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I A MANUAL
I OF OPERATIONS
I FOR SMALL
I HOSPITALS
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I HU0 8.47
M31h
1992
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I Prepared by the
Committee to Develop a Manual of Operations for Small Hospitals

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1 TABLE OF CONTENTS

1 Page No.

1 FOREWORD

ACKNOWLEDGEMENTS
1 INTRODUCTION 1

1 Definition of Terms 1

Classification 2
1 Category 4

1 Minimum Standards for Primary Category 4

1 Basic Hospital Services 5

LICENSING REQUIREMENTS

1 PART 1- HOSPITAL CONSTRUCTION 6

Permit to Construct 6
1 Physical Plant Facilities 7

1 Basic Service Facilities 10

Patient Care Facilities 10

I Registration and Issuance of License to Operate 15

I LICENSING REQUIREMENTS
PART II - HOSPITAL OPERATIONS 17

I Administrative Service 17

Clinical and Ancillary Services 24

I Departmenl or Health

!1~l lIlIl l il!~ 1111

Nursing Service 44
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H1~8.47M31h 1992/ A
D042
manual of optmltlons for amaD hospitals

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I APPENDICES

I Office Order Creating the Committee to Develop a Manual of

Operations for Small Hospitals

I Procedures 1 to 7

I BLR Form 1: Application for Permit to Construct a Hospital

Letter to Hospital Owner Informing Approval of Permit to

I Construct, Expand, or Renovate

BLR Form 4: Application for Registration and Issuance of

I Renewal of License to Operate a Hospital

BLR Form 4-A: Statistical Report

I BLR Form 4-B: List of Technical Equipment and Instruments

I License

Medical Records Disposition Schedule

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Republic of the Philippines SAN LAZAROOOMPOUND

I Deportment of Health
OFFICE OF THE SECRETARY
RIZALAVENUE, STA.CRUZ
MANILA, PHIUPPINES
TELNO. 711-60-80

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I FOREWORD

I A critical facet in the nation's healthcare scheme is the system of

small hospitals scattered throughout the Philippines. These tacilities fill

I a vital niche for specialized health services needed by small communities

in both urban and rural settings. Even as the government's thrusts on
Primary Health Care will greatly contribute to the prevention of disease,
I it is necessary to have in place well-equipped, scphisticated health
facilities constantly prepared to respond to any contingency that may
arise.
I In this regard, the Department of Health is mandated to support
these initiatives through establishing the appropriate conditions for small
I hospitals to effectively function and serve their respective communities.
This Manual of Operation for Small Hospitals will assist owners.
I administrators, or operators of these establishments in their daily
management and in maintaining the high standards set by government and
demanded by the populace. At the same time, this manual will assist
I operators in meeting the requirements on registration and licensure set by
tile government for these hospitals.

I It is my hope that hospital managers and health workers make good

use of this carefully-crafted document designed to upgrade the quality of
I hospital care for the millions of Filipinos who encounter the need for
treatment at these vital health facilities.

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Republic of the Philippines SANLAZARO COMPOUND

I Department of Health
OFFICE OF THE SECRETARY
RIZAL AVENUE, STA. CRUZ
MANILA, PHILIPPINES
TEl. NO. 711-60·80

I FOREWORD

I
I The Bureau of Licensing and Regulation of the Department of Health has
developed this Manual of Operations for Small Hospitals to serve as a guide to
hospital administrators of small hospitals especially those in rural areas. This
I manual was developed during the period 1990-91 under the leadership and
direction of the former Undersecretary of Health for Standards and Regulation,
Dr. Tomas P. Maramba Jr. The information which follows is the work of a multi-
I sectoral committee which received input and advice from a variety of sources
including the Philippine Hospital Association, the Philippine College of Hospital
Administrators, and the Private Hospital Association of the Philippines.
I This manual is a revision and update of the Manual of Information on Philip-

I pine Hospital Licensure, A Standard Guide for Philippine Hospital Services,

originally issued by the Bureau of Medical Services in December 1965. The
contents of this manual refer to existing standards of the Department of Health

I at the time of formulation and do not include any new standards after that date.
Consequently, some of the items are for information only and the user will want
to check with the Department for any recent changes or additions. The
I process of devolution will also bring about even more changes in the future
which will dictate new regulations and the development of new standards.
However, we believe that the operating hospital administrator will find the infor-
I mation contained in this manual of value and we have pushed for the publica-
tion of this manual at this time.

I The pollcles. procedures, and guidelines outlined in this manual will assist the
practicing hospital administrator in the day-to-day decision-making process
necessary to operate an effective and efficient hospital. We urge the small-
I hospital administrator to consult this manual as often as needed in order to
answer the many administrative questions which arise in the daily operation of
delivering quality patient care to a diverse opulation in need of hospital ser-
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vices.

JUA
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~AGASI M.D.
Under ecretary of Health for

I Hospital and Facilities Services

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I ACKNOWLEDGMENTS

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I This Manual of Operations for Small Hospitals was developed with the help,
coordination, and administrative support of various health agencies, associa-
tions, and individuals to cope with the changing community needs.
I The Committee wishes to express sincerest thanks to Dr. Alfredo R. A.
Bengzon, former Secretary of Health, and to Dr. Tomas P. Maramba, Jr.,
I former Undersecretary of Health for Standards and Regulation, for their en-
couragement and wholehearted support in the preparation and finalization of
this manual during their term in office.
I Several people were generous with their time and expertise; they deserve
much credit for their wisdom and sound advice but are not to be held account-
I able for the end product: Dr. Thelma N. Clemente, President, Philippine Hospi-
tal Association; Dr. Yolanda M. Mison, Executive Director, Philippine Hospital
Association; Marco Antonio C. Sto Tomas and Grace M. Valderama of the
I Philippine Nurses Association; Ador A. Abueg and Ma. Theresa H. Gutierrez of
the Bureau of Food and Drugs; Agnette P. Peralta of the Radiation Health Ser-
vice; Dr. Teresita R. Sanchez of the Philippine Academy of Family Physicians;
I Dr. Ruben N. Caragay of the U.P. College of Public Health; Luis M. Ferrer of
the Hospital Infrastructure Services; Teresita G. Yambao of the DOH National
League of Nurses; Dr. Amelia Fernandez of the Philippine Pediatric Society; Sr.
I Paz T. Marfori, D.C. of San Juan de Dios Hospital; Dr. Marietta Baccay of the
Bureau of Research and Laboratories; Velonia A. Corpus of the Nutrionist-As-

I sociatlon of the Philippines; Dr. Narciso Navarro of the Private Hospital Associa-
tion of the Philippines; Dr. Siopin Co of the Philippine Society of Hospital Phar-
macists; and Dr. Delfin Tan of the Philippine College of Hospital Administrators.
I The Committee is likewise indebted to Dr. Primo V. Brillantes, Jr., Chief of
Hospital III, Jose R. Reyes Memorial Medical Center, for the use of their
I facilities and resources.

Special thanks also go to the technical staff of the Hospital Operations and
I Management Services for their valuable contributions in the making of the
Manual.

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I Lastly, to the Bureau of Licensing and Regulation staff who acted patiently as
secretariat - typing the manuscript in its various phases of revision - our
I deepest thanks.

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DR. ZENAIDA R. DE LA FUENTE

I Chairman
Committee to Develop a Manual of
Operations for Small Hospitals

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I INTRODUCTION

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I The Bureau of Licensing and Regulation (BLR) was created by Ex-
ecutive Order No. 119, which reorganized the Department of
I Health to improve the licensing and regulation of health care
facilities and make the delivery of public service more efficient and
effective. The Bureau is mandated to:
I • Formulate policies and establish standards for the licens-
ing and regulation of hospitals, clinics, and other health
I facilities
• Establish standards for health field offices

I • Provide consultative, training and advisory regulatory

functions over hospitals, clinics, and other health facilities.

I Small hospitals evolved in considerable number especially in far-

flung areas when in the mid 70's the Philippine Medical Care Corn-
mission started the implementation of the Medicare Program.

I Most of the small hospitals are run by physicians, nurses, phar-

macists, or businessmen, many or most of whom have not taken

I hospital administration. This often leads to problems in regula-

tions.

I This Manual of Operations for Small Hospitals intends therefore

to provide guidelines not only to help minimize problems on
registration, licensure, and operations of primary hospitals but,
I more importantly, to educate the non-professional small hospital
manager.

I DEFINITION OF TERMS
• Hospital is defined by the Expert Committee on Organiza-
I tion of Medical Care of the World Health Organization
thus: "the hospital, the function of which is to provide
for the population complete health care, both curative
I and preventive and whose outpatient services reach out
to the family in its home environment; the hospital is also
a center for the training of health workers and for bioso-
I cial research."

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I For the purpose of this manual, however, the term hospi-
tal as defined by Republic Act No. 4226, otherwise
known as the Hospital Licensure Law of the Philippines,
I shall refer to a place devoted primarily to the main-
tenance and operation of facilities for the diagnosis, treat-
ment, and care of individuals suffering from illness, dis-
I ease, or deformity, or in need of obstetrical or other
medical and nursing care. The term hospital shall also
be construed as any institution, building, or place where
I there are beds or cribs or bassinets for 24-hour use or
longer by patients in the treatment of diseases, diseased

I condition, injuries, deformities, or abnormal physical and

mental states, maternity cases, and all institutions such
as those for convalescence, sanatorial or sanitariaI

I cases, infirmities, nurseries, dispensaries, and such other

names by which they may be designated.
• Small Hospital covers all primary category, general hospi-
I tals, usually with less than twenty beds and providing
basic services such as: Administrative Service, Clinical
Service, and Nursing Service.
I • Drug Room - a room for storing emergency drugs only,
which could be dispensed by a doctor.
I CLASSIFICATION

I Hospitals are classified in many ways, but the most commonly ac-
cepted classifications are:
• Clinical, that is, depending on the type of patients treated
I • According to ownership and control
• Whether training and nontraining
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Clinical
I • General Hospital - provides services for all kinds of ill-
nesses, diseases, injuries, and deformities.

I • Special Hospital - provides services for one particular

kind of illness/disease or health and medical care.

I Examples:

Medicine Internal Medicine

I Tuberculosis
Children (Pediatric)
Communicable Disease

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I Surgery Eye, Ear, Nose and Throat
Orthopedic, etc.

I Maternity

Chronic
I Convalescent

I Ownership and Control

• Government - operated and maintained either partially or
I wholly by the National, Provincial, Municipal, or City
Government or other political subdivision, board, or other
agency thereof.
I Examples:

National Office of the President

I Department of Health
Department of National Defense
(Armed Forces)
I Government Corporation

Regional
I Provincial

I City
Municipal

I • Private or Nongovernmental - privately owned, estab-

lished, and operated with funds raised, capital, or other
means by private individuals, associations, corporations,
I religious organizations, firms, companies, or joint stock
associations.

I Examples:
Missionary

I Civic Organizations
Community
I Private - nonprofit

Private - for profit

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I Training/Nontraining
I • Training - a departmentalized hospital with accredited
residency training program in one or more specified
specialty or discipline.
I • Nontraining - a nondepartmentalized hospital without ac-
credited residency training program.
I CATEGORY

I Hospitals have been categorized into primary, secondary, and ter-

tiary levels of health care according to service capabilities that
they offer.
I • Primary - equipped with the service capabilities needed
to support licensed physicians rendering services in

I Medicine, Pediatrics, Obstetrics, and Minor Surgery.

• Secondary - equipped with the service capabilities
needed to support licensed physicians rendering ser-
I vices in the fields of Medicine, Pediatrics, Obstetrics, and
Gynecology, General Surgery, and Ancillary Services.

I • Tertiary - a fully departmentalized hospital equipped with

the service capabilities needed to support certified medi-
cal specialists and other licensed physicians rendering
I services in the fields of Medicine, Pediatrics, Obstetrics
and Gynecology, Surgery, their subspecialties, and Ancil-
lary Services.
I MINIMUM STANDARDS FOR PRIMARY CATEGORY

I • Administrative Service
• Clinical Services

I - General Medicine

- General Pediatrics
I - Obstetrics

I - Minor Surgery
• Nursing Service
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I BASIC HOSPITAL SERVICES

I .Administrative Service - This shall attend to the admis-

sion, disposition, and discharge of patients, including
financial transactions and other administrative aspects of
I hospital operations such as the provision of food and
preservation of medical and administrative records.

I • Clinical and Ancillary Services - The physicians shall

render services in General Medicine, Pediatrics,
Obstetrics, and Minor Surgery. Routine laboratory ser-
I vices shall be available either within the hospital
premises or by affiliation.

I • Nursing Service - This service shall be headed by a

registered nurse and shall provide professional nursing
care at all times.

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I LICENSING REQUIREMENTS
Part I - HOSPITAL CONSTRUCTION
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I As provided under the Hospital Licensure Act (R.A. 4226) and its
implementing Rules and Regulations (Administrative Order No. 68-
A series of 1989), no hospital, whether government or private,
I shall be constructed or renovated unless plans have been ap-
proved and a construction permit has been issued by the Bureau
of Licensing and Regulation, Department of Health. A permit to
I construct is a requirement for an initial license to operate.

The following are the requirements to be fulfilled before a permit

I to construct may be issued:
• A letter of application from the owner addressed to the
Director, Bureau of Licensing and Regulation through the
I Regional Health Director
• Feasibility study
I • Floor plans of the physical plant of the proposed hospi-
tal, three copies in blueprint

I • An endorsement letter from the Regional Health Director

to the Director, Bureau of Licensing and Regulation.

I The application shall be filed at the proper Regional Health Office

which shall endorse it to the Bureau of Licensing and Regulation.
It is important that all the above requirements are complied with.

I Otherwise, the application shall be returned without action to the

owner through the Regional Health Office.

I PERMIT TO CONSTRUCT
Any person, association, partnership, corporation, or government
I entity desiring to construct, remodel, or repair a hospital building
shall file with the Bureau of Licensing and Regulation an applica-
tion for a construction permit using the prescribed form (BLR
I Form I) which shall be accompanied by three copies of the floor
plans of the hospital plant proposed to be constructed,
remodeled, or repaired.
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I The construction permit shall be issued by the Bureau of Licens-
ing and Regulation upon approval of the floor plans and payment

I of the permit fee. Other building permits as required from other

government agencies shall be obtained.

I Construction shall start within the time specified in the construc-

tion permit and shall follow the approved floor plan and specifica-
tions. A new construction permit is required if the original permit

I was revoked due to violation of its terms and conditions or the

same expired before the construction could be started.

I PHYSICAL PLANT FACILITIES

• Physical Plant - Any structure put to use to house or

I provide direct services to patients shall conform with the

requirements prescribed by the Bureau of Licensing and
Regulation and those of local building codes applicable
I thereto.
• Mechanical and Structural Requirements - New or
remodeled hospital facilities shall not be licensed by the
I Bureau of Licensing and Regulation unless the following
requirements have been complied with :

I - Plans and Specifications - Construction of the new

building or floor remodeling shall not be undertaken
unless plans have been previously approved by the
I Bureau of Licensing and Regulation. The floor plans
for any new hospital construction or any proposed
annex of an existing hospital and for remodeling pur-
I poses which involve physical changes shall be sub-
mitted for approval. Said approval shall be obtained
from the licensing agency before construction work is
I begun. Such floor plans shall be prepared by an ar-
chitect or a civil engineer who is licensed to practice
in the Philippines. Floor plans and specifications for
I any new hospital or for changes in an existing hospi-
tal shall show that all necessary considerations have
been given to ensure proper functional relationship of
I physical facilities.

- General Requirements - In order that a permit to

I construct a hospital may be issued, the hospital plan
shall provide sufficient space as provided for in the re-
quirements.
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I Walls, floor, and ceilings of the hospital shall be of
sturdy materials, which shall permit frequent wash-
ing, cleaning, and painting.
I The hospital shall be adequately ventilated at all
times. Kitchens, bathrooms, and service rooms
I shall be ventilated by properly constructed vents,
windows, or other mechanical means to prevent of-
fensive odors from entering rooms of patients and
I public corridors. Window screens shall be
provided for all other exterior openings whenever
necessary.
I - Ventilation - Provision shall be made for adequate
ventilation to ensure comfort and safety of patients
I and personnel in every hospital.

Kitchen and toilets, service and utility and storage

I rooms, and janitors' closets and the like shall be
properly ventilated in compliance with requirements.

I - Plumbing - All parts of the plumbing system shall

comply with the existing rules and regulations

I prescribed by the Office of the City or Provincial or

Municipal Building Official and other local plumbing
codes or ordinances.
I - Water Supply System - Each hospital shall use an
approved public water supply system whenever avail-
I able. The water service shall be adequate and water
supply shall be brought into the building free of cross
connections in accordance with the requirements
I prescribed by the Office of the City or Provincial or
Municipal Building Official. If a private (deep or shal-
low well) water supply is provided, the requirement
I prescribed by the Office of the City or Provincial Build-
ing Official likewise shall be complied with.

I - Sewage Disposal System - Hospital sewage shall be

discharged into an approved public sewerage system
where such system is available, otherwise, the
I sewage shall be collected, treated, and disposed of in
an independent system (septic tank type) which com-
plies with requirements prescribed by the Office of the
I City or Provincial or Municipal Building Official and
local ordinances and the Sanitation Code of the

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I Philippines. Separate toilet facilities shall be main-
tained for patients and personnel, male and female,
with a ratio of 8 to 10 patients/personnel for every
I water closet. This shall be conveniently located in the
area served.

I - Electrical Installations - The installation of the electri-

cal system and equipment shall comply with all local

I ordinances relative thereto and with the National

Electrical Code, as well as those herein provided:

I All equipment and installations shall be acceptable

as established by the Fire Department.

I Emergency lighting shall be provided for exits,

stairs, patient corridors, emergency rooms and
similar areas as necessary for safe and efficient

I patient care.. Emergency lighting shall be supplied

by an emergency generator or its equivalent.

I All rooms and areas in the hospital shall be

provided with sufficient illumination to enable per-
sonnel to properly carry out procedures per-
I formed therein.

- Solid Waste Management - All hospitals shall have a

I program of solid waste management covering sorting,
storage, pre-treatment, collection, and disposal sys-
tems.
I All hospital infectious solid waste shall be
pretreated in any approved method before
I storage, collection, and disposal.

Proper sorting of solid waste (sharps, syringes,

I linens, mattresses from isolation/infectious wards)
must be done, segregating it from the general
waste.
I Separate puncture-proof refuse containers proper-
ly labelled and with covers must be assigned to
I prevent any accident or contamination before dis-
posal.

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I Disposal shall be done either through burying, in-
cineration or through city or other collecting agen-
cy.
I BASIC SERVICE FACILITIES

I Hospital basic service facilities shall include the following:

I Administrative Service
• Lobby with information counter

I • Admitting Office
• Director's/Chief of Hospital's administrative office

I • Toilet facilities

Clinical and Ancillary Services

I • Emergency Room

I • Examination/treatment Room
• X-ray room (optional)

I • Laboratory (optional)
• Emergency drug cabinets

I • Toilet facilities

Nursing Service
I • Nurses' station with toilet facilities

:. • Male ward
• Female ward

I • Isolation ward

PATIENT CARE FACILITIES

I All patient care areas and units shall be segregated from those
used by the public.

I • Nursing Units - All nursing units shall have the following

facilities:

I - Nurses' Station Counter

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I - Medicine Area

Fixed and locked narcotic storage facilities

I Refrigerator for drugs

I - Utility Facilities

I Clean linen storage area

Soiled linen storage area

I Lavatory

I Sterilizing equipment

Treatment Area - Area for patient treatment is re-

I quired in all hospitals.

- Patient Rooms - The design' and equipment of patient

I rooms shall be similar for all types of patients.

The maximum number of patient rooms planned for a

I nursing unit shall depend on the type of patients to
be served and the plan of operation as well as other
matters.
I The minimum amount of usable floor space required
shall be as follows:
I For private rooms:

I 9 sq. m. per adult bed

7.5 sq. m. per crib or pediatric bassinet

I For rooms with two or more beds:

I 7.5 sq. m. per adult bed or pediatric crib

4 sq. m. per pediatric bassinet

I (Note: It is recommended that the area and design
of the room be such as to provide 0.91 m. of usable
I floor space.)

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I - Lavatories

Lavatories shall be in each patient's room or its adjoin-

I ing toilet room.

Any room used for isolation shall have a lavatory

I within the room.

A lavatory shall be provided in toilet rooms used

I by patients who give self care or which are used
for isolation.

I One lavatory shall be provided for every eight beds.

- Toilets - These shall be required for rooms which do

I not have adjoining ones. These shall be made avail-
able within 30.3 m. (100 feet) distance from the far-
thest patient room served by such toilets. ,
I - Patient Bathing Facilities - These shall be provided in

I each patient unit according to the type of patients

served and procedures planned.

I - Janitor's Closet - This shall be provided within the

nursing unit.

I - Storage Areas - The space 'required depends on the

plan of operation. All nursing units shall have space
to store a reserve supply of linen and other things.
Corridors and service work areas shall not be used
111 for storage.

- Personnel Toilets - These shall be in or near each

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nursing unit with adequate hand washing facilities.

I - Public Toilets - These are required for nursing units

adjacent to public areas and shall have adequate
space and handwashing facilities.
I - Floor Waiting Area - The desirability of this area is de-
pendent on the plan of operation and size of the
I hospital. In small hospitals this area may be com-
bined with the lobby.

I • Gowning Area - This is required in contagious nursing

units only.

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I «tsolstion Facilities - There shall be available isolation
facilities for patients who are known to have infectious,
communicable diseases, and for burn cases. The isola-
I tion facilities shall be provided with all utility and other
services required to carry out isolation techniques. Such
facilities shall be designated for isolation and shall be
I available for use whenever necessary.
• Emergency Care Facilities - Provisions shall be made for
I an emergency room which may be combined with out-
patient service.

I - The emergency room shall be so equipped as to

provide whatever lifesaving measures may be needed
for the patients.

I - It shall have an emergency drug cabinet.

I - It shall have a toilet with lavatory within or in close

proximity to it.
• Dietetic Service Facility - For primary hospitals this ser-
I vice is not a requirement. A kitchen will suffice wherein
food for inpatients are prepared/dished out. However if
. the hospital opts to have one, the following shall be
I provided:
Areas Equipment/Supplies
I Receiving area Weighing scale, table model (10
kg.)
I Food preparation area Utility table/work table
Hand sink
I Chopping board
Garbage receptacle with cover

I Storage area Refrigerator, upright, reach-in

Bins (for rice)

I Cooking area Kawa (30"-diameter),

finish
cast-iron

10-gallon stock pot (2)

I Top burners (2)
Work tables

I Sink, 2 compartments

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I Chopping boards
Hood with filter and suction fan
Exhaust fan
I Dishwashing area Soiled dish table
Clean dish table
I Utility rack (for tray storage)
Garbage can with cover

I Pots and pans Sink, 24" deep ( at least two

compartments)
Shelves/racks (for pots and
I pans drying and storage)
Refuse receptacle with cover

I Serving area Tray assembly area

Food carts (screened, if not
metal made or finish)
I Utility carts
Hand sink

I Provisions shall be made for:

- Adequate ventilation
I - Screened windows and doors

I - Adequate drainage system

• Facilities for Ancillary Diagnostic and Treatment Ser-
I vices - These are not included in the standards for
primary category hospitals. However, if the hospital opts
to have such services, they should be located con-
I venient to both inpatient and outpatient areas.
The following are required :
I _ General Service Areas - There may be provided a
waiting area or room for patients awaiting service.
I _ Laboratory Service - This shall be provided through
affiliation with a nearby licensed laboratory. However,
I if the hospital opts to provide such service within the
hospital premises, it has to obtain a license from the
Bureau of Research and Laboratories. A minimum of
I 18.5 - 20.9 sq. m. for exclusive washing and steriliz-
ing area should be provided.

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I - Radiological Service - This shall be provided
through affiliation with a licensed x-ray facility.
However, if the hospital opts to provide such service
I within its premises, it has to obtain a license from the
Bureau of Licensing and Regulation upon recommen-
dation by the Radiation Health Service.
I - Pharmacy Service - In the absence of a pharmacy
service, an emergency drug cabinet kit shall be
I provided. However if the hospital opts to provide
such service it has to obtain a license from the
Bureau of Food and Drugs and comply. with its re-
I quirements.

- Examination and Treatment Rooms - All hospitals

I shall at least have one all-purpose room for examina-
tions, treatment, etc.

I • General Service Facilities - Facilities for service units

may be provided and shall include the following:
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Employee F~i1ities. - These may include a rest
I room/lounge area with locker facilities and separate
toilets for female and male employees.

I - Laundry - Laundry facilities required in the hospital

will depend on whether hospital laundry is operated

I within the hospital premises or commercial services

are utilized.

I Housekeeping This should include

housekeeper's Office (may be part of another ser-
a

Vice), lavatory, storage room (for supplies and equip-

I ment), and other facilities that may be required for the
type of service rendered. The amount of space
provided for this service shall depend on the person-
I nel assigned and the volume of work.

- Maintenance - There should be a maintenance

I shop/area in each hospital.

REGISTRATION AND ISSUANCE OF LICENSE TO

I OPERATE
Section 4 of A.A. 4226 provides that no hospital shall operate or
I be opened to the pubtic unless it shall have been registered and

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I a license for its operation shall be obtained from the Bureau of
Licensing and Regulation, Department of Health.

I Initial License to Operate

In the issuance of the initial license to operate, there are proces-
I ses involved. First, after completion of the hospital bUilding, the
hospital owner shall accomplish and file BLR form NO.4 (applica-
tion for Registration and Issuance of License to operate a hospi-
I tal. Next, a written request for an ocular inspection of the finished
hospital shall be submitted to the Bureau of Licensing and Regula-
tion authorities with the prescribed requirements (please see
I annex procedure and checklist no. 2). The Regional Licensing Of-
ficer has to certify that the hospital is ready for inspection. Finally
the license shall be issued if the application has been found to be
I meritorious and the licensure fee duly paid.

I The license specifies its bed capacity as well as its classification

and kind of service/capabilities provided, and is not transferable.
Should there be a change in ownership, management, or name of

I the hospital, the licensing agency shall be notified.

The license to operate a hospital shall be placed in a con-

I spicuous place readily seen by the public.

Renewal of License to Operate

I The license to operate and maintain a hospital shall be renewed
annually and shall expire on the last day of December. A transfer
I of location shall require an application for a new license.
Separate licenses are required for hospitals operating in separate
premises (not in the same compound) even if they are under the
I same ownership or management.

To renew a license, the hospital owner accomplishes and files

I BLR form No.4 between January 2 and March 31 of each year.
For the requirements please see annex checklist 3. There is a
penalty for renewal of licenses filed after March 31.
I A provisional license shall be granted to hospitals for three to six
months pending full compliance with all the necessary require-
I ments and standards governing their operations.

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I LICENSING REQUIREMENTS
Part II - HOSPITAL OPERATIONS
I
I
ADMINISTRATIVE SERVICE
I The administration of the hospital is the responsibility of the
governing body, the Administrator, and Representatives of the
I medical staff.

I The Governance'
The governing body, owner, or board of trustees, is the top

I authority responsible for the management and control of the en-

tire institution, including employment of a hospital administrator
and appointment of members of the medical staff. In the case of

I the Department of Health, it shall be the responsibility of the

Secretary of Health or his duly authorized representative.

I If the governing body is composed of more than one person, it

shall be organized as a corporate body to conduct hospital affairs.

I The governing body assumes responsibility for the management

and control of the hospital. Evidence that the governing body is
assuming this responsibility shall be:
I • That a written set of goals and policies duly promulgated
and updated by the governing body is in the hands of
I I the Administrator (updating means review and revision
as the need arises).
• That the responsibility and authority of the hospital ad-
I ministrator have been written and are known to persons
working in the hospital.

I • That the reports of hospital operations including services

provided and results thereof in the care of the patients,
are reviewed at least once a year by the governing body.
I • That provisions have been made to safeguard the assets
of the hospital to insure its continuing operation.

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I
I • That provisions have been made for the close relation-
ship between the hospital and the community and the

I various health or welfare agencies.

The Medical Staff should review the medical records of patients.
It should audit the medical care plans of the attending physicians,
I permitting only those that are acceptable.

The Hospital Administrator

I The Administrator/Director is responsible for planning, organizing,
directing, coordinating, and controlling hospital operations, except
I medical care. In the case of the Department of Health, it is the
Director or Chief who is designated to carry out its policies. He
shall be expected, under licensing rules and regulation, to carry
I out the responsibilities of the executive office which are listed as
follows:

I • Formulation and writing in clear statements of:

- The goals or ends to be attained by the hospital

I - The goals or ends to be attained by each service in

terms of what the service is to produce, its contribu-

I tion to other services, and its place in the total hospi-

tal program; and

I - Basic guides for attaining the established goals and

dissemination of goals.
• Development, with the assistance of hospital personnel
I and the medical staff, of a program of patient care and
hospital operation in line with the needs of patients
served.
I • Establishment and maintenance of an organizational
structure for the hospital which clearly defines the
I authority and responsibilities of various positions and
their relationship, and which should be communicated,
reviewed, and revised as the need arises.
I • Provision of an effective method of communication be-
tween the various elements in the hospital organization.

I • Maintenance of a written record of all business transac-

tions and patient services rendered and submission of
reports to the governing body. Effectiveness of hospital
I operations shall be measured in terms of the expected
results of patient care rendered.

I 18

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I • Development of long-range plans for the continuing im-
provement of the hospital.

I • Provision of the administrative control of the entire hospi-

tal during the absence of the hospital administrator.

I • Preservation and protection of patients and personnel

against hazards and contagious diseases including:
- The checking of all patients admitted as deemed
I necessary by the medical staff to insure that con-
tagious diseases are made known, for appropriate

I -
measures to prevent its spread and to eradicate it;

Pre-employment and periodic physical and laboratory

I examination are deemed necessary as well as daily

observation of all personnel having direct or indirect
contact with patients; and

I - Development of policies on the administration, treat-

ment, and diagnostic procedures in cooperation with
I the medical staff.
• Provision of orientation and follow-up training for all
hospital personnel.
I • Establishment and maintenance of a plan for emergency
operation of the hospital, to provide for the safety and
I well being of inpatient in case of fire, explosion or other
disaster occurring within the hospital, as well as for the
care of casualties.
I Administrative Policies

I • Hospital personnel are expected to maintain proper

decorum at all times in their relationship with patients,
relatives, and with each other.
I • Management shall see to it that all employees are given
proper orientation and training in the performance of
I their assigned work.
• All employees are required to obey the lawful instructions
of their supervisors connected with the performance of
I their duties.
• Administration shall establish a system of recr,uitment,
I selection, and placement of employees on the 'basis of

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I fitness to perform the duties and responsibilities of the
position.

I • Management shall provide its personnel with reasonable

protection against unreasonable demands, harassments,
and physical harm.
I • The hospital management reserves the right to change,
revise, or amend hospital rules and regulations as the
need arises and any such changes or amendment there-
I to shall become effective after proper dissemination to all
concerned.

I • Hospital administration, is not responsible for any loss of

patients valuables.
• Administration/management is tasked to direct and coor-
I dinate the activities of the medical staff as well as all the
activities of the hospital to ensure efficient and judicious

I delivery of hospital services based on its objectives.

• Coordination and teamwork among hospital personnel
shall serve as a common approach to attain overall
I goals and objectives.
• The tasks of every employee shall be clearly spelled out

I and mutually understood, reasonably quantified, and ac-

tual performance shall be regularly evaluated.
• All patients shall immediately be attended to upon arrival
I giving preference to emergency cases and/or seriously ill
patients.

I • Clinical and nursing care shall be made effective via the

following provisions:
_ Clear, written hospital policies including reasonable
I rates.

I _ Emergency room logbooks and protocols, treatment

and physical examination, consent, emergency room,
and outpatient consultation forms.

I _ Well-understood and well-written discharge advice

and instructions.

I _ Forms for reporting/recording medico-legal and report-

able diseases.
I - Complete and uniform in-patient records.

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I - Equipment and instruments to comply with the
Bureau of Licensing and Regulation requirement.

I Management shall ensure maintenance of ade-

quate facilities, equipment, and supplies necessary
for good patient care for the nursing unit.
I Management shall provide an environment that is
conducive to the physical, spiritual, and emotional
I well being of patients and personnel.

I Dietetic Unit
This unit is not a requirement. However, if the hospital opts to
have one, for hospitals less than 20 beds, the cook acts as
I marketer/menu planner and is the informal leader in the dietetic
unit, under the direct supervision of the Administrator or Medical
Director, assisted by two food service workers (FSW) or utility
I workers. While it may not be required that a nutritionist-dietitian
be employed in a 10- to 15-bed hospital, it is, however, recom-
mended that such hospital must try to consult, coordinate, and
I avail itself of the services of a nutritionist-dietitian in a nearby
secondary category hospital, through its networking system.

I Policies
• The food budget shall be sufficient to provide nutritionally
I adequate and palatable diets, and food served shall be
regularly evaluated to meet these ends.

I • Personal hygiene and proper food handling practice of

dietetic personnel shall be such as to ensure that the
patients receive safe, clean, and wholesome food.
I • Pertinent safety practices, including the control of electri-
cal, flammable, mechanical, and appropriate radiation
hazards must be observed.
I • The dietetic unit shall be designed and equipped to
facilitate the safe, sanitary, and timely provision of food
I service to meet the nutritional needs of patients (includ-
ing garbage disposal, dishwashing and general cleaning,
transport of food).
I • The quality and appropriateness of nutritional care
provided by the dietetic unit shall be regularly reviewed

I and evaluated.
Department of Health

I 21
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D042

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I • Meals shall be provided to patients in accordance with a
written order by the responsible medical practitioner. Ap-

I propriate dietetic information shall be recorded in the

patient's medical records by the nurse in charge.
• The hospital should have a standard diet manual or
I guide to be used by the medical staff in diet ordering
and the staff in fulfilling the diet orders.

I Hospital Maintenance Unit

The main function of this unit is to create a pleasant and comfort-
I able, safe and clean physical environment for patients,
employees, medical staff, and general public by maintaining and
servicing utilities such as light, water, power, garbage system,
I and security. The hospital as a whole, and its various parts, in-
cluding fixtures, walls, floors, ceilings, and furnishings shall be

I well-maintained.

Policies

I • It shall have a space for repair and maintenance.

• It shall have the required number of personnel depend-

I ing on the size and needs of the hospital. There shall be

a definite assignment of maintenance functions to
qualified personnel.
I • It shall plan and supervise security refuse collection and
disposal, and insect and rodent control.

I • Provision shall be made for periodic inspection and

repair of hospital plant and equipment by qualified per-
sonnel. Insofar as possible, repair shall be made prior
I to breakdown so that plant operation and patient care
shall not be jeopardized.

I • Instructions for operating and maintaining equipment

shall be made available to maintenance personnel.
• Operating and maintenance record shall be kept and
I analyzed periodically.
• Hospital maintenance may be on contractual basis.
I Housekeeping Unit

I The housekeeping unit shall be responsible for the maintenance

of a clean and healthful environment within the hospital premises.

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I It shall ensure an environment conducive to the recovery of
patients. The hospital, including fixtures, walls, floors, ceiling, and
furnishings shall be kept clean and free of vermin and rodents.
I The housekeeper, together with the nursing staff, may participate
in the formulation of hospital policies and guidelines to prevent
I the occurrence of nosocomial infection.

Policies
I • The hospital shall formulate standard procedures in the
sanitation and cleanliness of the different patient care

I units.
• The assignment and scheduling of institutional
workers/janitors shall take into consideration the needs
I of the patient care units for 24 hours.
• Janitorial cleaning supplies and equipment shall be

I provided in sufficient amount and type required, to ade-

quately care for the hospital.
• There shall be a definite assignment of housekeeping
I functions, preferably to one who has had institutional ex-
perience. Such person shall provide immediate super-
vision over his/her staff.
I
Linen and Laundry Unit
I Every hospital has the responsibility of providing sufficient linen to
ensure the comfort of patients and safeguard them from infec-

I tions and communicable diseases transmitted through linen. The

minimum amount of linen required will vary with the number and
type of patients cared for, the time required to process linen and
I return to use, and other factors.

For small hospitals of less than 20 beds, the standard manpower

I complement includes one laundry worker. The Nursing Service
has the added responsibility of providing these specific functions:
• Determine the utilization, processing, life span of linen:
I • Develop a system to provide adequate and continuous
supply of linen, required for patient care and other hospi-
I tal units.
• Ensure efficient collection of soiled linen from, and dis-

I tribution of clean linen to the different units of the hospi-

tal.

I 23

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I • Conduct periodic inventory of linen materials in wards
and in stock.

I • Project linen requirements yearly or as the need arises,

including budgetary requirements.

I • Change bed linen as often as necessary.

• The minimum requirement of at least four sets of linen
per bed or bassinet shall always be made available.
I CLINICAL AND ANCILLARY SERVICES

I Clinical Service (Patient Care)

The primary role of the hospital is to care for the sick and injured.
I Other important functions are subordinate although recognized as
part of the responsibility of the institution insofar as they con-
tribute directly or indirectly to patient care. The existence and
I viability of the small hospital is dependent on the immediate com-
munity it serves.

I The secondary role is to be a relevant link in a network of clinical

care and public health services either as a referring unit or an end
unit. As a referring unit, it refers to the next higher level facility
I which is accessible (within an hour away by usual means of
transportation). However, when a small hospital is so situated

I geographically that the nearest higher level facility is more than an

hour (for emergency and/or critical cases) to four hours (for non
emergency and/or elective cases) away, it then assumes the role

I and function of an end unit which would render the needed ser-
vices.
• Comprehensive patient care shall essentially be com-
I posed of the activities of the patient's physician and
hospital personnel to meet specific needs of the patient
for diagnosis, treatment, rehabilitation, disease preven-
I tion, and personal care. Its purpose is to cure or al-
leviate the effects of disease, injury, or disorder and to
promote a positive state of health, restoring the patient
I to constructive living in consideration of his disability as
well as abilities and capacities.

I • Patterns of hospital organization shall provide the neces-

sary mechanism for the promotion of unity of purpose
and efforts by physicians and hospital personnel. If
I necessary, control measures shall be instituted to bring
about teamwork among them.

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I • The contents of a plan for patient care shall include the
following:

I - Goals and objectives of care or what is to be ex-

pected as a result of given care;

I - Basic principles of care, including several procedures

that the staff need to perform in carrying them out;

I - Specific roles of each discipline and the means of

maintaining the necessary relationships between them
in giving care; and
I - Means of determining and planning the care needs of
individual patients.
I The small hospital has the following specific roles and functions:

I • To cater to the clinical care needs of the community it

serves.

I - To render diagnostic and therapeutic services.

- To deliver emergency services to patients in terms of

I evaluation/diagnosis/emergency room care and treat-

ment and be able to either transfer, admit, or send
home patients after four to eight hours' emergency

I room stay at most.

To give 24-hour inpatient medical and nursing care

I not ordinarily available for the following categories of
cases:

II Cases which need one to seven days of confine-

ment and general medical care.

I Cases which need to be isolated and cared for by

a general practitioner or practitioner of family
medicine.
I Cases which are very critical and cannot be trans-
ferred.
I Cases admitted during disasters.

I
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I Cases which need to be transferred to the next
higher accessible facility within eight to twenty four
hours.
I Cases which cannot be referred right away and
need to be clinically stabilized first.
I • To be a relevant part of a health care delivery system as
an end unit or as a referring unit.

I - To acquire competencies and provision for delivering

relevant primary care services.

I - To have written policies, procedures, records of its

delivered clinical services. This shall include patient
data in the emergency room/outpatient department
I (OPD), wards and laboratory. There shall be ad-
ministrative records for the purpose of determining
the nature and cost of patient services and for
I monitoring feedback to management, government
regulatory and professional bodies.

I - To have procedures and forms for communicating

with and relating to other parts of the network and the
community at large.
I The medical staff is responsible for the quality of medical care

I provided, and for submitting reports on the quality of care

provided to the governing board of the hospital at frequent inter-
vals.

I • While the governing body of the hospital is the final

authority as regards the administrative aspects of hospi-
tal operation, it must be recognized that all elements in
I the hospital, including the medical staff, have important
contributions to make in the area of Administration and
should be accorded a voice.
I • The complexity of the modern hospital requires a team
approach concept in hospital administration and opera-
I tion if the best patient care is to be provided. The wide
array of services and personnel required to meet the
needs of patients today necessitates that a program of
I patient care be developed for the various categories of
patients cared for. .

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I
Ancillary Services
I • Admitting Service/Unit
Provision shall be made for the admission of patients to
I the hospital in accordance with their needs. and due
regard for their safety and well-being. Admitting person-
nel shall not only get personal information on patients
I but also on the nature and needs of other patients and
the services available in each nursing unit.

I - Specific policies for the admitting service shall be as

follows:

I Information about patients, including an admitting

diagnosis, clinical condition, and their personal
characteristics shall be submitted to the admitting
I service before or at the time of admission of
patients to the hospital. Physicians and nursing
service personnel shall recommend placement of
I patients in the hospital in accordance with
patients' needs and facilities available.

I Admitting procedures shall be adapted to patients'

needs. Patients shall be admitted in such a way
as to insure others against transmission of dis-
I eases.

I Patients having or suspected of having com-

municable diseases shall be assigned to beds in
such a place where transmission of diseases or in-

I fection of other patients or personnel could be

prevented. Any such transmission or infection
shall be promptly reported to the authorities con-
I cerned.

Mothers who deliver outside of the hospital's

I obstetrical unit may, however, be admitted
provided that they are housed in a way as to
separate them from other patients.
I Working arrangements with other services in the
same hospital shall be made to insure that all
I patient's needs are properly met.

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I Hospital rules and regulations and admitting proce-
dures shall be made available at all times for the
use or reference of personnel.
I Admitting personnel shall be given orientation train-
ing and kept informed of policy or procedure chan-
I ges affecting their work from time to time.

- The discharge of hospital patients shall be as follows:

I Patients shall be discharged only upon written
order of the attending physician.
I The attending physician shall be required to enter
in the summary sheets his final diagnosis of the
I given case with a brief summary and final
progress note and affixes his signature thereon.

I When the discharge order. is duly signed by the

physician, the nursing and admitting units shall be

I promptly notified.

In case of death of a patient, a statement to that

I effect shall be entered in the progress notes of the

chart including the final diagnosis and the cause
of death, duly signed by attending physician. The
I nurse in charge of the ward shall notify the admit-
ting unit, prepare the body, and inform the rela-
tives of the deceased patient.
I - Policies for clinical care are as follows:

I There shall be competent medical and nursing

staff supported by adequate logistics to handle
routine outpatient and inpatient needs.
I There shall be a 24-hour physician staff that can
provide diagnosis and appropriate treatment of
I emergency cases.
• Medical Records
I It is said that good medical records generally imply good
medical care. Inadequate medical records often reflect
poor medical care. For this reason, the medical record
I is selected as one of the yardsticks to be used in

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I measuring the quality of medical care rendered by a
hospital and its medical staff.

I They shall serve as basis for planning patient care,

provide means of communication between physicians
and other professional groups contributing to patient
I care, furnish documentary evidence on the course of the
patient's illness and treatment, and serve as basis for
review, study, and evaluation of medical care rendered.
I The function of the Medical Records Unit is to keep and
preserve all charts and records pertinent to the stay of
I the patient in the hospital and to make the charts and
records easily available to authorized persons at all times.

I For primary hospitals of less than 20 beds, the standard

manpower complement includes at least one medical
records clerk. In some hospitals, the medical records
I clerk may be assigned other administrative functions.

- Functions of the Medical Records Unit

I Receive, classify, analyze, codify, and file charts

I and records of patients.

Keep and maintain all charts and records of treat-

I ment of patients and make them easily available

only to authorized persons.

I Maintain and update patient's index, death

registry, and registry of admissions and dischar-
ges. Accurate and complete medical records shall
I be maintained on all patients from the time of ad-
mission to the time of discharge. There should
be space for retrieval of records.
I Prepare and issue medical, birth, and death certifi-
cates.
I Prepare periodically statistical reports of the hospi-
tal as required.
I - Policies

I An accepted method shall be established within

each hospital for recording data. All records shall

I 29
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I be part of the hospital records system. No medi-
cal record shall be permanently filed until it is com-
. pleted.
I The completion of the medical records shall be
the responsibility of the attending physician. Or-
I ders for treatment and all reports shall be legibly
entered into the medical record, either in ink or
typewritten and signed by the physician. The com-
I pleted medical record including signature of attend-
ing physician shall be forwarded to the records
area/room within 24 hours, following the patient's
I discharge from the hospital.

A trained medical records clerk or any other

I responsible hospital employee shall be given the
responsibility for the proper custody, supervision,
filing and indexing of completed medical records
I of all patients discharged from the hospital. He
will also prepare medical statistics and reports.

I Medical records shall be made available for inspec-

tion by any authorized representative of the

I Bureau of Licensing and Regulation.

Confidential information obtained from medical

I records shall be furnished only on the written
authority of the patient or executor of his estate or
his attending physician. Such authorization shall
I be kept on file together with the patient's record.

All previous records shall be made available for

I the use of the physician attending a readmission
case.

I - Content of Medical Records - All medical records

shall contain the following information:

I Identification data

Chief complaint
I Present illness

I History and physical examination - Only physicians

are competent to write or dictate medical histories

I
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I and physical examinations. Nurses, medical
records clerk, or secretaries shall not be permitted
to take medical histories.
I Provisional diagnosis - There shall be a provisional
or admitting diagnosis made on every patient at
I the time of admission.

Clinical laboratory reports - The original signed

I laboratory report shall be entered in the patient's
record. Duplicates are filed in the laboratory and
reports from laboratories outside the hospital shall
I be acceptable in lieu of tests performed in the
hospital if the examination was performed in a
licensed laboratory. As the hospital shall be held li-
I able for the quality of laboratory work reported in
the medical record, the hospital shall limit outside

I laboratory work.

X-ray reports - The original report signed by the

I radiologist shall be entered in the patient's record.

Consultations - Consultations shall imply an ex-

I amination of the patient and patient's record. The

consultation note shall be recorded and signed by
the consultant.

I Medical and surgical treatment - All treatment pro-

cedures shall be documented in the medical
I record.

Progress notes - Progress notes give a chronologi-

I cal picture and basis of analysis of the clinical
course of a patient and shall be made at a fre-
quency as determined by the condition of the
I patient.

Final diagnosis - A definite final diagnosis shall be

I written as part of the patient's records.

Nursing record - Nursing records on patient charts

I shall include a graphic chart of vital signs such as
temperature, pulse and respiration, blood pressure
readings, intake and output reports as indicated,
I medications and treatments given, and nursing ob-
servations or nursing notes.

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I Discharge summary - A summary of the patient's
condition on discharge shall be required a
recapitulation of the patient's hospitalization.
I Obstetrical records - All obstetrical records shall,
in addition, to other required records, include
I reports on the following:

xx Past obstetrical history of the patient's previous

I pregnancy.

I xx Admission of obstetrical examination describing

condition of mother and fetus.

I xx Complete description of the progress of labor

includinq reasons for induction or operative pro-
cedures, if any, signed by the attending

I physician.

xx Anesthesia, analgesia, and medication given.

I xx Signed report of a qualified obstetrical consult-

ant when such service was obtained.

I xx Names of assistants present during parturition.

I xx Condition of infant one hour after delivery.

xx Progress notes, including involution of the

I uterus, type of lochia, and condition of breasts
and nipples.

I Records of the newborn - Records of newborn in-

fants are required to form part of patient's whole
medical record, and shall include the following:
I xx Date and time of birth, birth weight, and length,
and period of gestation.
I xx Parents' name and address.

I xx Description of complications of pregnancy or

delivery, if any, inclUding premature rupture of
membranes, condition at birth such as color,
I quality of cry, and method as well as duration
of resuscitation.

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I ):{ Record of instillation into each eye at delivery
as prophylaxis.

I ):{ Report of initial physical examination including

any abnormalities signed by the attending
physician.
I ):{ Progress notes, including weight and feeding
charts, temperature, number, consistency,
I color of stools, condition of eyes, and umbilical
cord, condition and color of skin and motor be-

I havior.

):{ Physical examination on discharge.

I ):{ Recommendations and signature of attending

physician.

I - Forms

I The Bureau of Licensing and Regulation shall

evaluate medical records on the basis of contents
and form that each hospital shall find useful and ac-
I ceptable for their purpose.

A short-form medical record which contains informa-

I tion that will specifically identify the patient is accept-
able in certain treatment and diagnostic cases of a
minor nature which require less than 48 hours
I hospitalization.

- Ownership
I The medical record is the property of the hospital and
shall be maintained for the benefit of the patient, the
I physician, and the hospital itself. It shall be the
responsibility of the hospital to safeguard the informa-
tion on the record of each patient against loss,
I tampering, or use by unauthorized persons.

- Preservation of Medical Records

I The medical records of hospital in-patients shall be
kept for a reasonable length of time, usually 25 years,
I for clinical and scientific purposes after discharge or

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I death. Disposition thereof after the specified period
may be made pursuant to provision of law.

I In hospitals where the use of medical records for

scientific purposes is limited and the rate of read-
missions is low as well as where the needs of
I medical staff and patients are adequately met and
protected by retention of medical records for less
than 25 years, a 10-year period of retention is con-
I sidered minimum. After said period, the same
may be disposed of, pursuant to legal provisions,
provided the hospital retains an index, registry, or
I summary card of such basic information as iden-
tification data of patient, date of admission and dis-
charge, name or responsible physician, and
I record of diagnosis and operation.

- Hospital Records
I Each hospital shall maintain the following hospital

I records:

Daily census

I Register of admissions and discharges

I Register of outpatients

Register of births

I Register of deaths

I Register of operations

Narcotic register, and

I Emergency room admissions.

I - Reports

All hospitals shall comply with laws, ordinances, rules,

I and regulations, which provide for the registration of
births and deaths and the reporting of communicable
diseases.
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I Private hospitals shall submit quarterly and annual
reports on patient statistics and hospital operations to
the Bureau of Licensing and Regulation on the
I prescribed forms. On the other hand, government
hospitals shall submit monthly and annual reports in
accordance with the existing Department of Health
I rules, regulations, or orders relative thereto.

- Storage of Medical Records

I Storage on open shelves is far preferable to the old
method of filing cabinets, making records more easily
I available and occupying less floor space.
• Emergency/OPO Unit
I Whether a hospital maintains an emergency unit or not,
a plan for the reception and care of mass casualties

I shall be required for all hospitals. If an emergency unit

is maintained, the following shall be the guiding prin-
ciples:

I - There shall be a well organized emergency unit,

headed by a competent licensed physician.
I _ Facilities shall be provided to assure prompt diag-
nosis and emergency treatment.
I - A small observation room/area where patients can be
observed after emergency treatment may be provided.
I - There shall be adequate medical and nursing person-
nel available at all times for emergency service.
I - Adequate medical records on every patient shall be
taken and kept.
I _ There shall be a written plan for the care of mass
casualties and which shall be coordinated with the in-
I patient and outpatient services of the hospital.

_ The emergency operating area need not be so large,

I but it shall be provided with the equipment and instru-
ments required by the Bureau of Licensing and
Regulation.
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I
I • Laboratory Unit
As a general rule, in the evaluation of a patient's condi-
I tion, more so when examinations have to be done else-
where, the patient or a responsible family member shall
be made aware and informed of the reasons, ad-
I vantages, and the cost of these examinations.

When a small hospital affiliates with another in the use of

I its facilities, expertise, and ancillary services, a regular
(monthly or quarterly) meeting between affiliating units
shall be held to tackle problems and work out improve-
I ments in the network.

Feedback relating to specific critical or problematic

I cases shall be instantaneous and automatic whether by
telephone, messenger, personal, or other means of com-
munication.
I Basic pre-analytic specimen collection, transport, han-
dling, and post-analytic (recording, reporting, charging)
I requirements shall be written and posted in the emergen-
cy room/outpatient unit/ward and the physician's office.

I The following shall be met whether examinations are

done in-house or referred out:

I - Specimen container specification and labeling

- Request forms, duly signed

I t~
- 'Accompanying data

I - Method and time of specimen collection and accep-

tance by laboratory

I - Amount of specimen required for each requested ex-

amination

I - Time and method of transport

- Temperature requirements
I - Precautions against infections or hazards, and

I - Rates and charges

I 36

I
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l
I Policies for outpatient laboratory services

- When requests for outpatient, nonemergency

I laboratory examinations are sent out to affiliating
laboratories

I Specimen shall be collected and transported ac-

cording to the requirements of the affiliate
laboratory pertaining to:
I n Requests/results
I n Specimen collection/ handling and transport

I Requirements shall be put in writing, or printed

and posted in the ward, emergency room/out-
patient unit and in the doctor's room.

I Waiting time for results shall be known to the

physician and the patient.
I When adequacy of specimen cannot be assured
because of natural (distance, weather) or (human
I factors, either the hospital staff or the patient him-
self, if able, shall be instructed and made to go to
the affiliating hospital laboratory.
I - Where there is no accessible higher level laboratory
facility within eight hours of total travel time, basic
I laboratory services of a level determined by the
needs of the community and the expertise of the
physician shall then be set up. This laboratory
I facility shall be maintained by the hospital or the corn-
munity according to the rules and regulations relating
to the establishment and operations of clinical
I laboratories.

Policies for emergency laboratory services

I - In-house or affiliate services shall be able to provide
the physician, within one hour, the laboratory support
I or data needed for the initial or complete evaluation of:

Surgical and nonsurgical abdominal condition (HB,

I Hct, WBC, differential indices)

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37
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I Presence or absence of urinary tract infection
(urinalysis, WBC count, differential count)

I Causes of
(fecalysis)
diarrhea amoeba/non-amoeba

I Degree and type of anemia/blood loss dehydration.

l:l HB, Hct, indices, blood smear, morphology,

I urine specific gravity

Blood typing, cross matching

I l:l

Pediatric diarrhea - Hct, blood smear morphology,

stool examination, urine specific gravity, and
I Response to emergency room care

I - When the nearest affiliate laboratory is more than an

hour (total waiting time) away, the hospital or com-

I munity shall set up and maintain basic laboratory ser-

vices for emergency care according to the rules and
regulations relating to the establishment and opera-

I tions of clinical laboratories.

Policies for inpatient laboratorv service

I - Laboratory services and their results, whether in-
house or referred, shall be available at a four-hour in-
I terval during a 24-hour day.

- When this is not possible, such a capability shall be

I provided by the hospital or community and main-
tained according to the rules and regulations relating
to the establishment and operations of clinical
I laboratories.
• Pharmacy Unit

I The pharmacy is the repository of drugs, chemicals,

pharmaceuticals, and narcotics in the hospital. The law
requires that only a licensed pharmacist shall com-
I pound prescriptions.

This is not a requirement, however. A drug room will

I suffice in which prepared drugs are stored. If the hospi-
tal opts to have a pharmacy which serves only

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38
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I inpatients, the pharmacy shall be placed within the hospi-
tal premises convenient to the hospital personnel. If it
serves both outpatients and inpatients, it shall be easily
I accessible to both and shall:

- Ensure continuous supply of drugs and medicines of

I quality standard to patients by maintaining adequate
quantities of stocks.

I _ Fill out prescriptions and dispense drugs in accord-

ance with the laws pertinent thereto.

I _ Distribute to the different units of the hospital routi-

nary drug supplies.

I _ Request, distribute, and control the use of all drugs.

I _ Maintain proper storage and preservation of drugs.

- Maintain records, files, and reports on dangerous

I drugs and other pharmaceuticals as required by law.

- Serve as drug information center to all hospital per-

I sonnel and patients.

Policies
I - Drugs and medicines used in hospitals for emergency
cases shall always be made available.
I _ An official hospital formulary in generics based on
Department of Health Hospital Formulary shall be es-
I tablished.

- Prohibited drugs in vials shall be issued to inpatients

I through the nurse on duty.

- Records, files, and reports on dangerous drugs and

I other pharmaceuticals shall be maintained in com-
pliance with government regulations.

I _ There shall be a policy on paid drugs returned by

patients upon their discharge.

I
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39
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I - Expired and deteriorated drugs, fluids, etc. shall be
properly discarded in accordance with the policy on
deteriorated and expired drugs.
I - In the sale of medicines, official receipts must be is-
sued by the cash clerk or anyone designated to do
I so if possible.

- All drug products delivered to the pharmacy shall be

I subjected to random testing by the Bureau of Food
and Drugs.

I - Drug products received shall not have less than 12

months interval between their delivery and their expiry
date.
I A pharmacy unit shall provide for the following:

I For the Outpatient Unit

I - It shall maintain an inventory of basic generic, non-

prohibited drugs and first-line antibiotics in oral
(tablets/liquid), parenteral and suppository forms.

I - It shall have on stock (at level as dictated by its

budget and the usual demand) drugs, supplies, or
I agents that are not ordinarily available from regular
community outlets such as skin, eye, ear prepara-
tions, and vaccines.
I - It shall have adequate provisions for its usual load of
minor surgical procedures: instruments and con-
I sumabies such as sutures, anesthetics, antitetanus,
dressings and antibiotics.

I For the Emergency Room

- Life-saving drugs and special pharmacologic agents

I in sufficient stock to permit timely replacements from
the nearest pharmacy service.

I Examples:

Cardiac/CNS stimulants, depressants, anticonvul-

I sants

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40
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I Sedatives/tranquilizers

Analeptics
I Local anesthetics

I Steroids

Coronary vasodilators
I Anti-asthma agents - bronchodilators

I Drugs for hypertension (oral and parenteral)

I Anti-ulcer drugs

Plasma expanders

I Replacement water/electrolyte solution

I Oxytoxics

- There shall be available stock of the following sup-

I plies:

Intravenous infusion sets

I Syringes

I Masks

Sterile specimen containers

I 10% Formalin

I Glass slides

Disinfectants
I Splints

I Ice bags, packs

Oxygen with gauge

I
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41
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I - There shall be at least a week's supply of basic
necessities and supplies in the event of natural or
man-made disasters such as floods, fire, typhoons,
I and earthquake which can lead to an emergency
situation affecting public health:

I Water containers
chlorinated water
or jugs with potable or

I Disinfectants (Lysol, Clorox)

I Portable IV stands

Emergency bag with provisions

I Medicine bag with prescriptions and medicines

I Extra linens

Antitetanus serum

I Kerosene lamps

I Portable emergency lights

For Inpatient Service

I - Medicines shall be available in sufficient quantity for
the duration of a patient's confinement.
I - Routine immunization and other needs for normal
neonatal postpartum care shall be provided for by the
I hospital.
• Radiology Unit

I This is not a requirement for a primary-category hospital;

however, if the hospital opts to provide one within the
hospital premises, the following guidelines shall be ob-
I served.

As a general rule, in the evaluation of a patient's condi-

I tion, more so when examinations have to be done else-
where, the patient or a responsible family member shall
be made aware and informed of the reasons, ad-
I vantages, and the cost of these examinations.

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42
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I When a small hospital affiliates with another in the use of
its facilities, expertise, and ancillary services, a regular
(monthly or quarterly) meeting between affiliating units
I shall be held to tackle problems and work out improve-
ments in the network.

I Feedback relating to specific critical or problematic

cases shall be instantaneous and automatic whether by

I telephone, messenger, personal, or other means of com-

munication.

I - Requests for X-ray shall be signed and shall include

the following information:

I Patients' name, age, sex, status, and address

Date of request, pertinent clinical data, and ex-

I amination requested

Tentative diagnosis
I Clinical unit shall have written schedules including
required patient preparation and rates of x-ray pro-
I cedures.

- Follow-up examination requests shall include:

I Date of last x-ray examination

I Nature and result of the previous x-ray examina-

tion being monitored.

I Previous clinical findings if any

For Outpatients
I - The hospital shall affiliate with a unit which is not
more than four hours away by usual means of
I transportation.

- When the hospital decides to set up its own x-ray

I facility, there shall be available corresponding man-
power competencies and facilities to support such ad-
ditional services. Only qualified personnel shall be al-
I lowed to operate the x-ray equipment.

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43
I
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I - In-house service may be set up at a level which will
depend on the needs of the community and com-
petence and skills of available manpower. Only
I qualified personnel will be allowed to operate the x-
ray equipment.

I For Inpatients

I - Patients requiring serial x-ray for their diagnosis and

monitoring shall be referred out when no in-house ser-
vice is available.

I NURSING SERVICE

I Every hospital shall have a nursing service responsible for the

planning, organizing, directing, and control of the service which
shall be capable of providing comprehensive quality nursing care.

I • Planning - Planning shall be based on the type of agen-

cy, the services it offers, its philosophy, and its objec-
tives. It shall be congruent with the overall development
I plan of the hospital.
The nursing service shall have established policies, stand-
I ards, and procedures to ensure conformity and consis-
tency with pre-established regulations:

I - Approved personnel and nursing policies are in writ-

ing, communicated and kept up-to-date.

I - Procedure manuals are available in each clinical area

which shall be reviewed/revised periodically.

I - A mechanism for assessing personnel performance

and quality of nursing care shall be developed and es-
tablished.
I - Policies, procedures, standards, and evaluation sys-
tems are included in nursing personnel orientation.
I - Needs in each patient care area are assessed and
determined by the collective suggestion of nurses in
I that area.

- Each care unit shall have a list of essential equipment

I it is responsible for.

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44
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I - Stock of basic emergency medicines shall be main-
tained in each area.

I • Organizing the Nursing Service - The Chief Nurse or

his/her designate shall be responsible for the organiza-
tion and administration of the Nursing Service. He/she
I shall be directly responsible to the Chief of Hospital/Medi-
cal Director/Administrator.

I - Organizational structure - depends on the category

of hospital. It shall establish a harmonious working
relationship with the other services of the hospital and
I clearly defines the responsibilities for each level of
nursing personnel.

I - Staffing - The Nursing Service shall develop and

maintain a staffing pattern that will meet the needs of
the patients and standards of the profession and as-
I sure adequate provision of care at all times.

The number of nursing personnel shall be in accord-

I ance with licensing requirements of the Bureau of
Licensing and Regulation, Department of Health.

I - Job descriptions - Job descriptions shall be clear

and in writing. The seven cardinal functions of a
professional nurse shall be followed:
I Undertaking responsible nursing care and super-
vision of medical communicable, psychiatric, minor
I surgical, pediatric, obstetric patients involving
management of nursing care, requiring the ap-
plication of principles based upon the biological,
I psychological, physical, and social sciences.

I Observation of symptoms of physical, mental con-

ditions and needs requiring evaluation or applica-
tion of principles based upon the biologic, physi-

I cal, and behavioral sciences.

Accurate reporting and recording of facts, includ-

I ing evaluation of the whole case.

Supervision of other personnel contributing to the

I nursing care of patients.

Execution of nursing procedures and techniques.

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45
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I Direction and education to secure physical and
mental care.

I Application and execution of written legal orders of

physicians concerning treatment and medications,

I including the application of hypodermic and in-

tramuscular injections.

I _ Qualifications of nursing personnel

~ .: '.,/ " "r
The chief nurse or his/her designate must be a

I registered nurse, preferably a holder of a Bachelor

of Science degree in Nursing with at least one
year of experience and satisfactory performance.
I The staff nurse shall be a registered nurse,
preferably a holder of a Bachelor of Science de-
I gree in Nursing.

Nursing attendants shall be at least a high school

I graduate, preferably registered midwives.
• Directing the Nursing Service - The Nursing Service shall
provide the mechanism whereby organizational goals
I and objectives are achieved to the highest extent pos-
sible.

I _ Directions must be reasonable, clear, and complete.

- Effective supervision shall be provided to ensure at-

I tainment of the nursing service objectives.

- Intra- and inter-departmental coordination shall be ob-

I served.

_ A staff development program shall be provided to en-

I hance nursing personnel's knowledge, skills, and at-
titudes.

I Orientation to introduce them to their new job

I In-service education in specific areas to increase

knowledge and develop proper attitude.

I Continuing education beyond the basic curriculum.

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46
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I Incidental learning
demonstration.
through observation and

I • Controlling the Nursing Service - The Nursing Service

shall utilize various mechanisms to determine whether its
goals, objectives, planned programs, and activities are
I -
achieved.
Records and reports shall be complete and concise,

I legible, and give effective information, retrievable and

kept safely from unauthorized persons and damage.

I - Standards

- Nursing audit

I - Performance appraisal

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47
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I
I
I Republic of the Philippines
Department of Health
Bureau of Licensing and Regulation
I Manila

I
March 20, 1990
I
OFFICE ORDER

I No.6, s. 1991

Subject: CREATION OF A COMMITIEE TO DEVELOP A MANUAL OF

I OPERATIONS FOR SMALL HOSPITALS

In line to update hospital regulatory policies, rules, and regulation in order to

I cope with changing needs, a committee is hereby created to develop a Manual
of Operations for Small Hospitals. The committee shall be composed of the fol-
lowing, with the Undersecretary of Health for Standards and Regulation as Ad-
I viser:
• Dr. ZENAIDA R. DE LA FUENTE Chairman

I Bureau of Licensing & Regulation

• Dr. MARIETTA C. BACCAY Member
Bureau of Research & Laboratories
I • Dr. MARGARITA GALON Member
Hospital Operations and Management Services
I • Ms. LYDIA VENZON
Quirino Memorial Hospital
Member

I • Mr. HERNANDO VELOSO

National Kidney Center
Member

Member
I • Dr. FRANCISCO AGUILAR
Ateneo de Manila University
• Dr. JOSE PRIELA Member
I Philippine Hospital Association

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I • Dr. MIRANDO UNCIANO Member
Philippine Medical Association
I • Dr. EMILIANO FRANCISCO
Philippine Medical Association
Member

I • Ms. MA. ALMA RITA JIMENEZ

Medical City General Hospital
Member

I • Bureau of Licensing and Regulation Secretariat

The Committee shall meet as often as necessary to facilitate the formulation of
said manual. It may invite some authoritative persons if deemed necessary.
I This order issued in the interest of the service is hereby declared official, con-
firmed, and made of record.
I
I
I TOMAS P. MARAMBA, JR., M.D., M.H.A.
Undersecretary of Health for

I Standards and Regulation

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I
I Republic of the Philippines
Department of Health
I BUREAU OF LICENSING AND REGULATION
Manila

I
Procedure 1
I
I APPLICATION TO CONSTRUCT/EXPAND/RENOVATE A HOSPITAL

I • Applicant requests information and assistance from BLR - Hospital License

Regisirar gives BLR Form No. 1 (Application for Permit to Construct a Hospi-
I tal).
• Owner submits Application Form No. 1 duly accomplished together with a let-
I ter of application addressed to the Director of BLR through the Regional
Health Director under whose jurisdiction the applicant's locality falls.
• In addition to the Application Letter and BLR Form No.1, the owner attaches
I the other requirements listed in the Checklist 1 (Requirements for the Con-
struction/Expansion/Renovation of Hospitals).

I • BLR Hospital License Registrar gives BLR Form No. 2 (Answer to Applica-
tion) to the owner while the documents are being studied and evaluated by
the Technical Personnel of BLR composing two Committees, namely:
I - Committee on Review and Evaluation of Floor 'Plans

I - Committee on Evaluation and Review of Application for Hospital Es-

tablishment, Bed Increase, and Change in Category.
• If BLR recommends the establishment of such hospital, the Director initials
I the BLR Form No. 3 (Permit to Construct) and forwards this to the Under-
secretary of Health for OSR for approval.

I • If there are deficiencies noted in the floor plan, the owner is informed by BLR
through the Regional Health Office.
• If approved, BLR sends back to the applicant through the Regional Health Of-
I fice the approved BLR Form NO.3 together with the owner's documents.

I
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I • Owner pays the corresponding fee for the Permit to Construct to the DOH
Cashier.
I After payment of the fee for the Permit to Construct, the owner shall obtain a
Building Permit from the local municipality/city before starting the construction

I of the hospital following the approved floor plan within 365 days.

I
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I
I Republic of the Philippines
Department of Health
I BUREAU OF LICENSING AND REGULATION
Manila

I
Checklist 1
I
I REQUIREMENTS FOR THE CONSTRUCTION/EXPANSION/RENOVATION
OF HOSPITALS

I
• Letter of Application of the owner.
I • BLR Form No. 1 (Application for Permit to Construct a Hospital)
• Feasibility study
I - Description of site

I n Source of/distance from main water supply

n Source of main electric power

I n Accessibility to transportation facilities

I n Approximate distance from nuisance and hazards such as

railroad stations, market place, cemetery, recreational
centers.
I - Bed-to-population ratio of the locality

I - Areas to be served

_ Economic situation in the area

I - Availability of professionals in the locality (physicians, nurses, phar-
macists, etc.
I _ Average per capita income of the locality

I
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I
I - Status of the existing hospitals in the locality. if any

I l:( Bed occupancy rate (if expansion)

l:( Skill and capabilities

I - Zoning Clearance
• Floor plan of physical plant of the proposed hospital (3 copies)
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I
I Republic of the Philippines
Department of Health
I BUREAU OF LICENSING AND REGULATION
Manila

I
Procedure 2
I
I APPLICATION FOR LICENSE TO OPERATE A NEW HOSPITAL

I • Applicant gets BLR Form No. 4 (Application for Registration and is-
suance/Renewal of License to Operate a Hospital) from BLR or from the
I Regional Health Office, which shall endorse the application to BLR.
• Applicant files duly accomplished BLR form No. 4 with BLR and requests for
I ocular inspection of the finished building by the BLR Inspection Team,
together with the Regional Health Office Licensing Officer.
• The BLR Inspection Team and the Regional Health Licensing Officer visit the
I hospital to be licensed and evaluate the physical facilities, technical equip-
ment and instruments, personnel complement and service capabilities, for
compliance with the hospital standards and requirements prescribed by the
I DOH.
• BLR inspection Team submits its findings, evaluation, and recommendations
I to the BLR Director for approval.
• If all the requirements conform with the hospital standards and requirements

I prescribed by the DOH, the hospital is registered and an initial license to

operate is issued after the applicant pays the corresponding fee to the DOH
Cashier.

I • If on inspection, there are substantial deficiencies found in the hospital, the

licensing agency may deny the issuance of license until such time that the
deficiencies are corrected.
I BLR Form No. B (Deficiency Form) is sent to the owner stating the deficien-
cies noted during inspection which shall be corrected within six (6) months
I from the time of inspection.

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I • BLR sends the initial license of the hospital to the Regional Health Office con-
cerned for release.
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I
I Republic of the Philippines
Department of Health
I BUREAU OF LICENSING AND REGULATION
Manila

I
Checklist 2
I
I REQUIREMENTS FOR REGISTRATION AND APPLICATION
FOR LICENSE TO OPERATE NEW HOSPITALS

I
• BLR Form No.4 Application for Registration and Issuance/Renewal of
I License to Operate a Hospital
• BLR Form No. 4-B List of Technical Equipment and Instruments
I • BLR Form No. 4-C List of Personnel - including PRC 10 card numbers
and signatures of personnel. List must be notarized.
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I
I Republic of the Philippines
Department of Health
I BUREAU OF LICENSING AND REGULATION
Manila

I
Procedure 3
I
I APPLICATION FOR RENEWAL OF LICENSE TO OPERATE A HOSPITAL

I • Applicant gets BLR Form No. 4 (Application for Registration and Is-
suance/Renewal of License to Operate a Hospital) from BLR or from the
I Regional Health Office.
• Applicant submits duly accomplished BLR Form NO.4 to:
I - BLR - for Tertiary Hospital

- Regional Health Offices - for Primary or Secondary Hospital

I • BLR Inspection Team inspects and evaluates the hospitals falling under its
jurisdiction while the Regional Inspection Team inspects and evaluates the
I hospitals whose categories fall under its jurisdiction.
• BLR Inspection Team submits its findings, evaluation, and recommendations
to the BLR Director while the Regional Inspection Team to the Regional
I Health Director for approval.
• If all the hospital standards and requirements prescribed by DOH are met, a
I license to operate is re-issued after payment by the applicant of the cor-
responding fee.

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I
I Republic of the Philippines
Department of Health
I BUREAU OF LICENSING AND REGULATION
Manila

I
Checklist 3
I
I REQUIREMENTS FOR RENEWAL OF LICENSE TO OPERATE HOSPITALS

I • BLR Form No.4 Application for Registration and Issuance/Renewal of

License to Operate a Hospital
I • BLR Form No. 4-A Statistical Report - Annual

I • BLR Form No. 4-B Updated

Instruments
List of Technical Equipment and

List of Personnel - includes PRC 10 card numbers

I • BLR Form No. 4-C
and signatures of personnel. List must be notarized.

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I
I Republic of the Philippines
Department of Health
I BUREAU OF LICENSING AND REGULATION
Manila

I
Procedure 4
I
I APPLICATION FOR CHANGE IN CATEGORY

I • Applicant prepares Letter of Application for a change in category.

I • Applicant submits Application Letter to BLR through the respective Regional

Health Office under whose jurisdiction the applicant's locality falls, with the fol-
lowing supporting documents:
I _ Floor plans of the proposed expansion (3 copies) including a copy
of the existing structure properly marked

I _ BLR Form No. 4-A (Statistical Report) for the past six (6) months

I _ BLR Form No. 4-B (Updated List of Technical Equipment and In-
struments)

I - BLR Form No. 4-C (List of Personnel - includes PRC ID card num-
bers and signatures of personnel. List must be notarized.)

I - Feasibility study

_ Endorsement from the Regional Health Director

I • BLR Committee on Evaluation and Review of Application for Hospital Es-
tablishment, Bed Increase and Change in Category evaluates all supporting
documents and submits its recommendations to the BLR Director.
I • If all the requirements conform with the hospital standards and requirements
prescribed by the DOH, a permit to construct is issued by BLR.
I • BLR prepares Letter of Endorsement to the Regional Health Office informing
the latter about the outcome of the application.

I
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I • Upon completion of the building construction, the owner requests the BLR In-
spection Team to inspect the finished building. (Please refer to Checklist 3
I for the requirements for application for registration and application of license
to operate a hospital).

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I •

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I
I Republic of the Philippines
Department of Health
I BUREAU OF LICENSING AND REGULATION
Manila

I
Checklist 4
I
I REQUIREMENTS FOR CHANGE IN CATEGORY

I • Letter of Appllcafion of the owner

I • BLR Form No. 4-A (Statistical Report) for the past six (6) months
• Feasibility study

I • Floor plans of the proposed expansion (3 copies) including a copy of the ex-
isting structure properly identified
• BLR Form No. 4-B (Updated List of Technical Equipment and Instruments)
I • BLR Form No. 4-C (List of Personnel - includes PRC ID card numbers and
signatures of personnel. List must be notarized.)
I • Endorsement from the Regional Health Director

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I
I Republic of the Philippines
Department of Health
I BUREAU OF LICENSING AND REGULATION
Manila

I
Procedure 5
I
I APPLICATION FOR AN INCREASE IN BED CAPACITY

I • Applicant prepares letter of Application for an increase in bed capacity.

I • Applicant submits letter of Application to BlR through the respective

Regional Health Office with the following supporting documents:
_ Floor plans of the proposed expansion (3 copies) together with the
I existing structure properly marked or identified

- BlR Form No. 4-A (Statistical Report) for the past six (6) months
I - BlR Form No. 4-B (Updated List of Technical Equipment and In-
struments)
I - BlR Form No. 4-C (List of Personnel - includes PRC ID card num-

I -
bers and signatures of personnel. List must be notarized.)

Feasibility study

I - Endorsement from the Regional Health Director

• BlR reviews and evaluates all the supporting documents.
I • If all documents conform with the hospital standards and requirements
prescribed by the DOH, permit to construct is issued by the BlR.

I • BlR prepares letter of Endorsement to the Regional Health Office informing

the latter of the outcome of the application.

I • Upon completion of the building construction, the owner requests for inspec-
tion of the finished building prior to registration/issuance of license to

I
I
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I operate. (Please refer to Checklist 3 for the requirements for application for
registration and application of license to operate a hospital).

I BLR Committee on Evaluation and Review of Application for Hospital Es-

tablishment, Bed Increase and Change in Category evaluates all supporting
documents and submits its recommendations to the BLR Director.
I
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I
I Republic of the Philippines
Department of Health
I BUREAU OF LICENSING AND REGULATION
Manila

I
Checklist 5
I
I REQUIREMENTS FOR AN INCREASE IN BED CAPACITY

I • Letter of Application of the owner

I • BLR Form No. 4-A (Statistical Report) for the past six (6) months
• Feasibility study

I • Floor plans of the proposed expansion (3 copies) including a copy of the ex-
isting structure properly marked or identified

I • BLR Form No. 4-B (Updated List of Technical Equipment and Instruments)
• BLR Form No. 4-C (List of Personnel - includes PRC ID card numbers and
signatures of personnel. List must be notarized.)
I • Endorsement from the Regional Health Director

I
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I
I
I
I Republic of the Philippines
Department of Health
I BUREAU OF LICENSING AND REGULATION
Manila

I
Procedure 6
I
I APPLICATION FOR INSPECTION OF HOSPITAL PRIOR TO
ISSUANCE OF LICENSE TO OPERATE NEW HOSPITAL

I
• Applicant submits duly accomplished form and supporting documents to BLR.
I • Hospital Licensing Registrar reviews accomplished form including supporting
documents submitted to the Central Office.
I• • Inspection Team conducts ocular inspection of the finished establishments.
• Inspection Team assesses and evaluates findings to check compliance with
I the hospital standards and requirements prescribed by the DOH.
• Technical Staff submits its recommendations to the Chief, Regulatory Com-
pliance Division. The Regulatory Compliance Division Chief submits his/her
I recommendations to the BLR Director who in turn may recommend issuance
or non-issuance of the license. Final approval is done by the Undersecretary

I of Health for Office of Standards and Regulation.

I
I
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I
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I
I
I
I Republic of the Philippines
Department of Health

I BUREAU OF LICENSING AND REGULATION

Manila

I
Procedure 7

I
I APPLICATION FOR LICENSE TO OPERATE
A HOSPITAL TO BE REOPENED
(After Two Years' Closure)
I
I • Applicant secures BLR Form No. 4 (Application for Registration and is-
suance/Renewal of License to Operate a Hospital) from BLR or the respec-
tive Regional Health Office.
I • Applicant files the duly accomplished BLR Form No. 4 with BLR or the
Regional Health Office.

I • Applicant submits three (3) blueprint copies of the floor plan of the existing
hospital building.

I • The floor plan of the existing hospital buildinq will be evaluated by the Com-
mittee on Review and Evaluation of Floor Plans. (This is also one of the
tools to be used by the inspection team during inspection of the existing
I building.) -
• Applicant requests for ocular inspection of the existing hospital building.

I • The BLR Inspection Team and the Regional Health Licensing Officer visit the
hospital to be licensed, and evaluate the physical facilities, technical equip-
ment and instruments, personnel complement and service capabilities for
I compliance with the hospital standards and technical requirements
prescribed by the DOH.

I • The BLR Inspection Team submits its findings, evaluation, and recommenda-
tion to the BLR Director for approval. -
• If all the requirements conform with- the hospital standards and requirements.
I for licensure prescribed by the DOH, the hospital is registered and a license

I
I
I
I to operate is issued after the applicant pays the corresponding fee to the
DOH Cashier.

I • If, on inspection, there are substantial deficiencies found in the hospital, the
licensing agency may deny the issuance of a license until such time that the
deficiencies are corrected.
I • BLR furnishes the Regional Health Office concerned a copy of the initial
license of the hospital.

I
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1
1
1 BLR Porm No. 1
(1987)
AnpLIC.........
"'~IO'l ... ...T'T;l:!'T'T' 'T""' consrz.cr
1....r.:C·'1 t I'e~'" T':' . T
r1J.- ~ J,.;,) ........

(or for: alteration or Lmpr ovemerrt thereof) -

.~v
-
-' ,.1.) ....... J. • • •. 1 ··t::Jr' ... J.r.JJ
~

I
I . (~.,.te)

The Director
I i3ureau of Li cen s i ng and
Department of Health
R;::g~.l~.aHon

l"i a n i 1 a

I Sir/r.iadam:

I he r eby apply for a p e rrci t to const ru ct a (ee!:era1./snccial) l;o~~~c t a l of

I Cconcrete, riixed nat e rLa.l s ) at
for _ _., \'J:10~e

'i',
----------------_._-_. -le name of the ~roposed hospital
I ~s
---------------------- '----_._------------- --'
To S'lf-liJort this app.l i c a t ion , the f o Ll.owi ng is hereby nubmitted:

I 1. Plans du l y p repa r ed and s i gned by r egi st e r ed l.rci1i tect or Civil Engineer

and to include the f o.l l.ovzi ng dr awi ng s t

I a. Conplete Architectural
L::7 Floor P12~s
~ra\'.'ings:

(3 copies)

I b. EnGineering Drawings:
CJ Electrical / I l;echani cal

I 2. L::7 topoGraphical survey of the site approved by the 3ureau of Lands.

3. L::7 Project Study

I 4. U List of Eqt!i:)ment as per equi pmen t plan Lay-out of the proposed
hospital.

I· o 5. L--I Bed Popul~tion R~tio:

In connection VJi th tl:e application, I he r eby tender payment of the required

I perd.t fee. (Unr efundabf e )

Very truly yours,

I o

------,--- -_._------
I lahh c

I· G

o
o
I
I'LR Fo rr.. ue , 4

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L:7 Cor)oraticn

I Chairman of trie Governing Eoci,y

_._--_.- -'._'--'-- ..

----_._-------------
I S•
/ ,• r1
---,-------------, .. _-----------'---'---
r~ ~'r' e;
'.4'''_''- . . .

No. of Goverl1i~g Sody:

---------- .._-,-_._-- __
.

._----------
I rnvsrcu.
--,,.-
PUJ!T:
------,.---~_----

I A. Type of Str:lcture:
/::1 Pc ruanen t U Serd I'cr'i':·,2.l1cnt U Tcnpo r ary
(woolen)
I ;-:
-'.
o
t12.ture of St r uct r re s
Existing L:t~ildj.ng ':cl1ovatcd !.:J :~:dsting Lailding
c and expanded renovated

I C. St~tus of Ownership:
/ I new S't r uc tu re

I CJ Priv~tely owned U Rented [J Lc ascd: LJ Gove rnmen t

I
I
., -
-'

I Fac5.!.i tics:
1. Sci.r ce s ___ '''._4. __ .. _. _ _. ~ . _

I Stan<.:-ty Gcnc r n.t o r Used: 'l""JC

Un i t Powc r (I:V1:.)
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-_. __ .-.-.~---_
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R...diology
Service:

I Pe r sonne l e
:J. Others

Please f Ll L up attached f o rn on r.c r sormc I (~LF. Po rii ilo. 11·-C)

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Plcase fHI up attached foni on cr,.d.pi··'C:lt (~L3. Po rn ;·10. 4-1:)

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1 Lease at t ac h c d a copy f '"
your ,105::1 t~ po La"c"t e s wa" .rn t"ru s app 1 a" c a t·a on
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f 0 rr.i,

___._- _0 · _._----- -_.,,---_. _._-_ ..----- -_._-_._---

I llr;.i:lc and Title of Icrson cor.• )leting this form

I Pr~nt: ----_._._-- _._--_.__ __... --_._-- _._--- ._-------_. . __.---

1') a n e Tit 1 e

I -------- --------------
S,.gnaturc ;) a t e
I
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I Rcpuol.I c of the :L-'hi.Ulh1:i.ncs

I P::ovince----_._-_.... __-_.
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I Res. Cer t , no ,
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---_._~

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_~~ ".. t en°

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Person
- --:----,,-
L~Jini~tcring Oath

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 I
I BLR Form No. 4-A
Re ..... i s ad 1 =t':; 1

.....
..... E~lJ-.J l. J. I,:
R
I BURE~U
DE D:;..rt'T,er, t
OF LiCENSING AND
vf ~i..,a: t::i
REG~Lni'ION

I Fc·:-
HQSPITAL STATISfICAL PEPCRf
..
or- h,,~
..
' ..
, Ci
'

I PLEASE: ~'-r':E =_,(::'ST

I .• ------------------_._-----_.---
ADDRESS .•
I P.EGION .•

I GENERHL I NFOt?l'';;-1 TION :

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:

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G i'" ',,, r:

Pay : TOTr=lL:
·•
[c.n:
V J. CE : c-z re ·• :

I • · : · ·• ·•
•

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------'.. _-- ._-------- -~

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·
·
·•
·
· ·•
·· :

·•
·•
·
·
·
••

c', -r,p-',.
_ ...... '';:_'1
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·· ·• · ·
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·• :

I r·- ,.....,
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2. 't d

- _. - - -- - .- - - - - - . ~

.'
•
------ ------ -- - -- - ._-- - -_.
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••• - _ _ • ," .' _ _ • _ ••• _ _ .... -
:
_ .... . _ - _ .
•
• .' ._ ••• -0
:

Oed ia tr i '_ : ·• : •
-_.- ----- ---_ ..------------- ----_._----- ------._-----------_.- -"--
I ·• ·• : · : :

: ·• ·• ·• :

· ·• : ·• :
------_._-_.. _----_._----------_._----
·• .• .•
I (3ynecc log"
·
••
:

·•
·•
··
------_._-------------_._--------------
·• : :
--------------------------------.--------
I ·•
- - --.0;- - - - - - - - - - - - -
·• .• .• :
.... - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - _ . _ - - - - - _ . _ - - - - - - - . - . - _ . _ - _ . - _. - - -

rOTAL ·
• ·• : •• · ·•
I ================~==:~~============~~==========~;======~===~===============

A.j '.of

I
I 2

I
I
I 2.5 Ten Leading Causes of Disch~rg~= (riral Diagnosis).

I Final Diaqnosis f'Jo~ of

In-pc:ti?,-,'.:s
No. 9t
1..'"' -pQ t .i.e.. t 5

I ..,1.
L
..,.
...;..
•
b .
7.

4. q. .
I 5. 10.

I 3. Surgical Operations :

Type of Operations · · Female •• TCJtal

I ----_._--------_._------------------~-----------------
- ----- - ---- ---- - ------

Majo·r OperatIons · ·• :

I Minor Operation (in-patient) ·• •• :

Minor O~eration (out-patient) •• ·• ••

I Caesarian Operation •• ·• ••

· ·•
I TOTAL ••

4. Ou t-Pa. tien t

I - - ...
t_'I_'.~-P,~.~_ ;en~_-_-

Net..; :
.ntt--da~
-'- ,=" -~
.
Ole :
I To "\.. c".- l -•

....
4 .., Average numbar of p'?l'" day :

I a.. . ..,.
.... Services render~j in the

4.3.1 Con s u I tations :

_
'"'L': I t -P c:. . ~_
" t ; F=on

I " d s c-.-
K.1n f r~onsu£'t'"
a~~cn

r"led i cine

I Pediatrics
Surqer):
Obstetrics
Gynecoloq~:

I EENT
Dental
Fc3mily Planning

I TOTAL

I
3

I
I
I 4.3.: Ter, 1.-_ . . . i. riu
, e.ad ":-I r-"<:<:5
... __n~
. ,~I,-~_.L. Cor, SLI1 ta t i on ..

I CaL\SeS 1"... 0 •

P
0. f rv.
....:;."J "
- .. .L' <=>_1"_
,'-=-\. - .-
1_ - C..::\l.'. S E? S !\lo. of Out-
pD.t:ient

I 1.
2.
~.
......
--- ----------
-=.
..,
I
,--
•

.::l •
- - - . _.._------
------_ .._--_.
4. -----_._. c, . ---- •. _- --------_.-
I ..
0=
~
--_._--------- ---_._--
..
I 5. Other Services Rendered

Act i v i tiE 5 · Irr- ..: O,;;tie·nt : n~d:-?,:.tient ·· To tell

I RADIOLOGY
. r- I- . ...
( '-Itesl.~ " t_·W\"",I."
.... ,...,~·cn ·• •• ·
.. .
r-r .... I '!II

""
I Spec.Lal Radiolog.Lcal Procedures
(Ultra Sound, CT scan, etc.'
.... '- ,...-
·• · ·•

I TQH\L

EX r.'''' 1... "'CoT

·• ·• ·•
LA' B ~ R' A TI U
_'_' r',R 'J
J ",.....,'J \I. . . .T.OI"e'
... ~

I 1
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t·.: : ·• ·•
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t

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~----_._--.------
·•
---- ---------_._- -_ ... _---
8ec; Fluids E~aminatian : •• ·
I Hematology E~2minaticn
-- - _.- -. -..- -._..,---_. -- .... __ ....-- - - - -- -- ._.- - - -_.- - --_.-
· ·•
_

·•
--_._------_ .. _- --_._---,------ - _._---- -- ----

I ·• ••
----_._----------_.----------------------
•• ·•
••

••
----_ .. - --- ---_._---_.- --_.------- -'---- - ----
I SErology/Imm~nclo~y : ••
- - - ----------- -- - --_.- ----- -_. -- - - - - - - -- ---
·
Blood Ccllected

I Vo 1 loU, ta ry Dcnor- ·-• --- _. __._-------_.·• __.._-_._-- ---- -- -· -----_._----

Paid Donc·r · •• ••

I Blood Procured
--------------------------------------
·· ·•
I PNRC ••
-----------------_._--------------------
Hosoital Blood Sank ·----_.-."
• •• :
-_..._------- ----------------------
I 4

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I, 7 :nin~ july S;-1On, certify on my aoaor

t~l'l: .ill Dtdes on c.d.s lLst are t rue 'I,d;----~----
:.or('z::.i:.

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~ei:SOO Ad:.uru.s
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-_ .. _-_ ... _----------,-

Republic of the Phiiippines

Department of Health
BUREAU OF LICENSING AND REGULATION
Manila

hereby grants a license to

(Name of Hospital)
Located at
to operate as a level, hospital
------~-----,-"'--------- ----:-.:~~--:---:---
(Category) (Classiiicatlon)
with an authorized bed capacity of for the period
19 to , 19 pursuant to the provisions of
---------
Issued this - - - - - - - d~ ~
- - - - - - - 19 - - - at Manila,
Philippines:

BY AUTHORITY OF THE SECRETARY OF HEALTH

Director Undersecretary of Health

For Standards and Regulation

LICENSE NO.
----
I
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Republic of the Philippines
I Ministry of Health
OFFICE OF 'I'lIE MINISTER
Mo.nila.

I August 19, ).901

I MINISTRY CIRCULAR
NO.--JJL-.-s. 1981
I TO I The Bureau Directors, Regional Health Directors,
Project Directoro, Chiefs of Offices/Services!
Hospitals directly under the office of the Minister,
I Technical Staff;. Unit Heads and others concerned.

SUBJECT Approved Agency's Medical Hecords Disposition Schedule.

I ~'oriYour information and guidance, enclosed io a copy of the letter
dated June 9, 1981, transmitting the original copy of the Hedical Records
I Disposition Schedule of this Ministry as approved by the Director of Bureau
of Records Management which shall serve as a guide to your Records Diepoeit-
ion Program.
I All concerrted are hereby direct~d to be guided accordin{jly.

I (SGD.) J. C. AZUnIN
Ninister of Health
I
CEHTIFIED TRUE COPY a

I ~aA~'
G~O~A v. BAUTISTA
Chief, Records Section
I Ministry of Health
hbm-S/30/81

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Application for release of information 6 mons. : 6 mons. ; 1 yr.:
2. Bir:h ~crtificatc
·
·• ·
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Clinical Facc Sheet •

: ~
25 Republic Act 1\0. 4226;:-::-::-
4. Consent: ·
0 :
:
a. For. Aneathcsia • 25 do _
b. For care • 25
·• do
c. For surgery ·• • ·· ••
25 ·• de
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d. For tissue organ donation ·• 25
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f. For Voluntary consent 2!> : - fio -
g For special consent for surgery 25
·
0
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0

5. ··
0
Death Certificate P E B MAN E:N T - do -
6. Diet List
·
: • Dispose afterdischarge
·• ·•
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stall destroy or sell 8,(1 records with·Jut r:av~nr::
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~~~A·~~en:. in accordance with Rule 6 of De par-t.nerit Order-No.4 dated July 19, 19E8. For dispo3al of re c or-ds , acco!!;pEs.h
i>R;1 Form Z\o. 3
ue/4-9-o.1
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Item ~. ".- 1' .~ ". ·• Storage •• ·
Ho:o · RECORDS SERIES TITLE & DESCRIPTIOi "v '-\JL
''?C:,/ .A. "". :~.~':\
· Area · Total •• Disposition Authority/Remark
~ ...wJ·'-

·· · ·· ·•
70 : Discharge: ··
ao against medical advice ·· * ·· ·• 25 Republic Act No. 4226

b· summary ·• *
· 25 - do-
·•
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·· ··
8. Disease Index P A N E N• T
·• .t" • _'" •
• · ·•
9. •• Disposition of Cadaver 1 yr. · 24 · 25 : - do -
10.
•· History and Ppysical Examination
· *
· · 25 ·· do -
•• : •
:
·
11. Impatient Index Card * : ••
25 - do -
12. Laboratory Findings: ·· · · ·•
· a. Blood chemistry • : :
25 - do -
· ; ·•
•• b. Bone mqrroVi :
• ; ·• 25 - do -
·• c. Feces · * : •• 10 · - do -
·
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·•
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·• 25 ·•
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·• t'!. lfrinalysis : • ·• ·• 25
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,
13. • Haster Patient Index Card ·· P E RH A N E I~ T

14. Hedico Legal

·• ·• : I f use d as evidence
., .
•• •• ·• · follo\'l6 the retention
periods of the Court r-e cor cr
·• ·• ·• ·• ·•
·• •• · ·•
•• •• ·• ·•
: ·• •• ·•
•• ·• •• •• ·•
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5. Page 3 of 5 - a
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Act No. 4226
16. ·· Pediatric Hispory ~~d Physical Examination ·• • · ••
- do -
: : · ·• ·•
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·· Progress Notes : · ·• - do -
18. · Radiology findings and interpretation ••
• ••
·• ••
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· Record: ·• : ·•
·
a. E~erGen~y Room
:

·• . ...
:
: :
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b. Eight-hours observation ... : 25 ··
c. Graphic records (temperature, pulse, ·· : ·•
respiratory, etc.) : ... : 25 · do -
:
d. Labor ·• ... ·· · 25 : - do -
· : · : ·
·• e. NeVI Born ·• ... · 25 · - do -
·· f. Nurses Notes and l-ledication •· • :
·• 25 · - do -
••
g. Operation
· •
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• Report: ·• · ·· ·•
·• a Hospital daily census : 6 mons , ! 6 mons
0 : 1 yro: do -
•
·• ·
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bo Surgical pathology 25 - do -
·• •• :
· •
· •

•• c. Trunsfusion
· • • •
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•
25 ••
... do ...

••
•• · ·• ·•
·· ·• ·• ·• ·•
·• ••
•• ·• ••
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5. Page 4 of pc.

(6) .
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0
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21.
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Types and Cross-match blood bank

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2, Prepared by: : 13. hpproved by:

~~
FUENTE N.D.
·•
ist -III I

Ctu~
·
i
_:~RIQUE", ;. G, :~CIA l·j.D.
Directot- . Age*y Head ._
· of Heal}.l!''/"
l,~inisttir

,~~====~~~~===~==============~==============================================================~=~=======================
TO BE ACCOMPLISHED BY THE BUREAU OF RECORDS MANAGEMENT

""
1~18 R , tlon
' D l~PCSl
,ecorus ' o r -vC h e d u 1 e

C7 18 being retur~ed for improvement/correction

/x/ 15 recommended for approval.

June 5, 1981
"---=--= Chief, C~rrent Records Division Date
! RELr 4s;::---~-- ,
I r/~}2?:fD
- __ ~~) _-APPROVED:
By:_ W~ June 5, 1981
,
- BUREM/ ~- Director Date
- - -~ RECOp.::~ ~!""""I<" Bureau of Records Management
. .- . ; - .'1. £;'1'1'
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