Mu 63

(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
C S TIM CHNG
I. THNG TIN V C S C THM NH
1.Tn c s:
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:...........................................
+ Trung tm Y t d phng:
1 .......................................................; Chc v:............................................
2. .......................................................; Chc v:............................................
3. .......................................................; Chc v:............................................
B. i din ca c s c thm nh:
1. ..
2.
III. CN C PHP L THM NH
- Cn c Lut Phng, chng bnh truyn nhim ngy 21 thng 11 nm 2007;
- Cn c Quyt nh s 23/2008/Q-BYT ngy 07 thng 7 nm 2008 ca B
trng B Y t Quy nh v s dng vc xin, sinh phm y t trong d phng v
iu tr;
- Cn c Thng t s 01/1999/TT-BYT ngy 10 thng 02 nm 1999 ca B
trng B Y t hng dn vic qun l, s dng v vc xin, sinh phm min dch
dng cho ngi;
- Theo n ngh 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 63
(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 tim chng c qui m........................c t chc nh sau:
a. B phn qun l:
- Gim c Trng trm Y t

Ch c s

- Cc phng: ...
b. B phn chuyn mn: (Bao gm cc khoa/ phng chuyn khoa)
- .......
- ...
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 t vn

Phng khm
loi tr

Phng k thut

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)

Ghi ch

1
2
Tng s

b. Ngi chu trch nhim chuyn mn k thut phi c chng ch hnh ngh
t Khng t
c. Ngi thc hin k thut c tp hun v c cp giy chng nhn v
tim chng an ton
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
- C s ng k .phng, trong :
+ Phng .+ Phng ..
+ Phng +Phng ..
- C s c bin hiu
t Khng t
4.1. Phng khm, t vn:
- Bung khm bnh, cha bnh c din tch 12m2 t Khng t
- S khm bnh
t Khng t

Mu 63
(Ban hnh km theo Quyt nh s 617/Q-UBND-HC
ngy 28 thng 6 nm 2013 ca Ch tch UBND tnh ng Thp)

- Bn, gh ngi khm bnh

t Khng t
4.2. Phng k thut:
- Hp thuc chng sc v phc x l sc phn v t
Khng t
- S qun l, theo di tim chng
t Khng t
- S theo di cc ca phn ng sau tim chng
t Khng t
- Dng c, trang thit b y t
t Khng t
- C ging bnh
t Khng t
- T lnh v lch cp nht nhit
t Khng t
- C biu mu bo co tim chng theo quy nh
t Khng t
- C phiu (s) tim chng cho ngi tim chng
t Khng t
4.3. Bo qun vc xin
- S qun l, kim tra v i chiu nhp, xut v hn dng tng l vc xin,
sinh phm y t
t Khng t

Vc xin, sinh
phm
y
t
OPV
BCG
Si
MMR
MR
Hib ng kh
Vim gan B
DTP-VGB
Hib dung dch
DTP
DT/TT/Td
DTaP
DTP-VBGHib
DTP-VBGIPV-Hib

Tnh
Ti a 3 thng
-15C n -25C

Kho cc tuyn
Huyn
C s y t
im tim chng
1 thng
Theo k hoch bui
1-3 thng
hoc t hn
tim chng
+2C n +8C

Bo qun nhit +2C n

+8C nhng c th bo qun
nhit -15C n -25C nu
khng c ch.

+2C n +8C

Bo qun +2C n +8C,

Khng c ng bng

Bo qun +2C n +8C, Khng

c ng bng

Kt
qu

- H thng bo qun, lch theo di nhit h thng lnh

t Khng t
5. in, nc, v sinh, 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
- m bo cc iu kin x l cht thi v v sinh mi trng
t Khng t
- H thng PCCC
t Khng t
- Phng v sinh
t Khng t
6. Phm vi hnh ngh c th:

Mu 63
(Ban hnh km theo Quyt nh s 617/Q-UBND-HC
ngy 28 thng 6 nm 2013 ca Ch tch UBND tnh ng Thp)

..
..
7. 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
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

gi

pht, cng ngy.

TRNG ON

TH K

I DIN C S C THM NH