Cardio & Pulmo

POLICIES AND PROCEDURES
TITLE: CARDIOLOGY AND PULMONARY

UNIT
Prepared by:
Reviewed by:
DOC NO.
REV. NO.
PAGE
EFFECTIVE DATE
:
:
:
:
Approved by:
CARDIOLOGY AND PULMONARY UNIT

1 PURPOSE
To deliver a modern and high quality medical education, cardiovascular service/
pulmonary service and health promotion that are favorable, productive and
affordable to the needs of all cardio vascular individuals
The aim is to standard method to be followed by the Cardiologist/
Pulmonologist/ therapist in giving procedures/ treatments and tests.
To establish and operate a Heart and Lung Unit where patient of the hospital, inhouse-consultants, and those referred by other (outside) physicians can be
taken cared of as on an outpatient basis servicing heart and lung procedure/.
Treatments.
2
SCOPE
The Heart and Lung Unit will encompass an outpatient clinic for treating
patients scheduled for Electrocardiogram (ECG), 2D-Echocardiography, 24
Holter Monitoring, Ambulatory BP Monitoring, Peripheral Venous and Arterial
Duplex Scan, Arterial Blood Gas Extraction, Spirometry, Inhalation Therapy,
Chest Physiotherapy, etc. that are done in a non-admitted set up.
The areas covered include from Central Registration (for consultation/ receiving
of request of a procedure/ treatment), Cashier (to settle the services/
procedure), Heart and Lung Unit, Cashier (additional charges if any) up to
discharge.
POLICY
It is the policy of the Fe Del Mundo Medical Center (FDMMC) Heart and Lung
Unit to:

UNIT
Prepared by:
Reviewed by:
DOC NO.
REV. NO.
PAGE
EFFECTIVE DATE
:
:
:
:
Approved by:
ADMINISTRATIVE POLICIES
i.
The Heart and Lung Unit can be used by all affiliated physicians, of Fe Del
Mundo Medical Center (FDMMC) provided they are able to comply with all
the requirements of the FDMMC to be submitted to their department and
approved by the respective chairman.
ii.
The chairman of Heart and Lung Unit is an active affiliated cardiologist of

good medical standing and should be appointed by the Medical director
of the FDMMC upon recommendation of the chairman of the Department
of Medicine and he/ she must be a certified Fellow of the Philippine
College of Physicians, Fellow of the Philippine Heart Association/
Philippine College of Cardiology.
iii.
The co-chairman of Heart and Lung Unit is an active affiliated

pulmonologist of good medical standing and should be appointed by the
Medical Director of the FDMMC upon recommendation of the chairman of
the Department of Medicine and must be a certified Fellow of the
Philippine College of Physicians and Fellow of the Philippine Society of
Pulmonary Medicine.
iv.
All regular or non-critically ill patients in the floor/ unit should be seen
within twenty four (24) hours from admission or referral and should make
daily rounds and must put entry to chart every visit.
v.
All Intensive Care Unit (ICU) or emergent cases should be seen within
twelve (12) hours from admission or referral and should make more than
once daily rounds as necessary and must put entry to chart for every
visit.
vi.
All long standing/ status quo patients may be seen in less than once
daily if no new or active medical attention ids needed and only waiting to
be discharged from the hospital due to non-medical reasons or other
hospital policy issues.
vii.
The cardiovascular diagnostic procedures will be officially read only by

affiliated cardiologist and he/ she must be a certified Fellow of the
viii.
The pulmonary diagnostic procedures will be officially read only by

affiliated pulmonologist and he/ she must be a certified fellow of the
Philippine College of Physicians and fellow of the Philippine Society of
Pulmonary Medicine.

UNIT
Prepared by:
Reviewed by:
DOC NO.
REV. NO.
PAGE
EFFECTIVE DATE
:
:
:
:
Approved by:
ix.
The ICU will be supervised by the current chairman and co-chairman of

the Heart and Lung Unit and he/ she must be a certified fellow of
Philippine College of Physicians, Fellow of the Philippine Heart
association/ Philippine College of Cardiology or Fellow of the Philippine
Society of Pulmonary Medicine.
x.
While the cardiac catheterization laboratory/ facility is not available

temporarily in Fe Del Mundo Medical Center, the affiliated interventional
cardiologist and electrophysiologist will be allowed to do the procedures
upon formal letter of request signed by chairman of Internal Medicine in
other three accredited medical centers of the Pinehurst Medical Services,
Incorporation, namely; VRP Medical Center, Medical Center Manila, and
Unihealth Tagaytay Hospital and Medical Center.
xi.
The patients of Cardiac Rehabilitation Center facility when available or if

there will be in-patients for cardiac rehabilitation co-management he/ she
will be supervised only by affiliated cardiac rehabilitation cardiologists or
by choice of requesting physician and he/ she must be a certified Fellow
of the Philippine College of Physicians, Fellow of the Philippine Heart
Association/ Philippine College of Cardiology, and Member or Fellow of
Council on Cardiac rehabilitation Society of the Philippines.
xii.
All affiliated clinicians of the Department of Medicine of Fe Del Mundo

Medical Center are required to attend medical staff meeting every three
(3) months (January-April-July-November) during the 4 th Wednesday of the
scheduled month at 1:30 P.M. to be conducted by Dr. Mariano Lopez, the
Medical Director.
xiii.
An affiliated cardiologist or pulmonologist may be requested to give

lecture pertaining his/ her specialty or expertise and the topic and
schedule of lecture will be announced by the Chairman of the
Department of Medicine at least one month prior to the schedule.
xiv.
An affiliated cardiologist or pulmonologist must attend to at least 50% of

the department meetings, conferences or grand rounds in a year to
maintain good medical standing in the medical center.
xv.
An affiliated cardiologist/ pulmonologists are permitted to give

suggestions or requests either by personal or written statement to be
forwarded to the office of the Department of Medicine for approval by
Head of Heart and lung Unit, Chairman of the Department of Medicine
and the Medical Director for final approval.

UNIT
Prepared by:
Reviewed by:
DOC NO.
REV. NO.
PAGE
EFFECTIVE DATE
:
:
:
:
Approved by:
OPERATIONAL POLICIES
1.
ECG reading will be officially read/ decked on a weekly basis among

affiliated Cardiologists, and he/ she must be a certified Fellow of the
Philippine College of Physicians and Fellow of the Philippine Heart
Association/ Philippine College of Cardiology.
2.
Ambulatory BP monitoring will be officially read/ decked on a weekly basis

among affiliated Cardiologists or by choice of requesting physician and
must be a certified Fellow of the Philippine College of Physicians and Fellow
of the Philippine Heart Association/ Philippine College of Cardiology.
3.
Twenty four (24)-hour Holter monitoring will be officially read/ decked on a

weekly basis among affiliated Cardiologists or by choice of requesting
physician and must be a certified Fellow of the Philippine College of
Physicians and Fellow of the Philippine heart association/ Philippine College
of Cardiology.
4.
Treadmill Exercise Stress test will be supervised and officially read on a

weekly basis among affiliated cardiologists or by choice of requesting
Physician and must be certified Fellow of the Philippine College of
Physicians and a Fellow of the Philippines Heart association/ Philippine
College of Cardiology.
5.
2D-Echocardigraphy with Doppler study will be officially read/ decked on a

weekly basis among affiliated cardiologist or by choice of requesting
physician and must be certified fellow of the Philippine College of
Physicians and Fellow of the Philippine Heart Association/ Philippine College
of Cardiology.
6.
Trans-esophageal echocardiography (TEE), stress echocardiography,

Dobutamine stress echocardiography, Saline contrast study and 3D or 4D
echocardiography with Doppler study will be officially read/ decked on a
weekly basis among affiliated level 111 Echo cardiographers or by choice
of requesting physician and must be a certified Fellow of the Philippine
College of Physicians, fellow of the Philippine Heart Association/ Philippine
College of cardiology fellow of the Philippine Society of Echocardiography.

UNIT
Prepared by:
Reviewed by:
DOC NO.
REV. NO.
PAGE
EFFECTIVE DATE
:
:
:
:
Approved by:
7.
Endothelial function of test, Ankle: Brachial Index (ABI), arterial duplex

scan of upper and lower extremities, venous compression study, venous
mapping, venous duplex scan of both upper and lower extremities, renal
duplex scan, and abdominal duplex scan will be officially read/ decked on a
weekly basis by affiliated vascular cardiologist or by choice or requesting
physician and must be a certified fellow of Philippine College of Physicians,
Fellow of the Philippine Heart Association/ Philippine College of Cardiology
and Fellow of the Philippine Society of Vascular Medicine.
8.
Carotid and vertebral duplex scan and transcranial Doppler study will be
officially read/ decked on a weekly basis by affiliated Vascular Cardiologist,
affiliated Neurologist or by choice of requesting Physician and must be a
Certified Fellow of Philippine College of Physicians, Fellow of the Philippine
Heart Association/ College of Cardiology and Fellow of the Philippine
Society of Vascular Medicine or Fellow of Philippine Neurologic Society.
9.
Stress or pharmacologic nuclear cardiovascular imaging (Thallium or

Sestamibi) will be officially read/ decked among the Nuclear Cardiologist or
Nuclear Medicine Specialists, or by choice of requesting physician and
must be a certified Fellow of Philippine College of Physicians, Fellow of the
Philippine Heart Association/ Philippine College of Cardiology and Fellow of
the Philippine Society of Nuclear Cardiology or Fellow of Philippine Society
of Nuclear Medicine.
10. Cardiac Magnetic Resonance Imaging (MRI) will be officially read by MR

Cardiologist or by choice of the Philippine Heart Association/ Philippine
College of Cardiology and Fellow of the Philippine Society of MRI/ Cardiac
Imaging.
11. Cardiac catheterization or invasive cardiovascular procedures like
pericardiocentesis, hemodialysis access wire or catheter insertion,
temporary pacemaker insertion (TPI), coronary angiogram and angioplasty,
carotid angiogram, inferior vena cava filter insertion, and percutaneous
transmittal commisurotomy, (PTMC), will be performed by affiliated
interventional cardiologist or by choice of requesting physician and must
be a certified Fellow of Philippine College of
12. Physicians, Fellow of the Philippine Heart Association/ Philippine College
Cardiology, and Fellow of the Philippine society of invasive Catheterization.
13. Tilt table testing, electrical cardioversion, electro physiologic study (EPS)
radio frequency ablation (RFA), permanent pacemaker insertion, cardiac
resynchronization therapy (CRT) devise insertion automatic implantable
cardioverter defibrillator, (AICD) devise insertion will be performed by
affiliated electrophysiologists or by choice of requesting physician and
must be a certified Fellow of the Philippine College of Physicians, Fellow of

UNIT
Prepared by:
Reviewed by:
DOC NO.
REV. NO.
PAGE
EFFECTIVE DATE
:
:
:
:
Approved by:
the Philippine Heart Association/ Philippine College cardiology, and Member

or Fellow of Council on Cardiac Pacing and Electrophysiology.
4. MATERIALS/ SUPPLIES
5. RESPONSIBILITY
6. DEFINITION OF TERMS
Electrocardiogram the record produced by electrocardiography; a tracing

representing the Hearts electrical action derived by amplification of the
minutely small electrical impulses ok normally generated by the heart.
Called also ECG and EKG.
Ambulatory BP Monitoring a non-invasive method of obtaining blood

pressure readings over a 24-hour period, whilst the patient is in their own
environment, representing a true reflection of their BP.
Holter Monitoring (24-hour) refers to a 24 hour, continuous test to record

your heart rate and rhythm (using a Holter Monitor). A patient wears the
monitor for 12-48 hours as they go about their normal daily lives, to
determine if the heart is getting enough oxygen or if electrical impulses in
the heart are delayed.
Treadmill Exercise Stress Test is a cardiovascular stress test that uses

treadmill bicycle exercise with electrocardiography and BP monitoring. It is
used most frequently to estimate prognosis and determine functional
capacity to assess the probability and extent of coronary heart disease, and
to assess the effects of therapy.
2-D Echocardiography and Doppler Study a test in which ultrasound is used

to picture out the heart. It is capable of displaying a cross sectional slice of
the beating heart including the chambers, valves and the major blood
vessels. Doppler is a special part of the ultrasound examination that
assess blood flow (direction & velocity). Doppler examination shows the flow
of blood as it makes its way through and out of the heart.
Peripheral Venous Duplex Scan is a test that uses sound waves to image
the blood flow to the veins of the arms or legs. The peripheral veins are

UNIT
Prepared by:
Reviewed by:
DOC NO.
REV. NO.
PAGE
EFFECTIVE DATE
:
:
:
:
Approved by:
examined to check for deep vein thrombosis 9a blood clot in the large veins
of the arms or legs).
Ultrasound Duplex Scanning - can help determine if arterial disease might be

appropriately treated with an endovascular intervention. Also, the location
and severity of arterial narrowing and occlusions can be identified.
7. REFERENCE DOCUMENTS
8. PROCEDURES/ GUIDELINES
o
o
o
o
o
o
o
o
ELECTOCARDIOGRAM (ECG/ EKG)

AMBULATORY MONITORING
24 HOUR
HOLTER MONITORING
TREADMILL EXERCISE STRESS TEST
2D ECHOCARDIOGRAPHY AND DOPPLER STUDY
PERIHERAL ARTERIAL/VENOUS
DUPLEX SCAN
SCHEDULING OF PROCEDURE
Personal or phone scheduling by receiver personnel.

Check/ ask for doctors request for the procedure.
Get patients information.
Schedule the patient.
Explain the preparation of the procedure, if there are any.
Instruct the patient to inform/call the Heart and Lung for re-scheduling
or cancellation of the procedure.
OUT PATIENT CHARGES

Receive and check the request for the procedure.
HMO- ask patient to get a Letter of Approval/ Authorization (LOA) (and any
valid ID) to HMO office.
COMPANY PAYORS - ask for the companys LOA or referral letter including
patients company ID.

UNIT
Prepared by:
Reviewed by:
DOC NO.
REV. NO.
PAGE
EFFECTIVE DATE
:
:
:
:
Approved by:
Fe Del Mundo Medical Center employees for salary deduction- ask patient for
the LOA from the departments payroll or instruct the patient to get LOA.
1. Patients who are entitled for a discount (refer to the discount categories
issued by the accounting: VIPs, or board of directors, etc.
Senior Citizens- ask for senior citizen ID.
Employee discounts- ask for the employee ID. For relatives of
The employees, the employee himself must settle the charges.
2. Instruct the patient to stay at the waiting area and wait for his/her name
to be called if there are patients who came in first.
3. Ask the patient to fill up personal information sheet.
4. Input patients data in the hospital information system and printout
charge slip.
5. Cash basis- give charge slip to the patient or relative and instruct to pay
at the accounting office/ cashier.
6. Discounted procedures are listed on a daily basis for inventory.
VERIFICATION
Verify medical Doctors (MD) written order and patients identification.
Walk-in patients without doctors requests who personally want to undergo a
procedure are accepted provided that they can present a valid ID.
Inform the patient regarding the turnaround time of the result.
ECG result- 3 days
Inform patient that upon the release of the result, anybody can claim it as
long as they bring the official receipt and a valid ID of the patient or the
health card ID, whichever applies.
Proceed with the procedure.
On releasing of the official result, person claiming shall sign on the
department departments copy of the result or logbook, whichever applies.
FORMS
ELECTROCARDIOGRAM (ECG/ EKG)
OUT PATIENT PROCEDURE
1. Introduce self to the patient and explain the procedure thoroughly.
2. Let the patient rest for few minutes and ask to remove metal objects (e.g.
watch, coins, keys, bracelets, belts) for it may interfere with the procedure.
3. Perform hand hygiene.

UNIT
Prepared by:
DOC NO.
REV. NO.
PAGE
:
:
:
EFFECTIVE DATE
Reviewed by:
:
Approved by:
4. Instruct to lie down on bed and expose chest and extremities if needed
(securing patients privacy)
5. Clean patients chest and limbs (may use gel) where the electrodes will be
placed using cotton balls with alcohol for better conduction and clear
tracing.
6. Dispose cotton balls properly.
7. Attach the electrodes on designated areas
8. Instruct patient to relax, not to move nor speak while the procedure is
ongoing.
9. Switch on the machine and start with the procedure.
10.Label the tracing with the complete data (complete name, age, gender,
date, time, and requesting doctor of the patient), while doing the procedure.
11.Remove leads and wipe off the gel from the patients chest or limbs with
tissue paper if needed.
12.Perform hand hygiene.
13.Remind the patient regarding the release of the result. Departments phone
number may be given to the patient for follow up of result.
14.Log the procedure.
15.If the patient needs to pull-out the tracing even without official reading, ask
them to sign in the ECG logbook. The patient can borrow the tracing if
urgently needed by the requesting doctor. Patient can choose to return or
not the tracing for official reading.
16.Prepare ECG tracing for reading by attaching it to an ECG template form.
17.Initial reading is done by MROD if available.
18.Final reading is done by the cardiologist.
19.Results are type written by the tech and tracings are attached at the back
of the official result.
20.Official results are released within 72 hours after the procedure.
21.In claiming of the result, the patient or relative needs to show patients
identification and/or receipt or HMO card if any.

UNIT
Prepared by:
DOC NO.
REV. NO.
PAGE
:
:
:
EFFECTIVE DATE
Reviewed by:
:
Approved by:
22.Patient or relative will then sign the duplicate form of the result (sign at the
logbook).
23.The duplicate will remain at heart station for filing.
IN PATIENT PROCEDURE
1. Nurse on duty (NOD) endorses request to the Heart and Lung unit.
2. Receive the request from the NOD.
3. Stat requests are coordinated thru phone calls from the NOD and are done
as soon as possible.
4. Requests are received at the nurses station after the procedure. Check
hospital information system for posted request.
5. Print charge slip.
6. Verifies MDs written order in patients chart at nurses station.
8. Proceed to patients room for the procedure.
10.Ask to remove metal objects (e.g. watch, coins, keys, bracelets, and belt)
for it may interfere with the procedure.
11.Instruct the patient to lie down on bed (if necessary and expose chest
(securing patients privacy).
12.Clean patients chest and limbs (may use gel) where the electrodes will be
tracing.
13.Dispose cotton balls properly.
14.Attach the electrodes on designated areas.
15.Instruct patient to relax, not to move nor speak while the procedure is
ongoing.
16.Switch on the machine and start with the procedure.

UNIT
Prepared by:
DOC NO.
REV. NO.
PAGE
:
:
:
EFFECTIVE DATE
Reviewed by:
:
Approved by:
date, time, and requesting doctor of the patient),
while doing the
procedure.
19.Inform patient and requesting MD regarding the initial result (if MROD is
available) if urgently needed.
20. Endorse ECG tracing to NOD for referral and initial reading that will be done
by the MROD. (ECG tracings are endorsed back to Heart and Lung unit for
official reading immediately after the requesting physician or cardiologist
has seen it)
21. Final reading will be done by the decked cardiologist for that week.
22. Official result is released within 72 hours after the procedure.
23.Official result with attached tracing is released to the NOD for the chart
filing.
24.NOD will sign duplicate copy/ logbook. Duplicate copy will remain at Heart
and Lung unit.
Duration of the entire ECG routine procedure: 3-5 minutes
Result: 3 working days
ELECTROCARDIOGRAM
1. PURPOSE
To have a documented policy and procedure on the performance of
electrocardiogram examination.
2. SCOPE
This procedure starts from registration of the patient at the central registration,
give charge slips and instruct to pay at the cashier for service fee/ ECG
(electrocardiogram) procedure, Heart Station up to their discharge.

UNIT
Prepared by:
DOC NO.
REV. NO.
PAGE
:
:
:
EFFECTIVE DATE
Reviewed by:
:
Approved by:
The receipt and ECG request of the doctor be given to Heart Station Staff to
render the procedure, result is available for release, and a computer generated
result is filed.
3. POLICY
It is the policy of the Fe Del Mundo Medical Center Heart Station to:
1. Correctly identify patients by their name and date of birth;
2. Receive and check the Medical Doctors written request for the procedure.
3. For HMO- ask patient to get a Letter of Approval/ Authorization (LOA) (and
any valid ID) to HMO office.
4. For COMPANY PAYORS- ask for the companys LOA or referral letter
including patients company ID.
5. For Fe Del Mundo Medical Center employees for salary deduction- ask
patient for the LOA from the departments payroll or instruct the patient to
get LOA.
6. Patients who are entitled for a discount (refer to the discount categories
issued by the accounting: VIPs, or board of directors, etc.
7. For Senior Citizens- ask for senior citizen ID.
8. For Employee discounts- ask for the employee ID. For relatives of
9. The employees, the employee himself must settle the charges.
10.Instruct the patient to stay at the waiting area and wait for his/her name
to be called if there are patients who came in first.
11.Ask the patient to fill up personal information sheet.
12.Input patients data in the hospital information system and printout
charge slip.
13.Cash basis- give charge slip to the patient or relative and instruct to pay
at the accounting office/ cashier.
14.Discounted procedures are listed on a daily basis for inventory.
15.Walk-in patients without doctors requests who personally want to undergo
a procedure are accepted provided that they can present a valid ID.

UNIT
Prepared by:
DOC NO.
REV. NO.
PAGE
EFFECTIVE DATE
Reviewed by:
:
:
:
:
Approved by:
16.Inform the patient regarding the turnaround time of the result.

17.ECG result- 3 days
18.Inform patient that upon the release of the result, anybody can claim it as
long as they bring the official receipt and a valid ID of the patient or the
health card ID, whichever applies.
19.On releasing of the official result, person claiming shall sign on the
department departments copy of the result or logbook, whichever
applies.
20.Issue only one ECG control number per patient;
21.Inform the patient/ relatives of Fe Del Mundo Medical Center Code of
Patients Rights and Responsibilities
22.Respect patients privacy and dignity;
23.Respect patients with special needs;
24.Carry-out doctors order;
25.Assess customer / patient satisfaction;
26.Keep 2 copies (draft and computer generated) of electrocardiogram result;
and
27.Maintain confidentiality of patient and records based on Policies and Rules
and
Regulations on Release of Hospital Records
ECG Machine GE Mac 5500 MC 5500

Cotton Ball
Alcohol
Gel
Tissue paper
Face mask
ECG Paper
ECG Form to paste the ECG tracing
ECG Suction Cup
ECG Leads
5. RESPONSIBILITY

UNIT
Prepared by:
DOC NO.
REV. NO.
PAGE
EFFECTIVE DATE
Reviewed by:
:
:
:
:
Approved by:
Heart Station Technicians are responsible for:

a. Performing the Electrocardiogram as detailed in section 8 procedures
b. Maintaining all patients records in an orderly and organized manner
Heart Station - the section wherein all non-invasive diagnostic

examinations are done.
Central Registration Section - the section wherein the patient needs to be
enlisted into the system before consultation and rendering the
examination.
Cashier the person with whom the patient settles their bills after
registration.
Electrocardiogram a non-invasive examination used to evaluate the
electrical activities of the heart.
Work Instructions on Electrocardiogram
ECG machine GE Mac 5500 MC 5500 User Manual
Guidelines on Electrode Placement for Electrocardiogram, Holter Monitor,
and Treadmill Stress Test
Guidelines on Assessment and Treatment of Patient with Special Needs
Policy and Procedure on Patient Evaluation Report
Policy and Procedure on Patients Rights and Responsibilities
Policies, Rules and Regulations on Release of Hospital Records
8. PROCEDURE
OUT-PATIENT PROCEDURE
2. The Heart Station Technician shall schedule the patients at least a day prior
to the examination.
3. For in-patients, the staff nurse must coordinate with the Heart Station Staff
for the schedule, and must encode the request into the system.
NOTE:
Written consent must be secured.

4. The Heart Station Technician shall turn-on the machine and inspect if ready
and safe to use.
DOC NO.
REV. NO.
PAGE

UNIT
Prepared by:
:
:
:
EFFECTIVE DATE
Reviewed by:
:
Approved by:
5. The Heart Station Technician shall receive doctors request from the patient/
relative/ companion or check the patients chart (for in-patients) if correct
order was given. He/ she shall identify patients by mentioning their name
and date of birth. Refer policy and procedure on Identify Patient Correctly.
6. For
out-
patients,
the
Heart
Station
Technician
shall
request
the
patient/relative/ companion to present the official receipt and system

printout. For in-patients, the Heart Station Technician must make sure that
the requested examination was encoded in the system.
7. The Heart Station Technician shall instruct the patient / relative to fill out
patient information on the ECG report form. For in-patients, the staff nurse
must be the one to fill out the form.
8. The Heart Station Technician shall review the form and check if all the
pertinent data have been properly filled out.
9. For
pre-employment
electrocardiogram
requests,
the
Heart
Station
Technician shall request an identification card from the patient to ensure that
the examination will be performed on the same person, identified in the
form.
10.The Heart Station Technician shall log the date and name of the patient on
the ECG logbook and assign an ECG number. ECG number must be unique
per patient.
11.The Heart Station Technician shall inform the patient or their relatives about
Fe Del Mundo Medical Center Code of Patients Rights and Responsibilities.
12.The Heart Station Technician shall inform the patient about the examination
to be done; refer to Work Instruction for Electrocardiogram.
13.The Heart Station Technician must respect patients privacy and dignity. If
the patient is with special needs, the Heart Station Technician shall place the
patient in a room.
14.Let the patient rest for few minutes and ask to remove metal objects (e.g.
Watch, coins, keys, bracelets, belts) for it may interfere with the procedure.
15.Perform hand hygiene before the procedure.

UNIT
Prepared by:
DOC NO.
REV. NO.
PAGE
EFFECTIVE DATE
Reviewed by:
:
:
:
:
Approved by:
16.The Heart Station Technician shall prepare the patients skin. Clean patients
chest and limbs (may use gel) where the electrodes will be placed using
cotton balls with alcohol for better conduction and clear tracing. Dispose
cotton balls properly. Refer to ECG work instruction.
17.The Heart Station Technician shall properly place the electrodes on patients
chest and limbs and instruct patient to relax, not to move nor speak while
the procedure is ongoing. Refer to Guidelines on Electrode Placement for
Electrocardiogram, Holter Monitor, and Treadmill Stress Test.
18.The Heart Station Technician switch on the ECG machine and start with the
procedure. Refer to Work Instruction for Electrocardiogram or ECG GE MC
5500 User Manual.
20.The Heart Station Technician shall remove the electrodes attached to the
patients when the procedure has been completed. Wipe off the gel from the
patients chest and limbs with tissue paper and dispose tissue paper
properly.
21.The Heart Station Technician shall clean the electrodes used, with cotton and
alcohol.
22.Do handwashing after the procedure
23.Remind the patient regarding the release of the result. Heart Station Unit
phone number may be given to the patient for follow up of result.
24.Log the procedure.
25.Prepare ECG tracing for reading by attaching it to an ECG template form
26.The Resident-on-Duty shall interpret first ECG tracing and the Cardiologist
shall make the final reading/ interpretation.
27.The Heart Station Technician shall correctly encode the interpretation into
the system. And verify accuracy of encoding.
28.The Heart Station Technician shall print three copies of the reviewed final
report. One serves as doctors copy, second is patients copy, and the third
one will be a file copy of the Heart Station.

UNIT
Prepared by:
DOC NO.
REV. NO.
PAGE
:
:
:
EFFECTIVE DATE
Reviewed by:
:
Approved by:
29.The Heart Station Technician shall issue the final report to requesting parties.
30.If the patient needs to pull-out the tracing even without official reading, ask
them to sign in the ECG logbook. The patient can borrow the tracing if
urgently needed by the requesting doctor. Patient can choose to return or
not the tracing for official reading.
31.Official results are released within 72 hours after the procedure.
32.in claiming of the result, the patient or relative needs to show patients
33.Identification and/ or receipt or HMO card if any.
34.Patient or relative will then sign the duplicate form of the result (sign at the
logbook). The duplicate will remain at heart station for filing.
35.The Heart Station Technician shall file the draft and the computer generated
report numerically and shall always maintain confidentiality of patients
records.
36.The Heart Station Technician shall file the draft and the computer generated
report numerically and shall always maintain confidentiality of patients
record.
37.The Heart Station Technician shall give patient evaluation form (for outpatients only) to patient/ relative/ companion to evaluate their
performance.
38.
IN-PATIENT PROCEDURE
1. Nurse-on-duty endorses request to the Heart and Lung unit.
2. Receive the request from the Nurse-on-duty.
3. Stat requests are coordinated thru phone calls from the Nurse-on-duty and
are done as soon as possible. Requests are received at the nurses station
after the procedure.
4. Check hospital information system for posted request.
5. Print charge slip.
6. Verifies MDs written order in patients chart at nurses station.

UNIT
Prepared by:
DOC NO.
REV. NO.
PAGE
:
:
:
EFFECTIVE DATE
Reviewed by:
:
Approved by:

10.Ask to remove metal objects (e.g. watch, coins, keys, bracelets, and belt) for
it may interfere with the procedure.
11.Instruct the patient to lie down on bed (if necessary and expose chest
(securing patients privacy)
12.Clean patients chest and limbs (may use gel) where the electrodes will be
tracing.
13.Dispose cotton balls properly.
15.Instruct patient to relax, not to move nor speak while the procedure is
ongoing.
16.Switch on the machine and start with the procedure.
19.Inform patient and requesting MD regarding the initial result (if MROD is
available) if urgently needed.
20.Endorse ECG tracing to NOD for referral and initial reading that will be done
by the MROD. (ECG tracings are endorsed back to Heart and Lung unit for
official reading immediately after the requesting physician or cardiologist
has seen it)
21.Final reading will be done by the decked cardiologist for that week.
22.Official result is released within 72 hours after the procedure.
23.Official result with attached tracing is released to the Nurse-on-duty for the
chart filing. NOD will sign duplicate copy/ logbook. Duplicate copy will remain
at Heart and Lung Unit.
Duration of the entire ECG routine procedure: 3-5 minutes

UNIT
Prepared by:
Reviewed by:
DOC NO.
REV. NO.
PAGE
:
:
:
EFFECTIVE DATE
:
Approved by:

8 FORMS
ECG Report Form
ECG Mounting Card
Out Patient Evaluation Form
AMBULATORY BP MONITORING
1. PURPOSE
To have a documented policy and procedure on the performance of Ambulatory
BP Monitoring.
2.
SCOPE
This procedure starts from registration of the patient at the Central Registration,
give charge slips and instruct to pay at the Cashier for service fee/ Ambulatory
Blood Pressure (ABP) Monitoring procedure, Heart Station up to their discharge.
The official receipt is to be given to the Heart and Lung Unit Staff to render the
procedure.
3.
POLICY
It is the policy of the Fe Del Mundo Medical Center Heart and Lung Unit to:
3.1.
Correctly identify patients by their name and date of birth;

UNIT
Prepared by:
3.2.
DOC NO.
REV. NO.
PAGE
EFFECTIVE DATE
Reviewed by:
:
:
:
:
Approved by:
Receive and check the Medical Doctors written request for the
procedure.
3.3
For HMO- ask patient to get a Letter of Approval/ Authorization (LOA)
(and any valid ID)

3.4.
to HMO office.
For COMPANY PAYORS- ask for the companys LOA or referral letter
including
patients company ID.
3.5.
For Fe Del Mundo Medical Center employees for salary deduction- ask
patient
for the LOA from the departments payroll or
instruct the patient to get LOA

3.6.
Patients who are entitled for a discount (refer to the discount
categories issued
by the accounting: VIPs, or board of
directors, etc.
3.7.
For Senior Citizens- ask for senior citizen ID.
3.8.
For Employee discounts- ask for the employee ID. For relatives of the
employees, the
3.9.
employee himself must settle the charges.
Instruct the patient to stay at the waiting area and wait for his/her
name to be called if
there are patients who came in first.
3.10
Ask the patient to fill up personal information sheet.
3.11
Input patients data in the hospital information system and printout
charge slip.
3.12
Discounted procedures are listed on a daily basis for inventory.
3.13
Walk-in patients without doctors requests who personally want to
undergo a
procedure are accepted provided that they
can present a valid ID.

3.14
Inform the patient regarding the turnaround time of the result.

3.15 Inform patient that upon the release of the result, anybody can claim
it as
long as they
bring the official receipt and a valid ID of the
patient or the health card ID, whichever
applies.
3.16 On releasing of the official result, person claiming shall sign on the
department departments copy of the result or logbook, whichever applies.

UNIT
Prepared by:
DOC NO.
REV. NO.
PAGE
EFFECTIVE DATE
Reviewed by:
3.17
:
:
:
:
Approved by:
Issue only one Ambulatory BP Monitoring control number per patient;
3.18 Inform the patient/ relatives of Fe Del Mundo Medical Center Code of
Patients Rights
and Responsibilities;
3.19
Respect patients privacy and dignity;
3.20
Respect patients with special needs;
3.21
Carry-out doctors order;
3.22
Assess customer / patient satisfaction;
3.23
Keep 2 copies (draft and computer generated) of electrocardiogram
result; and
3.25
Maintain confidentiality of patient and records based on Policies and
Rules and
4.
Regulations on Release of Hospital Records
MATERIALS/ SUPPLIES
Ambulatory BP device
Cotton Ball
Alcohol
Gel (if needed)
Tissue paper
Ambulatory BP
5.
RESPONSIBILITY
Heart Station Technicians are responsible for:
a. Performing the Ambulatory BP Monitoring as detailed in section 8
procedures

examination.

UNIT
Prepared by:
7.
DOC NO.
REV. NO.
PAGE
EFFECTIVE DATE
Reviewed by:
:
:
:
:
Approved by:
registration.
Ambulatory BP Monitoring a non-invasive method of obtaining blood
pressure readings over a 24-hour period, whilst the patient is in their own
environment, representing a true reflection of their BP.
REFERENCE DOCUMENTS
Work Instructions on Ambulatory PB Monitoring

Ambulatory BP Monitoring device User Manual
Guidelines on BP Placement for Ambulatory BP Monitoring
8. PROCEDURE
8.1.1 Introduce self to the patient and explain the procedure thoroughly.
8.1.2 Let the patient sit down and put one arm on table.
8.1.3
Position the ABP on patients arm.
8.1.4 Switch on the machine and set to the desire frequency of monitoring
as
indicated in the ABP gadget.

8.1.5 Remind the patient regarding the release of the result. Departments
phone number may be given to the patient for
follow up of result.
8.1.6 Log the procedure.
8.1.7 If the patient needs to pull-out the tracing even without official
reading,
ask them to sign
in the ABP Monitoring logbook. The patient
can borrow the tracing if urgently needed by
the requesting physician.
Patient can choose to return or not the tracing for official

8.1.8 Prepare ABP monitoring papers for official reading.
reading.

UNIT
Prepared by:
DOC NO.
REV. NO.
PAGE
:
:
:
EFFECTIVE DATE
Reviewed by:
:
Approved by:
8.1.9 Initial reading will be done by MROD if there is any.

8.1.10Final reading will be done by the assigned/decked cardiologist for the
week.
8.1.11Results are to be typed written by the ABP technician and BP records
are attached at the back of the official result.
8.1.12Official results are released within 72 hours after the procedure.
8.1.13In claiming of the result, the patient or relative needs to show
patients
identification and/or receipt or HMO
card if any.
8.1.14Patient or relative will then sign the duplicate form of the result (sign
at
the logbook). The duplicate will remain at the
Heart and Lung Unit for
filing.
8.2.1 Nurse on duty (NOD) endorses request to the heart station.
8.2.2 Receive the request from the NOD.
8.2.3 Stat requests are coordinated thru phone calls from the NOD and are
done as soon as
possible. Requests are received at the nurses
station after the procedure.

8.2.4 Check hospital information system for posted request.
8.2.5 Print charge slip.
8.2.6 Verifies MDs written order in patients chart at nurses station.
8.2.7 Perform hand hygiene.
8.2.8 Proceed to patients room for the procedure.
8.2.9 Introduce self to the patient and explain the procedure thoroughly.
8.2.10Instruct the patient to sit up/get up from bed and expose one arm.
Patient may need not to get up from the bed if
clinical condition cannot
permit him/her to do so.
8.2.11Attach the ABP gadget on designated arm and switch on the machine
and start BP
recording.

UNIT
Prepared by:
DOC NO.
REV. NO.
PAGE
:
:
:
EFFECTIVE DATE
Reviewed by:
:
Approved by:
8.2.12Label the ABP form with the complete data (complete name, age,
gender, date, time and
name of requesting physician), after turning on the
gadget.
8.2.13Inform
patient
regarding
physician/cardiologist will
the
result
(MROD
or
attending
explain)
8.2.14
Final reading will be done by the assigned/ decked cardiologist.
8.2.15
Official result is released within 72 hours after the procedure.
8.2.16Official result with attached tracing is released to the Nurse-on-duty

for chart
filing. Nurse-on-duty will sign the duplicate copy/
logbook. Duplicate copy will
remain at Heart and Lung Unit
for filing.
Duration of the entire ABP monitoring procedure: 24 hours
9. FORMS
24 HOUR HOLTER MONITORING

a. Receive and check on the request for Holter monitoring (Verify MDs
written order and patients identification)

UNIT
Prepared by:
DOC NO.
REV. NO.
PAGE
:
:
:
EFFECTIVE DATE
Reviewed by:
:
Approved by:
b. Tell patient to fill up personal information sheet.

c. Input patients data in hospital information system.
d. Mode of payment:
Cash basis- print charge slip and asks the patient to pay at the
accounting office/
cashier.
HMO card holders- asks the patient for letter of approval from
HMO office
e. Let patient rest for few minutes.

f.
Introduce self to the patient and explain the procedure thoroughly.
g. Duration of the entire Holter monitoring routine procedure: 24 hours

for the holter monitoring and 5-15 minutes for hooking and removing
of Holter machine.
h. Hook Holter Monitoring record to the patient.
i.
Input patients information in the recorder.
j.
Instruct the patient to sit or lie down on bed and expose chest
(securing privacy)
k. Clean patients chest where the electrodes will be put, using cotton
balls with alcohol.
l.
Attach the electrodes on designated areas and properly secure with

sterile micropore.
m. Attach the electrodes cable to the recorder and check for the
connection and ECG tracing.
n. Instruct the patient not to take a bath and to avoid scratching the
areas where the electrodes are attached so as to avoid damaging of
the recorder and acquiring poor ECG tracings.
o. Instruct the patient about what to put on the diary and when to press
the recorder.
p. Instruct the patient to return on the same time of the following day
for removal of the recorder.

UNIT
Prepared by:
DOC NO.
REV. NO.
PAGE
:
:
:
EFFECTIVE DATE
Reviewed by:
:
Approved by:
q. On the next day, remove the Holter Monitoring recorder off the
patient.
r.
Check if the recorder has stopped, or wait until the end of the 24
hour period.
s. Transfer the content of the recorder to the computer scanner.

t. Enter patients information and edit the acquired ECG tracings.
u. Prepare the edited tracings for final reading done by the cardiologist.
v. Official result will be released within 72 hours after the procedure.
w. In claiming of result, the patient or relative needs to show
identification and/ or receipt of payment.
x. Patient or relative will sign the duplicate form of the result. The
duplicate will remain at heart station for filing.
1. Receive and check on the request from NOD.
2. Check hospital information system for posted request and charging.
3. Verify MDs written order in patients chart at nurses station.
7. Duration of the entire Holter monitoring routine procedure: 24 hours
for the holter monitoring and 5-15 minutes for hooking and removing
of Holter machine.
8. Hook Holter Monitoring record to the patient.
9. Input patients information in the recorder.
10.Instruct the patient to sit or lie down on bed and expose chest
(securing privacy)
11.Clean patients chest where the electrodes will be put, using cotton
balls with alcohol.
12.Attach the electrodes on designated areas and properly secure with
sterile micropore.

UNIT
Prepared by:
DOC NO.
REV. NO.
PAGE
:
:
:
EFFECTIVE DATE
Reviewed by:
:
Approved by:
13.Attach the electrodes cable to the recorder and check for the
connection and ECG tracing.
14.Instruct the patient not to take a bath and to avoid scratching the
areas where the electrodes are attached so as to avoid damaging of
the recorder and acquiring poor ECG tracings.
15. Instruct the patient about what to put on the diary and when to
press the recorder.
16. Remove the Holter Monitoring recorder off the patient.
17. Check if the recorder has stopped, or wait until the end of the 24
hour period.
18. Transfer the content of the recorder to the computer scanner.
19. Enter patients information and edit the acquired ECG tracings.
20. Prepare the edited tracings for final reading done by the
cardiologist.
21. Official result will be released within 72 hours after the procedure.
22. Official result will be given to the NOD for chart filing. Duplicate
copy will remain at Heart and Lung Unit for filing.
Done on the first come, first served basis for out-patient by
personal or phone call appointment.
For in-patient, once the department receives the request from the
designated floors and charges are made, the Holter technician goes
to patients bedside to hook the Holter recorder and comes back the
next day to remove the Holter machine.
Result: 3 working days.

UNIT
Prepared by:
DOC NO.
REV. NO.
PAGE
EFFECTIVE DATE
Reviewed by:
:
:
:
:
Approved by:

1. Require consent from the attending physician/cardiologist and an
accompanying relative to be present on the day of the procedure as
witness.
2. Receive and check on the request for TET (verify MDs written order
and patients identification)
3. Instruct patient to fill up personal information sheet.
4. Input patients data in hospital information system.
5. Mode of payment:
Cash basis- print charge slip and asks the patient to pay at the
accounting office/ cashier.
HMO card holders- asks the patient for letter of approval from
HMO office
6. Let patient rest for few minutes.
7. Inform MROD (Patient assessment)
9. Secure patients consent by signing on the consent form.
11.Input patients data on cardiac monitor.

UNIT
Prepared by:
DOC NO.
REV. NO.
PAGE
:
:
:
EFFECTIVE DATE
Reviewed by:
:
Approved by:
12.Instruct the patient to remove all metals from pockets, jewels, watch,
belt or any materials that
can lead to poor ECG tracing.
13.Instruct patient to change for proper attire (offer gown)

14.Hook patient to TET cardiac monitor.
15.Clean patients chest where the electrodes will be placed, using cotton
balls with alcohol.
16.Attach the electrodes to designated areas.
17.Put the BP apparatus on patients arm and record baseline BP (sitting
and standing)
18.Instruct the patient to sit down and watch while the technologist
demonstrates what the patient will do.
19.Ask the patient if there are any questions regarding the procedure, if
none, continue with the test.
20.On each stage, acquire BP of the patient and update the patient for
change of speed/ inclination.
21.Update
on
patients
status,
if
the
patient
feels
anything
unusual/abnormal.
22.MROD or monitoring cardiologist can stop the test if he/she sees
anything abnormal on the ECG tracing.
23.The patient can stop the procedure if he/she feels anything unusual.
24.Assist the patient during recovery. Until termination of the procedure,
still monitoring the vital signs.
25.Ask the patient to sit down and rest for a while until his/her heart rate
and BP reached the pre
stress test vital signs.
26.Initial reading will be done by the MROD.

27.Prepare the treadmill tracing for the official reading/result.
28.Final reading will be done by the assigned/decked cardiologist for that
week.
29.Official result will be released within 72 hours after the procedure.
30.In claiming of the result, the patient or relative needs to show
identification and/ or receipt of payment.

UNIT
Prepared by:
DOC NO.
REV. NO.
PAGE
:
:
:
EFFECTIVE DATE
Reviewed by:
:
Approved by:
31.Patient or relative will then sign the duplicate form of the result. The
duplicate will remain at Heart and Lung unit for filing.
1. Receive and check on the request from the NOD.
3. Verify MDs order in patients chart at nurses station.
4. Nurse on duty brings the patient accompanied by at least one
relative as witness via wheelchair.
5. Inform MROD or assigned/decked cardiologist once patient arrives at
Heart and Lung unit.
6. Introduce self to the patient and explain the procedure.
8. Input patients data on cardiac monitor.
9. Instruct the patient to remove all metals from pocket, jewels, watch,
belt or any materials that can lead to poor ECG tracing.
10.Offer gown to the patient and assist in changing.
11.Hook patient to TET cardiac monitor.
12.Clean patients chest where the electrodes will be placed, using
cotton balls with alcohol.
13.Attach the electrodes to designated areas.
14.Put the BP apparatus on patients arm and record baseline BP (sitting
and standing)
15.Tell the patient to sit down and watch while the technologist
demonstrates what the patient will
do.
16.Ask the patient if there are any questions regarding the procedure, if
none, continue with the test.
17.On each stage, acquire BP of the patient and update the patient for
change of speed/ inclination.

UNIT
Prepared by:
DOC NO.
REV. NO.
PAGE
:
:
:
EFFECTIVE DATE
Reviewed by:
:
Approved by:
18.Update on patients status, if the patient feels anything unusual/

abnormal.
19.MROD or monitoring cardiologist can stop the test if he/she sees
anything abnormal on the ECG tracing.
20.The patient can stop the procedure if he/she feels anything unusual.
21.Assist the patient during recovery. Until termination of the procedure,
still monitoring the vital signs.
22.Ask the patient to sit down and rest for a while until his/her heart rate
and BP reached the pre stress test vital signs.
23.Remove all electrodes, BP cuff and tell the patient to change his/her
own clothes or ward gown.
24.Initial reading will be done by MROD or assigned/decked cardiologist.
25.Prepare the treadmill tracing for the official reading/result.
26.Final reading will be done by the cardiologist assigned for that week.
28.Official result will be given to NOD for chart filing. Duplicate copy will
remain at Heart station for filing.
Done on first come, first served basis for out-patient by personal
or phone call appointment.
For in-patients, once the department receives the request from
the designated floors and charges are made, the nurse on duty
brings the patient to the Heart and Lung Unit via wheelchair.
Requires patients consent.
A medical resident or attending/decked cardiologist is always
present during the procedure.
Duration of the entire Treadmill Exercise Test routine procedure:
30-60 minutes.

UNIT
Prepared by:
DOC NO.
REV. NO.
PAGE
:
:
:
EFFECTIVE DATE
Reviewed by:
:
Approved by:
ECHOCARDIOGRAPHY AND DOPPLER STUDY

1. Receive and check on the request for 2D-Echo plain study or with
Doppler study (Verify MDs written order and patients identification).
2. Tells patient to fill up personal information sheet.
3. Inputs patients data in hospital information system.
4. Mode of payment:
CASH basis print charge slip and asks the patient to pay at
the accounting office/cashier.
HMO card holders Asks the patient for letter of approval from
HMO office.
5. Let patient rest for few minutes.

8. Tell patient to remove all metals from pocket, jewels, watch, belt or
any material that can lead to poor ECG tracing.

UNIT
Prepared by:
DOC NO.
REV. NO.
PAGE
:
:
:
EFFECTIVE DATE
Reviewed by:
:
Approved by:
9. Instruct the patient to lie down on bed and expose chest (securing
patients privacy).
11.Instruct to relax, and not to make unnecessary movements while the
procedure is ongoing.
12.Input patients data in the machine and assist on proper positions.
13.Start the procedure.
14.Wipe off gel from chest and remove ECG electrodes.
15.Fill up 2D-Echo form and DVD for official reading.
16.Label DVD.
18.Prepare the 2D-Echo form and DVD for official reading.
19.Official
reading
will
be
done
by
an
assigned/decker
echo
cardiographer.
identification and/or receipt.
duplicate will remain at Heart and Lung Unit for
filing.
3. Verifies MDs order in patients chart at nurses station.
4. Nurse on duty or nursing assistant brings the patient here in the
Heart and Lung Unit via wheelchair or stretcher.
5. Introduce self to the patient and explains the procedure thoroughly.
7. Instruct the patient to lie down on bed.

UNIT
Prepared by:
DOC NO.
REV. NO.
PAGE
EFFECTIVE DATE
Reviewed by:
:
:
:
:
Approved by:
8. Instruct to relax and not to talk nor make unnecessary movements

while the procedure is ongoing.
9. Input patients data in the machine and assist in proper position.
11.Wipe off gel and remove the ECG electrodes after the procedure.
12.Fill up 2D-Echo form with measurements acquired from the machine.
13.Label DVD.
14.Prepare the carotid duplex scan form and DVD for official reading.
15.Official reading will be done by assigned/decked echo cardiographer.
17.Official result will be given to the NOD for chart filing. Duplicate copy
will remain at Heart and Lung Unit for filing.
Done on a first come, first served basis for out-patient personal or

phone call appointment.
Scheduled out patients will be prioritized except when there is an
emergency in-patient request.
For in-patients, once the department receives the request from
the designated floors and charges are made, technologist calls the
nurse on duty to bring the patient to the Heart and Lung Unit via
wheelchair/stretcher.
Beside request are allowed for ER and ICU patients unwilling to be
brought to Heart and Lung Unit but explain that charges will be
higher or same as in ICU procedural rate.
Procedure is recorded on a DVD for the official reading.
Duration of the entire 2D-Echo routine procedure: 30-45 minutes.

UNIT
Prepared by:
Reviewed by:
DOC NO.
REV. NO.
PAGE
EFFECTIVE DATE
:
:
:
:
Approved by:
PERIPHERAL VENOUS DUPLEX SCAN

1. PURPOSE
To have a documented policy and procedure on the performance of Peripheral
Venous Duplex Scan examination.
2. SCOPE
This procedure starts from registration at the Central Registration to register at
the bizbox, charging the service fee and Peripheral Venous Duplex Scan
procedure, Cashier for payment, Heart and Lung Unit for the procedure up to
their discharge.
The official receipt be given to Heart and Lung Unit Staff to render the
Peripheral Venous Duplex Scan request, result is available for release, and
computer generated result is filed.
3. POLICY
a. Done by appointment.

UNIT
Prepared by:
Reviewed by:
DOC NO.
REV. NO.
PAGE
EFFECTIVE DATE
:
:
:
:
Approved by:
b. Scheduled out patients will be prioritized except when there is an

emergency in-patient request.
c. For in-patients, once the department receives the request from the
designated floors and charges are made, the NOD brings the patient here
in the Heart and Lung Unit via wheelchair or stretcher.
d. Bedside request are only allowed for ER or ICU patients and private/semiprivate/ward unit patient unable to or unwilling to be brought to Heart and
Lung Unit medical reason or privacy but to aware/explain to patient the
same procedural rate similar to special unit charge.
e. Procedure is recorded on a DVD for the official reading.
f. Duration of the entire Peripheral Venous Duplex Scan routine procedure: 90120 minutes.
g. Result: 3-5 working days.
Peripheral Duplex Scan

DVD
Ultrasonic gel
Tissue paper
Clean gloves
5. RESPONSIBILITY
Heart and Lung Unit Staff are responsible for:
a. Performing the Ambulatory Peripheral Venous Duplex Scan detailed in
section 8 procedures

examination.
registration.

UNIT
Prepared by:
DOC NO.
REV. NO.
PAGE
:
:
:
EFFECTIVE DATE
Reviewed by:
:
Approved by:

Peripheral Venous Duplex Scan is a test that uses sound waves to image
the blood flow to the veins of the arms or legs. The peripheral veins are
examined to check for deep vein thrombosis 9a blood clot in the large
veins of the arms or legs).
Work Instructions on Peripheral Duplex Scan device User Manual
8. PROCEDURES
1. Receive and check on the request for Peripheral Venous Duplex Scan
(Verify MDs written order and patients identification).
2. Tells patient to fill up personal information sheet.
3. Inputs patients data in hospital information system.
4. Mode of payment:
CASH basis print charge slip and asks the patient to pay at the
accounting office/cashier.
HMO card holders ask the patient for letter of approval from HMO
office.
5. Let the patient rest for few minutes.

6. Introduce
yourself
to
the
patient
and
explain
the
procedure
thoroughly.
8. Instruct the patient to lie down on bed and remove lower garments
except underwear.
9. Cover the extremities with blanket and expose only the area needed
during the procedure.

UNIT
Prepared by:
DOC NO.
REV. NO.
PAGE
EFFECTIVE DATE
Reviewed by:
:
:
:
:
Approved by:
10.Tell patient to relax and not to make unnecessary movements while

the procedure is ongoing.
11.Inform the patient regarding the need to do compressions.
12.Input patients data in the machine and assist in proper position.
14.Wipe off the gel.
15.Fill up Peripheral Venous Duplex Scan form.
16.Label DVD.
17.Prepare the Peripheral Venous Duplex Scan form and DVD for official
reading.
18.Official reading will be done by assigned/decked Vascular cardiologist
on that week.
19.Official result will be released within 3-5 days after the procedure.
identification and/or receipt.
duplicate will remain at Heart and Lung Unit for filing.
3. Verifies MDs order in patients chart at nurses station.
4. Nurse on duty/nursing assistant brings the patient in the Heart and
Lung Unit via wheelchair or
room bed
5. Introduce yourself to the patient and explains the procedure

thoroughly.
8. Instruct the patient to relax and not to talk nor make unnecessary
movements while the procedure is ongoing.
9. Input the patients data in the machine and assist in proper position.
10.
Start the procedure.

UNIT
Prepared by:
Reviewed by:
DOC NO.
REV. NO.
PAGE
EFFECTIVE DATE
:
:
:
:
Approved by:
11.
Wipe off the gel.
12.
Fill up the Peripheral Venous Duplex Scan with measurements
acquired from the machine.

13.
Label DVD.
14.
Prepare the Peripheral Venous Duplex Scan form and DVD for
official reading.
15.
Official reading will be done by assigned/decked vascular
cardiologist.
16.
Official result will be released within 3-5 days after the
procedure.
17.
Official result will be given to the NOD for chart filing. Duplicate
copy will remain at the Heart
and Lung Unit for filing.
9. FORMS
PERIPHERAL ARTERIAL DUPLEX

UNIT
Prepared by:
1.
DOC NO.
REV. NO.
PAGE
EFFECTIVE DATE
Reviewed by:
:
:
:
:
Approved by:
PURPOSE
To have a documented policy and procedure on the performance of Peripheral
Arterial Duplex Scan examination.
2. SCOPE
This procedure starts from registration at the Central Registration to register at
the bizbox, charging the service fee and Peripheral Arterial Duplex Scan
procedure, Cashier for payment, Heart and Lung Unit for the procedure up to
their discharge.
The official receipt be given to Heart and Lung Unit Staff to render the
Peripheral Venous Duplex Scan request, result is available for release, and
computer generated result is filed.
3. POLICY
1. Done by appointment.
2.
Scheduled out patients will be prioritized except when there

is an emergency in-patient request.
3.
For in-patients, once the department receives the request

from designated floors and charges are made, the Nurse-on-duty or
nursing assistant brings the patient in the Heart and Lung Unit via
wheelchair/ stretcher.
4.
Bedside request are only allowed for ER or ICU patients and

private/ semi-private/ ward unit if patient is unable to or unwilling to be
brought to Heart and Lung Unit for medical reason or privacy but to
aware/ explain to patient the same procedural rate similar to special unit
charge.
5.
Procedure is recorded on a DVD for the official reading.
6.
Duration of the entire Peripheral arterial Duplex Scan routine

procedure: 90-120 minutes
7.
Result; 3-5 working days

UNIT
Prepared by:
DOC NO.
REV. NO.
PAGE
EFFECTIVE DATE
Reviewed by:
:
:
:
:
Approved by:
Peripheral Duplex Scan

DVD
Ultrasonic gel
Tissue paper
Clean Gloves
Face mask (if needed)
5. RESPONSIBILITY
Heart and Lung Unit Staff are responsible for:
a. Performing the Ambulatory Peripheral Venous Duplex Scan detailed in
section 8 procedures
7.
8.

examination.
registration.
Ultrasound Duplex Scanning - can help determine if arterial disease might
be appropriately treated with an endovascular intervention. Also, the
location and severity of arterial narrowing and occlusions can be
identified.
REFERENCE DOCUMENTS
PROCEDURES
1. Receives and checks on the request for Peripheral arterial Duplex Scan
(Verify MDs written order and patients identification)
2. Instructs patient to fill up personal information sheet

UNIT
Prepared by:
DOC NO.
REV. NO.
PAGE
:
:
:
EFFECTIVE DATE
Reviewed by:
:
Approved by:
3. Inputs patients data in hospital information system

4. Mode of Payment
Cash basis print charge slip and asks the patient to pay at the cashier
5. Let patient rest for few minutes

6. Introduce self to the patient and explain the procedure thoroughly
7. Perform hand hygiene
8. Duration of the entire Peripheral Arterial Duplex Scan routine procedure:
90-120 minutes
9. Instructs the patient to lie down on bed and remove lower garments
except underwear
10.Cover the extremities with blanket and expose only the area needed
during the procedure
11.Instructs the patient to relax and not to make unnecessary movements
while the procedure is ongoing
12.Informs patient regarding the need to do compression
13.Inputs patient data in the machine and assists in proper position
14.Start the procedure
15.Wipe off gel
16.Fill up Peripheral Arterial Duplex Scan form
17.Label DVD
18.Prepare the Peripheral Arterial Duplex Scan form and DVD for official
reading
19.Official reading will be done by assigned/ decked vascular cardiologist
20.Official result will be released with 3-5 days after the procedure
21.In claiming of result, the patient or relative needs to show identification
or receipt
22.
Patient or relative will then sign the duplicate form of the result. The
duplicate will remain at Heart and Lung Unit for filing.


UNIT
Prepared by:
DOC NO.
REV. NO.
PAGE
:
:
:
EFFECTIVE DATE
Reviewed by:
:
Approved by:
1. Receives and checks on the request from the Nurse-on-duty.

2. Checks hospital information system for posted request and charging.
3. Verifies doctors order in patients chart at nurses station.
4. Nurse-on-duty or nursing assistant brings the patient in the Heart and
Lung Unit via wheelchair or stretcher.
5. Introduce self to the patient and explains the procedure thoroughly.
6. Performs hand hygiene.
8. Instruct the patient to relax, and not to talk nor make unnecessary
movements while the procedure is ongoing.
9. Input patients data in the machine and assist in proper position.
11.Wipe off gel
12.Fill up Peripheral Arterial Duplex Scan with measurements acquired from
the machine
13.Label DVD
14.Prepare the Peripheral Arterial Duplex Scan form and DVD for official
reading
15.Official reading will be done by assigned/ decked vascular cardiologist
16.Official result will be released with 3-5 days after the procedure
17.Official result will be given to the Nurse-on-duty for chart filing. Duplicate
copy will remain at Heart and Lung Unit for filing.
9. FORMS

UNIT
Prepared by:
Reviewed by:
DOC NO.
REV. NO.
PAGE
EFFECTIVE DATE
:
:
:
:
Approved by:
CARDIOLOGY-PULMONARY STAFF
SECTION HEAD
Professional Preparation
i. Must be licensed physician of the Philippines under RA 1080
( with current PRC medical doctor license).
ii. Should be a diplomate/ fellow of the Specialty and
Subspecialty Society of good standing.
iii. Should be a member of the accredited specialist Philippine
health insurance.
Responsibilities
1. Performs quality patient care.
2. Has authority to execute hospital and section policies and
guidelines.
3. Maintains the hospital standards and quality.
4. Coordinate with all the visiting and active consultant.
5. Exercise administrative and operational duties.
6. Make the over-all administrative decisions and planning.
7. Supervise all the cardiology staff and consultants.
8. Attend and participate in the clinical heads and meeting
activities.
9. Coordinate with the all staff concern and suggestions for the
benefit of the cardiology unit.
ACTIVE CONSULTANT
1.
Must be a licensed physician of the Philippines under RA 1080 (with current

PRC license medical doctor license.

UNIT
Prepared by:
2.
3.
4.
Reviewed by:
DOC NO.
REV. NO.
PAGE
EFFECTIVE DATE
:
:
:
:
Approved by:
Should be a diplomate/ fellow of the Specialty and Subspecialty Society of

good standing.
Should be a member of the accredited specialist Philippine health insurance
Be recommended favorably by the section, Department and Hospital
Credentials Committee
Responsibilities
1. Should use the available ancillary hospital services.
2. Should attend 80% of the Section and Department services.
3. Be willing to teach or educate the cardiology staff
4. Able to attend and be a resource speaker or reactor in any
hospital
conference once he was invited.
5. Willing to rotate as Cardio consultant of the month as
attending
physician of the service patients.
6. An active consultant who fails to meet the prescribed
requirements
in a year period
Removed from the 24 hour duty rotation in the
Department of Medicine.
Will be listed from the active consultant in the
Department of Medicine.
Preventing to be listed in decking schedule .
7. An active consultants who fails to meet the prescribed
requirements in second year.
The consultants will be dropped from the rooster of
active consultant staff.
8. Re-appointment of active consultant is done yearly.
VISITING CONSULTANTS
1. Be licensed physician of the Philippine under RA 1080 (with
current PRC medical doctor license).
2. Be diplomate/ fellow of the Specialty and Subspecialty
Society of good standing.

UNIT
Prepared by:
Reviewed by:
DOC NO.
REV. NO.
PAGE
EFFECTIVE DATE
:
:
:
:
Approved by:
3. Be a member and accredited specialist of the Philippine

health insurance.
4. Be recommended favorably by the Department and Hospital
Credentials Committee.
Responsibilities
1.
Utilize the ancillary service of the hospital
2.
Adhere to the existing rules and regulations of the hospital
and endoscopy
unit.
3.
Attend at least 50% of the Unit and Departmental activities.
4.
Re-appointment is done every 2 years.
CARDIOLOGY NURSE
1. Be a registered nurse in the Philippines with special training in
cardiology procedures
2. Possess a degree of Bachelor of Science in Nursing with at least
6 months of relevant experience in cardiology procedure.
3. Possess genuine interest and concern to work, have a good
moral character and with good interpersonal relationship with the
patients and other members of the hospital teamwork.
4. Must be punctual at all times.
Rules of Conduct
1. To observe proper decorum and wearing ID at the endoscopy
unit at all times.
2. Behave professionally and any misbehavior or unethical
conduct will subject for suspension and termination of contract
(see hospital code of conduct of employee).
Responsibilities:
1. To assist in the cardiologist with efficient and outmost
professional care
2. To get vital signs (Blood Pressure, Pulse/ Heart Rate, Respiratory
Rate, Temperature) of the patient before and after the procedure;
3. To carry out all orders of the Cardiologist
4. Responsible for the overall supervision of the cleanliness of the
cardiology-pulmonary unit.

UNIT
Prepared by:
DOC NO.
REV. NO.
PAGE
EFFECTIVE DATE
Reviewed by:
:
:
:
:
Approved by:
5. Accountability of the cardiology nurse

equipment in the cardiology unit.
6. To ensure that the policy is implemented
of
the
different
MATERIALS/ SUPPLIES/MACHINES
ELECTROCARDIOGRAM (ECG/EKG)
ECG paper, Cotton balls and alcohol, Face mask, Tissue paper, gel
AMBULATORY BP MONITORING
Cotton balls and alcohol, tissue paper and gel if needed.
Treadmill exercise test paper, cotton balls with alcohol and
electrodes. Face mask and gel if needed
24-HOUR HOLTER MONITORING
Electrodes, micropore and holter diary. Face mask and gel if
needed.
2D-ECHOCARDIOGRAPHY AND DOPPLER STUDY
Electrodes, DVD, ultrasonic gel, tissue paper, and 2D-Echo form.
Face mask if needed.
PERIPHERAL VENOUS DUPLEX SCAN
DVD, ultrasonic gel, tissue paper, clean gloves and Peripheral
Venous Duplex Scan form. Face mask if needed.
PERIPHERAL ARTERIAL DUPLEX SCAN
DVD, ultrasonic gel, tissue paper, clean gloves and Peripheral
Arterial Duplex Scan form. Face mask if needed
Stress test machine GE carestream Windows Based OS regular
paper printing (inkjet)
2D Echo Machine Philips iE33 or Siemens Sequola TDI TEE
capable
Venous Arterial Carotid & Transcranial Duplex Scan
Machine: Philips iu 22
ECG Machine GE mac 5500 MC 5500
Holter Machine: GE seerlight/ Rozinn Model RZ 153 +
digital holter recorder
Ambulatory BP monitoring device
Myocardial Perfusion Imaging; Brand Siemens, Model:
Symbia S, Type: Dual
BP Apparatus
FORMS
ECG form

UNIT
Prepared by:
DOC NO.
REV. NO.
PAGE
EFFECTIVE DATE
Reviewed by:
:
:
:
:
Approved by:
Peripheral Venous Duplex scan form

Peripheral Arterial Duplex scan form
1. PURPOSE
The aim of Heart and Lung Unit is to have a standard method to be followed by
the Cardiologists/ Pulmonologist/ Therapist in giving procedures/ treatments and
tests.
To establish and operate a Heart and Lung Unit where patient at the hospital, inhouse consultants, and those referred by other (outside) physicians can be
taken cared of as on an out-Patient basis serving Heart and Lung procedures/
treatment.
2. SCOPE
The Heart and Lung Unit will encompass an outpatient clinic for treating
patients scheduled for Electrocardiogram (ECG), 2D-Echocardiography, 24 Hour
Holter Monitoring, Treadmill Exercise Stress Test, Ambulatory BP Monitoring,
Peripheral Venous and Arterial Duplex Scan, Arterial Blood Gas Extraction,
Incentive Spirometry, Pulmonary Function Test, Peak Expiratory Rate, Pulse
Oximetry, Inhalation Therapy, and Chest Physiotherapy .that are done in a nonadmitted set up.
The areas covered include from Central Registration (names enlisted in the biz
box before consultation & rendering procedure/ treatment), Cashier (settles

UNIT
Prepared by:
DOC NO.
REV. NO.
PAGE
EFFECTIVE DATE
Reviewed by:
:
:
:
:
Approved by:
their bills after registration), Heart and Lung Unit (render consultation and noninvasive diagnostic are done), up to their discharge.
3. POLICY
It is the policy of the Fe Del Mundo Medical Center (FDMMC) Heart and Lung
Unit to:
GENERAL POLICIES
Pulmonary Unit provides pulmonary services twenty four (24) hours a

day for In-patients and Out-patient.
The Pulmonary Unit is open from Monday to Sunday.
The Respiratory Therapist are scheduled in three (3) shifts;

6:00 A.M. 2:00 P.M.
2:00 P.M. 10:00 P.M.
10:00 P.M. 6:00 A.M.
The Pulmonary Unit is composed of Section Head, Supervisor, and

Respiratory Therapist.
All pulmonary services are done according to doctors written order and/
or request.
Services and process involved in the unit are as follows:
Rendering treatment - Inhalation therapy, oxygen therapy, chest

physiotherapy, ventilation therapy, and incentive spirometers
Test for in- and out-patients - ABG, PFT, and PEFR
Charging of bills for In -and Out-patients
Requisition or Inventory of Supplies and solutions.
The Pulmonary staff administer medication (inhalation therapy) only on

the order of a license physician for a specific patient. All s such orders
shall be in writing and signed by the person when giving the order. All
Pulmonary Staff should be aware of the action and untoward reaction of
the medicine they administer. All medicines are available at Pulmonary
Unit.

UNIT
Prepared by:
DOC NO.
REV. NO.
PAGE
:
:
:
EFFECTIVE DATE
Reviewed by:
:
Approved by:
All medication orders must include the name, exact dosage and
frequency of treatment. Pulmonary Staff has the duty to question the
order if it is unclear or seems inappropriate. To promote accuracy and
consistency in giving treatment to patient the following scheduled has
been suggested:
OD 9AM
Q6 12AM/12PM/ -
6AM/6PM
TID 9AM. 1 PM 5 PM
Q8 6AM 2PM 10 PM
QID 8AM 12NN 4PM 8PM
Q12 9AM 9PM
Q4 1AM/1PM 5AM/5PM 9AM/9PM
Stat request examination or procedure are done on urgent cases, the

result shall be released immediately after the procedure. The following
are considered STAT request:
All pulmonary results needed immediately.
All results needed before releasing time.
All NOW request.
All
request
from
critical
areas
like
Intensive
Care
Unit
(ICU/PICU/NICU)
Operating Room and Emergency Room. During Code shall be

considered STAT.
For equipments repair:
Do not use malfunctioning equipment. Make all necessary repairs, or

ask an authorized representative for servicing.
After repair, test the equipment to ensure that it is functioning

properly,
in
accordance
with
the
manufacturers
published
specifications.
To ensure full reliability, have all repairs and service done by an

authorized representative. If this is not possible, replacement and
maintenance of parts should be performed by a competent, trained

UNIT
Prepared by:
DOC NO.
REV. NO.
PAGE
EFFECTIVE DATE
Reviewed by:
:
:
:
:
Approved by:
individual with experience in repair, and appropriate testing and

calibration equipment.
SPECIFIC POLICIES
Rendering treatment or test for In-patient and Out-patient
The Respiratory Therapist shall receive request from the system.

Respiratory Therapist shall verify the doctors order in the chart
regarding the ordered examination
(for
In-patient).
For
Outpatients, the Respiratory Therapist
determine
the
doctors
signed request for the test/ procedure. Patient will be scheduled
for the said request/s. The Respiratory Therapist advises the patient to
enroll at the registration.
Respiratory Therapist-on-duty ensures timely delivery of treatment to
patients.
Out-patients with pulmonary request are attended on first come first
serve basis except on emergencies.
No treatment or test is done without written request.
Respiratory Therapist make sure that they can comply with doctors
order by reviewing the patients chart and/ or doctors written request
for confirmation of the requested test or treatment.
Respiratory Therapiston-duty does calibration of ABG machine and
PFT machine every morning or as required prior to performing the
requested tests.
Respiratory Therapist-on-duty will monitor all oxygen set-up and
oxygen delivery devices as well as ventilators. Oxygen and ventilator
rounds are done every four (4) hours.
Charging of bills for In-and-Out patients
All items and supplies used during the patients procedures shall be
charged accordingly.
Cost of procedures vary according to the In-patients or Out-patients
status. In-patients rates will vary according to room accommodation.
Spirometry or PFT of all In-patients and Out-patients including those
under HMO, must be charge with a readers fee unless otherwise
specified on the request of the Attending Consultant
Data from charge slips shall be entered in a logbook and must be
signed by the receiving staff or personnel.

UNIT
Prepared by:
Reviewed by:
DOC NO.
REV. NO.
PAGE
:
:
:
EFFECTIVE DATE
:
Approved by:
Respiratory Therapist-on-duty prepares charge slip for out-patient

and payment is made at the cashier by patient or relatives.
Patients senior citizen ID or PWD ID must be presented to
Respiratory Therapist-on-duty prior to charging process.
Out-patients shall present and provide a copy of official receipt to
Respiratory Therapist-on-duty before ordered procedure is done.
For HMO patients, Letter of Authorization (LOA) shall be presented to
Respiratory Therapist-on-duty prior to rendering of procedure. LOA
should bear the printed name and signature of the authorized
representative.
Requisition and Inventory of supplies and solutions
The Respiratory Therapist is responsible for monitoring and ordering

supplies, reagents and solutions from pharmacy or purchasing
department for the unit.
Procurement of supplies is on weekly basis or before reaching 50% of
its stock level, whichever comes first.
The unit maintains listing of supplies in the supplies log book or
folder. All Respiratory Therapist are accountable for all stored medical
supplies and solutions.
A monthly or quarterly inventory report is logged and submitted to
purchasing department.
Maintenance of Pulmonary Equipment

Cleaning
Pulmonary Staff clean and disinfect machines and equipment (pulse
ox, nebulizers, ABG machines, ventilators, precursor, and others)
thoroughly after each use.
The manufacturers recommendation for cleaning shall be complied
with.
Each machine shall be allowed to dry completely in clean, dry and
sanitary.
Storage
All machines shall be stored in clean and dry and sanitary location
and protected against extremes in temperature, excessive moisture,
damaging chemicals sunlight and dirt.

UNIT
Prepared by:
Reviewed by:
DOC NO.
REV. NO.
PAGE
EFFECTIVE DATE
:
:
:
:
Approved by:
Maintenance and Repair

Only the manufacturers authorized/ approved replacement parts
will be utilized manufacturers parts will not be interchanged
unless the parts are listed as a substitute by the original
manufacturers.
All defective parts shall be replaced.
The manufacturers recommendation for repair and maintenance
work shall be complied with.
Only those property trained or certified by the manufacturers shall be

allowed to conduct repair or maintenance work on the
machine/equipment.
Physicians Telephone or Verbal Order

a. Respiratory Therapist is obligated to carry out a Physicians order
except when the therapist believes an order to be inappropriate.
b. Respiratory Therapist carrying out an inaccurate order may be legally
responsible for any harm suffered by the patients.
c. The Respiratory Therapist should clarify with the Nurse-on-duty or the
Physician
any unclear and/ or inappropriate order.
d. The respiratory Therapist should follow specific guidelines for
telephone/
verbal orders:
Date and time entry
Repeat the order to the physician and record the order.
Sign the order; begin with t.o (telephone order), write the
Physicians name, and then sign the order.
e. If another nurse witnessed the order, the nurses signature follows.
f.
The Physician needs to counter sign the order within a time frame
according to FDMMCs policy. The timeframe is within an hour up to
twenty four 24 hours.
g. The Respiratory Therapist should ensure that all components of a
medication order are documented.
Components of a medication order:
Date and time of order was written
Medication time
Medication dosage
Frequency of medications

UNIT
Prepared by:
DOC NO.
REV. NO.
PAGE
EFFECTIVE DATE
Reviewed by:
:
:
:
:
Approved by:
Physicians or health care providers signature.
h. The Respiratory Therapist should carry out immediately if accurate

and
Proper and no discrepancy with the orders being given. All Physicians
order must carried out within an hour to the most and all
emergency or STAT
orders must be carried out at once.
ADMINISTRATIVE GUIDELINES
Mechanical Ventilation and Weaning
The Mechanical Ventilators for Adults, Pediatrics, and Neonates are

available at the Pulmonary Unit, Ventilator set-up, hooking,
monitoring, change of tubing and troubleshooting are performed by
the Respiratory Therapist.
The necessary charges will be made once a particular ventilator unit
has been brought out to the ICU or NICU with a corresponding
Physicians order regardless whether the said machine was hooked to
the patient or not.
If the Mechanical Ventilators are on a standby or reserved, a
Corresponding charge will be made on a daily basis particularly if the
ventilator is at the ICU, NICU or PICU.
The Pulmonary Unit discourages manipulation of mechanical
ventilators by unauthorized personnel.
Weaning methods available are SIMV mode, ASV mode, PSV mode, Tpiece and Spontaneous Breathing Parameters.
Arterial Blood Gas (ABG)
Request for In-Patient procedures

The Attending Physicians request for ABG is in the chart stating the
specific condition at which the ABG will be taken as well as the time
the test should be taken.
Condition should be specific and stated clearly (if the patient is at
room air, nasal cannula, oxygen mask, tracheostomy, Fio2, tidal
volume, respiratory rate, PRRP, Pressure support, mode of mechanical
ventilator, or in T-piece, tracheostomy, etc.).
The Nurse will fill-up the designated forms bearing the patients data
including: name, age, sex, date and time to be taken, condition and

UNIT
Prepared by:
Reviewed by:
DOC NO.
REV. NO.
PAGE
EFFECTIVE DATE
:
:
:
:
Approved by:
position of the patient. The Pulmonary Unit will be informed of the

request and the Respiratory Therapist will proceed to the patients
room for blood extraction.
The Nurse and the Respiratory Therapist should ensure that the
desired setting is correct and should be in placed at least thirty
(30) minutes prior to extraction. If the desired setting is not in place,
the Respiratory Therapist will make the necessary corrections and will
extract blood after thirty (30) minutes. Initial results will be relayed to
the Nurse station.
If the results are deemed incorrect or in doubt, the Physician can
request for repeat ABG free of charge provided, it is done within 15
minutes of receipt of results. Repeat request can be done only once.
Request for Out-Patient (OPD) Procedures
A request form will be filled up by the Physician, stating the specific
condition at which the ABG will be taken. Condition should be specific
and stated clearly (if the patient is at room air, nasal cannula, oxygen
mask,
tracheostomy, Fio2, tidal volume, respiratory rate, PEEP,
Pressure support, mode of mechanical ventilator, or in T-piece, etc.)
and the patients data including: name, age, sex, date and time to be
taken, condition and position of the patient. The patient will be
instructed to proceed to Pulmonary Unit, where
the blood will be
extracted. After the procedure, the copy of the initial results will be
given to the patient.
Pulmonary Function Test (PFT)
For both In-Patient and Out-Patient, the patient will be instructed to

withhold all inhaled and oral medicine including: Beta2 Agonist (6
hours for short acting and 12 hours for long actin). Then a request
form should be filled up bearing the Patients data including: name,
age, sex, height, weight, diagnosis of the patient. And in addition, all
current medication should be informed of the request.
If the patient has taken such medication prior to actual procedure,
the Respiratory Therapist should notify the patients Attending
Physician to verify whether to proceed or to forgo the examination.
The PFT procedure is available from Monday to Saturday from 9:00
A.M. to 5:00 P.M. Official results will be given after three (3) working

UNIT
Prepared by:
DOC NO.
REV. NO.
PAGE
EFFECTIVE DATE
Reviewed by:
:
:
:
:
Approved by:
days but the initial unofficial result can be given to the patient, if he/
she requested a copy.
Inhalation Therapy
Request for In-Patients Procedure
Treatment request for In-Patients should be properly filled up bearing

the patients data including: name, age, sex, patients condition,
another particulars such as medication, dosage, and frequency must
be stated clearly.
Pulmonary Unit suggests that the treatment time be specified by the
Attending Physician. Whether treatment time be done on waking
hours or pulmonary treatment time. If the Attending Physician
requested that the treatment should be done during waking hours
no treatment shall be performed after 10:00 P.M. and it shall
commence at 5:00 A.M., the following day to give patients enough
time to rest during the night. Considering these, the Pulmonary Staff
will fill up a medication sheet, and indicate the name of the
Respiratory Therapist-on duty, date, time, and specific medication
given. Inhalation therapy will be given based on initial order unless
the doctor will revised the treatment time. If the patient refused the
treatment, the Pulmonary Staff should inform the Nurse-on-duty of
Medical Residence-on-duty.
In Pediatric treatment, nebulization will be done after the Pediatric
resident doctor on duty has made an assessment of the patient and
will inform the Respiratory Therapist to proceed the treatment.
Respiratory Therapist will not proceed with nebulization if the
Attending Physician or the Doctor-on-duty has not given any signal
to go ahead with procedure.
Request for Out-Patient Procedure

Pediatric nebulization will undergo the same procedure. All charges will be
covered through the
proper office.
Peak Flow Expiratory (PEFR)
All request for PEFR determination should be properly filled up bearing the
patients data
including: name, age, sex, height, weight, and frequency of
determination. Upon receiving the
request, the Respiratory Therapist will

UNIT
Prepared by:
Reviewed by:
DOC NO.
REV. NO.
PAGE
EFFECTIVE DATE
:
:
:
:
Approved by:
proceed to the patient to perform the test. PEFR

determination and monitoring
will be done before and after the bronchodilator use unless
specified by the
Attending Physician.
Chest Physiotherapy
The Respiratory Therapist utilizes either manual or mechanical method
percussion for patients
with thick retained secretions. And it must be done
after doing inhalation.
Incentive Spirometry
Given for pre and postoperative patients, to prevent lung collapse or
atelectasis. Timing and frequency of the procedure should be specified by the
Attending Medical Doctor.
Pulse Oximetry
Pulmonary Unit have pulse oximeter. It measures oxygen saturation in the
body and pulse rate
of the patient. No reservations shall be made, strictly first
come first serve basis.
MATERIALS/ SUPPLIES
Medical supplies, medical equipment
5. RESPONSIBILITIES
Section Head administrative function, responsible for evaluation of staff
(Respiratory Therapist)
Supervisor Takes responsibility in the supervision of pulmonary staff in all
aspects of work and
or services and prepares work schedule.
Represents the section in hospital meetings.

Trains newly hired Respiratory Therapist
Monitors functionality of different pulmonary equipments and
reports to the section Head if there is anything malfunctioning.
Responsible in the procurement and monitoring of pulmonary
supplies and reagents.
Checks and calibrates pulmonary equipments.
Maintains orderliness and cleanliness of the Unit.

UNIT
Prepared by:
Reviewed by:
DOC NO.
REV. NO.
PAGE
EFFECTIVE DATE
:
:
:
:
Approved by:
Performs other tasks that may be assigned by the immediate

superior.
Maintaining appropriate surveillance of working conditions of the
machines.
Assuring that subordinates comply with the requirements of this
policy.
Proper knowledge which shall include proper use of equipment and
cleaning techniques
Respiratory Therapist responsible for his/ her assigned duties.
Administer therapeutic gas via oxygen delivery system such as

nasal cannula, oxygen mask (simple, partial, non-rebreathing
mask), venturi, etc.
Administer aerosol drugs with the use of nebulizers as well as inline from mechanical ventilated patient.
Performs chest physiotherapy, chest percussion, vibration (manual
or mechanical), postural drainage.
Educates patients with breathing exercises, proper cough
maneuver.
Instruct patients for lung expansion therapy with the use of
INCENTIVE Spirometry.
Perform extraction for Arterial Blood Gas (ABG) analysis and
interpretation.
Administer respirator to patients needing Ventilatory support to
include troubleshooting and routine ventilator rounds every two (2)
hours.
Administer respirator to patients needing Ventilatory support.
Determine Spontaneous Breathing Parameters, Positive Expiratory
Flow Rate, and Pulse Oximetry.
Assist the Physician in weaning the patients from mechanical
ventilator.
Observe and evaluate immediate response and reaction of patients
undergoing ventilator therapy
Perform and assist the patient during Pulmonary Function Test:
Simple spirometry with or without bronchodilator/ Broncho
provocative test.
Assume responsibility for proper functioning and care of respirators
and other respiratory equipment
Assume responsibility for proper disinfecting and sterilization of all
respiratory equipment. Perform other duties that may be assigned
from time to time.

UNIT
Prepared by:
DOC NO.
REV. NO.
PAGE
EFFECTIVE DATE
Reviewed by:
:
:
:
:
Approved by:
All Pulmonary Personnel shall be responsible for:

a
b
Using the equipment properly.

Making sure that all equipment are functioning and in good condition.
Heart and Lung Unit - the unit wherein all non-invasive diagnostic
examinations are done
.
Central Registration - wherein the patient needs to be enlisted into the
system before
consultation and rendering the examination
registration.
Mechanical Ventilation a method to mechanically assist or replace
spontaneous breathing.
Weaning a process/ gradual withdrawal from ventilator support
Arterial Blood Gas (ABG) evaluate acid base status, ventilation and
arterial oxygenation.
Pulmonary Function Test (PFT) group of test to measure lung volume
and capacity.
Incentive Spirometry (IS) a method of encouraging voluntary deep
breathing.
Peak Expiratory Flow Rate (PEFR) a test that measure how fast a
person can exhale.
Inhalation Therapy various method of treatment that work when you
inhale.
Chest Physiotherapy a technique used to mobilize or loose secretions in
the lungs and the respiratory tract.
RT Respiratory Therapist
Guidelines on Assessment and Treatment of Patients with Special Need

UNIT
Prepared by:
Reviewed by:
DOC NO.
REV. NO.
PAGE
EFFECTIVE DATE
:
:
:
:
Approved by:

Policies, Rules and regulations on Release of Hospital records
8. PROCEDURE
a) The RT shall receive request from the system. RT shall verify the doctors
order in the chart regarding the ordered examination (for in patient). For outpatients, the RT shall determine the doctors signed request for the
test/procedure. Patient will be scheduled for the said request/s. The RT
advises the patient to enroll at the registration section.
b) The RT shall prepare the equipment needed. Refer to Pulmonary Unit work
instructions on preparation of equipments. Procedures that can be done
both in patients room and at Pulmonary Unit includes aerosol therapy, chest
physiotherapy and incentive spirometry. Mechanical ventilation is done only
at IMU while pulmonary function test shall be done at the Pulmonary Unit.
c) The RT shall wash hands and apply necessary/needed isolation/ precaution
barriers.
d) For In- patients, RT identifies the patient through patients acknowledgement
of name and patient ID band.
e) The RT shall introduce self and his/ her department. He/ she shall explain the
procedure and the purpose of the procedure and verify if the patient
understood the given explanation.
f) For outpatients,
The RT shall verify patients name and check the doctors request.
The RT shall sit the patient comfortably in the unit and respect patients
privacy and dignity.
The patient shall sign consent form.
g) The RT shall assess and monitor vital signs of the patient and shall verify for
indications, contraindications or possible hazards of the procedure. If the
blood pressure is more than 140/ 90 mm Hg, the respiratory therapist shall
inform the nursing staff to notify the attending physician for clearance prior
to performing the required procedure. For out-patients, the procedure is
deferred unless the patient presents clearance from the attending physician.
h) The RT shall perform the required procedure. Refer to work instructions
regarding procedures.
i) In the event of sudden change of patient status during the procedure, such
as but not limited to the following:
Abrupt increase or decrease of vital signs to as much as 20% of the baseline
Sudden headache, chest pain, hemoptysis, or sharp body ache, decreasing
level of consciousness. The RT shall discontinue the therapy and refer the
event to the
Attending Physician and / or Resident on Duty
immediately.
j) After the procedure has been performed, the RT shall re-assess general
condition of the patient.

UNIT
Prepared by:
Reviewed by:
DOC NO.
REV. NO.
PAGE
EFFECTIVE DATE
:
:
:
:
Approved by:
k) The RT shall educate the patient and his/ her family members regarding the
procedure and record it in Health Education Acknowledgement Form. Patient/
relative shall sign in the acknowledgement portion of the form.
l) The RT shall wash hands and disposed of used materials in the appropriate
disposal bins. Rinse the materials used (e.g Neb Kit, mouth piece for IS) with
water and air dry before repacking in the plastic.
m) The RT shall post and record the procedure done to the patient in Pulmonary
Unit Patient Chart and RCD Patient Logbook. And make appropriate
endorsement.
n) The RT shall hand out to patient/ relative Patient Evaluation Form and shall
collect it before the patient/ relative leaves RCD. Refer to Patient Survey
Form Policy and Procedure.
o) For PFT:
The RT shall forward the Pulmonary Function Test print out (PFT) to the
Pulmonologist for interpretation.
The RT shall transcribe correctly the interpretation made by the
Pulmonologist in the Pulmonary Unit Official Result form.
The RT shall file PFT result by date in a folder.
The RT shall issue the official result to the requesting party. As evidence
that the requesting party received the official result, receiving party shall
acknowledge by signing in the logbook.
p) All information in the RCD Patient Chart and RCD Patient Logbook must be
kept confidential as per Policies, Rules and Regulations on Release of
Hospital Records.
q) Maintenance of Equipment:
Daily endorsement of machine and equipment as part of maintenance.
Machines or equipment that are found defective should be reported
immediately to the Engineering Department. The staff from engineering
will check/ assess the machine, they will make a recommendation
forwarded to
Purchasing Department to coordinate to the supplier.
Instructions from the supplier to follow in Cleaning Respiratory Therapy
Equipment:
Personnel responsible for cleaning the equipment should be
instructed in proper handling methods necessary to reduce the
risk of infection and reduce contamination of the cleaning
area.
Manufacturers recommendations for equipment disassembly,
cleaning, pasteurization, and sterilization should be followed.
All equipment should be thoroughly washed and rinsed before
attempting pasteurization or sterilization. Debris interferes
with the action of pasteurization and sterilization.

UNIT
Prepared by:
DOC NO.
REV. NO.
PAGE
EFFECTIVE DATE
Reviewed by:
:
:
:
:
Approved by:
The exterior surfaces of large pieces of equipment (Ventilators,

PFT Machines, ABG Machines, Portable Suction Units, IPPB
Machines, end Tidal CO2 Monitor) should be cleaned and
disinfected between patients.
All equipments should be covered when not in use.
9. FORMS
Health Education Acknowledgement Form
ADMINISTRATIVE POLICIES
The Heart and Lung Unit can be used by all affiliated physicians, of FDMMC
provided they are able to comply with all the requirements of the FDMMC to
be submitted to their department and approved by the respective chairman.
The chairman of Heart and Lung Unit is an active affiliated Cardiologist of

good
medical standing and should be appointed by the Medical Director
of the FDMMC upon recommendation of the chairman of the Department of
Medicine. He/ she must be a certified Fellow of the Philippine College of
Physicians, and Fellow of Philippine Heart Association/ Philippine College of
Cardiology.
The Co-Chairman of Heart and Lung Unit is an active affiliated

Pulmonologist of good medical standing and should be appointed by the
Medical Director of the FDMMC upon recommendation of the chairman of
the Department of Medicine. He/ she must be a certified Fellow of the
Philippine College of Physicians and Fellow of the Philippine Society of
Pulmonary Medicine.
All regular or non-critically ill patients in the floor/ unit should be seen within
twenty four (24) hours from admission or referral and should make daily
rounds and must put entry to chart every visit.
All Intensive Care Unit (ICU) or emergent cases should be seen within
twelve (12) hours from admission or referral and should make more than
once daily rounds as necessary and must put entry to chart for every visit.
All long standing/ status quo patients may be seen in less than once daily
if no new or active medical attention is needed and only waiting to be
discharged from the hospital due to non-medical reasons or other hospital
policy issues.

UNIT
Prepared by:
Reviewed by:
DOC NO.
REV. NO.
PAGE
EFFECTIVE DATE
:
:
:
:
Approved by:
The cardiovascular diagnostic procedures will be officially read only by

affiliated Cardiologist and he/ she must be a certified Fellow of the
The pulmonary diagnostic procedures will be officially read only by affiliated

Pulmonologist and he/ she must be a certified Fellow of the Philippine
College of Physicians and Fellow of the Philippine Society of Pulmonary
Medicine.
The ICU will be supervised by the current Chairman and Co-Chairman of the
Heart and Lung Unit and he/ she must be a certified Fellow of Philippine
College of Physicians, Fellow of the Philippine Heart Association/ Philippine
College of Cardiology or Fellow of the Philippine Society of Pulmonary
Medicine.
While the cardiac catheterization laboratory/ facility is not available

temporarily in FDMMC, the affiliated interventional cardiologist and
electrophysiologist will be allowed to do the procedures upon formal letter
of request signed by chairman of Internal Medicine in other three accredited
medical centers of the Pinehurst Medical Services, Incorporation, namely:;
VRP Medical Center, Medical Center Manila, and Unihealth Tagaytay Hospital
and Medical Center.
The patients of Cardiac Rehabilitation Center facility when available or if

there will be in-patients for cardiac rehabilitation co-management he/ she
will be supervised only by affiliated cardiac rehabilitation Cardiologists or by
choice of requesting physician and he/ she must be a certified Fellow of the
Philippine College of Physicians, Fellow of the Philippine Heart Association/
Philippine College of Cardiology, and Member or Fellow of Council on
Cardiac Rehabilitation Society of the Philippines.
All affiliated clinicians of the Department of Medicine of FDMMC are required

to attend medical staff meeting every three (3) months (January-April-JulyNovember) during the 4th Wednesday of the scheduled month at 1:30 P.M.
to be conducted by Dr. Mariano Lopez, the Medical Director.
An affiliated Cardiologist or Pulmonologist may be requested to give lecture

pertaining his/ her specialty or expertise and the topic and schedule of
lecture will be announced by the Chairman of the Department of Medicine
at least one month prior to the schedule.

UNIT
Prepared by:
Reviewed by:
DOC NO.
REV. NO.
PAGE
EFFECTIVE DATE
:
:
:
:
Approved by:
An affiliated Cardiologist or Pulmonologist must attend to at least 50% of

the department meetings, conferences or grand rounds in a year to
maintain good medical standing in the medical center.
An affiliated Cardiologist/ Pulmonologists are permitted to give suggestions or

requests either by personal or written statement to be forwarded to the office of
the Department of Medicine for approval by Head of Heart and lung Unit, Chairman
of the Department of Medicine and the Medical Director for final approval

Cardio &amp; Pulmo

Uploaded by

Document Information

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Cardio &amp; Pulmo

Uploaded by

Copyright:

Available Formats

POLICIES AND PROCEDURES

TITLE: CARDIOLOGY AND PULMONARY

CARDIOLOGY AND PULMONARY UNIT

POLICIES AND PROCEDURES

The chairman of Heart and Lung Unit is an active affiliated cardiologist of

The co-chairman of Heart and Lung Unit is an active affiliated

The cardiovascular diagnostic procedures will be officially read only by

The pulmonary diagnostic procedures will be officially read only by

POLICIES AND PROCEDURES

The ICU will be supervised by the current chairman and co-chairman of

While the cardiac catheterization laboratory/ facility is not available

The patients of Cardiac Rehabilitation Center facility when available or if

All affiliated clinicians of the Department of Medicine of Fe Del Mundo

An affiliated cardiologist or pulmonologist may be requested to give

An affiliated cardiologist or pulmonologist must attend to at least 50% of

An affiliated cardiologist/ pulmonologists are permitted to give

POLICIES AND PROCEDURES

ECG reading will be officially read/ decked on a weekly basis among

Ambulatory BP monitoring will be officially read/ decked on a weekly basis

Twenty four (24)-hour Holter monitoring will be officially read/ decked on a

Treadmill Exercise Stress test will be supervised and officially read on a

2D-Echocardigraphy with Doppler study will be officially read/ decked on a

Trans-esophageal echocardiography (TEE), stress echocardiography,

POLICIES AND PROCEDURES

Endothelial function of test, Ankle: Brachial Index (ABI), arterial duplex

Stress or pharmacologic nuclear cardiovascular imaging (Thallium or

10. Cardiac Magnetic Resonance Imaging (MRI) will be officially read by MR

POLICIES AND PROCEDURES

the Philippine Heart Association/ Philippine College cardiology, and Member

Electrocardiogram the record produced by electrocardiography; a tracing

Ambulatory BP Monitoring a non-invasive method of obtaining blood

Holter Monitoring (24-hour) refers to a 24 hour, continuous test to record

Treadmill Exercise Stress Test is a cardiovascular stress test that uses

2-D Echocardiography and Doppler Study a test in which ultrasound is used

POLICIES AND PROCEDURES

Ultrasound Duplex Scanning - can help determine if arterial disease might be

ELECTOCARDIOGRAM (ECG/ EKG)

Personal or phone scheduling by receiver personnel.

OUT PATIENT CHARGES

POLICIES AND PROCEDURES

POLICIES AND PROCEDURES

POLICIES AND PROCEDURES

POLICIES AND PROCEDURES

POLICIES AND PROCEDURES

POLICIES AND PROCEDURES

16.Inform the patient regarding the turnaround time of the result.

Regulations on Release of Hospital Records

ECG Machine GE Mac 5500 MC 5500

POLICIES AND PROCEDURES

Heart Station Technicians are responsible for:

Heart Station - the section wherein all non-invasive diagnostic

Written consent must be secured.

POLICIES AND PROCEDURES

patient/relative/ companion to present the official receipt and system

POLICIES AND PROCEDURES

POLICIES AND PROCEDURES

POLICIES AND PROCEDURES

8. Proceed to patients room for the procedure.

POLICIES AND PROCEDURES

Result: 3 working days

Correctly identify patients by their name and date of birth;

POLICIES AND PROCEDURES

For HMO- ask patient to get a Letter of Approval/ Authorization (LOA)

(and any valid ID)

Cardio & Pulmo

Cardio & Pulmo