3 Repabllc of the Philippincs

PHILIPPINE HEALTH INSURANCE CORPORATION

PhilHcalth Rcgional Office vtll
I 6? P. BurScr St., TaclobaD City

Heahhlincs: (053) 325-35631523-1 195

www.philhcahh.gov.ph

Accteditation Self-assessment Tool for the Expanded Primary Cate Benefit (ePCB)
Health Care Institution (HCI)

Name of Health Care Instinrtion:

Ad&ess:
Date of Assessment:

Directions for the HCI:

1. Indicate the type of providet being evaluated by placiog a tick mark on the selection.
2. For each of the items in the categories of indicators, indicete capabiJity by writing YES or
NO in the apptopriate column of the facility being evaluated.
3. Fot outsoutced services, state in the REMARrS column that the sergice is outsowced and
write the name of the sewice provider

PROVIDERS
lFl'Accredited L1,
E1z, a 6flrledical Outparienr
L3 hospital 8Hc (e.g. HMO)
F,=l.Accredited
u-J
INDICATORS '-1nGrmary REN{.{RKS
Accreditcd
imbulatory
sutgical clinic
1. valid DOI-I LTO
1 With a currcnt DOH
Labomtory liccnse.

evailebility of the following

tcsts:
n cBc
! Lipid pro6lc
I] FBS
l-: Utiualysis
tr Fecdysis
l- Sputwn oictoscopy
r.] ECG
! Paps smcer
fl Orel Glucor Toletance
Test
1.3 Cureot DOH Radiology
license
ava:labili ofChest x-ray
Liceased pharmecY (valid FDA
license selvlce
The ePCB HCI has a cutrent DO NOT FILL
s Permit.

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 3 R.publlc of ,hc Phtltppines
PHILIPPINE HEALTH INSURANCE CORPORATION
PhilHealth Regional OIfice Vlll
167 P. Burgos St., Tacloban City
Healthlines: (053) 325-3 563/523. I 195
t )utw. ph ilheo I th. go e. ph
P
PROVIDERS
.-. Accredited Ll,
lll l=|Medicd Outpatient
L2, & Ll hospir.l EHic (c.g. HNlo)
[=l
l.J..
Accredited
INDICATORS uIhrmary RF-]\{ARKS
l:tv\ccredited
l,i-J
-ambul2tory
surgical clhic
Policy indicetiog it provides
the following services:
a. Hca.lth screening and
assessment, consultatioo a,ld
ueatraeot of uacooplicrted
upper respLatory iofections,
low-risk pneumonia, ecutc
gastroenteritis, udnary tract
infectioo, asthtna.
Cervical cancer essessment
usiog visual acetic acid end/or
Paps smcar
b. Brcest exminatioo
c. Digital rectal exem (fot
oales)
d. Diabetcs screeriag
Policy on providiag serices
duing weekends aod during
the cxteoded houts of the
clinic until 9:00 pm on
weekdays to accommodate
patient needs.
Poliqv and procedures for
referral of patients to higher
level of care, wheo needed
Has edequate and apptopiate
informatioo oaterids (e.g.
fl yers, brochutes, postcts,
audio visud presentation) on
health end wellness such as
anti- smoking, and proootion
of proper diet, exercise, and
immunizatioa.
Well-phced signages to ensure
ease ofaccess of clients to the
coasultation atea and ancillary
serviccs
Has a clean, adequate, and safe
area for consultaoons and
examinations that ensures
and confideo
Adiquate lighting/ electtic

Adequate clean water suPPlY

Well veotilated waiting area
with adequate seais f"f,Pl tt9!1,

Page 2 of5

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 3 Repu bllc
PHILIPPINE HEALTH INSURANCE CORPORATION
o! I he Philippine$

PhilHealth Regional Orfice VIII

167 P. Burgos St., Tacloban Ciry
Healthlines: (053) 325-3563/52 3- l 195
v,\!w. ph i lhea I th. goL ph

PRO\TIDERS
171.,{ccredited Ll, 0utpatient
P L2, & L3 hospirrl (e.g. I{NIO)
Accredired
INDICATORS in6rmarv REIL{RKS

em bulatory
sugical clinic
Besic equipraent aad supplies
for required services, induding:
' Non-meicuial BP apparatus
- Non'metcuddthelrnometer
Stethoscope
- Weighing scde (adult)
W.eighiog scale (infanO L Tape

L Nebulizer
Li Lubricatiog jelly
Ll Disposlble needles aod
syinges
l.l balls/ swabs
Sted]e cotton
E Applicrtot sticL J
Disposable gloves !
Specimen
cups/ botdes !
Sterilizer or its
equiveleot (auto clave)
.-
vrgnd speculuo OA)
Vrgrnd specu.lum (small) li
Decontarninetioo solutions
! 70% Isopropyl alcohol L.
3olo to 57o ecctic acid
. -
Glass slides
- Storage cabinet for sterile
instruments and su
A designeted, secure ,nd
appropriate dnrg storage area
for mcdicines.
Has a clern end irnctional Do oot 6ll
toilet with adequate supply of
watct, and wash area.

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 Repabhc ofh. Ph tppla6
PHILIPPINE HEALTH INSURANCE CORPORATION +:
PhilHealfi Regional Omce vltl
167 P. Burgos St., Tscloban City
Healthlines: (053) 32J-35631523-l 195
wutw. philheol h. goy.ph

PROVIDERS
fil g\ccrcdited Ll, fiflvledical Ougatient
El-2, & l-3 hospird iffic (e.g. HMO)
[Ft !,\ccredited
INDICATORS '-inErmary REIL\RKS
l=l Accredited
LJ,
'_ arnbulatorv
suqical c c
There is adcquate infectioa Do not frll
control and dsk oaoagernent,
including: !
Availability of a
sirrk, with adequatc q/ater ald
soap for handweshiag
1l Use of puncture proof
recepteclcs for disposed sharps
and ocedles
- Use ofgloves, onsks
I Staff observcs haadwzshing
techniques [1 Propcdy
segtegated and matked waste
bins
Has a designrtcd area for
sputum collection.
System tequtemcn:s fot
Electonic mcdical record
(EMR):
a. Software Apache, lvlySQL,
PHP
b. OS supportcd: lJVin7 x64,
!0inXP, Witvista, WinT x32,
WinS x32, WinS x64, Wtn10
x32, Wint0 x64, Vindours 8,
Windows 10
c. Memory: minirnum 64MB
RAM
d. Storage Capacity: Minimum
5OOGB
A PhilHealth accredired
physician is on site for the
duretion of clinic houts.
A duly liceoscd nuse is oa site
for the duration of clinic
hours.
A microscopist t!.ined in
Direct Sputum Smear
Microscopy (DSStr{)
/Ceni6crte of Treining is on
srte on schedules.

Pege 4 of 5

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 3 Repabllc o! rhe Philippines
PHILIPPINE HEALTH INSURANCE CORPORATION
I

PhilHealth Regional OIhce VIll

I67 P. Burgos St., Tacloban City
Healthlines: (053) 325-3563/523-1 195
we*.philheaih.gov.ph

PRO\{DERS
Ll, [:]Medicrl Outpatient
, & L3 hospital c*Hic (e.g. HNIO)
ccredited
INDICATORS irr6t-"ty RE]\L{RKS
ffiAccedited
'_
ambulatory
surgical clinic
Record of dtugs inventory: (e.g,
amoxicillin, co-amoxiclav,
cotimoxezole, erythromycin,
ofl oxacio, amlodipine, enalapril,
metoprolol,
hydrochlorothiazide*losatan,
simvastatin, metformin, gliclazide,
salbutamol inhaler, salbutamol oral,
fl uticasone- salmeterol iohaler,
prednisone, patacetemol, ORS)
Record of laboratory supplies
inventory
Record of tadiology supplies
rnvenroly
Record of submission of Noti6ablc
diseases (per DOH AO No. 2008-
0009 ' Adopting the 2008 Revised
List of Notifiable Diseases,
Syndromes, Health-Related Events
and Conditions')

Prepared by:

pesignation)

Attested corect by:

Head of Facility/ Medical Director/ Chief of Hospital
(Signature over name and &te signed)

Page 5 of 5

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