POLICIES AND PROCEDURES

CRITER CODE INDICATOR AREA REMARKS

IA
PATIENTS RIGHTS WARDS
RIGHT TO INFORMATION
RIGHT TO REFUSE TREATMENT
RIGHT TO PRIVACY
RIGHT TO PERSONAL CHOICE
2 DEAMHI_PAP_01
RIGHT TO CARE AND SECURITY OF PERSONAL
BELONGINGS
RIGHT TO FREEDOM FROM RESTRAINTS
RIGHT RO FREEDON FROM ABUSE,
MISTREATMENT AND ABU
WARD
ADOPTED/DEVELOPED PROTOCOL ER
13 DEAMHI_PAP_02
CPG OPD
ICU
WARD
ER
13 DEAMHI_PAP_03 PATIENT EDUCATION
OPD
ICU
28, 31, qualification standards,
DEAMHI_PAP_04 HIRING, CREDENTIALING AND PRIVILEGING
33 procedure of hiring
28 DEAMHI_PAP_05 BLOOD TRANSFUSION
28, 43, Memos, waste segregation,
DEAMHI_PAP_06 HEALTHCARE WASTE MANAGEMENT
60 treatment and disposal
28, 43 DEAMHI_PAP_07 PATIENT SAFETY
Defined roles and
INFECTION PREVENTION AND CONTROL responsibilities, manual,
28, 52 DEAMHI_PAP_08 - PP ON DISPOSITION OF DEAD BODIES WITH ADMIN Procedures in use of PPE,
DANGEROUS COMMUNICABLE DISEASE OFFICE isolation precaution and
hand washing
28 DEAMHI_PAP_09 PHARMACOLOGIC AND THERAPEUTIC
28, 43, HEM safe hospital checklist
DEAMHI_PAP_10 EMERGENCY AND DISASTER PREPAREDENESS
70
Minutes of meeting
28, 61 DEAMHI_PAP_11 CONTINUOUS QUALITY IMPROVEMENT Personnel evaluation
Performance Appraisal
28 DEAMHI_PAP_12 GRIEVANCE
37 DEAMHI_PAP_13 RECORD STORAGE, RETENTION AND DISPOSAL MEDICAL
 RECORD
SYSTEMATIC FILING, RETRIEVAL AND MANAGEMENT MEDICAL
39 DEAMHI_PAP_14
OF MEDICAL RECORDS RECORD
PROTECTS RECORDS AND PATIENT CHART AGAINST MEDICAL LOGBOOK FOR BORROWING
40 DEAMHI_PAP_15 LOSS, DESTRUCTION, TAM,PERING AND RECORD AND RETRIEVAL OF CHARTS
UNAUTHORIZED ACCESS OR IUUSE
Operating and manuals of
44 DEAMHI_PAP_16 QUALITY CONTROL the medical equipment and
non-medical equipment
Preventive and corrective
CORRECTIVE AND PREVENTIVE MAINTENANCE
43 DEAMHI_PAP_17 maintenance logbook
PROGRAM FOR MEDICAL EQUIPMENT
Film reject analysis
WARD
INCIDENT REPORTING/SENTINEL EVENT ER
47 DEAMHI_PAP_18
MONITORING SYSTEM ICU
OR
WARD
PREVENTION AND TREATMENT OF NEEDLE STICK
53 DEAMHI_PAP_19 LAB
INJURIES AND SAFE DISPOSAL OF NEEDLES
ER
ER PP on isolation
PREVENTION OF TRANSMISSION OF AIRBORNE WARD PIDSR referral
56, 73 DEAMHI_PAP_20
INFECTIONS, TUBERCULOSIS LAB TB Referral Logbook
ISOLATION
57 DEAMHI_PAP_21 REPORTING OF NOTIFIABLE DISEASES PIDSR
CLEANING, DISINFECTING, DRYING, PACKAGING AND CSSU
58 DEAMHI_PAP_22 STERILIZING EQUIPMENT, INSTRUMENT AND
SUPPLIES
WARD Logbook
65 DEAMHI_PAP_23 NEWBORN SCREENING
OR of filter papers
66 DEAMHI_PAP_24 ROOMING IN AND BREASTFEEDING WARD MBFHI
67 DEAMHI_PAP_25 IMMUNIZATION WARD Logbook (BCG records)
68 DEAMHI_PAP_26 ANTI-SMOKING HALLWAY NO SMOKING signage
PHARMACY
69 DEAMHI_PAP_27 GENERIC PRESCRIBING
WARD
71 DEAMHI_PAP_28 NEWBORN HEARING SCREENING OUTSOURCED
72 DEAMHI_PAP_29 FAMILY PLANNING SERVICES FP ACCEPTORS

DEAMHI_AS_PAP ADMIN Logbook- 15 day menu

I.A DIETARY
_01
B DEAMHI_AS_PAP LINEN Logbook
 _02
DEAMHI_AS_PAP Logbook
C SECURITY
_03
DEAMHI_AS_PAP Logbook
D HOUSEKEEPING
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DEAMHI_AS_PAP Logbook
E PROPER WASTE DISPOSAL
_05
DEAMHI_AS_PAP Logbook certificates
F MAINTENANCE PREVENTIVE MAINTENANCE
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