Manual RSSGH - 3 Levels

Form HOS-LTO-AT/L2-2007
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/
ASSESSMENT TOOL FOR LICENSING OF

LEVEL 2 HOSPITAL
Name of Hospital
Address of the Hospital
This tool serves as a guide for self-assessment of the health facility in preparation for
inspection/ monitoring visits.
1. GENERAL INFORMATION
Owner
Chief of Hospital/Medical Director
:
:
Classification
General
Special
[
[
Government
[
]
National
Local
Others, please
specify
[
]
Single
Proprietorship
Partnership
Corporation
Civic Organization
Religious
Foundation
Others, please
specify
Private
Chairman of the Board (If

Corporation)
Authorized Bed Capacity

Implementing Bed Capacity
:
:
]
]
[
[
]
]
[
[
[
[
[
]
]
]
]
]
Page 1 of 19
2. SERVICE CAPABILITY
Service Capability of a Level 2 Hospital:
2.1.1.
2.1.2.
2.1.3.
2.1.4.
( if Available)
Manual of
Operations/
Written Policies
and Procedures
AVAILABILITY
Written Vision
and Mission
SERVICE
Duties and
Responsibilities
The hospital shall render quality health services appropriate to the level
of care being provided:
Master Staffing
Plan
2.2.
Departmentalized hospital that provides clinical care and

management on the prevalent diseases in the locality, as well
as particular forms of treatment, surgical procedure and
intensive care
Clinical services provided in the Level 1 Hospital, as well as
specialty clinical care
Provides appropriate administrative and ancillary services
(clinical laboratory, radiology, pharmacy)
Nursing care provided in the Level 1 Hospital, as well as total
and intensive skilled care
Organizational
Chart
2.1.
REMARKS
Administrative Service
Personnel
Accounting
Bookkeeping
Cashiering
Billing
Collection
Medical Records
Supply
Housekeeping
(May be contracted out)
Laundry and Linen
(Laundry service may be
contracted out but is subject
to infection control
mechanisms.)
Maintenance
Patient Transport Service
((May be contracted out;
available for 24 hours)
Security
Dietary
Social Service
Clinical Service
General Clinical Care
Page 2 of 19
Manual of
Operations/
Written Policies
and Procedures
Written Vision
and Mission
Duties and
Responsibilities
( if Available)
Master Staffing
Plan
AVAILABILITY
SERVICE
Organizational
Chart
REMARKS
Medicine
Pediatrics
Obstetrics and
Gynecology
Surgery and Anesthesia
Emergency Service
Outpatient Service
Nursing Service
Intermediate Care and
Management
Health Education and
Counseling
Others, please specify
As defined in the Hospital Nursing Service Administration Manual (DOH, 1994), under the
intermediate, moderate or partial care category, the patient can feed, bathe, dress and go to the
toilet by himself without help, but requires some assistance from the nursing staff for special
treatment of certain aspects of personal care.
AVAILABILITY
SERVICE
( if Available)
LICENSE
NUMBER
DATE
ISSUED
VALIDITY
REMARKS
Ancillary Service
Secondary Clinical
Laboratory
Radiology 2nd Level

Pharmacy
A primary clinical laboratory may be considered; provided that a contract of service or
memorandum of agreement with a secondary clinical laboratory located within the locality
must be secured, and results for emergency cases must be transmitted within one hour.
May be contracted out but located within the premises of the hospital.
2.3.
Hospital Operations
2.3.1.
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
Page 3 of 19
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
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 Room
[
] Yes [
] No
Outpatient Department
[
] Yes [
] No
Operating Room
[
] Yes [
] No
Delivery Room
[
] Yes [
] No
Page 4 of 19
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
Final Diagnosis
Nursing Record
Discharge Summary
Obstetrical Record (if
applicable)
Consent
Doctors 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
Page 5 of 19
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
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 organizations 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
Page 6 of 19
Complaints and suggestions

Infectious / Notifiable diseases
Service shortfalls
2.5.
[
[
[
] Yes
] Yes
] Yes
[
[
[
] No
] No
] No
Hospital Committees
Committee
Availability of
Documentation on
Committee
Membership
( if Available)
Availability of
Written
Policies and
Procedures
( if Available)
Availability of
Minutes
of Meetings
( if Available)
Availability of
Monitoring and
Evaluation Reports
( if Available)
Blood
Transfusion
Credentials
Fire Safety
HIV/AIDS (as
required by R.A.
8504 Philippine
AIDS Prevention
and Control Act
of 1998)
Infection Control
Medical Audit
Quality
Assurance
Therapeutics
Waste
Management
Others, please
specify
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
Page 7 of 19
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
POSITION
Administrative
Service
Chief of Hospital /
Administrative Officer
Clerk (Pool)
Clerk (Accounting;
designation can be
flexible as long as
function is present)
Medical Records Clerk
Storekeeper/Linen
Custodian
Utility Worker (May be
contracted out)
Driver (May be
contracted out)
Nutritionist/Dietitian
(May be contracted out.
In case of shared
service,
nutritionist/dietitian
should be residing
within the locality.)
Cook/Food Service
Worker
Medical Social
Worker
REQUIREMENT
COMPLIANCE
( if Compliant)
STATUS
(FT if Full Time)
(PT if Part Time)
REMARKS
1
1:50 beds
1
1:50 beds
1
1/shift
1
1
1
1
In the absence of a Medical Social Worker, patients may be referred to the Municipal/City/Provincial
Social Worker, provided there is a Memorandum of Agreement between the hospital and the local
government.
Clinical Service
Physician
Physician (On call)
1:20 beds at any

time plus one (1)
reliever
1
The physician must not go on continuous duty for more than forty-eight (48) hours.
Nursing Service
Chief Nurse/
Supervising Nurse +
Page 8 of 19
POSITION
REQUIREMENT
Staff Nurse
COMPLIANCE
( if Compliant)
STATUS
(FT if Full Time)
(PT if Part Time)
REMARKS
1:12 beds at any

time
1:24 beds at any
time
Nursing Attendant/
Midwife
The number of registered nurses supervised should not exceed fifteen (15). Otherwise, one (1) Chief
Nurse and one (1) Supervising Nurse are required.
For every three (3) Nurses, there must be one (1) reliever.
The number of beds used in the ratio is the actual number of occupied Critical Care Unit beds at the
time of inspection. Plantilla items are not required.
Critical Care Units include all Intensive Care Units (ICUs) and Post-Anesthesia Care Unit
(PACU)/Recovery Room (RR).
For every three (3) Nurses or Nursing Attendants/Midwives, 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.
3.2.
Hospital Organization
3.2.1.
The Chief of Hospital has:
Completed at least twenty (20) units towards a masters
degree in hospital administration or related course.
[
] Yes [
] No
OR
At least three (3) years of experience in a
supervisory/managerial position.
[
] Yes [
] No
The Administrative Officer has:
Completed at least twenty (20) units towards a masters
degree in hospital administration or related course.
[
] Yes [
] No
OR
At least three (3) years of experience in a
[
] Yes [
] No
3.2.2.
Nursing Service
The Chief Nurse has:
Completed at least nine (9) units towards a masters degree
in nursing service administration or related course
.
[
] Yes [
] No
AND
Page 9 of 19
At least two (2) years of experience in a nursing

[
] Yes
] No
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

manufacturers instruction/operational manual.
[
] Yes [
] No
4.1.5.
Operational manuals of all equipment and instruments are

available for reference and guidance.
[
] Yes [
] No
ITEM
REQUIREMENT
COMPLIANCE
CONDITION
( if Compliant)
( if Serviceable)
REMARKS
Computer/Typewriter
Fire Extinguisher
Standby Generator
Food Conveyor
(closed type)
Refrigerator/Freezer
Stove
Transport Vehicle
(Available for 24
hours)
Clinical Service
Emergency Room
Outpatient Department
Ambu Bag
- Adult
- Pediatric
Clinical Weighing
Scale
EENT Diagnostic Set
(or its equivalent)
1
2
1
1
1
1
1
1
1
1
1
Page 10 of 19
ITEM
Emergency Cart (or
its equivalent)
Examining Table
Gooseneck Lamp /
Examining Light
Instrument Table
Medicine Cabinet
Minor Surgery
Instrument Set
Nebulizer
Neurological Hammer
Oxygen Unit
Sphygmomanometer
- Adult Cuff
- Pediatric Cuff Set
Stethoscope
Suction Apparatus
Suturing Set
Vaginal Speculum Set
Wheelchair
Wheeled Stretcher
Surgical Service
Obstetrical Service
Air-conditioning Unit
Anesthesia Machine
Bassinet
C/S Set
D/C Set
Delivery Set
DR Light
DR Table with Stirrup
Infant Weighing Scale
Instrument Table
Kelly Pad
Laparotomy Set
Laryngoscope with
Blades
Major Surgical
Instrument Set
OR Light
OR Table
Oxygen Unit
Sphygmomanometer
- Adult Cuff
- Pediatric Cuff Set
Spinal Set
REQUIREMENT
COMPLIANCE
CONDITION
( if Compliant)
( if Serviceable)
REMARKS
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
Page 11 of 19
ITEM
Stethoscope
Suction Apparatus
Wheeled Stretcher
Nursing Unit
Ambu Bag
- Adult
-
Pediatric
Bedside Table
Clinical Weighing
Scale
Emergency Cart (or
its equivalent)
Patient Bed
Nebulizer
Oxygen Unit
Sphygmomanometer
- Adult Cuff
-
Pediatric Cuff Set
Stethoscope
Suction Apparatus
REQUIREMENT
COMPLIANCE
CONDITION
( if Compliant)
( if Serviceable)
REMARKS
1
1
1
1/Nursing Unit
(in Adult Units)
1/Nursing Unit
(in Pediatric
Units)
Depends on
ABC*
1/Nursing Unit
1/Nursing Unit
Depends on
ABC*
1/Nursing Unit
1/Nursing Unit
plus one (1)
standby oxygen
unit
1/Nursing Unit
1/Nursing Unit
(in Adult Units)
1/Nursing Unit
(in Pediatric
Units)
1/Nursing Unit
1/Nursing Unit
* Authorized Bed Capacity
Central Sterilizing and

Supply Room
Autoclave
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.
Page 12 of 19
AREA
COMPLIANCE
LIGHTING
VENTILATION
( if Compliant)
( if Adequate)
( if Adequate)
REMARKS
Lobby
Waiting Area
Information and
Reception Area
Toilet
Business Office
Medical Records Room
Office of the Chief of
Hospital/Administrative
Officer
Laundry and Linen
Area
Maintenance and
Housekeeping Area
Parking Area for
Transport Vehicle
Supply Room
Waste Holding Room
Dietary
Dietitian Area
Supply Receiving
Area
Cold and Dry Storage
Area
Food Preparation
Area
Cooking and Baking
Area
Serving and Food
Assembly Area
Washing Area
Garbage Disposal
Area
Dining Area
Toilet
Cadaver Holding Room
Not required if the service is contracted out.
Clinical Service
Emergency Room
Waiting Area
Toilet (adjacent or
within ER)
Nurse Station
Page 13 of 19
AREA
COMPLIANCE
LIGHTING
VENTILATION
( if Compliant)
( if Adequate)
( if Adequate)
REMARKS
Examination and
Treatment Area with
Lavatory/Sink
Observation Area
Equipment and
Supply Storage Area
Wheeled Stretcher
Area
Outpatient
Department
Waiting Area
Toilet (accessible)
Admitting and
Records Area
Consultation Area
Examination and
Treatment Area with
Lavatory/Sink
OPD and ER departments may be combined in one complex. If OPD and ER are separate, all the
areas specified under OPD are required.
If OPD and ER are combined in one complex, only this area under OPD is required. The rest of the
areas under OPD are not required.
Surgical and Obstetrical

Service
Major Operating
Room
Delivery Room
Sub-sterilizing Area /
Work Area
Sterile Instrument,
Supply and Storage
Area
Scrub-up Area
Clean-up Area
Dressing Room
Toilet
Nurse Station / Work
Area
Wheeled Stretcher
Area.
Janitors Closet
Nursing Unit
Patient Room (Male
and Female)
Toilet (Male and
Female)
Page 14 of 19
AREA
COMPLIANCE
LIGHTING
VENTILATION
( if Compliant)
( if Adequate)
( if Adequate)
REMARKS
Isolation Room with

Toilet
Nurse Station
Treatment and
Medication Area with
Lavatory/Sink
Central Sterilizing and
Supply Room
Receiving and
Releasing Area
Work Area
Sterilizing Area
Sterile Supply Storage
Area
Nursing Service
Office of the Chief Nurse
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, childrens 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
Page 15 of 19
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
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 and ramps for access by patient and equipment are at least
2.44 Meters in width.
[
] 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
A ramp is provided as access to the entrance of the hospital or health
facility that is not on the same level of the site. [
] Yes [
] No

DOH licensed facilities shall be given until end of 2010 to comply.
Page 16 of 19
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
Panel boards and feeders are properly coded and labeled.

[
] Yes
] No
] No
5.11. Water Supply

The hospital has an approved water supply system.
[
] Yes
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
.....................................................
The water tank/water reservoir is flushed regularly.
[
] Yes [
] No
Frequency
.....................................................
5.12. Waste Management
5.12.1.
5.12.2.
The hospital has a waste management program.

[
] Yes
] No
Liquid Waste
Liquid waste is discharged into a multi-chamber septic tank.
[
] Yes [
] No
OR
Liquid waste is discharged into municipal/city sewers that are
connected to a sewage treatment plant.
[
] Yes [
] No
5.12.3.
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
Page 17 of 19
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
.....................................................
There are screen wires on doors, windows, and other openings.
Ward
[
] Yes [
Dietary Service
[
] Yes [
] No
] 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
.....................................................
Written policies and procedures are available.
] Yes
] No
5.15. Material Specification

Floors, walls and ceiling are made of sturdy materials that allow
durability, ease of cleaning and fire resistance.
[
] Yes [
] No
Page 18 of 19
5.16. Segregation
Wards observe segregation of sexes.
] Yes
] No
Separate toilets are available for patients and personnel, male and
female.
[
] Yes [
] No
5.17. Signage
There are visual aids and devices for:
Information and Orientation
Direction
Identification
Prohibition and Warning
Official Notice
[
[
[
[
[
] Yes
] Yes
] Yes
] Yes
] Yes
[
[
[
[
[
] No
] No
] No
] No
] No
5.18. Permits
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
Page 19 of 19

Manual RSSGH - 3 Levels

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Manual RSSGH - 3 Levels

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Form HOS-LTO-AT/L2-2007

Republic of the Philippines

BUREAU OF HEALTH FACILITIES AND SERVICES

ASSESSMENT TOOL FOR LICENSING OF

Address of the Hospital

Chairman of the Board (If

Authorized Bed Capacity

Departmentalized hospital that provides clinical care and

An exit interview is conducted for personnel who resign or

Written policies for all nursing service areas within the

The Medical Records Officer is trained in ICD 10.

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

Patient Charts are properly and completely filled up and

The hospital obtains blood and blood products collected from

Health Promotion and Disease Prevention

Human Resource Development

Complaints and suggestions

Each personnel is qualified, skilled and/or experienced to

Professional qualifications are validated, including evidence

An organized medical and nursing staff shall be responsible

Physician (On call)

1:20 beds at any

1:12 beds at any

At least two (2) years of experience in a nursing

Records of equipment are maintained and updated regularly.

A preventive maintenance program ensures that all

There is a plan in place for essential equipment replacement.

Personnel are competent when using equipment in line with

Operational manuals of all equipment and instruments are

Pediatric Cuff Set

* Authorized Bed Capacity

Central Sterilizing and

Others, please specify

Surgical and Obstetrical

Isolation Room with

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

Not located adjacent to railroads, freight yards, childrens playgrounds,

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

Lighting and Ventilation

Exposure to Environmental Tobacco Smoke

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

Auditory and Visual Privacy

5.10. Power Supply

Panel boards and feeders are properly coded and labeled.

5.11. Water Supply

The hospital has a waste management program.

The hospital observes segregation, coding and labeling of

5.15. Material Specification

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