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Application Form

DOH application form for license to opperate an ambulance and ambulance service provider

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Department of Health

HEALTH FACILITIES AND SERVICES REGULATORY BUREAU
ANNEX K - 3
AO No. 2012-0012

ASSESSMENT TOOL FOR LICENSING A HOSPITAL
GENERAL INSTRUCTIONS IN FILLING OUT THE TOOL:
1. The team shall make sure they have the complete set with the following:
Standards/Indicators for a specific Level of hospital, 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.

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ANNEX K - 3
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:

General

Government:

Private:

National

Single Proprietorship

Local

Corporation

Others: (specify) ____________________
Type of application:

Specialty

Initial

Others: (specify) ____________________
Renewal

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ANNEX K - 3
AO No. 2012-0012
DOH STANDARDS (Indicators) for LEVEL 3 HOSPITAL
CRITERIA
(This refers to the specific
and measurable indicators
that help determine
whether or not the
standard has been met.)

INDICATOR
(This is the
REQUIREM ENT 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
DOCUMENT
Wards
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 (including rights
of incompetent patient,
i.e. minors):

DOCUMENT
REVIEW
Policies and procedures
on patients' rights, i.e.
use of restraints,
patient’s refusal, etc.

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 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.
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ANNEX K - 3
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
DOCUMENT
ER
appropriate to patients' consistent with clinical
REVIEW
OPD
needs and the former's
service capability as
1. List of services
OR/RR
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
3. PNRI certification
the community.
to clients.
(when applicable)

4. A multi-level ramp
shall have a minimum
clear width of 1.22
meters in one direction
and slope is 1:12; an
elevator which can
accommodate at least a
patient bed, provided if
there is no ramp; Ramp
is provided at the
entrance if it is not at
the same level with the
inside
5. LEVEL
3CLINICAL AND
FACILITIES FOR
IN PATIENTS Intensive to highly
specialized care and
management

Presence of ramp or
elevator

Departmentalized
clinical services at least
for:
- Medicine
- Pediatrics
- Obstetrics and
Gynecology
- Surgery
- Anesthesia

OBSERVE
The facilities, and
structure. Check if the
service capability of
the hospital is in
accordance with the
health facility level.
including “Add On”
Services
OBSERVE

DOCUMENT
REVIEW
Separate recording of
patients per department
OBSERVE
Physical separation of
wards

6. TEACHING /
TRAINING
HOSPITAL
7. OTHER CLINICAL
SERVICES
A.Dental Service
(MOA if
outsourced and I by
Referral)
B. High Risk
Pregnancy Care

Department
head offices
Difference
clinical
areas

Training
Office

Presence of policies and
procedures

DOCUMENT
REVIEW
Implemented Policies
and procedures
OBSERVE
If Functional
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ANNEX K - 3
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CRITERIA
C. Neonatal Intensive
Care Unit

INDICATOR
Presence of policies and
procedures

EVIDENCE

AREAS

COMPLIED

REMARKS

DOCUMENT
REVIEW
Implemented Policies
and procedures

D.Intensive Care Unit
OBSERVE
If Functional
E. Respiratory Unit

F. Physical Medicine
and Rehabilitation
Unit
G.Ambulatory
Surgical Clinic

Refer to Assessment
Tool for ASC

H.Dialysis Clinic

Refer to Assessment
Tool for Dialysis Clinic

8. NURSING
SERVICES
Intensive to Highly
specialized Nursing Care
and Management
9. Entrances and exits
are clearly and
prominently marked,
free of any
obstruction and
readily accessible.

10. Directional signs are
prominently posted to
help locate service
areas within the
organization.

Licensed and
appropriately trained
nursing personnel
assigned in special and
critical areas
Presence of entrances
and exits that are readily
accessible and free from
obstruction

Presence of directional
signages to locate
service areas

DOCUMENT
REVIEW
PRC Valid license
Certificate of relevant
training
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.

Wards,
ER, OPD

ER
OPD
Wards
OR/RR/DR
Imaging

ER
OPD
Wards
Others
(Lobby)

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ANNEX K - 3
AO No. 2012-0012
CRITERIA

INDICATOR

11. 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

12. Corridors conform
with standard
measurement

Corridors used as access
for patients using bed or
stretcher are at least 2.44
meters while in areas not
commonly used for bed
or stretcher are at least
1.83 meters

13. All patients are
correctly identified by
their patient charts,
including newborn

The contents of patient's
charts
are the following:
1. Summary or face
sheet
2. Informed Consent
3. History and Physical
Examination
4. Doctor's order
5. Nurses Notes
6. TPR Sheet
7. Laboratory report
8. Imaging reports
9. Maternal Record
with Partograph (if
warranted)
10. Newborn record and
maturity rating, (if
warranted)
11. Medication and/or
treatment record
12. Operative and
anesthesia record (if
warranted)
13. Record of
interdepartmental
referral/consultation
to other physicians,
including notes
14. Record of referral or
transfer of patient to
other
facility/service/docto
r
including notes
15. Discharge summary
16. Clinical abstract
17. Advance directive,
whenever applicable

EVIDENCE

AREAS

OBSERVE
Check:
1. Alternative
passageways for
patients with
special needs.
2. They are
prominently
marked
3. They are free from
obstruction.
OBSERVE

REMARKS

ER
OPD
Wards
Other areas

DOCUMENT
Patient chart from ER,
ward, and OPD

COMPLIED

ER
OPD
Wards

INTERVIEW
verify with patient if
he/she really is the
person indicated in the
chart.
OBSERVE
Check newborn tags if
compatible with the
mother

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ANNEX K - 3
AO No. 2012-0012
CRITERIA

INDICATOR

EVIDENCE

AREAS

COMPLIED

REMARKS

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
14. The plan of care,
Presence of
DOCUMENT
Wards
aside from delineating adopted/developed
Adopted/developed
ER
responsibilities,
protocols, CPGs or
protocols, CPGs or
OPD
includes goals to be
pathways containing
pathways containing
ICU
achieved, services to
goals to be achieved,
goals to be achieved
be provided, patient
services to be provided,
services to be provided
education strategies to patient education
patient education.
be implemented, time
strategies to be
frames to be met, and
implemented, time
OBSERVE
resources to be used.
frames to be met and
Check if medicines and
resources to be used
treatment prescribed are
in accordance with
adopted
CPGs/protocols
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
15. An appropriate
All patients have
DOCUMENT
Wards
comprehensive
comprehensive history
Patient chart from
history and physical
and PE within 48 hours
wards or Medical
Medical
examination is
from admission.
Records have complete
Records
performed on every
history and P.E.
Office
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.
16. Previously obtained
All patient charts have
CHART REVIEW
Medical
information is
progress notes by
Patient chart from
records
reviewed at every
doctors and other health
medical records/wards. room
stage of the
professionals.
assessment to guide
Note: The progress
Wards
future assessments
notes should be done
regularly and
documented in the
patient chart either as
separate progress
notes' sheets or
separate column
17. Nurses make use of
Charts have progress
CHART REVIEW
Wards
Nursing Process in
notes by nurses as
Patients’ charts from
the care of patients
evidenced by their
medical records or
Medical
nurses’ notes
wards have nurses’
Records
notes
Office
Presence of Nursing
manual and properly
DOCUMENTS
utilized Kardex
Patients’ charts
Kardex

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ANNEX K - 3
AO No. 2012-0012
CRITERIA

INDICATOR

EVIDENCE

AREAS

COMPLIED

REMARKS

Standard: Assessments are performed regularly and are determined by patients’ evolving response to care.
18. Qualified personnel
give patients for
surgery pre-operative
physical and preanesthetic assessment

All patients for surgery
have undergone preoperative physical and
pre-anesthetic
assessment

CHART REVIEW
Patients’ charts of
surgery / OB-Gyne
patients who have
undergone surgery and
presently admitted.

Surgical /
OB-Gyne
Wards

Note: Look for written
and legible preoperative physical and
(e.g.. Cardiopulmonary clearance if
warranted) preoperative anesthetic
evaluation and surgical
safety checklist in the
patient's chart. Preoperative assessment
should be done for
patients requiring more
than local anesthesia.
B. 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. Diagnostic examinations
appropriate to the provider organization’s service capability and usual case mix are available and are
performed by qualified personnel
19. Policies and
There is Quality control
DOCUMENT
Laboratory
procedures for the
on diagnostic
REVIEW
X-ray
standard performance, examinations including
Proof of monitoring of
CSSD
monitoring and
film reject analysis, etc.
implementation of the
quality control of
and
policies and procedures
diagnostic
calibration of diagnostic
on quality control of
examinations
equipment
diagnostic examinations
20. Medicines are
administered in a
timely, safe,
appropriate and
controlled manner

All medicines are
administered observing
the five (5) R's of
medication which are:
1. Right
2. Right
3. Right
4. Right
5. Right

21. Only qualified
personnel order,
prescribe, dispense
prepare, and
administer drugs.

patient
medication
dose
route
time

All doctors, pharmacists
and nurses have updated
licenses

CHART REVIEW
Check patients charts
from the wards:
For the accuracy of
medicine
administration
INTERVIEW
Ask patients if the five
(5) R’s were observed
during administration
of any IM, IV and oral
medications
INTERVIEW
Randomly check the
licenses of some
doctors, nurses and
pharmacists if they are
updated.

ER
Wards

Wards
Pharmacy
ER
OPD

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ANNEX K - 3
AO No. 2012-0012
CRITERIA
22. 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

EVIDENCE
DOCUMENT
REVIEW
Procedures on
verification of
prescriptions and orders

AREAS

COMPLIED

REMARKS

Wards
ER

INTERVIEW
Ask staff how they
verify orders from
doctors prior to
administration of
medicines.

23. Patients are identified
before medicines are
administered

24. Medicine
administration is
properly documented
in the patient chart

Proof that patients are
correctly identified prior
to administration of
medications

All charts have proper
documentation of
medicine administration.

OBSERVE
How staff verifies the
prescriptions or orders
for medicines with the
doctor’s order.
INTERVIEW
Verify from patients if
they were correctly
identified prior to drug
administration.
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 from
medical records or from
the wards

Wards
ER

Medical
records
office
wards

OBSERVE
Note if complete doses
were given
C. 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.
25. Discharge plans for
All charts have discharge CHART REVIEW
Medical
patients to ensure
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.
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ANNEX K - 3
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
26. Organizational
Structure/Chart

Presence of
organizational structure

OBSERVE
Observe if the
organizational structure
/ chart is posted in
appropriate area.
DOCUMENT
REVIEW

27. The organization and
its services develop
their vision, mission
and corporate goals
based on agreed-upon
values
28. The organization and
its services develop
their policies and
procedures.

Presence of written
vision, mission, and
goals of the hospital and
all services/departments

Written policies and
procedures manual for
all services / departments
/ units

DOCUMENT
REVIEW
1.Written Policies
2.Procedure manual

29. Committees within
the organization
which includes the
terms of reference for
membership

Proof of the creation of
all committees within the
organization which
includes the terms of
reference for
membership.

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

The following are the
committees required:
1. Credentialing and
privileging
2. Blood Transfusion
3. Healthcare Waste
Management
4. Patient Safety
5. Infection Prevention
and Control
6. Antimicrobial
Stewardship
(functional by 2018)
7. Pharmacologic and
Therapeutic
8. Emergency and
Disaster
Preparedness
9. CQI
10. Ethics
11. Grievance

Written vision, mission
and goals

Other Areas
Lobby

Medical,
Nursing and
Administrative
Services
Laboratory
Medical,
Nursing and
Administrative
Services
Administrative office
Offices of
the different
committees

INTERVIEW
Ask members of the
different committees
their functions, how
often they meet, etc.

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ANNEX K - 3
AO No. 2012-0012
CRITERIA

INDICATOR

EVIDENCE

AREAS

30. Evaluation and
monitoring activities
to assess management
and organizational
performance

Presence of evaluation
and monitoring activities
to assess management
and organizational
performance

DOCUMENT
REVIEW
Evaluation activities to
assess management and
organizational
performance such as
semestral or annual
reports or Performance
and Budget Utilization
Review

COMPLIED

REMARKS

Administrative office

INTERVIEW
1. Ask the management
team about priorities
for performance
improvement that
relate to hospital
wide activities and
patient outcomes
2. Ask how targets are
set.
B. OUTSOURCED SERVICES
31. Outsourced services
are within the facility

DOCUMENT
REVIEW
1. Contracts/MOA for
outsourced services
2. Valid licenses of all
providers
3. Check contracts /
job orders

Administrative
Office

ADMINISTRATIVE SERVICES

A. Dietary

B. Linen/ Laundry

There shall be provision
of safe, quality and
nutritious food to
patients.
Diet prescription or diet
counselling is provided
to patients
If not contracted out,
there shall be:

DOCUMENT
REVIEW
- Check policies and
procedures in the
dietary.
- Monthly menu for
patients
DOCUMENT
REVIEW

- Sorting of soiled and
contaminated linens in
designated areas
- Systematic washing of
laundry with safeguard
against spread of
infection
- Disinfection of laundry
C. Security

Check procedures on
how soiled linens are
collected disinfected
and washed.

Policies and procedures
on security of patients,
visitors and hospital staff

Administrative Office

1.

Presence of all
outsourced services

DOCUMENT
REVIEW
Security check for
internal and external
customers including use
of visitor’s pass
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ANNEX K - 3
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INDICATOR

D. Housekeeping /
Janitorial

There shall be provision
and maintenance of
clean, safe and sanitary
facilities and
environment for hospital
personnel, patients and
clients

E. Proper Waste
Treatment and
Disposal

Policies and
procedures on proper
waste disposal.

EVIDENCE

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

AREAS

COMPLIED

REMARKS

Administrative Office

CRITERIA

Lobby
ER / OPD
Wards

OBSERVE
INTERVIEW

2.

ANCILLARY SERVICES

A. Tertiary Clinical
Laboratory with
Histopathology and
Blood Bank
B. Level 3 Imaging
Facility

C. Pharmacy

(Use separate tool for
Clinical Laboratory)

DOCUMENT
REVIEW

Open 24/7, providing
safe, affordable and
efficacious medicines

Check for Certificate of
Compliance or License
To Operate, whichever
is applicable, from
Center for Device
Regulation, Radiation
Health and Research
(CDRRHR), FDA
DOCUMENT
REVIEW
Check for Certificate of
Compliance or License
To Operate, whichever
is applicable, from
Center for Drug
Regulation and
Research (CDRR),
FDA

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ANNEX K - 3
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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.
32. 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

33. 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 Attachment of
Assessment Tool for
Personnel)

(Trainees, except
physicians
undergoing residency
training and
volunteers not
included)

DOCUMENT
REVIEW

Personnel
/Administrative office

Policies and procedures
for hiring, credentialing
and privileging of staff
INTERVIEW
DOCUMENT
REVIEW
1. List of licensed
doctors and nurses
based on HR records
2. Payroll
3. Schedule of duties for
the previous and
current month
4. Number of beds
authorized by DOH
and actual beds being
used

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.
34. Professional
qualifications are
validated, including
evidence of
professional
registration /license
where applicable,
prior to employment

Presence of Qualification
Standards

35. The staff are provided
with a documented
job description
outlining
accountabilities and
responsibilities

Staff provided with job
description outlining
their accountabilities and
responsibilities

DOCUMENT
REVIEW
Check Qualification
Standards; procedures
in hiring.
OBSERVE
Check PRC License of
some MDs. Nurses,
Pharmacists
DOCUMENT
REVIEW
Written job descriptions
with conforme

Personnel
/Administrative office

Personnel
/Administrative office

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INDICATOR

EVIDENCE

AREAS

COMPLIED

REMARKS

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.
36. New personnel , new
graduates and external
contractors are given
proper orientation and
adequately supervised
by qualified staff

Proof that new personnel
are adequately oriented
and supervised

DOCUMENT
REVIEW
- Policies and
procedures on
orientation
- Module on
orientation
- Documentation of
orientation
conducted

Personnel
/Administrative office

INTERVIEW
Ask new personnel
about the lines of
authority and
supervision and if the
supervision is adequate

37. Annual plan on
training activities

Presence of annual plan
on training activities

OBSERVE
DOCUMENT
REVIEW

Personnel
/Administrative office

Annual plan (including
resource/budgetary
allocation) on training
activities
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, quantitati ve and qualitative data are collected and used in a timely and efficient
manner for delivery of patient care and management of services
38. Records are stored,
retained and disposed
of in accordance with
the guidelines set by
National Archives of
the Philippines (NAP)

Policies and procedures
on record storage,
retention and disposal.

DOCUMENT
REVIEW
Policies and procedures
on record storage,
retention and disposal.

Medical
records
room

OBSERVE

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INDICATOR

EVIDENCE

39. 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
1. Compilation of
Annual Hospital
Statistical Report
2. Other additional
statistics as
determined by the
management or
hospital forms that
serve as instruments
for data collection
and aggregation
3. Proof of
training/seminar on
Basic Records
Management and
ICD 10 Coding of
staff in charge

Presence of qualified
staff involved in data
definition, generation,
collection and
aggregation

AREAS

COMPLIED

REMARKS

Medical
records
room

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.
40. When patients are
Presence of policies and
DOCUMENT
Medical
admitted or are seen
procedures on filing and
REVIEW
Records
for ambulatory or
retrieval of charts
Policies and procedures Room /
emergency care,
on systematic filing,
Office
patient charts
retrieval and
documenting any
management of medical
previous care can be
records
quickly retrieved for
review, updating and
OBSERVE
concurrent use.
Ask the medical records
officer to retrieve a
chart, then note the
actual length of time of
retrieval
Note: If organization
has not set a time
interval, use 5 minutes

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41. 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.

INDICATOR
Presence of procedures
to protect records and
patient charts against
loss, destruction,
tampering and
unauthorized access or
use

EVIDENCE
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
against loss, tampering
and unauthorized

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
42. Hospital has a valid
license

43. Hospital is free from
undue noise, pollution
and from foul odor

Presence of updated
DOH license to operate

DOCUMENT
REVIEW
1. Updated DOH
license
2. If facility has
nuclear medicine,
check certificate
issued by PNRI
OBSERVE
1. Ask staff at random:
their manner of
waste segregation
and disposal; safe
storage and disposal
of reagents.
2. Check presence of
MSDS (Material
Safety Data Sheet)
in the laboratory and
Engineering
3. Record of disposal
of radiologic wastes

Administrative office

Hospital
surroundings
Laboratory
Pharmacy
and other
part of the
facility and
Maintenance

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44. Presence of a
management plan,
policies and
procedures
addressing safety

45. Policies and
procedures for the
safe and efficient use
of medical equipment
according to
specifications are
documented and
implemented.

46. Patient areas provide
sufficient space for
safety, comfort and
privacy of the patient
and for emergency
care.

INDICATOR

EVIDENCE

AREAS

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

DOCUMENT
REVIEW
Management plan,
policies and procedures

Administrative office
Maintenance
office,
ER
Wards

Presence of policies and
procedures for:
- Quality Control
- Corrective and
Preventive
Maintenance Program
for medical
equipment

Presence of adequate
space, lighting and
ventilation in compliance
with structural
requirements (for patient
safety and privacy)

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
1. Presence of
operating manuals of
the medical
equipment
2. Preventive and
corrective
maintenance
logbook
3. Film reject analysis
4. Quality control tests
results
OBSERVE
How staff performs
necessary precaution or
safety procedures such
as: red light is on while
x-ray procedure is
being done.
Note: Look into their
storage of mercury
containing devices
which are no longer
allowed to be used
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

COMPLIED

REMARKS

ER
OPD
Wards
DR
Laboratory
Pharmacy
Maintenance
Office
Other areas

ER
OPD
Wards
DR

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INDICATOR

EVIDENCE

47. A coordinated
security arrangement
in the organization
assures protection of
patients, staff and
visitors.

Presence of an appointed
personnel in charge of
security.

AREAS

COMPLIED

REMARKS

DOCUMENT
REVIEW
Contract or
Appointment of person
in charge of security.
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.
48. An incident reporting
system identifies
potential harms,
evaluates causal and
contributing factors
for the necessary
corrective and
preventive action

Presence of incident
reporting system/sentinel
event monitoring system
(which may include
hospital associated
infections, unexpected
deaths, adverse drug
reactions, blood
transfusion reactions,
falls, etc.)

DOCUMENT
REVIEW
Incident/sentinel event
reports or
communications/
memoranda/orders or
proceedings on sentinel
events

Infection
Control
Committee
office
CQI Office
Wards
ER
ICU
OR

INTERVIEW
Ask at random any staff
from wards and ER:
- how the incident
reporting system
works
- correction,
corrective and
preventive actions
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.
49. Generator /
Presence of generator /
DOCUMENT
Engineering/
emergency light,
emergency light, water
REVIEW
Maintenance
water system,
system, adequate
- Check result of
Other
adequate ventilation
ventilation or air
water analysis for
Relevant
or air conditioning
conditioning.
the last 6 months.
Areas
- Preventive and
corrective
maintenance
logbooks
OBSERVE
1. Test if faucets and
water closets are
working
2. If emergency lights
and generators are
functional.

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INDICATOR

EVIDENCE

50. Equipment are
regularly maintained
with plan for
replacement
according to expected
life span or when no
longer serviceable.

Presence of policies and
procedures on preventive
and corrective
maintenance and
replacement if warranted

DOCUMENT
REVIEW
Records of preventive
and corrective
maintenance and plan
for replacement

51. Training of the staff
who is in charge of
the maintenance of
the equipment

Proof of training of the
staff who is in charge of
the maintenance of the
equipment

DOCUMENT
REVIEW
For in-house:
Certificate of training
of service personnel or
Certificate of training
For outsourced service:
MOA/Contract (verify
qualification of
technicians)

AREAS

COMPLIED

REMARKS

Engineering/
Maintenance
Office
Laboratory
Imaging
Other Areas

INTERVIEW
Ask about how
equipment (generator,
A/C, Medical and nonmedical devices, etc.)
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.
52. Operating manuals of
equipment

Presence of operating
manuals equipment

DOCUMENT
REVIEW
Operating manual of
Medical equipment,
generators, air
conditioners and other
non-medical equipment.

Engineering/
Maintenance
Office
Imaging,
Laboratory

C. INFECTION CONTROL
Goal: Risk of acquisition and transmission of infections among patients, employees, physicians and other
personnel, visitors and trainees are identified and reduced
Standard: An interdisciplinary infection control program ensures the prevention and control of infection in all
services.
53. Infection Prevention
Presence of an Infection
DOCUMENT
Infection
and Control
Prevention and Control
REVIEW
Control
Committee
Committee (IPCC) with
1. IPCC composition
Committee
defined roles and
2. Full time Infection
Office
responsibilities
Control Nurse
(1:100 beds)
3. IPCC functions and
activities
4. Minutes of
meetings.

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INDICATOR

54. Infection Prevention
and Control Program

EVIDENCE

AREAS

COMPLIED

REMARKS

Presence of an infection
control program ensuring
prevention and control of
infections on all services.

DOCUMENT
Nurse
REVIEW
Super1. IPC Manual.
visor’s
2. Policies on rational
Office
antimicrobial use
based on the hospital
antibiogram and
surveillance of AMR
3. Reports of infection
control activities e.g.
surveillance,
training, outbreak
investigation, etc.
4. Policies and
procedures on
disposition of dead
bodies with
dangerous
communicable
disease.
Standard: The organization uses a coordinated system-wide approach to reduce the risks of healthcareassociated infections.
55. Organization takes
Presence of a
DOCUMENT
ER
steps to prevent and
coordinated system-wide REVIEW
Wards
control outbreaks of
procedure for prevention Validate hospital
Laboratory
healthcare associated
of hospital associated
policies on infection
infections.
infections
control such as use of
PPEs, isolation
precautions and hand
washing.
INTERVIEW
Ask staff in ER and
wards the procedures
on isolation
(Isolation - physical
isolation of a patient
with infection and
reverse isolation).
Presence of a
coordinated system-wide
procedure for asepsis.

Ask staff from ER,
wards and laboratory
about the approaches
for asepsis during
diagnostic and
treatment procedures

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INDICATOR

EVIDENCE

AREAS

COMPLIED

REMARKS

Standard: The organization uses a coordinated system-wide approach to reduce the risks of infection the staff
are exposed to in the performance of their duties
56. There are programs
Presence of policies and
DOCUMENT
ER
for prevention and
procedures on the
REVIEW
Wards
treatment of needle
prevention and treatment
1. Policies on needle
Laboratory
stick injuries, and
of needle stick injuries
stick injuries.
policies and
and safe disposal of
2. Policies and
procedures for the
needles
procedures on
safe disposal of used
proper handling and
needles are
safe disposal of
documented and
sharps/needles.
monitored
INTERVIEW
Interview hospital staff
on how they handle and
dispose needles.

57. There are programs
for the prevention of
transmission of
airborne infections,
and risks from
patients with signs
and symptoms
suggestive of
tuberculosis or other
communicable
diseases are managed
according to
established protocols

Presence of program on
prevention of
transmission of airborne
infections and risks from
patients with signs and
symptoms suggestive of
tuberculosis or other
communicable diseases

OBSERVE
Presence of receptacles
for proper disposal of
sharps
DOCUMENT
REVIEW
1. Policies and
procedures on
isolation.
2. Occupational Health
and Safety Program
for employees
3. Policies on timely
referral and case
reporting of highly
transmissible and
notifiable infectious
disease
e.g.meningococcemia, SARS, avian
flu, etc.
4. Procedures on
recycling & reuse

ER
Wards
Isolation
room
Laboratory

OBSERVE
1. Use of gloves,
surgical masks
2. Lavatories or
designated areas for
hand washing or
dispenser for hand
sanitizers
3. Separate holding
room for highly
infectious cases.
4. Ask a staff to
demonstrate hand
washing technique

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INDICATOR

EVIDENCE

AREAS

COMPLIED

REMARKS

Standard: When needed, the organization reports information about infections to personnel and public health
agencies.
58. Policies and
procedures in
reporting notifiable
diseases (Refer to AO
No. 2008-0009).

Presence of policies and
procedures in reporting
notifiable diseases

DOCUMENT
REVIEW
Copy of reports
submitted to Philippine
Integrated Disease
Surveillance and
Response (PIDSR)
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. 2012 0012: DOH Guidelines in the Cleaning, Disinfecting, Drying, Packaging and Sterilizing of Reusable Items
in Hospitals and Other Health Facilities).
59. 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 sterilizing on cleaning,
sterilizing of
of equipment,
disinfecting, drying,
equipment,
instruments and supplies packaging and
instruments and
sterilizing of
supplies.
equipment, instruments
and supplies
OBSERVE
D. ENERGY AND WASTE MANAGEMENT
Standard: The handling, collection and disposal of waste conform with relevant statutory requirements and code
of practice
60. Licenses/permits/
clearances from
pertinent regulatory
agencies

Presence of
licenses/permits/
clearances from pertinent
regulatory agencies, if
applicable

DOCUMENT
REVIEW
1. Pertinent licenses /
permits from
regulatory agencies
(LGU, DENR, etc.)
2. Proof of compliance
i.e., generator
permit, elevator
permit, etc.

Administrative office

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61. Policies and
procedures on waste
disposal

INDICATOR
Proof of implementation
of policies and
procedures on waste
disposal

EVIDENCE

AREAS

COMPLIED

REMARKS

DOCUMENT
REVIEW
1. Issuances - memos,
guidelines on waste
segregation,
treatment and
disposal.
2. Hospital policy that
conforms to the
DOH Manual on
Healthcare Waste
Management, 3rd
edition, 2012
3. 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.
INTERVIEW
Ask staff regarding
SOPs on actual
procedure on waste
disposal

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.
62. Continuous Quality
Presence of Quality
DOCUMENT
AdminisImprovement
Improvement Program
REVIEW
trative
Program
1. Policies on CQI
Office
2. Proof of meetings or
similar documents
on CQI activities
3. Policies and
procedures on
Performance
measurement and
improvement
4. Performance
appraisal for
employees at least
once a year.
INTERVIEW
Validation of CQI
activities thru interview
of staff at random.
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INDICATOR

EVIDENCE

AREAS

COMPLIED

REMARKS

Standard: Management is primarily responsible for developing, communicating, and implementing a
comprehensive quality improvement program throughout the organization and delegating responsibilities
to appropriate personnel for its day-to-day implementation
63. Comprehensive
Proof that the
DOCUMENT
quality improvement
management is primarily
REVIEW
program throughout
responsible for
1. Memoranda/orders
the organization and
developing,
creating the QI
delegating
communicating and
team/Quality circle
responsibilities to
implementing a
2. Minutes of
appropriate personnel comprehensive quality
meetings/extracts of
for its day-to-day
improvement program
minutes relating to
implementation
implementation
concerned topic,
documentation of
activities
3. Monitoring reports
on CPG use or
similar QI activities
4. Designation of a
point person for the
CQI
INTERVIEW
Validate the activities
by asking the
management team or
officer involved in CQI
program
Standard: The organization provides better care service as a result of continuous quality improvement activities
64. Customer satisfaction
survey

Presence of customer
satisfaction survey

DOCUMENT
REVIEW
1. Domains of the
survey form used.
2. Survey results and
how complaints /
comments are acted
upon.

Administrative
Office

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65. Better patient
outcome.

INDICATOR
Proof of better patient
outcomes

EVIDENCE
DOCUMENT
REVIEW
Documentation of
better outcomes for
patients as a result of
CQI activities
(Correction, corrective
and preventive actions
of problems identified)
Validation and
resolution of client
concern
(Patient response time,
Compare infection rate
of previous and current
years, ALOS,
complaints from
Customer Satisfaction
Survey, declining
trends of hospital
associated infections
and increase in patient
satisfaction rating.)

AREAS

COMPLIED

REMARKS

Administrative
Office
Different
clinical
services
Laboratory
ICC Office
Medical
Records
Office

VIII. DOH PROGRAMS IMPLEMENTED IN HOSPITALS AND OTHER HEALTH FACILITIES
66. Newborn Screening
Newborn Screening – in
compliance to RA 9288
and its IRR

67. Hospital is Certified
on MBFHI
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.

Proof of implementation
of Rooming-in and
Breastfeeding

DOCUMENT
REVIEW
- Policies and
procedures on
Universal Newborn
Screening
- Logbook of
Newborns who were
tested and copies of
waiver for those who
were not screened
- OR of filter papers
DOCUMENT
REVIEW
MBFHI Certificates:
- MBF Hospital
- MBF Workplace

OB Ward
(Rooming
In)

OB Ward

(MOU for those who
are not certified yet).
OBSERVE
- Breastfeeding area
should be provided at
the NICU
- There shall be no
nursery for normal
newborns

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68. Immunization of
newborn babies with
BCG and first dose
Hepatitis B vaccine

INDICATOR
Newborn babies given
BCG and first dose
Hepatitis B vaccine

Immunization – in
compliance to RA No.
306
69. Hospital is a “No
Smoking zone

Generic Prescribing – in
compliance to RA 6675
(Generics Act of 1988)

71. Emergency
Preparedness,
Response and
Recovery Plan

DOCUMENT
REVIEW
Records of Newborns
given BCG and first
dose Hepa-B vaccine

AREAS

COMPLIED

REMARKS

OB Ward

OBSERVE

Policies and procedures
on anti-smoking

Anti-smoking – in
compliance to RA 9211

70. Generic prescribing
and recording

EVIDENCE

Actual implementation
of policies and
procedures on generic
prescribing

Proof of implementation
of the plan

Health Emergency
Management Services
(HEMS) – in compliance
to AO 2004-0168
"National Policy on
Health Emergencies and
Disasters"

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
- Self-assessment for
disaster readiness
using the “Safe
Hospital Checklist”
available at the
HEMB website.
- Result of selfassessment and how
gaps were resolved

Hallways

Pharmacy
Wards

ER
Wards
Offices

OBSERVE
Exit plans posted in all
hallways and rooms
72. Newborn Hearing
Screening
Universal Newborn
Hearing Screening – in
compliance to RA 9709
(Universal Newborn
Hearing Screening Act)

Newborn Hearing
Screening being
implemented

DOCUMENT
REVIEW
- Logbook of
Newborns who were
tested on hearing
- Proof of referral if
service is not
available

Newborn
hearing
screening
room

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73. Family planning
service

INDICATOR
Presence of Family
planning services

Family planning – in
compliance to RA
10354 (Responsible
Parenthood and
Reproducti ve Health
Act of 2012)

74. National Tuberculosis
Program
NTP – in compliance
with RA 10767
(Comprehensive TB
Elimination Plan Act)

Implementation of
National TB Program

EVIDENCE
DOCUMENT
REVIEW
- List of FP acceptors
- Evidence as
conscientious
objector if FP
services are not
provided
- Referral System to
other facilities for FP
if conscientious
objector.
DOCUMENT
REVIEW
- Presence of Hospital
TB Referral Logbook
- List of Diagnosed TB
Cases Notified (with
received remarks by
DOH-Regional
Office)

AREAS

COMPLIED

REMARKS

OPD
OB wards

OPD
Wards

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ASSESSMENT TOOL FOR LEVEL 3 HOSPITAL
ATTACHMENT A - PERSONNEL
POSITION

QUALIFICATION

EVIDENCE

NUMB ER /
RATIO

COMPLIED

REMARKS

TOP MANAGEMENT
Chief of Hospital
/Medical Director

For Government
Hospitals:
Master’s Degree in
Hospital
Administration or
related course AND at
least five (5) years
experience in a
supervisory /
managerial position.

DOCUMENT REVIEW
- Diploma / Certificate of
units earned
- Updated PRC license
- Certificates of Trainings
attended
- Proof of Employment /
Appointment

1

INTERVIEW

Grandfather’s Clause
may be accepted in
place of the Master’s
Degree in Hospital
Administration (or
related course),
provided that the
individual is fifty-five
(55) and above, AND
currently holding the
position for at least
five years. A two-year
moratorium is granted
to allow those who are
yet to finish their
Master’s Degree.
For Private Hospitals:
Master’s Degree in
Hospital
Administration (or
related course)
AND/OR at least five
(5) years experience
in a supervisory /
managerial position.
A two-year
moratorium is granted
to allow those who are
yet to finish their
Master’s Degree

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ANNEX K - 3
AO No. 2012-0012
POSITION
Chief of Clinics /
Chief Medical
Professional
Services

Department Head
(Specialty)

Training Officer
for Physicians
Chief Nurse /
Director of Nursing

QUALIFICATION

EVIDENCE

Must be a fellow /
diplomate in a
specialty /
Subspecialty society
AND at least five (5)
years experience in a
supervisory or
managerial position
Must be a fellow /
diplomate in a
specialty /
Subspecialty society
of the department he /
she heads
Must be a fellow /
diplomate in a
specialty society
Master’s Degree in
Nursing

DOCUMENT REVIEW
- Diploma / Certificate
from Specialty society, if
applicable
- Updated PRC license
- Certificates of Trainings
attended
- Proof of Employment /
Appointment
INTERVIEW

NUMB ER /
RATIO

COMPLIED

REMARKS

1

1 per
department

1
DOCUMENT REVIEW
- Diploma / Certificate of
units earned
- Updated PRC license
- Certificates of Trainings
attended
- Proof of Employment /
Appointment

1

INTERVIEW
Chief
Administrative
Officer

Must have completed
a Master's Degree in
Hospital
Administration or
related course (MPA,
MBA, MPH, MHSA,
MBM among others)
AND at least five (5)
years experience in a
supervisory or
managerial position
Grandfather’s Clause
may be accepted in
place of the Master’s
Degree in Hospital
Administration (or
related course),
provided that the
individual is fifty-five
(55) years old and
above, AND currently
holding the position
for at least five years.
A two-year
moratorium is granted
to allow those who are
yet to finish their
Master’s Degree.

DOCUMENT REVIEW
- Diploma / Certificate of
units earned
- Updated PRC license
- Certificates of Trainings
attended
- Proof of Employment /
Appointment

1

INTERVIEW

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ANNEX K - 3
AO No. 2012-0012
POSITION

QUALIFICATION

EVIDENCE

NUMB ER /
RATIO

COMPLIED

REMARKS

ADMINISTRATIVE SERVICES
Accountant
Billing Officer
Budget / Finance
Officer
Cashier
Human Resources
Management
Officer / Personnel
Officer
Clerk, pool
Engineer

Supply Officer/Storekeeper

Certified Public
Accountant
With Bachelor’s
Degree relevant to the
job

Medical Social
worker

NutritionistDietician

DOCUMENT REVIEW
- Diploma
- Updated PRC license, if
applicable
- Certificates of Trainings
attended
- Proof of Employment /
Appointment

1
1
1
1
1:50 beds

Licensed Engineer

With appropriate
training and
experience

Laundry Worker
Medical Records
officer

1

Bachelor's Degree
And Training in ICD
10 and Medical
Records Management

Licensed Social
Worker

Licensed NutritionistDietician

DOCUMENT REVIEW
- Diploma
- Updated PRC license (if
Engineer)
- Certificates of Trainings
attended
- Proof of Employment /
Appointment
DOCUMENT REVIEW
- Certificates of Trainings
attended
- Proof of Employment /
Appointment
DOCUMENT REVIEW
- Diploma / Certificate of
units earned
- Certificates of Trainings
attended
- Proof of Employment /
Appointment
INTERVIEW
DOCUMENT REVIEW
- Diploma / Certificate of
units earned
- Updated PRC license
Certificates of Trainings
attended
- Proof of Employment /
Appointment

1

1
1

1

1

1

INTERVIEW
Driver
Cook
Building
Maintenance Man /
Utility Worker
Security Guard

1
1
May be outsourced

DOCUMENT REVIEW
Certificates of Trainings
attended

1 per shift
1 per shift

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ANNEX K - 3
AO No. 2012-0012
POSITION

QUALIFICATION

EVIDENCE

NUMB ER /
RATIO

COMPLIED

REMARKS

CLINICAL SERVICES
Consultant Staff in
Ob-Gyn,
Pediatrics,
Medicine, Surgery
and Anesthesia
Physician
(Shall not go on
duty for more than
48 hours straight).

Fellow / Diplomate
with updated PRC
License

Updated PRC license

DOCUMENT REVIEW
- Diploma / Certificate
from Specialty society, if
applicable
- Updated PRC license
- Certificates of Trainings
attended
- Proof of Employment /
Appointment

At least one
(1) per
specialty

1:20 beds at
any time

NURSING SERVICES
Assistant Chief
Nurse

Supervising
Nurse/Nurse
Managers

Head Nurse/Senior
Nurse

With updated PRC
license, with twenty
(20) units towards
Master’s Degree in
Nursing and three (3)
years experience in
hospital supervisory /
managerial position

With updated PRC
license, with at least
nine (9) units of
Master's Degree in
Nursing with 3 years
hospital experience.
Updated PRC License
With at least 3 years
hospital experience

Staff Nurse

Updated PRC License
BLS certified

Staff Nurse in
every Critical Unit
(CCU, ICU, NICU,
PICU, SICU,
HRPU etc.)
Nursing Attendant
/ Midwife

Updated PRC License
Certificate of Training
in Critical Care
Nursing

Nursing Attendant
/ Midwife in CCUs

DOCUMENT REVIEW
- Diploma / Certificate of
units earned
- Updated PRC license
- Certificates of Trainings
attended
- Proof of Employment /
Appointment
INTERVIEW
DOCUMENT REVIEW
- Diploma / Certificate of
units earned
- Updated PRC license
- Certificates of Trainings
attended
- Proof of Employment /
Appointment

DOCUMENT REVIEW
- Diploma
- Updated PRC license
- Certificate of trainings
attended
- Proof of employment

With relevant training
(may be in house
training)
DOCUMENTS REVIEW
Certificates of Trainings
attended

1

1 per
Department

1 per shift per
clinical
department
1:12 Beds at
any time (1
reliever for
every 3 RNs)
1:3 beds at
any time per
shift (plus 1
reliever per 3
CCU RNs)
1:24 beds at
any time (1
reliever for
every 3
NA/MWs)
1:12 patients
at any time
(plus 1
reliever for
every 3
NA/MWs)

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ANNEX K - 3
AO No. 2012-0012
POSITION
Operating Room
Nurse

QUALIFICATION

EVIDENCE

With updated PRC
license
Training OR Nursing

Scrub Nurse
Circulating Nurse
Delivery Room
Nurse

With updated PRC
license
Certificate of Training
in Maternal and Child
Nursing (may be in
house training or
training in EINC)
Emergency Room
With updated PRC
Nurse
license
Certificate of Training
in Trauma Nursing,
ACLS and other
relevant training
Out-patient
With updated PRC
Department Nurse
license
ANCILLARYS ERVICES
With updated PRC
Dentist
license

DOCUMENT REVIEW
- Diploma
- Updated PRC license
- Certificates of Trainings
attended
- Proof of Employment /
Appointment

Physical Therapist
Radiologist
Radiologic
Technologist
Radiation Safety
Officer
Respiratory
Therapist

REMARKS

1 per
functioning
DR per shift

1 per
department

1
1
2 in AM and
2 in PM shift;
1 in the
evening shift

Medical
Laboratory Aide

Pharmacist

COMPLIED

1 ORN, SN,
CN per
functioning
OR per shift

Medical
Technologists

Pathologist

NUMB ER /
RATIO

Adequate
With updated PRC
license;
Fellow / Diplomate in
Pathology
With updated PRC
license
With updated PRC
License
Fellow or Diplomate
in Radiology

DOCUMENT REVIEW
- Diploma
- Updated PRC license, if
applicable
- Certificates of Trainings
attended
- Proof of Employment /
Appointment

1
1 per shift
1
1

1 per shift
1
1 per shift

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ANNEX K - 3
AO No. 2012-0012

ASSESSMENT TOOL FOR LEVEL 2 HOSPITAL
ATTACHMENT B - PHYSICAL PLANT
PHYSICAL FACILITY
(Specify “ADD ON” Services, if
any)
ADMINISTRATIVE SERVICE

DESCRIPTION

COMPLIED

REMARKS

Lobby
Waiting Area
Information and Reception
Communication Booth / Room
Human Resource / Personnel
Office
Library
Conference Room
Property / Supply Office / Room
Office of the Chief of Hospital /
Medical Director
Office of the Chief of Clinics /
Chief Medical Professional
Services
Office of Chief Administrative
Officer
Office of the Chief Nurse
Office of the Training Officer
Budget and Finance Office
Accounting Office
Budget and Finance Office
Billing / Cashier
Linen and Laundry room
Receiving Area
Sorting Area and Disinfection
Area
Washing Area
Clean Linen Storage and
Release Area
Housekeeping room for cleaning
tools and supplies

Not required if outsourced

Parking Area for transport vehicle
Motor pool Area
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ANNEX K - 3
AO No. 2012-0012
PHYSICAL FACILITY
(Specify “ADD ON” Services, if
any)
Central Waste Storage Area
Staff Toilet

DESCRIPTION

COMPLIED

REMARKS

Shall have color-coded
segregation; clean and free from
foul odor
Provided with water; clean and
free from foul odor

Public Toilet (M/F/PWD)
Dietary
Nutritionist-Dietician Office
Supply receiving Area
Dry and Cold Storage Area
Special Diet Preparation Area
Food preparation Area

(not required if contracted-out)
Shall have adequate space, clean
and Free from foul odor; no insects
and rodents.

Cooking Area
Dishwashing Area
Assembly Area
Dining Area
Garbage Area
Medical Records Office
Filing Room
Storage Room

With area for completion of
patients' charts by physicians and
other professionals

Medical Social Worker’s Office
Counselling Area
Morgue
PRAYER ROOM
CLINICAL SERVICES

EMERGENCY ROOM /
EMERGENCY
DEPARTMENT

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.

Triage Area
Decontamination Area
(with separate entrance and exit
– adjacent to main ER entrance)
Holding Room for Infectious
cases awaiting transfer
Examination and Treatment
Area

Shall be provided with shower,
receptacle for used or
contaminated clothing; shelf for
clean patient gowns
Shall have ante-room with
rack/shelf for PPEs
Shall be provided with hand
washing/hand disinfection facility

Medication Preparation Area

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ANNEX K - 3
AO No. 2012-0012
PHYSICAL FACILITY
(Specify “ADD ON” Services, if
any)

DESCRIPTION

COMPLIED

REMARKS

Minor OR / Area
Observation Area /Ward
Area / Room for Imminent
Normal Spontaneous Delivery
Waiting area

Shall have adequate lighting and
ventilation.

Nurses' station
Equipment and supply storage
area
Wheeled Stretcher and
Wheelchair Area
Doctor's On-Duty Room
Admitting Office
Toilet for patients and
companions

Separate Male from Female; Clean
and Free from foul odor; no insects
and rodents

Staff Toilet
OUTPATIENT DEPARTMENT
Waiting area

Consultation Area

Examination and Treatment
Area

Shall have adequate lighting and
ventilation.
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.
Shall be provided with hand
washing/hand disinfection facility

Nurse’s counter
Patients’ Area
Toilet for patients and
companions

Separate Male from Female; Clean
and Free from foul odor; no insects
and rodents

OFFICES OF DEPARTMENT HEADS
Internal Medicine
Surgery
Obstetrics and Gynecology
Pediatrics
Anesthesia
Emergency Department
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ANNEX K - 3
AO No. 2012-0012
PHYSICAL FACILITY
(Specify “ADD ON” Services, if
any)

DESCRIPTION

COMPLIED

REMARKS

Out-patient Department
Pathology
Radiology
OPERATING ROOM /
COMPLEX

Shall have control door or
demarcation line between dirty to
clean area

Major OR
Dressing Room
Nurses’ Station with work Area
Sub-sterile Area
Sterile Area
Scrub up Area
Clean up Area
Storage Area for Sterile packs
and supplies
Wheeled Stretcher Area
Janitors’ Closet with slop sink
POST ANESTHES IA CARE UNIT / RECOVERY ROOM
Patients Area
Nurses’ Station with Medication
Area
DELIVERY ROOM / COMPLEX
Labor Room (provided with
toilet)
Delivery Room proper
Scrub Up Area
Dressing Room
Nurse’s Station
Storage Area for Sterile packs
and supplies
Wheeled Stretcher Area
Janitors’ Closet with slop sink
HIGH RISK PREGNANCY
AREA
(May be put up as part of the
Labor Room or patient may be
admitted in the ICU)

Indicate if it is a separate unit or if
patients are admitted in ICU or
Labor Room

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ANNEX K - 3
AO No. 2012-0012
PHYSICAL FACILITY
(Specify “ADD ON” Services, if
any)

DESCRIPTION

COMPLIED

REMARKS

NEONATAL INTENS IVE CARE UNIT (NICU)
Nurses’ Station with lavatory
Medication preparation area
Incubator / Warmer Area
Treatment Area
Breastfeeding Area with
Lavatory
INTENS IVE CARE UNIT (ICU)
Dressing Room
Nurses’ Station with lavatory
Medication Preparation Area
Patients’ beds Area
NURSING SERVICE / WARD

Patient Rooms with Toilet

Nurses’ Station with Lavatory

Adequate privacy for patients is
provided such that sensitive or
private discussion, examination,
and/or procedure are conducted in
a manner or environment where
these cannot be observed or the
Risk of being overheard by others
is minimized.
Adequate space is provided to
allow patients and personnel to
move safely around patient bed
areas
All point of care areas should be
provided with hand-washing / hand
disinfection facility.

Medication preparation area
with lavatory
Treatment area with Lavatory
Equipment and Supply Area
Staff Toilet
Linen Area
Waste bins

Color-coded

Janitor’s Closet
AMBULATORY SURGICAL
CLINIC

Refer to Assessment Tool for ASC

DIALYS IS CLINIC

Refer to Assessment Tool for DC

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ANNEX K - 3
AO No. 2012-0012
PHYSICAL FACILITY
(Specify “ADD ON” Services, if
any)

DESCRIPTION

COMPLIED

REMARKS

ISOLATION ROOM
Ante room with lavatory and
PPE Rack
Hand-washing / Hand
disinfection facility in all point
of care areas
RESPIRATORY UNIT
DENTAL CLINIC
Dental chair unit area
Consultation Area with Access
to Toilet

Not required if by Referral

CENTRAL STERILIZING AND SUPPLY UNIT / DIVISION / AREA
Receiving and Cleaning Area
Inspection and Packaging Area
Sterilizing Area
Storage and Releasing Area

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ANNEX K - 3
AO No. 2012-0012

ASSESSMENT TOOL FOR LEVEL 3 HOSPITAL
ATTACHMENT C –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

Computer with Internet Access

1

Emergency Light

1 per unit or
area

Fire Extinguishers

1 per unit or
area

LCD Projector
Generator set with Automatic Transfer
Switch (ATS)
KITCHEN/DIETARY
Exhaust fan
Food Conveyor or equivalent
Food Scale
Blender/Osterizer
Stove
Refrigerator/Freezer
Utility cart
Garbage Receptacle with Cover colorcoded)
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
ECG Machine

1
1

Parking
Administrative
Office
lobby, hallway,
nurses' station,
office/unit and
stairways
lobby, hallway,
nurses' station,
office/unit and
stairways
Conference
Room
Genset house

1
1
1
1
Kitchen
1
1
1
1 for each
color
EMERGENCY ROOM
1
1
1
1
1
2 sets
1 per set
1 per set

ER

2 per set
1 per set
1 per set
2 sets
1 per set
2 per set
1
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ANNEX K - 3
AO No. 2012-0012
EQUIPMENT/ INSTRUMENT
(Functional)
(Use separate sheet if equipment is for
a specific “ADD ON” Service/s).
EENT Diagnostic Set with
Ophthalmoscope and Otoscope
Emergency Cart (for contents, refer to
separate list).
Examining table
Examining table (with Stirrups for OBGyne
Gooseneck lamp/Examining Light
Instrument/Mayo Table
Laryngoscope with different sizes of
blades
Minor Instrument Set (May be used for
Tracheostomy, Closed Tube
Thoracostomy, Cutdown, etc.)
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
Negatoscope
Neurologic Hammer
OR Light (portable or equivalent)
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
Mayo scissors
Mosquito forceps
Needle holder
Tissue forceps
Thermometer, non-mercurial
- Oral
- Rectal
Vaginal Speculum, Different Sizes
Wheelchair
Wheeled Stretcher with guard/side rails
and wheel lock or anchor.

QUANTITY

AREA

COMPLIED

REMARKS

1
1
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
1
1
1

ER

2
1
1
1
1
1
1
2 sets
1 per set
1 per set
1 per set
1 per set
1
1
1 set of
different sizes
1
1

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ANNEX K - 3
AO No. 2012-0012
EQUIPMENT/ INSTRUMENT
(Functional)
(Use separate sheet if equipment is for
a specific “ADD ON” Service/s).
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
Mosquito forceps – straight
Needle holder
Scalpel handle No. 3
Scalpel handle No. 4
Skin retractor
Tissue forceps
Thumb forceps
Neurologic Hammer
Oxygen Unit
Tank is anchored/chained/ strapped or
with tank holder if not pipeline
Peakflowmeter
- Adult
- Pediatric
Sphygmomanometer, Non-mercurial
- Adult cuff
- Pediatric cuff
Stethoscope
Thermometer, non-mercurial
- Oral
- Rectal
Suture Removal Set
Wheelchair / Wheeled Stretcher
Air conditioning Unit
Anesthesia Machine
Cardiac Monitor with Pulse Oximeter
Ceasarian Section Instrument
Emergency Cart (for contents, refer to
separate list).
Instrument / Mayo Table
Laparotomy pack (Linen pack)

QUANTITY

AREA

COMPLIED

REMARKS

OUT- PATIENT DEPARTMENT
1
1
1
1
1
1
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

OPD

1

1
1
1
1
1
1
1
1
1
OPERATING ROOM
1
1
1
1
OR
1
1
1 per OR

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ANNEX K - 3
AO No. 2012-0012
EQUIPMENT/ INSTRUMENT
(Functional)
(Use separate sheet if equipment is for
a specific “ADD ON” Service/s).
Laparotomy / Major Instrument Set
Towel Clamp
Scalpel handle No. 3
Scalpel handle No. 4
Army-navy retractor
Richardson retractor – double-end
Self-retraining retractor (Balfour)
Kelly hemostatic forceps – curved
Kelly hemostatic forceps – straight
Halsted mosquito forceps – straight
Allis forceps
Mixter – curved
Mixter – straight
Needle holder
Tissue forceps
Thumb forceps
Metzenbaum scissors – curved
Mayo scissors – curved
Mayo scissors – straight
Orthopedic Instrument Set
Periosteal elevator
Bone chisel / osteotome
Bone mallet
Bone Rongeur
Bone holder
Bone drill with different sizes of drill
bits
Gigli saw (handle and wire)
Pin / Wire cutter
Pin / Wire puller
Bone curette
Cast spreader
Bone clamp
Zimmer
Screw driver
Oxygen Unit
Tank is anchored/chained/ strapped or
with tank holder if not pipeline
Rechargeable Emergency Light (in case
generator malfunction)
Sphygmomanometer, Non-mercurial
- Adult cuff
- Pediatric cuff
Spinal Set
Stethoscope
Suction Apparatus
Thermometer, non-mercurial
- Oral
- Rectal

QUANTITY

1 per OR
4 per set
1 per set
1 per set
1 pair per set
1 per set
1 per set
4 per set
4 per set
4 per set
4 per set
1 per set
1 per set
2 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
1 per set
1 per set
1 per set

AREA

COMPLIED

REMARKS

OR

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 per OR
1 per OR
1 per OR
1 per OR
1
1
1
1
1
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ANNEX K - 3
AO No. 2012-0012
EQUIPMENT/ INSTRUMENT
(Functional)
QUANTITY
COMPLIED
AREA
(Use separate sheet if equipment is for
a specific “ADD ON” Service/s).
Tracheostomy set
1 set
- Obturator
- Inner Cannula
OR
- Outer Cannula
Wheeled Stretcher with guard/side rails
1
and wheel lock or anchor.
POST ANESTHES IA CARE UNIT / RECOVERY ROOM
Air conditioning Unit
1
Cardiac Monitor
1
Mechanical / patient bed, with guard
1
side rails and wheel lock or anchored
Oxygen Unit
Tank is anchored/chained/ strapped or
1
PACU/RR
with tank holder if not pipeline
Sphygmomanometer, Non-mercurial
- Adult cuff
1
- Pediatric cuff
1
Stethoscope
1
Thermometer, non-mercurial
1
LABOR ROOM
Fetal Doppler
1
Oxygen Unit
Tank is anchored/chained/ strapped or
1
with tank holder if not pipeline
Patient Bed
1
Labor Room
Pulse Oximeter
1
Sphygmomanometer, Non-mercurial
1
Stethoscope
1
Thermometer, Non-mercurial
1
DELIVERY ROOM
Air-conditioning Unit
1
Bag valve mask unit (Adult and
1
pediatric)
Bassinet
1
Clinical Infant Weighing Scale
1
Dilatation/Curettage set
1 set
Uterine Sound / Hysterometer
1 per set
Uterine forceps
1 per set
Dull Uterine curette
1 per set
Sharp Uterine curette
1 per set
Vaginal Retractor
1 per set
DR
Vaginal Speculum
1 per set
Ovum forceps
1 per set
Hegars dilator, graduated sizes
1 per set
Sponge forceps
1 per set
Delivery set, primigravid
1 set
Metzenbaum scissors, straight
1 per set
Mayo scissors, straight
1 per set
Kelly hemostatic forceps, curved or
2 per set
straight
Needle Holder
1 per set
Tissue forceps
1 per set

REMARKS

DOH-HOS-LTO-AT-L3
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08/09/2016
Page 43 of 51

ANNEX K - 3
AO No. 2012-0012
EQUIPMENT/ INSTRUMENT
(Functional)
(Use separate sheet if equipment is for
a specific “ADD ON” Service/s).
Delivery set, multigravid
Mayo scissors, straight
Kelly hemostatic forceps, curved or
straight
DR Light
DR Table
Emergency Cart (for contents, refer to
separate list).
Instrument/Mayo Table
Kelly Pad or equivalent
Laryngoscope
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
Wheeled Stretcher

QUANTITY

AREA

COMPLIED

REMARKS

2 sets
1 per set
2 per set
1
1
1
(if DR is
separate from
OR Complex)
1
1
1

DR

1
1
1
1
1
1
HIGH RISK PREGNANCY UNIT
1
1

Cardiac Monitor with Pulse Oximeter
Cardiotocography (CTG) Machine
Oxygen Unit
HRPU
Tank is anchored/chained/ strapped or
1
with tank holder if not pipeline
Suction Apparatus
1
NEONATAL INTENS IVE CARE UNIT (NICU)
Air conditioning unit
1
Bassinet
1
Bilirubin Light / Phototherapy machine
1
or equivalent
Cardiac Monitor
1
Clinical Infant Bag-valve mask unit
1
Clinical Infant weighing scale
1
Emergency Cart (for contents, refer to
1
separate list).
EENT Diagnostic Set with
1
ophthalmoscope and otoscope
Glucometer
1
NICU
Incubator
1
Infusion pump / Syringe pump
1
Laryngoscope with neonatal blades of
1
different sizes
Neonatal Stethoscope
1
Oxygen Unit
Tank is anchored/chained/ strapped or
1
with tank holder if not pipeline
Pulse Oximeter
1
Refrigerator for Breastmilk storage
1
Suction apparatus
1

DOH-HOS-LTO-AT-L3
Rev ision:00
08/09/2016
Page 44 of 51

ANNEX K - 3
AO No. 2012-0012
EQUIPMENT/ INSTRUMENT
(Functional)
QUANTITY
COMPLIED
AREA
REMARKS
(Use separate sheet if equipment is for
a specific “ADD ON” Service/s).
Umbilical Cannulation set
1
Umbilical scissors
1 per set
NICU
Kelly hemostatic forceps, curved or
1 per set
straight
INTENS IVE CARE UNIT (ICU) – For all types of ICU (PICU, SICU, Medical ICU, etc.)
Air conditioning unit
1
Bag-valve-mask Unit
- Adult
1
- Pediatric
1
Cardiac Monitor with Pulse Oximeter
1
Defibrillator
1
Emergency Cart (for contents, refer to
1
separate list).
EENT Diagnostic Set with
1
ophthalmoscope and otoscope
Infusion pump
1
Laryngoscope
1
Depending on
Mechanical Bed
the number of
ICU
beds declared
Mechanical Ventilator / Respirator (May
1
be outsourced)
Minor Set for cut down
1
Oxygen Unit
Tank is anchored/chained/ strapped or
1
with tank holder if not pipeline
Sphygmomanometer, non-mercurial
(reserved for sudden breakdown of
cardiac monitor)
- Adult cuff for adult unit
1
- Pediatric cuff for pediatric unit
1
Stethoscope
1
Suction Apparatus
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 with
1
ophthalmoscope and otoscope
NURSING
Laryngoscope with different sizes of
UNIT/ WARD
1
blades
Mechanical/Patient bed With locked, if
ABC
wheeled; with guard or side rails
Bedside Table
ABC
Nebulizer
1
Neurologic Hammer
1
Oxygen Unit
1
tank is anchored/chained if not pipeline

DOH-HOS-LTO-AT-L3
Rev ision:00
08/09/2016
Page 45 of 51

ANNEX K - 3
AO No. 2012-0012
EQUIPMENT/ INSTRUMENT
(Functional)
(Use separate sheet if equipment is for
a specific “ADD ON” Service/s).
Sphygmomanometer, Non- Mercurial
- Adult cuff
- Pediatric cuff
Stethoscope
Suction Apparatus
Thermometer, non-mercurial
- Oral
- Rectal

ABG Machine
Spirometer
Transcutaneous Electric Nerve
Stimulator (TENS)
Exercise Plight / Bed
Exercise Stairs with Rails
Overhead pulley
Paraffin Wax
Parallel Bars
Dynamometer
Cold Therapy Products
Hot Therapy Products
Cervical Traction
Lumbar Traction
Light Therapy
Pedometer
Goniometer
Therapy rolls
Therapy mats
Therapy wedges
Diagonal mirrors
Pulley System
Ultrasound Therapy machine

QUANTITY

AREA

1
1
1
1

COMPLIED

NURSING
UNIT/ WARD

REMARKS

1
1

DIALYS IS CLINIC
(Specify if Hemodialysis or Peritoneal Dialysis or both)
Refer to Assessment Tool for Dialysis Clinics
AMBULATORY SURGICAL CLINIC
Refer to Assessment Tool for ASC
RESPIRATORY / PULMONARY UNIT
1
Respiratory /
Pulmonary Unit
1
PHYSICAL MEDICINE AND REHABILITATION UNIT
1

1
1
1
1
1
1
1
1
1
PMRU
1
1
1
1
1
1
1
1
1
1
DENTAL CLINIC – not required if service is by Referral
Air compressor
1
Autoclave
1
Bone file, stainless
1
Cotton pliers
1
Cowhorn Forceps
1
Dental Chair unit
1
DENTAL
Explorer, double-end
1
CLINIC
Forceps, No. 8
1
Forceps, No. 17 Upper molar
1
Forceps, No. 18 Upper molar
1
Forceps, No. 150 Maxillary Universal
1
Forceps, No. 150 S Primary Teeth
1
Forceps, No. 151 Lower Universal
1

DOH-HOS-LTO-AT-L3
Rev ision:00
08/09/2016
Page 46 of 51

ANNEX K - 3
AO No. 2012-0012
EQUIPMENT/ INSTRUMENT
(Functional)
QUANTITY
COMPLIED
AREA
(Use separate sheet if equipment is for
a specific “ADD ON” Service/s).
Forceps, No. 151 Mandibular Pre-molar
1
Forceps, No. 151 S Lower Primary
1
Teeth
Gum separator
1
High speed handpiece with Burr
1
remover
Low speed handpiece, Angled head
1
DENTAL
Mouth mirror explorer
1
CLINIC
Periosteal elevator No. 9, double-end
1
Rongeur
1
Root elevator
1
Scaler Jacquettes Set No. 1, 2, and 3
1
Surgical Chisel
1
Surgical Malette
1
Ultrasound Therapy machine
1
CENTRAL STERILIZING & SUPPLY ROOM
Autoclave/Steam Sterilizer
1
CSSR
MORGUE
Autopsy table
1
Autopsy instrument set
1
MORGUE
Cadaver freezer
1
Cadaver Shower
1

REMARKS

EMERGENCY CART CONTENTS
EQUIPMENT/ INSTRUMENT

QUANTITY
MEDICINES
Β-adrenergic agonists (i.e. Salbutamol 2mg/ml)
20
5 Caloric agent (D50W 50mg/vial)
10
20
Activated charcoal sachet
10
Amiodarone 150mg/ampule
5
Anti-rabies vaccine (active)
5
Anti-rabies vaccine (passive)
Anti-tetanus serum (either equine-based antiserum or
40
human antiserum)
Anti-venims* (for centres with high incidence of
poisonous animal bites)
20
Aspirin USP grade (325 mg/tablet)
15
Atropine 1mg/ml ampule
Benzodiazipine (Diazepam 10mg/2ml ampule and/or
10
Midazolam)
10
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
30
Epinephrine 1mg/ml ampule

COMPLIED

REMARKS

DOH-HOS-LTO-AT-L3
Rev ision:00
08/09/2016
Page 47 of 51

ANNEX K - 3
AO No. 2012-0012
EQUIPMENT/ INSTRUMENT
QUANTITY
20
Furosemide 20mg/2ml ampule
10
Haloperidol 50mg/ampule
10
Hydrocortisone 250mg/vial
5
Hyoscine N-butyl-bromide 20mg/vial
20
Lidocaine 5% solution vial 1g/50ml
10
Magnesium sulfate 1g/ampule
10
Mannitol 20% solution 500ml/vial
10
Mefenamic Acid 500mg/tablet
10
Methylprednisolone 4mg/tablet
5
Metoclopramide 10mg/ampule
10
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)
15
Phenobarbital 30mg/ml IV or 30mg tablet
15
Phenytoin 300mg/capsule or IV preparation
10
Plain LRS 1L/bottle
10
Plain NSS 1L/bottle
15
Potassium Chloride 40mEq/vial
10
Pyridoxine 1g/ampule
10
Sodium bicarbonate 50mEq/ampule
5
Succinylcholine 200mg/vial
20
Tetanus Toxoid 0.5ml/vial
Thiamine (usually in parenteral Vitamin B complex
10
preparation)
10
Tramadol 50mg/capsule
10
Verapamil 5mg/2ml ampule
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)
Flashlights or Pen lights
Gloves (examination and sterile, different sizes)
Hydrogen peroxide solution
Nasal cannula
Povidine iodine wound and cleaning solutions
Protective face shield or mask

COMPLIED

REMARKS

DOH-HOS-LTO-AT-L3
Rev ision:00
08/09/2016
Page 48 of 51

ANNEX K - 3
AO No. 2012-0012
EQUIPMENT/ INSTRUMENT
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

QUANTITY

COMPLIED

REMARKS

DOH-HOS-LTO-AT-L3
Rev ision:00
08/09/2016
Page 49 of 51

ANNEX K - 3
AO No. 2012-0012
Name of Health Facility:

_______________________________________________________________________

Date of Inspection:

_______________________________________________________________________

RECOMMENDATIONS:
A.
For Licensing Process
[ ]
For Issuance of License To Operate 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
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________

[ ]

Non-issuance. Specify reason/s: ___________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________

Inspected by:
Printed name

Signature

Position/Designation

_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Received by:
Signature: ___________________________________
Printed Name: ___________________________________
Position/Designation: ___________________________________
Date: ___________________________________

DOH-HOS-LTO-AT-L3
Rev ision:00
08/09/2016
Page 50 of 51

ANNEX K - 3
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-HOS-LTO-AT-L3
Rev ision:00
08/09/2016
Page 51 of 51
 
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