OPERATING ROOM COMPLEX POLICIES AND GUIDELINES
1. All patients for surgery must be properly identified and the following documents
and data should be presented to the operating room staff upon entry of the patient
to the operating room complex;
● patient's OPD record
● complete and properly filled-up Philheath
forms
● initial vital signs and IOP
2. Relatives and significant others of the patient should not be allowed to enter the
operating room complex before, during, and after the operation unless otherwise
necessary as in the case of minor and mentally challenged patients.
3. The earliest cutting time is at 8:00 am and the last case cutting time is at 4:00
pm, unless the case is an emergency.
4. The schedule of surgeries is only from Mondays to Fridays. Surgery during
Saturdays is reserved for emergency cases and for the full-time government-
affiliated doctors and other doctors whose practice are not in the city.
5. The OR staff should be notified ahead of time for cases that needs emergency
operation.
6. For cases that are done under general anesthesia, the OR staff should be notified
at least three(3) days prior to the schedule of the operation.
7. A business office clearance must be presented to the OR staff before the patient
is moved/wheeled to the OR complex.
8. All staff and patients entering the OR complex must wear the proper OR attire,
e.g., OR gown , OR slippers, scrub suit, cap, and mask.
9. All surgeries must have a HbsAg result and other laboratory results needed by
the anesthesiologists for their reference.
10. Proper handwashing must be observed at all times when entering the operating
room complex.
11. For the circulating and nurse assist, the following World Health Organization
checklist should be observed;
● sign-in
● time-out
● sign-out
12. All OR documents should be properly recorded by the OR staff.
13. All OR staff must remain in the OR complex or inside the center as long as a
post-surgery patient is still inside the center premises.
14. The cleaning and sterilization of the instruments and preparing the surgical
packs must be done by nurses and other OR trained staff.
15. Audit of drugs and other OR supplies, and checking of the status of OR
machines and instruments should be done weekly by the OR nurses.
16. The availability and usability of OR linens, drapes, and gowns should be checked
weekly by the OR practical nurses and allied personnel.
17. Preparation of OR linens, drapes, and gowns for sterilization should be done by
whoever is available at the OR complex , be it the nurses, the practical nurses, and
allied personnel.
18. Cleanliness and orderliness of the whole OR complex should be maintained at all
times.
19. Waste segregation and disposal should be properly followed.
20. Logbooks for the instruments, machines, and drugs should be submitted to the
Human Resource Office every 3rd Monday of the month.