Form HOS-LTO-IT/L1-2007

Republic of the Philippines

Department of Health
BUREAU OF HEALTH FACILITIES AND SERVICES
Building 15, San Lazaro Compound, Rizal Avenue, Sta. Cruz, 1003 Manila
Trunk Line: 743-83-01; Direct Line: 711-6982; Fax: 781-4179
URL: http://www.doh.gov.ph/

INSPECTION TOOL FOR LICENSING OF

LEVEL 1 HOSPITAL

Name of Hospital :

Address of the Hospital :

1. GENERAL INFORMATION

Owner :
Chief of Hospital/Medical Director :

Classification : General [ ]
Special [ ]

Government [ ]
National [ ]
Local [ ]
Others, please
specify
Private [ ]
Single [ ]
Proprietorship
Partnership [ ]
Corporation [ ]
Civic Organization [ ]
Religious [ ]
Foundation [ ]
Others, please
specify

Chairman of the Board (If :

Corporation)

Authorized Bed Capacity :

Implementing Bed Capacity :

Page 1 of 17
Form HOS-LTO-IT/L1-2007
Republic of the Philippines
Department of Health
BUREAU OF HEALTH FACILITIES AND SERVICES
Building 15, San Lazaro Compound, Rizal Avenue, Sta. Cruz, 1003 Manila
Trunk Line: 743-83-01; Direct Line: 711-6982; Fax: 781-4179
URL: http://www.doh.gov.ph/

INSPECTION TOOL FOR LICENSING OF

LEVEL 1 HOSPITAL

Name of Hospital :

Address of the Hospital :

2. SERVICE CAPABILITY

2.1. Service Capability of a Level 1 Hospital:

2.1.1. Provides emergency treatment and care to the sick and

injured, as well as clinical care and management to mothers
and newborn

2.2. The hospital shall render quality health services appropriate to the level
of care being provided:

and Procedures
Responsibilities

Written Policies
Master Staffing
Organizational

Written Vision
and Mission

Operations/
Duties and

Manual of
Chart

AVAILABILITY
Plan

SERVICE (
if Available)
REMARKS

Administrative Service
General Administrative
Service
− Records
− Bookkeeping
− Clerical Work
− Maintenance
Patient Transport Service
(May be contracted out;
available for 24 hours)
Clinical Service
General Medicine
General Pediatrics
General Obstetrics and Non-
Surgical Gynecology

Minor Surgery
Emergency and Outpatient
Service

Non-surgical Gynecology involves the diagnosis and treatment of gynecologic problems through
non-surgical or medical means.

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Form HOS-LTO-IT/L1-2007

and Procedures
Responsibilities

Written Policies
Master Staffing
Organizational

Written Vision
and Mission

Operations/
Duties and

Manual of
Chart
AVAILABILITY

Plan
SERVICE (
if Available)
REMARKS

Nursing Service
Minimal Care and
Management 
Health Education and
Counseling

 As defined in the Hospital Nursing Service Administration Manual (DOH, 1994), under the minimal or
self-care category, the patient is capable of carrying out daily activities as long as the nurse provides
the necessary materials and supplies.

AVAILABILITY LICENSE DATE

SERVICE VALIDITY REMARKS
(
if Available) NUMBER ISSUED
Ancillary Service
Clinical Laboratory 
Radiology 
Pharmacy 

 The health facility must be affiliated with a licensed clinical laboratory and radiology facility.
 A licensed pharmacy is optional.

2.3. Hospital Operations

2.3.1. Administrative Service

The performance of each personnel is monitored and

evaluated. [ ] Yes [ ] No

New personnel receive an orientation program that covers the

essential components of the service being provided.
[ ] Yes [ ] No

An exit interview is conducted for personnel who resign or

retire from the service. [ ] Yes [ ] No

2.3.2. Emergency Room

Personnel to deliver emergency care are available for 24

hours. [ ] Yes [ ] No

All equipment, medicines and supplies necessary to provide

emergency care are available. [ ] Yes [ ] No

2.3.3. Obstetrical Service

Proper identification of newborns is ensured before they leave

the delivery room and until discharge. [ ] Yes [ ] No
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Form HOS-LTO-IT/L1-2007

2.3.4. Nursing Service

Nursing care is provided at all times. [ ] Yes [ ] No

Written policies for all nursing service areas within the

hospital are available and reviewed annually.
[ ] Yes [ ] No

A Nursing Procedure Manual and a properly utilized Kardex

are available in all patient care units.
Nursing Procedure Manual [ ] Yes [ ] No
Properly Utilized Kardex [ ] Yes [ ] No

The delivery of nursing care utilizes the nursing process.

[ ] Yes [ ] No

2.3.5. Medical Records

Medical records contain patient information that is uniquely

identifiable, accurately recorded, current, confidential and
accessible when required. [ ] Yes [ ] No

Medical diagnoses, procedures and/or operations performed

on patients are recorded using ICD – 10.
[ ] Yes [ ] No

ICD – 10 reference books are available. [ ] Yes [ ] No

The Medical Records Officer is trained in ICD – 10.

[ ] Yes [ ] No

A Patient Logbook is properly filled up in the following areas:

Admitting Office [ ] Yes [ ] No
Emergency and Outpatient [ ] Yes [ ] No
Delivery Room [ ] Yes [ ] No

Patient Charts are properly and completely filled up and

contain up-to-date information on the following:
In-Patient Out-Patient
Contents of Medical Chart (
if (
if
available) Available)
Identification Data
Chief Complaint
History of Present Illness
Physical Examination
Diagnosis/Admitting Diagnosis
Admitting/Attending Physician
Clinical Laboratory Report
X-ray Report
Consultation/Referral Notes
Medication/Treatment
Progress Notes
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Form HOS-LTO-IT/L1-2007
In-Patient Out-Patient
Contents of Medical Chart (
if (
if
available) Available)
Final Diagnosis
Nursing Record
Discharge Summary
Obstetrical Record (if
applicable)
Consent
Doctor’s Order Sheet

Records of newborns are properly and completely filled up.

[ ] Yes [ ] No

Records of medico – legal cases are properly and completely

filled up. [ ] Yes [ ] No

Birth certificate forms are properly and completely filled up.

[ ] Yes [ ] No

Death certificate forms are properly and completely filled up.

[ ] Yes [ ] No

Confidentiality of patient information is maintained at all times.

[ ] Yes [ ] No

2.3.6. Blood Services

The hospital ensures that its supply of blood and blood

products is safe. [ ] Yes [ ] No

The hospital obtains blood and blood products only from

blood service facilities licensed/authorized by the Department
of Health (as required by R.A. 7719 National Blood Services
Act of 1994 and Its Implementing Rules and Regulations).
[ ] Yes [ ] No

The hospital obtains blood and blood products collected from

healthy voluntary blood donors only (as required by R.A. 7719
National Blood Services Act of 1994 and Its Implementing
Rules and Regulations). [ ] Yes [ ] No

2.4. Programs

2.4.1. Health Promotion and Disease Prevention

The hospital has a health promotion and disease prevention

program that shall include the following:
Breastfeeding (as required by R.A. 7600 The Rooming-In and
Breastfeeding Act of 1992) [ ] Yes [ ] No
Family Planning [ ] Yes [ ] No
Immunization [ ] Yes [ ] No

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Form HOS-LTO-IT/L1-2007
Newborn Screening (as required by R.A. 9288 Newborn
Screening Act of 2004 and Its Implementing Rules and
Regulations) [ ] Yes [ ] No
Rooming-In (as required by R.A. 7600 The Rooming-In and
Breastfeeding Act of 1992) [ ] Yes [ ] No

2.4.2. Disaster Management

The hospital has a documented emergency and disaster

management plan. [ ] Yes [ ] No

2.4.3. Human Resource Development

The hospital implements a human resource development

program that identifies, plan, facilitate and record training and
education for all personnel. [ ] Yes [ ] No

An appraisal system identifies and reviews the effectiveness

and appropriateness of the training provided.
[ ] Yes [ ] No

2.4.4. Quality Management

The hospital has an established, documented and maintained

quality management program that reflects continuous quality
improvement principles. [ ] Yes [ ] No

The program identifies the organization’s quality goals,

objectives and scope; quality responsibility, authority and
resources; and quality activities and review processes.
[ ] Yes [ ] No

There is an exception reporting system that includes the

recording, reporting, investigation, analysis, corrective action
and review process for adverse, unplanned, or untoward
events such as:
Accidents, incidents, near misses, and adverse clinical events
[ ] Yes [ ] No
Complaints and suggestions [ ] Yes [ ] No
Infectious / Notifiable diseases [ ] Yes [ ] No
Service shortfalls [ ] Yes [ ] No

Page 6 of 17
Form HOS-LTO-IT/L1-2007
Republic of the Philippines
Department of Health
BUREAU OF HEALTH FACILITIES AND SERVICES
Building 15, San Lazaro Compound, Rizal Avenue, Sta. Cruz, 1003 Manila
Trunk Line: 743-83-01; Direct Line: 711-6982; Fax: 781-4179
URL: http://www.doh.gov.ph/

INSPECTION TOOL FOR LICENSING OF

LEVEL 1 HOSPITAL

Name of Hospital :

Address of the Hospital :

3. PERSONNEL

3.1. The health facility appoints and allocates personnel who are suitably
qualified, skilled and/or experienced to provide the service and meet
patient needs.

3.1.1. Each personnel is qualified, skilled and/or experienced to

assume the responsibilities, authority, accountability and
functions of the position. [ ] Yes [ ] No

3.1.2. Professional qualifications are validated, including evidence

of professional registration/license, where applicable, prior to
employment. [ ] Yes [ ] No

3.1.3. An organized medical and nursing staff shall be responsible

for the quality of patient care and for the ethical conduct and
professional practices of its members. [ ] Yes [ ] No

COMPLIANCE STATUS
POSITION REQUIREMENT (FT if Full Time) REMARKS
(
if Compliant)
(PT if Part Time)
Administrative
Service
Administrator 1
Clerk (Accounting and 1
records)
Utility Worker 1
Driver (May be 1
contracted out)
Clinical Service
Physician
1 at any time plus
one (1) reliever

The physician must not go on continuous duty for more than forty-eight (48) hours.

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Form HOS-LTO-IT/L1-2007

COMPLIANCE STATUS
POSITION REQUIREMENT (FT if Full Time) REMARKS
(
if Compliant)
(PT if Part Time)

Nursing Service
Nurse  1:12 beds at any
time
Nursing Attendant/ 1:24 beds at any
Midwife  time

 For every three (3) Nurses, there must be one (1) reliever.
 Nursing Attendant/Midwife is optional if the Authorized Bed Capacity (ABC) is less than twenty-four
(24) beds. If the ABC is 24 beds and above, the ratio will apply.

For every three (3) Nursing Attendants/Midwives, there must be one (1) reliever.

Page 8 of 17
Form HOS-LTO-IT/L1-2007
Republic of the Philippines
Department of Health
BUREAU OF HEALTH FACILITIES AND SERVICES
Building 15, San Lazaro Compound, Rizal Avenue, Sta. Cruz, 1003 Manila
Trunk Line: 743-83-01; Direct Line: 711-6982; Fax: 781-4179
URL: http://www.doh.gov.ph/

INSPECTION TOOL FOR LICENSING OF

LEVEL 1 HOSPITAL

Name of Hospital :

Address of the Hospital :

4. EQUIPMENT/INSTRUMENT

4.1. All equipment and instruments necessary for the safe and effective
provision of services are available and are properly maintained.

4.1.1. Records of equipment are maintained and updated regularly.

[ ] Yes [ ] No

4.1.2. A preventive maintenance program ensures that all

equipment are maintained and/or calibrated to an appropriate
standard or specification. [ ] Yes [ ] No

4.1.3. There is a plan in place for essential equipment replacement.

[ ] Yes [ ] No

4.1.4. Personnel are competent when using equipment in line with

manufacturer’s instruction/operational manual.
[ ] Yes [ ] No

4.1.5. Operational manuals of all equipment and instruments are

available for reference and guidance. [ ] Yes [ ] No

COMPLIANCE CONDITION
ITEM REQUIREMENT (
if Compliant) (
if Serviceable)
REMARKS

Administrative Service
Emergency Light 1
Fire Extinguisher 1
Standby Generator 1
Transport Vehicle 1
(Available for 24 hours)
Typewriter/Computer 1
Clinical Service
Ambu Bag
− Adult 1
− Pediatric 1
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Form HOS-LTO-IT/L1-2007

COMPLIANCE CONDITION
ITEM REQUIREMENT (
if Compliant) (
if Serviceable)
REMARKS

Clinical Weighing Scale 1

Delivery Set 1
Emergency Cart (or its 1
equivalent)
Examining Table with 1
Stirrup
Gooseneck Lamp / 1
Examining Light
EENT Diagnostic Set (or 1
its equivalent)
Instrument Table 1
Kelly Pad 1
Minor Surgery Instrument 1
Set
Neurological Hammer 1
Oxygen Unit 1
Sphygmomanometer 1
− Adult Cuff 1
− Pediatric Cuff Set 1
Sterilizer 1
Stethoscope 1
Suction Apparatus 1
Suturing Set 1
Vaginal Speculum Set 1
Wheelchair 1
Wheeled Stretcher 1

Others (Please specify)

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Form HOS-LTO-IT/L1-2007
Republic of the Philippines
Department of Health
BUREAU OF HEALTH FACILITIES AND SERVICES
Building 15, San Lazaro Compound, Rizal Avenue, Sta. Cruz, 1003 Manila
Trunk Line: 743-83-01; Direct Line: 711-6982; Fax: 781-4179
URL: http://www.doh.gov.ph/

INSPECTION TOOL FOR LICENSING OF

LEVEL 1 HOSPITAL

Name of Hospital :

Address of the Hospital :

5. PHYSICAL PLANT

5.1. All physical facilities and utility systems necessary for the safe and effective
provision of services are available and are properly maintained.

COMPLIANCE LIGHTING VENTILATION

AREA (
if Compliant) (
if Adequate) (
if Adequate)
REMARKS

Administrative Service
Waiting Area
Admitting and Records
Area
Administrative and
Business Office
Staff Toilet
Parking Area for
Transport Vehicle
Clinical Service
Emergency and
Outpatient
− Waiting Area
− Toilet (adjacent or
within ER)
− Nurse Station
− Consultation Area
− Examination and
Treatment Area with
Lavatory/Sink
− Equipment and
Supply Storage Area
− Wheeled Stretcher
Area
Delivery Room
− Birthing Area
− Scrub-up Area

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Form HOS-LTO-IT/L1-2007

COMPLIANCE LIGHTING VENTILATION

AREA (
if Compliant) (
if Adequate) (
if Adequate)
REMARKS

− Newborn Area with

lavatory/sink
− Equipment and
Supply Storage Area
Nursing Unit
− Patient Room
− Toilet
− Nurse Station

5.2. Environment

The hospital is:

Readily accessible to the community. [ ] Yes [ ] No

Free from undue noise, smoke, dust, foul odor, flood.

[ ] Yes [ ] No

Not located adjacent to railroads, freight yards, children’s playgrounds,

airports, industrial plants, and waste disposal plants.
[ ] Yes [ ] No

5.3. Occupancy

The location of the hospital complies with all local zoning ordinances.
[ ] Yes [ ] No

5.4. Safety

The hospital provides and maintains a safe environment for patients,

personnel and public. [ ] Yes [ ] No

Buildings pose no hazards to the life and safety of patients, personnel

and public. [ ] Yes [ ] No

Exits are restricted to the following types: door leading directly outside
the building, interior stair, ramp, and exterior stair.
[ ] Yes [ ] No

A minimum of two (2) exits, remote from each other, are provided for
each floor of the building. [ ] Yes [ ] No

Exits terminate directly at an open space to the outside of the building.

[ ] Yes [ ] No

5.5. Security

The hospital ensures the security of person and property within the
facility. [ ] Yes [ ] No

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Form HOS-LTO-IT/L1-2007
5.6. Lighting and Ventilation

Areas used by patients and personnel are adequately lighted and

ventilated. [ ] Yes [ ] No

5.7. Exposure to Environmental Tobacco Smoke

Patients and personnel are not put at risk by exposure to

environmental tobacco smoke. [ ] Yes [ ] No

Smoking is absolutely prohibited throughout the hospital in accordance

with R.A. 9211 Tobacco Regulation Act of 2003. [ ] Yes [ ] No

5.8. Patient Movement

Adequate space is provided to allow patients and personnel to move

safely around patient bed areas. [ ] Yes [ ] No

Patients who use mobility aids are able to safely maneuver with the
assistance of their aid within their bed area. [ ] Yes [ ] No

Doorways, corridors, elevators and turning areas readily accommodate

the bed, attached equipment and any escorts of patients who require to
be transported or transferred between rooms or services in their beds.
[ ] Yes [ ] No

Corridors in areas not commonly used for bed, stretcher and

equipment transport are at least 1.83 Meters in width.

[ ] Yes [ ] No

A ramp or elevator is provided for ancillary, clinical and nursing

services located on the upper floor.
[ ] Yes [ ] No

DOH licensed facilities shall be given until end of 2010 to comply.

5.9. Auditory and Visual Privacy

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. [ ] Yes [ ] No

5.10. Power Supply

The hospital has an approved power supply system.

[ ] Yes [ ] No

5.11. Water Supply

The hospital has an approved water supply system.

[ ] Yes [ ] No

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Form HOS-LTO-IT/L1-2007
The hospital has available water supply that is potable and safe for
drinking. [ ] Yes [ ] No

Records of water analysis (bacteriological examination) are available

and updated regularly (at least annually). [ ] Yes [ ] No
Frequency .....................................................

5.12. Waste Management

5.12.1. Liquid Waste

Liquid waste is discharged into a multi-chamber septic tank.

[ ] Yes [ ] No

5.12.2. Solid Waste

Solid waste is collected, treated and disposed of in

accordance with the Health Care Waste Management Manual
of the Department of Health, 2004. [ ] Yes [ ] No

The hospital observes segregation, coding and labeling of

waste.
Black Trash Bag
(General – Non-Infectious – Dry) [ ] Yes [ ] No
Green Trash Bag
(General – Non-Infectious – Wet) [ ] Yes [ ] No
Yellow Trash Bag
(Infectious – Pathological) [ ] Yes [ ] No
Sharp Container
(Sharps) [ ] Yes [ ] No

Logbook Available and Updated [ ] Yes [ ] No

Frequency .....................................................

Protective equipment and clothing appropriate to the risks

associated with the handling, storage, and disposal of wastes
are provided to and used by personnel. [ ] Yes [ ] No

5.13. Sanitation

The hospital observes pest and vermin control:

In-House [ ] Yes [ ] No
Contractor [ ] Yes [ ] No
Company Name .....................................................

Memorandum of Agreement is available and updated.

[ ] Yes [ ] No
Frequency .....................................................

Records are available and updated. [ ] Yes [ ] No

Frequency .....................................................

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Form HOS-LTO-IT/L1-2007
There are screen wires on doors, windows, and other openings.
[ ] Yes [ ] No

5.14. Maintenance

A building maintenance program is in place to ensure that all

buildings/facilities are kept in a state of good repair.
[ ] Yes [ ] No

A building/facility inventory is maintained and updated regularly.

[ ] Yes [ ] No
Frequency .....................................................

5.15. Material Specification

Floors, walls and ceiling are made of sturdy materials that allow
durability, ease of cleaning and fire resistance. [ ] Yes [ ] No

5.16. Signage

There are visual aids and devices for:

Information and Orientation [ ] Yes [ ] No
Direction [ ] Yes [ ] No
Identification [ ] Yes [ ] No

5.17. Permits

The hospital maintains current licenses and permits to ensure safe and
effective operations. [ ] Yes [ ] No

A Permit to Construct is available for:

Construction of New Hospital (if applicable) [ ] Yes [ ] No
Alteration/Expansion/Renovation of Existing Hospital (if applicable)
[ ] Yes [ ] No
Change in Classification (if applicable) [ ] Yes [ ] No
Increase in Bed Capacity (if applicable) [ ] Yes [ ] No

For New Hospital (Secured for Initial License)

AVAILABILITY DATE
TYPE REMARKS
(
if Available) ISSUED
Building Permit (including
Plumbing, Electrical and
Mechanical Permits)
Fire Safety Permit
Fire Safety Inspection
Certificate
Sanitary Permit
Health Certificate
Certificate of Occupancy
Water Source Analysis
Report

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Form HOS-LTO-IT/L1-2007
OR
For Existing Hospital (Secured for License Renewal on a Yearly Basis)
AVAILABILITY DATE
TYPE REMARKS
(
if Available) ISSUED
Annual Building
Inspection Certificate
Fire Safety Inspection
Certificate
Sanitary Permit
Health Certificate
Water Source Analysis
Report

Page 16 of 17
Form HOS-LTO-IT/L1-2007
Republic of the Philippines
Department of Health
BUREAU OF HEALTH FACILITIES AND SERVICES
Building 15, San Lazaro Compound, Rizal Avenue, Sta. Cruz, 1003 Manila
Trunk Line: 743-83-01; Direct Line: 711-6982; Fax: 781-4179
URL: http://www.doh.gov.ph/

INSPECTION TOOL FOR LICENSING OF

LEVEL 3 HOSPITAL

Name of Hospital :

Address of the Hospital :

PERSONS INTERVIEWED:

Printed Name and Signature Position

SURVEYED BY:

Printed Name and Signature Position

DATE ___________________________
TIME ___________________________

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