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Policy on General Discharge Document No.
Revision 1
Administrative Division Effectivity Date July 1, 2022
1.0 Purpose
To ensure that patient is safe and satisfied upon discharge.
2.0. Scope
Applies to OPD/ER and in-patients with a written signed order of discharge by the
Attending Physician/ROD until the patient will be wheeled out.
3.0 Policies
It is the policy of the hospital that systematic and integral discharge process shall be
implemented within the principles set to ensure smooth delivery of services and timely
discharge.
3.1. That the Nurse-on-Duty (NOD) ensures that discharge order shall be signed by the
Attending Physician/ROD for patient disposition.
3.2. For Private patient – That the Consultant/Resident on duty shall completely fill up
the Doctor’s Professional Fee form
3.3. MGH order shall be tag at HIS by the NOD and facilitate completion of
requirements for patients with Philhealth membership prior to bringing down the
chart at the Billing Section.
3.4. Discharge notice slip shall be given to patient’s relative for non-Philhealth
member by the NOD
3.5. NOD/NA shall collaborate the patient’s referrals to other interdepartmental
referrals such as Dietary, Medical Social Service, Rehabilitation and other required
referrals.
3.6. Discharge instructions shall be advised by the NOD upon discharge.
4.0 Responsibility
4.1. AP/ROD – writes the admission order legibly and clear
4.2. Supervisor-on-Duty – Assist the concern ward/unit for any support and resources
needed and monitor the enforcement of the policy and
procedures.
4.3. Head Nurses – Disseminate orders to the staff nurses and other concerned
allied medical personnel and ensures that all procedures must be
carried out
4.4. Staff Nurse – Make an individualized care of plan per patient and implement all
procedures that have been ordered.
4.5. Nursing Attendant – performs various patient’s care such as preparation of room
assignment, taking vital signs, provide safety and comfort and HIS
tagging.
4.6. It is the patient/relative’s right to receive discharge information.
5.0. Definition of Terms
5.1. SOP – Standard Operating Procedure
5.2. OPD – Out-Patient Department
5.3. ER – Emergency Room
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Policy on General Discharge Document No.
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Administrative Division Effectivity Date July 1, 2022
5.4. ROD – Resident on Duty
5.5. NOD – Nurse on Duty
5.6. MGH – May Go Home
5.7. NA – Nursing Attendant
5.8. HIS – Hospital Information System
5.9. Discharge Instructions – refers to the release of patient from confinement, custody
or care.
5.10. Pay or Private Patient– refer to patient admitted at Payward and under the
service of an Attending Physician/Consultant.
5.11. Philhealth Patient – refer to a patient with PhiliHealth cards or active member
5.12. Service Patient – refer to patient admitted at the charity ward
2.13. Wheeled out – transfer of patient to their own vehicle.
6.0. Evaluation and Monitoring
Daily
7.0. Forms
7.1. Discharge notice slip
7.2. Patient Medical Record
7.3. Discharge Plan
7.4. Discharge clearance
8.0. Effectivity
This policy shall take effect on July 1, 2022
9.0 Sanction/Penalty
Appropriate disciplinary measures based on CSC ruling and hospital policies shall be
applied to any hospital staff proven to have violated this policy
10. Reference Documents
SOP Nursing Service Vol 1.
Nursing Service Quality Manual of Policies and Procedure June 2012.
Nursing Service Prepared by: Reviewed by: Recommended by:
Group 1:
EVELYN D. ARENAS, RN, MAN
DESIREE F. BATOLINA, MARILOU J. PALAFOX,
JEAN BARIN, RN RN, MAN RN, PhD.
DOLORES G. RAMIREZ, RN,
MAN
ROLIZA M. ORTILANO, RN
YBETH T. BITOLINAMISA,
RN,MAN
Division/Dept. NURSE SUPERVISOR ASST. CHIEF NURSE CHIEF NURSE
name
This is a property of QCGH, unauthorized reproduction is prohibited. Please contact QA-DC for your
request
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Policy on General Discharge Document No.
Revision 1
Administrative Division Effectivity Date July 1, 2022
Description Flow Chart Person
Responsible
START
Makes an initial assessment to ERO/Tent
patient’s complaint and classifies Initial Assessment, Classification and Endorsement
ROD
patient of Patient to Respective Department
Issues PIS to patient’s relative and
advise to bring it to the Admitting
Section for registration and deck the Issues PIS (Personal Identification Slip) ERO/Tent
patient to concern department based ROD
on his/her assessment
Issues ER chart and bring it to the
nurse on duty for recording Issue ER Chart Admitting
Section
Logs the ER chart to Census
Staff
Logbook with corresponding time
and department and give patient
chart to designated department Nurse on Duty records charts
Provides necessary work-up and Nurse on
management to patient Duty
Clinical (specialty) treatment and
management Resident on
If patient is Admitted Rod will Duty
prepare a complete PMR (Patient
Complete Record) to be given by
Nurse on duty which will be Evaluation
forwarded to respective wards
together with the admitted patient
ROD
If Patient is not Admitted
N
Sent Home with Medication
with strict Home Quarantine Admission Discharg
protocol advise e
Transfer to Hospital of ROD
Y according
Choice
Home Against Medical
Advice Complete Patient Medical Record
Death (PMR)
ROD/NOD
Facilitate Admission
NOD
END
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Policy on General Discharge Document No.
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