Dr. Jose Rizal Memorial Hospital Citizen's Charter Handbook

Tongue Depressor, 5 cc Piece ₱2.25 ₱1.80
10 cc Piece ₱3.80 ₱3.04
Tourniquet 20 cc Piece ₱10.10 ₱8.08
Ultrasound gel 250 grams 50 cc Piece ₱23.50 ₱18.80
Umbilical Cord Clamp Asepto Piece ₱39.00 ₱31.20
Underpad Non-sterile Box ₱58.50 ₱46.80
Urinal Sterile Piece ₱1.00 ₱0.80
Urine Bag Adult Piece ₱26.00 ₱20.80
Urine Collector Pedia A Bot ₱84.50 ₱67.60
Ventilator Tubing Piece ₱5.80 ₱4.64
Adult Piece ₱14.50 ₱11.60
Ventilator Tubing With Water Piece ₱46.80 ₱37.44
Ventilator Filter Piece ₱19.50 ₱15.60
Wound Drain Traps Piece ₱5.10 ₱4.08
Wadding Sheet Piece ₱1,014.00 ₱811.20
Jackson Pratt
3-Way StopCock 4 inches Piece ₱1,495.00 ₱1,196.00
Oxygen 6 inches ₱715.00 ₱572.00
Pink Card Piece
Sterile DS Piece ₱1,852.00 ₱1,481.60
Piece ₱43.00 ₱34.40
Piece ₱50.50 ₱40.40
Piece ₱53.50 ₱42.80
lbs ₱0.48 ₱0.38

Piece ₱20.00 ₱16.00
₱30.00 ₱24.00
Pack

50 | P a g e

5. Availment of Out-Patient Department Consultation

The Out-Patient Department Consultation caters only non-emergent medical/surgical health cases of

patients.

Office/Division: Outpatient Department (OPD)

Classification: Simple

Type of Transaction: G2C – Government to Citizen

Who May Avail: OPD Clients

CHECKLIST OF REQUIREMENTS WHERE TO SECURE

OPD Registration Form (ORF) – 1 copy OPD
Hospital ID Card Ward
FEES
Tagubilin Form – 1 copy (For Post-Admission Patient)
TO
CLIENT STEPS AGENCY ACTION BE PROCESSING PERSON
PAID
None TIME RESPONSIBLE
None
If Old Client: 1.a.1 Requests client to present 3 minutes OPD Pre
1.a.1 Presents Hospital ID Hospital ID and instructs to None 7 minutes registration
fills out ORF None
then fills up ORF Nurse
1.a.2 Submits ORF to 1.a.2 Receives ORF and verifies None
data in the computer 35 minutes OPD Pre-
designated personnel NONE 5 minutes registration
If New Client / Old Client 1.b.1 Instructs client to secure None 20 minutes
Hospital ID Nurse
(Without ID):
1.b.1 Secures Hospital ID 1.b.2 Verifies data in the OPD Pre-
computer registration
1.b.2 Returns to OPD Nurse/ Medical
Registration and Records Staff
presents Hospital ID Triage Nurse

2. Presents self for 2. Asks client for Tagubilin Form, if 20 minutes OPD Physician
assessment and vital applicable and interviews 15 minutes
signs checking and patient regarding their medical Consultation
waits name to be condition and checks vital Room Nurse /
called for consultation signs then issues queuing
number accordingly. Cashier
3. Presents self for
Physical Consult GREEN - Non priority
YELLOW – Urgent, PWD/ Senior
4. Receives instruction for
Citizen/Pregnant Women
Diagnostics examination, BLUE – Follow-Up on scheduled

medications and follow- time
up check-up 3. Provides Clinical Consultation

4. Carries out doctor’s order

TOTAL: None If Old Client -
(1 hour & 5 minutes)

If New Client
1 hour and 20 minutes
if Old Client (Without ID):

1hour & 35 minutes

51 | P a g e

6. Availment of TB-DOTS Service – New TB DOTS Clients

The Dr. Jose Rizal Memorial Hospital TB DOTS clinic caters services to patients who are suspected of
Tuberculosis. It aims to provide basic information and initial assessment to probable TB patients.

Office/Division: TB-DOTS Clinic

Classification: Simple

Type of Transaction: G2C – Government to Citizen

Who May Avail: New TB DOTS Clients

CHECKLIST OF REQUIREMENTS WHERE TO SECURE

NONE NONE

CLIENT STEPS AGENCY ACTION FEES PROCESSING PERSON
TO TIME RESPONSIBLE
BE
PAID TB-DOTS Nurse

1. Presents self and fills 1. Receives client/patient and Physician
TB-DOTS Nurse
up attended patient list gives instructions.

logbook and waits None 30 minutes

name to be called for

consultation

2. Presents self for 2. Provides Clinical Consultation None 10 minutes

Physician Consult

3. Receives instruction by 3. Provides instructions

the TB-DOTS Nurse pertaining to laboratory and None 3 minutes

diagnostics then advise to follow-

up per physician’s schedule given

TOTAL: None 43 minutes

52 | P a g e

7. Availment of TB-DOTS Service – Patient follow-up for

Enrolled TB Clients

The Dr. Jose Rizal Memorial Hospital TB-DOTS clinic as a DOH Certified facility can give available
Anti-TB medication to enrolled patients as well as provide follow up check up. It aims to provide care to
patient undergoing treatment.

Office/Division: TB-DOTS Clinic

Classification: Simple

Type of Transaction: G2C – Government to Citizen

Who May Avail: Enrolled TB Clients

CHECKLIST OF REQUIREMENTS WHERE TO SECURE

NTP ID Card TB-DOTS Clinic

CLIENT STEPS AGENCY ACTION FEES PROCESSING PERSON
TO TIME RESPONSIBLE
1. Presents NTP ID Card 1. Receives NTP ID Card and BE
and waits for gives instructions PAID 3 minutes TB-DOTS Nurse
instructions None
2. Gives Anti-TB medication and
2. Receives Anti-TB instructs for follow-up None 3 minutes TB-DOTS Nurse
medication and schedule.
instructions for follow-
up schedule

TOTAL None 6 minutes

53 | P a g e

8. Availment of TB-DOTS Service – Patient follow-up for

continuation of treatment at the Hospital

The Dr. Jose Rizal Memorial Hospital TB-DOTS clinic as an accredited Philhealth facility can avail TB
DOTS Package from patients who are philhealth beneficiary. Furthermore, non-member patients can
still avail of the free services of TB medications and consultation.

Office/Division: TB-DOTS Clinic

Classification: Simple

Type of Transaction: G2C – Government to Citizen

Who May Avail: TB-DOTS Client – Diagnose as TB Patient wants to be treated at the
hospital

CHECKLIST OF REQUIREMENTS WHERE TO SECURE

PHIC Note Billing/Claims Section

CLIENT STEPS AGENCY ACTION FEES PROCESSING PERSON
TO TIME RESPONSIBLE
BE
1. Presents self and fills up 1. Receives client/patient and PAID TB-DOTS Nurse
attended patient list gives instructions. None Physician
logbook and waits
name to be called for 2. Provides Clinical Consultation 30 minutes TB-DOTS Nurse
consultation
3.a For client/patient with None 10 minutes TB-DOTS Nurse
2. Presents self for PhilHealth: None 3 minutes TB-DOTS Nurse
Physician Consult Instructs patients to go the
PhilHealth Section None 30 minutes
3.a For client/patient with
PhilHealth: 3.b For client/patient w/o None 3 minutes
Proceeds to Philhealth PhilHealth:
Section and asks for Proceeds to Step 5
PHIC note
4. Receives PHIC Note and enroll
3.b For client/patient w/o patient as TB Client
PhilHealth:
Proceeds to Step 5 5. Issues NTP ID Card then gives
instructions for follow-up
4. Returns to TB-DOTS schedule
Clinic then presents
PHIC Note

5. Receives NTP ID Card
and instructions for
follow-up schedule

TOTAL: None w/ PHIC
1 hour and
16 minutes

w/o PHIC
43 minutes

54 | P a g e

9. Availment of TB-DOTS Service – Patient follow-up for

continuation of treatment at the RHU/CHO

As part of the Universal Health Care, the Dr. Jose Rizal Memorial Hospital TB DOTS partners with
other health care facilities to strengthen the service delivery network. It aims to give patients the right
to choose their treatment partner for better treatment outcome.

Office/Division: TB-DOTS Clinic

Classification: Simple

Type of Transaction: G2C – Government to Citizen

Who May Avail: TB-DOTS Client – Diagnose as TB Patient wants to be treated at Rural
Health Unit/City Health Office

CHECKLIST OF REQUIREMENTS WHERE TO SECURE

NONE NONE

CLIENT STEPS AGENCY ACTION FEES PROCESSING PERSON
TO TIME RESPONSIBLE
1. Presents self and fills 1. Receives client/patient and BE
PAID 30 minutes TB-DOTS Nurse
None

up attended patient list gives instructions.

logbook and waits

name to be called for

consultation

2. Presents self for 2. Provides Clinical Consultation None 10 minutes Physician
None 3 minutes TB-DOTS Nurse
Physician Consult

3. Receives NTP Referral 3. Prepares and Issues NTP

Form and further Referral Form then gives further

instructions instructions.

TOTAL None 43 minutes

55 | P a g e

10. Issuance of Patients Identification Card

The Outpatient Department is in charged in the Issuance of Patient’s Identification Card for Outpatient
Clients. Hospital ID card issued with the patient’s hospital number serves as his/ her permanent
record in this health facility.

Office/Division: Outpatient Department (OPD)

Classification: Simple

Type of Transaction: G2C – Government to Citizen

Who May Avail: New OPD Clients / Old OPD Clients without/lost Hospital ID

CHECKLIST OF REQUIREMENTS WHERE TO SECURE

OPD Registration Form (ORF) - (1 copy) OPD
Charge Slip - (1 copy)
Hospital ID - (1 copy) Cashier
Stamped ‘Paid’ charge slip - (1 copy) FEES
TO BE
CLIENT STEPS AGENCY ACTION PAID PROCESSIN PERSON
None G TIME RESPONSIBL
1. Fills out ORF 1. Instructs client to completely
fill up the ORF None 10 minutes E
OPD Pre
registration

Nurse

For New Client: 2.a Receives filled up ORF 10 minutes Medical Records
2.a Receives Hospital ID encodes data into Staff
computer and Issues
For Old Client Hospital ID. Php 30.00 20 minutes Medical Records
(Without ID) Staff / Cashier
2.b.1 Submits ORF and 2.b.1 Receives filled up ORF
and verifies data in the
Receives charge slip computer. Issues charge
then proceed to slip and instructs client to
cashier for payment proceed to cashier for
payment

2.b.2 Returns to OPD, 2.b.2 Receives charge slip and None 5 minutes Medical Records
presents charge slip Issues Hospital ID Staff
stamped as paid and
receives Hospital ID

TOTAL For New Client
-

Php 30.00 20 minutes

For Old Client-
35 minutes

56 | P a g e

11. Issuance of Triage Pass

The new normal due to the COVID-19 pandemic stresses observation of Infection Prevention and

Control protocols as well as contact traceability. The following steps must be followed to facilitate

delivery of goods/entry of persons inside health facility during this pandemic.

Office/Division: Operational Center (OPCEN)

Classification: Simple

Type of Transaction: Government-to-Citizen

Who May Avail: All watcher’s and visitors

CHECKLIST OF REQUIREMENTS WHERE TO SECURE

Watcher’s Pass, if applicable Admitting Section

If Deliveries of goods from areas with positive case of

COVID-19 (outside the Province), if applicable

Proof of Identification/Proof of Employment/Good’s Supplier

Pass/Delivery Receipt

FEES

CLIENT STEPS AGENCY ACTION TO PROCESSING PERSON

BE TIME RESPONSIBLE

PAID

1. Wears appropriate PPE 1. Provides advice on donning None 2 minutes Security Guard
on Duty
prior to entering the appropriate PPE prior to

hospital premises. entering hospital premises.

1.1 Performs hand wash/ 2.1 Directs client/s to hand None 5 minutes Security Guard
alcohol rub/foot bath wash/alcohol rub/foot bath None 5 minutes on Duty
disinfection and disinfection and receives
presents watcher’s watcher’s pass Designated
pass. Triage Nurse on
2.2 Assesses client for any of the
2.2 Submits self for following : Duty
assessment in to
designated Triage a. Travel history to areas with
Area (located at positive case of COVID 19.
hospital gate) and
provides information b. Contact to person with positive
as requested. COVID-19.

c. Signs and Symptoms.
d. Body temperature.

If Deliveries of goods
from areas with
positive case of
COVID-19

2.3 Presents any proof of 2.3 Request for any proof of None 5 minutes Designated
transaction transaction None 15 minutes Triage Nurse on

2.4 Allows hospital staff to 2.4 Disinfects vehicle and provides Duty/ Nursing
disinfect the vehicle advice regarding Drop Off Attendant
and receives advice to Point.
proceed to the Drop
Off Point

57 | P a g e

3. Registers in the Triage 3. Registers client in the Triage None 5 minutes Designated
Logbook and receives Logbook and issues Triage Triage Nurse on
triage pass and other Pass and other instructions as
instructions. necessary. Duty/ Nursing
Attendant

*Note:
Only one watcher/visitor can go

inside the hospital
premises.

TOTAL None 37 minutes

58 | P a g e

12. Patient’s Registration at the Emergency Room

Patient registration at the Emergency Room is necessary for documentation purposes. The service
caters all patients for registration. In order for the client/patient to be registered, the following steps are

to be followed:

Office/Division: Emergency Department

Classification: Simple

Type of Government-to-Citizen
Transaction:

Who May Avail: All patients for registration

CHECKLIST OF REQUIREMENTS WHERE TO SECURE

Hospital ID Admitting Section

FEES

CLIENT STEPS AGENCY ACTION TO PROCESSING PERSON

BE TIME RESPONSIBLE

PAID

1. Proceeds to Triage 1. Receives patient and requests None 1 minute Nurse on Duty
Area for registration for Hospital ID

(Note: Attendance to patient’s
medical needs shall be
given utmost priority and the
following steps may be
withheld temporarily for an
obviously emergency case)

For Old Patient 1.a Receives hospital ID for patient None 2 minutes Nurse on Duty
verification and registration
1.a Presents Hospital ID through IHOMIS
and provides
information
for registration
through IHOMIS

For Old Patient with 1.b.1 Instructs Client/s or None 2 minutes Nurse on Duty
Lost ID and for New Significant other to secure
Patient hospital ID at the Admitting
Section
1.b. Watcher or significant
other secures hospital
ID as instructed

2. Presents secured 1.b.2 Issues Hospital ID None 37 minutes Admitting Section
hospital ID 2. Receives hospital ID for patient None 2 minutes Nurse on Duty
verification and registration through
IHOMIS

TOTAL None Old Patient:
5 minutes

Old Patient with Lost ID:
42 minutes

New Patient:
24 minutes

59 | P a g e

13. Patient’s Triage at the Emergency Room

Patient triaging using the three (3) point triage scale category is done to ensure efficient services at the

Emergency Room.

Office/Division: Emergency Department

Classification: Simple

Type of Transaction: Government-to-Citizen

Who May Avail: All patients for triage

CHECKLIST OF REQUIREMENTS WHERE TO SECURE

Referral form, if applicable Referring unit/hospital

FEES

CLIENT STEPS AGENCY ACTION TO PROCESSING PERSON

BE TIME RESPONSIBLE

PAID

1. Proceeds to Triage 1. Receives patient and patient’s None 2 minutes Triage Nurse on
Area for assessment related documents such as Duty
and submission of referral form if available
related documents

(Note: Attendance to patient’s 2. Does initial client assessment None 5 minutes Nurse on Duty
medical needs shall be and data recording in the ER
given utmost priority and the form
following steps may be
withheld temporarily for an .
obviously emergency case)

2. Provides requested
data for proper
assessment and

recording

FOR EMERGENT
CASE/S

None 15 minutes Nurse on Duty

2.a Receives information 2.a Gives advice that their case
regarding prioritization has 1st priority in the provision of
of care in the
Emergency Room. May clinical management. May
be directed to transfer client directly to
designated area in the designated area in the
Emergency Room
immediately upon entry Emergency Room.
as necessary.

FOR URGENT CASE/S

2.b Receives information 2.b Gives advice that their case None 2 hours Nurse on Duty
regarding prioritization has 2nd priority in the provision
of care in the
Emergency Room. of clinical management.

FOR NON-URGENT 2.c Gives advice that their case None 3 hours and 40 Nurse on Duty
CASE/S has 3rd priority in the provision minutes 60 | P a g e

2.c Receives information of clinical management.
regarding
prioritization of care
in the Emergency

Room.

3. Transfers to 3. Transports to designated area in None 2 minutes Nurse on Duty
Emergency Room for the emergency room for Post- Nursing
Post-triage assessment Attendant
and disposition. triage assessment and disposition

For Emergent Case
24 minutes

TOTAL None For Urgent Case
2 hours & 9 minutes

For Non-Urgent Case
3 hours & 49 minutes

61 | P a g e

14. Patient’s post triage disposition at the Emergency Room

Proper patient disposition (admission, referral or discharge) at the ER ensures efficient services, better

health outcomes and satisfied clients.

Office/Division: Emergency Department

Classification: Simple

Type of Government-to-Citizen
Transaction:

Who May Avail: All patients directed to ER

CHECKLIST OF REQUIREMENTS WHERE TO SECURE

Emergency Room Form Triage Section

Admission and Discharge Record Admitting Section

Prescription Attending MD/ Nurse

Diagnostic Request Attending MD/Nurse

Official Receipt/ MSS Stamped Charge Slip Cashier/ Medical Social Service

Referral form, if applicable Referring unit/hospital

CLIENT STEPS AGENCY ACTION FEES TO BE PROCESSING PERSON

PAID TIME RESPONSIBLE

1. Receives post 1. Receives patient with None 2 minutes Nurse on Duty
triage advice ER Form stating post None
triage assessment

Patients for Admission

2.a.1 Patient or 2.a.1 Gives Order of 30 minutes Physician on
Significant other Admission and Duty
signs consent for provides necessary
Clinical management at the Nurse on Duty
Management Emergency Room
and/or
Admission

2.a.2 Significant other 2.a.2 Provides Admission None 2 minutes Nurse on Duty
proceeds to Slip and directs
Admitting significant other to
Section with the Admitting
Admission Slip Section for
then, secure and issuance of
sign the Admission and
Admission and Discharge form
Discharge form.

2.a.3 Returns to the 2.a.3 Receives Admission None 10 minutes Nurse on Duty
Emergency and Discharge
Room with the Form from the
secured designated staff of
Admission and the Admitting
Discharge form Section
from the
designated staff
of the Admitting
Section.

62 | P a g e

2.a.4 Takes the 2.a.4 Provides Charge None 10 minutes Nurse on Duty
medical supplies Slip and instructs to
in the Central proceed to Central 10 minutes Nursing
Supply Room Supply Room to get 10 minutes Attendant
and Medicines in the medical Nurse on Duty
the Hospital supplies used then, 30 minutes Nurse on Duty
Pharmacy. to Hospital 2 minutes Nursing
Pharmacy to 2 minutes Attendant
secure drugs and 17 minutes
medicines. 20 minutes Physician on
Duty/
2.a.5 Patient waits for 2.a.5 Endorses patient for None
ward/room ward/room transfer Nurse on Duty
transfer
Nurse on Duty
2.a.6 Patient transfers 2.a.6 Transports to None
from ER to ward/room transfer None Nurse on Duty
ward/room
2.b.1 Gives necessary Nurse on Duty
Patients for Referral management at the Cashier
Emergency Room
(Patients for referral in other and/or Order of 63 | P a g e
hospitals in Dipolog City Referral
requiring ambulance
conduction with
accompanying nurse trained
in EMT)

2.b.1 Patient or
Significant other
signs consent for
Clinical
Management
and/or Referral

2.b.2 Receives charge 2.b.2 Prepares charge None
slips slips for
ER/procedures/
services/supplies
used.

2.b.3 Receives other 2.b.3 Gives Instructions None
instructions for for settlement of
settlement of charges. None
charges
2.b.4 Processes Depends on the
*If patient will avail availment of charge
for medical discounts.
assistance: slip/SOA/discounts
2.b.5 Issues Official availed
2.b.4 Proceeds to Receipt
Medical Social
Service for
medical
assistance

2.b.5 Proceeds to
Cashier and
pays
corresponding
amount

*If patient will avail
for Malasakit
assistance:

2.b.6 Presents official

receipt and/or 2.b.6 Checks official None 30 minutes Malasakit Center
proof of medical receipt/s and/or On duty
assistance proof of medical None 30 minutes
assistance (Excess None 15 minutes Physician on
2.b.7 Waits once Waived per AO 137 Duty
patient is ready Series of 3 hours
to transfer to 2002,Patila Pay, Nurse on duty
higher institution Poor/Indigent ,C/O 2 minutes
and/or hospital of Medical Assistance 2 minutes Ambulance
choice. Program (MAP ) 23 minutes Nurse on Duty/
20 minutes
2.b.7 Stabilize patient and Driver on Duty
coordinates to the Physician on
receiving health
facility Duty
Nurse on Duty
2.b.8 Conducts patient
Nurse on Duty
to referral 2.b.8 Arranges for patient
Nurse on Duty
hospital transport
Billing/Claims
Patients to be discharged from the ER Staff

2.c.1 Patient or 2.c.1 Provides necessary None Cashier Staff
Significant other management at the
signs consent for Emergency Room
Clinical and gives
Management Discharge Order
and/or applicable
forms for
Discharge.

2.c.2 Receives charge 2.c.2 Prepares charge None
slips. slips for ER None
services/supplies
2.c.3 Receives other used.
instructions for
settlement of 2.c.3 Gives instructions
charges for settlement of
charges and directs
client to go to billing
and cashier

2.c.4 Proceeds to 2.c.4.1 Billing Section – None
Billing Section (for status post sutured
then to Cashier patients): Issues SOA Depends on
for issuance of 2.c.4.2 Cashier: Issues SOA/Charge Slips
official receipt for Official Receipt or any equivalent
payment of
charges.

*if patient will avail 2.c.5 Processes None 17 minutes MSS Staff
for medical availment of 64 | P a g e
assistance

2.c.5 Proceeds to
Medical Social
Service and/or

Malasakit Center medical assistance.
for medical
assistance.

*if patient will avail 2.c.6 Checks official None 30 minutes Malasakit
for Malasakit assistance receipt/s and/or staff/MSS Staff
proof of medical None
2.c.6 Presents official assistance and None
receipts and/or replenishment of None
proofs of medical medical supplies
assistance and and medicines None
replenished used. assistance None
medical supplies (Excess Waived None
and medicines per AO 137 Series
used. of 2002,Patila Pay,
Poor/Indigent ,C/O
Medical Assistance
Program (MAP )

2.c.7 Receives discharge 2.c.7 Gives discharge 3 minutes Physician on
instructions. instructions. 1 hour Duty/

Discharge Against Medical Advice (DAMA) Nurse on Duty

2.d.1 Patient or 2.d.1 Provides necessary Resident on Duty
management at the Nurse on Duty
Significant other Emergency Room
signs consent for
Clinical
Management

2.d.2 Signs consent for 2.d.2 Explained the 3 minutes Resident on Duty
the Release from possible consequences Nurse on Duty
Responsibility and secures consent for
form. the release of
responsibility.
( Note: for minor
patients the patient next
of kin will sign the
consent )

2.d.3 Patient’s 2.d.3 Instructs the 5 minutes Resident on Duty
significant others significant other to
will remove all remove all the
the contraptions. contraptions.

2.d.4 Receives charge 2.d.4 Prepares charge 2 minutes Nurse on Duty
slips. slips for ER
services/supplies used.

2.d.5 Receives other 2.d.5 Gives Instructions 2 minutes Nurse on Duty
instructions for for settlement of charges
settlement of and directs client to go to
charges billing and cashier

2.d.6 Proceeds to 2.d.6.1 Billing Section – None 23 minutes Billing/Claims
Billing Section (for status post sutured 20 minutes Staff
then to Cashier patients): Issues SOA Depends on
for issuance of 2.d.6.2 Cashier: Issues SOA/Charge Slips Cashier Staff
official receipt for or any equivalent
payment of 65 | P a g e

charges. Official Receipt

*if patient will avail for 2.d.7 Processes None 17 minutes Nurse on Duty
availment of medical None
medical assistance/ assistance
Malasakit assistance: None

2.d.7 Proceeds to
Medical Social
Service and/or
Malasakit Center
for medical
assistance.

2.d.8 Presents official 2.d.8 Checks official 30 minutes Malasakit Center
receipts and/or receipt/s and/or proof of on Duty
proofs of medical medical assistance and
assistance and replenishment of medical 3 minutes Nurse on Duty
replenished supplies and medicines
medical supplies used. assistance (Excess
and medicines Waived per AO 137
used. Series of 2002,Patila Pay,
Poor/Indigent ,C/O
2.d.9 Receives Medical Assistance
discharge Program (MAP )
instructions.
2.d.9 Gives discharge
instructions.

Patients for Admission

1 hour & 14 minutes

Patients for referral
1 hour and 43 minutes

Patients to be discharge
3 hours and 52 minutes

Depends on DAMA
SOA/Charge Slips 1 hour and 58 minutes
or any equivalent
TOTAL and availment of

medical *if client will avail medical
assistance assistance

Patients for referral
2 hours and 30 minutes

Patients to be discharge
4 hours and 39 minutes

DAMA
2 hours and 45 minutes

66 | P a g e

15. Triaging and Admission of Suspect, Probable and

Confirmed COVID-19

Proper referral and coordination for triaging and admission of suspect, probable and confirmed

COVID-19 clients is important to facilitate appropriate care to clients and minimize contamination and

cross transmission among patients and caregivers.

Office/Division: Emergency Department

Classification: Simple

Type of Transaction: Government-to-Citizen

Who May Avail: All patients for admission of suspect, probable and confirmed case of
Covid-19

CHECKLIST OF REQUIREMENTS WHERE TO SECURE

Referral form, if applicable Referring unit/hospital

FEES

CLIENT STEPS AGENCY ACTION TO PROCESSING PERSON

BE TIME RESPONSIBLE

PAID

1. Notifies the health care 1.1 Verifies referral and determines None 20 minutes Nurse on Duty/

facility in advance prior appropriateness of admission Resident on Duty

transport and gives within the capability of the

information related to institution for its management.

present health 1.2 Prepares the room/s for None 10 minutes Nurse on Duty/

condition. patient’s accommodation and Resident on Duty

necessary medical supplies and

*Arrival at the facility depends medical equipment to be used.
on the distance where the
referral came from.

For suspect, probable 2.1 Directs client/s to identified None 5 minutes Nurse on Duty
and confirmed covid-19 COVID-19 Isolation Unit. None 15 minutes
2.1 Proceeds to identified Resident on
2.2 Performs patient’s initial Duty/
COVID-19 Isolation assessment on the following :
Unit IM on duty/
2.2 Submits self for initial a. Travel history to areas with ISO Nurse on
assessment positive case of COVID-19.
duty
b. Contact to person with positive

COVID-19.

c. Present signs and symptoms

d. Check the referral

2.3 Signs consent for e. Check the body temperature. 5 minutes ISO Nurse
Admission 2.3 Secures consent for admission None

2.4 Provides requested 2.4 Asks to provide demographic None 10 minutes ISO Nurse
data for Input to data for his/her Admission and
his/her Admission and Discharge Form
Discharge Form.

2.5 Submits self for 2.5 Does patient assessment for None 3 minutes ISO Nurse/
assessment for appropriate medical nursing None 5 minutes ISO Physician
appropriate medical care
nursing care Nursing
2.6 Transports patient to assigned Attendant
room.

TOTAL None 1 hour and 13 minutes

67 | P a g e

Internal Services

68 | P a g e

1. Discharge Process/Discharging a Patient from Clinical Areas

This service involves processing of patient’s discharge from the time of order until the time the patient

is cleared and released from the clinical area of the institution.

Office/Division: Nursing Service – Clinical Areas

Classification: Simple

Type of Transaction: G2C – Government to Client

Who May Avail: Patient
Patient’s Representative: Relative or Legal Guardian

CHECKLIST OF REQUIREMENTS WHERE TO SECURE

Discharge order from physician Nurse’s station (written on patient’s health

record)

Statement of Account Billing and Claims Office
Clearance Slip
Cash Operations Office

CLIENT STEPS AGENCY ACTION FEES PROCESSING PERSON
TO BE
PAID TIME RESPONSIBLE

1. Acknowledges Notice 1.1. Writes discharge order None 15 minutes Physician
of Discharge
1.2. Notifies costs centers and
carries-out discharge order None 50 minutes Nurse

1.3 Completes and clears None 1 hour Cost Centers
hospital 23 minutes (Central Supply
charges and Notifies ward
stations for discharge 47 minutes Room,
15 minutes Pharmacy,
2.a Acquires SOA from 2.a.1 Receives and verifies None 5 minutes Laboratory,
the Billing and Claims completeness of all Radiology,Billing/
Office documents None
Claims)
[Situation Specific] 2.a.2 Prints the Statement of Based on Billing and
If client needs further Account (SOA) SOA Claims Staff
None
financial assistance: 2.b Processes medical MSW Staff
Proceed to Step 2.1 assistance/ classification/
discount referrals Cashier Staff
2.b Proceeds to
MSW/Malasakit 3.1 Receives the payment and Cashier Staff
Center for SOA with indicated amount to
assistance/ be paid 69 | P a g e
classification/discount
3.2 Issues the OR and
3.1 Proceeds to the Cash Clearance Slip to the client
Operations Office to
settle bills

3.2 Receives copy of
paid SOA, Official
Receipt (OR) and
Clearance
Slip

4. Presents the Clearance 4. Signs the clearance slip after None 5 minutes Linens in Charge
Slip to the Linen Room all linens issued to the patient
of the Central Supply are properly accounted None 10 minutes Nurse
Room (CSR) for None 5 minutes
clearance from linens 5.1 Discusses all information None 5 minutes Nursing
written in the Tagubilin and Attendant
5. Presents the signs the Clearance Slip
Clearance Slip to the Guard
Nurse’s Station 5.2 Ushers the patient to the
where the patient is hospital exit
admitted and receive
the Tagubilin 5. Signs and collects Clearance
Slip and performs final
6. Presents Clearance inspection of patient’s
Slip to the guard and belongings.
exits the hospital

TOTAL: Based 3 hours and 13
on SOA minutes

*Discounts (for clients
Availed needing further

financial
assistance)
= 4 hours

70 | P a g e

2. Issuance of Medical Supplies

The Central Supply Room provides the medical and surgical supplies necessary for the treatment of

the hospital clients in the best, most efficient and timely manner. The CSR ensures the availability of

medical and surgical supplies for hospital consumption.

Office or Division: Central Supply Room; Nursing Service

Classification: Simple

Type of Transaction: G2G - Government-to-Government

Who may avail: Nurses, Nursing Attendant/Administrative Aide

CHECKLIST OF REQUIREMENTS WHERE TO SECURE

Prescription for Medical Supplies Prescribing Doctor or Nurse
Logbook
CSR Office

CLIENT STEPS AGENCY ACTION FEES PROCESSING PERSON
TO BE TIME RESPONSIBLE
PAID
Nurses /
1. Inputs charges to 1. Reviews iHOMIS and None 5 minutes Nursing
Attendant /
patient’s account through checks the availability of CSR Staff

iHOMIS requested supplies

2. Waits for notification 2.1 Prepares the available None 10 minutes CSR Staff on
requested supplies Duty

2.2 Clicks “ISSUE” to patients’ None 5 minutes CSR Staff on
IHOMIS account. Duty

3. Receives requested 2.3 Notifies requestor to pick None 5 minutes CSR Staff on
items and up prescribed medical None 5 minutes Duty
acknowledges receipt supplies
through logbook CSR Staff on
3. Dispenses items to Duty
requesting party and
informs requesting staff to
acknowledge
receipt through logbook.

TOTAL None 30 minutes

71 | P a g e

MEDICAL AND ANCILLARY SERVICE

72 | P a g e

External Services

73 | P a g e

1. Availment of Blood Units

The service involves storage and releasing of blood units, compatibility testing & antibody screening,

testing for transfusion transmissible infection and releasing of blood units to outpatients who avail this

service.

Office/Division: Laboratory Section/ Blood Station

Classification: Simple

Type of Transaction: G2C-Government to Citizen; G2B-Government to Business; G2G-
Government to Government

Who May Avail: OPD/Walk-in Patients that needs blood units

CHECKLIST OF REQUIREMENTS WHERE TO SECURE

Blood Request Form – 1 copy Requesting Physician
Charge Slip – 1 copy Laboratory Section

CLIENT STEPS AGENCY ACTION FEES TO PROCESSING PERSON

BE PAID TIME RESPONSIBLE

1.1 Presents blood 1.1 Receives and assesses the None 5 minutes Laboratory Staff
request form request form None 15 minutes
Med Tech on
1.2 Waits for the advice 1.2 Checks for the availability of None duty
on blood unit blood unit requested
availability None 10 minutes Med Tech on
1.3 Instructs client to provide duty
1.3 Secures a container transport container and ice Refer to
with ice pack for the packs. fees for 2 minutes Laboratory staff
transportation of
blood unit(s) 2. Issues charge slip and directs the 20 minutes Cashier
to cashier for payment of specific
2. Receives charge slip blood screening fee of the procedure
and proceeds to blood unit(s). None
cashier for payment
3. Issues official receipt None
3. Presents charge slip
and pays Refer to
corresponding fees for
amount
the
4. Presents Stamped 4. Receives Charge Slip and specific 30 minutes Laboratory staff
paid charge slip with instructs client to wait while procedure Duty
OR Number and blood unit is being packed for
waits while the blood transport. 5 minutes Med Tech on
unit(s) is prepared Duty
5. Hands-over the donor’s
5. Gets the donor’s screening result separately
screening result from the packed blood unit(s)
together with the
packed blood unit

TOTAL 1 hour and 27 minutes

74 | P a g e

DEPARTMENT OF HEALTH DEPARTMENT OF HEALTH
DR. JOSE RIZAL MEMORIAL HOSPITAL DR. JOSE RIZAL MEMORIAL HOSPITAL

LAWAAN, DAPITAN CITY LAWAAN, DAPITAN CITY
TELEFAX: (065) 213-6421 TELEFAX: (065) 213-6421
Website: www.djrmh.doh.gov.ph Website: www.djrmh.doh.gov.ph

Email: [email protected] Email: [email protected]

Pricelist for Blood Units Pricelist for Blood Units
as of June 30, 2020 as of June 30, 2020

SERVICES RATE SERVICES RATE
PHILHEALTH/ PAY/ Blood Bag (250 ml) PHILHEALTH/ PAY/ OPD/
Blood Donor Screening
Blood Screening: Whole OPD/ SERVICE SERVICE WARD/
Blood WARD/ PRIVATE WARD

PRIVATE WARD 114.00

1,500.00 138.50

1,800.00 Blood Bag (450 ml)

75 | P a g e

2. Availment of In-Patient Registration

The Admitting Section is responsible in collecting in patient’s demographic data, patient’s registration,
and printing of Admission and Discharge Record for every Admission.

Office/Division: Admitting Section

Classification: Simple

Type of Transaction: G2C – Government to Citizen

Who May Avail: For Admission Clients

CHECKLIST OF REQUIREMENTS WHERE TO SECURE

Admission Slip Emergency Room (ER)
* Any of the following requirements listed:
 Any Valid ID (Government Issued ID) - (1 copy)  BIR, Post Office, DFA, PSA, SSS, GSIS,
PAG-IBIG, LTO, COMELEC

CLIENT STEPS AGENCY ACTION FEES TO PROCESSING PERSON
BE PAID
1.1 Presents Admission 1.1 Receives filled-out TIME RESPONSIBLE
Slip admission slip and None
instructs to provide 15 minutes Admitting Staff
any valid document

1.2 Provides any valid ID 1.2 Performs initial PHIC None 30 minutes Admitting Staff

for PHIC Initial assessment of patient None
None
Assessment and give information

and receives to comply any

information on PHIC requirements needed

compliance as indicated in the

requirements system Portal/

eClaims).

2. Affixes signature on the 2. Prints Admission and 5 minutes Admitting Staff

data furnished portion of Discharge Record then

the Admission and forwards to Emergency

Discharge Record Room

TOTAL 50 minutes

76 | P a g e

3. Availment of Laboratory Services for Out-Patients

Laboratory services are sought to assist the clinical management of patients. Various procedures
within the scope of its license as a secondary laboratory can be availed by Outpatients

SECONDARY Routine Blood SPECIAL TESTS
 Hospital-based Laboratory Chemistry INCLUDE:
 Availability of Services (Monday to Friday):
 FBS/RBS  Gram Staining
8AM to 5PM  BUN  KOH
 Creatinine  HIV Testing
ROUTINE TESTS INCLUDES:  Lipid Profile  HbsAg
 Complete Blood Count (with Platelet)  BUA
 Urinalysis  SGPT
 Fecalysis/ Stool Exam  SGOT
 Blood Typing

Office/Division: Laboratory Section
Classification: Simple

Type of Transaction: Government to Citizen; Government to Business; Government to
Government
Who May Avail: Out-Patients / Walk-In Patients

CHECKLIST OF REQUIREMENTS WHERE TO SECURE

Completely filled up laboratory request Requesting Agency / OPD

Official Receipt/ Stamped Paid or MSS Stamped Cashier/MSS

Charge Slip or its equivalent / Claim Slip Laboratory Section

CLIENT STEPS AGENCY ACTION FEES PROCESSING PERSON
TO BE TIME RESPONSIBLE
1. Presents Laboratory 1. Reviews submitted PAID Laboratory Staff
request/s and receives Laboratory None 10 minutes
instruction/s for the request/s and Laboratory staff
procedure provides None 2 minutes
instructions for the MSS Staff
2.a Receives charge slip procedure None 17 minutes Cashier
and proceeds to cashier
for payment 2.a Issues charge slip Refer to 20 minutes Laboratory Staff
and directs to fees for 3 minutes 77 | P a g e
*If patient will avail for cashier for
medical assistance payment of the
charges specific
2.b Proceeds to MSS for procedure
Availment of medical 2.b Processes
assistance Availment of None
medical
3. Presents charge slip for Assistance
payment and pays
corresponding amount 3. Issues official
receipt

4.1 Presents Stamped paid 4.1 Receives stamped
charge slip with OR paid charge slip with
Number / MSS Stamped OR number / MSS
Charge Slip together Stamped charge slip

with the laboratory then receives None 10 minutes Medical
request/s laboratory request/s None Technologist/Laboratory
4.2 Presents self for sample None
extraction and/or gives 4.2 Verifies the clients’ Staff
sample information then None
proceeds to 2 minutes Laboratory Staff
4.3 Receives claim slip and extraction and/or Laboratory Staff
waits for the result receive specimen Routine:
within 4 hours Laboratory Staff
4.3 Provides claim slip upon receiving
for the claiming of
results of samples

4.4 Processes and Routine Blood
analyzes specimen Chemistry: 8
according to the
procedure hours upon
requested receiving of

5. Presents claim slip 5. Gets and verifies samples
and signs Releasing claim slip and 5 minutes
Logbook upon claiming releases laboratory
the Laboratory Results results

TOTAL (check schedule Routine:
of fee, compute 4 hours and 49 minutes
*If patient will avail for medical
accordingly)
*If patient will assistance
= 5 hours and 3 minutes
avail for
medical Routine Blood Chemistry:
assistance 8 hours and 49 minutes
Depends on the *If patient will avail for medical
assistance
availed assistance
= 9 hours and 3 minutes

78 | P a g e

DEPARTMENT OF HEALTH DEPARTMENT OF HEALTH

DR. JOSE RIZAL MEMORIAL HOSPITAL DR. JOSE RIZAL MEMORIAL HOSPITAL

LAWAAN, DAPITAN CITY LAWAAN, DAPITAN CITY
TELEFAX: (065) 213-6421 TELEFAX: (065) 213-6421
Website: www.djrmh.doh.gov.ph Website: www.djrmh.doh.gov.ph

Email: [email protected] Email: [email protected]

Pricelist for Blood Units Pricelist for Blood Units
as of June 30, 2020 as of June 30, 2020

SERVICES RATE SERVICES RATE
PHILHEALTH/ PAY/ PHILHEALTH/ PAY/ OPD/
10% Formalin 10% Formalin 900ml
10% Formalin 90ml OPD/ SERVICE 10% Formalin 1000ml SERVICE WARD/
10% Formalin 100ml WARD/ AFB Stain PRIVATE WARD
10% Formalin 150ml Albumin
10% Formalin 200ml PRIVATE WARD Alkaline Phosphatase 146.70
10% Formalin 250ml 163.00 Anti- HBs Determination 136.00
10% Formalin 300ml ASO 60.00
10% Formalin 350ml 14.67 Blood Bag 250 ml 100.00
Blood Bag 450 ml- 350.00
16.30 Laboratory 165.00
Blood Donor Screening 100.00
24.45 Blood Smear for Malaria 114.00
Parasites (BSMP)
32.60 Blood Typing with Rh 138.50
BUA
40.75 FBS 1,500.00
Fecalysis only
48.90 Fecalysis with Occult 50.00
Blood
57.05 Gram Stain 90.00
95.00
10% Formalin 400ml 65.20 H. Pylori Detemination 95.00
30.00
10% Formalin 500ml 81.50 Hba 1C
HBsAg 130.00
10% Formalin 600ml 97.80 HCV
50.00
10% Formalin 700ml 114.10 HDL/ LDL
10% Formalin 800ml 130.40 295.00
BUN 140.00 Hematocrit
CBC 150.00 Hemoglobin 792.00
HIV 185.00
CBC with Platelet 210.00 Salmonella 330.00
SGOT (AST)
Cholesterol 95.00 SGPT (ALT) 135.00
Clotting Time/ Bleeding Time
(CTBT) 70.00 45.00
Creatinine 45.00
135.00 165.00
Crossmatching 70.00 600.00
85.00 125.00
CRP 115.50
Dengue Antibody 550.00
Determination
Dengue NS1 300.00
40.00
Differential Count 135.00
35.00
ESR 550.00
100.00
KOH Preparation

Lipid Profile (Package)

Occult Blood only

79 | P a g e

Oral Glucose Tolerance Test 375.00 Sodium (Na+) 275.00
50 g

Oral Glucose Tolerance Test 460.00 Total Bilirubin 250.00
75 g (Total Direct & Indirect)
85.00
Platelet Count only 115.00 Total Protein 245.00
Potassium (K+) 275.00 Triglyceride 552.00
Pregnancy Test 80.00 Triple Bag 500.00
Prothrombin Time 450.00 Troponin I 1,004.00
RBC Count 30.00 Troponin T 50.00
RBS/ Strips (Wet Method) 95.00 Urinalysis (Manual) 150.00
Reticulocyte 150.00 Urinalysis (Automated)

80 | P a g e

4. Availment of Dental Services

This process starts with presenting the OPD Form until receiving of dental procedures and instructions
for oral care.

Office/Division: Dental Service
Classification: Simple
Type of Transaction: G2C – Government to Citizen
Who May Avail: Out-Patient Clients

CHECKLIST OF REQUIREMENTS WHERE TO SECURE

Out Patient Department (OPD) Form OPD Triage
Stamped-Paid Charge Slip
Medical Social Service (MSS) Stamped Charge Slip Cashier
MSS

CLIENT STEPS AGENCY ACTION FEES PROCESSING PERSON
TO BE TIME RESPONSIBLE
1. Presents OPD Form 1. Receives OPD Form for PAID
initial examination None 10 minutes Dentist/
2.a Receives prescription Dental Aide
and charge slip then 2.a Issues prescription & None 5 minutes
proceeds to cashier charge slip and instructs Dentist
for payment. client to go to cashier for
payment

*If patient will avail for None 17 minutes MSS Staff
medical assistance
2.b Processes Availment of Php 20 minutes Cashier
2.b Proceeds to MSS for medical assistance 300.00
Availment of medical
assistance 3. Issues Official Receipt.

3. Presents charge slip 4. Initiates Dental None 1 hour Dentist/
and/or prescription Procedures Dental Aide
and pays
corresponding 5. Gives final oral care None 5 minutes Dentist
amount
instruction
4. Returns to Dental Clinic
and presents
stamped “Paid”
charge slip with OR
Number/MSS
Stamped charge Slip

5. Receives instruction for
oral care

Php 300.00 1 hour & 40 minutes

TOTAL *If patient will avail for *If patient will avail for medical
medical assistance assistance
Amount to be paid
1 hour & 57 minutes
depends on the discount
given

81 | P a g e

5. Availment of Medical Assistance

Provision of Medical Assistance to the poor or indigent patients, or those with chronic/catastrophic
illnesses seeking medical services in the hospital.

Office/Division: Medical Social Service (MSS)
Classification: Simple
Type of Transaction: G2C – Government to Citizen
Who May Avail: All patients

CHECKLIST OF REQUIREMENTS WHERE TO SECURE

Any of listed requirements as applicable - Radiology/Laboratory/CSR/ER
- Charge Slip - (1 copy) - Billing & Claims
- Statement of Account - (1 copy) - Pharmacy
- Order of Payment Slip - (1 copy) - Health Information Management Office
- Medical Certificate/Medical Abstract MSS
Medical Social Service Card
Any of listed requirements, as applicable - Barangay/DSWD
- Certificate of Indigency - (1 copy)
- 4P’s ID (1 copy) - DSWD
- Sponsored MDR/PBEF - (1 copy)
- Senior Citizen ID - (1 copy) - PHIC
- PWD ID - (1 copy)
- Office of Senior Citizen’s Affairs

- City/Municipal Social Welfare and

Development Office

- BHW ID - (1 copy) - Rural Health Unit / DOH Regional Office
- Barangay Official ID - (1 copy)
- DILG

CLIENT STEPS AGENCY ACTION FEES PROCESSING PERSON
TO BE
PAID TIME RESPONSIBLE

1. Presents charge 1. Updates patient’s record & None 8 minutes Social worker on
slip/SOA/Order of receives any documentary
Payment Slip & requirements (as applicable) Duty
Medical Social then checks charge
Service Card and any slip/Order of Payment None 6 minutes Social Worker on
documentary Slip/statement of account duty
requirements, as and determines amount for
applicable. medical assistance to be *Amount 3 minutes Social Worker on
provided to client, or possible to be paid 3 minutes duty
2. Acknowledges cost sharing. may vary
Medical Assistance depending Social Worker on
availed or signs 2. Indicates amount assisted duty
logbook of Quantified and/or amount to be paid in on 82 | P a g e
Free Services(QFS) the charge slips/Order of discount
payment slip or SOA.
For OPD clients with given
counterpart payment: 3.a Instructs client to proceed to
3.a Proceeds to cashier the Cashier for payment
for payment before going before proceeding
to the cost centers for the to the cost centers for the
services needed. services needed.

For OPD clients without 3.b Instructs client to proceed to
counterpart or Full
MAIP assistance:
3.b Proceeds to the cost

centers for the services the cost center to avail the None 3 minutes Social Worker on
needed. services needed. 17 minutes duty
For ER and In patients: *Amount
3.c Proceeds to the 3.c Instructs client to proceed to to be paid
cashier for payment the cashier for payment and/or may vary
and/or clearance. clearance that is needed to be depending
presented to the ward nurse or
ER nurse for their final on
discharge. discount

given

TOTAL: *Amount
to be paid
may vary
depending

on
discount

given

83 | P a g e

6. Availment of Medico-Legal Examination at the Women and

Child Protection Unit

WCPU Is a unit that serves a holding and processing area to victims/survivors of violence against

women and their children (VAWC) and child abuse. It is a composed of multidisciplinary team

members that provides comprehensive medical and psychosocial services to women and children

survivors of violence.

Office or Division: Women and Children Protection Unit

Classification: Simple

Type of Transaction: Government-to-Client

Who may avail: Victims/survivors of VAWC

CHECKLIST OF REQUIREMENTS WHERE TO SECURE
- Government agencies such as but not
- Referral letter
limited to, DSWD, PNP, NBI, etc. or
- Police request NGOs/Pos.
- Philippine National Police

Note : Walk in clients need not present requirements.

CLIENT STEPS AGENCY ACTION FEES TO PROCESSING PERSON
BE PAID TIME RESPONSIBLE
1. Presents referral 1. Assesses referral letter as
letter/police request, to what kind of service/s None 10 minutes Emergency
if available. is/are requested or needed Room (ER)
Triage staff

2. Accomplishes 2.1 Verifies personal None 15 minutes ER Triage staff
Patient Data information submitted and None
Information at the ER prints patients’ record. None 5 minutes Designated
Triage for 1 hour Nurse/ Resident
registration 2.2 Informs physician and
forwards patient to WCPU. in-charge
3.1 Gives consent/
assent for medical 3.1 Secures informed consent, Social Worker
examination. assent and/or other on-duty and
applicable consent for
interview and examination. Attending
Physician
3.2 Submits for interview 3.2 Conducts intake interview

and examination assessment.

3.3 Submits for Medical 3.3 Conducts medical None 45 minutes Attending
Examination, examination, takes 9 hours Physician
evidence gathering appropriate documentation *(Cost vary
and documentation and orders necessary depending on Designated
tests, procedures and/or nurse on duty
4. Proceeds to cost prescribe medicine, the
centers for the including referral test/procedures 84 | P a g e
performance of to other agency or or medicines)
test/procedure or get sections, as necessary.
prescribed
medicines, as 4. Carries out request,
ordered by facilitates performance of
necessary tests/
procedure or medicines.

physician.

5. Returns to WCPU for 5.1 Explains disposition and None 3 minutes Attending
planning & give further instructions. None 2 hours physician
counseling, and
waits for further 5.2 Makes medico-legal Attending
instruction. certificate. physician

6. Receives advice 5.3 Initiates plan of action and None 15 minutes Social Worker
where to proceed to provides counseling. None 2 minutes on-duty
claim medico-legal
certificate. 6.1 Advices patient/ Social Worker
accompanying on-duty
adult to proceed to
HIM/Medical Record to Social Worker
claim the Medico-legal on-duty
Certificate.

6.2 Endorses patient health None 10 minutes
record to HIM.
*(Cost vary 1 day, 5 hours
TOTAL depending on and 45
minutes
the
test/procedures
or medicines)

85 | P a g e

7. Availment of MSS Classification/Re-Classification of Patient

Patient social classification is a type of categorization of patients who seek consultation or admission

in the hospital on the basis of their economic status or paying capacity and poverty threshold level.

There are three social classifications namely; full pay, partial pay and the poor and indigent.

Office/Division: Medical Social Service (MSS)

Classification: Simple

Type of Transaction: G2C – Government to Citizen

Who May Avail: Walk IN or Referred Patients (In- Patients, ER clients, OPD)

CHECKLIST OF REQUIREMENTS WHERE TO SECURE

Medical Social Service Card MSS Section

CLIENT STEPS AGENCY ACTION FEES PROCESSING PERSON
TO BE TIME RESPONSIBLE
For NEW Clients: 1.a Interviews and assesses PAID Social Worker
1.a Fills out necessary client’s socio-economic status
or the financial capability and None 20 minutes on Duty
information and submits coping capacity of the client.
for interview and None 5 minutes Social Worker
assessment . and 1.b Receives Medical Social on duty
presents ID as necessary Service Card and updates
for identification record
purposes

For OLD Clients:
1.b Presents Medical Social

Service Card

2. Receives assessment and 2. Provides assessment, issues None 3 minutes Social Worker
Medical Social Service Medical Social Service Card on Duty
Card. for new clients, re-issue or
revalidates Medical Social None 10 minutes Social Worker
3. Asks information relative Service Card for old clients on Duty
to
hospitalization/consultati 3. Provides information on the
on issues/ concerns and scope of services and
or difficulty. limitations and explains
necessary requirements and
provides necessary
intervention to client’s
presenting problem.

TOTAL: None New Client : 33 minutes
Old Client : 18 minutes

86 | P a g e

8. Availment of Nutritional and Dietetics Service

The Nutrition and Dietetics Section is responsible in the provision of optimal nutrition care through
quality food service. Client starts from presenting the required documents until receiving of dietary
instruction.

Office/Division: Nutritional and Dietetics Service
Classification: Simple
Type of Transaction: G2C – Government to Citizen
Who May Avail: Out-Patient Clients

CHECKLIST OF REQUIREMENTS WHERE TO SECURE

Intra-Agency Referral Sheet OPD
Laboratory Result/s OPD
Prescription Form OPD

CLIENT STEPS AGENCY ACTION FEES TO PROCESSING PERSON

BE PAID TIME RESPONSIBLE

1. Presents required 1. Receives required None 2 minutes Dietitian on
documents documents None 15 minutes Duty

2. Receives dietary 2. Prepares necessary Dietitian on
instruction instructional materials and Duty
provides dietary instruction
regarding prescribed diet

TOTAL None 17 minutes

87 | P a g e

9. Availment of Patient’s Data Correction

Changes and corrections for In-Patient’s registered data is done in Admitting Section. This is to ensure
that the patient’s information on his/her hospital record is correct based on the valid document
received in this office.

Office/Division: Admitting Section

Classification: Simple

Type of Transaction: G2C – Government to Citizen

Who May Avail: In-Patients

CHECKLIST OF REQUIREMENTS WHERE TO SECURE

* Any of the following requirements listed:

 Any Valid ID (Government Issued ID) - (1 copy)  BIR, Post Office, DFA, PSA, SSS, GSIS,
PAG-IBIG, LTO, COMELEC

 Birth Certificate - (1 copy)  PSA
 Marriage Contract - (1 copy)  PSA
 Baptismal Certificate - (1 copy)
 Company ID - (1 copy)  Church
 Employer

CLIENT STEPS AGENCY ACTION FEES PROCESSING PERSON
TO BE TIME RESPONSIBLE
PAID

1. Informs the 1. Retrieves the patient’s data None 10 minutes Admitting Staff
Admitting Staff for from the IHOMIS, verifies
any corrections on with the filled-out None 10 minutes Admitting Staff
the patients’ data. admission slip instructs the
patient/watcher to provide
2. Provides any valid document to
photocopy of any support the changes
valid document
needed to support 2. Receives the Valid
the changes. Document / ID and corrects
the patient’s data.

TOTAL None 20 minutes

88 | P a g e

10. Availment of Patients Hospital Identification Card

The Admitting Section is in charged for the Issuance of Patient’s Identification Card for patients

managed at the Emergency Room. Hospital ID card issued with the patient’s hospital number serves

as his/her permanent record in this health facility.

Office/Division: Admitting Section

Classification: Simple

Type of Transaction: G2C – Government to Citizen

Who May Avail: Patients managed at the Emergency Room (New Patient and Old Patient with
lost Hospital ID)

CHECKLIST OF REQUIREMENTS WHERE TO SECURE

Stamped Paid Charge slip with OR Number - (1 original Cashier
copy) Admitting
Charge Slip – (1 original copy)

CLIENT STEPS AGENCY ACTION FEES PROCESSING PERSON
TO BE TIME RESPONSIBLE
PAID

1. Provides patient’s data 1. Checks in the computer if None 8 minutes Admitting Staff
the patient has existing None 3 minutes
2. Receives charge slip hospital record None 10 minutes Admitting Staff
and proceeds to cashier Admitting Staff
for payment 2.a (if old Client w/o ID) :
Issues charge slip and directs
to cashier for payment of
charges
2.b (if New Patient): Creates
Patient’s Master Record and
generates hospital record
number then proceeds to Step
5

3. Presents charge slip 3. Issues official receipt Php 20 minutes Cashier
and pays 30.00 3 minutes Admitting Staff
corresponding amount 4. Receives stamped paid
charge slip with None
4. Returns to admitting OR number
section and presents
stamped paid charge
slip with OR number

5. Receives Patient’s 5. Issues Patient’s None 3 minutes Admitting Staff
identification Card Identification Card

TOTAL Php New Client -
30.00 21 minutes

Old Client w/o ID
37 minutes

89 | P a g e

11. Availment of Philhealth Enrolment through Point Of Service

(POS)

Point of Service (POS) refers to the program to cover all Filipinos (The unregistered and inactive
members) under the National Health Insurance Program, through the General Appropriations Act for
the current year.

Office/Division: Medical Social Service (MSS)

Classification: Simple

Type of Transaction: G2C – Government to Citizen

Who May Avail: Admitted clients/patients

CHECKLIST OF REQUIREMENTS WHERE TO SECURE

* Any of listed documentary requirements (as - Philippine Statistics Authority (PSA)
applicable) - Public Attorney’s Office
- Birth Certificate - (1 copy)
- Affidavit of guardianship of the legal guardian

in the absence of their parents - (1 copy)

CLIENT STEPS AGENCY ACTION FEES TO BE PROCESSING PERSON
PAID TIME RESPONSIBL
1. Asks information 1. Provides information
how to access PHIC and instructs watcher None 5 minutes E
enrolment. or patient to secure Social Worker on
complete requirements
1.1 Secures needed including timelines for its Duty
documentary completion.
requirements as None 2 days
needed.

2. Presents 2. Checks completeness of None 10 minutes Social Worker on
documentary required documents and Duty
requirements and provides Philhealth
accomplishes Membership
Philhealth Registration Form
Membership (PMRF)
Registration Form
(PMRF).

2.1 Waits to be enrolled 2.1 Enrolls patient to None 10 minutes Social Worker on
at Philhealth POS Philhealth POS System, Duty
System and issues note as
proof of PHIC enrolment

2.2.a Proceeds to the For Financially Incapable: None 2 minutes Social Worker on
Billing and Claims to 2.2.a Instructs watcher/ Duty
submit documents.
patient to submit
2.2.b Proceeds to documents to Billing &
Claims for proper
tagging.
For Financially Capable:

90 | P a g e

Philhealth Local 2.2.b Instructs client to pay None 3 hours Social Worker on
Health Insurance Annual Premium at Duty
Office, Dipolog City the PHIC-LHIO,
to pay the Annual
PHIC Premium then Dipolog City for PHIC
returns to submits to membership and
Billing and Claims instruct patient to submit
the proof of proof of payment at
payment. Billing & Claims.

TOTAL: None Financially
Incapable:

2 days and 27
minutes

Financially
Capable:

2 days, 3 hours
and 25 minutes

91 | P a g e

12. Availment of Services at Malasakit Center (Medical/Financial

Assistance & Verification of PHIC Status

Malasakit Center serves as a one-stop shop, where the different participating agencies receive and

process request for medical and financial assistance for indigent and financially incapacitated

patients.

Office/Division: Malasakit Center

Classification: Simple

Type of Transaction: G2C – Government to Citizen

Who May Avail: All patients

CHECKLIST OF REQUIREMENTS WHERE TO SECURE

A. For Medical Assistance: DOH-MSW - Radiology/Laboratory/CSR/ER
Any of listed requirements as applicable ( as proof of - Billing & Claims
the needed medical services) - Pharmacy
- Charge Slip - (1 copy) MSS
- Statement of Account - (1 copy)
- Order of Payment Slip - (1 copy) - Barangay/DSWD
Medical Social Service Card - DSWD
Any of listed requirements, as applicable ( as proof of - PHIC
indigency/underpriviledge sector) - Office of Senior Citizen’s Affairs
- Certificate of Indigency - (1 copy) - City/Municipal Social Welfare and
- 4P’s ID (1 copy)
- Sponsored MDR/PBEF - (1 copy) Development Office
- Senior Citizen ID - (1 copy) - Rural Health Unit / DOH Regional
- PWD ID - (1 copy)
Office
- BHW ID - (1 copy) - DILG

- Barangay Official ID - (1 copy) Barangay
For Financial (Burial, Transportation, etc.) Assistance: Health Information Mgt System at the
DSWD hospital
Hospital/CHO or MHO
1. Certificate of Indigency - (1 copy)
2. Medical Certificate/Medical Abstract Municipality Social Welfare Office or
medical social worker
3. Proof of needed assistance such as, death
certificate, request of test/procedure,etc. PHIC LHIO
PSA, Local Civil Registar
4. Social case summary report/social case study

For PHIC status inquiry/problems, PHIC data
updating,etc.
Any of the following:
-PHIC ID with PIN or MDR
- Birth Certificate or correct data of member esp.
name & birthdate

CLIENT STEPS AGENCY ACTION FEES PROCESSING PERSON
TO
BE TIME RESPONSIBLE
PAID
1. Presents documentary 1. Provides information of None 3 minutes Designated
staff at the
requirements for the services and requirements

92 | P a g e

services needed and endorses client to the None 3 minutes information
partner agency by providing None 5 minutes counter
2. Accomplishes priority number. None 15 minutes
necessary forms and 2. Advises client to proceed to 4 minutes Designated
waits for the number to the waiting area and waits for staff at the
be called the number to be called 30 minutes information
and/or displayed on the
screen. counter

3. Proceeds to the 3. Receives queuing number. MSW/PHIC
designated counter of Receives review and Cares/DSWD
the partner agency validates documents Social Worker
when called and presented.
presents queuing MSW/PHIC
number. Cares/DSWD
Social Worker
4. Provides accurate and 4. Interviews client, assesses
complete information needs and provides MSW/PHIC
as needed, and signs necessary assistance. Cares/DSWD
necessary documents Social Worker

5. Proceeds to the cashier 5. Advises client where to None
for payment, if proceed. None
applicable, or to the
appropriate service
centers they needed as
advised by the partner
agency or social
worker.

TOTAL

93 | P a g e

13. Availment of X-ray Services for Out-Patient

The Out-Patient X-ray services provides best quality radiographic images and accurate fast diagnostic
reading using the state of the art high end X-ray machines ensuring utmost safety and quality service
to our clients. This service takes in from the presentation of x-ray request form until the result is
release.

Office/Division: Radiology and Imaging Section

Classification: Simple

Type of Transaction: Government-to-Citizen

Who May Avail: All Out-Patients

CHECKLIST OF REQUIREMENTS WHERE TO SECURE
X-ray Request Form – 1 copy (original) Prescribing Doctor

Charge Slip Radiology Clerk

Official Receipt – 1 copy (original) Cashier Section

MSS Approval/ Acknowledgment (if applicable) Medical Social Worker

Claim slip Radiology Clerk

If by an Authorized Representative Any Government issued ID
1 Valid ID photocopy of the authorized representative Any Government issued ID
1 Valid ID photocopy of the patient

Authorization Letter from the patient Patient

CLIENT STEPS AGENCY ACTION FEES TO PROCESSING PERSON

BE PAID TIME RESPONSIBLE

1. Presents x-ray request 1.1 Receives patient’s x-ray None 2 minutes Radiologic clerk

form request form

2.a Receives charge slip 1.2 Checks for completeness None 2 minutes Radiologic clerk
and proceeds to of data and verifies the last None 3 minutes Radiologic clerk
cashier for payment menstrual period (if
female client).

2.a Issues order of payment
and directs to cashier for
payment of charges

*If patient will avail for 2.b Processes availment of None 17 minutes MSS Staff
medical assistance medical assistance Cashier Staff
Please 20 minutes
2.b Proceeds to MSS for 3. Issues official receipt. refer to
Availment of medical approved
assistance schedule
of fees
3. Presents charge slip
and pays corresponding

amount

94 | P a g e

4. Returns to Radiology 4. Receives Official Receipt / None 2 minutes Radiologic clerk
and presents Official Stamped paid charge slip
Receipt / Stamped with OR number / MSS None 32 minutes Radiologic
paid charge slip with Stamped charge slip Technologist
OR Number / MSS
Stamped Charge Slip 5.1 Calls patient for x-ray
procedure and performs
5.1 Waits until name is the requested x-ray
called and submits self procedure
for x-ray procedure

5.2 Acknowledges 5.2 Informs the patient when None 5 minutes Radiologic clerk
schedule of x-ray to return for the official
result result. Issues claim slip
and instructs to bring the
official receipt or claim
stub upon claiming the
result.

5.3 Sends images to PACS None 5 minutes Radiologic
and assigns to the Technologist
Radiologists for
6.1 Returns to releasing interpretation of None 3 days Radiologic clerk
counter on the Radiologist
scheduled release of
result and submits 6.1 Releases x-ray result to
claim slip. the patient.

6.2 Signs the releasing 6.2Let the patient sign the None 2 minutes Radiologic clerk
logbook releasing logbook.

TOTAL (check 3 days, 2
schedule of hours and 28

fee, minutes
compute
accordingly)

95 | P a g e

SERVICES RATE
A. RADIOLOGIC PROCEDURE
CHEST X-RAY 200.00
A. ADULT PA/AP VIEW 200.00
LATERAL VIEW 300.00
B. PEDIA PAL/APL VIEW 200.00
PA/AP VIEW
SKULL X-RAY 400.00
A. ADULT/PEDIA APL VIEW
EXTREMITIES X-RAY 350.00
A. ADULT APL VIEW 300.00
B. PEDIA APL VIEW
THIGH X-RAY 400.00
A. ADULT APL VIEW 300.00
B. PEDIA APL VIEW
ABDOME X-RAY 200.00
ADULT/PEDIA FLAT PLATE VIEW 200.00
UPRIGHT VIEW
THORACOLUMBAR SPINE X-RAY 200.00
AP VIEW 200.00
LATERAL VIEW
LUMBOSACRAL X-RAY 200.00
AP VIEW 200.00
LATERAL VIEW
PELVIC X-RAY 200.00
AP VIEW

B. MAMMOGRAM 1,500.00 WITH PRINT
WITH OUT PRINT OUT
D. C-ARM OUT 800.00
700.00 1,500.00
1. LESS THAN 30 MINUTES 1,000.00
30 MINUTES TO 1 HOUR 700.00
FOR EVERY HOUR BEYOND, AN ADDITIONAL 500.00
OF:

96 | P a g e

14. Conduct of Procedure and Releasing of Result for Out-
Patient (X-ray Special Procedure, Ultrasound and 2D Echo)

Radiology services for Out-Patient provides best quality radiographic images and accurate diagnostic
reading using the state of the art high end imaging machines ensuring utmost safety and quality
service to our clients. This service only includes the following special procedures: 1) X-ray Special
Procedure 2) Ultrasound 3) 2D Echo

Office/Division: Radiology and Imaging Section - OPD

Classification: Complex

Type of Transaction: Government-to-Citizen

Who May Avail: Patients (Out-patient and Walk-In patients)

CHECKLIST OF REQUIREMENTS WHERE TO SECURE

Request for procedure Doctor
Charge Slip Radiology Clerk
Official Receipt for paid procedure Cashier
MSS Approval/ Acknowledgment (if applicable) Medical Social Worker
Contrast Media History and Assessment Form
Pertinent Clearances, if needed Radiology nurse
Complete materials for procedure Requesting doctor
Bowel Preparation Instruction Form, if needed Pharmacy
Claim Slip Radiology clerk

CLIENT STEPS AGENCY ACTION Radiology Clerk PERSON
FEES RESPONSIBLE
1. Returns on the 1. Receives request and stamped
scheduled date of the charge slip and instructs patient TO PROCESSING Radiology clerk
procedure and submits to proceed to designated waiting BE TIME
requirements. area. PAID
None 2 minutes
For Ultrasound & 2D
Echo:

Proceed to step 2

For procedures with 1.1.Instructs patient to go to OPD None 30 minutes Radiologic
contrast: for skin testing of contrast Technologist/
media and gives further None 15 minutes OPD Nurse
1.1 Patient goes to OPD for instruction None 10 minutes
skin testing X-Ray Special Radiologic
1.2.Prepares patient materials for Procedure: Nurse
1.2 Returns to Radiology the procedure 30 minutes
Section Radiologic
2.a.1 Calls patient’s name, checks Technologist/
2.a Waits until name is compliance to pre-procedural
called and submits self and material requirements, 2D Echo
for the procedure. prepares materials and instructs Technologist
patient on what to do.
For Ultrasound & 2D Radiologic
Echo: 2.a.2 Conducts procedure. None Ultrasound: Technologist
30 minutes
Proceed to step 3 97 | P a g e

2D Echo:
60 minutes

For procedures with 2.b Observes patient for post None 1 hour Radiology
contrast: contrast reaction and provides None 2 minutes nurse
post procedural instructions
2.b Receives post- Radiology clerk
procedural instructions 3.Issues claim slip and instructs to
and receives claim slip bring the official receipt or claim None X-Ray Special Radiology clerk
slip upon claiming the result on Procedure: Radiology clerk
3. Receives claim slip specified date 3 days
Ultrasound:
4.1 Returns to releasing 4.1 Releases x-ray special Simple case:
counter on the procedure/ct scan result to the 1 hour
scheduled release of patient. Complicated
result and submits claim case:
slip. 1 day
2D Echo:
5 days

4.2 Signs the releasing 4.2 Let the patient sign the None 2 minutes
logbook releasing Logbook.
X-Ray Special Procedure:
3 days, 3 hours & 5 minutes

TOTAL None Ultrasound:
Simple case:
1 hr & 49 minutes

Complicated case:
1 day & 49 minutes

2D Echo:
5 days & 49 minutes

98 | P a g e

15. Conduct of Procedure and Releasing of Result for Out-
Patient (CT-Scan and Mammogram)

Radiology services for Out-Patient provides best quality radiographic images and accurate diagnostic
reading using the state of the art high end imaging machines ensuring utmost safety and quality
service to our clients. This service only includes the following special procedures: 1) CT-Scan 2)
Mammogram

Office/Division: Radiology and Imaging Section - OPD

Classification: Complex

Type of Transaction: Government-to-Citizen

Who May Avail: Patients (Out-patient and Walk-In patients)

CHECKLIST OF REQUIREMENTS WHERE TO SECURE

Request for procedure Doctor
Charge Slip Radiology Clerk
Official Receipt for paid procedure Cashier
MSS Approval/ Acknowledgment (if applicable) Medical Social Worker
Contrast Media History and Assessment Form
Pertinent Clearances, if needed Radiology nurse
Complete materials for procedure
Bowel Preparation Instruction Form, if needed Requesting doctor
Claim Slip Pharmacy
Radiology clerk

CLIENT STEPS AGENCY ACTION Radiology Clerk PERSON
RESPONSIBLE
1. Returns on the 1. Receives request and stamped FEES
scheduled date of the charge slip and instructs patient TO PROCESSING Radiology clerk
procedure and submits to proceed to designated waiting BE TIME
requirements. area. PAID
None 2 minutes
For Plain procedure &
Mammogram:

Proceed to step 2

For procedures with 1.1.Instructs patient to go to OPD None 30 minutes Radiologic
contrast: for skin testing of contrast None Technologist/
media and gives further None 15 minutes OPD Nurse
1.1 Patient goes to OPD for instruction
skin testing None 10 minutes Radiologic
1.2.Prepares patient materials for Nurse
1.2 Returns to Radiology the CT-Scan:
Section procedure 30 mins Radiologic
Mammogram: Technologist/
2. Waits until name is 2. Calls patient name, checks
called and submits self compliance to pre-procedural 2D Echo
for the procedure. and material requirements, Technologist
prepares materials and instructs
For Plain procedure & patient on what to do. Radiologic
Mammogram: Technologist
2.1. Conducts procedure.
Proceed to step 3 99 | P a g e