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    Review Ambulatory

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    Mary Hope A. Lima
    This document is a checklist for reviewing floor plans of an ambulatory surgical clinic. It contains sections for evaluating the physical plant, planning and design, and provides space for comments. The physical plant section includes items like the administrative areas, clinical service areas, and requirements for specific types of clinics. The planning and design section addresses requirements for properly labeled floor plans, building exits, and prescribed functional areas. The form is to be completed during the review process and provides a space for recommendations and signatures of the evaluation committee.

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    Attribution Non-Commercial (BY-NC)
    Download as PDF, TXT or read online from Scribd

    Review Ambulatory

    Uploaded by

    Mary Hope A. Lima
    184 views3 pages
    This document is a checklist for reviewing floor plans of an ambulatory surgical clinic. It contains sections for evaluating the physical plant, planning and design, and provides space for comments. The physical plant section includes items like the administrative areas, clinical service areas, and requirements for specific types of clinics. The planning and design section addresses requirements for properly labeled floor plans, building exits, and prescribed functional areas. The form is to be completed during the review process and provides a space for recommendations and signatures of the evaluation committee.

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    inspection tool

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    This document is a checklist for reviewing floor plans of an ambulatory surgical clinic. It contains sections for evaluating the physical plant, planning and design, and provides space for comments. The physical plant section includes items like the administrative areas, clinical service areas, and requirements for specific types of clinics. The planning and design section addresses requirements for properly labeled floor plans, building exits, and prescribed functional areas. The form is to be completed during the review process and provides a space for recommendations and signatures of the evaluation committee.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    184 views3 pages

    Review Ambulatory

    Uploaded by

    Mary Hope A. Lima
    This document is a checklist for reviewing floor plans of an ambulatory surgical clinic. It contains sections for evaluating the physical plant, planning and design, and provides space for comments. The physical plant section includes items like the administrative areas, clinical service areas, and requirements for specific types of clinics. The planning and design section addresses requirements for properly labeled floor plans, building exits, and prescribed functional areas. The form is to be completed during the review process and provides a space for recommendations and signatures of the evaluation committee.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 3

    Form ASC-PTC-CR-2007 Republic of the Philippines Department of Health

    BUREAU OF HEALTH FACILITIES AND SERVICES


    Building 15, San Lazaro Compound, Rizal Avenue, Sta. Cruz, 1003 Manila Trunk Line: 743-83-01; Direct Line: 711-9572; Fax: 781-4179 URL: http://www.doh.gov.ph/

    CHECKLIST FOR REVIEW OF FLOOR PLANS AMBULATORY SURGICAL CLINIC Name of Ambulatory Surgical Clinic Address Date 1

    Review:

    1st

    2nd

    3rd

    PHYSICAL PLANT ____ 1.1 Administrative Service ____ 1.1.1 Lobby ____ 1.1.1.1 Information Counter/Admitting Area ____ 1.1.1.2 Patient Waiting Area ____ 1.1.1.3 Toilet ____ 1.1.2 Business Office ____ 1.1.2.1 Cashier/Billing ____ 1.1.3 Medical Records Area ____ 1.1.4 Parking Area for Patient Transport Vehicle ____ 1.2 Clinical Service ____ 1.2.1 All Ambulatory Surgical Clinics (except those performing Lithotripsy ONLY or No-Scalpel Vasectomy ONLY) ____ 1.2.1.1 Operating Room ____ 1.2.1.2 Scrub-up Area with sink ____ 1.2.1.3 Sterilizing Room ____ 1.2.1.4 Sterile Instrument, Supply and Storage Area ____ 1.2.1.5 Clean-up Area ____ 1.2.1.6 Dressing Room with sink and toilet ____ 1.2.1.7 Recovery Room with toilet ____ 1.2.1.8 Consultation/Examination/Treatment Area ____ 1.2.1.9 Room with radiation hazard-protected walls and soundproofed (for ASC performing Lithotripsy) ____ 1.2.2 Ambulatory Surgical Clinic performing Lithotripsy ONLY ____ 1.2.2.1 Room with radiation hazard-protected walls and soundproofed ____ 1.2.2.2 Consultation/Examination/ Treatment Area ____ 1.2.3 Ambulatory Surgical Clinic performing No-Scalpel Vasectomy ONLY ____ 1.2.3.1 Consultation/Examination/Treatment Room ____ 1.2.3.1.1 Consultation/Examination/ Treatment Area ____ 1.2.3.1.2 Scrub-up Area with sink ____ 1.2.3.2 Clean-up Area ____ 1.2.3.3 Dressing Area ____ 1.2.3.4 Sterile instrument, supply and storage Area ____ 1.2.3.5 Sterilizing Area ____ 1.2.3.6 Recovery Area
    Page 1 of 3

    Form ASC-PTC-CR-2007

    PLANNING AND DESIGN ____ 2.1 Floor plans properly identified and completely labeled ____ 2.2 Conforms to applicable codes as part of normal professional service: ____ 2.2.1 Exits restricted to the following types: door leading directly outside the building, interior stair, ramp, and exterior stair ____ 2.2.2 Minimum of two (2) exits, remote from each other, for each floor of the building ____ 2.2.3 Exits terminate directly at an open space to the outside of the building ____ 2.3 Meets prescribed functional programs: ____ 2.3.1 Main entrance of the ambulatory surgical clinic directly accessible from public road ____ 2.3.2 Business Office located near the main entrance of the ambulatory surgical clinic ____ 2.3.3 Operating Room/Treatment Room (for No-Scalpel Vasectomy) located and arranged to prevent non-related traffic through the room ____ 2.3.4 Dressing Room/Dressing Area arranged to avoid exposure to dirty areas after changing to surgical garments ____ 2.3.5 Scrub-up Area recessed into an alcove or other open space out of the main traffic

    COMMENTS:

    Page 2 of 3

    Form ASC-PTC-CR-2007 Republic of the Philippines Department of Health

    BUREAU OF HEALTH FACILITIES AND SERVICES


    Building 15, San Lazaro Compound, Rizal Avenue, Sta. Cruz, 1003 Manila Trunk Line: 743-83-01; Direct Line: 711-9572; Fax: 781-4179 URL: http://www.doh.gov.ph/

    Name of Ambulatory Surgical Clinic Address RECOMMENDATION: [ [ ] ] Approved Disapproved Date Date

    REVIEWED AND EVALUATED BY:

    Engr. HERMINIO G. DIONCO Chairperson

    Dr. MA. BRENDA C. PANCHO Vice-Chairperson

    Engr. RODELIO A. PINEDA / Engr. JUN JORGE O. SORIANO Member

    Engr. AIDA M. ANGELES / Engr. NELEEN A. ANINO Member

    Arch. EFREN C. LOPEZ / Arch. ANNABELLE C. SOTTO Member

    Ms. ROSE MYLENE A. SOTOCINAL / Dr. LILIBETH M. VALEZA Member

    Mr. JOSELYN T. VIORGE / Ms. NILDA B. SILVERA Member

    Mr. ALFONSO A. FAVIS Member

    Page 3 of 3

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