Republic of the Philippines

Department of Health
HEALTH FACILITIES AND SERVICES REGULATORY BUREAU
ANNEX K - 2
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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I. HEALTH FACILITY INFORMATION

Name of Facility: _____BULUAN DISTRICT HOSPITAL _ __

Address: ____POBLACION BULUAN, MAGUINDANAO _ _ __

_____ ___

Geographic Coordinates of the Facility: Latitude: 6.723152436169078 Longitude: 124.79773578085896

Email Address: _buluandistricthospital@yahoo.com ___ __ Tel. / Fax Nos.: _____ ____

Name of Owner: _Government ____ __ Tel. / Fax Nos.: _____ ____

Hosp. Administrator: Maisarrah S. Lumawan-Asim, RMT, MPA Tel. / Fax Nos.: _____ ____

Chief of Hospital/Med. Director: _ Rizaldy L. Piang, MD __ Tel. / Fax Nos.: _____ ____

License To Operate: __15-0126-22H1-1 ___ Authorized Bed Capacity: __100 ___ _

Classification: General / Specialty

Government: / Private:

National / Single Proprietorship

Local Corporation

Others: (specify) ____________________ Others: (specify) ____________________

Type of application: Initial Renewal /

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 ANNEX K - 2
AO No. 2012-0012
DOH STANDARDS (Indicators) for LEVEL 2 HOSPITAL

CRITERIA INDICATOR EVIDENCE AREAS Put a check REMARKS

(This refers to the specific (This is the (Proof of compliance to (Not limited if complied.
and measurable indicators REQUIREMENT of the the indicator: to the
that help determine standard. This is what document, interview or suggested
whether or not the Licensing Officers will observation) areas)
standard has been met.) look for. It refers to
measurable variables or
characteristics used to
determine the degree of
adherence to a standard.)
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
the proposed Ask patient/family from
intervention; the risks, the wards/ICU if they
benefits, and uncertainties were appropriately
related to each informed by authorized
alternative; assessment to personnel (doctor or
patient understanding; nurse) about their disease,
and patient's acceptance condition or disability, its
severity, prognosis,
or refusal of the benefits and possible
intervention. adverse effects of
treatment options and the
likely cost of treatment.
2. Policies and Presence of policies and DOCUMENT Wards
procedures which procedures to identify REVIEW
identify and address and address patients' Policies and procedures
patients’ rights and rights (including rights on patients' rights, i.e.
responsibilities are of incompetent patient, use of restraints,
documented and i.e. minors): patient’s refusal, etc.
monitored.
1. Right to information INTERVIEW
2. Right to refuse May ask a staff (doctor
treatment or nurse) to enumerate
3. Right to privacy patients’ rights or ask
4. Right to personal some patients at
choice random if their rights
5. Right to care and were explained to them.
security of personal
belongings OBSERVE
6. Right to freedom If patients’ rights are
from restraint posted in conspicuous
7. Right to freedom places.
from mistreatment
and abuse, etc.
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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)

OBSERVE
The facilities, and
structure. Check if the
service capability of
the hospitalis in
accordance with the
health facility level.
including “Add On”
Services
4. A multi-level ramp Presence of ramp or OBSERVE
shall have a minimum elevator
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 Departmentalized DOCUMENT Department
2CLINICAL AND clinical services at least REVIEW head offices
FACILITIES FOR for: Separate recording of Difference
IN PATIENTS - - Medicine patients per department clinical
Intensive to highly - Pediatrics areas
specialized care and - Obstetrics and OBSERVE
management Gynecology Physical separation of
- Surgery wards
- Anesthesia
6. OTHER CLINICAL
SERVICES
A.Dental Service Presence of policies and DOCUMENT
(MOA if procedures REVIEW
outsourced and by Implemented Policies
Referral) and procedures
B. High Risk
Pregnancy Care OBSERVE
If Functional

C. Neonatal Intensive
Care Unit

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D.Intensive Care Unit Presence of policies and DOCUMENT
procedures REVIEW
Implemented Policies
and procedures
E. Respiratory Unit
OBSERVE
If Functional

F. Others. Specify: Use applicable

Assessment tools of
other health facilities,
if merited. (i.e. ASC,
Dialysis clinic)

Refer to separate
checklist for other
services
7. NURSING Licensed and DOCUMENT Wards,
SERVICES appropriately trained REVIEW ER, OPD
Intensive to Highly nursing personnel PRC Valid license
specialized Nursing Care assigned in special and Certificate of relevant
and Management critical areas training
8. Entrances and exits Presence of entrances OBSERVE ER
are clearly and and exits that are readily 1. With entrance OPD
prominently marked, accessible and free from and exit signs. Check Wards
free of any obstruction ER, OPD and wards OR/RR/DR
obstruction and 2. Entrances and exits Imaging
readily accessible. 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)
9. Directional signs are Presence of directional OBSERVE ER
prominently posted to signages to locate Directional signs are OPD
help locate service service areas prominently posted. Wards
areas within the Others
organization. (Lobby)

10. Alternative Presence of alternative OBSERVE ER

passageways for passageways (ramps, Check: OPD
patients with special elevators) that are 1. Alternative Wards
needs (e.g. ramps) are prominently marked and passageways for Other areas
available, clearly and free from obstruction for patients with
prominently marked patients with special special needs.
and free of any needs 2. They are
obstruction. prominently
marked
3. They are free from
obstruction.

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CRITERIA INDICATOR EVIDENCE AREAS COMPLIED REMARKS
11. Corridors conform Corridors used as access OBSERVE
with standard for patients using bed or
measurement stretcher are at least 2.44
meters while in areas not
commonly used for bed
or stretcher are at least
1.83 meters
12. All patients are The contents of patient's DOCUMENT ER
correctly identified by charts Patient chart from ER, OPD
their patient charts, are the following: ward, and OPD Wards
including newborn 1. Summary or face
sheet INTERVIEW
2. Informed Consent verify with patient if
3. History and he/she really is the
Physical person indicated in the
Examination chart.
4. Doctor's order
5. Nurses Notes OBSERVE
6. TPR Sheet Check newborn tags if
7. Laboratory report compatible with the
8. Imaging reports mother
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 / doctor
including notes
15. Discharge summary
16. Clinical abstract
17. Advance directive,
whenever applicable

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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
13. 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
14. 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.
15. 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
16. 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 DOCUMENTS
properly utilized Patients’ charts
Kardex Kardex

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Standard: Assessments are performed regularly and are determined by patients’ evolving response to care.
17. Qualified personnel All patients for surgery CHART REVIEW Surgical /
give patients for have undergone pre- Patients’ charts of OB-Gyne
surgery pre-operative operative physical and surgery / OB- Wards
physical and pre- pre-anesthetic Gyne patients who
anesthetic assessment assessment have
undergone surgery and
presently admitted.

Note: Look for written

and legible pre-
operative physical and
(e.g. Cardio-pulmonary
clearance if warranted)
pre-operative anesthetic
evaluation and surgical
safety checklist in the
patient's chart. Pre-
operative 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 avai lable and are
performed by qualified personnel
18. 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

19. Medicines are All medicines are CHART REVIEW ER

administered in a administered observing Check patients charts Wards
timely, safe, the five (5) R's of from the wards:
appropriate and medication which are: For the accuracy of
controlled manner medicine
1. Right patient administration
2. Right medication
3. Right dose INTERVIEW
4. Right route Ask patients if the five
5. Right time (5) R’s were observed
during administration
of any IM, IV and oral
medications
20. Only qualified All doctors, pharmacists INTERVIEW Wards
personnel order, and nurses have updated Randomly check the Pharmacy
prescribe, dispense licenses licenses of some ER
prepare, and doctors, nurses and OPD
administer drugs. pharmacists if they are
updated.

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CRITERIA INDICATOR EVIDENCE AREAS COMPLIED REMARKS
21. Prescriptions or Proof that prescriptions DOCUMENT Wards
orders are verified or orders are verified REVIEW ER
and patients are before medications are Procedures on
identified before administered verification of
medications are prescriptions and orders
administered
INTERVIEW
Ask staff how they
verify orders from
doctors prior to
administration of
medicines.

OBSERVE
How staff verifies the
prescriptions or orders
for medicines with the
doctor’s order.
22. Patients are identified Proof that patients are INTERVIEW Wards
before medicines are correctly identified prior Verify from patients if ER
administered to administration of they were correctly
medications 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.)
23. Medicine All charts have proper CHART REVIEW Medical
administration is documentation of Medication sheet in records
properly documented medicine administration. patient chart from office
in the patient chart medical records or from wards
the 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.
24. 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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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
25. Organizational Presence of OBSERVE Other Areas
Structure/Chart organizational structure Lobby
Observe if the
organizational structure
/ chart is posted in
appropriate area.
26. The organization Presence of written DOCUMENT Medical,
and its services vision, mission, and REVIEW Nursing and
develop goals of the hospital and Adminis-
their vision, mission
and corporate goals all services/departments Written vision, mission trative
based on agreed-upon and goals Services
values Laboratory
27. The organization and Written policies and DOCUMENT Medical,
its services develop procedures manual for REVIEW Nursing and
their policies and all services / departments 1.Written Policies Adminis-
procedures. / units 2.Procedure manual trative
Services
28. Committees within Proof of the creation of DOCUMENT Adminis-
the organization all committees within the REVIEW trative office
which includes the organization which Proof of the creation of Offices of
terms of reference for includes the terms of all committees which the different
membership reference for includes the terms of committees
membership. reference for
membership e.g. memo,
The following are the office order, etc.
committees required: - written policies and
1. Credentialing and procedures
privileging - minutes of meetings
2. Blood Transfusion of the different
3. Healthcare Waste committees
Management
4. Patient Safety INTERVIEW
5. Infection Prevention Ask members of the
and Control different committees
6. Antimicrobial their functions, how
Stewardship often they meet, etc.
(functional by 2018)
7. Pharmacologic and
Therapeutic
8. Emergency and
Disaster
Preparedness
9. CQI
10. Ethics
11. Grievance

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29. Evaluation and Presence of evaluation DOCUMENT Adminis-
monitoring activities and monitoring activities REVIEW trative office
to assess management to assess management Evaluation activities to
and organizational and organizational assess management and
performance performance organizational
performance such as
semestral or annual
reports or Performance
and Budget Utilization
Review

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
30. Outsourced services Presence of all DOCUMENT Adminis-
are within the facility outsourced services REVIEW trative
1. Contracts/MOA Office
for outsourced
services
2. Valid licenses of all
providers
3. Check contracts
/ job orders
1. ADMINISTRATIVE SERVICES
A. Dietary There shall be provision DOCUMENT
of safe, quality and REVIEW
nutritious food to - Check policies
Administrative Office

patients. and procedures in

the dietary.
Diet prescription or diet - Monthly menu for
counselling is provided patients
to patients
B. Linen/ Laundry If not contracted out, DOCUMENT
there shall be: REVIEW

- Sorting of soiled and Check procedures on

contaminated linens how soiled linens are
in designated areas collected disinfected
- Systematic washing of and washed.
laundry with safeguard
against spread of
infection
- Disinfection of laundry

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C. Security Policies and procedures DOCUMENT
on security of patients, REVIEW
visitors and hospital staff Security check for
internal and external
customers including use
of visitor’s pass

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CRITERIA INDICATOR EVIDENCE AREAS COMPLIED REMARKS
D. Housekeeping / There shall be provision
Janitorial and maintenance of
clean, safe and sanitary
facilities and

Administrative Office
environment for hospital
personnel, patients and
clients

E. Proper Waste Policies and DOCUMENT

Disposal procedures on proper REVIEW
waste disposal.
Proof of
implementation of
policies and procedures
on proper waste
disposal.
F. Maintenance Proof of implementation OBSERVE Lobby
of policies and ER /
procedures INTERVIEW OPD
Wards
G. Ambulance (Use separate assessment OBSERVE
tool for Ambulance)
INTERVIEW
2. ANCILLARY SERVICES
A. Tertiary Clinical (Use separate tool for
Laboratory Clinical Laboratory)

B. Level 2 Imaging DOCUMENT

Facility REVIEW

Check for Certificate of

Compliance or License
To Operate, whichever
is applicable, from
Center for Device
Regulation, Radiation
Health and Research
(CDRRHR), FDA
C. Pharmacy Open 24/7, providing DOCUMENT
safe, affordable and REVIEW
efficacious medicines
Check for Certificate of
Compliance or License
To Operate, whichever
is applicable, from
Center for Drug
Regulation and
Research (CDRR),
FDA
D. Blood Station for There shall be 24 hours / DOCUMENT
Level 2 7 days a week provision REVIEW
of safe blood

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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.
31. The organization Presence of policies and DOCUMENT Personnel
documents and procedures for hiring, REVIEW /Adminis-
follows policies and credentialing and trative office
procedures for hiring, privileging of staff Policies and procedures
credentialing, and for hiring, credentialing
privileging of its staff. and privileging of staff

INTERVIEW
32. Staff numbers and Staff to bed ratio for DOCUMENT Personnel
skill mix are based on licensed doctors, REVIEW /Adminis-
actual clinical needs. registered nurses and trative office
midwives/nursing aides 1. List of licensed
(Trainees, except follows the DOH doctors and nurses Wards
physicians prescribed ratio. (Refer based on HR
undergoing residency to Attachment of records
training and Assessment Tool for 2. Payroll
volunteers not Personnel) 3. Schedule of duties
included) for the previous and
current month
4. Number of beds
authorized by DOH
and actual beds
being
used
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.
33. Professional Presence of Qualification DOCUMENT Personnel
qualifications are Standards REVIEW /Adminis-
validated, including Check Qualification trative office
evidence of Standards; procedures
professional in hiring.
registration /license
where applicable, OBSERVE
prior to employment Check PRC License of
some MDs. Nurses,
Pharmacists
34. The staff are Staff provided with job DOCUMENT Personnel
provided with a description outlining REVIEW /Adminis-
documented job their accountabilities and Written job descriptions trative office
description outlining responsibilities with conforme
accountabilities and
responsibilities

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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.
35. New personnel , new Proof that new personnel DOCUMENT Personnel
graduates and external are adequately oriented REVIEW /Adminis-
contractors are given and supervised - Policies and trative office
proper orientation and procedures
adequately supervised on orientation
by qualified staff - Module
on
orientation
- Documentation of
orientation
conducted

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

OBSERVE
36. Annual plan on Presence of annual plan DOCUMENT Personnel
training activities on training activities REVIEW /Adminis-
trative 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
37. Records are stored, Policies and procedures DOCUMENT Medical
retained and disposed on record storage, REVIEW records
of in accordance with retention and disposal. Policies and procedures room
the guidelines set by on record storage,
National Archives of retention and disposal.
the Philippines (NAP)
OBSERVE

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38. The organization Presence of annual DOCUMENT Medical
defines data sets, data statistical reports and REVIEW records
generation, collection other additional 1. Compilation of room
and aggregation hospital statistics as Annual Hospital
methods and the determined by the Statistical
qualified staff who management Report
are involved in each 2. Other additional
stage statistics as
determined by the
management or
hospital forms that
serve as instruments
for data collection
Presence of qualified and aggregation
staff involved in data 3. Proof of
definition, generation, training/seminar on
collection and Basic Records
aggregation Management and
ICD 10 Coding of
staff in charge
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.
39. When patients are Presence of policies and DOCUMENTREVIE Medical
admitted or are seen procedures on filing and W 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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40. The organization has Presence of procedures DOCUMENT Medical
policies and to protect records and REVIEW Records
procedures, and patient charts against Policies and procedures Room /
devotes resources, loss, destruction, on records management Office
including tampering and to maintain Wards
infrastructure, to unauthorized access or confidentiality/privacy,
protect records and use accuracy and
patient charts against prevention of loss and
loss, destruction, destruction, tampering
tampering and and unauthorized
unauthorized access access.
or use. Only
authorized individuals DOCUMENT
make entries in the Logbooks for
patient chart. 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 provide d 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
41. Hospital has a valid Presence of updated DOCUMENT Adminis-
license DOH license to operate REVIEW trative office
1. Updated
DOH license
2. If facility has
nuclear medicine,
check certificate
issued by PNRI
42. Hospital is free from OBSERVE Hospital
undue noise, pollution 1. Ask staff at surroundings
and from foul odor random: their Laboratory
manner of Pharmacy
waste segregation and other
and disposal; safe part of the
storage and disposal facility and
of reagents. Maintenance
2. Check presence of
MSDS (Material
Safety Data Sheet)
in the laboratory
and Engineering
3. Record of disposal
of radiologic wastes

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43. Presence of a Presence of a DOCUMENT Adminis-
management plan, management plan, REVIEW trative office
policies and policies and procedures Management plan, Maintenance
procedures addressing: policies and procedures office,
addressing safety 1. Safety ER
2. Security INTERVIEW Wards
3. Disposal and Ask about the
control of hazardous frequency of the
materials and biologic following:
wastes 1. Fire drill conducted
4. Emergency and in the past 12
disaster preparedness months
2. Earthquake drill
conducted in the past
12 months
44. Policies and Presence of policies and DOCUMENT ER
procedures for the procedures for: REVIEW OPD
safe and efficient use - Quality Control 1. Presence of Wards
of medical - Corrective and operating manuals of DR
equipment according Preventive the medical Laboratory
to Maintenance Program equipment Pharmacy
specifications are for medical 2. Preventive and Maintenance
documented and equipment corrective Office
implemented. maintenance Other areas
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
45. Patient areas Presence of adequate OBSERVE ER
provide sufficient space, lighting and Observe for the OPD
space for ventilation in compliance following: Wards
safety, comfort and with structural 1. Adequate space DR
privacy of the patient requirements (for patient 2. Adequate lighting
and for emergency safety and privacy) (lights are working,
care. lighting is adequate
enough for conduct
of general
activities)
3. Adequate ventilation

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46. A coordinated Presence of an appointed DOCUMENT
security arrangement personnel in charge of REVIEW
in the organization security. Contract or
assures protection of Appointment of person
patients, staff and in charge of security.
visitors.
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.
47. An incident reporting Presence of incident DOCUMENT Infection
systemidentifies reporting system/sentinel REVIEW Control
potential harms, event monitoring system Incident/sentinel event Committee
evaluates causal and (which may include reports or office
contributing factors hospital associated communications/ CQI Office
for the necessary infections, unexpected memoranda/orders or Wards
corrective and deaths, adverse drug proceedings on sentinel ER
preventive action reactions, blood events ICU
transfusion reactions, OR
falls, etc.) 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 provide d for, in keeping
with relevant statutory requirements and codes of practice.
48. 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 Areas
months.
- 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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49. Equipment are Presence of policies and DOCUMENT
regularly maintained procedures on preventive REVIEW
with plan for and corrective Records of preventive
replacement maintenance and and corrective
according to expected replacement if warranted maintenance and plan
life span or when no for replacement
longer serviceable.

50. Training of the staff Proof of training of the DOCUMENT Engineering/

who is in charge of staff who is in charge of REVIEW Maintenance
the maintenance of the maintenance of the For in-house: Office
the equipment equipment Certificate of training Laboratory
of service personnel or Imaging
Certificate of training Other Areas
For outsourced service:
MOA/Contract (verify
qualification of
technicians)

INTERVIEW
Ask about how
equipment (generator,
A/C, Medical and non-
medical 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.
51. Operating manuals of Presence of operating DOCUMENT Engineering/
equipment manuals equipment REVIEW Maintenance
Operating manual of Office
Medical equipment, Imaging,
generators, air Laboratory
conditioners and other
non-medical equipment.
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.
52. 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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53. Infection Prevention Presence of an infection DOCUMENT Nurse
and Control Program control program ensuring REVIEW Super-
prevention and control of 1. IPC Manual. visor’s
infections on all services.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 healthcare-
associated infections.
54. 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 Ask staff from ER,
procedure for asepsis. wards and laboratory
about the approaches
for asepsis during
diagnostic and
treatment procedures

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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
55. 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
needles are and safe disposal
documented and of
monitored sharps/needles.

INTERVIEW
Interview hospital staff
on how they handle and
dispose needles.

OBSERVE
Presence of receptacles
for proper disposal of
sharps
56. There are programs Presence of program on DOCUMENT ER
for the prevention prevention of REVIEW Wards
of transmission of transmission of airborne 1. Policies and Isolation
airborne infections, infections and risks procedures room
and risks from from patients with signs on isolation. Laboratory
patients with signs and 2. Occupational Health
and symptoms symptoms suggestive of and Safety Program
suggestive of tuberculosis or other for employees
tuberculosis or communicable diseases 3. Policies on timely
other communicable referral and case
diseases are managed reporting of highly
according to transmissible and
established protocols notifiable
infectious disease
e.g.meningococce-
mia, SARS, avian
flu, etc.
4. Procedures on
recycling & reuse

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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Standard: When needed, the organization reports information about infections to personnel and public health
agencies.
57. Policies and Presence of policies and DOCUMENT
procedures in procedures in reporting REVIEW
reporting notifiable notifiable diseases Copy of reports
diseases (Refer to AO submitted to Philippine
No. 2008-0009). 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).
58. 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
59. Licenses/permits/ Presence of DOCUMENT Adminis-
clearances from licenses/permits/ REVIEW trative office
pertinent regulatory clearances from pertinent 1. Pertinent licenses /
agencies regulatory agencies, if permits from
applicable regulatory agencies
(LGU, DENR, etc.)
2. Proof of
compliance i.e.,
generator permit,
elevator
permit, etc.

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60. Policies and Proof of implementation DOCUMENT
procedures on waste of policies and REVIEW
disposal procedures on waste 1. Issuances -
disposal 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 improveme nt.
61. Continuous Quality Presence of Quality DOCUMENT Adminis-
Improvement 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
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activities thru
interview of staff at
random.

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Standard: Management is primarily responsible for developing, communicating, and implementing a
comprehensive quality improveme nt program throughout the organization and delegating responsibilities
to appropriate personnel for its day-to-day implementation
62. 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
63. Customer satisfaction Presence of customer DOCUMENT Adminis-
survey satisfaction survey REVIEW trative
1. Domains of the Office
survey form used.
2. Survey results
and
how complaints /
comments are acted
upon.
64. Better patient Proof of better patient DOCUMENT Adminis-
outcome. outcomes REVIEW trative
Documentation of Office
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.)
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CRITERIA INDICATOR EVIDENCE AREAS COMPLIED REMARKS

VIII. DOH PROGRAMS IMPLEMENTED IN HOSPITALS AND OTHER HEALTH FACILITIES

65. Newborn Screening Newborn Screening DOCUMENT OB Ward
being implemented. REVIEW (Rooming
Newborn Screening – in - Policies and In)
compliance to RA 9288 procedures on
and its IRR Universal
Newborn
Screening
- Logbook of
Newborns who were
tested and copies of
waiver for those
who were not
screened
- OR of filter papers
66. Hospital is Certified Proof of implementation DOCUMENT OB Ward
on MBFHI of Rooming-in and REVIEW
Breastfeeding MBFHI Certificates:
Mother- Baby Friendly - MBF Hospital
Hospital Initiative – in
- MBF Workplace
compliance to RA 7600
and RA 10028 and its
(MOU for those who
IRR, and Executive
are not certified yet).
Order No. 51 (Milk
Code)
OBSERVE
- Breastfeeding area
should be provided at
the NICU
- There shall be no
nursery for
normal newborns
67. Immunization of Newborn babies given DOCUMENT OB Ward
newborn babies with BCG and first dose REVIEW
BCG and first dose Hepatitis B vaccine Records of Newborns
Hepatitis B vaccine given BCG and first
dose Hepa-B vaccine
Immunization – in
compliance to RA No. OBSERVE
306
INTERVIEW STAFF
68. Hospital is a “No Policies and procedures DOCUMENT Hallways
Smoking zone on anti-smoking REVIEW
Policies and procedures
Anti-smoking – in on anti-smoking
compliance to RA 9211
OBSERVE
“No Smoking” signages
69. Generic prescribing Actual implementation DOCUMENT Pharmacy
and recording of policies and REVIEW Wards
procedures on generic - Prescriptions filled in
Generic Prescribing – in prescribing the Pharmacy
compliance to RA 6675 - Physicians’ orders
(Generics Act of 1988)
in patients’ charts
- Documentation of
nurses on medicines.

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70. Emergency Proof of implementation DOCUMENT ER
Preparedness, of the plan REVIEW Wards
Response and - Self-assessment Offices
Recovery Plan for disaster
readiness using the
Health Emergency “Safe Hospital
Management Services Checklist”
(HEMS) – in compliance available at the
to AO 2004-0168 HEMB website.
"National Policy on - Result of self-
Health Emergencies and assessment and how
Disasters" gaps were resolved

OBSERVE
Exit plans posted in all
hallways and rooms
71. Newborn Hearing Newborn Hearing DOCUMENT Newborn
Screening Screening being REVIEW hearing
implemented - Logbook of screening
Universal Newborn Newborns who were room
Hearing Screening – in tested on hearing
compliance to RA 9709
- Proof of referral
(Universal Newborn if service is not
Hearing Screening Act) available
72. Family planning Presence of Family DOCUMENT OPD
service planning services REVIEW OB wards
- List of FP acceptors
Family planning – in - Evidence as
compliance to RA conscientious
10354 (Responsible objector if FP
Parenthood and services are not
Reproducti ve Health
provided
Act of 2012)
- Referral System to
other facilities for FP
if conscientious
objector.
73. National Tuberculosis Implementation of DOCUMENT OPD
Program National TB Program REVIEW Wards
- Presence of Hospital
NTP – in compliance TB Referral Logbook
with RA 10767 - List of Diagnosed
(Comprehensive TB TB Cases Notified
Elimination Plan Act) (with received
remarks by DOH-
Regional
Office)

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ASSESSMENT TOOL FOR LEVEL 2 HOSPITAL
ATTACHMENT A - PERSONNEL

NUMB ER /
POSITION QUALIFICATION EVIDENCE COMPLIED REMARKS
RATIO

TOP MANAGEMENT
Chief of Hospital Must have completed DOCUMENT REVIEW 1
/Medical Director at least twenty (20) - Diploma / Certificate of 1- Permanent
units towards a units earned Chief of
Master’s Degree in - Updated PRC license hospital
position
Hospital - Certificates of
 detailed to
Administration or Trainings attended regional
related course (MPH, - Proof of Employment / office
MBA, MPA, MHSA, Appointment 2- OIC- Chief
etc.) AND at least five of hospital
(5) years experience in INTERVIEW present.
a supervisory or
managerial position

Chief of Clinics / Must be a fellow DOCUMENT REVIEW 1

Chief Medical / diplomate in a - Diploma / Certificate De signated
Professional specialty / from Specialty society, X
Services Subspecialty society if applicable
AND at least five (5) - Updated PRC license
years experience in a - Certificates of
supervisory or Trainings attended
managerial position - Proof of Employment /
Department Head Must be a fellow / Appointment 1 per Not yet
(Specialty) diplomate in a department departmentalize
specialty / INTERVIEW
Subspecialty society X
of the department he /
she heads
Chief Nurse / Master’s Degree in DOCUMENT REVIEW 1 1- Permanent
Director of Nursing Nursing - Diploma / Certificate of
units earned
- Updated PRC license 
- Certificates of
Trainings attended
- Proof of Employment /
Appointment

INTERVIEW
Chief 20 Units towards DOCUMENT REVIEW
Administrative Master’s Degree in - Diploma / Certificate of 1 1- Permanent
Officer Hospital units earned
Administration or - Updated PRC license 
related course AND at - Certificates of
least five (5) years Trainings attended
experience in a - Proof of Employment /
supervisory / Appointment
managerial position.
INTERVIEW

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NUMB ER /
POSITION QUALIFICATION EVIDENCE COMPLIED REMARKS
RATIO
ADMINISTRATIVE SERVICES
Certified Public 1 X
Accountant
Accountant
Billing Officer With Bachelor’s DOCUMENT REVIEW 1  4 –JO & Contractual
Degree relevant to the - Diploma  1- Permanent
Budget / Finance 1
job - Updated PRC license, if
Officer
Cashier applicable 1  1- Permanent
- Certificates of Trainings
Human Resources 1 Designated
attended
Management X
- Proof of Employment /
Officer / Personnel
Appointment
Officer
Clerk, pool 1:50 beds  3-Job Order
Engineer Licensed Engineer DOCUMENT REVIEW 1
- Diploma
- Updated PRC license
(if Engineer) X
- Certificates of
Trainings attended
- Proof of Employment /
Appointment
Supply Officer/- With appropriate DOCUMENT REVIEW 1  1 - Permanent
Storekeeper training and - Certificates of
experience Trainings attended
1  1-Permanent
Laundry Worker - Proof of Employment / 2-Job Order
Appointment
Medical Records Bachelor's Degree DOCUMENT REVIEW 1
officer And Training in ICD - Diploma / Certificate of
10 and Medical units earned
Records Management - Certificates of Trainings  1-Contractual
attended
- Proof of Employment /
Appointment

INTERVIEW
Medical Social Licensed Social DOCUMENT REVIEW 1 1-Contractual
worker Worker - Diploma / Certificate of 4-Job Order
units earned 
- Updated PRC license
Certificates of
Nutritionist- Licensed Nutritionist- Trainings attended 1 1-Permanent
Dietician Dietician - Proof of Employment / 1-Contractual
Appointment 

INTERVIEW
Driver 1  2 – (vacant position)
6-Job Order
Cook 1  1-Permanent
3-Contractual
Building May be outsourced 1 per shift 1-Permanent
Maintenance DOCUMENT REVIEW 
Man/Utility Certificates of Trainings 4-Job Order
Worker attended
Security Guard 1 per shift  12- Job Order

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NUMB ER /
POSITION QUALIFICATION EVIDENCE COMPLIED REMARKS
RATIO
CLINICAL SERVICES
Consultant Staff in Fellow / Diplomate DOCUMENT REVIEW At least one 1-Pedia
Ob-Gyn, with updated PRC - Diploma / Certificate (1) per
Pediatrics, License from Specialty society, specialty
Medicine, Surgery if applicable
and Anesthesia - Updated PRC license
Physician Updated PRC license - Certificates of 1:20 beds at 5-Permanent
(Shall not go on Trainings attended any time 
duty for more than - Proof of Employment / 13-Job Order and
48 hours straight). Appointment Contractual

NURSING SERVICES
Assistant Chief With updated PRC DOCUMENT REVIEW 1
Nurse license, with twenty - Diploma / Certificate of
(20) units towards units earned X
Master’s Degree in - Updated PRC license
Nursing and three (3) - Certificates of
years experience in Trainings attended
hospital supervisory - Proof of Employment /
/ managerial position Appointment

INTERVIEW
Supervising With updated PRC DOCUMENT REVIEW 1 per
Nurse/Nurse license, with at least - Diploma / Certificate of Department
Managers nine (9) units of units earned X 1-Dessignated
Master's Degree in - Updated PRC license
Nursing with 3 years - Certificates of
hospital experience. Trainings attended
UpdatedPRC License - Proof of Employment / 1 per shift per
With at least 3 years Appointment clinical
hospital experience department

Staff Nurse Updated PRC License DOCUMENT REVIEW 1:12 Beds at

BLS certified - Diploma any time (1  6-permanent
- Updated PRC license reliever for
- Certificate every 3 RNs)
oftrainings attended
- Proof of employment
Staff Nurse in Updated PRC License 1:3 beds at
every Critical Unit Certificate of any time per
(CCU, ICU, NICU, Training in Critical shift (plus 1
PICU, SICU, Care reliever per
HRPU etc.) Nursing 3 CCU RNs)
Nursing Attendant With relevant training 1:24 beds at
/ Midwife (may be in house any time(1
training) reliever for
every 3
DOCUMENTS REVIEW NA/MWs)
Nursing Attendant Certificates of Trainings 1:12 patients
/ Midwife in CCUs attended at any time
(plus 1
reliever for
every 3
NA/MWs)

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NUMB ER /
POSITION QUALIFICATION EVIDENCE COMPLIED REMARKS
RATIO
Operating Room With updated PRC 1 ORN, SN,
Nurse license CN per
Training OR Nursing functioning
Scrub Nurse OR per shift
Circulating Nurse
Delivery Room With updated PRC 1 per
Nurse license functioning
DOCUMENT REVIEW
Certificate of DR per shift
- Diploma
Training in Maternal
- Updated PRC license
and Child Nursing
- Certificates of
(may be in house
Trainings attended
training or
training in EINC) - Proof of Employment /
Emergency Room With updated PRC Appointment 1 per
Nurse license department
Certificate of
Training in Trauma
Nursing, ACLS and
other
relevant training
Out-patient With updated PRC 1
Department Nurse license
ANCILLARYS ERVICES
Dentist With updated PRC 1
license  1-Permanent

Medical 2 in AM and  1-Permanent

Technologists 2 in PM shift; 7-Job Order &
1 in the Contractuals
evening shift
Medical Adequate 2-Job Order &
Laboratory Aide  Contractual

Pathologist With updated PRC 1

license;  1-Consultant
Fellow / Diplomate in DOCUMENT REVIEW
Pathology - Diploma
Pharmacist With updated PRC - Updated PRC license, if 1 per shift 1-Permanent
license applicable  1-Contractual
- Certificates of
Trainings attended
Radiologist With updated PRC - Proof of Employment / 1
License  1-Job Oder
Appointment
Fellow or Diplomate
in Radiology
Radiologic 1 per shift
Technologist  5-Job Order

Radiation Safety 1
Officer  1-Permanent

Respiratory 1 per shift

Therapist X

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 ANNEX K - 2
AO No. 2012-0012

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 ANNEX K - 2
AO No. 2012-0012
ASSESSMENT TOOL FOR LEVEL 2 HOSPITAL
ATTACHMENT B - PHYSICAL PLANT

PHYSICAL FACILITY
(Specify “ADD ON” Services, if DESCRIPTION COMPLIED REMARKS
any)
ADMINISTRATIVE SERVICE

Lobby
x
Waiting Area
x
Information and Reception
x
Communication Booth / Room
Human Resource / Personnel 
Office
x
Library

Conference Room

Property / Supply Office / Room
Office of the Chief of Hospital / 
Medical Director
Office of the Chief of Clinics / x
Chief Medical Professional
Services
Office of Chief Administrative x
Officer

Office of the Chief Nurse
x
Budget and Finance Office

Accounting Office

Budget and Finance Office

Billing / Cashier

Linen and Laundry room
x
Receiving Area
Sorting Area and Disinfection x
Area

Washing Area
Not required if outsourced ?
Clean Linen Storage and
Release Area
Housekeeping room for cleaning ?
tools and supplies

Parking Area for transport vehicle

Motor pool Area
Shall have color-coded X
Central Waste Storage Area segregation; clean and free from
foul odor
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 ANNEX K - 2
AO No. 2012-0012
PHYSICAL FACILITY
(Specify “ADD ON” Services, if DESCRIPTION COMPLIED REMARKS
any)
Provided with water; clean and 
Staff Toilet
free from foul odor
X
Public Toilet (M/F/PWD)

Dietary 

Nutritionist-Dietician Office 

Supply receiving Area (not required if contracted-out) 

Dry and Cold Storage Area Shall have adequate space, clean 
and Free from foul odor; no insects
Food preparation Area 
and rodents.
Cooking Area 

Dishwashing Area 

Assembly Area
Dining Area 

Garbage Area 

Medical Records Office 

With area for completion of
Filing Room patients' charts by physicians and 

Storage Room other professionals ?

Medical Social Worker’s Office 

Counselling Area 

Cadaver Holding Area 

PRAYER ROOM 
CLINICAL SERVICES
Adequate privacy for patients is 
provided such that sensitive or
private discussion, examination,
EMERGENCY ROOM /
and/or procedures are conducted in
EMERGENCY
a manner or environment where
DEPARTMENT
these cannot be observed or the
risk of being overheard by others is
minimized.

Triage Area

Shall be provided with shower, x

Decontamination Area
receptacle for used or
(with separate entrance and exit
contaminated clothing; shelf for
– adjacent to main ER entrance)
clean patient gowns
Holding Room for Infectious Shall have ante-room with x
cases awaiting transfer rack/shelf for PPEs
Examination and Treatment Shall be provided with hand x
Area washing/hand disinfection facility
?
Medication Preparation Area

Minor OR / Area

Observation Area /Ward
Area / Room for Imminent x
Normal Spontaneous Delivery

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 ANNEX K - 2
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PHYSICAL FACILITY
(Specify “ADD ON” Services, if DESCRIPTION COMPLIED REMARKS
any)
Shall have adequate lighting and ?
Waiting area
ventilation.
 Available/serviceable
Nurses' station
Equipment and supply storage x
area
Wheeled Stretcher and  Available/serviceable
Wheelchair Area
 Available/serviceable
Doctor's On-Duty Room
 Admitting corner area only
Admitting Office
Separate Male from Female; Clean  Not separated male from female
Toilet for patients and
and Free from foul odor; no insects
companions
and rodents
 Available/serviceable
Staff Toilet

OUTPATIENT DEPARTMENT
Shall have adequate lighting and  Available/serviceable
Waiting area
ventilation.
Adequate privacy for patients is  Available/serviceable
provided such that sensitive or
private discussion, examination,
and/or procedures are conducted in
Consultation Area
a manner or environment where
these cannot be observed or the
risk of being overheard by others is
minimized.
Examination and Treatment Shall be provided with hand  Available/serviceable
Area washing/hand disinfection facility
 Available/serviceable
Nurse’s counter
 Available/serviceable
Patients’ Area
Separate Male from Female; Clean x No patient toilet
Toilet for patients and
and Free from foul odor; no insects
companions
and rodents
OFFICES OF DEPARTMENT HEADS
x
Internal Medicine
x
Surgery
x
Obstetrics and Gynecology
x
Pediatrics
x
Anesthesia
x
Emergency Department
x
Out-patient Department
x
Pathology

Radiology

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 ANNEX K - 2
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PHYSICAL FACILITY
(Specify “ADD ON” Services, if DESCRIPTION COMPLIED REMARKS
any)
Shall have control door or
OPERATING ROOM /
demarcation line between dirty to
COMPLEX
clean area

Major OR
x
Dressing Room
x
Nurses’ Station with work Area
x
Sub-sterile Area
x
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

x
Patients Area
Nurses’ Station with Medication x
Area
DELIVERY ROOM / COMPLEX
Labor Room (provided with  Can cater one patient only ( 1 bed)
toilet)
 Can cater 1 patient only ( 1 bed)
Delivery Room proper

Scrub Up Area

Dressing Room

Nurse’s Station
Storage Area for Sterile packs 
and supplies

Wheeled Stretcher Area
x
Janitors’ Closet with slop sink
HIGH RISK PREGNANCY X
AREA
Indicate if it is a separate unit or if
patients are admitted in ICU or
(May be put up as part of the
Labor Room
Labor Room or patient may be
admitted in the ICU)
NEONATAL INTENS IVE CARE UNIT (NICU)
x
Nurses’ Station with lavatory

Medication preparation area
 Non functional
Incubator / Warmer Area
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 ANNEX K - 2
AO No. 2012-0012
PHYSICAL FACILITY
(Specify “ADD ON” Services, if DESCRIPTION COMPLIED REMARKS
any)

Treatment Area
Breastfeeding Area with 
Lavatory
INTENS IVE CARE UNIT (ICU)
x Available/Non functional
Dressing Room
 Available/Non functional
Nurses’ Station with lavatory
 Available/Non functional
Medication Preparation Area
 Available/Non functional
Patients’ beds Area

NURSING SERVICE / WARD

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
Patient Rooms with Toilet 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 
Nurses’ Station with Lavatory provided with hand-washing / hand
disinfection facility.
Medication preparation area 
with lavatory
?
Treatment area with Lavatory

Equipment and Supply Area
 Available/serviceable at nurse station
Staff Toilet
x
Linen Area

Waste bins Color-coded
 Available outside nurses station
Janitor’s Closet

ISOLATION ROOM
Ante room with lavatory and  Available, without lavatory and PPE
PPE Rack Rack
Hand-washing / Hand 
disinfection facility in all point
of care areas
x Available respiratory ward
RESPIRATORY UNIT

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 ANNEX K - 2
AO No. 2012-0012
PHYSICAL FACILITY
(Specify “ADD ON” Services, if DESCRIPTION COMPLIED REMARKS
any)
DENTAL CLINIC
 Availble/serviceable
Dental Chair unit area
Consultation Area with access Not required if referral system x Not available
to toilet
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 - 2
AO No. 2012-0012
ASSESSMENT TOOL FOR LEVEL 2 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) QUANTITY COMPLIED
AREA REMARKS
(Use separate sheet if equipment is for
a specific “ADD ON” Service/s).
ADMINISTRATIVE SERVICE
Ambulance, available 24/7 and physically  In good condition/serviceable
1 Parking
present; if outsourced, shall be on call
Administrative  In good condition/serviceable
Computer with Internet Access 1
Office
lobby,
hallway,
Emergency Light
nurses' station,
office/unit and
stairways
lobby,  In good condition/serviceable
1 per unit or hallway,
Fire Extinguishers
area nurses' station,
office/unit and
stairways
Conference  In good condition/serviceable
LCD Projector 1
Room
Generator set with Automatic Transfer
1 Genset house
Switch (ATS)
KITCHEN/DIETARY
Exhaust fan 1  In good condition/serviceable
Food Conveyor or equivalent 1 x Not available
Food Scale 1  For repair/serviceable
Blender/Osterizer 1  Serviceable
Stove 1 Kitchen X Not available

Refrigerator/Freezer 1  Serviceable
Utility cart 1 x Not available
Garbage Receptacle with Cover color- 1 for each  Serviceable
coded) color
EMERGENCY ROOM
Bag-valve-mask Unit  Serviceable
- Adult 1
- Pediatric 1
Calculator for dose computation 1  Serviceable
Clinical Weighing scale 1  Serviceable
Defibrillator 1  Serviceable
Delivery set, primigravid 2 sets  Serviceable
Metzenbaum scissors, straight 1 per set  Serviceable
Mayo scissors, straight 1 per set  Serviceable
Kelly hemostatic forceps, curved or ER  Serviceable
2 per set
straight
Needle Holder 1 per set  Serviceable
Tissue forceps 1 per set  Serviceable
Delivery set, multigravid 2 sets  Serviceable
Mayo scissors, straight 1 per set  Serviceable
Kelly hemostatic forceps, curved or  Serviceable
2 per set
straight
ECG Machine 1  Serviceable
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 ANNEX K - 2
AO No. 2012-0012
EQUIPMENT/ INSTRUMENT
(Functional) QUANTITY COMPLIED
AREA REMARKS
(Use separate sheet if equipment is for
a specific “ADD ON” Service/s).
EENT Diagnostic Set with x
1
Ophthalmoscope and Otoscope
Emergency Cart (for contents, refer to 
1
separate list).
Examining table 1 
Examining table (with Stirrups for OB- x
1
Gyne
Gooseneck lamp/Examining Light 1
Instrument/Mayo Table 1
Laryngoscope with different sizes of
1 set
blades
Minor Instrument Set (May be used for
Tracheostomy, Closed Tube 2 sets
Thoracostomy, Cutdown, etc.)
Kelly hemostatic forceps – curved 2 per set
Kelly hemostatic forceps – straight 2 per set
Mayo scissors – straight 1 per set
Metzenbaum scissors – curved 1 per set
Mosquito forceps – curved 4 per set
Mosquito forceps – straight 4 per set
Needle holder 1 per set
Scalpel handle No. 3 1 per set
Scalpel handle No. 4 1 per set
Skin retractor 1 pair
Tissue forceps 1 per set
Thumb forceps 1 per set
Nebulizer 1  unserviceable
Negatoscope 1 ER 
Neurologic Hammer 1 
OR Light (portable or equivalent) 1 
Oxygen Unit 
Tank is anchored/chained/ strapped or 2
with tank holder if not pipeline
Pulse Oximeter 1 
Sphygmomanometer, Non-mercurial 1 
- Adult Cuff 1
- Pediatric Cuff 1
Stethoscope 1 
Suction Apparatus 1 
Suturing Set 2 sets 
Mayo scissors 1 per set 
Mosquito forceps 1 per set 
Needle holder 1 per set 
Tissue forceps 1 per set 
Thermometer, non-mercurial x
- Oral 1
- Rectal 1
1 set of x
Vaginal Speculum, Different Sizes
different sizes
Wheelchair 1 
Wheeled Stretcher with guard/side rails 
1
and wheel lock or anchor.

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 ANNEX K - 2
AO No. 2012-0012
EQUIPMENT/ INSTRUMENT
(Functional) QUANTITY COMPLIED
AREA REMARKS
(Use separate sheet if equipment is for
a specific “ADD ON” Service/s).
OUT- PATIENT DEPARTMENT
Clinical Height and Weight Scale 1 
EENT Diagnostic Set with x
1
ophthalmoscope and otoscope
Gooseneck lamp/Examining Light 1 
Examining table with wheel lock or x
1
anchor
Instrument/Mayo Table 1 
Minor Instrument Set: 1 
Kelly hemostatic forceps – curved 2 per set 
Kelly hemostatic forceps – straight 2 per set 
Mayo scissors – straight 1 per set 
Metzenbaum scissors – curved 1 per set 
Mosquito forceps – curved 4 per set 
Mosquito forceps – straight 4 per set 
Needle holder 1 per set 
Scalpel handle No. 3 1 per set 
Scalpel handle No. 4 1 per set 
Skin retractor 1 pair 
Tissue forceps 1 per set OPD 
Thumb forceps 1 per set 
Neurologic Hammer 1 
Oxygen Unit  Serviceable is not
Tank is anchored/chained/ strapped or 1 anchored/chained/strapped
with tank holder if not pipeline
Peakflowmeter 
- Adult 1
- Pediatric 1
Sphygmomanometer, Non-mercurial 
- Adult cuff 1
- Pediatric cuff 1
Stethoscope 1 
Thermometer, non-mercurial x
- Oral 1
- Rectal 1
Suture Removal Set 1
Wheelchair / Wheeled Stretcher 1
OPERATING ROOM
Air conditioning Unit 1  Seviceable
Anesthesia Machine 1  Seviceable
Cardiac Monitor with Pulse Oximeter 1  Seviceable
Ceasarian Section Instrument 1  Seviceable
OR  Seviceable
Emergency Cart (for contents, refer to
1
separate list).
Instrument / Mayo Table 1  Seviceable
Laparotomy pack (Linen pack) 1 per OR  Seviceable

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 ANNEX K - 2
AO No. 2012-0012
EQUIPMENT/ INSTRUMENT
(Functional) QUANTITY COMPLIED
AREA REMARKS
(Use separate sheet if equipment is for
a specific “ADD ON” Service/s).
Laparotomy / Major Instrument Set 1 per OR  Serviceable
Towel Clamp 4 per set  Seviceable
Scalpel handle No. 3 1 per set  Seviceable
Scalpel handle No. 4 1 per set  Seviceable
Army-navy retractor 1 pair per set  Seviceable
Richardson retractor – double-end 1 per set  Seviceable
Self-retraining retractor (Balfour) 1 per set  Seviceable
Kelly hemostatic forceps – curved 4 per set  Seviceable
Kelly hemostatic forceps – straight 4 per set  Seviceable
Halsted mosquito forceps – straight 4 per set  Seviceable
Allis forceps 4 per set  Seviceable
Mixter – curved 1 per set  Seviceable
Mixter – straight 1 per set  Seviceable
Needle holder 2 per set  Seviceable
Tissue forceps 1 per set  Seviceable
Thumb forceps 1 per set  Seviceable
Metzenbaum scissors – curved 1 per set  Seviceable
Mayo scissors – curved 1 per set  Seviceable
Mayo scissors – straight 1 per set  Seviceable
Orthopedic Instrument Set 1 x Seviceable
Periosteal elevator 1 per set  Seviceable
Bone chisel / osteotome 1 per set  Seviceable
Bone mallet 1 per set  Seviceable
Bone Rongeur 1 per set  Seviceable
Bone holder 1 per set  Seviceable
OR
Bone drill with different sizes of drill  Seviceable
1 per set
bits
Gigli saw (handle and wire) 1 per set  Seviceable
Pin / Wire cutter 1 per set  Seviceable
Pin / Wire puller 1 per set  Seviceable
Bone curette 1 per set  Seviceable
Cast spreader 1 per set  Seviceable
Bone clamp 1 per set  Seviceable
Zimmer 1 per set  Seviceable
Screw driver 1 per set  Seviceable
Oxygen Unit  Seviceable
Tank is anchored/chained/ strapped or 1 per OR
with tank holder if not pipeline
Rechargeable Emergency Light (in case  Seviceable
1 per OR
generator malfunction)
Sphygmomanometer, Non-mercurial  Seviceable
- Adult cuff 1 per OR
- Pediatric cuff 1 per OR
Spinal Set 1  Seviceable
Stethoscope 1  Seviceable
Suction Apparatus 1  Seviceable
Thermometer, non-mercurial x Not available
- Oral 1
- Rectal 1

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 ANNEX K - 2
AO No. 2012-0012
EQUIPMENT/ INSTRUMENT
(Functional) QUANTITY COMPLIED
AREA REMARKS
(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 x
Mechanical / patient bed, with guard  Partly damaged
1
side rails and wheel lock or anchored
Oxygen Unit 
Tank is anchored/chained/ strapped or 1
with tank holder if not pipeline PACU/RR
Sphygmomanometer, Non-mercurial 
- Adult cuff 1
- Pediatric cuff 1
Stethoscope 1 
Thermometer, non-mercurial 1  digital
LABOR ROOM
Fetal Doppler 1  1 doppler only for the use of L&D
& OR
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 x Not available
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 X
Vaginal Speculum 1 per set 
Ovum forceps 1 per set 
Hegars dilator, graduated sizes 1 per set X
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 

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 ANNEX K - 2
AO No. 2012-0012

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 ANNEX K - 2
AO No. 2012-0012
EQUIPMENT/ INSTRUMENT
(Functional) QUANTITY COMPLIED
AREA REMARKS
(Use separate sheet if equipment is for
a specific “ADD ON” Service/s).
Delivery set, multigravid 2 sets 
Mayo scissors, straight 1 per set 
Kelly hemostatic forceps, curved or 
2 per set
straight
DR Light 1 
DR Table 1 
1 
Emergency Cart (for contents, refer to (if DR is
separate list). separate from
OR Complex)
Instrument/Mayo Table 1 
Kelly Pad or equivalent 1 DR 
Laryngoscope 1 
Oxygen Unit 
Tank is anchored/chained/ strapped or 1
with tank holder if not pipeline
Rechargeable Emergency Light (In case 
1
of generator malfunctions)
Sphygmomanometer -Non-mercurial 1 
Stethoscope 1 
Suction Apparatus 1 
Wheeled Stretcher 1 
HIGH RISK PREGNANCY UNIT
Cardiac Monitor with Pulse Oximeter 1
Cardiotocography (CTG) Machine 1
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 X
Clinical Infant Bag-valve mask unit 1 x
Clinical Infant weighing scale 1 x From Delivery room
Emergency Cart (for contents, refer to x Improvised only
1
separate list).
EENT Diagnostic Set with x
1
ophthalmoscope and otoscope
Glucometer 1 X
NICU
Incubator 1  Non-functional need oxygen with
port
Infusion pump / Syringe pump 1 
Laryngoscope with neonatal blades of 
1
different sizes
Neonatal Stethoscope 1 X
Oxygen Unit 
Tank is anchored/chained/ strapped or 1
with tank holder if not pipeline
Pulse Oximeter 1 
Refrigerator for Breastmilk storage 1 X
Suction apparatus 1 X
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 ANNEX K - 2
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 set 
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
separate list). 1
EENT Diagnostic Set with
ophthalmoscope and otoscope 1
Infusion pump 1
Laryngoscope 1
Depending on
Mechanical Bed the number of ICU
beds declared
Mechanical Ventilator / Respirator (May
be outsourced) 1
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 x
1
ophthalmoscope and otoscope
Laryngoscope with different sizes of 
1
blades NURSING
Mechanical/Patient bed With locked, if UNIT/ WARD 
wheeled; with guard or side rails ABC
Bedside Table ABC x
Nebulizer 1  2 pcs
Neurologic Hammer 1 x
Oxygen Unit 
1
tank is anchored/chained if not pipeline
Sphygmomanometer, Non- Mercurial 
- Adult cuff 1
- Pediatric cuff 1

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 ANNEX K - 2
AO No. 2012-0012
EQUIPMENT/ INSTRUMENT
(Functional) QUANTITY COMPLIED
AREA REMARKS
(Use separate sheet if equipment is for
a specific “ADD ON” Service/s).
Stethoscope 1 
Suction Apparatus 1 
NURSING
Thermometer, non-mercurial 
UNIT/ WARD
- Oral 1
- Rectal 1
RESPIRATORY / PULMONARY UNIT
ABG Machine 1 Respiratory /
Spirometer 1 Pulmonary Unit
DENTAL CLINIC – not required if service is by Referral
Air compressor 1  Available/serviceable
Autoclave 1  Available/serviceable
Bone file, stainless 1  Available/serviceable
Cotton pliers 1  Available/serviceable
Cowhorn Forceps 1  Available/serviceable
Dental Chair unit 1  Available/serviceable
Explorer, double-end 1  Available/serviceable
Forceps, No. 8 1  Available/serviceable
Forceps, No. 17 Upper molar 1  Available/serviceable
Forceps, No. 18 Upper molar 1  Available/serviceable
Forceps, No. 150 Maxillary Universal 1  Available/serviceable
Forceps, No. 150 S Primary Teeth 1  Available/serviceable
Forceps, No. 151 Lower Universal 1  Available/serviceable
Forceps, No. 151 Mandibular Pre-molar 1  Available/serviceable
Forceps, No. 151 S Lower Primary DENTAL  Available/serviceable
1 CLINIC
Teeth
Gum separator 1  Available/serviceable
High speed handpiece with Burr  Available/serviceable
1
remover
Low speed handpiece, Angled head 1  Available/serviceable
Mouth mirror explorer 1  Available/serviceable
Periosteal elevator No. 9, double-end 1  Available/serviceable
Rongeur 1  Available/serviceable
Root elevator 1  Available/serviceable
Scaler Jacquettes Set No. 1, 2, and 3 1  Available/serviceable
Surgical Chisel 1 x Not available
Surgical Malette 1  Available/serviceable
Ultrasound Therapy machine 1 x Not available

CENTRAL STERILIZING & SUPPLY ROOM

Autoclave/Steam Sterilizer 1 CSSR  Steam Sterilizer only-
Available/serviceable
CADAVER HOLDING AREA/ROOM
CADAVER
Bed or stretcher for cadaver 1 HOLDING
AREA

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 ANNEX K - 2
AO No. 2012-0012
EMERGENCY CART CONTENTS

EQUIPMENT/ INSTRUMENT QUANTITY COMPLIED REMARKS

MEDICINES
Β-adrenergic agonists (i.e. Salbutamol 2mg/ml) 20
5 Caloric agent (D50W 50mg/vial) 10
Activated charcoal sachet 20
Amiodarone 150mg/ampule 10
Anti-rabies vaccine (active) 5
Anti-rabies vaccine (passive) 5
Anti-tetanus serum (either equine-based antiserum or
40
human antiserum)
Anti-venims* (for centers with high incidence of
poisonous animal bites)
Aspirin USP grade (325 mg/tablet) 20
Atropine 1mg/ml ampule 15
Benzodiazipine (Diazepam 10mg/2ml ampule and/or
10
Midazolam)
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 10
Epinephrine 1mg/ml ampule 30
Furosemide 20mg/2ml ampule 20
Haloperidol 50mg/ampule 10
Hydrocortisone 250mg/vial 10
Hyoscine N-butyl-bromide 20mg/vial 5
Lidocaine 5% solution vial 1g/50ml 20
Magnesium sulfate 1g/ampule 10
Mannitol 20% solution 500ml/vial 10
Mefenamic Acid 500mg/tablet 10
Methylprednisolone 4mg/tablet 10
Metoclopramide 10mg/ampule 5
Morphine sulfate 10mg/ampule 10
Nitroglycerin spray or Isosorbide dinitrate 5mg
10
tablet/ampule
Noradrenaline 2mg/ampule 5
Oral Rehydration Solution salt preparation sachet 10
Paracetamol 300mg/ampule (IV preparation) 15
Phenobarbital 30mg/ml IV or 30mg tablet 15
Phenytoin 300mg/capsule or IV preparation 15
Plain LRS 1L/bottle 10
Plain NSS 1L/bottle 10
Potassium Chloride 40mEq/vial 15
Pyridoxine 1g/ampule 10
Sodium bicarbonate 50mEq/ampule 10
Succinylcholine 200mg/vial 5
Tetanus Toxoid 0.5ml/vial 20

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EQUIPMENT/ INSTRUMENT QUANTITY COMPLIED REMARKS
Thiamine (usually in parenteral Vitamin B complex
10
preparation)
Tramadol 50mg/capsule 10
Verapamil 5mg/2ml ampule 10
BASIC ER SUPPLIES
Airway adjuncts (oropharyngeal and nasopharyngeal
airways)
Airway / Intubation Kit
Alcohol disinfectant
Arm sling (or sling and swathe bandages)
Aseptic bulb syringe
Biomedical refrigerator (for storage of biological and
other heat-sensitive drugs)
Calculator
Cardiac Board
Cardiac / EKG Leads
Cervical collars (different sizes)
Different sets of Bins (including puncture-proof sharp
containers)
Elastic Bandages (different sizes)
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
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

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 ANNEX K - 2
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: _____

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 ANNEX K - 2
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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: _____ _

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 ANNEX K - 2
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EQUIPTMENT/INSTRUMENTS REQUESTED PER DEPARTMENT

DEPARTMENT ITEM QUANTITY REMARKS

NAME/DESCRIPTION/RECOMMENDATIONS
LABOR ROOM 1. Pulse Oximeter 2
2. BP Apparatus 1
3. Doppler 2
4. Dressing table for Baby 1
5. Glucometer with strips 1
6. Droplight 2
7. Delivery table 1
DELIVERY ROOM 1. Pulse Oximeter 1
2. Droplight 2
3. FHT Monitor with BP Monitor 2
4. DR light 1 Not yet installed
5. Doppler 1
6. BP Apparatus 1
7. Defibrillator with paddler 1
8. Kelly pad 2
9. Delivery table 2
10. Infusion pump 1
11. Wheeled Stretcher 2
12. Suction Machine 1
13. Glucometer 1
14. Infant weighing scale 1

OPERATING ROOM 1. Infant weighing scale 1

2. Droplight 2
3. Defibrillator with paddlers 1
4. Orthopedic instruments set 1
5. Thermometer non-mecurial oral & rectal 2
6. Glucometer with strips
7. EX-LAP Instruments set 2
8. Nebulizer machine 1

NICU 1. Clinical Infant weighing scale 1

2. Defibrillator with paddles 1
3. Neonatal stethoscope 2
4. Refrigerator for breastmilk storage 1

GENERAL WARD 1. Nebulizer Machine 10

2. Droplight 2
3. O2 gauze 10
4. Infusion pump 2
5. Weighing scale (pedia) 1
6. Weighing scale for diaper 1
7. Glucometer 2
8. ECG Machine 2
RADIOLOGY 1. Portable X-ray 1
2. Radiologist Area, separate room for our
Radiologist (includes reading station) both x-
ray and CT-scan.
3. Ultrasound intended room.
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 ANNEX K - 2
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4. Films storage room .
5. Request for Radtechs specific training
a.1 –CT Scan training (atleast 3 techs)
b. Request for ultrasound training (basic
ultrasound & 2D echo)
6. Additional Manpower atleast 4 techs

OPD 1.Pulse oximeter (pedia) 1

2.BP Apparatus (pedia) 1
3.3.)ECG Machine 1
4.BP Cuff (newborn) 1
5.Pen light 1
6.Mayo table stainless for dressing 1
7.Toilet for patient separate male and 1
female
8. Handwashing area 1
Dental 1. Exhaust fan (ceiling) 1

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