NUMBER /

POSITION QUALIFICATION EVIDENCE COMPLIED REMARKS

RATIO
Surgeon, (notarized)
Anesthesiologist
OR an Intensivist
Neonatal Intensive  Licensed physician A team
DOCUMENT REVIEW
Care Unit:  Fellow/Diplomate composed of at
least 1 per
Multidisciplinary  Certificate from
specialty
team composed of, Specialty society, if
(May be part
but not limited to, applicable (for Board
Certified) time or visiting
pediatric
 Residency Training consultant) OR
cardiologist,
Certificate (for Board a neonatologist
pediatric
Eligible)
nephrologist,
 Certificate of
pediatric Residency Training /
pulmonologist OR Medical Specialists
a neonatologist (*DOH Medical
High Risk  Licensed physician Specialist, last exam General
Pregnancy Unit:  Fellow/Diplomate was in 1989) Obstetricians,
General  Updated PRC license Perinatologist,
 Certificates of and IM
Obstetricians,
Trainings attended specialists
preferably with a  Proof of Employment/ (May be part
Perinatologist, and Appointment time or visiting
a referral team of (notarized) consultant)
IM specialists
Resident Physician Licensed physician DOCUMENT REVIEW Wards - 1:20
on Duty (Shall not  Updated PRC license beds at any
go on duty for  Certificates of given time
Trainings attended PLUS
more than 48 hours
 Proof of Employment/ ER – at least 1
straight).
Appointment at any given
(notarized) time
 Schedule of duty *This ratio does
approved by Medical not include
Director/Chief of Resident
Hospital Physicians on
Duty that shall
be required for
add-on services
such as dialysis
facility. It shall
be counted
separately.
Rehabilitation  Licensed physician DOCUMENT REVIEW 1
Medicine Specialist  Fellow/Diplomate  Certificate from
Specialty society, if
applicable (for Board
Certified)
 Residency Training
Certificate (for Board
Eligible)
 Updated PRC license
 Certificates of
Trainings attended

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 NUMBER /
POSITION QUALIFICATION EVIDENCE COMPLIED REMARKS
RATIO
Nursing Attendant  Highschool DOCUMENTS REVIEW 1:24 beds at
graduate  Certificates of Trainings any time (1
 With relevant attended reliever for
health-related  Proof of Employment every 3
training ( notarized ) NA/MWs)
Nursing Attendant (may be in house
in CCUs training) 1:12 beds at
any time (plus
1 reliever for
every 3 NAs)

Operating Room Training OR Nursing DOCUMENT REVIEW 1 SN and 1 CN

Nurse per functioning
 Diploma OR per shift
-Scrub Nurse (SN)  Updated PRC license (plus 1 reliever
-Circulating Nurse  Certificate of trainings for every 3
(CN) attended nurses)
Delivery Room  Training in  Proof of employment 1 per 3
Nurse Maternal and Child (notarized) delivery table
Nursing (may be in  If nursing staffing is per shift
house training or outsourced: Validity of (plus 1 reliever
training in Essential the contract of for every 3
Integrated Newborn employment should be nurses)
Care [EINC]) at least one (1) year and
 Training in BLS and within the validity
ACLS period of the hospital’s
LTO.
Emergency Room  Licensed nurse  Schedule of duty 1:3 beds per
Nurse  Training in Trauma approved by Chief shift
Nursing, ACLS and Nurse (plus 1 reliever
other relevant for every 3
training nurses)
Outpatient  Licensed nurse 1
Department Nurse  Training in BLS Office hours
only
(8am – 5pm)
Dentist – MOA or Licensed dentist DOCUMENT REVIEW 1
outsourced but  Diploma Office hours
should be within  Updated PRC license only
the vicinity of  Certificates of (8am – 5pm)
hospital Trainings attended
Physical Therapist
Licensed physical  Proof of Employment/ 1
therapist Appointment
Licensed respiratory
(notarized)
therapist or licensed
 If outsourced: Validity
nurse with respiratory of the contract of
Respiratory therapy training employment should be 1 per shift
Therapist at least one (1) year
and within the validity
period of the
hospital’s LTO.

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 ATTACHMENT 3.B - PHYSICAL PLANT

DOCUMENTS COMPLIED REMARKS

1. DOH -Approved PTC

2. DOH Approved Floor Plan

3. Checklist for Review of Floor Plans (accomplished)

OBSERVATIONS/FINDINGS (may use separate additional sheets if needed):

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 Nursing units located on the
same floor may share the
defibrillator and the E-card,
Defibrillator with paddles 1
provided that they are not
more than 50 meters away
from each other.
Emergency cart or equivalent (refer to
1
separate list for the contents)
EENT Diagnostic Set with
1
ophthalmoscope and otoscope
NURSING
Laryngoscope with different sizes of
1 UNIT/ WARD
blades
Mechanical/Patient bed With locked, if
ABC
wheeled; with guard or side rails
Bedside Table ABC
Nebulizer 1
Neurologic Hammer 1
Oxygen Unit
1
tank is anchored/chained if not pipeline
Sphygmomanometer, Non- Mercurial
- Adult cuff 1
- Pediatric cuff 1
Stethoscope 1
Suction Apparatus 1
Thermometer, non-mercurial
- Oral 1
- Rectal 1
DIALYSIS CLINIC
(Specify if Hemodialysis or Peritoneal Dialysis or both)
Refer to Assessment Tool for Dialysis Clinics
AMBULATORY SURGICAL CLINIC
Refer to Assessment Tool for ASC
RESPIRATORY / PULMONARY UNIT
ABG Machine 1
Pulmonary Function Test (PFT) or Peak
Expiratory Flow Rate (PEFR) Tube Respiratory /
Pulmonary Unit
Spirometer 1
Nebulizer 1
PHYSICAL MEDICINE AND REHABILITATION UNIT
Bicycle ergonometer 1
Cervical Traction 1
Cold Therapy Products 1
Diagonal mirrors 1
Dynamometer 1
Exercise Plight / Bed 1
Exercise Stairs with Rails 1
Goniometer 1 PMRU
Hot Therapy Products 1
Light Therapy 1
Lumbar Traction 1
Overhead pulley 1
Paraffin Wax 1
Parallel Bars 1
Pedometer 1

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Pulley System 1
Therapy machine 1
Therapy mats 1
Therapy rolls 1
Therapy wedges 1
Transcutaneous Electric Nerve
1
Stimulator (TENS)
DENTAL CLINIC – not required if service is by Referral
Air compressor 1
Autoclave 1
Bone file, stainless 1
Cotton pliers 1
Cowhorn Forceps 1
Dental Chair unit 1
Explorer, double-end 1
Forceps, No. 8 1
Forceps, No. 17 Upper molar 1
Forceps, No. 18 Upper molar 1 DENTAL
Forceps, No. 150 Maxillary Universal 1 CLINIC
Forceps, No. 150 S Primary Teeth 1
Forceps, No. 151 Lower Universal 1
Forceps, No. 151 Mandibular Pre-molar 1
Forceps, No. 151 S Lower Primary
1
Teeth
Gum separator 1
High speed handpiece with Burr
1
remover
Low speed handpiece, Angled head 1
Mouth mirror explorer 1
Periosteal elevator No. 9, double-end 1
Rongeur 1
DENTAL
Root elevator 1
CLINIC
Scaler Jacquettes Set No. 1, 2, and 3 1
Surgical Chisel 1
Surgical Malette 1
CENTRAL STERILIZING & SUPPLY ROOM
Autoclave/Steam Sterilizer 1 CSSR
MORGUE
Autopsy table 1
Autopsy instrument set 1
MORGUE
Cadaver freezer 1
Cadaver Shower 1

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