Mu 60

(Ban hnh km theo Quyt nh s 617/Q-UBND-HC

ngy 28 thng 6 nm 2013 ca Ch tch UBND tnh ng Thp)

UBND TNH NG THP

S Y T

CNG HO X HI CH NGHA VIT NAM

c lp- T do- Hnh phc

........................., ngy....... thng... .....nm 20....

BIN BN THM NH
NH H SINH........................
I. THNG TIN V C S C THM NH
1.Tn c s khm bnh, cha bnh:.
2. a ch:
3. in thoi:. Email (nu c):.
4. Fax:
II. THNH PHN THAM GIA THM NH
A. Thnh phn on thm nh
+ S Y t:
1. .......................................................; Chc v:...........................................
2. .......................................................; Chc v:...........................................
3. .......................................................; Chc v:...........................................
4. .......................................................; Chc v:...........................................
+ Phng Y t:
1 .......................................................; Chc v:............................................
2. .......................................................; Chc v:............................................
B. i din ca c s c thm nh:
1. ..
2.
III. CN C PHP L THM NH
- Cn c Lut Khm bnh, cha bnh ngy 23 thng 11 nm 2009;
- Cn c Ngh nh s 87/2011/N-CP ngy 27 thng 9 nm 2011 quy nh
chi tit thi hnh mt s iu ca Lut khm bnh, cha bnh;
- Cn c Thng t s 41/2011/TT- BYT ngy 14/11/2011 ca B Y t hng
dn cp chng ch hnh ngh i vi ngi hnh ngh v cp giy php hot
ng i vi c s khm bnh, cha bnh.
- Theo n ngh cp giy php hot ng khm bnh, cha bnh ca ng
(B):
IV. NI DUNG THM NH
1. H s php l: (Lit k y cc giy t c lin quan)

...

Nhn xt: ..........

Mu 60
(Ban hnh km theo Quyt nh s 617/Q-UBND-HC
ngy 28 thng 6 nm 2013 ca Ch tch UBND tnh ng Thp)

2. T chc b my:
C s khm bnh, cha bnh c qui m........................c t chc nh sau:
a. B phn qun l:
- Ban gim c

Ch c s

- Cc phng: ...
b. B phn chuyn mn:
- .......
- ...
Nhn xt: .....

3. T chc, nhn s:
a. C s c tng s nhn vin: ...... ngi; trong nhn vin lm cng vic
chuyn mn: ....... ngi.
TT

Chc danh

Phng khm
thai

Phng khm
ph khoa

Phng k
thut KHHG

Phng

1
2
3
Tng s
TT

Chc danh

Hp ng lm vic
thng xuyn (ton thi
gian)

Hp ng lm vic
khng thng xuyn
(mt phn thi gian)

Tng s

1
2
Tng s

b. Ngi chu trch nhim chuyn mn k thut phi c chng ch hnh ngh
v thc hin vic khm bnh, cha bnh trong phm vi phn cng
t
Khng t
4. C s vt cht:
- Din tch chungm2, (di.m. x rngm.......);
- Kt cu nh ................................................................
- Trn nh chng bi:
t
Khng t
- Tng v nn s dng vt liu d ty ra lm v sinh
t
Khng t
- nh sng
t
Khng t
- Tch bit vi ni sinh hot gia nh
t
Khng t
- C s ng k .Phng, trong :
+ Phng .+ Phng ..
+ Phng + Phng ..
+ Phng + Phng ..
- C s c bin hiu ng qui nh (tn c s, a ch, gi lm vic, ngi
ph trch, in thoi..)
t
Khng t
- Phng v sinh
t
Khng t

Mu 60
(Ban hnh km theo Quyt nh s 617/Q-UBND-HC
ngy 28 thng 6 nm 2013 ca Ch tch UBND tnh ng Thp)

- H thng cc Phng thit k lin hon , hp l thun tin cp cu; khm

bnh, cha bnh
t Khng t
4.1. Din tch phng khm:
- Phng khm thai c din tch 10m2
t Khng t
2
- Phng khm ph khoa c din tch 10m
t Khng t
- Phng thc hin cc dch v KHHG c din tch 10m2
t Khng t
2
- Phng c din tch 16m
t Khng t
2
- Phng hu sn c din tch 20m (hoc m bo din tch 05m2
/ging)
t Khng t
4.2. Kt cu v hon thin cng trnh:
4.2.1. Tng cc phng , phng thc hin cc dch v KHHG phi p
gch men knh hoc sn chng thm t sn ti trn nh. t
Khng t
4.2.2. Sn nh lt bng gch hoa xi mng, ring phng , phng thc hin
cc dch v KHHG phi c bin php chng trn v d dng v sinh c ra (s
dng granito mi ti ch hoc gch Ceramic kh to). t Khng t
4.2.3. Trn nh c th phng hoc dc nhng phi iu kin cch nhit,
cch m, chng thm tt. C th kt hp chiu sng t trn phng, phi sn hoc
qut vi mu sc sng sa, nh nhng.
t Khng t
4.2.4. Ca s cc phng , phng thc hin cc dch v KHHG v cc
phng khm - lu bnh nhn cc min c ma lnh cn c thm lp ca pan
knh (nhm hoc g).
t Khng t
4.2.5. Ca i phi c khun, pan g hoc nhm, st. Cc ca bn trong
phng , phng thc hin cc dch v KHHG, khm ph khoa phi kn o
(ca pan knh m).
t Khng t
5. in, nc, v sinh mi trng, phng chy cha chy:
- H thng in, h thng nc m bo, c trang b labo ra tay, ra dng c
t Khng t
- C h thng x l nc thi ng quy nh
t Khng t
- C h thng x l cht thi rn ng quy nh (hoc hp ng x l cht thi
rn vi trm y t hoc bnh vin)
t Khng t
t Khng t
- H thng PCCC
t Khng t
6. Thuc v thit b dng c y t:
- Danh mc thuc (nh km bin bn)
t Khng t
- Trang thit b y t (nh km bin bn)
t Khng t
7. Phng tin cp cu:
T trang b phng tin vn chuyn cp cu trong v ngoi nh h sinh
C
Khng c
Nu khng c phng tin vn chuyn cp cu ngoi nh h sinh th c hp
ng vi c s c phng tin cp cu
C hp ng
Khng c hp ng

Mu 60
(Ban hnh km theo Quyt nh s 617/Q-UBND-HC
ngy 28 thng 6 nm 2013 ca Ch tch UBND tnh ng Thp)

8. Phm vi hnh ngh c th:

..
..
9. Quy trnh k thut
1. C bng quy trnh k thut y
t Khng t
2. Bo m an ton cho ngi bnh khi thc hin cc k thut
t Khng t
3. Ghi s lu kt qu y
t Khng t
10. Gi dch v d kin:...................................................................................
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
V. KT LUN V KIN NGH
1. Kt lun:
..
2. Kin ngh:
..
..
..
..
3. kin khng ng vi kt lun v kin ngh ca on thm nh (nu c)
.....
..
..
..
..
Bin bn kt thc lc
TRNG ON

gi

pht, cng ngy.

PHNG Y T

I DIN C S C THM NH

TH K