Professional Documents
Culture Documents
Department of Health
Longitude:
Email Address:
Name of Owner:
Hospital Administrator:
General
Specialty
Government:
Private:
National :
Single Proprietorship :
Local:
Corporation:
Others, specify:
Others, specify:
Initial :
Renewal:
II. TECHNICAL REQUIREMENTS
Instruction: In the appropriate box, place a check mark () if the hospital is compliant or x mark (x) if it is
not compliant.
STANDARDS AND REQUIREMENTS
COMPLIANT
REMARKS
PART 1:
I.
The hospital appoints and allocates personnel who are suitably qualified, skilled and/or
experienced to provide service and meet patient needs.
1. All personnel are qualified, skilled and/or
experienced to assume the responsibility, authority,
accountability, and functions of their respective
positions.
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COMPLIANT
REMARKS
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COMPLIANT
REMARKS
II.A. The hospital provides and maintains a safe environment for patients, personnel and the public.
1.
2.
3.
4.
5.
6.
7.
8.
9.
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COMPLIANT
REMARKS
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COMPLIANT
REMARKS
II B. The hospital provides adequate and proper maintenance of all of its basic utilities.
1. The hospital has an approved power supply system.
Panel boards and feeders are properly coded and
labeled.
2. The hospital has an approved water supply system.
Its water is potable and safe for drinking. Records of
water analysis (bacteriological examination) are
available and updated every six months.
3. The water tank/water reservoir is flushed, cleaned
and disinfected at least annually.
4. The hospital has established a system for both
proper solid and liquid waste management which is in
accordance with the 2012 3rd edition of Health Care
Waste Management Manual of the DOH and
EMB/DENR environmental laws.
a. There is proper management of temporary
storage and areas prior to hauling for disposal.
b. The hospital practises pre-treatment of solid
wastes prior to disposal.
c.
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REMARKS
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COMPLIANT
REMARKS
III. All equipment and instruments necessary for the safe and effective provision of services
are available and are properly maintained.
1. There is presence of operations manual of medical
equipment
2. There is presence of policies and procedures for safe
and efficient use of medical equipment.
3. There is proof of the implementation of the policies
and procedures for the safe and efficient use of
medical equipment
4. There is preventive maintenance program that
ensures all equipment are checked, maintained,
and/or calibrated to an appropriate standard or
specification.
5. There is presence of operations manual of
generators, air conditioning unit, and other nonmedical equipment.
6. Records of equipment are maintained and updated
regularly.
7. There is a proof of training of the staff in charge of
the maintenance of equipment.
8. There is proof of monitoring of the implementation of
the policies/procedures on quality control of
diagnostic examination of equipment.
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COMPLIANT
REMARKS
IV. The hospital evaluates and monitors its activities to effectively assess its overall performance.
1. There is presence of Quality Improvement Program.
2. There is presence of patient satisfaction survey.
3. There is presence of evaluation and monitoring
activities to assess management and organization
performance.
V. The hospital provides safe blood and blood products.
1. The hospital ensures that its supply of blood and blood
products is safe.
2. The hospital has the appropriate blood service facility.
3. The hospital obtains blood and blood products only
from blood service facilities licensed/authorized by the
DOH. (R.A. 7719, otherwise known as National Blood
Services Act)
4. The hospital obtains blood and blood products
collected from healthy voluntary blood donors only.
(R.A. 7719, otherwise known as National Blood
Services Act)
PART 2:
I.
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COMPLIANT
REMARKS
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REMARKS
drug
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COMPLIANT
REMARKS
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COMPLIANT
REMARKS
REMARKS/COMMENTS/RECOMMENDATIONS :
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Remarks
Compliant
Medical Records
Officer/Statistician
Bookkeeper
Supply Officer
Storekeeper/Linen
Custodian
Laundry Worker
Budget Officer
Nutritionist/Dietitian
Billing Officer
Cashier
Cash Clerk
Accounting Clerk
Maintenance Personnel
Engineer/Medical
Equipment Technician
Clerk (pool)
Human Resource
Officer/Personnel
Officer
Utility Worker
Driver
Medical Social
Worker
B. Nursing Service
Personnel
Chief Nurse
Remarks
Security Guard
C. Clinical Service
Chief of Clinics/Chief of
the Medical Professional
Staff
Assistant Chief
Nurse
Supervising Nurse
Department Head
Head Nurse
Dentist
Dental Aid
Physicians
Physical Therapist
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Epinephrine 1 mg/ml
amp
Furosemide 20 mg/2 ml
amp
Haloperidol 50 mg/amp
Hydrocortisone 250
mg/vial
Hyoscine-N-ButylBromide
20 mg/vial
Lidocaine 2%
solution/vial
1g/50 ml
Mannitol 20%
solution 500 ml/vial
Remarks
Compliant
Remarks
Pyridoxine 1 g/amp
Sodium bicarbonate 50
mEq/amp
Succinylcholine 200
mg/vial
Thiamine (Vit.B
complex)
Tramadol 50 mg/cap
Terbutaline 0.5 mg/amp
Tetanus toxoid 0.5
ml/vial
Verapamil 5 mg/2 ml
5 Caloric agent D50
W50 ml/vial
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I.
Compliant
Remarks
III. BASIC E R EQUIPMENT/INSTRUMENTS/SUPPLIES
Airway adjuncts
(oropharyngeal and
Nasopharyngeal
airways)
Airway/Intubation kit
Alcohol disinfectant
Arm sling (or sling
and swathe
bandages)
Aseptic bulb syringe
Bag-valve-mask
device (adult, child,
infant sets)
Biomedical
Refrigerator for
storage of biological
and other heatsensitive drugs
Calculator for dose
computation
Cardiac board
Cardiac EKG
Cervical collars of
different sizes
Clinical Weighing
scale
Closed Tube
Thoracostomy Set
Cut Down Set
Defibrillator (with
cardiac monitor
and/or pacemaker
functions)
Diagnostic
(opthalmoscope/
otoscope) set
Different sets of bins
(to include a
puncture-proof
sharp container)
Elastic bandages of
different sizes
Compliant
ET tube
sizes)
Remarks
(different
Fire extinguishers
Floor lamps (drop light
and gooseneck)
Foot stools
Gloves (examination
and sterile gloves)
Hydrogen peroxide
solution
IV stand
Laryngoscope (adult
and pediatric sets)
Mayo table and tray
Minor Surgical Set
Nasal cannula
Nasogastric tube
Oxygen tank w/
holder/chain/trolley
Oxygen tubing
Penlights or
flashlights
Portable suction
device (suction
catheters included)
Povidine iodine
wound and
cleaning solutions
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Pulse oximeter
Pulmonary Function
Test (PFT) or Peak
Expiratory Flow
Rate (PEFR) tube
Random blood sugar
meter
Sphygmomanometer,
non-mercurialadult and pedia
cuff
Spine board with
straps
Splinting/immobilization devices
Standard face mask
Stethoscope
Sterile gauze
IV. EQUIPMENT BY SERVICE
A. Obstetrical
Service
Air-conditioning
unit
Anesthesia
machine
D/C set
Delivery set
DR table with
stirrup
Emergency light
Instrument table
Kelly pad
Oxygen unit
Wheeled stretcher
Remarks
Compliant
Remarks
Stretchers and
Gurneys (Wheeltype and the fixedtyped stretchers)
Sutures
Surgical airway
Syringes
Thermometers, non
mercurial
Tracheostomy set
Urethal cathether
Urine collection bag
Water-proof aprons
X-ray reading lamp
or negatoscope
B. Recovery Room
Air-conditioning unit
Bed with guard rail
Sphygmomano
meter
(non-mercurial)
with adult and
pedia cuff
Stethoscope
Emergency light
Oxygen unit
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Compliant
IV. EQUIPMENT BY SERVICE
C. Pathologic/
Premature Nursery
Air-conditioning unit
Bassinet
Remarks
Compliant
D. Intensive Care Unit
Air-conditioning
unit
Bili light
Ambu bag
(pediatric and
adult)
Bed with guard rail
Cardiac monitor
Cardiac monitor
Emergency cart
Defibrillator
Emergency light
ECG machine
Examining light
Emergency cart
Emergency light
Incubator
Endotracheal
tubes
Laryngoscope with
blade
Oxygen unit
Oxygen unit
Respirator
Remarks
Stethoscope
(pediatric)
Sphygmomano
meter (nonmercurial)
with pedia and
adult cuff
Suction apparatus
Weighing scale
(infant)
Stethoscope
Tracheostomy set
Suction apparatus
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Remarks
Compliant
Remarks
Ambu bag
Bedside table
Electrical stimulator
Clinical weighing
scale
Exercise plinth/bed
Defibrillator
Overhead pulley
ECG machine
Emergency cart
Paraffin Wax
Emergency light
Nebulizer
Oxygen unit
Ultrasound
Sphygmomanometer
(non-mercurial)
with adult and
pedia cuff
Stethoscope
Suction apparatus
F. Respiratory Therapy
Unit
ABG
Spirometer
Ventilator
I. CSR
H. Operating Room
Anesthesia machine
Cardiac monitor
OR table
OR light
Mayo table
Suction machine
Autoclave
Emergency light
J. Dental
Complete set of
equipment for oral
exam/oral prophylaxis/
extraction
Dental unit/chair
Equipment for sterilization
or equivalent
K. Engineering/
Maintenance
Stand- by generator
Automatic transfer
Switch
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II.
V.
I.
II.
Compliant
Remarks
Compliant
Remarks
V. PROPERLY FILLED OUT AND UPDATED PATIENT LOGBOOK OR ITS EQUIVALENT IN THE FOLLOWING AREAS
Admitting Office
Emergency Room
DR
OPD
OR
VI. CONTENTS OF THE MEDICAL CHART
Admitting Diagnosis
Advance Directive
Anesthesia Record
Attending Physician
Chief Complaint/
HPI
Clinical Laboratory
Report
Consultation
Referral Notes
Doctors Order
Sheet
Discharge
Summary
Final Diagnosis
Informed Consent
Medication/Treatment
Record
Nurses Progress Note
Operative/Surgical
Technique
Partograph/
Obstetrical Record
Patient Identification
Data
Physical Examination
Physicians Progress Note
X-ray Report
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Clinical service:
a. Medicine
b. Pediatrics
c. Obstetrics and
Gynecology
d. Pharmacy
e. Others, specify
Ancillary service:
a. Clinical Laboratory
b. Blood Station
c.Radiology
d.Pharmacy
e.Others, specify
Remarks
Compliant
Remarks
LEVEL 2 HOSP.
Emergency Service
Outpatient Service
Medical Social Service
Medical Records Section
Dental Service
Isolation Room
Surgical/Maternity Facility
Recovery Room
Prayer Room
Dietary
Security
Engineering/Maintenance
Housekeeping/Janitorial
Laundry/linen
Patient transport service/
ambulance
Nursing Service:
Provision for intermediate
to specialized nursing
care and management;
and highly specialized
critical care in Internal
Medicine, Pediatrics,
Obstetrics and
Gynecology, Surgery,
and Anesthesia
Clinical service:
a. Department of
Medicine
b. Department of
Pediatrics
c. Department of
Obstetrics and
Gynecology
d. Department of
Surgery
e. Others, specify
Ancillary service:
a. Clinical Laboratory
b. Blood Station
c. Radiology
d. Pharmacy
e. Others, specify
Other additional services:
a. Intensive Care/ICU
b.
c.
d.
e.
Pathologic/Premature/
NICU
High Risk Pregnancy
Care
Respiratory Therapy
Service/Unit
Others, specify
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Remarks
Compliant
LEVEL 3 HOSP.
Emergency Service
Outpatient Service
Accredited Residency
Training Program:
Internal Medicine
General Surgery
Clinical Service:
a. Department of Medicine
b. Department of
Pediatrics
c. Department of
Obstetrics and
Gynecology
d. Department of Surgery
e. Others, specify
Nursing Service:
a. Provision for
intermediate to
specialized nursing care
and management;
highly specialized
critical care in Internal
Medicine, Pediatrics,
Obstetrics and
Gynecology, Surgery,
and Anesthesia, and in
other specialty or subspecialties.
Remarks
Obstetrics and
Gynecology
Pediatrics
Others:
Ancillary Service:
Clinical Laboratory and
Histopathology
Blood Bank
Radiology
Pharmacy
Others, specify
Ambulatory Surgical
Clinic
Physical Medicine and
Rehabilitation Service
Others, specify
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Compliant
IX. SERVICES/ EQUIPMENT THAT MAY BE
OUTSOURCED
Remarks
Compliant
Remarks
X. POLICIES/ PROCEDURES/SAFETY PROGRAMS
Ambulance
Chemical
Biomedical
equipment
(ventilators)
Database (offsite)
Combustible Material
Dental Service
Dialysis
Dietary Service
Engineering
b. Emergency
Housekeeping/
Janitorial
c. Disaster
Preparedness
Maintenance
Information System
Mechanical
Laboratory
Mechanical Device
Linen/Laundry
Radiation
Maintenance
(medical and
non-medical
equipment)
Security
Parking
Utility systems
Physical Therapy
and Rehabilitation
Water
Respiratory
Therapy
Security
Waste Disposal
Others, specify
Waste Management
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Compliant
XI. DOH-BHFS PTC AND FLOOR PLAN
Remarks
Compliant
Remarks
XII. PERMITS/LICENSES FROM OTHER REGULATORY
AGENCIES
Latest approved
PTC
ECC
Latest approved
floor plan
Permit to operate a
generator set
(R.A.8749) and
elevator
Solid waste/water
discharge permit
(R.A.9003)
Toxic
substances/hazardous
waste generation
report (R.A. 6969)
*Refer to
INTEGRAL NOTES
1. The number of nurses required for the general nursing unit is 1:12 beds at any time.
2. The number of nurses required for the critical care units is 1:3 beds at any time.
3. The number of midwives/nursing attendants for the general nursing unit is 1:24 beds at any time.
4. The number of midwives/nursing attendants for the critical care units is 1:15 beds at any time.
5. There must be one reliever for every three nurses or midwives/ nursing attendants.
6. There must be one head nurse to supervise every fifteen staff nurses.
7. There must be one nurse supervisor for every 50 beds counted from the ABC.
8. There must be an assistant chief nurse/ nurse training officer for every 100 beds counted from the ABC.
9. There must be one nutritionist/dietician for every 100 beds counted from the ABC.
10. There must be one physician for every 20 beds counted from the ABC.
11. Plantilla items are not required to fill up hospital positions.
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Name of Hospital :
Date of Inspection:
RECOMMENDATIONS:
A.
For Licensing Process:
[ ]
For issuance of License as Hospital.
Validity from
to
[ ]
Issuance depends upon compliance to the recommendations given and submission of the
following within
days from the date of inspection:
[ ]
Inspected by:
Printed Name
Signature
Position/Designation
Received by:
Signature
Printed Name
Position/Designation
Date
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[ ]
[ ]
Others (Specify)
Monitored by:
Printed Name
Signature
Position/Designation
Received by:
Signature
Printed Name
Position/Designation
Date
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