DEM Module 1

MANILA DOCTORS HOSPITAL
DEPARTMENT OF EMERGENCY MEDICINE

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MODULE 1:
INTRODUCTION TO
MDH EMERGENCY DEPARTMENT
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Course/Program Title: Department of Emergency Medicine Training Module
Course Description:
This training module is a primary guide in developing staff nurses to build aptitude and
proficiency in performing their task in the ED. This will hone the nurses with the appropriate knowledge,
skills and attitude in order to become highly skilled Emergency Nurses.
Intended Audiences: Staff Nurses
Teaching Strategy:
Lecture
Return Demonstration
Video Presentation
General Objectives:
This module will introduce the processes of the Manila Doctors Hospital Emergency Department
to the staff nurses. This will serve as a guide to the nursing staff on the necessary knowledge, skills and
utilization of the nursing process in the management of emergency and critical cases.
Specific Objectives:
After studying this module, the participants will be able to:
1. Define and identify roles and functions of ED personnel and staff.
2. Define ED policies, procedures, and guidelines.
3. Identify the cases coming into the ED and classify if non-urgent, urgent, or emergency.
4. Identify supplies and equipment to be used for different procedures.
5. Demonstrate proper use and handling of equipment in the ED.
6. Identify appropriate nursing intervention and perform with accuracy and precision.
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Introduction to Manila Doctors Hospital Department of Emergency Medicine
The Manila Doctors Hospital Department of Emergency Medicine

first evolved and became an independent department in 1991. It was
during that time that the Manila Doctors administration decided to
have dedicated consultants to run the department’s operations 24/7.
The pioneer consultants were from different departments namely
from Pediatrics, Surgery, and Internal Medicine.
In 1995, the department transferred to its present location and

this is where its census of consults grew and gradually developed
into the highly specialized and organized unit it is at present.
The Department of Emergency Medicine of Manila Doctors

Hospital envisions to be a model department promoting Manila
Doctors Hospital as a leading center of excellence in health care and
wellness in the Philippines providing holistic quality and client-
centered service in partnership with stakeholders.
General Functions
To provide safe and quality service in the field of Emergency Medicine to the clients of Manila
Doctors Hospital.
Specific Functions
 Triages patients according to the urgency of their health condition.
 Provides appropriate and timely interventions, both medical and nursing care to non-urgent,
urgent and emergent cases after performing adequate history and physical examination with
special attention to vulnerable patients (pediatric, elderly, pregnant and non-English-speaking
patients)
 Provides resuscitative measures in life- threatening conditions (arrest situations)
 Admits, discharge, refer and transfer patients accordingly following Policies and Procedures of
DEM on such.
 Manages mass casualty incidents according to the Guidelines in Sudden Influx of Patient and
Disaster Preparedness
 Manages the hospital’s emergency response and ambulance unit.
 Ensures compliance to all relevant standards of ISO 9001:2015, PhilHealth, Accreditation Canada
International and the United Nations Global Compact
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DEM Organizational Chart

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Trainings
The MDH-DEM aims to provide continuing professional education through implementation of a
training program in emergency medicine for its staff (consultants, residents, interns, nurses, etc.) so as
to continually improve quality of service.
Corporate Social Responsibility

The Department of Emergency Medicine desires to participate in the programs of the hospital’s
Corporate Social Responsibility Office to help empower our communities to sustain health and wellness.
The DEM is a reliable partner to the CSRO in their mission to make healthcare accessible to the
marginalized and the underserved of the community.
Nursing Roles and Responsibilities of Emergency Department Nurses

 Provides direct and indirect patient care activities.
 Triages patients according to the urgency of their health condition based on assessment and
prompt referral to the doctors.
 Encodes accurately patient’s data at the HIS.
 Provides appropriate and timely interventions to both medical and nursing care.
 Provides resuscitative measure in life threatening conditions (arrest situation).
 Utilizes nursing process to admit, refer, transfer, and discharge patients.
 Helps in the management of mass casualty incidents during sudden influx of patients and
disasters.
 Reviews the patient charts for appropriateness and documents pertinent observations and
interventions at the nurse’s notes.
 Acts as custodian by doing proper inventory of E-cart items and Animal Bite Center medicines.
 Ensures that correct laboratory and diagnostic examinations are requested or encoded.
 Requests, prepares, administers, and records medications cognizant of effect and report any
adverse reactions.
 Assists the physician in the provision of highly specialized therapy or treatment or in performing
highly complicated procedures in the department.
 Makes frequent rounds to check on the patient’s condition especially the critically- ill patients
and those who require intensive nursing care.
 Clearly coordinates, collaborates, and communicates with other members of the healthcare
team in attaining patient’s total needs and experience.
 Helps provide a comfortable, clean, orderly and safe environment for the patients and family.
 Receives booking of ambulance conduction.
 Reports issues and concerns encountered in the unit.
 Participates in the orientation of new personnel in the department.
 Ensures confidentiality of records and processes data in adherence to the data privacy policy of
the hospital
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Roles and Responsibilities of the Charge Nurse

 Management of Personnel and Unit
 Receives and gives endorsement.
 Prepares the nurse-patient assignment of bedside nurses.
 Supervises activities of staff including affiliates.
 Assists Head Nurse in giving orientation to Staff Nurses and Nursing Auxiliaries.
 Assists the Head Nurse in evaluating and recording the quality of service rendered by the Staff
Nurse and Nursing Auxiliaries.
 Informs, refers and consults Head Nurse/ Supervisor on duty for any problem encountered in
the unit.
 Recommends the disciplinary measures to the Head Nurse for any infraction of hospital and
nursing service rules and policies.
 Encourages participation of staff in the hospital and divisional activities:
 Continuing education, research and quality improvement programs.
 Unit meetings.
 Orientation of the unit policies and technical skills development of the trainees and students.
 Delegates some tasks to staff nurse.
 Makes adequate provision of nursing care of patients in his/ her unit and supervise for that care.
 Ensures smooth transition of patient’s admission, referral, transfer and discharge.
 Supervises triaging of patients according to the urgency of their health condition.
 Manages mass casualty incidents in sudden influx of patients and during disasters.
 Reviews patient’s chart to validate proper carrying out of doctor’s orders and ensures accurate
documentation in the nurse’s notes.
 Ensures proper coordination and documentation of ambulance conduction.
 Plans and implements adequate quality nursing care depending on individual needs.
 Makes frequent rounds to check on the patient’s condition.
 Assists and accompanies doctors during rounds as necessary.
 Coordinates, collaborates, and communicates with other member of the healthcare team in
attaining patient’s total needs and experience.
 Supervises the activities of staff nurses including resuscitative measure in life threatening
conditions (arrest situation).
 Ensures provision of a comfortable, clean, orderly and safe environment for the patients and
family.
 Keeps and maintains records including updating of charts, logbooks and master list of patients.
 Accomplish a 24-hour report for his/ her shift.
 Maintains good interpersonal relationship with patients, their relatives, staff and other
members of the healthcare team.
 Helps in the implementation of Infection Prevention and Control practices.
 Ensures completeness and accuracy of received bookings of ambulance conduction
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Roles and Responsibilities of Triage Clerk

 Acts as DEM receptionist.
 Encodes patient’s data to HIS.
 Assists the Triage Nurse in getting vital information from the patient.
 Assists the Triage Nurse in sorting the patients entering the department according to the
urgency of health condition.
 Responsible for encoding and printing out of Death Certificates.
Roles and Responsibilities of Counter Clerk

 Answers telephone calls with courtesy.
 Maintain confidentiality of patient’s data and ensures security of records.
 Prepares charges or payments such as consultation fees.
 Coordinates and validates patient’s charges with the Stock Clerk.
 Coordinates patients concerns regarding policies of HMO’s and affiliated companies.
 Registers patient’s data in the computer daily census.
 Reviews, monitors and safe-keeps patient’s charts and ensures completeness.
 Releases Discharge Instructions, Medical Certificate and Discharge Slip to patients upon
settlement of account.
 Coordinates the release of any medical certificate abstracts and death certificates if necessary.
Roles and Responsibilities of Stock Clerk

 Handles medical supplies and ensures proper recording.
 Does forecasting, periodic, and emergency requisitions as necessary.
 Receives weekly supplies from the Materials Planning and Inventory Management (MPIM)
Department.
 Dispenses/Issues medical supplies to the nurses and doctors for patient’s usage.
 Monitors and does supplies inventory periodically.
 Monitors and updates sundry sheet of each patient and that all supplies and any diagnostic fees.
 Coordinates patient’s charges to the billing clerk.
 Updates files and forms.
 Reports broken or damaged unit equipment or article to the Facilities and Management Division
(FMD) and monitors its status.
Roles and Responsibilities of Inventory Clerk

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 Performs monthly inventory of assets, accomplishes monthly report, and reconciles variances.
 Maintains records of supplies inventory
 Receives requested supplies from the Materials Planning and Inventory Management (MPIM)
and ensures its completeness, quality and accuracy.
 Checks and returns expired or defective supplies and accomplishes incident report.
 Reports any overstock or missing items.
 Plans, and forecasts, needed supplies. Replenishes as deemed necessary.
 Ensures clean and organize stock room.
 Files all inventory and delivery receipts.
DEM Policies and Procedures

Monitoring and Waiting Fee in the DEM
1. The following are the technical terms that will be applied in their policies.
A. Monitoring Fee: Hospital fee charged to patients.
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B. Waiting Fee: Hospital fee charged to patients staying for more than two (2) hours
C. Disposition: definite plan for the patient which can be admission, discharge, transfer of hospital
or home against medical advice.
D. Admitting Orders: written orders by doctors signifying that the patient if for admission or
confinement and itemizing the procedures and medication that will be given to the patient.
E. Overstaying patients:
 Patients who have stayed more than two hours at the DEM due to any of the following:
O Still awaiting laboratory results or have not submitted needed
laboratory specimens (urine or stool).
O Still awaiting to be seen to refer specialty service or awaiting final
disposition from specialty consultant.
2. Policies for Monitoring and Waiting Fee
A. All patients seen at the DEM will have proper disposition within two (2) hours of stay at the
DEM:
 Admit
 Discharge
 Still for Observation
B. Charged to patients who:
 Have written admitting orders
 Still at the DEM after two (2) hours after the admitting orders were accomplished
 Are waiting for inpatient rooms even if there are no rooms available
 Are already discharged but opted to stay longer (2 hours after order of discharge has been
given).
 Are advised for admission but are still undecided (2 hours after order of admission
has been given).
C. Patient or relative will be informed of the hospital policy and will be asked to sign the DEM
Chart in which the following are indicated:
 Time of start of monitoring fee
 Monitoring fee amount per hour of stay at the DEM.
3. Patients for Direct to Room (DTR) admission
a. With written admitting orders opted or need to stay in the DEM during processing shall be
charged a waiting fee.
b. Without written admitting orders or when the service resident makes the orders here in the
DEM, shall also be charged a waiting fee.
C. Started out as DER patient during stay, DTR orders were made shall be charged our standard
consultation fee.
Control and Recording Patient’s Clinical Charts

1. The following policies govern the control and recordkeeping of patient’s clinical charts from the
Department of Emergency Medicine (DEM).
a. The Department of Emergency Medicine shall keep at a suitable storage the records of
patients seen at the DEM for the period of six (6) months.
b. The DEM charts shall be stored per day in alphabetical order (patient’s name) and will be
contained in a storage box. Each box will be labeled accordingly as to day, month and year
covered
c. These boxes of each record will be endorsed to outside storage facility for safekeeping
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d. for a period of ten (10) years. After ten (10) years, records will be shredded.
e. Upon discharge of a patient from the emergency room, he/she shall receive a document of
DISCHARGE INSTRUCTIONS AND MEDICAL CERTIFICATE. This serves as certificate of Department of
Emergency consultation. No other medical certificate will be issued for any other purposes.
f. If patient loses the above document or requires another certificate of medical consultation,
the DEM shall be given two weeks’ notice to provide another copy and this be charged
minimum fee.
g. The DEM Masterlist of Patients will also be kept at a suitable storage in the DEM for a period of
ten (10) years, after which they will be shredded and discarded.
h. Trainees and consultants may borrow the DEM Chart upon leaving his IDENTIFICATION CARD with
the clerk on duty. The said chart may not be photocopied or brought out of the premises of the
DEM. Appropriate sanction will be imposed for violation hereof.
DEM CSR Patients

1. POLICY AND PURPOSE
a. All patients who are seen at the Department of Emergency Medicine (DEM) shall be
charged including Corporate Social Responsibility (CSR) patients. CSR patients who might
need admission shall be forwarded by the ERO Consultant to the CSR Department for
evaluation.
b. Non-emergency consults shall be seen at the Outpatient Department (OPD) except after
office hours and weekends when the OPD is closed.
2. RESPONSIBILITY
a. The medical and nursing staff of the OPD handling CSR patients, the CSR Department and
the Department of Emergency Medicine shall be responsible for policy dissemination and
enforcement.
3. SCOPE
a. Consults of CSR patients in the Department of Emergency Medicine.
4. DEFINITION OF TERMS
a. CSR – refers to the patients under this program are assisted financially by the Hospital for
their medical and hospital expenses.
b. Non-emergent complaint – refers to the complaint that is non-life threatening and shall be
evaluated as a non-emergency consult.
HMO Consultations at DEM

1. OBJECTIVE
a. To maintain a documented procedure for Health Maintenance Organization (HMO)
consultations at the Department of Emergency Medicine (DEM).
b. To identify risks related to the services being rendered at the DEM.
2. SCOPE
a. This procedure covers processes involved from HMO patient’s entry up to patient admission or
discharge
3. POLICIES
a. All HMO’s and insurance companies accredited and honored by Manila Doctors Hospital (MDH)
shall submit written documents on the following:
1. List of accredited (MDH) coordinator with clinic schedule and contact number.
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2. List of accredited doctors from MDH (by specialty) with clinic schedule and contact
number.
3. Telephone number of 24-hour hotline.
4. Telephone number and name of MDH medical representative.
5. Department of Emergency Medicine (DEM) consultation policy, procedures and
forms.
6. Department of Emergency Medicine (DEM) admission policy, procedures and forms.
b. Approval for coverage for consults at the DEM for non-emergent complaints shall not be
sought by the DEM personnel.
c. Patients with expired HMO cards and/or those whose HMO coverage cannot be verified will
be asked to settle account on cash basis.
d. The DEM personnel will not take responsibility to inform the MDH-HMO medical
representative of admissions under their HMO.
e. A back-up system is in place just in case the HMO Coordinator cannot be contacted.
5. RESPONSIBILITIES AND ACCOUNTABILITY
a. DEM Consultant and DEM Resident on duty shall ensure that
the flow of referral will be followed.
b. HMO Coordinator must be available at all times to receive calls
for referral.
c. HMO and Insurance Companies shall inform their clients of their pertinent DEM consultation
policies and coverage.
d. Clerk-on-duty shall verify HMO card validity and insurance
coverage for diagnostic and therapeutic procedures.
6. All referrals must be acknowledged and answered promptly by the service ROD within 5 to 10
minutes from the time of referral.
7. Pending response from the HMO Coordinator should not delay management and referrals from
being seen by the specialty resident informed about the case.
NOTES
1. A notation is made on the DEM ADMISSION SHEET on the classification of a HMO patient.
2. Confirmation of the HMO authenticity will be made by the DEM clerk on duty together with the
financial counselor on duty.
3. All HMO patients will be initially seen by DEM Consultant, DEM Resident-on-Duty and/or Pediatric
Resident-on-Duty.
4. All HMO patients needing specialty referral will follow the following procedures:
a. All pediatric HMO patients seen by the Pediatric Resident-on-Duty will follow the referral
system of the Department of Pediatrics.
b. For HMO’s with Department of Family and Community Medicine (DFCM) consultant
coordinators, the DFCM Resident-on-Duty will be informed and succeeding referrals and
admitting orders will be under the care of DFCM resident informed.
c. For non-DFCM HMO coordinators, the DEM resident will decide based on the following:
d. If the case of the patient is within the specialty of the HMO coordinator, the DEM Resident will
inform the resident of the coordinator and succeeding referrals and admitting orders will be
under the care of the resident of the coordinator.
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5. If the case of the patient is not within the specialty of the HMO coordinator, the DEM resident will
inform the appropriate specialty resident for the patient; this will assure that there will be no delays
in the management of the patient.
d. The DEM Resident then proceeds to inform the HMO coordinator to ask for a specialty
consultant appropriate for the patient.
e. If the HMO coordinator cannot be contacted thru calls or text messaging, the DEM Resident
will utilize the specialty deck given by the different departments at the DEM. This will be
matched against the list of HMO accredited doctors.
f. The priority will be the appropriate on deck consultant accredited by HMO.
6. All succeeding referrals and admitting orders will be under the care of the specialty resident.
7. The DEM NOD carries out all doctor’s orders in accordance with Policies and Procedures on
Department of Emergency Medicine.
8. Records shall be kept and maintained in accordance with Policies and Procedure on Control of
Documents and Records.
9. All concerned personnel shall be adequately informed prior to the implementation of this document.
NON-ADHERENCE TO POLICIES AND PROCEDURES

1. Staff with a single non-conformity but with detrimental repercussion to the hospital operation and/or
with recurrent non-conformity to the Policies and Procedures HMO Consultations at the Department
of Emergency Medicine shall be subjected to disciplinary actions following existing hospital rules and
regulations.
Issuance of Certificate of DEM Consultations

1. Upon discharge of a patient from the emergency room, he/she shall receive a document of DISCHARGE
INSTRUCTIONS AND MEDICAL CERTIFICATE. This serves as Certificate of Department of Emergency Medicine
Consultation. No other medical certificate will be issued for any other purpose.
2. Patients who are Discharged Against Medical Advice or are transferred to a hospital of choice will be
given the same document of DISCHARGE INSTRUCTIONS AND MEDICAL CERTIFICATE to serve again as
Certificate of Department of Emergency Medicine Consultation. However, it will be indicated in the
discharge instructions sheet the patient went DAMA or TRANSFER.
3. Trauma cases or cases of physical injury discharged from the Department of Emergency Medicine
(DEM) shall receive a sheet of DISCHARGE INSTRUCTIONS AND MEDICAL CERTIFICATE which will also serve as
Certificate of Department of Emergency Medicine Consultation.
4. The DEM will not however issue a medical certificate for medico-legal purposes. Medico-legal cases
will be referred to the Hospital’s Medico-legal Consultants upon consent. The DEM does not have the
duty to discuss the matter of fees charged by the medico-legal consultations.
DEM for Rotating Residents

1. All referrals must be acknowledged and answered promptly by duty residents within 5-10
minutes from the time of referral. Appropriate sanctions shall be imposed on any personnel who fail
to respond to referrals promptly.
2. The service resident in-charge of patients in the DEM must judiciously facilitate the disposition
(admission, discharge, or transfer) of patients referred to their service. Emergent or urgent
admissions must be facilitated within two (2) hours from arrival at the DEM.
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3. Laboratory and other ancillary services as well as diagnostic procedures should be utilized judiciously.
Response of resident physicians and disposition of patients should never be delayed due to absence
of results of diagnostic tests.
4. All emergency room admission and discharges must be cleared by the Emergency Room Officer (ERO)
Consultant.
5. Residents who received calls for transfer of patients to our institution must inform the ERO Consultant
of such transfer.
6. Proper decorum should always be observed in the emergency room with emphasis among others on
courtesy, empathy and prompt attention to the patient’s needs and courtesy as well as respect to
consultants, fellows, residents, interns, nurses, and other DEM personnel.
7. Residents from the Department of Family and Community Medicine (FAMED) who goes 24 hours at
the DEM must:
a. Initially assess and manage any patients consulting at the DEM and not only those
referred to their services.
b. Inform the ERO Consultant of their whereabouts.
c. Report for duty on time and submit written excuse letter for such absences.
d. Make-up all absences and tardiness based on the number of hours they have been absent or
late.
8. ERO Consultant shall have prerogative to admit and to admitting orders for patients whose admissions
are delayed.
DEM for Unaccompanied Patients

1. Conscious patient for admission
a. The emergency room physician and the attending physician (patient’s preference or on-deck or
HMO/company coordinator) shall allow the patient to be admitted to the room of choice. The
ERO/ attending physician shall advice the patient regarding room accommodation, expected
examinations and possible expenses. The patient shall be admitted to the lowest available
accommodation unless the patient desires otherwise. If the patient chooses to be admitted to a
higher priced bed, a deposit shall be required.
b. The MDH Security Service shall be informed by the ER Head Nurse upon admission to diligently
search for the relatives of the patient. It shall be the discretion of the designated MDH security to
ask for assistance from the Philippine National Police (PNP).
c. Where there are no relatives within 24 hours, the Hospital Director, Medical Director, Chairman of
the department of the attending physician and the Corporate Social Responsibility (CSR) office
shall be informed. The CSR will assess the patient regarding eligibly in the CSR program of the
hospital.
d. Consent for transfer is required for those who shall be brought to another facility.
2. Unconscious patient for admission

a. In case where the patient is unconscious and unaccompanied and admission is deemed necessary,
emergency management shall be instituted by the ERO/Consultant/Resident on duty.
b. The ER Head Nurse shall inform the nurse supervisor on duty immediate upon admission of the
patient. It shall be the responsibility of the ERO/ consultant/ resident on duty to ensure the
appropriate transfer of the patient to the designated treatment area.
c. The ER personnel and the MDH Security, in the presence of the nurse supervisor, shall search the
personal and/or the names and address or relatives, work place associates, etc.
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d. The ER Head Nurse shall inform the Hospital Director, Medical Director and Chairman of the
department of the attending physician within twelve (12) hours of the admission of the patient at
the ER.
e. The MDH Security shall be tasked to locate the relatives/ work associates of the patient as soon as
possible with the assistance of the Philippine National Police (PNP).
2.6 If the whereabouts of relatives cannot be determined, arrangement for transfer to a
government hospital should be made at the earliest possible time if indicated as determined by
the consultant in charge.
f. A resident/ intern shall accompany the patient for transfer to another hospital, for diagnostic
testing in the another institution, or any other authorized reasons provided that:
 The MDH ambulance is used.
 Authorization is given by the department, and hospital rules on the use of hospital
transportation shall be followed.
Unaccompanied Foreign Patients

1. The following are the technical terms that shall be applied in these policies:
a. Foreign Patients – all non-Filipino patients that consult the Department of Emergency Medicine
(DEM).
b. Unaccompanied Patients – all patients who consult alone of who are brought in by person not
directly related to the foreign patients.
c. Unconscious Patients – all patients who consult the DEM unresponsive to any stimuli and/or
severely intoxicated or comatose.
d. Uncooperative Patients – conscious patients who consult the DEM but are disoriented, confused
or exhibiting violent behavior.
e. Conscious Patients – awake, oriented, cooperative patients who consult the DEM.
f. Dead on Arrival (DOA) – patients who arrive at the DEM who are unresponsive and no pulse
noted.
g. Died at DEM – patients who arrive at the DEM alive but eventually expire while still being
treated at the DEM
2. Policies for Conscious Patients

a. Patient shall pass through be triage and shall be classified using the same criterion (emergent,
urgent or non-urgent) used for all patients consulting the DEM.
b. If the patient is unable to understand English or the native dialect, an interpreter from the
Business Development Division (BDD) of any available hospital staff shall be called to assist in
interviewing the patients.
c. All emergent and urgent cases shall be directed to the respective treatment areas.
d. All non-urgent cases shall be referred to appropriate Department of Outpatient Services a.k.a
OPD clinics during office hours and may be seen at the DEM after office hours.
e. Patient is given initial treatment and classified after two (2) hours if he/she is for admission of
discharge.
f. If the patient expresses any difficulty in paying for his/her hospital bills, he/she is referred to
DEM Financial Councilor or the Credit and Collection.
g. If the patient expressed need to inform his/her own embassy or personnel relatives to be
informed about his/her condition, the following shall assist the patient:
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 Financial Officer
 DEM Head Nurse
 DEM Administrative Officer
 DEM Charge Nurse
h. Any medical information needed shall be provided by the DEM resident-in-charge or the DEM
consultant-on-duty.
i. If for admission, the patient shall be informed and will be admitted under the appropriate walk-
in consultant for his/her condition.
j. If for discharge, the patient shall be given all the necessary papers and proper advice.
3. Policies for Unconscious Patients

a. Patient shall be immediately brought into the treatment area for assessment.
b. Initial treatment and management shall be instituted by the DEM resident or DEM consultant on-
duty.
c. The DEM clear/nurse on duty, together with the duty guard shall look through the personal
belongings and obtain any identification of the patients or any relatives that can be contracted.
d. Contracting the relatives or any responsible person shall be done by the following:
 DEM Head Nurse
e. The MDH Security Service shall be tasked to locate the relatives here in Manila with the assistance
of the Philippine National Police (PNP).
f. If patient regains consciousness then the above policy will apply.
g. If patient remains unconscious or is uncooperative and would be needing admission, the embassy
personnel or contacted relative will be informed of the plan for the patient.
h. The DEM charge nurse shall then inform the nursing supervisor and the DEM consultant shall
inform the DEM chair if the DEM administrative officer is unavailable.
9. The DEM administrative officer shall inform the Medical Director.
i. The DEM consultant or the nursing supervisor shall inform the Medical Director if the DEM
administrative officer is unavailable.
j. If no relatives are contacted, or embassy personnel are unavailable, the patient shall be admitted
into the appropriate hospital unit under an appropriate walk-in consultant.
k. If relatives are located and are amenable for admission in our institution, patient is then admitted
to the appropriate walk-in consultant and unit in the hospital.
l. If the relatives’ requests transfer to another institution, proper coordination is done and patient is
transferred using the DEM ambulance and accompanied by the DEM resident on duty.
m. After all necessary papers are accomplished; the patient is then transferred to the appropriate in-
patient room.
4. Policies for Dead on Arrival (DOA) or Died at DEM

a. All DOA patients shall be resuscitated at the resuscitation area.
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 If a patient is revived, then the rules for unconscious patients shall apply.
 If the patient expires, no death certificate shall be used.
b. Patients’ body shall then be brought to the morgue except for other religious sectors that require
bringing the body home immediately.
c. If brought to the morgue for temporary storage, all necessary paperwork shall be accomplished by
the DEM personnel.
d. Patient shall be kept at the morgue until relatives are available for release of the body or until an
LOA is obtained for any appointed guardian of the patient.
e. The DEM duty clerk/nurse, together with the duty guard shall look through the personal
belongings and obtain any identification of the patient or any relatives that can be contacted.
f. Contacting the relatives or any responsible person shall be done by the following:
 DEM Head Nurse
g. The MDH Security Service shall be tasked to locate the relatives here in Manila with the assistance
of the Philippine National Police (PNP).
h. The DEM charge nurse shall then inform the nursing supervisor and the DEM consultant shall
inform the DEM chair if the DEM administrative officer is unavailable.
i. The DEM administrative officer shall inform the Medical Director.
j. The DEM consultant or the nursing supervisor shall inform the Medical Director if the DEM
administrative officer is unavailable.
k. If no relatives are located, the embassy shall be informed and LOA will be obtained to dispose of
the body to an accredited funeral homes.
l. If relatives are contacted, but are unable to get the body, they shall ask to appoint a guardian or
authorized the appropriate embassy to act in their behalf.
m. After all appropriate personnel are informed and all paperwork’s accomplished, the patient’s body
shall be released to NBI accredited funeral homes.
DEM for Walk-In Patients

1. Whereas, the patient has deemed admissible by Department of Emergency Medicine (DEM).
2. Whereas, the patient has no previous Attending Physician at Manila Doctors Hospital (MDH).
3. Whereas, the patient has signed in the DEM Chart that he/she agrees to be admitted to the
consultant on-deck.
4. Whereas, the following services have provided the DEM the schedule of Consultant-on-deck for the
whole year.
 Surgery
 Internal Medicine
 Pediatrics
 Obstetrics and Gynecology
 Otorhinolaryngology
 Ophthalmology
 Orthopedics
5. Whereas, DEM Consultant-on-duty has the authority to decide on the service to which the patient
shall be admitted based on his clinical assessment.
6. Therefore, the following procedures shall apply:
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a. A patient for admission shall asked to sign in the chart that he/she was informed of the admission
and consents to be admitted under the service of the consultant-on-deck for his/her case.
b. The patient shall refer to the service under which he/she shall be admitted (e.g. Internal Medicine,
Surgery, etc.) resident shall assess the patient referred to him/her and immediately inform the
consultant –on-deck of the admission. Said consultant shall be given 30 minutes to acknowledge
the referral. Failure to respond within this time, refusal of referral for whatever reason (e.g. will be
out of town) or resident
c. In case where the patient is unconscious and unaccompanied and admission is deemed necessary,
emergency management shall be instituted by the ERO/Consultant/Resident on duty.
d. The ER Head Nurse shall inform the nurse supervisor in duty immediate upon admission of the
patient. It shall be the responsibility of the ERO/ consultant/ resident on duty to ensure the
appropriate transfer of the patient to the designated treatment area.
e. The ER personnel and the MDH Security, in the presence of the nurse supervisor, shall search the
personal and/or the names and address or relatives, work place associates, etc.
f. The ER Head Nurse shall inform the Hospital Director, Medical Director and Chairman of the
department of the attending physician within twelve (12) hours of the admission of the patient at
the ER.
g. The MDH Security shall be tasked to locate the relatives/ work associates of the patient as soon as
possible with the assistance of the Philippine National Police.
h. If the whereabouts of relatives cannot be determined, arrangement for transfer to a government
hospital should be made at the earliest possible time if indicated as determined by the consultant in
charge.
i. A resident shall accompany the patient for transfer to another hospital, for diagnostic testing in the
another institution, or any other authorized reasons provided that:
 The MDH ambulance shall be used.
 Authorization is given by the department, and hospital rules on the use of hospital transportation
shall be followed.
DEM for Management and Disposition of Patients

1. OBJECTIVE
These policies have been formulated in order to provide competent and efficient evaluation.
Decision-making and treatment necessary to prevent death and disability of individuals I health
crises who present themselves for care at the Manila Doctors Hospital – Department of Emergency
Medicine (MDH-DEM).
2. GENERAL POLICY STATEMENT

a. All health personnel in DEM shall endeavor to provide emergency evaluation and stabilization to
all individuals who seek emergency care regardless of ability to pay. Thus, all personnel are
expected to conduct themselves with utmost professionalism and place the benefit and welfare
of patients above all considerations.
b. The DEM in coordination with the other department shall conduct regular continuing education
activities in order to properly orient new and rotating staff and to maintain and enhance the
professional knowledge and skills of the staff in managing various aspects of emergency case.
c. A legible and appropriate medical record must be established and maintained for every
individual who presents for emergency care.
TRAINING MODULE
 All pertinent findings, events and transactions involving patient care shall be documented
through specific and legible written entries by all health care providers involved in care of a
patient. All referrals must also be documented to include the date and time that the referral
was made and date time that referral was answered of acknowledged.
 Final disposition of patients including instructions for follow-up arrangement for transfer
should be clearly reflected in the chart.
 All records are to be completed within 24 hours.
 All appropriate sanctions shall be imposed on all personnel who fail to record relevant and
appropriate information or misplaces medical records.
 All referral must be acknowledged and answered promptly by all health care providers and
specialist. Emergent cases should be seen immediately and urgent cases within 15-20
minutes.
 All patients must have a disposition within 2 hours of consult.
 Appropriate sanctions shall be imposed on any personnel who fail to respond to referrals
promptly.
 Laboratory and other ancillary services as well as diagnostic procedures should be utilized
judiciously and discriminately by the DEM physicians’ staff. Response of physicians to referral
and disposition of patients should never be delayed due to absence of results of diagnostic
tests.
d. Differences of opinion between different physicians managing a particular patient should be
resolved promptly through direct communication with each other. Resolution should be
facilitated by referral to the senior residents of the department and/or specialty services
concerned and, if necessary, the consultants. Unresolved differences shall be arbitrated by the
DEM Chair or the Hospital Chief Resident, or if necessary, the Medical Director.
DEM for Trauma and Physical Injury

1. The referral of all traumatic cases of physical injuries to our medico-legal consultants / officers is
made for the following reasons:
a. The medico-legal consultants / officers in our hospital are all members of our active medical staff
are duly licensed as both physicians and lawyers.
b. It is our belief as doctor-lawyers; they are in a better position to more effectively testify in court
regarding the injuries sustained by the patient.
c. A doctor-lawyer who appears as a witness is entitled to fees for his time for appearing in court
which undeniable takes him away from his adequately compensated services.
RESIDENCY TRAINING
1. OBJECTIVE
To establish a documented procedure on Department of Emergency Medicine Residency
Training Program.
2. SCOPE
This procedure covers the activities and processes involved from receipt of application for
residency training up to recommendation for graduation.
3. POLICIES
TRAINING MODULE
a. Attainment of a rating of at least 60% in the evaluation of the training program by the
trainees.
b. Attainment of accreditation of all the training programs offered by the unit.
c. The 60% of the basic requirements for training-related infrastructure and resources are
provided
d. Provision of support for CME to at least 60% of trainees.
e. Provision of at least one (1) educational course is for external customers per year.

a. Department Chairman
 Coordinates all activities of the Departments
 Monitors progress of activities of the Department in training, research service and
governance.
 Convenes quarterly evaluation conference for the activities, trainees’ progress and
consultant’s participation.
b. Training Officer
 Plans, implements, supervises and monitors the yearly schedule of training
activities
 Sees to it that the department follows the recommendation of the Phil. Academy of
Family Physicians.
 Coordinates and monitor the rotation of trainees
 Monitors, reports and coordinates system to address the concerns pertaining to
training
5. The Committee on Medical Education and Training (COMET) Secretary receives application for
residency training and instructs the applicant to accomplish the APPLICATION FOR RESIDENCY TRAINING
PROGRAM.
6. The applicant submits the completed application form with the necessary accompanying
documents to the Office of the Medical Director. These are then forwarded to the Department of
Emergency Medicine. The requirements for application include two (2) copies of the following:
 Accomplished application form
 Current 2x2 picture (within the last 3 months)
 Certificate of Internship
 Board Rating
 Board Certificate
 Transcripts of Records
 At least two(2) letters of reference
 Letter of Intent
7. The application form is forwarded to the Department Chair for deliberation.

8. The deliberation committee is comprised of the Training Officer as the chair with the
department staff as members.
9. The applicant must pass the written examination and the interview requirements.
10. The Department has the following criteria for pre-residency evaluation with a total of 100%.
a. Medical School Grades and other documents……….65%
TRAINING MODULE
b. Pre-Residency examination …………………………15%

c. Interview……………………………………………..10%
d. Pre-residency Rotation ………………………………10%
Note: Training Officer Evaluation, Written Evaluation by designated consultants
11. The applicant will not be accepted in the training program or he/she will be given one more
chance to apply provided he/she meets all the requirements.
12. The applicant undergoes residency training and is evaluated based upon set objectives and
requirements as stated in the Department of Emergency Medicine Residency Training Program
Manual.
13. Applicant shall undergo a period of Pre-Residency Training where his competencies shall be
assessed prior to the actual Residency Training Program.
14. If the applicant was not able to comply with the competencies required during pre-residency
training, he/she will not be accepted in the training program.
15. The following records shall be accomplished during residency training:
A. RESIDENT’S HOUR/MONTHLY MORBIDITY AND MORTALITY CONFERENCE EVALUATION
B. RESIDENT’S CASE PRESENTATION EVALUATION
C. RESIDENT’S ORAL EXAMINATION EVALUATION
D. RESIDENT’S RESEARCH PRESENTATION (ORAL) EVALUATION
E. RESIDENTS’ PERFORMANCE EVALUATION
16. The following records shall be accomplished during Internship
A. INTERNS’/ CLINICAL CLERK’S PERFORMANCE EVALUATION
B. POST-ROTATION EVALUATION BY INTERNS/ CLINICAL CLERKS EVALUATION (See Attached)The Internship
Training Program allows opportunity to learn and practice medicine and other related skills
relevant and necessary for the fulfilment of the program (refer to clause 5.0 of the
Department of Emergency Medicine Residency Training Program Manual)
17. A Resident shall have at least a passing grade on all rotations. He/She should complete all the
required rotations in his/her level before promotion to the next level.
18. In case the resident fails in the written and oral requirements, a probationary period be given for
completion and re-evaluation.
19. In case the resident fails in one rotation, he/ she shall repeat the rotation.
20. The resident will be dismissed from the training if he/she fails for the second time.
a. The resident shall be recommended for graduation once he/she has satisfied all the training
requirements.
b. Records shall be kept and maintained in accordance with Policies and Procedure on Control of
Quality Records
c. All concerned personnel shall be adequately informed prior to the implementation of this
document.
NON- ADHERENCE TO POLICIES AND PROCEDURES

1. A corrective and preventive action request (CPAR) shall be issued to any staff/ unit not
adhering to the policies and procedures on Emergency Medicine Residency Training.
2. Staff with a single non-conformity but with detrimental repercussion to the hospital
operation and/or with recurrent non-conformities to the policies and procedures on
Emergency Medicine Residency Training shall be subjected to disciplinary actions following
existing hospital rules and regulations.
TRAINING MODULE
EMS Disaster Preparedness Plan

1. OBJECTIVE
a. To design the emergency department disaster plan primarily in situations of sudden influx of
patients at the ER resulting from mass casualty incidents (both natural and man-made) in the
areas served by the hospital.
b. To train emergency department personnel to respond appropriately according to the guidelines
outlined in this plan.
c. To identify risks related to the services being rendered at the Department of Emergency
Medicine (DEM).
2. SCOPE
These policies and procedure cover activities starting from activation of disaster plan up to
admission and discharge.
3. POLICIES
a. It is the policy of Department of Emergency Medicine (DEM) to ensure effective communication
and facilitation of delivery of health services.
b. It is the policy of DEM to follow the procedures on Activation of Disaster Plan, Command
Structure, Treatment Areas and Patient Flow, Treatment Teams, Security and Ambulance Flow,
Patient Tracking and Documentation, Admission and Discharge Procedures.

a. Nurse-on-duty / Clerk-on-duty shall be responsible in receiving calls of Mass Casualty Incidents
(MCI) and documents them the appropriate form.
b. Supervisor-on-duty shall act as Incident Commander and Liaison Officer, which will be
responsible in notifying concerned hospital authorities in sudden influx.
c. Emergency Department Consultant-on-duty (ERC) shall be responsible in declaration of “CODE
WHITE” and briefing and designating DEM personnel in case of sudden influx.
d. The Nurses and Treatment Teams shall be responsible in triaging following the Treatment Areas
and Patients Flow Procedure.
5. PROCEDURE FOR ER CONSULTANT ON DUTY

a. The decision to declare a CODE WHITE is the discretion of the ER consultant on duty. This is
mainly guided by our rule of greater than 10 patients from the same incident.
b. This may also apply to any other situation where the DEM resources will be overwhelmed and
we will need the help of other personnel from the hospital.
c. Once declared the ER consultant makes sure the Nursing supervisor (Initial Incident
Commander) has been informed who must consequently inform the Hospital and Medical
Director (assume Incident Command on arrival) of the situation.
d. Inform the DEM chair of the CODE WHITE activation.
e. The DEM consultant on duty will be the TREATMENT AREA (DEM) Supervisor or Team Leader/
f. Gather all staff present at the DEM and brief them of what is going to happen/
g. Delineate RED, YELLOW and GREEN AREAS
h. Assign present staff to each area
 Team leader
 Team members
TRAINING MODULE
i. Move existing patients

i. Admit immediately
j. Discharge immediately
k. Gather additional personnel who will report to the DEM
 Determine how many who will be needing
 Assign them into teams
 Personnel not assigned back to their stations
l. Continuously supervise all areas making sure no patient, whether from the incident or our
regular patients, are not yet assessed or left unattended.
14. Make a master list of patients on the White Board.
 Dispose patients immediately
 Admit/Refer patients
 Utilize list of consultants if present
 Utilize walk in decking from departments
 If above consultants are unavailable the department chairs of the each department will be the
default consultant
 Discharge patients
m. Coordinate with finance to facilitate patient charging.
n. Once all patients have disposition and there are no more possible patients from the incident,
recommend to the incident commander lifting of the code white status.
o. Join the debriefing of the Incident Command.
NOTES
1. Activation of Disaster Plan
a. Any call reporting a mass casualty incident must be directed to the Department of
Emergency Medicine. The nurse or clerk on duty receives call made by the witness on-site.
The Mass Casualty Incident Message Form (see attached) located at ER nurse’s table will be
used to get the following information:
 Date and time of call
 Identity of caller
 Nature of Incident
 Number of Victims
 Status of Victims
 Treatments given
 Mode of transfer
 Contact number of calling party
b. The call will be confirmed by same nurse or clerk on duty (NOD/COD) by calling the contact
number of the caller.
c. Once report is confirmed NOD/COD informs Emergency Department Consultant on duty
(ERC) and Senior/ Charge Nurse/ ER Unit Manager (whoever is on duty).
d. ERC declares CODE WHITE (code for sudden influx of patients at ER). ERC may likewise
declare the same if >10 patients have arrived at the ER from a single mass casualty
incident even without a call being made.
TRAINING MODULE
e. ERC establishes temporary incident command post at the ER Conference Room and will act
as Treatment Area Team Leader until relieved by a higher ranked officer (DEMS Chairman
or Disaster Control Office).
 ERC will brief ER personnel on the situation
 ERC designates roles to ER personnel
 ER personnel will facilitate disposition of present ER patients
 Discharged, if suitable
 Admitted and immediately transferred to their respective rooms
 Transferred to the Pediatric/Adult Observation Area if for observation
f. ER personnel will wear their IDs, read their job description and take up their respective
posts
g. Senior/ Charge Nurse/ ER Unit Manager (whoever is on duty) will receive post as
COMMUNICATION OFFICER and will:
 Get disaster box at ER Conference Room
 Informs Supervisor on duty
 Notify telephone operator of CODE WHITE who will subsequently announce it through
the PA system (to alert hospital personnel of the activation of their respective
department disaster plan)
h. Supervisor-on-Duty will assume Incident Commander post

i. Notify the concerned hospital authorities
 Hospital Director
 Medical Director
 Nursing Directress
 Disaster Control Officer
 Chair, Hospital Disaster Preparedness Committee
 Department/Division Heads
 Operations and Hospitality Director
j. Notify nursing units to facilitate admission of ER patients
2. Command Structure:
The disaster plan is patterned from the Hospital Emergency Incident Command Systems (HEICS)
which outlines clear lines of authority and decision-making. Each position reports to a higher
ranked officer, supervises specified tasks and mans a particular post. This ensures effective
communication and facilitation of delivery of health services.
3. Treatment Areas and Patient Flow:

a. Triage –The triage will be set up outside the emergency room’s main entrance door.
 The nurse tags patients coming from the MCI according to the urgency in which they
need to be treated. The color code scheme which shall be used is red (needing
immediate resuscitation from a life-threatening condition), yellow (treatment for
injuries may be delayed from 15-20 minutes), green (treatment for injuries may be given
in an hour) and black (dead on arrival).
 Clerk/Nurse will likewise attach to the tag a number which
corresponds to the patient. If belongings from the patient need to be removed, these
shall be placed in a same numbered bag. This shall facilitate victim identification and
TRAINING MODULE
shall secure the belongings of the patient until such time as they can be released to the
appropriate authorities (for criminal investigation) or relatives.
 The clerk/nurse will also log the patient in the Mass Casualty
Incident Logsheet (see attached), tracking board and ER form (attached to a clipboard).
 Orderly will bring patient to appropriate treatment area.
 For patients NOT coming from the MCI, they shall enter the emergency room through
the 2nd triage area and will be treated in the OBSERVATION ROOM. The usual ER
procedures will follow.
a. RED AREA –Those needing immediate resuscitation will be brought to the red area (4 beds,
cardiac1-2, trauma 1, Minor OR-1).
b. YELLOW AREA –Those whose injuries may be treated within 15-20 minutes will be brought
to the yellow area (4-6 beds, ER beds 6-7, OB room and nearby hallway beds of. The area
can expand to the lobby area if needed.
c. GREEN AREA –Those whose injuries may be treated within an hour will be brought to the
hallway at the back of the emergency room and at the Industrial Medical Services
Department (IMSD).
d. BLACK AREA –Those who are dead on arrival will be brought to the morgue.
e. DECONTAMINATION AREA –In cases of hazardous material incidents, all patients will have
to pass through the decontamination area before going to the treatment areas. The
entrance to which is the driveway at the side to the emergency room. If immediate
resuscitation is needed, a separate team (with their own equipment) will be dispatched to
the decontamination area to give treatment. They will not be allowed access back to the ER
until they are likewise decontaminated.
f. OBSERVATION ROOM – ER patients (prior to MCI) still for observation and new patients (not
from MCI) will receive treatment at the Observation area (Adult and Pediatric isolation/
Pediatric). If discharged they will exit through the adult isolation entrance. If for admission,
they will exit through the ER back exit.)
 Treatment Teams
Triage Team
Team FM Consultant or Senior Nurse
Leader:
Members: (2) ER Clerk
(1) Orderly
(1) ER Nurse
Red Team
Team ED Consultant Back-up or IM/Surgery Consultant
Leader:
Members: 3rd – 5th year Service Residents
3rd year Medicine Resident (ER Rotator)
2-3 ER Nurses
Yellow Team
TRAINING MODULE
Team ED Consultant Back-up or IM/Surgery Resident

Leader:
Members: 2nd year Service Residents
2nd year Medicine Resident (ER Rotator)
2nd year FM Resident (ER Rotator)
2-3 Nurses from unit
Green team
Team ED Consultant Back-up
Leader:
Members: 1st year Service Residents
1st year Medicine/ FM Resident (back-up)
Observation Team
Team IM Consultants
Leader:
Members: IM Residents
Transport/ Discharge Team

Team Any available consultant
Leader:
Members: (1) ER Nurse
(2) Orderly (back-up from admitting)
Hazardous Material Incident Resuscitation Team

Team Resident Toxicology Consultant
Leader:
Members: 3rd year Medicine
Pulmonary Fellow
1 ER Nurse
SECURITY AND AMBULANCE FLOW

1. Once notified by the Supervisor-on-Duty/ Liaison Officer or ERC/ Incident Commander, the
emergency department shall be immediately secured.
2. The parking area in front of the emergency room shall be cleared and necessary signage and cordon
placed to direct ambulance traffic flow.
3. Ambulance will drop patients at the ER main entrance and immediately leave the area to avoid
clogging the traffic flow.
4. The MDH ambulance however will be stationed at the parking area in anticipation of needed
transport for deployment to MCI site or for transport to referral institutions.
TRAINING MODULE
PATIENT TRACKING AND DOCUMENTATION

1. All Unknown MCI patients will receive a number upon entrance at the triage. Belongings will be
placed in a bag and tagged with the same number. The ER form containing the same number
together with the colored sticker (red, yellow, green, black) shall be filled out subsequently for the
details of injuries, treatment, and disposition.
2. Patients shall be logged in MCI Logbook which shall be the source of information for the command
center and public information officer. This shall be continually updated as victims are identified,
treated and disposed. ER Clerks will have the primarily responsibility in patient tracking and
documentation with the help of the Nurse assigned in each treatment area.
3. Since periodic re-assessment will be done, color tags may change accordingly. A tracking board will
be placed at the ER waiting area where patients are also logged but this is unofficial record and will
be used primarily to track patients as they come in or go out the ER.
ADMISSION AND DISCHARGE PROCEDURES

1. Admitting section must update Incident Commander on the status of available beds. MCI patients
must receive utmost priority in admission. Transport team must readily transfer patients to their
room as soon as admitting orders have been carried out.
2. If beds become unavailable, the hospital will refer cases to Philippine General Hospital, Medical
Center Manila, San Juan de Dios Hospital, Ospital ng Maynila, Pasay City General Hospital, Adventist
Hospital.
3. When surgery is needed, the incident commander shall be informed immediately on the number of
cases that the surgery service can accommodate.
4. Patient for transport to referral institutions will be outsourced.
5. Patients for discharge will be charged accordingly by the Discharge Clerk. Upon payment, patient
receives prescription and written discharge instructions, and exits through the exit door located at
the back of the ER.
6. For MCI patients with HMOs procedure shall be as follows:
1. Initial treatment/ management done together with immediate referral to proper service as
indicated by injury.
2. Verification of coverage of HMO of the injury.
3. Referral to service of the HMO coordinator.
4. Same admission/ discharge procedures.
FAMILY ASSISTANCE AND INFORMATION CENTER

1. The Center, located at the lobby, shall be staffed by Public Relations Officer and people from the
Information Service Staff. Status of victims, their identity, treatment/ disposition and location shall
be fed to the center by the ER Triage clerk upon verification by the Incident Commander.
2. The Disaster Control Officer shall have the sole responsibility to release information regarding the
MCI. Information will be made available to him every hour by the staff in the information center.
3. Hospital pastoral services and the Department of Psychiatry maybe called upon to assist grieving
relatives and patients or to conduct psycho-social interventions.
4. The press area will be at the front entrance of the hospital (waiting area). No interviews, videos,
pictures will be taken/ done inside the emergency room.
COMMUNICATIONS
TRAINING MODULE
1. Two-way radios will be provided for, one for the control center and one for the triage for emergent
communications.
2. All decisions shall be properly documented.
3. Non-emergent communications will be carried by a messenger.
SECURITY
1. Only one relative per patient will be allowed inside the ER.
2. All personnel shall wear proper identification tags. Security will not allow entry to people
without such ID.
3. All entrances/ exits shall be secured by security personnel.
ANCILLARY SERVICES
The unit leader of the following ancillary services must ensure that the needs of the emergency
department are responded to at all times. The unit leaders shall report to the incident commander.
 Laboratory
 Radiology
 Pharmacy
 Respiratory Care
 Cardiac Care and ICU
 Dietary
 Housekeeping
 Materials Management
Records shall be kept and maintained in accordance with Policies and Procedure on Control of
All concerned personnel shall be adequately informed prior to the implementation of this document.

A Corrective and Preventive Action Request (CPAR) shall be issued to any staff / unit not adhering to the
policies and procedures on quality management system and continuous quality improvement program.
Staff with a single non-conformity but with detrimental repercussion to the hospital operation and/or
with recurrent non-conformity to the Policies and Procedures on Department of Emergency Medicine
Disaster Preparedness Plan for Sudden Influx of Patients shall be subjected to disciplinary actions
following existing hospital rules and regulations.
Ambulance Conduction
1. OBJECTIVES
a. The Department of Emergency Medicine (DEM) is the unit of the Hospital in charge of providing
efficient, safe fast transport service to patients. The DEM shall develop policies and guidelines
that shall ensure efficient management of the hospital’s ambulance service. It shall endeavor to
maintain the ambulance and its equipment and supplies. It shall coordinate with the Nursing
Service, Facility and Management Department and the Administrative Director to achieve these
activities.
b. The DEM is tasked to handle the transport services of the MDH in accordance with contract
entered into by the hospital with a specific ambulance service provider.
TRAINING MODULE
c. To identify risks related to the services being rendered at the DEM.
2. SCOPE
a. This following are the types of Ambulance Services (in order of Priority).
1. Conduction of patients for admission to MDH (from airport, seaport and other health care
facilities).
2. Conduction of patients for special procedures to be done in other hospitals or health care
facilities.
3. Pick-up of patients from an emergency call.
4. Scheduled coverage for an event necessitating an emergency medical team.
5. Transfer of patients to other hospitals.
6. Conduction of discharged patients to their place of residence.
3. POLICIES
a. All conductions are documented at the DEM AMBULANCE LOGBOOK.
b. Patients for transport to MDH from another institution must comply with the following policies:
 Referring hospital must have confirmed the patient’s readiness for transport, prepared the
comprehensive clinical abstract and confirmed availability of room at MDH for the patient.
 Receiving service at MDH must have received proper patient endorsement from the referring
hospital prior to transfer including special precautions.
 Relatives have been informed of possible expenses by the DEM Financial Counselor
3. Patients for transport from MDH to another institution must comply of the following:
 Proper endorsement and referral has been made to accepting institution.
 Receiving Hospital has acknowledged and accepted the transfer of patient.
 Ambulance fee and all hospital charges are already settled.
 Proper scheduling with DEM Staff for the use of the ambulance.
4. All resuscitation procedures or other procedures will be properly documented in patient’s chart by
the physician and nurse. This shall be duly kept as hospital record.
5. Patients pronounced dead on site will not be transported to MDH (unless requested by the relative).
Death certificate will not be issued by MDH. The appropriate fees will still apply (including ambulance
fee, charges on use of equipment, professional fees for procedures and resuscitation as previously
approved by the hospital).
6. An AMBULANCE SATISFACTION SURVEY (see attached) will be used to assess that transport service of the
hospital.
RESPONSIBILITIES AND ACCOUNTABILITY

1. It is the responsibility of DEM Consultant-on-duty to approve the request for ambulance conduction.
2. It is the responsibility of DEM staff to inform the ambulance service provider of the request and
needs of the patient. Ambulance service provider staff shall confirm with DEM staff appropriate
charges if questions arise.
3. It is the responsibility of the Team Leader of ambulance service provider to submit a monthly report
on ambulance conduction to the DEM Chair.
4. The DEM Chair shall coordinate with the office of the Hospital Director and Medical Director for
proper dissemination of the policy to the staff and MDH clients.
5. All bookings from all units/departments of the hospital shall be arranged through the DEM staff.
TRAINING MODULE
6. The DEM staff receiving the request for ambulance conduction shall accomplish the AMBULANCE
LOGSHEET YEAR (see attached). The patient or his/her relative will be informed of the appropriate fees
upon consultation with ambulance service provider.
7. DEM Consultant-on-duty shall approve he request for ambulance conduction.
8. The DEM staff shall inform the ambulance service provider of the request and needs of the patient,
ambulance service provider staff shall confirm with DEM staff appropriate charges if questions arise.
9. The DEM staff will inform and get the name of the duty ambulance MD-Resident who will accompany
the patient for conduction (Internal Medicine Residents for adult patients, Pediatrics Resident for
pediatric patients, Surgery Residents for surgical patients, OB-Gynecology Residents for OB-
GYNECOLOGY patients and other services). If DEM Consultant or Family Medicine DEM rotator is
available, he/she may also do the conduction. All conductions must be accompanied by a doctor
unless his/her attending physician waives such provision.
AMBULANCE TRANSPORT SERVICE shall be accomplished the following situation:

1. Patients for transport to Manila Doctors Hospital (MDH) from another institution:
a. Physician of referring hospital shall confirm readiness of patient to be transported to MDH; shall
complete patient’s clinical abstract; shall confirm availability of room at MDH: shall properly
endorse the patient to the resident of the receiving service of at MDH.
b. Resident of receiving service at MDH shall receive the proper endorsement from the referring
hospital and shall inform the DEM Consultant of the details of such transfer.
2. Patient for transport to MDH as an emergency pick-up from home wherein an out-of-hospital
resuscitation was done, the following guidelines will apply:
a. All resuscitation procedures will be properly documented in patient’s chart by physician and nurse
and this shall be duly kept as hospital record.
b. Patients pronounced dead on site will not be transported to MDH (unless requested by the
relative). Death certificate will not be issued by MDH. The appropriate fees will still apply
(including ambulance fee, charge on use of equipment, professional fees for procedures and
resuscitation as previously as previously approved by the hospital).
3. The ambulance staff will stay at their designated area if there is no ambulance conduction. Likewise
encouraged to stay at the DEM even if there is no ambulance conduction.
4. All duty Ambulance staff will report to the Charge/Head Nurse on Duty at the start of their duty shift.
5. For every conduction, TRIP TICKET (external) will be duly accomplished and one copy will be submitted
by the ambulance driver or paramedic to the DEM staff for filling, the other copy will be for the
ambulance service provider.
6. On the 16th and 31st of each month, the summary of ambulance conductions including the trip tickets
filed will be submitted by the ambulance service to the accounting department after being after
being duly noted by the DEM Head Nurse/Nurse Manager who shall countercheck the report.
7. Payment for ambulance services will be released by the accounting department to the ambulance
service provider after 15 working days from the date of the bill/invoice.
8. The summary of the doctor’s fees will also be submitted by the DEM Chair to the accounting
department for proper disbursement to the respective departments.
9. All consumables (medications, supplies and use of equipment) will be charged to the patient. The IT
department will asked to generate the reports for this in summary each month.
10.The members of the ambulance team shall be covered by insurance.
11.Ambulance report will be submitted monthly by the Head Nurse/Nurse Management to the Chair of
the DEM.
TRAINING MODULE
12.Total bill for ambulance services shall be included in the patient billing as follows:
TYPE OF CONDUCTION TIMING OF CHARGING

Conduction (pick-up) of patient for admission upon admission
CONDUCTION OF PATIENTS FOR SPECIAL PROCEDURES Upon approval of request for ambulance
(PROCEDURAL RUN)
Emergency pick-up of patients Upon admission for in-patient, and upon discharge
for out-patient
Transfer of patients to other hospital Upon approval of request for ambulance
Discharge patients for home conduction Upon approval of request for ambulance
TYPE OF CONDUCTION TIMING OF CHARGING
Conduction (pick-up) of patient for admission upon admission
CONDUCTION OF PATIENTS FOR SPECIAL PROCEDURES Upon approval of request for ambulance
(PROCEDURAL RUN)
Emergency pick-up of patients Upon admission for in-patient, and upon discharge
for out-patient
Transfer of patients to other hospital Upon approval of request for ambulance
Discharge patients for home conduction Upon approval of request for ambulance
 Summary of Records and Reports to be collated and submitted:

1. Trip Ticket filed per month (one copy with the ambulance provider, one to the ER)
2. Patient’s Evaluation of Ambulance Service
3. Monthly Report of Ambulance Service
4. Summary of Conduction (every 16th and 31st of the month).
Date of Room Name of Type of Conduction Waiting Total amount Transaction

Conduction # patients conduction Fee time of nos.
consumables
and
Equipment
 Type of Conduction:
1. Procedure
2. Transfer
3. Pick-up (ER)
4. Airport
5. Home
6. Coverage of event
TRAINING MODULE

1. A Corrective and Preventive Action Request (CPAR) shall be issued to any staff/unit not adhering to
the policies and procedures on quality management system and continuous quality improvement
program.
with recurrent non-conformities to the Policies and Procedures on DEM Ambulance Conduction shall
be subjected to disciplinary actions following existing hospital rules and regulations.
Stroke Pathway
1. OBJECTIVES
a. To maintain a tool in coordinating the care and service for suspected stroke patients at the
Manila Doctors Hospital (MDH) Department of Emergency Medicine (DEM).
b. To coordinate with the Department of Internal Medicine (IM), Section of Neurology, using the
stroke pathway to achieve the desired outcomes within an anticipated time frame by utilizing
the appropriate resources. It is also a blueprint that will guide the Clinician in the provision of
care for stroke patients.
c. To train DEM personnel to respond appropriately according to the guidelines outlined in this
plan.
d. To identify risks related to the services being rendered at the DEM.
2. SCOPE
a. This covers activities starting from activation of the stroke pathway to the disposition of the
patients
b. Once a patient is identified as having an acute stroke based on the signs and symptoms, a set
of orders will be carried out. These intend to reduce variability and cost, increase efficiency
and ultimately improve patient care.
c. The pathway also emphasizes the multi-disciplinary team approach of the various services:
DEM, Internal Medicine (Neurology), Radiology, Laboratory and Intensive Care hopefully to
achieve better patient outcomes.
3. POLICIES
a. It is the policy of DEM to ensure effective communication and facilitation of delivery of health
services for stroke patients.
b. It is the policy of DEM to follow the procedures on activation of the Stroke Pathway including
initial management, diagnostic and therapeutic interventions and early referral to the IM –
Section of Neurology for possible thrombolysis.

TRAINING MODULE
a. Physician-on-Duty (either Consultant or Resident) shall be responsible in activating the

pathway. All necessary data shall be documented in the ER ADMISSION SHEET and the STROKE
PATHWAY including the NIH STROKE SCALE.
b. Nurse-on-Duty shall carry out all relevant orders included in the pathway. Likewise he/she
shall also document the variance in the non-compliance with the pathway.
c. Emergency Department Consultant-on-duty [ERC] shall ensure that the Department of IM –
Section of Neurology has been immediately informed of the case.
1. NOTES
A. Activation of Stroke Pathway
a. The DEM Resident or Consultant activates the pathway once stroke is suspected in
accordance with the STROKE PATHWAY:
Symptoms:
 Sudden unilateral numbness or weakness.
 Sudden confusion, trouble speaking or understanding.
 Sudden trouble seeing in one or both eyes.
 Sudden trouble walking, loss of balance or coordination.
 Sudden severe dizziness with nausea or vomiting.
 Sudden headache with no known cause.
B. The DEM Resident/ Consultant then accomplish the NIH STROKE SCALE (see attached).
a. Define when the form is filled-out (A – Admission, B – 3 rd day, C – Discharge)
b. Define where the form was filled-out (ER, ICU, Regular Room)
 Patient is evaluated using a tabular sheet based on Consciousness
 Best Gauze
 Visuals
 Facial Paralysis
 Motor Arm (Right or Left)
 Motor Leg (Right or Left)
 In Coordination
 Sensory
 Aphasia
 Dysarthria
 Neglect
C. Total Score is noted on last page signed and dated by Resident/
Consultant accomplishing NIH Stroke Scale.
2. Intervention
The Nurse-in-charge carries out all mandatory intervention and also monitors variance in pathway
usage based on the variance code on the stroke pathway. The Nurse-in-charge encodes variance
code which was not done.
3. Assessment
The IM Resident and Neurology Consultant immediately respond to the referral to assess a patient
with acute stroke.
4. Admission
The IM Resident re-assesses the patient and shall facilitate the admission of patient in accordance
with Policies and Procedures on Admitting Patients
TRAINING MODULE
5. Records shall be kept and monitored in accordance with Policies and Procedures on Control
of Documents and Records.
6. All concerned personnel shall be adequately informed prior to the implementation of this
document.

1. A Corrective and Preventive Action Request (CPAR) shall be issues to any staff/division not adhering
to the Policies and Procedures on Stroke Pathway.
with recurrent non-conformities to the Policies and Procedures on Stroke Pathway shall be subjected
to disciplinary actions following existing hospital rules and regulation.
DEFINITION OF TERMS
1. Emergency refers to a medical or surgical condition that warrants immediate intervention
because failure to do so will result in disability.
2. Pathway refers to as:
 A tool used in achieving coordinated care and desired outcomes within an anticipated time
frame by utilizing the appropriated resources.
 A blue print that guides the clinician in the provision of care.
 Intended to reduce variability and cost, increase efficiency and ultimately improved patient
care.
 Uses Multi-disciplinary team approach.
Animal Bite Center

1. OBJECTIVE
a. To maintain a documented Policies and Procedures on the Animal Bite Center (ABC) at the
Department of Emergency Medicine of Manila Doctors Hospital in accordance with the
Department of Health (DOH).
b. To identify risks related to the service being rendered at DEM.
2. POLICY
a. The Animal Bite Center will follow the recommended intradermal or intramuscular schedule as
endorsed and approved by the Infection Control Committee (ICC) and the DOH.
a. The Chairman shall be responsible on monitoring the operation of the Animal Bite Center (ABC).
b. The Attending Physician shall be responsible on managing patients with animal bite.
c. The Nurse shall be responsible on the administration of treatment for Animal Bite Center
patients.
d. The ABC Manager shall be responsible for all the data collection, audit and census (daily,
monthly, and annual).
NOTES
1. On the patient’s first consult, the nurse-on-duty shall ask the patient to fill-in the ANIMAL
BITE CENTER (ABC) ADMISSION SHEET (see attached) and VACCINATION RECORD (see attached).
TRAINING MODULE
a. The attending physician shall assess and document the patient’s clinical condition and injuries
and provide appropriate therapeutic management. It shall be written in the ANIMAL BITE CENTER
ADMISSION SHEET and VACCINATION BOOKLET (see attached)
2. If Rabies Immunoglobulin (RIG) is not available, the patient will be referred to other
ABC/ ABTC with available RIG.
3. On the subsequent consultation, the patient will only need to present his VACCINATION
RECORD.
4. The clerk on duty shall retrieve the ABC admission sheet. The Attending Physician shall
note the consultation in the patient records.
5. The Nurse in charge of the patient shall inform the clerk on duty of the vaccine to be
administered for charging and payment including the professional fee, injection fee of Php 55 and
supplies.
6. The Clerk on duty shall provide the patient with payment slip to be settled at the
cashier.
7. For HMO/ Company clients, an additional ANIMAL BITE CENTER (ABC) IMPORTANT REMINDERS
FORM (see attached) shall be given.
8. The Clerk in charge of the patient will receive the receipt as proof of payment.
9. The Nurse in charge administers the vaccine as ordered by the Attending Physician.
10. The Nurse in charge of the patient will follow strictly the Infection Control Manual page
159 of 192 on Environmental care 10.1.
11. The ABC Manager will get a print-out of the ABC transaction for filing.
12. The Clerk shall file the Animal Bite Patient Record.
13. The Attending Physician/ Resident on Duty will give discharge instructions to the
patient.
14. The ABC Manager shall report census of consultations and follow-up at the end of the
month.
15. Records shall be kept and monitored in accordance with Policies and Procedures on
Control of Documents and Records.
16. All concerned personnel shall be adequately informed prior to the implementation of
this document.

with recurrent non-conformities to the Policy and Procedures on Animal Bite Center (ABC) shall be
subjected to disciplinary actions following existing hospital rules and regulation.
DEFINITION OF TERMS
1. Animal Bite – refer to as bite sustained by a patient in contact with animals.
2. Animal Bite Center – Private facilities certified by DOH as capable of managing victims of animal
bite.
3. Animal Bite Treatment Center (ABTC) – Government facilities certified by DOH as capable of
managing victims of animal bite.
4. Completed Treatment – refer to a case of animal bite that has received day0, day 3, and day 7 of
the anti-rabid treatment course.
5. Post Exposure Prophylaxis – anti-rabies treatment administered after an exposure (such as
bites, scratch, lick, etc.) to potentially rabid animals.
TRAINING MODULE
Handling VIP Patients at DEM

1. OBJECTIVE
To establish a standard document on handling VIP patients at the Department of Emergency
Medicine.
2. SCOPE
This procedure applies only to Very Important Personalities (VIP) who arrives at the Manila
Doctors Hospital Department of Emergency Medicine.
3. POLICIES
a. Information (thru written communication or telephone) received shall be confirmed
by DEM Consultant.
b. All units concerned shall be properly informed of the VIP patient.

a. The Chairman shall be responsible on implementing these policies and procedure.
b. DEM Consultant shall ensure that all concerned personnel are informed of the situation.
NOTES
 VIP patients may arrive at the DEM and are made known thru the following ways:
 With advance call or advance party preparation
 Walk-in without any prior notification
 Only after being interviewed or when relatives make the staff aware of the stature of the
Patient
5. Prior to arrival of VIP patient

a. After receiving the call or letter stating the arrival of any VIP patients, confirmation is first
obtained by the DEM Staff.
b. The DEM Consultant/ Senior Resident shall inform Nursing Supervisor. The Isolation Room shall
be prepared and equipped with necessary instruments except for lift threatening conditions.
c. The DEM Staff will determine if our AEROMED Ambulance will pick-up the patient or if they have
their own ambulance service.
d. If AEROMED Ambulance is designated to pick-up the patient, all necessary arrangement will be
made by the team.
6. The DEM Consultant ensures that the following units are informed of the situation.
a. DEM – DEM Chairman
b. NSD – Nursing Supervisor, The Nursing Supervisor shall inform the following:
1. Hospital Director
2. Medical Director
3. Heads/ most Senior-on-duty of the following units:
1. Laboratory
2. Admitting, Information and Telephone Service
3. Radiology
c. Security Service – Head, The Security Service Head shall:
TRAINING MODULE
1. Secure all exits and entrances in the hospital

2. Isolate an area for media personnel
3. Coordinates with nearly police if added security service needed
d. Department Head of specialty who will be admitting the patient.
7. Upon arrival of the patient
a. The patient shall be directed to the Adult Isolation area, except in arrest and life
threatening situations.
8. Patient Management
a. The patient shall be seen by the DEM Consultant-on-Duty. Initial evaluation and patient
management shall be conducted.
b. Management and Work-up shall be ordered and disposition may already be given:
 Admission
 Discharge
 Specialty referral
 Observation
c. DEM Consultant ensures all needed referrals and facilitated using the MDH Consultant list,
especially for critical patient where the nearest consultant to MDH must be contacted.
9. VIP patient is for admission
a. Once room for VIP patient is ready, the patient shall be transported immediately and must be
facilitated without any delay unless in life threatening conditions.
b. Laboratory and Radiology Work-up is facilitated at once
c. Unavailability of laboratory or radiological results, unless critical, will be a deterrent to
admission in the private room.
b. Once patient is directed to the private room, the Nursing Supervisor and Charge Nurse of the
receiving unit will ensure that all residents and consultants are informed to see the patient
immediately.

o A corrective and preventive action request [CPAR] shall be issued to any staff/unit not adhering to
the Policies and Procedures on Handling VIP Patients at the Department of Emergency Medicine.
o Staff with a single non-conformity but with detrimental repercussion to the hospital operation
and/or with recurrent non-conformities to the Policies and Procedures on Handling VIP Patients at
Manila Doctors Hospital Department of Emergency Medicine shall be subjected to disciplinary
actions following existing hospital rules and regulations.
DEFINITION OF TERMS
1. VIP refers to very important personalities
a. Metrobank Foundation:
1. Officials
2. Stockholders
3. Families and Friends
b. Politically exposed persons:
1. National, regional, local officials both foreign and domestic
2. Members of the Executive, Legislative, Judiciary
c. Company Officials: CEO, President, or other Officials
d. Members of the press, media or relative industry personnel
TRAINING MODULE
e. Any patient who are endorsed as VIP
Interdepartmental Referrals at DEM

1. OBJECTIVE
1. To maintain a documented for interdepartmental referrals at the Department of Emergency
Medicine (DEM).
2. To identify risks related to the services being rendered at DEM.
2. SCOPE
These policies and procedures apply to patient who arrives at the Manila Doctors Hospital
Department of Emergency Medicine needing specialty referrals.
3. POLICIES
a. All patients will be initially seen by the triage and classified according to the system of the
department (Emergent, Urgent, Non-urgent).
b. All patients will be evaluated and managed initially by the DEM Consultant or Resident and if
there is a need for a specialty consult, he/she will be referred to the appropriate specialty
service.
c. All patients will have a disposition within 2 hours of consult, whether they are for discharge,
admission, needing further observation or will be needing specialty consult.
d. Patients are referred to specialty services for:
 Admission and management
 Evaluation and management
 To have their private Attending Physician informed of the patients presence at the ER
e. Patients are referred to the specialty service concerned by the DEM consultant or resident on
duty.
f. Attending Physicians or private patients will be informed initially by the DEM staff of the
presence of the patient at the ER (MDO Directive).
g. Specialty service resident may be called upon immediately to see referrals especially for
Emergent cases.
 For Emergent cases, patients must be seen by the specialty service immediately.
 For Urgent cases, patients must be seen by the specialty service within 15 to 20 minutes.
h. ONE-WAY referral system will be strictly observed.
i. All referrals, along with reason for referral, will be properly documented in the ER chart or
appropriate doctors order sheets.
j. Specialty services must make their disposition for the patient within 2 hours
k. Patients must be physically transferred to in patient rooms within 1 hour from the time the
receiving unit is ready for the patient.

a. The Chairman shall be responsible on implementing these policies and procedure.
b. DEM Consultant shall ensure that all concerned personnel are informed of the situation.
NOTES
1. DEM-on-duty consultant, Resident or Intern receives patient for referral.
2. Patients referred for evaluation
TRAINING MODULE
a. Patients are referred for evaluation to the appropriate specialty service according to the
presenting medical or surgical condition.
b. Patients may be referred simultaneously to different specialty services for evaluation.
c. Patients are seen and examined by the specialty service concerned and depending on their
working impression, disposition is given which may be for discharge, admission or needing
further work-up or other specialty referral.
d. The decision whether the patient will be for discharge, admission, other specialty referral
needing further work-up or will be the responsibility of the specialty service.
e. If the patient is discharged, discharge instructions must be provided by the specialty service and
this must show the consultant with whom the patient will go on follow-up with. Discharge
process shall follow the Policies and Procedures on Department of Emergency Medicine.
f. Specialty service will inform DEM of plan for the patient.
g. The DEM consultant on duty will decide upon any disagreements or problems regarding patient
disposition.
3. Patients referred for admission
a. Patients are referred for admission to the appropriate specialty service according to the
following:
 HMO
 Attending Physician
 Company
 Walk-in according to the presenting medical or surgical condition
4. Once referred to a specialty service for admission, the patient must be admitted in accordance to
Policies and Procedures on Admitting Patients
a. If patient needs other specialty consults, the admitting service will be responsible for
succeeding referrals
b. Specialty service must be immediately write the admitting orders for the DEM staff to
facilitate the admission
c. If the admission is deferred or patient is discharged, it will be the responsibility of the
specialty service to dispose patient, provide discharge instructions and/or sign waiver for
discharge against medical advice.
d. There must be written diagnosis or working impression given by the specialty service once
they have seen and examined any patient referred to their service.
e. If the patient has more than one medical or surgical condition, he DEM will facilitate referrals
to the specialties concerned and make sure that all conditions are properly treated and
managed.
f. If the patient has more than one medical or surgical condition, and is discharged, discharge
instructions must be provided by the concerned specialties that have seen the patient and
these collated by the DEM.
g. If the specialty concerned cannot see the patient immediately, the DEM will facilitate referral
directly to the service consultant concerned.
h. In the interest of patient safety and to assure the continuation in patient care, all patients
referred, must be referred to specialty consultant, with whom the patient will eventually go
on follow-up check-up.
i. Pending specialty doctor from HMO coordinator will not be a deterrent to seeing and
examining any referred patient.
TRAINING MODULE
j. Consent for procedures must be obtained and explained thoroughly by the resident (whether
DEM or Specialty Service) who ordered the procedure.
5. Surgery and OB-Gyn referrals will follow the policies agreed upon with the DEM.
6. Unavailability of results of laboratory or radiological examination will not be a deterrent to seeing or
evaluating patients at the DEM.
7. Telephone orders will not be allowed especially if the service concerned has not yet seen and
examined the patient.
8. Any other concerns of patient referrals or disposition will be referred and decided upon by the DEM
Consultant on duty.
9. Records shall be kept and maintained in accordance with Policies and Procedures on Control of
10.All concerned personnel shall be adequately informed prior to the implementation of this
document.

o A corrective and preventive action request [CPAR] shall be issued to any staff/unit not adhering to
the Policies and Procedures on Interdepartmental Referrals at the Department of Emergency
Medicine.
o Staff with a single non-conformity but with detrimental repercussion to the hospital operation
and/or with recurrent non-conformities to the Policies and Procedures on Interdepartmental
Referrals at the Department of Emergency Medicine shall be subjected to disciplinary actions
following existing hospital rules and regulations.
1. DEFINITION OF TERMS
a. Company refers to patients of accredited private companies
b. Disposition refers to plan for the patient (admit, discharge, further referral, observation or
management)
c. HMO refers to health insurance card members
d. One-way system referral means that when the DEM refers a patient to specialty service for a
particular medical or surgical condition, all management and further orders related to said
condition, will be responsibility of the referred service and will not be referred back to DEM
for final disposition.
e. Private patients refers to patients with their own Attending Physician
f. Reasons for Referrals:
 Admission refers to patient referred to specialty service for admission.
 Evaluation refers to patient referred to specialty service for evaluation but not yet
admitted under any specialty service.
 Consultant Information refers to patients who requested or required to have their
private doctors informed of the presence of the patient in the DEM.
g. Specialty Service refers to Internal Medicine, Surgery, ORL, OB-GYN, Ophthalmology,
Orthopedics, Family Medicine, Dentistry
h. Walk-in patient refers to patients who did not have their own or do not know any
Attending Physician in MDH
TRAINING MODULE
HMO Consultations at DEM

1. OBJECTIVE
a. To maintain a documented procedure for Health Maintenance Organization (HMO) consultations
at the Department of Emergency Medicine (DEM).
b. To identify risks related to the services being rendered at the DEM.
2. SCOPE
This procedure covers processes involved from HMO patient’s entry up to patient admission or
discharge
3. POLICIES
a. All HMO’s and insurance companies accredited and honored by Manila Doctors Hospital (MDH)
shall submit written documents on the following:
 List of accredited (MDH) coordinator with clinic schedule and contact number.
 List of accredited doctors from MDH (by specialty) with clinic schedule and contact number.
 Telephone number of 24-hour hotline.
 Telephone number and name of MDH medical representative.
 Department of Emergency Medicine (DEM) consultation policy, procedures and forms.
 Department of Emergency Medicine (DEM) admission policy, procedures and forms.
b. Approval for coverage for consults at the DEM for non-emergent complaints shall not be sought
by the DEM personnel.
c. Patients with expired HMO cards and/or those whose HMO coverage cannot be verified will be
asked to settle account on cash basis.
d. The DEM personnel will not take responsibility to inform the MDH-HMO medical representative
of admissions under their HMO.
e. A back-up system is in place just in case the HMO Coordinator cannot be contacted.
RESPONSIBILITIES AND ACCOUNTABILITY

1. DEM Consultant and DEM Resident on duty shall ensure that the flow of referral will be followed.
2. HMO Coordinator must be available at all times to receive calls for referral.
3. HMO and Insurance Companies shall inform their clients of their pertinent DEM consultation
4. Clerk-on-duty shall verify HMO card validity and insurance coverage for diagnostic and therapeutic
procedures.
5. All referrals must be acknowledged and answered promptly by the service ROD within 5 to 10
6. Pending response from the HMO Coordinator should not delay management and referrals from
NOTES
1. A notation is made on the DEM ADMISSION SHEET on the classification of a HMO patient.
2. Confirmation of the HMO authenticity will be made by the DEM clerk on duty together with the
financial counselor on duty.
3. All HMO patients will be initially seen by DEM Consultant, DEM Resident-on-Duty and/or Pediatric
Resident-on-Duty.
TRAINING MODULE
4. All HMO patients needing specialty referral will follow the following procedures:
a. All pediatric HMO patients seen by the Pediatric Resident-on-Duty will follow the referral
system of the Department of Pediatrics.
b. For HMO’s with Department of Family and Community Medicine (DFCM) consultant
coordinators, the DFCM Resident-on-Duty will be informed and succeeding referrals and
admitting orders will be under the care of DFCM resident informed.
c. For non-DFCM HMO coordinators, the DEM resident will decide based on the following:
1. If the case of
the patient is within the specialty of the HMO coordinator, the DEM
Resident will inform the resident of the coordinator and succeeding
referrals and admitting orders will be under the care of the resident of the
coordinator.
2. If the case of
the patient is not within the specialty of the HMO coordinator, the DEM
resident will inform the appropriate specialty resident for the patient; this
will assure that there will be no delays in the management of the patient.
A. The DEM Resident then proceeds to inform the HMO coordinator to
ask for a specialty consultant appropriate for the patient.
B. If the HMO coordinator cannot be contacted thru calls or text
messaging, the DEM Resident will utilize the specialty deck given by the
different departments at the DEM. This will be matched against the list
of HMO accredited doctors.
C. The priority will be the appropriate on deck consultant accredited by
HMO.
5. All succeeding referrals and admitting orders will be under the care of the specialty resident.
6. The DEM NOD carries out all doctor’s orders in accordance with Policies and Procedures on
Department of Emergency Medicine.
a. Records shall be kept and maintained in accordance with Policies and Procedure on Control
b. All concerned personnel shall be adequately informed prior to the implementation of this
document.

with recurrent non-conformity to the Policies and Procedures HMO Consultations at the Department of
Emergency Medicine shall be subjected to disciplinary actions following existing hospital rules and
regulations.
DEFINITION OF TERMS
1. Emergency refers to a medical or surgical condition that warrants immediate interventional because
failure to do so will results in disability. As per Patient’s Definition, it is the perception of the
acuteness of the medical condition and the need for immediate management.
2. Subspecialty Department refers to medical hospital department which involve in the
management of specific specialized classification of diseases.
a. Department of Family and Community Medicine
b. Department of Internal Medicine
TRAINING MODULE
c. Department of OB-GYN
d. Department of Ophthalmology
e. Department of Otorhinolaryngology
f. Department of Pediatrics
g. Department of Surgery
h. Department of Orthopedic
3. Triage refers to the sorting and treatment of the wounded according to chance of survival.
Patient Identification at DEM

1. OBJECTIVE
1. To establish documents to maximize patient safety through a universal standard of unique patient
identification.
2. To identify risks related to the services being rendered at the Department of Emergency Medicine
(DEM).
2. SCOPE
a. This procedure covers all patients who consult the DEM.
b. This procedure covers all activities from patient arrival, to admission or discharge.
3. POLICIES
a. All patients will have a uniform process of identification to promote safe patient practices at the
DEM
b. Two identifiers must be verified on all patients: Patients name and date of birth
c. Bed number does not constitute an appropriate identifier.
d. In the event the patient is unable to provide the healthcare personnel the correct date of birth
or a discrepancy exists with written identification, the patient record number will be used as the
second patient identifier

a. DEM Consultant and DEM Resident on duty shall ensure that the flow of referral will be
followed.
b. HMO Coordinator must be available at all times to receive calls for referral.
c. HMO and Insurance Companies shall inform their clients of their pertinent DEM consultation
d. Clerk-on-duty shall verify HMO card validity and insurance coverage for diagnostic and
therapeutic procedures.
e. All referrals must be acknowledged and answered promptly by the service ROD within 5 to 10
f. Pending response from the HMO Coordinator should not delay management and referrals from
NOTES
1. All patients will immediately be identified at the triage.
2. This is done by affixing a permanent band to the patient's wrists.
TRAINING MODULE
3. Prior to the administration of any medication, treatment, therapy, procedure, dietary meal, snack,
transport, or transfer to another facility, the healthcare provider will identify the patient at the
bedside using the identification band.
4. The healthcare provider will identify the patient by asking him or her to state his or her name and
date of birth. This information will be compared with the information contained on the requisition or
encoded record of each patient.
5. Permanent identification bands will be originated by the triage personnel and placed on the patient.
In the event this is not accomplished, the assigned healthcare provider will be responsible for placing
the identification band.
6. Under no circumstances should volunteer place an identification band on a patient.
7. This band will be worn throughout the patient’s length of stay.
8. Patients not requiring an identification band will be identified by the patient stating their name and
date of birth.
9. Patients may come into the DEM without adequate identification (“Jane or John Doe.”)
10.“Adequate identification” is defined as the ability of the patient or their escort to identify the patient
by name and date of birth or the patient has written identification such as a driver’s license that
contains that information.
11.Unidentified patients will be entered into the computer as “John or Jane Doe” and will receive a
Medical record number and ID band.
12.Any succeeding patient with the same circumstances as above will follow the sequence as John or
Jane Doe 2, John or Jane Doe 3, etc.
13.In the event the patient’s identity becomes known, the healthcare provider should document this in
the medical record.
14.In cases where there are changes to previously given patient information, proper presentation of
supporting documents to justify changes must be presented. This includes legal documents,
government IDs or company IDs with picture.
15.The healthcare provider then informs IT and Admitting and they will then update or correct the
information in the computer and notify Medical Records of any duplicate medical record numbers for
this patient so the medical record might be merged, if applicable.
16.DEM will issue a new ID band.
17.It is the responsibility of the healthcare provider to replace the ID band on the patient.
18.If a patient enters DEM and is not able to communicate their name and date of birth the admitting
officer will verify two (2) patient identifiers with the patient’s escort(s).
19.If no escort is available then the registration personnel will verify the patient’s name and date of
birth by using an alternate means of identification, including but not limited to, driver’s license, social
security card or other documentation accompanying the patient such as ambulance or nursing home
information sheets.
20.In the event an identification band must be removed if it interferes with treatment or it becomes too
tight fitting, a new identification band shall be placed on the patient’s alternative wrist or ankle prior
to removing the old identification band.
21.The assigned healthcare provider will ask the patient to state their name and date of birth and will
compare for accuracy the name and date of birth on the new identification band against the
identification band, which is being removed.
22.In no event should the patient’s bed number be used as the sole source of patient identification.
23.Disciplinary Steps
TRAINING MODULE
a. The appropriate manager will review violations of the Patient Identification policy and when
necessary, may work together with the appropriate Human Resources representative.
 Factors considered in determining the disciplinary step are seriousness of violation, previous
violations of the Patient Identification policy, patient outcome, if any and any other factors
related to the violation.
 MDH has established the following progressive disciplinary steps when an employee violates
the Patient Identification Policy:
o In order of severity, discipline may take the following forms:
 Written warning, b.
 Disciplinary probation (90 days)
 Termination of employment
 MDH reserves the right to take other disciplinary action in addition to, or in place of, the
steps outlined in this policy. This policy does not limit MDH right to discharge employees
with or without notice.
o Records shall be kept and maintained in accordance with Policies and Procedure on Control
o All concerned personnel shall be adequately informed prior to the implementation of this
document.

with recurrent non-conformity to the Policies and Procedures for Patient Identification at the
Department of Emergency Medicine shall be subjected to disciplinary actions following existing hospital
rules and regulations.
DEFINITION OF TERMS
1. Emergency refers to a medical or surgical condition that warrants immediate interventional
because failure to do so will results in disability. As per patient’s definition, it is the perception of the
acuteness of the medical condition and the need for immediate management
2. Triage refers to the sorting and treatment of the wounded according to chance of survival
TRAINING MODULE
TRAINING MODULE
References
Manila Doctors Hospital, Department of Emergency Medicine. (year). Policies and Procedures. In
M.D.H. Hospital, Manual of DEM Policies and Procedures. Manila: Unpublished
TRAINING MODULE
INTRODUCTION TO DEM
KNOWLEDGE CHECKLIST
INSTRUCTIONS:
Please check (√) on the space provided for whether the participant is able to perform the steps
correctly or if it is not done.
CD – Correctly done ND – Not done
*Manila Doctors Hospital Transmutation Table will be utilized for rating. (basis of 0 = 50%)
STEPS CD ND REMARKS
Familiarize self with DEM Organizational Chart
Familiarize self with DEM Policies and Procedures
Familiarize self with DEM Consultants, Nursing Staff and Personnel
Familiarize self with the different roles and responsibilities of DEM
staff and personnel
TOTAL
_______________________ _______________________ _____________________________

_ _ _
Signature of Preceptee / Signature of Preceptor / Signature of Head Nurse/Date
Date Date
TRAINING MODULE

DEM Module 1

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MANILA DOCTORS HOSPITAL

DEPARTMENT OF EMERGENCY MEDICINE

Course/Program Title: Department of Emergency Medicine Training Module

Intended Audiences: Staff Nurses

Introduction to Manila Doctors Hospital Department of Emergency Medicine

The Manila Doctors Hospital Department of Emergency Medicine

In 1995, the department transferred to its present location and

The Department of Emergency Medicine of Manila Doctors

DEM Organizational Chart

Corporate Social Responsibility

Nursing Roles and Responsibilities of Emergency Department Nurses

Roles and Responsibilities of the Charge Nurse

Roles and Responsibilities of Triage Clerk

Roles and Responsibilities of Counter Clerk

Roles and Responsibilities of Stock Clerk

Roles and Responsibilities of Inventory Clerk

DEM Policies and Procedures

Control and Recording Patient’s Clinical Charts

DEM CSR Patients

HMO Consultations at DEM

NON-ADHERENCE TO POLICIES AND PROCEDURES

Issuance of Certificate of DEM Consultations

DEM for Rotating Residents

DEM for Unaccompanied Patients

2. Unconscious patient for admission

Unaccompanied Foreign Patients

2. Policies for Conscious Patients

3. Policies for Unconscious Patients

4. Policies for Dead on Arrival (DOA) or Died at DEM

DEM for Walk-In Patients

DEM for Management and Disposition of Patients

2. GENERAL POLICY STATEMENT

DEM for Trauma and Physical Injury

4. RESPONSIBILITIES AND ACCOUNTABILITY

7. The application form is forwarded to the Department Chair for deliberation.

b. Pre-Residency examination …………………………15%

NON- ADHERENCE TO POLICIES AND PROCEDURES

EMS Disaster Preparedness Plan

4. RESPONSIBILITIES AND ACCOUNTABILITY

5. PROCEDURE FOR ER CONSULTANT ON DUTY

i. Move existing patients

h. Supervisor-on-Duty will assume Incident Commander post

3. Treatment Areas and Patient Flow:

Team ED Consultant Back-up or IM/Surgery Resident

Transport/ Discharge Team

Hazardous Material Incident Resuscitation Team

SECURITY AND AMBULANCE FLOW

PATIENT TRACKING AND DOCUMENTATION

ADMISSION AND DISCHARGE PROCEDURES

FAMILY ASSISTANCE AND INFORMATION CENTER

NON-ADHERENCE TO POLICIES AND PROCEDURES

c. To identify risks related to the services being rendered at the DEM.

RESPONSIBILITIES AND ACCOUNTABILITY

AMBULANCE TRANSPORT SERVICE shall be accomplished the following situation:

TYPE OF CONDUCTION TIMING OF CHARGING

 Summary of Records and Reports to be collated and submitted:

Date of Room Name of Type of Conduction Waiting Total amount Transaction

NON-ADHERENCE TO POLICIES AND PROCEDURES

4. RESPONSIBILITIES AND ACCOUNTABILITY

___________ _ ___________________