Documenti di Didattica
Documenti di Professioni
Documenti di Cultura
OUTLINE OF CONTENTS
I. GENERAL INFORMATION(page 2) 8. Human Resource Management (page 18) 2.6. Delivery Room
9. Data Collection, Management and Use 2.7. Neonatal Intensive care Unit
II. HOSPITAL ADMINISTRATION (pages18-19) 2.8. Intensive Care Unit
10. Safe Practice and Environment including 3. Nursing Unit/Ward
A. Services Patient and Staff Safety (pages 20-25) 4. Isolation Room
1. Administrative Service (pages 3-8) 11. Maintenance of Environment of Care (pages 5. Central Supply and Sterilization Unit/ Room
1.1. Human Resource 26-27) 6. Physical Medicine and Rehabilitation Unit
1.2. Accounting 12. Infection Control (pages 28-32)) 7. Dialysis Clinic
1.3. Budget and Finance 13. Energy and Waste Management (page 33) 8. Ambulatory Surgical Clinic
1.4. Billing and Claims 14. Improving Performance (page 34) 9. Dental Clinic
1.5. Procurement 10. Dietary
1.6. Property and Supply Management III. PERSONNEL V. PHYSICAL PLANT REQUIREMENT(53-57)
1.8 Linen and Laundry Required rooms/areas/offices
1.9 Housekeeping POSITION STAFFING REQUIREMENT(pages 35-43)
1.7. Nutrition and Dietary 1. Top Management Personnel Qualification VI.HOSPITAL PROGRAMS (pages 58-60)
1.8. Security Services Standard 1. Blood Services
1.9. Ambulance Services 2. Administrative 2. Newborn Screening
1.10. Central Information Management 3. Clinical
4. Nursing 3. Mother-Baby Friendly Hospital Initiative
1.11. Medical Records (Including Dental 4. Health Promotion and Disease Prevention
Records) 5. Ancillary
1.12. Medical Social Services 5. Generics Act
1.13. Nutrition and Dietetics IV. EQUIPMENT AND INSTRUMENTS (pages44-52) 6. Health Emergency Management Services
1.14. Pharmacy List of Equipment and Instrument Requirement
2. Patients Rights and Organizational Ethics 1. Administrative VII. HOSPITAL COMMITTEES (page 61)
(pages 9-10) 2. Clinical
3. Patient Care (pages 10-13) 2.1. Emergency Room VII. HOSPITAL OPERATIONS CRITERIA (page 62)
4. Implementation of Care (pages 13-15) 2.2. Outpatient Care
5. Evaluation of Care (page 16) 2.3. Operating Room VIII. SIGNATURE PAGE (page 63)
6. Leadership and Management (pages 16-17) 2.4. Recovery Room
7. External Services (page 17) 2.5. High Risk Pregnancy Unit
DOH INSPECTION
DOH MONITORING
CODE STANDARDS CRITERIA INDICATOR EVIDENCE AREA REMARKS
HOSPITAL ADMINISTRATION:
Goal- To be responsive to the requirements of quality health service delivery, health regulation, health financing and good governance.
ADMINISTRATIVE AND
FINANCE SERVICE: The
AFS shall ensure adequate ●Documented and
1.1.1 and timely financial and implementable policies and
direct support services to all procedures
hospital units. Approved documented policies,
guidelines and procedures on:
Administrative Group: a) Staffing plan
Human Resource b) Recruitment and ● Complete, updated and
Management Selection easily retrievable
There shall be a c) Hiring/Appointment individual personnel file
comprehensive human d) Orientation & Staff ● Evidence of continuous
1.1.1.a resource management plan Development improvement
1.1.1.a.1 which includes recruitment, e) continuing education, and
selection, promotion, training
separation, welfare and Approved documented policies,
benefits in accordance with guidelines and procedures on
applicable laws. a) Staffing plan
b) Recruitment and Selection
c) Hiring/Appointment
d) Orientation & Staff
Development
e) continuing education, and
training
Financial Management
1.1.1.b
Group
Accounting
1.1.1.b.1
There shall be a systematic documented and
recording of all financial implementable policies and Verifier:
transactions, preparation of procedures Documents review,
financial statements and Interview staff,
relevant reports, and maint- Validate
enance and safekeeping of
Books of Accounts.
Budget
1.1.1.b.2
There shall be a
consolidation and
preparation of the Budget documented and
Proposal, Work and implementable policies and Verifier:
Financial/ Operational procedures Documents review,
Plans including its Interview staff,
implementation and Validate
monitoring by the hospital
staff concerned.
Verifier:
Property and Supply documented and implementable Proof of transactions Documents review,
1.1.1.d Management: policies and procedures Documents are readily Interview staff,
There shall be a systematic Available Validate
way of receipt, storage,
issuance and conduct of
inventory .
1.1.1.l Pharmacy
There shall be 24 hours, 7 Actual implementation and documented and
days a week provision of evidence of continuous implementable policies Verifier:
safe, affordable and review of policies and and procedures Observe, Interview
efficacious drugs and procedures staff, Validate
medicines in accordance
with the Generics Act,
PNDF and DOH policies,
rules and regulations.
INSPECTION
SELF-
DOH
CODE EVIDENCE
STANDARDS CRITERIA INDICATOR AREA REMARKS
PATIENTS’ RIGHTS AND ORGANIZATIONAL ETHICS
2.1 Goal: To improve patient outcomes by respecting patients' rights and ethically relating with patients and other organizations
2.1.1 DOCUMENT
1.Organizational policies Informed consent is obtained All patient charts have Patient charts – sample Wards
and procedures respect and from patients prior to initiation signed consent. charts of patients currently (sample
support patients' right to of care. admitted. If hospital is size-10
quality care and their department-alized, get charts, if
responsibilities in that care. samples during tour of the department-
different departments. alized, get
two from
Note: *Informed consent - each depart-
includes a patient-doctor ment; when
discussion of the following a chart is
issues: the nature of the found to
decision or procedure; have no
reasonable alternatives to consent
the proposed intervention; before you
the relative risks, benefits, reach 10,
and uncertainties related to you do not
each alternative; have to go
assessment to patient further.)
understanding; and
patient's acceptance or
refusal of the intervention.
RR
PACU
2.2.1 ACCESS - Goal: The organization is accessible to the community that it aims to serve.
2.2.1.a 3.Physical Access to Entrances and exits are Presence of entrances and OBSERVATION ER
the organization and its clearly and prominently exits that are readily Entrances and exits are OPD
services is facilitated marked, free of any accessible and free from accessible and free from Wards
and is appropriate to obstruction and readily obstruction. any obstruction. ICU
patients' needs. accessible. Note: Exit signs should be OR/RR/
luminous or illuminated DR/PACU
and prominently marked. Imaging
There should be exit signs
Laboratory
in major areas of the
hospital and all doors
leading to the
outside.(Reference: RA
6541 Building Code of the
Philippines)
2.2.1.b 4.Physical access to the Directional signs are Presence of directional ER
organization and its services prominently posted to help signages to locate service OPD
is facilitated and is locate service areas within areas. Wards
appropriate to patients' the organization. Other Areas
needs. Directional signs are Lobby
prominently posted. Check
ER, OPD, wards and lobby.
6.The organization uniquely All patients are correctly All patients are correctly DOCUMENT and ER
2.2.2.a identifies all patients identified by their patient identified by their charts. INTERVIEW
including newborn infants, charts. Patient chart from ER,
and creates a specific ward, OPD and ICU and
patient chart for each verify with patient if he/she OPD
patient that is readily really is the person Wards
accessible to authorized indicated in the chart. ICU
personnel.
2.2.3 ASSESSMENT
Goal: Comprehensive assessment of every patient enables the planning and delivery of patient care.
2.2.3.a 7.Each patient's physical, An appropriately All patients have CHART REVIEW Wards
psychological and social comprehensive history and comprehensive history and
status is assessed. physical examination is PE within 24 hours from
performed on very patient admission.
within 24 hours from
ER
admission. The history
includes present illness, past DOCUMENT
medical, family, social and
personal history. Patient chart from wards
or ER.
NOTE: comprehensive
history includes present
illness, review of systems,
past medical, family and
personal history.
2.2.3.c 9.Assessments are Qualified personnel give All patients for surgery have CHART REVIEW
performed regularly and patients for surgery pre- undergone pre-operative Note: Look for pre-
are determined by patient's operative physical and pre- anesthetic assessment. operative anesthetic
evolving response to care. anesthetic assessment. evaluation in the patient
chart. Pre-operative
assessment should be
done for patients requiring
more than local
anesthesia.
2.3.1 10.Diagnostic examinations Policies and procedures for Proof of monitoring of the DOCUMENT REVIEW X-ray
appropriate to the provider the standard performance, implementation of the Monitoring reports, Laboratory
organization's service monitoring and quality control policies and procedures on e.g..utilization review of
capability and usual case of diagnostic examinations quality control of diagnostic diagnostics exams done,
mix are available and are are documented and examinations audit reports, manual of
performed by qualified monitored. procedures, or DOH
personnel. monitoring reports e.g..
Quality control diagnostic
reports (QC reports on
softwares, calibration of
diagnostic equipment, film
reject analysis, etc.)
2.3.2.c 13.Drugs are administered Prescriptions or orders are Proof that the prescriptions DOCUMENT
in a standardized and verified and patients are or orders are verified before Procedures on verification
systematic manner in the identified before medications medications are of orders. INTERVIEW
provider organization are administered. administered. Observe if staff verifies
the prescriptions or orders
for drugs with the doctor
and the drug against the
doctor's order
OBSERVATION
Observe if the staff
verifies the identity of
patient prior to
administration of
medications.
2.3.2.e 15.Drugs are administered Drug administration is All charts have proper CHART REVIEW
in a standardized and properly documented in the documentation of drug Medication sheet in
systematic manner in the patient chart. administration patient chart from the
provider organization medical records.
.
2. EVALUATION OF CARE
Goal: Care is coordinated between the organization and other health care providers in the community to ensure that the
needs of the patient are continuously met.
2.4.1 16. The discharge plan is All charts have discharge CHART REVIEW
part of the patient's care plans Patient chart from medical
plan and is documented in records room, the
the patient chart. discharge orders should
contain the ff.:
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.
INTERVIEW
1. Ask the management
2.5.1.c Presence of evaluation and team about priorities for
monitoring activities to performance improvement
19.The organization's assess management and that relate to hospital wide
management team regularly organizational performance activities and patient
assesses its own outcomes
performance and the 2. Ask management team
performance of the how targets are set.
organization.
OBSERVATION
Actual presence of the
Imaging
outsourced services within
the hospital if applicable
Laboratory
Other areas
Note: The contracts/MOA
should be updated. MOA
is sufficient for some
hospitals where the
outsourced services are
not within the facility.
3.1 Human Resource Management
3.1.1 Human Resource Planning
Goal: The organization provides the right number and mix of competent staff to meet the needs of its internal and
external customers and to achieve its goals.
3.1.1.a 21. Planning ensures that The organization Presence of policies and Policies and procedures
appropriately trained and documents and follows procedures for for credentialing and
qualified (and where relevant, policies and procedures credentialing and privileging of staff
credentialed) staff are for hiring, credentialing, privileging of staff
available to undertake the
type and level of activity
and privileging of its staff.
performed by the
organization. This includes
those who are consulted
when suitable expertise is
not available within
the organization
OBSERVATION
Number of beds
25.Clinical records are readily The organization has policies DOCUMENT REVIEW
Presence of procedures to
accessible to facilitate patient and procedures and devotes Polices and procedures
protect records and patients
care, are kept confidential resources including on records management
charts against loss,
and safe, and comply with all infrastructure to protect for the entire hospital to
destruction, tampering and
relevant statutory require- records and patients charts maintain privacy,
unauthorized access or use
ments and codes of practice against loss, destruction, accuracy and prevent
tampering and unauthorized loss and destruction.
access or use. Only
authorized individuals make OBSERVATION
entries in the patient chart. Observe 20 nurses in the
wards and records
personnel on how they
protect patient chart
against loss, tampering
and unauthorized use.
6.1.1.d 29.The organization provides a Policies and procedures that Proof of implementation of Document review
safe and effective environment address safety, security, the policies, procedures and 1. Water safety - water
of care consistent with its control of hazardous safety programs on analysis results for the past
mission and services, and with materials and biological 6 months.
laws and regulations. wastes, emergency and
disaster preparedness, fire
safety, radiation safety and
utility systems are
documented and
implemented.
1. electrical safety 2. Fire and emergency
preparedness - check for
2. medical device safety ER
exit plans, plans for
3. chemical safety earthquake and other
disasters. OPD
4. radiation safety Wards
3. Control of hazardous
5. mechanical safety Imaging
materials - MOA/Contract
of outsourced services for
6. water safety waste management Laboratory
INTERVIEW
1. Ask staff from ER, Wards,
7. combustible material OPD, Laboratory, Pharmacy
safety Pharmacy, and facilities
8. waste management and maintenance on the Facilities and
manner of waste maintenance
segregation and disposal
(general waste, liquid &
solid waste, infectious
waste; non-infectious,
9. hospital safety program hazardous and non- Other areas
(fire, emergency and hazardous
disaster preparedness) 2. Hospital safety program
3. Mechanical safety
program of the hospital
6x1.1.g 32.The organization provides a Risks are identified, assessed Presence of policies and DOCUMENT REVIEW Document
safe and effective environment and appropriately controlled. procedures on risk policies and procedures review
of care consistent with its Where elimination or identification, assessment on risk identification,
mission and services, and with substitution is not possible, and control. assessment and control,
laws and regulations. adequate warning and security risks and use of
protection devices are used. personal protective
equipment, etc.
33. The organization provides A coordinated security Presence of an appointed Hospital order or Memo.
a safe and effective arrangements in the personnel in charge of
environment of Care consistent organization assures DOCUMENT REVIEW
security.
with its mission and services, protection of patients, staff Policies and procedures on
and with laws and regulations. and visitors. risk identification,
assessment and control,
security risks, use of
personal protective
OBSERVATION
1. Presence of Facilities and
generator/emergency maintenance
light, water tanks,
adequate ventilation or
air conditioning
2. Test if faucets and
water closets are
working
7.1.3 36.Equipment is serviced only Proof of training of the staff Facilities and
by people trained in the who is in charge of the DOCUMENT REVIEW
maintenance of that maintenance of the Proof of training of service maintenance
equipment. Registers and equipment. personnel if in-house or Imaging
records of equipment and Certificate of Training, Laboratory
related maintenance are kept. attendance sheet,
Certificate of Attendance,
diploma, citation or Other
MOA/Contract for areas
outsourced services
(verify qualification of
technicians).
Presence of operating
manuals equipment
DOCUMENT
Operating manual of
generators, air
conditioners and other
non-medical equipment.
INTERVIEW Wards
Ask= staff in ER, wards and ICU
ICU the procedures on
isolation
isolation - physical isolation
of a patient with infection
8.1.2.b 41.The organization uses a The organization takes steps Presence of coordinated DOCUMENT Document
coordinated system-wide to prevent and control system-wide procedure for REVIEW Procedures on review
approach to reduce the risks of outbreaks of nosocomial case containment of case containment of
nosocomial infections. infections. nosocomial infections. nosocomial infections ER
Note: case containment Wards
- means prevention of ICU
spread of infection
examples: reverse isolation,
prophylaxis for exposed
personnel, vaccination,
immunization
INTERVIEW
Validate from staff in ER,
.
wards and ICU the
procedures on case
containment
8.1.2.c 42.The organization uses a The organization takes steps Presence of coordinated DOCUMENT REVIEW ER
coordinated system-wide to prevent and control system-wide procedure for Procedures on asepsis Wards
approach to reduce the risks of outbreaks of nosocomial asepsis. INTERVIEW
nosocomial infections. infections. Ask staff from ER, wards, ICU
laboratory and ICU about Laboratory
the approaches for asepsis
during diagnostic and
treatment procedures.
8.1.3.a 43.The organization uses a There are programs for Presence of policies and DOCUMENT REVIEW
coordinated system-wide prevention and treatment of procedures on the 1. Policies and procedures
approach to reduce the risks of needle stick injuries, and prevention and treatment of for prevention and
infection the staff are exposed policies and procedures for needle stick injuries and treatment of needle stick
to in the performance of their the safe disposal of used safe disposal of needles. injuries
INTERVIEW
OBSERVATION
1. Observe for use of OR/DR
gloves, surgical masks.
INTERVIEW
50.The organization Validation of alI activities
provides better care Presence of patient thru interview of
10.1.2 service as a result of satisfaction survey pertinent staff including
continuous quality frontliners and
improvement activities. Committee members.
DOCUMENT REVIEW
1. Patient satisfaction
survey results
2.Patient satisfaction
survey
questionnaire(may check
on the domains and
items)
MONITORING
INSPECTION
CODE POSITION STAFFING CRITERIA INDICATOR EVIDENCE AREA REMARKS
10.1 REQUIREMENT I:
SELF-
DOH
DOH
(Top Management
Positions)
Hospital Administrator
10.1.1 (Optional)
DOH MONITORING
DOH INSPECTION
CODE POSITION STAFFING REQUIREMENT LEVEL 1 LEVEL 2 LEVEL 3
II
11.1 ADMINISTRATIVE
Chief of Hospital /Medical 1 1 1
11.1.1 Director/Medical Center Chief
11.1.2 Administrative Officer 1 1 1
Clerk: 1:50 beds 1:50 beds 1:50 beds
11.1.3.a - Pool
11.1.3.b - Accounting 1 1 1
11.1.4 Medical Records Officer trained in ICD- 1:50 beds 1:50 beds 1:50 beds
10 and Medical Records Management
11.1.5 Cash Clerk 0 1
11.1.6 Accountant 1 1 1
11.1.7 Budget /Finance Officer 1 1
11.1.8 Bookkeeper 1 1 1
11.1.9 Billing Officer 1 1 1
11.1.10 Cashier 1 1 1
11.1.11 Human Resource Mgt. Officer 1(designate) 1 1
11.1.12 Training Officer 1(designate) 1 1
Medical Records Officer (ICD- 10 and 1 1 1
11.1.13 Medical Records Management trained)
11.1.14 Supply Officer 1 1 1
11.1.15 Storekeeper/ Linen Custodian 1 1 1
11.1.16 Laundry Worker 1 1:50 beds 1:50 beds
11.1.17 Utility Worker 1/Shift 1:50 beds/shift 1:50 beds/shift
11.1.18 Security Guard 1/shift 1/entrance/exit 1/entrance/exit per
per shift shift
11.1.19 Engineer 1 1
11.1.20 Medical Equipment/Biomedical 1 1
Technician
11.1.1.21 Maintenance Personnel 1 1/shift 1/shift
11.3.2 Asst. Chief Nurse (maybe 0 100 beds and 100 beds and
designated as above=1 above=1
Training Officer)
Nursing Attendant/ Midwife 1:24 beds at any 1:24 beds at 1:24 beds at any
-Optional if the Authorized Bed time any time plus 1 time plus 1
11.3.8 Capacity (ABC) is less than twenty- reliever reliever
four (24) beds. If the ABC is 24
beds and above, the ratio will apply.
11.3.9 Nursing Attendant/ Midwife (CCUs) 1:15 beds at 1:15 beds at any
-For every three (3) Nursing any time time
Attendants/Midwives, there must be
one (1) reliever
11.3.10 Operating Room Nurse 1/shift 1/shift( may 1/OR/shift( may
increase increase
11.4.2 Pathologist 1 1 1
11.4.5 Dentist 1 1 2
11.4.7 Radiologist 1 1 2
FINDINGS
ASSESSMENT
MONITORING
INSPECTION
(Indicate actual
no.
SELF –
DOH
DOH
CODE STANDARD REQUIREMENT Level 1 Level 2 Level 3 equipment REMARKS
& instruments)
13.1.1.1.a Adult 1 1 1
13.1.1.1.b Pediatric 1 1 1
13.1.1.2 Clinical Weighing Scale
13.1.1.3 Defibrillator 1 1 1
Pediatric Cuff 1 1 1
13.2.1.11 11. Stethoscope 1 1 1
13.2.1.12 12. Suture Removal Set 1 1 1
13.2.1.13 13. Thermometer, non-mercurial
13.2.1.14 13. Vaginal Speculum Set 1 1 1
13.2.1.15 14. Wheelchair 1 1 1
13.3.1 OPERATING ROOM
13.3.1.1 1. Air-conditioning Unit 1 1/OR 1/OR
13.3.1.2 2. Anesthesia Machine 1 1/OR 1/OR
13.3.1.3 3. Cardiac Monitor with pulse oximeter Pulse 1/OR 1/OR
Oximeter
13.3.1.4 4. C/S Set 1 1 1
13.3.1.5 5. Instrument Table 1 1/OR 1/OR
13.3.1.6 6. Laparotomy Set 1 1/OR 1/OR
13.3.1.7 7. Laryngoscope with Blades 1 set 1 set/OR 1 set/OR
13.3.1.8 8. Major Surgical Instrument Set 1 1/OR 1OR
13.3.1.9 9. OR Light 1 1/OR 1/OR
13.3.1.10 10.OR Table 1 1/OR 1/OR
13.3.1.11 11. Ortho Instrument Set 1 1 1
13.3.1.12 12. Oxygen Unit (anchored) 1 1/OR 1/OR
13.3.1.13 13. Sphygmomanometer (non-mercurial) 1 1/OR 1/OR
13.3.1.13a Adult Cuff 1 1/OR 1/OR
13.3.1.1b Pediatric Cuff 1 1/OR 1/OR
13.3.1.14 14. Spinal Set 1 1/OR 1/OR
13.3.1.15 15. Stethoscope 1 1/OR 1/OR
13.3.1.16 16. Suction Apparatus 1 1/OR 1/OR
DENTAL CLINIC
Dental Chair
Operating Stool per Dental Chair
Autoclave
Air Compressor
Dental X-ray
Mouth Mirror Explorer
Explorer, double end
Scaler jacquettes set No. 1,2,3
Low speed hand piece (angled head)
Cotton pliers
High speed hand piece with bur remover
No.150 forceps (maxillary universal forceps)
No.151 forceps (lower universal)
No.150 S forceps (primary teeth)
No. 8L and No18R forceps(upper molar)
No.151A forceps (mandibular premolar)
No.17 forceps
No.15 S forceps (lower primary teeth)
Rongeur forceps
Surgical chisel and mallet
.. Bone file
Surgical Scissor
. Root elevator
. Periostal elevator No. 9 double end
Gum Separator double end
Cowhorn forceps
Bonefile Stainless end
DIALYSIS CLINIC- Not required for Levels 1 and 2.
(Refer to AO 2012-0001 “ New Rules and Regulations
Governing the Licensure and Regulation of Dialysis
Facilities in the Philippines”
Use checklist for Dialysis facility
Ultrasound
TENS
Electric Stimulator
Electric Stimulator
Exercise plinth/bed
Overhead pulley
Exercise stair with rails
Paraffin wax
Parallel bars with postural mirrors
• Lobby
• Waiting Area
• Information and Reception
• Communication Booth (Area for level 1)
• Toilet
• Admitting Office ( Area for level 1)
• Medical Records Office/Room
• Business Office with the following sections
• Billing
• Cashier
• Budget and Finance
• Personnel Office (may be combined with
Administrative Office for level 1)
• Office of the Admin. Officer
• Office of Chief of Hospital
• Office of the Chief of Clinics/Chief Medical
Professional Services
• Conference and Training Room
• Library
• Staff Toilet
• Property/ Supply Office /Room for level
Laundry and Linen Room or Area
• Receiving and Releasing Area not required
• Sorting and Washing Area if contracted-
• Pressing and Ironing Area out.
• Storage Area
Engineering /Maintenance Office for Level 2
• Maintenance Area not required
• Motor Pool Area if contracted-
• Housekeeping Area out.
LABOR ROOM
• Toilet
• Consultation room
• Toilet
CENTRAL SUPPLY ROOM
• Receiving and Cleaning Area
• Inspection Area
• Packaging Area
• Sterilizing Area
• Sterile Supply Storage Area
• Releasing Area
PRAYER ROOM (AREA FOR LEVEL 1)
MONITORING
INSPECTION
SELF –
DOH
41 B.DOH Programs • Documented policies: Actual implementation and Verifier:
Implemented in the To ensure adequate evidence of continuous Documents review,
Hospital> supply of safe blood review of policies and Observe
41x1 1.Blood Services and blood products. procedures Interview staff
Compliance to RA 7719 blood and blood Validate
and its IRR, AO 2008- products obtained from
0008 Levels 1 and 2, blood service facilities
should be at least a licensed by DOH
Blood Station Facility and for BC, blood and
level 3, Blood Bank Facility blood products
collected, obtained
from healthy voluntary
blood donors only
41X9.a
• Conduct of drills/exercises ● Documentation of
i.e, Fire,Earthquake, etc. (For drills/exercises conducted.
fire, it should be supervised by
the Bureau of Fire Protection). ● Evacuation Plan/Route
posted in every room/area
1.Credentials
42x1
2.Blood transfusion
42x2
3.HIV/AIDS Core Team
42x3
4.Waste Management
42x4
42x5 5.Patient Safety
40x6 6.Infection Control
40x7 7.Pharmacologic/Therapeutics
8.Health Emergency/
428 Crisis Management
42x9 9.CQI
10.Tissue
42x10 (for levels 2 and 3 only)
11.Ethics
42x11 (for levels 2,and 3 only)
12.Grievance
42x12
Emergency
Anesthesia
OB/ Gyne
Pediatrics
Medicine
(Delivery
only to level 3 ).
Surgery
Room)
REMARKS
Rehab
OPD
OR
1.Clinical Practice Guidelines
(CPG)
43x1
2.Recording, Reporting,
Records Keeping
43x2
43x3 3.Inter/Intra Departmental
Referrals
4.Disaster
43x4 Management/Crisis
Management
5.Infection Control
43x5
6.Drug Management and
43x6 Control
7.Blood Service
43x7
8.Pre-Operative and Post-Op
43x8 Care
43x9 9.Triaging (when applicable)
10.Referrals/ Transfer
43x10
11.Others, please specify
43x11
CONCURRED BY:
_______________________________
Signature over Printed Name
_______________________________
Position/Designation
_______________________________
Date