Standard Operating Procedure (Medical Division)

Medical Residency Training Program

Hiring of Residents

Training Proper

Graduation of Resident Doctors

Selection of Department Chairman

Selection of Department Training Officer

Hiring of Medical Consultants

Hiring of Visiting Medical Consultants

Handling of ResidencyTraining Related Compliants against Residents/Consultants

Department of Surgery

Management of Breast Cancer and Breast Diseases in Breast Care Center

Surgical Intensive Care Unit Protocol


Discipline, Suspension, Demotion and Termination of Personnel at all levels

Infection Control

Prevention and Management of Needle Prick Injuries

Bio safety and Bio security

Hiring, Orientation and Promotion for all level Personnel in the Laboratory

Reporting and dealing with incidents, adverse events and complaints in the Department of Laboratory

Receiving of laboratory request

Reporting of laboratory results

Releasing of Results

policies & Procedures on Accessing and Referring Patients to Approved External Providers

Intraoperative Consultation

Mortuary Service

Blood Procurement, issuance and release

Performance of STAT Laboratory Examinations

Use of Point of Care Devices

Collection and Recieving of Specimen on Bacteriology Section

Recieving of Specimen from the Operating Room

Standard Operating Procedure Autopsy

Laboratory Waste Management

Collection of blood sample

Blood Bank: Receipt and Handling incoming, unprocessed blood and plasma derivatives

Blood Bank: Referral of Blood Specimens (Blood Units) for Confirmation of Reactivity to Transfusion-Transmitted Infections to RITM

Blood Bank: Contingency Plan on Equipment Breakdown

Blood Bank: Management on adverse reaction of blood donor

Blood Bank: Blood cold chain

Specimen Handling, Transport and Storage

Blood Bank: Labelling of blood bag

Blood Bank: Blood collection process

Blood Bank: Blood clearance

In-house Blood Donation

Preventive Maintenance on all Blood bank equipment

Blood from other Blood Banks

Unscreened and Uncrossmatched Blood for Transfusions

Blood rates

HIV Testing

Blood replacement program

Reservation of Blood to Patients confined to CLMMRH

Histopath: Safe keeping of items as medico legal evidence

Selection Process for Pre-Residency

Evaluation of Resident's Performance and Promotion

Performance of Surgical Pathology Gross Examinations

Signing out and Reporting of Anatomic Pathology Cases

Nutrition and Dietetrics Service

Diet Counseling

Cafeteria Mealtime Schedule

Patient Mealtime Schedule

Personal Hygiene

Department of Pediatrics

Pedia ICU Isolation Admission

Standard Operating Procedure On Neonatal Admission of Outborn Delivery

Kangatoo Mother Care Program

Kangatoo Mother Care Program Pediatric Out Patient Department


Standard Operating Procedure Pharmacy

Department of Physical Medicine and Rehabilitation

General In-Patient Treatment

Consultation with Physiatrist

General out-Patient Treatment


Arterial Blood Gas

Mechanical Ventilation

Standard Operating Procedure SPIROMTRY

Peak Flow Therapy

Incentive Spirometry

Pulse Oximetry

Aerosol Treatment

Department of Diagnostic Imaging and Radiologic Sciences

Standard Operating Procedure for Conduct of Daily Report of the Quality Analysis of X-ray images

Standard Operating Procedure for Conduct of Daily Report of the Quality Analysis of CT images

Standard Operating Procedure in Cases of Breakdown/Malfunction of Radiology Equipment

Standard Operating Procedure for Addressing Complaints

Selection of Residents


Selection of Residents

Selection of Residents