SEARCH
Philippine Government Forms All in One Location
Tweet
Share
Annex M Infirmary
DOH assessment tool for licensing an infirmary
Your Browser Doesn't Support Canvas. Showing the Text Content of the PDF Instead: Republic of the Philippines
Department of Health
REGIONAL OFFICE _
ANNEX M
AO No. 2012-0012
ASSESSMENT TOOL FOR LICENSING AN INFIRMARY
GENERAL INSTRUCTIONS IN FILLING OUT THE TOOL:
1. The team shall make sure they have the complete set with the following:
Standards/Indicators for an Infirmary, Attachments A, B and C.
2. The team leader shall assign sections of the assessment tool to corresponding team
members.
3. The Licensing Officer shall make use of: DOCUMENT REVIEW, INTERVIEW AND
OBSERVATION to validate findings. The team members should not limit their tour to
the areas suggested under Column "AREAS".
4. If the corresponding items are present or available, place a check (√) on the column
“COMPLIED” opposite each box alongside each corresponding item; if not, put an (X).
5. The team shall document relevant observations both positive and negative, including
innovations and initiatives undertaken by the facility under "REMARKS" Column.
Indicate also if the service/s is/ are “ADD ON” in this column.
6. The Team Leader shall at the end of the inspection or monitoring visit, make sure that
the team members complete their respective tool sections.
7. The team leader shall ensure that all team members write down their printed names,
designation and affix their signature and indicate the date of inspection or monitoring at
the last page of the Assessment Tool.
8. The Team Leader shall make sure that the Head of the facility or, when not available, the
authorized next most senior or responsible officer affix his/her signature on the same
aforementioned pages and indicate the position, to signify that inspection or monitoring
results were discussed during the exit conference.
9. The team shall provide a copy of the accomplished and signed assessment tool to the
facility.
10. The assessment tool shall be used for self-assessment, inspection and monitoring
activities.
DOH-I-LTO-AT
Revision:02
08/05/2016
Page 1 of 32
ANNEX M
AO No. 2012-0012
I.
HEALTH FACILITY INFORMATION
Name of Facility: _____________________________________________________________________________
Address:
_____________________________________________________________________________
_____________________________________________________________________________
Geographic Coordinates of the Facility:
Latitude: _______________
Longitude: _______________
Email Address: _____________________________________
Tel. / Fax Nos.: __________________________
Name of Owner: ____________________________________
Tel. / Fax Nos.: __________________________
Hosp. Administrator: _________________________________
Tel. / Fax Nos.: __________________________
Chief of Hospital/Med. Director: _______________________
Tel. / Fax Nos.: __________________________
License To Operate: _________________________________
Authorized Bed Capacity: __________________
Classification: INFIRMARY
Government:
Private:
National
Single Proprietorship
Local
Corporation
Others: (specify) ____________________
Type of application:
Initial
Others: (specify) ____________________
Renewal
DOH-I-LTO-AT
Revision:02
08/05/2016
Page 2 of 32
ANNEX M
AO No. 2012-0012
DOH STANDARDS (Indicators) for INFIRMARY
CRITERIA
(This refers to the specific
and measurable indicators
that help determine
whether or not the
standard has been met.)
INDICATOR
(This is the
REQUIREMENT of the
standard. This is what
Licensing Officers will
look for. It refers to
measurable variables or
characteristics used to
determine the degree of
adherence to a standard.)
EVIDENCE
(Proof of compliance to
the indicator:
document, interview or
observation)
AREAS
(Not limited
to the
suggested
areas)
Put a check
if complied.
REMARKS
I.
PATIENT RIGHTS AND ORGANIZATIONAL ETHICS
Goal: To improve patient outcomes by respecting patients' rights and ethically relating with patients and other
organizations
Standard: Organizational policies and procedures respect and support patients' rights to quality care and their
responsibilities in that care. (A standard shall be expressed as a general statement. This is the ideal
performance.)
1. Informed consent is
All patient charts have
Wards
DOCUMENT
obtained from patients
signed consent.
Patients charts – get
prior to initiation of
charts of patients
care.
currently admitted. If
hospital is
departmentalized, get
Note: *Informed consent samples during tour of
includes a patient-doctor
the different
discussion of the nature of
departments.
the decision or
procedure; alternatives to
INTERVIEW
Ask patient/family from
the proposed
the wards/ICU if they
intervention; the risks,
were appropriately
benefits, and uncertainties
informed by authorized
related to each
personnel (doctor or
alternative; assessment to
nurse) about their disease,
patient understanding;
condition or disability, its
and patient's acceptance
severity, prognosis,
or refusal of the
benefits and possible
intervention.
adverse effects of
treatment options and the
likely cost of treatment.
2. Policies and
procedures which
identify and address
patients’ rights and
responsibilities are
documented and
monitored.
Presence of policies and
procedures to identify
and address patients'
rights:
DOCUMENT
REVIEW
Policies and procedures
on patients' rights.
1. Right to information
2. Right to refuse
treatment
3. Right to privacy
4. Right to personal
choice
5. Right to care and
security of personal
belongings
6. Right to freedom
from restraint
7. Right to freedom
from abuse,
mistreatment and
abuse, etc.
Wards
INTERVIEW
May ask a staff (doctor
or nurse) to enumerate
patients’ rights or ask
some patients at
random if their rights
were explained to them.
OBSERVE
If patients’ rights are
posted in conspicuous
places.
DOH-I-LTO-AT
Revision:02
08/05/2016
Page 3 of 32
ANNEX M
AO No. 2012-0012
CRITERIA
INDICATOR
EVIDENCE
AREAS
COMPLIED
REMARKS
II. PATIENT CARE
A. ACCESS
Goal: The organization is accessible to the community that it aims to serve.
Standard: The organization informs the community about the services it provides and the hours of their
availability.
3. Clinical services are
Presence of facilities
ER
DOCUMENT
appropriate to patients' consistent with clinical
OPD
REVIEW
needs and the former's
service capability as
1. List of services
availability is
stipulated in its DOH
available.
consistent with the
LTO which is posted and 2. DOH LTO (updated,
organization's service
displayed in a
valid and original).
capability and role in
conspicuous area visible
the community.
to clients.
OBSERVE:
The facilities, and
structure. Check if the
service capability of the
infirmary is in
accordance with the
health facility level.
including “Add On”
Services
Medical
4. CLINICAL
DOCUMENT
Records
SERVICES FOR
REVIEW
Check final diagnosis
Room
INFIRMARY
Minimal to Intermediate
and interventions done
Wards
care and management in
in the logbook /record
the following areas:
of Admission/patients
- Medicine,
charts.
- Pediatrics.
- Non-surgical
Obstetrics and
Gynecology
- Minor Surgery
Wards,
5. NURSING
DOCUMENT
ER, OPD
SERVICES
REVIEW
Minimal to Intermediate
Check final diagnosis
Nursing Care and
and interventions done
management in the
in the logbook /record
following areas:
of Admission
- Medicine,
- Pediatrics.
OBSERVE
- Non-surgical
How patients are
Obstetrics and
managed and cared for.
Gynecology
- Minor Surgery
INTERVIEW
Staff what services are
being provided.
DOH-I-LTO-AT
Revision:02
08/05/2016
Page 4 of 32
ANNEX M
AO No. 2012-0012
CRITERIA
INDICATOR
6. Entrances and exits
are clearly and
prominently marked,
free of any
obstruction and
readily accessible.
Presence of entrances
and exits that are readily
accessible and free from
obstruction
7. Directional signs are
prominently posted to
help locate service
areas within the
organization.
Presence of directional
signages to locate
service areas
8. Alternative
passageways for
patients with special
needs (e.g. ramps) are
available, clearly and
prominently marked
and free of any
obstruction.
Presence of alternative
passageways (ramps,
elevators) that are
prominently marked and
free from obstruction for
patients with special
needs
EVIDENCE
OBSERVE
1. With entrance and
exit signs. Check ER,
OPD and wards
2. Entrances and exits
are accessible and free
from any obstruction
Note: Exit signs should
be luminous or
illuminated and
prominently marked.
There should be exit
signs in major areas of
the hospital and all
doors leading to the
outside.(Reference: RA
6541 Building Code of
the Philippines)
OBSERVE
Directional signs are
prominently posted.
Check ER, OPD, wards
and lobby.
OBSERVE
Check:
1. Alternative
passageways for
patients with
special needs.
2. They are
prominently
marked
3. They are free from
obstruction.
AREAS
COMPLIED
REMARKS
ER
OPD
Wards
ER
OPD
Wards
Others
(Lobby)
ER
OPD
Wards
DOH-I-LTO-AT
Revision:02
08/05/2016
Page 5 of 32
ANNEX M
AO No. 2012-0012
CRITERIA
INDICATOR
EVIDENCE
AREAS
COMPLIED
REMARKS
B. ENTRY
Goal: The entry process meet patient needs and are supported by effective systems and a suitable environment
Standard: The organization uniquely identifies all patients including newborn infants, and creates a specific
patient chart for each patient that is readily accessible to authorized personnel.
9. All patients are
The contents of patient's
ER
DOCUMENT
correctly identified by charts
Patient chart from ER,
OPD
their patient charts.
are the following:
ward, and OPD
Wards
1. Summary or face
sheet
INTERVIEW
2. Doctor's order
verify with patient if
3. Informed Consent
he/she really is the
4. TPR graphic sheet
person indicated in the
5. History and Physical
chart.
Examination
6. Maternal Record with
Partograph (if
warranted)
7. Newborn record and
maturity rating, (if
warranted)
8. Doctor's progress
notes
9. Medication and/or
treatment record
10. Laboratory and X-ray
reports, if any
11. Nurses Notes
12. Record of referral or
transfer of patient to
other
facility/service/doctor
including notes
13. Discharge summary
14. Clinical abstract
Goal: The health care team develops in partnership with the patients a coordinated plan of care with goals.
Standard: The care plan addresses patient's relevant clinical, social, emotional and religious needs
10. Coordinated plan of
Presence of
Wards
DOCUMENT
care with goals.
adopted/developed
Proof of
ER
protocols, CPGs
implementation of
OPD
adopted/developed
protocols, CPGs.
Footnote: Clinical
pathways derived from
clinical practice
guidelines and other
types of clinical
evidence should be
developed or
implemented for the top
5 cases of admissions
and/or consultations
DOH-I-LTO-AT
Revision:02
08/05/2016
Page 6 of 32
ANNEX M
AO No. 2012-0012
CRITERIA
INDICATOR
EVIDENCE
AREAS
COMPLIED
REMARKS
Goal: Comprehensive assessment of every patient enables the planning and delivery of patient care
Standard: Each patient's physical, psychological and social status is assessed
11. An appropriate
All patients have
Wards
DOCUMENT
comprehensive
comprehensive history
Patient chart from
history and physical
and PE within 48 hours
wards
examination is
from admission.
performed on every
patient within 48
hours from admission.
The history includes
present illness, past
medical, family,
social and personal
history.
Standard: Appropriate professionals perform coordinated and sequenced patient assessment to reduce waste
and unnecessary repetition.
12. Previously obtained
All patient charts have
Medical
CHART REVIEW
information is
progress notes by
Patient chart from
records
reviewed at every
doctors and other health
medical records/wards.
room Wards
stage of the
professionals.
assessment to guide
Note: The progress
future assessments
notes should be done
regularly and
documented in the
patient chart either as
separate progress
notes' sheets or
separate column
C. IMPLEMENTATION OF CARE
Goal: Care is delivered to ensure the best possible outcomes for the patients
Standard: Medicines are administered in a standardized and systematic manner
13. Medicines are
All medicines are
Wards
CHART REVIEW
administered in a
administered observing
Check patients charts
timely, safe,
the five (5) R's of
from the wards:
appropriate and
medication which are:
For the accuracy of
controlled manner
medicine
1. Right patient
administration
2. Right medication
3. Right dose
4. Right route
5. Right time
14. Only qualified
personnel order,
prescribe, dispense
prepare, and
administer drugs.
All doctors, pharmacists
and nurses have updated
licenses
INTERVIEW
Randomly check the
licenses of some
doctors, nurses and
pharmacists if they are
updated.
Wards
ER
OPD
DOH-I-LTO-AT
Revision:02
08/05/2016
Page 7 of 32
ANNEX M
AO No. 2012-0012
CRITERIA
15. Prescriptions or
orders are verified
and patients are
identified before
medications are
administered
16. Prescriptions or
orders are verified
and patients are
identified before
medications are
administered
INDICATOR
Proof that prescriptions
or orders are verified
before medications are
administered
Proof that patients are
correctly identified
prior to administration
of medications
EVIDENCE
INTERVIEW
Ask staff how they
verify orders from
doctors prior to
administration of
medicines.
OBSERVE
if staff verifies the
prescriptions or orders
for medicines with the
doctor’s order.
Note: This is on case to
case basis; includes the
route of administration
(slow IV) and other
precautionary
measures/instruction
e.g.. ANST
INTERVIEW
Verify from patients if
they were correctly
identified prior to drug
administration.
AREAS
COMPLIED
REMARKS
Wards
ER
Wards
ER
OBSERVE
if the staff verifies the
identity of patient prior
to administration of
medications (patient
should be the one to state
his/her name.)
CHART REVIEW
Medication sheet in
patient chart.
17. Medicine
All charts have proper
Medical
administration is
documentation of
records
properly documented
medicine
office
in the patient chart
administration.
wards
D. EVALUATION OF CARE
Goal: The health care team routinely and systematically evaluates and improves the effectiveness and efficiency
of care delivered to patients.
Standard: The discharge plan is part of the patient's care plan and is documented in the patients’ chart.
18. Discharge plans for
All charts have
Medical
CHART REVIEW
patients to ensure
discharge plans.
Patients' charts from
records
continuity of care.
medical records, look at
room
the discharge orders. It
wards
should contain all of the
following:
1. May go home order
2. Home medications
(if applicable)
3. Follow up
visits/schedule
4. Home care/advise
Note: Discharge plan is
not synonymous with
discharge summary.
DOH-I-LTO-AT
Revision:02
08/05/2016
Page 8 of 32
ANNEX M
AO No. 2012-0012
CRITERIA
INDICATOR
EVIDENCE
AREAS
COMPLIED
REMARKS
III. LEADERSHIP AND MANAGEMENT
A. MANAGEMENT REVIEW
Goal: The organization effectively and efficiently governed and managed according to its values and goals to
ensure that care produces the desired health outcomes, and is responsive to patient's and community needs
Standard: The provider organization's management team provides leadership, acts according to the
organization's policies and has overall responsibility for the organization's operation, and the quality of its
services and its resources
19. Organizational
Structure/Chart
20. The organization and
its services develop
their vision, mission
and corporate goals
based on agreed-upon
values
21. The organization and
its services develop
their policies and
procedures.
22. Committees within
the organization
which includes the
terms of reference for
membership
23. Evaluation and
monitoring activities
to assess management
and organizational
performance
Presence of
organizational structure
Presence of written
vision, mission, and
goals of the hospital
and all
services/departments
Written policies and
procedures manual for
all services /
departments / units
Proof of the creation of
all committees within
the organization which
includes the terms of
reference for
membership.
The following are the
committees required:
1. Credentialing and
privileging
2. Waste Management
3. Patient Safety
4. Infection Control
5. Emergency and
Disaster
Preparedness
6. CQI
7. Grievance
8. Selection and
Promotions
Presence of evaluation
and monitoring
activities to assess
management and
organizational
performance
OBSERVE
Observe if the
organizational structure /
chart is posted in
appropriate area.
DOCUMENT
REVIEW
Written vision, mission
and goals
DOCUMENT
REVIEW
1.Written Policies
2.Procedure manual
DOCUMENT
REVIEW
Proof of the creation of
all committees which
includes the terms of
reference for
membership e.g. memo,
office order, etc.
- written policies and
procedures
- minutes of meetings of
the different committees
Other Areas
Lobby
Medical,
Nursing and
Administrative Services
Medical,
Nursing and
Administrative Services
Administrative office
INTERVIEW
Ask members of the
different committees
their functions, how
often they meet, etc.
DOCUMENT
REVIEW
Accomplishment reports
or other annual reports as
applicable
Administrative Office
DOH-I-LTO-AT
Revision:02
08/05/2016
Page 9 of 32
ANNEX M
AO No. 2012-0012
CRITERIA
INDICATOR
EVIDENCE
AREAS
COMPLIED
REMARKS
B. OUTSOURCED SERVICES
24. Outsourced services
are within the facility
if applicable.
Presence of
memorandum of
agreement/contract for
all outsourced services
DOCUMENT
REVIEW
1. Contracts/MOA for
outsourced services
2. Valid licenses of all
providers
Administrative Office
OBSERVE
Actual presence of the
outsourced services
within the hospital if
applicable
● Disinfection of
laundry
C. Security
DOCUMENT
REVIEW
- Check policies and
procedures in the dietary.
- Monthly menu for
patients
DOCUMENT
REVIEW
Check procedures on
how soiled linens are
collected disinfected and
washed.
DOCUMENT
REVIEW
Security check for
internal and external
customers including use
of visitor’s pass
D. Housekeeping /
Janitorial
Policies and procedures
on security of patients,
visitors and hospital
staff
E. Proper Waste
Disposal
Policies and
procedures on proper
waste disposal.
Administrative Office
ADMINISTRATIVE SERVICES
A. Dietary
If not contracted out,
there shall be
maintenance and
provision of safe,
quality and nutritious
food to patients and
personnel.
B. Linen/ Laundry
If not contracted out,
there shall be
● Sorting of soiled and
contaminated linens in
designated areas
F. Maintenance
G. Ambulance
Proof of
implementation of
policies and procedures
(Use separate
assessment tool for
Ambulance)
DOCUMENT
REVIEW
Proof of implementation
of policies and
procedures on proper
waste disposal.
OBSERVE
INTERVIEW
Lobby
ER / OPD
Wards
OBSERVE
INTERVIEW
DOH-I-LTO-AT
Revision:02
08/05/2016
Page 10 of 32
ANNEX M
AO No. 2012-0012
CRITERIA
INDICATOR
EVIDENCE
AREAS
COMPLIED
REMARKS
IV. HUMAN RESOURCE MANAGEMENT
A. HUMAN RESOURCES PLANNING
Standard: Workload is monitored and appropriate guidelines consulted to ensure that appropriate staff
numbers and skill mix are available to achieve desired patient and organizational outcomes.
25. The organization
documents and
follows policies and
procedures for hiring,
credentialing, and
privileging of its staff.
Presence of policies and
procedures for hiring,
credentialing and
privileging of staff
26. Staff numbers and
skill mix are based on
actual clinical needs.
Staff to bed ratio for
licensed doctors,
registered nurses and
midwives/nursing aides
follows the DOH
prescribed ratio. (Refer
to personnel
requirement sheet)
DOCUMENTREVIEW
Policies and procedures
for hiring, credentialing
and privileging of staff
INTERVIEW
DOCUMENTREVIEW
201 files of employees.
Personnel
/Administrative office
Personnel
/Administrative office
Wards
B. STAFF RECRUITMENT, SELECTION, APPOINTMENT AND RESPONSIBILITIES
Goal: Recruitment, selection and appointment of staff comply with statutory requirements and are consistent
with the organization's human resource policies.
Standard: There are relevant orientation, training and development programs to meet the educational needs of
management and staff.
27. Annual plan on
training activities
Presence of annual plan
on training activities
DOCUMENTREVIEW
Annual plan (including
resource/budgetary
allocation) on training
activities
Personnel
/Administrative office
C. STAFF TRAINING AND DEVELOPMENT
Goal: A comprehensive program of staff training and development meets individual and organizational needs.
Standard: There are relevant orientation, training and development programs to meet the educational needs of
management and staff.
28. New personnel , new
graduates and external
contractors- are
adequately supervised
by qualified staff
Proof that new
personnel are
adequately oriented and
supervised
DOCUMENT
REVIEW
Documentation of
orientation conducted
Personnel
/Administrative office
INTERVIEW
Ask new personnel about
the lines of authority and
supervision and if the
supervision is adequate
29. The staff are provided
with a documented
job description
outlining
accountabilities and
responsibilities
Proof that staff are
provided with job
description outlining
their accountabilities
and responsibilities
OBSERVE
DOCUMENT
REVIEW
Written job descriptions
with conforme
Personnel
/Administrative office
DOH-I-LTO-AT
Revision:02
08/05/2016
Page 11 of 32
ANNEX M
AO No. 2012-0012
CRITERIA
INDICATOR
EVIDENCE
AREAS
COMPLIED
REMARKS
V. INFORMATION MANAGEMENT
A. DATA COLLECTION AND AGGREGATION
Goal: Collection and aggregation of data are done for patient care, management of services, education and
research.
Standard: Relevant, accurate, quantitative and qualitative data are collected and used in a timely and efficient
manner for delivery of patient care and management of services
30. The organization
defines data sets, data
generation, collection
and aggregation
methods and the
qualified staff who
are involved in each
stage
31. The organization
defines data sets, data
generation, collection
and aggregation
methods and the
qualified staff who
are involved in each
stage
Presence of annual
statistical reports and
other additional
hospital statistics as
determined by the
management
DOCUMENT
REVIEW
Compilation of Annual
Statistical Report for
Infirmary
Medical
records
room
Presence of qualified
staff involved in data
definition, generation,
collection and
aggregation
DOCUMENTREVIEW
Policies and procedures
on record storage,
safekeeping and
maintenance, retention
and disposal
Medical
records
room
Note: Policies and
procedures on records
management are updated
every 5 years
- Records disposal shall
be in accordance with
the guidelines set by
National Archives of the
Philippines (NAP) per
DC No. 70 s. 1996.
B. RECORDS MANAGEMENT
Goal: Integrity, safety, access and security of records are maintained and statutory requirements are met.
Standard: Clinical records are readily accessible to facilitate patient care, are kept confidential and safe, and
comply with all relevant statutory requirements and codes of practice.
32. When patients are
Presence of policies and OBSERVE
Medical
admitted or are seen
procedures on filing
Ask the medical records
Records
for ambulatory or
and retrieval of charts
officer to retrieve a
Room /
emergency care,
chart, then note the
Office
patient charts
actual length of time of
documenting any
retrieval
previous care can be
Note: If organization
quickly retrieved for
has not set a time
review, updating and
interval, use 5 minutes
concurrent use.
DOH-I-LTO-AT
Revision:02
08/05/2016
Page 12 of 32
ANNEX M
AO No. 2012-0012
CRITERIA
INDICATOR
EVIDENCE
33. The organization has
policies and
procedures, and
devotes resources,
including
infrastructure, to
protect records and
patient charts against
loss, destruction,
tampering and
unauthorized access
or use. Only
authorized individuals
make entries in the
patient chart.
Presence of procedures
to protect records and
patient charts against
loss, destruction,
tampering and
unauthorized access or
use
DOCUMENT
REVIEW
Policies and procedures
on records management
to maintain
confidentiality/privacy,
accuracy and prevention
of loss and destruction,
tampering and
unauthorized access.
AREAS
COMPLIED
REMARKS
Medical
Records
Room /
Office
Wards
DOCUMENT
Logbooks for borrowing
and retrieval of charts
OBSERVE
- nurses in the wards
and records personnel on
how they
protect patient chart
VI. SAFE PRACTICE AND ENVIRONMENT
A. PATIENT AND STAFF SAFETY
Goal: Patients, staff and other individuals within the organization are provided a safe, functional and effective
environment of care
Standard: The organization plans a safe and effective environment of care consistent with its mission, services,
and with laws and regulations
34. The organizational
Presence of updated
DOCUMENTREVIEW Adminisenvironment complies DOH license to operate Updated DOH license
trative office
with structural
standards and safety
codes as prescribed
by law
35. Presence of a
management plan,
policies and
procedures
addressing safety
36. There are
management plans for
the safe and efficient
use of medical
equipment according
to specifications.
Presence of a
management plan,
policies and procedures
addressing:
1. Safety
2. Security
3. Disposal and control
of hazardous
materials and
biologic wastes
4. Emergency and
disaster
preparedness
Preventive Maintenance
Program of equipment
DOCUMENT
REVIEW
Management plan,
policies and procedures
INTERVIEW
Ask about the frequency
of the following:
1. Fire drill conducted in
the past 12 months
2. Earthquake drill
conducted in the past
12 months
DOCUMENT
REVIEW
Proof of implementation
of Preventive
Maintenance Program of
equipment.
Administrative office
Maintenance
office,
ER
Wards
ER
OPD
Wards
DR
Maintenance
Office
Presence of operating
manuals of the medical
equipment
DOH-I-LTO-AT
Revision:02
08/05/2016
Page 13 of 32
ANNEX M
AO No. 2012-0012
CRITERIA
INDICATOR
EVIDENCE
37. Design of patient
areas provides
sufficient space for
safety, comfort and
privacy of the patient
and for emergency
care.
Presence of adequate
space, lighting and
ventilation in
compliance with
structural requirements
(for patient safety and
privacy)
38. A coordinated
security arrangement
in the organization
assures protection of
patients, staff and
visitors.
Presence of an
appointed personnel in
charge of security.
OBSERVE
Observe for the
following:
1. Adequate space
2. Adequate lighting
(lights are working,
lighting is adequate
enough for conduct of
general activities)
3. Adequate ventilation
DOCUMENT
REVIEW
Contract or Appointment
of person in charge of
security.
AREAS
COMPLIED
REMARKS
ER
OPD
Wards
DR
INTERVIEW
Ask the personnel in
charge of security what
the policies on security
are.
OBSERVE
Security measures
Standard: The organization plans a safe and effective environment of care consistent with its mission, services,
and with laws and regulations.
39. An incident reporting
system identifies
potential harms,
evaluates causal and
contributing factors
for the necessary
corrective and
preventive action
Presence of incident
AdminisDOCUMENT
reporting
trative office
REVIEW
system/sentinel event
Record of sentinel events
monitoring system
(which may include
hospital associated
infections, unexpected
deaths, adverse drug
reactions, blood
transfusion reactions,
falls, etc.)
B. MAINTENANCE OF THE ENVIRONMENT OF CARE
Goal: A comprehensive and maintenance program ensures a clean and safe environment
Standard: Emergency light and / or power supply, water and ventilation systems are provided for, in keeping
with relevant statutory requirements and codes of practice.
40. Generator /
Presence of generator /
Maintenance
DOCUMENT
emergency light,
emergency light, water
Other
REVIEW
water system,
system, adequate
Check result of water
Relevant
adequate ventilation
ventilation or air
analysis for the last 6
Areas
or air conditioning
conditioning.
months.
OBSERVE
1. Test if faucets and
water closets are
working
2. If emergency lights
and generators are
functional.
DOH-I-LTO-AT
Revision:02
08/05/2016
Page 14 of 32
ANNEX M
AO No. 2012-0012
CRITERIA
41. Training of the staff
who is in charge of
the maintenance of
the equipment
INDICATOR
EVIDENCE
AREAS
Proof of training of the
staff who is in charge of
the maintenance of the
equipment
DOCUMENT
REVIEW
Certificate of training of
service personnel if inhouse or Certificate of
training or
MOA/Contract for
outsourced services
(verify qualification of
technicians)
COMPLIED
REMARKS
Maintenance
Office
INTERVIEW
Ask about how are
maintained
Standard: Current information and scientific data from manufacturers concerning their products are available
for reference and guidance in the operation and maintenance of plant and equipment.
42. Operating manuals of Presence of operating
Engineering/
DOCUMENT
equipment
manuals equipment
Operating manual of
Maintenance
Medical equipment,
Office
generators, air
Imaging,
conditioners and other
Laboratory
non-medical equipment.
C. INFECTION CONTROL
Standard: An interdisciplinary infection control program ensures the prevention and control of infection in all
services.
43. Physician and nurse
A designated doctor
Nurse
DOCUMENT
in charge of infection
and nurse in-charge of
SuperREVIEW
control.
infection control
1. Proof of designation
visor’s
of a doctor and nurse
Office
in-charge of infection
control with their
functions.
2. Statistics on hospital
associated infections
INTERVIEW
Ask about their activities
related to infection
control.
DOH-I-LTO-AT
Revision:02
08/05/2016
Page 15 of 32
ANNEX M
AO No. 2012-0012
CRITERIA
INDICATOR
EVIDENCE
AREAS
COMPLIED
REMARKS
Standard: The organization uses a coordinated system-wide approach to reduce the risks of healthcareassociated infections.
44. Organization takes
Presence of a
ER
DOCUMENT
steps to prevent and
coordinated systemWards
REVIEW
control outbreaks of
wide procedure for
Validate hospital policies
healthcare associated
prevention of hospital
on infection control such
infections.
associated infections
as use of PPEs, isolation
precautions and hand
washing.
OBSERVE
1. Use of gloves,
surgical masks, etc.
(check if they have
enough supplies of
PPEs.)
2. Sinks or lavatories or
designated areas for
hand washing or
dispenser for
sanitizers
3. Ask a hospital staff to
demonstrate hand
washing.
INTERVIEW
Ask staff their policies
on needle stick injury
45. There are programs
Presence of policies and
ER
for prevention and
procedures on the
Wards
treatment of needle
prevention and
stick injuries, and
treatment of needle
policies and
stick injuries and safe
OBSERVE
procedures for the
disposal of needles
Use of PPEs in doing
safe disposal of used
minor surgeries, IV
needles are
insertions, etc.
documented and
monitored
Standard: Cleaning, disinfecting, drying, packaging and sterilizing of equipment, and maintenance of associated
environment, conform to relevant statutory requirements and codes of practice.(Annex B of A.O. No. 20120012: DOH Guidelines in the Cleaning, Disinfecting, Drying, Packaging and Sterilizing of Reusable Items
in Hospitals and Other Health Facilities).
46. Policies and
Presence of policies and DOCUMENT
CSSU
procedures on
procedures on cleaning, REVIEW
cleaning, disinfecting, disinfecting, drying,
Policies and procedures
drying, packaging and packaging and
on cleaning, disinfecting,
sterilizing of
sterilizing of
drying, packaging and
equipment,
equipment, instruments sterilizing of equipment,
instruments and
and supplies
instruments and supplies
supplies.
OBSERVE
Standard: When needed, the organization reports information about infections to personnel and public health
agencies.
47. Policies and
Presence of policies and DOCUMENT
procedures in
procedures in reporting REVIEW
reporting notifiable
notifiable diseases
Copies of reports
diseases (Refer to AO
submitted to PIDSR.
No. 2008-0009).
DOH-I-LTO-AT
Revision:02
08/05/2016
Page 16 of 32
ANNEX M
AO No. 2012-0012
CRITERIA
INDICATOR
EVIDENCE
AREAS
COMPLIED
REMARKS
D. ENERGY AND WASTE MANAGEMENT
Standard: The handling, collection and disposal of waste conform with relevant statutory requirements and code
of practice
48. Licenses/permits/
clearances from
pertinent regulatory
agencies
49. Policies and
procedures on waste
disposal
Presence of
licenses/permits/
clearances from
pertinent regulatory
agencies implementing:
1. RA 9003 (Ecological
Solid Waste
Management Act)
2. RA 9275 (Philippine
Clean Water Act)
3. PD 1586
(Establishing An
Environmental
Impact Statement
System, Including
Other Environmental
Management Related
Measures and for
other Purposes
4. RA 8749 (Clean Air
Act)
Healthcare Waste
Manual, 3rd Revision
roof of implementation
of policies and
procedures on waste
disposal
Administrative office
DOCUMENT
REVIEW
1. Issuances - memos,
guidelines on waste
segregation, treatment
and disposal.
2. Contracts with waste
handlers or disposal
contractors, (if
applicable)
OBSERVE
1. Segregation of waste
2. Proper labelling of
waste receptacles
3. Recyclable waste
staging areas
4. Proper management
of temporary storage
areas prior to hauling
for disposal.
DOH-I-LTO-AT
Revision:02
08/05/2016
Page 17 of 32
ANNEX M
AO No. 2012-0012
CRITERIA
INDICATOR
EVIDENCE
AREAS
COMPLIED
REMARKS
VII. IMPROVING PERFORMANCE
Goal: The Organization continuously and systematically improves its performance by invariably doing the right
thing the right way the first time and meeting the needs of its internal and external clients.
Standard: The organization has a planned systematic organization- wide approach to process design and
performance measurement, assessment and improvement.
50. Continuous Quality
Presence of Quality
AdminisDOCUMENT
Improvement
Improvement Program
trative
REVIEW
Program
CQI plan and proof of
Office
implementation
INTERVIEW
Ask about their activities
on CQI.
Standard: The organization provides better care service as a result of continuous quality improvement activities
51. Customer satisfaction Presence of customer
AdminisDOCUMENT
survey
satisfaction survey
trative
REVIEW
1. Domains of the
Office
survey form used.
2. Survey results and
how complaints /
comments are acted
upon.
52. Better patient
Proof of better patient
AdminisDOCUMENT
outcome.
outcomes
trative
REVIEW
Documentation of better
Office
outcomes for patients as
a result of CQI activities,
e.g. declining trends of
hospital associated
infections and increase
in patient satisfaction
rating.
VIII. DOH PROGRAMS IMPLEMENTED IN HOSPITALS AND OTHER HEALTH FACILITIES
53. Newborn Screening
Newborn Screening – in
compliance to RA 9288
and its IRR
54. Mother– baby
Friendly Facility
Mother –Baby
Friendly Workplace
Mother- Baby Friendly
Hospital Initiative – in
compliance to RA 7600
and RA 10028 and its
IRR, and Executive
Order No. 51 (Milk
Code)
Newborn Screening
being implemented.
Certified “Mother –
Baby Friendly Hospital
Facility
DOCUMENT
REVIEW
- Logbook of Newborns
who were tested and
copies of waiver for
those who were not
screened
- OR of filter papers
DOCUMENT
REVIEW
MBFHI Certificate
(MOU for those who are
not certified yet).
Policies on Mother –
baby Friendly Facility
and Mother –Baby
Friendly
Workplace
OB Ward
(Rooming
In)
OB Ward
OBSERVE
There shall be no nursery
for normal newborns
DOH-I-LTO-AT
Revision:02
08/05/2016
Page 18 of 32
ANNEX M
AO No. 2012-0012
55. Immunization of
newborn babies with
BCG and first dose
Hepatitis B vaccine
Newborn babies given
BCG and first dose
Hepatitis B vaccine
Immunization – in
compliance to RA No.
306
56. Hospital is a “No
Smoking zone
Policies and procedures
on anti-smoking
Policies and procedures
on generic prescribing
Generic Prescribing – in
compliance to RA 6675
(Generics Act of 1988)
58. Emergency
Preparedness,
Response and
Recovery Plan
With designated
HEMS Coordinator
Health Emergency
Management Services
(HEMS) – in compliance
to AO 2004-0168
"National Policy on
Health Emergencies and
Disasters"
59. Newborn Hearing
Screening
Universal Newborn
Hearing Screening – in
compliance to RA 9709
(Universal Newborn
Hearing Screening Act)
OB Ward
OBSERVE
Anti-smoking – in
compliance to RA 9211
57. Generic prescribing
and recording
DOCUMENT
REVIEW
Records of Newborns
given BCG and first dose
Hepa-B vaccine
Newborn Hearing
Screening being
implemented
INTERVIEW STAFF
DOCUMENT
REVIEW
Policies and procedures
on anti-smoking
OBSERVE
“No Smoking” signages
DOCUMENT
REVIEW
- Prescriptions filled in
the Pharmacy
- Physicians’ orders in
patients’ charts
- Documentation of
nurses on medicines.
DOCUMENT
REVIEW
- Hospital/Office order
designating one
- Proof of
implementation of the
plan
- Documentation of
drills/exercises
conducted
- Emergency
Preparedness,
- Response and
Recovery Plan
- Documentation of
drills conducted.
OBSERVE
Exit plans posted in all
hallways and rooms
DOCUMENT
REVIEW
Logbook of Newborns
who were tested on
hearing
Hallways
Wards
Pharmacy, if
applicable
ER
OB wards
DOH-I-LTO-AT
Revision:02
08/05/2016
Page 19 of 32
ANNEX M
AO No. 2012-0012
CRITERIA
INDICATOR
EVIDENCE
AREAS
60. Family planning
service
Presence of Family
planning services
Implementation of
National TB Program
DOCUMENT
REVIEW
- Presence of Hospital
TB Referral Logbook
- List of Diagnosed TB
Cases Notified (with
received remarks by
DOH-Regional Office)
REMARKS
OPD
OB wards
Family planning – in
compliance to RA
10354 (Responsible
Parenthood and
Reproductive Health
Act of 2012)
61. National Tuberculosis
Program
DOCUMENT
REVIEW
List of FP acceptors
-Referral
System to other facilities
for FP. If conscientious
objector.
COMPLIED
OPD
Wards
NTP – in compliance
with RA 10767
(Comprehensive TB
Elimination Plan Act)
DOH-I-LTO-AT
Revision:02
08/05/2016
Page 20 of 32
ANNEX M
AO No. 2012-0012
ASSESSMENT TOOL FOR INFIRMARY
ATTACHMENT A - INFIRMARY PERSONNEL
POSITION
QUALIFICATION
Chief of Hospital
/Medical Director
EVIDENCE
DOCUMENT REVIEW
- Updated PRC license /
Certificates of Trainings
attended
- Proof of Employment /
Appointment
Administrative
Officer/
Personnel officer
Accountant or
Accounting Clerk
Bachelor’s Degree
Medical Records
officer
Bachelor's Degree
And Training in ICD
10 and Medical
Records Management
Bachelor’s Degree in
Accountancy
Billing
Clerk/cashier
Clerk, Pool
Supply Officer/Storekeeper
Building
Maintenance
Man/Utility
Worker
Laundry Worker
Driver
Physician
COMPLIED
REMARKS
1
1
1
DOCUMENT REVIEW
- Diploma/Certificate of
Units earned /
Certificates of Trainings
attended
- Proof of Employment /
Appointment
1
1
DOCUMENT REVIEW
- Certificates of Trainings
attended
- Proof of Employment /
Appointment
Relevant training
(May be outsourced)
1
1:50
beds
11
1 per
shift
1
1
Professional driver's
license
Cook
Security Guard
(May be
outsourced)
NUMBER /
RATIO
1
1 per shift
DOCUMENT REVIEW
Certificates of Trainings
attended
Updated Professional
Regulatory
Commission license
DOCUMENT REVIEW
- Diploma
- Updated PRC license
- Certificate of
employment
- Proof of employment
1:20 beds at
any time
(Shall not go
on duty for
more than 48
hours).
DOH-I-LTO-AT
Revision:02
08/05/2016
Page 21 of 32
ANNEX M
AO No. 2012-0012
POSITION
Supervising
Nurse/Nurse
Managers
Head Nurse/Senior
Nurse
Staff Nurse
Nursing Attendant
(NA) there shall be
1 reliever for every
3 Nursing
Attendant
Delivery Room
Nurse; number
may increase
depending on the
number of cases
Emergency Room
Nurse/OPD; may
increase depending
on the number of
patients
QUALIFICATION
With updated
Professional
Regulatory
Commission license,
with at least nine (9)
units of Master's
Degree in Nursing
with 3 years hospital
experience.
Updated Professional
Regulatory
Commission License
-With 3 years hospital
experience
Updated Professional
Regulatory
Commission License
With relevant training
(may be in house
training)
-With updated
Professional
Regulatory
Commission license
and Training in
Maternal and
-Child Nursing (may
be in house training or
training in EINC)
-With updated
Professional
Regulatory
Commission license
and
-Certificate of
Training in ACLS
EVIDENCE
NUMBER /
RATIO
COMPLIED
REMARKS
1
DOCUMENT REVIEW
- Diploma
- Updated PRC license
- Certificate of
employment
- Proof of employment
DOCUMENTS REVIEW
Certificates of Trainings
attended
1:15 Nurses
1:12 Beds at
any time (1
reliever for
every 3 RNs)
1:24 beds at
any time( 1
reliever for
every 3 NAs
1/ DR/
Shift
1/shift
DOH-I-LTO-AT
Revision:02
08/05/2016
Page 22 of 32
ANNEX M
AO No. 2012-0012
ASSESSMENT TOOL FOR INFIRMARY
ATTACHMENT B - INFIRMARY PHYSICAL PLANT
PHYSICAL FACILITY
DESCRIPTION
COMPLIED
REMARKS
ADMINISTRATIVE SERVICE
Waiting Area
Admitting and Records Area
Public Toilet
(Male/Female/PWD)
Administrative and Business
Office
Office of the Chief of Hospital /
Medical Director
Provided with water; clean and
free from foul odor
Supply/Linen room
Laundry Area
Janitor’s Closet
Parking Area for transport vehicle
Central Waste Storage Area
Shall have color-coded
segregation; clean and free from
foul odor
Kitchen
Supply receiving Area
Dry and Cold Storage Area
Food preparation Area
Cooking Area
(not required if contracted-out)
Shall have adequate space, clean
and Free from foul odor; no insects
and rodents.
Dishwashing Area
Dining Area
Garbage Area
Medical Records Office
With area for completion of
patients' charts by physicians and
other professionals
Cadaver Holding Area
CLINICAL SERVICE
EMERGENCY ROOM /
EMERGENCY DEPARTMENT
(May be combined with OPD),
Adequate privacy for patients is
provided such that sensitive or
private discussion, examination,
and/or procedures are conducted in
a manner or environment where
these cannot be observed or the
risk of being overheard by others is
minimized.
Examination and Treatment
Area
Shall be provided with hand
washing/hand disinfection facility
DOH-I-LTO-AT
Revision:02
08/05/2016
Page 23 of 32
ANNEX M
AO No. 2012-0012
PHYSICAL FACILITY
Waiting area
DESCRIPTION
COMPLIED
REMARKS
Shall have adequate lighting and
ventilation.
Nurses' station
Equipment and supply storage
area
Wheeled Stretcher and
Wheelchair Area
Doctor's On-Duty Room
Toilet for patients and
companions
Separate Male from Female;
Clean and Free from foul odor; no
insects and rodents
Staff Toilet
DELIVERY
Labor Room (provided with
toilet)
Scrub Up Area
BIRTHING ROOM
Newborn Resuscitation Area
Equipment and Supply Area
Clean – Up and Sterilization
Room
NURSING SERVICE
Nurses’ Station
Patient Room
Toilet
DOH-I-LTO-AT
Revision:02
08/05/2016
Page 24 of 32
ANNEX M
AO No. 2012-0012
ASSESSMENT TOOL FOR INFIRMARY
ATTACHMENT C – INFIRMARY EQUIPMENT/INSTRUMENT
(Indicate in REMARKS Column if service is “Add On” and check applicable equipment or instrument for such
service.)
EQUIPMENT/INSTRUMENT
(Functional)
(Use separate sheet if equipment is for
a specific “ADD ON” Service/s).
QUANTITY
AREA
COMPLIED
REMARKS
ADMINISTRATIVE SERVICE
Ambulance, available 24/7 and physically
present; if outsourced, shall be on call
1
Typewriter or Computer
1
Emergency Light
Fire Extinguishers
1 per unit or
area
Generator set
KITCHEN
Exhaust fan
Food Conveyor or equivalent
Food Scale
Stove
Refrigerator/Freezer
Utility cart
Garbage Receptacle with Cover colorcoded)
1
1
1
1
1
1
1
1 for each
color
Parking
Administrative
Office
lobby, hallway,
nurses' station,
office/unit and
stairways
lobby, hallway,
nurses' station,
office/unit and
stairways
Genset house
Kitchen
EMERGENCY ROOM
Bag-Valve-Mask Unit
- Adult
- Pediatric
Calculator for dose computation
Clinical Weighing scale
Defibrillator
Delivery set, primigravid
Metzenbaum scissors, straight
Mayo scissors, straight
Kelly hemostatic forceps, curved or
straight
Needle Holder
Tissue forceps
Delivery set, multigravid
Mayo scissors, straight
Kelly hemostatic forceps, curved or
straight
EENT Diagnostic Set: or equivalent
Emergency Cart (for contents, refer to
separate list).
1
1
1
1
1
2 sets
1 per set
1 per set
2 per set
ER
1 per set
1 per set
2 sets
1 per set
2 per set
1
1
DOH-I-LTO-AT
Revision:02
08/05/2016
Page 25 of 32
ANNEX M
AO No. 2012-0012
EQUIPMENT/INSTRUMENT
(Functional)
Examining table
Examining table (with Stirrups for OBGyne
Gooseneck lamp/Examining Light
Instrument/Mayo Table
Laryngoscope with different sizes of
blades
Minor Instrument Set:
Kelly hemostatic forceps – curved
Kelly hemostatic forceps – straight
Mayo scissors – straight
Metzenbaum scissors – curved
Mosquito forceps – curved
Mosquito forceps – straight
Needle holder
Scalpel handle No. 3
Scalpel handle No. 4
Skin retractor
Tissue forceps
Thumb forceps
Nebulizer
Oxygen Unit
Tank is anchored/chained/ strapped or
with tank holder if not pipeline
Pulse Oximeter
Sphygmomanometer, Non-mercurial
- Adult Cuff
- Pediatric Cuff
Stethoscope
Suction Apparatus
Suturing Set:
Thermometer, non-mercurial
- Oral
- Rectal
Vaginal Speculum, Different Sizes
Wheelchair
Wheeled Stretcher with guard/side rails
and wheel lock or anchor.
Clinical Height and Weight Scale
EENT Diagnostic Set with
ophthalmoscope and otoscope
Gooseneck lamp/Examining Light
Examining table with wheel lock or
anchor
Instrument/Mayo Table
Minor Instrument Set:
Kelly hemostatic forceps – curved
Kelly hemostatic forceps – straight
Mayo scissors – straight
Metzenbaum scissors – curved
Mosquito forceps – curved
QUANTITY
AREA
COMPLIED
REMARKS
1
1
1
1
1 set
2 sets
2 per set
2 per set
1 per set
1 per set
4 per set
4 per set
1 per set
1 per set
1 per set
1 pair
1 per set
1 per set
1
ER
2
1
1
1
1
1
2 sets
1
1
1 set of
different sizes
1
1
OUT- PATIENT DEPARTMENT
1
1
1
1
1
1
2 per set
2 per set
1 per set
1 per set
4 per set
OPD
DOH-I-LTO-AT
Revision:02
08/05/2016
Page 26 of 32
ANNEX M
AO No. 2012-0012
EQUIPMENT/INSTRUMENT
(Functional)
Mosquito forceps – straight
Needle holder
Scalpel handle No. 3
Scalpel handle No. 4
Skin retractor
Tissue forceps
Thumb forceps
Neurologic Hammer
Sphygmomanometer, Non-mercurial
- Adult cuff
- Pediatric cuff
Stethoscope
Thermometer, non-mercurial
- Oral
- Rectal
QUANTITY
4 per set
1 per set
1 per set
1 per set
1 pair per set
1 per set
1 per set
1
AREA
COMPLIED
REMARKS
OPD
1
1
1
1
1
LABOR ROOM
Oxygen Unit
Tank is anchored/chained/ strapped or
with tank holder if not pipeline
Patient Bed
Sphygmomanometer, Non-mercurial
- Adult cuff
Stethoscope
Thermometer, non-mercurial
- Oral
- Rectal
Air-conditioning Unit
Bag valve mask unit (Adult and
pediatric)
Bassinet
Dilatation/Curettage set
Uterine Sound / Hysterometer
Uterine forceps
Dull Uterine curette
Sharp Uterine curette
Vaginal Retractor
Vaginal Speculum
Ovum forceps
Hegars dilator, graduated sizes
Sponge forceps
Delivery set, primigravid
Metzenbaum scissors, straight
Mayo scissors, straight
Kelly hemostatic forceps, curved or
straight
Needle Holder
Tissue forceps
Delivery set, multigravid
Mayo scissors, straight
Kelly hemostatic forceps, curved or
straight
1
1
1
1
Labor Room
1
1
DELIVERY ROOM
1
1
1
1 set
1 per set
1 per set
1 per set
1 per set
1 per set
1 per set
1 per set
1 per set
1 per set
1 set
1 per set
1 per set
DR
2 per set
1 per set
1 per set
2 sets
1 per set
2 per set
DOH-I-LTO-AT
Revision:02
08/05/2016
Page 27 of 32
ANNEX M
AO No. 2012-0012
EQUIPMENT/INSTRUMENT
(Functional)
DR Light
DR Table
Clinical Infant Weighing Scale
Instrument/Mayo Table
Kelly Pad or equivalent
Oxygen Unit
Tank is anchored/chained/ strapped or
with tank holder if not pipeline
Rechargeable Emergency Light (In case
of generator malfunctions)
Sphygmomanometer, Non-mercurial
Stethoscope
Suction Apparatus
Thermometer, non-mercurial
Wheeled Stretcher
QUANTITY
AREA
COMPLIED
REMARKS
1
1
1
1
1
1
DR
1
1
1
1
1
1
NURSING UNIT/WARD
Bag-Valve-Mask Unit
- Adult
1
- Pediatric
1
Clinical Height and Weight Scale
1
Emergency cart or equivalent (refer to
1
separate list for the contents)
EENT Diagnostic Set or
1
equivalent(Medical Ward)
Mechanical/Patient bed With locked, if
ABC
wheeled; with guard or side rails
Bedside Table
ABC
NURSING
Nebulizer
1
UNIT/ WARD
1
Neurologic Hammer
Oxygen Unit
1
tank is anchored/chained if not pipeline
Sphygmomanometer, Non- Mercurial
1
- Adult cuff
1
- Pediatric cuff
1
1
Stethoscope
1
Suction Apparatus
Thermometer
- Oral
1
- Rectal
1
CENTRAL STERILIZING & SUPPLY ROOM
Autoclave/Steam Sterilizer
1
CSSR
CADAVER HOLDING AREA/ROOM
Bed or stretcher for cadaver
CADAVER
1
HOLDING
AREA
DOH-I-LTO-AT
Revision:02
08/05/2016
Page 28 of 32
ANNEX M
AO No. 2012-0012
EMERGENCY CART CONTENTS
EQUIPMENT/INSTRUMENT
QUANTITY
COMPLIED
REMARKS
MEDICINES
Β-adrenergic agonists (i.e. Salbutamol 2mg/ml)
10
5 Caloric agent (D50W 50mg/vial)
5
10
Activated charcoal sachet
5
Amiodarone 150mg/ampule
5
Anti-rabies vaccine (active)
5
Anti-rabies vaccine (passive)
Anti-tetanus serum (either equine-based antiserum or
20
human antiserum)
Anti-venims* (for centres with high incidence of
poisonous animal bites)
10
Aspirin USP grade (325 mg/tablet)
10
Atropine 1mg/ml ampule
Benzodiazipine (Diazepam 10mg/2ml ampule and/or
10
Midazolam)
5
Calcium (usually calcium gluconate 10mg/ampule)
10
D5 0.3 NaCl 500ml/bottle
10
D5 LR 1L/bottle
10
D5 NSS 1L/bottle
10
Digoxin 0.5mg/ampule
10
Diphenhydramine 50mg/ampule
10
Dobutamine 250mg/20ml vial
10
Dopamine 20mg/vial
20
Epinephrine 1mg/ml ampule
10
Furosemide 20mg/2ml ampule
5
Haloperidol 50mg/ampule
10
Hydrocortisone 250mg/vial
5
Hyoscine N-butyl-bromide 20mg/vial
10
Lidocaine 5% solution vial 1g/50ml
5
Magnesium sulfate 1g/ampule
1
Mannitol 20% solution 500ml/vial
10
Mefenamic Acid 500mg/tablet
5
Methylprednisolone 4mg/tablet
5
Metoclopramide 10mg/ampule
5
Morphine sulfate 10mg/ampule
Nitroglycerin spray or Isosorbide dinitrate 5mg
10
tablet/ampule
5
Noradrenaline 2mg/ampule
10
Oral Rehydration Solution salt preparation sachet
15
Paracetamol 300mg/ampule (IV preparation)
5
Phenobarbital 30mg/ml IV or 30mg tablet
10
Plain LRS 1L/bottle
10
Plain NSS 1L/bottle
15
Potassium Chloride 40mEq/vial
10
Pyridoxine 1g/ampule
10
Sodium bicarbonate 50mEq/ampule
20
Tetanus Toxoid 0.5ml/vial
Thiamine (usually in parenteral Vitamin B complex
10
preparation)
DOH-I-LTO-AT
Revision:02
08/05/2016
Page 29 of 32
ANNEX M
AO No. 2012-0012
EQUIPMENT/INSTRUMENT
Tramadol 50mg/capsule
Verapamil 5mg/2ml ampule
QUANTITY
COMPLIED
REMARKS
10
10
BASIC ER SUPPLIES
Airway adjuncts (oropharyngeal and nasopharyngeal
airways)
Airway / Intubation Kit
Alcohol disinfectant
Arm sling (or sling and swathe bandages)
Aseptic bulb syringe
Biomedical refrigerator (for storage of biological and
other heat-sensitive drugs)
Calculator
Cardiac Board
Cardiac / EKG Leads
Cervical collars (different sizes)
Different sets of Bins (including puncture-proof sharp
containers)
Elastic Bandages (different sizes)
Flashlight or Penlight
Gloves (examination and sterile, different sizes)
Hydrogen peroxide solution
Nasal cannula
Povidine iodine wound and cleaning solutions
Protective face shield or mask
Pulmonary Function Test (PFT) or Peak Expiratory
Flow Rate (PEFR) Tube
Spine board with straps
Splinting / immobilization devices
Standard face mask
Sterile gauze
Sutures
Syringes (different volumes)
Urethral catheter
Urine collection bag
Waterproof aprons
X-ray reading lamp or negatoscope
DOH-I-LTO-AT
Revision:02
08/05/2016
Page 30 of 32
ANNEX M
AO No. 2012-0012
Name of Health Facility:
_______________________________________________________________________
Date of Inspection:
_______________________________________________________________________
RECOMMENDATIONS:
A.
For Licensing Process
[ ]
For Issuance of License To Operate as INFIRMARY
Validity from _________________________
[ ]
to
__________________________
Issuance depends upon compliance to the recommendations given and submission of the following within
____________________ days from the date of inspection
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
[ ]
Non-issuance. Specify reason/s: ___________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
____________________________________________________________________________________
Inspected by:
Printed name
Signature
Position/Designation
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Received by:
Signature: ___________________________________
Printed Name: ___________________________________
Position/Designation: ___________________________________
Date: ___________________________________
DOH-I-LTO-AT
Revision:02
08/05/2016
Page 31 of 32
ANNEX M
AO No. 2012-0012
Name of Health Facility:
_______________________________________________________________________
Date of Monitoring:
_______________________________________________________________________
RECOMMENDATIONS:
A. For Monitoring Process
[ ]
Issuance of Notice of Violation
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
[ ]
Non-issuance of Notice of Violation
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
[ ]
Others. Specify ________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Monitored by:
Printed name
Signature
Position/Designation
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Received by:
Signature: ___________________________________
Printed Name: ___________________________________
Position/Designation: ___________________________________
Date: ___________________________________
DOH-I-LTO-AT
Revision:02
08/05/2016
Page 32 of 32
