nutritional Assessment
HOSP- 17A Diet List
HOSP- 18 Doctors Order Sheet
HOSP- 19 Vital Signs Sheet
HOSP- 19A Graphic Chart (Centigrade)
HOSP- 19B Vital Signs Record
HOSP- 19C Monitoring Sheet
HOSP- 20 Medication Sheet
HOSP- 20A OPS Medication Sheet
HOSP- 20B Medication Card
HOSP - 21 Record of ECT
HOSP - 21A Medical Intern/Clerk Pre ECT Examination
HOSP - 21B Medical Intern/Clerk Post ECT Examination
HOSP - 22 Nurses Notes and Treatment Record
HOSP - 23 Record of Visitors
HOSP- 23A Watcher’s Request
HOSP – 24 Cost of Services Rendered
HOSP - 25 Accident/Incident Report
HOSP - 26 Report of Absconded Patient
HOSP - 27 Report of Illness
HOSP- 27A Court Case Patient under physical treatment (relative)
HOSP- 27B Non Court Case Patient under physical treatment (relative)
HOSP- 27C Court Case Patient under physical treatment (escort)
HOSP- 27D Court Case Patient under physical treatment (Judge)
HOSP- 27E Non Court Case Patient under physical treatment (escort)
HOSP- 27F Non Court Case Patient in weak condition (escort)
HOSP- 27G Non Court Case Patient in weak condition (relative)
HOSP- 27H Court Case Patient in weak condition (Judge)
HOSP- 27I Court Case Patient in weak condition (escort)

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HOSP- 27J Court Case Patient died (Judge)
HOSP- 27K Non court case patient died
HOSP- 27L Court Case Patient died (escort)
HOSP - 28 Discharge Slip
HOSP - 28A Home Against Medical Advice
HOSP - 28B Authorization/Consent to Discharge
HOSP - 28C Paunawa Para sa mga Kamag-anak ng Pasyente
HOSP- 28D Discharge Clearance
HOSP- 28E Request for Trial Home Visit
HOSP - 29 Death Report
HOSP - 29A Disposition of Cadaver
HOSP - 29B Cadaver Claimant Form
HOSP – 29C Cadaver Clearance
HOSP - 30 Prenatal Record
HOSP - 30A Labor Record
HOSP - 30B Newborn Maturity Rating and Classification
HOSP - 30C Newborn Record
HOSP- 30D Report of Live Birth
HOSP - 30E Summary of Parturation
HOSP - 31 Pulmonary Function Test
HOSP - 31A Pulmonary Laboratory Blood Gas Analysis
HOSP - 32 Intravenous Fluid Sheet
HOSP – 33 Fluid Intake and Output Chart
HOSP - 33A Parenteral Fluid Sheet
HOSP - 34 Diabetic Record
HOSP - 35 Anti-Coagulant Therapy Record
HOSP - 36 Pre-Anesthetic Assessment
HOSP - 36A Anesthesia Record
HOSP - 37 Operating Room Preparation and Premedication
HOSP – 37A Operating Room Notification Slip
HOSP – 37B Operating Room Record
HOSP – 37C Surgical Safety Checklist
HOSP – 37D Operation and Anesthesia Record

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HOSP – 37E Operative Record
HOSP – 37F Surgical Recovery Room Record
OSP – 37G Recovery Room Record
HOSP- 38 Tissue/Biopsy Report
HOSP -39 Confidential Report on Adverse Drug Experience
HOSP- 40 Inter-Agency Referral Slip
HOSP - 41 Certificate of Consultation
HOSP - 42 Certificate of Confinement
HOSP - 43 Clinical Abstract
HOSP - 43A Medical Certificate
HOSP- 43B Medical Certificate – Detoxification Unit
HOSP- 43C Medical Certificate – Infirmary
HOSP - 44 Certificate of Appearance
HOSP - 44A Certificate of Appearance Forensic Psychiatric Service
HOSP - 44B Certificate of Appearance Psychological
HOSP - 45 Human Resource Assessment Centre (Applicant’s Form)
HOSP- 45A Human Resource Psychological Assessment Report
HOSP - 46 Surveillance of Nosocomial Infection Worksheet
HOSP - 47 Patient’s Transfer Out And In Sheet

Page 22 of 33
 XII. LIST OF APPROVED NON-HOSPITAL FORMS AND RECORD SHEETS
HOSPITAL SERVICE
1. 24 Hours Referrals Report - Adult Female
2. 24 Hours Referrals Report – Adult Male
3. WCPU Daily Census Adult
4. WCPU Daily Census Child
5. WCPU Patients’ Log Record
6. WCPU- Child & Adolescent Psychiatric Monitoring Sheet (Follow-up)
7. WCPU- Child & Adolescent Psychiatric/ Psychological Monitoring Sheet (1st Consultation
8. WCPU- Community Outreach Program Attendance Record
9. WCPU- Receiving Records
10. WCPU- Adult Psychiatric Monitoring Sheet
11. WCPU- Adult Psychiatric Monitoring Sheet (1st Consultation)
12. Leave Application Log Sheet
13. Obligation Request & Voucher Sheet
14. Physician Section Leave Application Log Sheet
15. Purchase request of Drugs and Medicine Sheet
16. Requisition & Issue Slip Sheet
Activity Therapy Section
17. Spiritual Programs
18. Patient’s Endorsement Form
19. Patient’s Activity Attendance Report
Anatomic Laboratory Section
20. Drug Testing- Confirmatory Test
21. Drug Testing- Preventive Maintenance
22. Drug Testing- Quality Control Result
23. Drug Testing- Receiving/ Accessioning/ Releasing
24. Drug Testing- Remote Collection
25. Drug Testing Results
26. Drug Testing- Specimen Validity Test Result
27. Drug Testing- Storage and Disposal
28. Drug Testing- Visitors Record Sheet
29. Histopathology- Preventive Maintenance
30. Histopathology- Receiving Record Sheet
31. Histopathology- Releasing of Result
32. Histopathology Tissue Blocks Monitoring
33. Histopathology- Waste Disposal
34. Morgue- Building Maintenance
35. Morgue- Preventive Maintenance
36. Morgue- Receiving of Cadaver
37. Morgue- Releasing of Cadaver
38. Paps/ Cytology Receiving & Releasing
39. Temperature Monitoring Sheet
Clinical Laboratory Section
40. List of Rejected Specimen
41. List of Unclaimed Clinical Laboratory
42. Endorsement Record Sheet (7-3, 3-11, 11-7 Shift)
43. List of Cancelled Request
44. List of Released STAT Laboratory Result
45. List of Requested STAT Examination
46. Blood Receiving/ Releasing Record Sheet
47. Anti- TP Record Sheet
48. Blood Typing Record Sheet
Page 23 of 33
49. Clinical Chemistry Record Sheet A
50. Clinical Chemistry Record Sheet B
51. Corrective Action Form
52. Crossmatching Record Sheet
53. Daily PM of Machine/ Equipment
54. Daily Reagent Calibration Sheet
55. Daily Summary Report - In Patient Charity
56. Daily Summary Report - In Patient Pay
57. Daily Summary Report - In Patient Pay- HSM
58. Daily Summary Report - In Patient Pay- Philhealth
59. Daily Summary Report - Out Patient Charity
60. Daily Summary Report - Out Patient Pay
61. Dengue IgG and IgM Record Sheet
62. Dengue NS1 Record Sheet
63. Fecalysis Record Sheet
64. HB a1c Record Sheet
65. HBsAg Record Sheet
66. Hematology Record Sheet A
67. Hematology Record Sheet B
68. HIV Record Sheet
69. Laboratory Reagent and Other Supplies Inventory
70. List of Released Routine Laboratory Result
71. List of Requested Routine Examination
72. Microbiology Blood Culture and Sensitivity Record Sheet
73. Microbiology- Enterics Culture and Sensitivity Record Sheet
74. Microbiology- Exudates Culture and Sensitivity Record Sheet
75. Microbiology- Gram Stain Record Sheet
76. Microbiology- KOH Record Sheet
77. Microbiology- Sputum Culture and Sensitivity Record Sheet
78. Microbiology- Throat Swab Culture and Sensitivity Record Sheet
79. Microbiology- Urine Culture and Sensitivity Record Sheet
80. Miscellaneous Record Sheet
81. Monthly Reagent Monitoring Sheet
82. Monthly Temperature Monitoring Sheet
83. Pregnancy Test Record Sheet
84. Preventive Maintenance of Machine/ Equipment
85. Typhi DOT Record Sheet
86. Troponin I Record Sheet
87. Urinalysis Record Sheet
Dental Section
88. Dental Diseases and Service Report
89. Dental Supplies, Medicines, and Miscellaneous Items
90. Patient’s Dental Treatment Record Sheet
91. Dental Monitoring
Psychological Section
92. Billing Statement for Contract of Affiliation
93. Screening Interview Rating Scale
94. In / Out Patients’ Psychological Assessment Data Form
95. Affiliated Colleges and Universities
96. Applicants’ Examination Result Form
97. Accomplishment Report
98. Referral Record Sheet
99. Endorsement Form for Psychological Tests
100. Basic Personality Inventory
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 101. DOSC- Dimension of Self Concept
102. Guide for Autobiography
103. Hand Test
104. MD5- Mental Ability Test
105. MDQ- Competency Model
106. MMPI- Minnesota Multiphasic Personality Inventory
107. Sach’s Sentence Completion Test ( Clinical Adult)
108. Sach’s Sentence Completion Test (Clinical Child)
109. Self- Analysis Test ( Industrial)
110. Supervisory Practices Inventory
111. WAIS- R Wechster Adult Intelligence Scale- Revised
112. WEPSS- Wagner Enneagram Personality Style Scale
113. WISC- R Wechster Intelligence Scale for Children- Revised
114. Psychological Assessment Request Form
115. Group Dynamics Monitoring Form
116. Psychological Test Materials
Radiology Section
117. Personnel Dosimetry Service Dose Report
118. Maintenance Record for G.E. Digital X-Ray
119. Maintenance Record for Processor
120. Maintenance Record for Shimadzu Conventional X-Ray
121. Borrower’s (Film)
122. Daily Summary of Charge Slip (Charity)
123. Daily Summary of Charge Slip (Pay)
124. List of Radiograph Report
125. List of Retakes of X-ray
126. List of Ultrasound Report
127. Patient’s Record of Ultrasound
128. Patient’s Record of X-ray
129. Releasing of Result
130. Infection Control Committee
131. Antimicrobial Order Form
132. Isolation Precaution Monitoring Sheet
133. Sharps Injury Form Needle Stick Report
134. Weekly Disease Update
COMMUNITY SERVICE
135. ACIS 5pm- 7am Report
136. Daily Patients Census for ACIS
137. DDU 5pm- 7pm Report
138. OPS Child & Adolescent Daily Report
139. OPS Pay Lane Daily Report
140. OPS Service Lane Daily Report
141. Psychiatric Emergency Room 5pm-7am Report
142. Psychiatric Emergency Room 8am-5pm Report
143. Public Health Unit Daily Report
144. Senior House Officer’s Report
145. Specialty Clinic Daily Report
146. Weekly Patients Status for Drug Detoxification and Rehabilitation Unit
147. Psychoeducation Record Sheet
148. Daily Census Follow-up Consultation OPS-Child & Adolescent
149. Daily Census First Consultation OPS-Child & Adolescent
150. Daily Activity Report for KIOSK (Hi-5)
151. Training Workshop
152. Post Activity Report
Page 25 of 33
 153. Daily Report
154. Top Inquiries From
155. Action/ Progress Routing Slip
156. Outreach Consultation Census
NURSING SERVICE
157. Census of Outreach Consultation to Different Institutions
158. Injection Record Sheet of Patients
159. Daily List of Admission of Patients
160. Specialty Clinic- Daily Census
161. TB DOTS Referral/ Consultation Record Sheet
162. TB DOTS Clinic Report/ Accomplishments
163. TB DOTS OPD-Daily Record of Activities
164. Record of Educational Tour
165. Census of Outreach Consultation in Gumaca District Hospital
166. Orientation Record for Nursing Affiliates
167. Borrower’s and Return Slip
168. Chart Filing Record Sheet
169. Clinical Instructor Attendance Sheet
170. Daily Census- First Consultation
171. Daily Census- Follow Up
172. Daily Census Record Sheet for Nursing Attendant
173. Daily Medicine Consumption Record Sheet
174. Discharge Record Sheet
175. Electroconvulsive Therapy Record Sheet
176. Emergency Kit (Psyche Ward)
177. Equipment Endorsement Record Sheet
178. Evaluation of the Quality and Efficacy of Nursing Intervention Using the Established Outcome Criteria and
Standard
179. Family Education Record Sheet
180. Laboratory Request Record Sheet
181. Long Acting Injection Record Sheet
182. Medicine Issued from the Pharmacy
183. Medicine Monitoring & Endorsement Report (Anti psychotic)
184. Medicine Monitoring & Endorsement Report (Non anti psychotic)
185. Monthly Census Record Sheet
186. Nursing Affiliation Bills
187. Out Patient Service- Pay Record Sheet
188. Patient Interaction Request
189. Patient’s Belonging’s Record Sheet
190. Patient’s Daily Activity Record Sheet
191. Physician in Charge Decking Record Sheet
192. Referral Record Sheet
193. Requested Supplies Record Sheet
194. Student Affiliates Borrower’s Record Sheet
195. Supervisor’s Staff Schedule of the Attendance 1 to 15
196. Supervisor’s Staff Schedule of the Attendance 16 to 31
197. Trans- in Record Sheet
198. Trans- out Record Sheet
199. Visitor’s Record Sheet
200. Weekly Requisition Sheet
201. Report of Illness Record Sheet
202. 24- Hours Narrative Report of the Nursing Service Ending At 7:00 A.M.
203. Kardex
204. Memorandum Sheet
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205. Nurse Report
206. Nurse Supervisor Officer of the Day
207. Nurse Supervisor Report
208. Nursing Attendant Report
209. Officer of the Day
210. Patient Census as of 12:00 Midnight
211. PHIC Room Checklist
212. Referral Slip for Long Acting IM Antipsychotic
213. Report of the 24 Hours Ending at 12:00 Midnight
214. Schedule of Assignment for Nurses and Nursing Attendant
215. Weekly Circle Meeting Report
216. Nursing Personnel Schedule and Patient Ratio Record Sheet
Central Supply
217. Costing of Ordered Medicines
218. Daily Summary of Charge Slip
219. Medical Supplies Delivery Report
220. Requisition and Issue Slip (Half Sheet)
221. Requisition and Issue Slip (One-third Sheet)
222. Product Feedback Form
Infirmary Section
223. ECG Monitoring
224. List of IN Patient
225. Emergency Cart Checklist page 1
226. Emergency Cart Checklist page 2
227. ER Decking
228. ER Decking (Non Psyche)
229. Hospital Sponsored Member Daily Log Sheet
230. Hospital Sponsored Member Monthly Census
231. OPD Report
232. Patients’ Disposition
233. PHIC Patient Monitoring
234. Radio Monitoring
235. OR- Scheduling Sheet
236. OR- Delivery Room Log Sheet
237. OR- Record Sheet
238. OR- Delivery Room Log Sheet
239. Report of Illness Record Sheet
240. OR- Supplies and Instruments Sterilization Record Sheet
Nursing Education, Training and Research
241. Performance Evaluation Tool for Nursing Attendant
242. Attendance Record
243. Clinical Rotation of New Nursing Staff for Orientation
244. Exit Interview
245. Information Sheet
246. Permit for Physical Tour, ECT Observation and Clinical Exposure
247. Personal Evaluation
248. In- Service Training Evaluation Tool
249. Residency Nurses Oral Revalida Evaluation Tool
250. Training Evaluation Tool From Other Agency
251. Criteria for the Case Presentation
252. Nursing Journal Evaluation Tool
253. Therapeutic Communication Skills Competency Checklist

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ADMINISTRATIVE SERVICE
254. Bin Card
255. Daily Attendance Record Sheet
256. Disbursement Voucher
257. Minutes of the Meeting
258. Incoming Communication Record Sheet
259. Monitoring of Photocopied Documents
260. Outgoing Communication Record Sheet
Dietary Section
261. Inventory of Equipment and Utensils Form
262. Daily Food Consumption
263. Delivery Sheet (Breakfast)
264. Delivery Sheet (Lunch / Supper)
265. Dietary History Form
266. Loading Sheet
267. Market Order
268. Meal Tag
269. Notice to Deliver
270. Nutrition Counselling and Schedule Form
271. Nutrition History Questionnaire
272. Receipt of Donation
273. Request for Packed Meals and Nourishment
274. Requisition Slip
275. Therapeutic Form (Pay)
276. Therapeutic Form (Service)
277. Nutrition Education Form
278. Supplementary Diet Form
279. PRO Active and Preventive Maintenance
280. Body Mass Index Monitoring Sheet
281. Meal Census and Distribution Monitoring Sheet
282. Special Function Patients/ Personnel Programs/ Activities
283. Patients/ Personnel Programs/ Activities
Engineering Section
284. Bill of Quantities
285. Calibration Plan
286. Maintenance Work Request
287. Preventive Maintenance Checklist (Air Conditioning Unit)
288. Preventive Maintenance Checklist (Computers)
289. Preventive Maintenance Checklist (Service Report for Ambulance)
290. Preventive Maintenance Plan
291. Scope of Work
292. Status Report of Corrective Maintenance
293. Status Report of Preventive Maintenance
294. Status Report of Rehabilitative Maintenance
295. Technical Specifications
296. Preventive Maintenance Service Plan
297. Daily Accomplishment – Job Orders & Projects
298. Job Order Monitoring
299. Waste Collection Monitoring
300. Calibration Service Plan
301. Calibration Plan
302. Preventive Maintenance Checklist- Generator

Page 28 of 33
Laundry Section
303. Request for Laundry Service
304. Laundry Collection and Delivery
305. Monthly Laundry Supplies Monitoring
306. Laundry Collection and Deliver
307. Laundry Machine Maintenance Record
Legal Section
308. Affidavit of No Pending Legal case
309. Declaration of Pendency/ Non-Pendency of Case
Linen Section
310. Linen Request and Issuance Record Sheet
311. Sewing Machine Maintenance Record Sheet
312. Mending
313. Condemned
Material Management Section
314. Credit Slip (Half Sheet)
315. Inspection and Acceptance Report
316. Credit Slip (Whole Sheet)
317. Donors and Donations Report
318. Gate Pass
319. Inventory Custodian Slip (Whole Sheet)
320. Inventory Custodian Slip (Half Sheet)
321. Request for Pre- Repair & Post-Repair Inspection
322. Request Slip (Half Sheet)
323. Request Slip (Whole Sheet)
324. Stock Position Sheet
325. Acknowledgement Receipt for Equipment
326. Inventory Form
327. Inspection and Acceptance Report (Delivery of Supplies)
328. Cash Advance
329. Consignment Order
330. Credit Slip
331. Disbursement Voucher
332. Documents Approved by MCC
333. Donation
334. Equipment- Purchase Record
335. Equipment- Request for Pre/ Post Repair Inspection
336. Inspection & Acceptance Report (Job Order)
337. Medicine – Charity
338. Medicine – Consignment
339. Medicine- Stock & Resale
340. Receipt & Deliveries – Other Supplies
341. Receipt & Deliveries – Rice
342. Receipt & Deliveries- Affiliation
343. Receipt & Deliveries- Fuel
344. Receipt & Deliveries- Income (Supplies)
345. Receipt & Deliveries Inspection & Acceptance Report
346. Report of Unserviceable Equipment/ Materials
Medical Records Section
347. Patients’ Census for the Day
348. Request for Photocopy / Risograph
349. Chart Coming From The Ward
350. Child Record Sheet
351. Correspondence Record Sheet
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352. Court Case Record Sheet
353. Daily Census of Archived Charts
354. Detoxification Record Sheet
355. Hospital Daily Census Report
356. Medical Records Daily Census of Admission
357. Medical Records Daily Census of Consultation
358. OPS Daily Record of Released Charts (Not scheduled)
359. OPS Daily Record of Released Charts (Scheduled)
360. OPS Daily Record Sheet ( Not Scheduled)
361. OPS Daily Record Sheet (Scheduled)
362. Overseas Filipino Worker Record Sheet
363. Record All Released Medical Certificates
364. Records of Incidence for Missing Medical Records
365. Release of Live Birth Record Sheet
366. Release of Medical Information
367. Released of Death Record Sheet
368. Vagrant Record Sheet
369. Women and Children Protection Record Sheet
370. Daily Monitoring of Discharged Charts
371. Patient Checklist (Infirmary)
372. Patient Checklist (Psychiatry)
373. Daily Monitoring of Assembled Charts
374. Daily Monitoring of Indexes and Verification of Patient Record
375. Daily Monitoring of Encoded and Verified Patients Charts
Medical Social Service Section
376. Acknowledgement for Assistance
377. Acknowledgement Receipt of Donated items/ Goods
378. Cash/ Check Donation (Incoming)
379. In- Kind Donation (Incoming)
380. Acknowledgement Slip for Medical Assistance
381. Census Monitoring Tool
382. Daily Statistical Record
383. Discharge Slip Endorsement Sheet
384. Endorsement Report of Patient’s Valuables
385. Family Day Attendance Record Sheet
386. Family Health Teaching Attendance Record Sheet
387. Family Meeting Attendance Record Sheet
388. Home Conduction Monitoring Sheet
389. Incoming Communication- Court Case
390. Incoming Communication
391. Inter-Office Referral of Medical Social
392. List of Enrolled Patients for Hospital – Sponsored Membership (HSM) of Philhealth
393. Monthly Monitoring Sheet of Patient’s Home Conduction
394. MSS Number Record Sheet
395. Outgoing Communication
396. Patient Classification Monitoring Sheet
397. Pavilion/ Ward Referral Forms
398. Records of MSS Leave of Absences
399. Referral for Medical Assistance Record Sheet
400. Referral for Medical Assistance Monitoring Sheet
401. Referral for Non- Medical Assistance Record Sheet (Incoming)
402. Referral for Non- Medical Assistance Record Sheet (Outgoing)
403. Socialized Fee Record Sheet
404. User’s and ER Fee Record Sheet
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405. Visitor’s Log Sheet
Personnel Section
406. Certification of Overtime Rendered
407. Clearance From All Money and Property Accountabilities
408. Exchange of Duty and Non-Working Day
409. I.D. Request Slip
410. Referral Slip for NP Screening
411. Requisition Form
412. Requisition Form (Certification)
413. Leave Application Log Sheet
414. List of Appointee
415. List of Certificate of Compensatory Overtime Credits
416. List of Released Vouchers
417. Monthly Report of Attendance
418. Summary of Absences
Pharmacy Section
419. Acknowledgement Report
420. Drug Administration Sheet
421. Pharmacy Endorsement Form
422. Requisition From Storeroom
423. Charge Slip/ RIS Monitoring Sheet (Accounting)
424. RIS Monitoring Sheet (Pavilion) -Deleted
425. Temperature Monitoring Chart
426. Quarterly Report for Stock Requisition
427. Expired Medicine Monitoring Tool
Procurement Section
428. Canvass Form
429. Consignment Order
430. Petty Cash Replenishment Report
431. List of Bidders
432. Purchase Order for COA
433. Purchase Order- In Process
434. Purchase Order- Outgoing
435. Purchase Order/ Invoice Received by Accounting
436. Receipt & Deliveries – Medical/ Laboratory/ Dental/ Radiology
437. Records of Issuance Purchase Thru Cash Advance
438. Schedule of Preventive Maintenance- Aircon
439. Supplier Information Sheet
440. Supplier’s Performance Evaluation
Security Section
441. Blotter Report Form
442. Firearms Deposit Form
443. Independent Narrative
444. Malayang Salaysay
445. Missing Person
446. Permit to Tour
447. Request for Use of Hospital Facilities
448. Vehicle Sticker Pass Application Form
449. Post Monitoring Report Form
450. Endorsement Report Form
451. Patient Monitoring Form
452. Confiscated Items Form
453. Vehicle Monitoring Form
454. Jogger’s Monitoring Form
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 455. Visitor’s Monitoring Sheet
456. Confiscated Monitoring Sheet
Transport Section
457. Monthly Consumption of Transport Supplies
458. Trip Ticket
459. Daily Summary Report
IHOMP
460. Computer Ledger Form
461. Computer/ Peripheral Request Form
462. Preventive Maintenance Plan Monitoring Sheet
463. Database Back-up Log
FINANCE SERVICE
Accounting Section
464. Itinerary of Travel
465. Monitoring of Home Conduction of Patients
466. Clearance Record Sheet Charity for Discharge
467. ABC, CAF & Contracts
468. Affiliation and User’s Fee Record Sheet
469. Clearance Record Sheet Charity for Discharge
470. Disbursement Vouchers
471. Notice to Deliver
472. PO, JO, RPB & APR
473. Reports and Documents Forwarded to COA
474. Voucher Preparation
475. Promissory Note
Budget Section
476. Budget Utilization Request and Status
477. Obligation Request and Status
478. Budget Utilization Request and Status – Capital Outlay
479. Budget Utilization Request and Status – MOOE
480. Obligation Request & Status – Capital Outlay
481. Obligation Request & Status – MOOE
482. Obligation Request & Status – Personnel Service
Cashier Section
483. Daily Collection Report
484. List of Collection National Government Account ( Account of Patient)
485. List of Collection National Government Account ( Other Income)
486. List of Collection Regular Agency Account ( Code 101-651)
487. List of Collection Regular Agency Account ( DOH NCMH CONSIGNMENT DRUG)
488. List of Collection Regular Agency Account (Code 184-131)
489. List of Collection Regular Agency Account (STOCK & RESALE)
490. Summary of Collection
491. Summary of Collection on Parking Fees
492. Current Account
493. Issued Official Receipts
494. LDDAP – ADA Payment
495. List of Daily Summary Collection
496. List of Summary of Collection
497. MDS Check Payment
498. Report of Collection ad Deposits (Drug Consignment)
499. Report of Collection and Deposits (National Government)
500. Report of Collection and Deposits (Regular Agency)

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 Special Disbursement
501. Cash Disbursement Record
502. Inspection & Acceptance Report
503. Petty Cash Replenishment Record
Training Office
504. Clinical Supervision Agreement
505. Court Testimony
506. Diagnostic and Therapeutic Conference for Resident Physician I
507. Final Tribunal/ Oral Evaluation Grading Sheet
508. General Staff Conference/ Grand Rounds for Resident Physician II
509. General Staff Conference/ Grand Rounds for Resident Physician III or IV
510. Performance Evaluation Summary Consultation- Liason Resident Physician
511. Performance Evaluation Summary for Resident Physician I
512. Performance Evaluation Summary for Resident Physician II
513. Performance Evaluation Summary for Resident Physician III & IV
514. Record of Supervision Meetings
515. Residency Competency Evaluation Form
516. Residency Competency Evaluation Guide
517. Supervisor’s Performance Evaluation Form
518. Tribunal/ Oral Evaluation (Grading Sheet/ Form B prior to promotion to Second Year)
519. Tribunal/ Oral Evaluation (Grading Sheet/ Form B prior to promotion to Third Year
520. Tribunal/ Oral Evaluation Appraisal Sheet/ Form A
QUALITY MANAGEMENT TEAM
521. Annual Audit Program
522. Audit Plan
523. Audit Summary Report
524. Auditor’s Notes
525. Corrective Preventive Improvement Action Report
526. PDCA Audit Checklist
527. Qualified Internal Auditors
528. Customer Satisfaction Survey
529. Distribution List
530. Document Request Form
531. Master list of Externally Generated Documents
532. Master list of Guidelines
533. Master list of Procedures
534. Master list of Quality Records
535. Master list of Work Instruction
536. Patient Care Complaint Report
537. Public Assistance and Complaint Desk
538. Staff Satisfaction Survey
539. Document Transmittal Letter
540. Post Training Evaluation Questionnaire
541. Post Training Evaluation Survey
542. Skills and Training Inventory
543. Skills and Training Matrix
544. Training Plan
545. Training Requirements
546. Opportunities for Improvement (OFI) Monitoring Sheet

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