Mu 56

(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
PHNG KHM A KHOA.....................
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)

Mu 56
(Ban hnh km theo Quyt nh s 617/Q-UBND-HC
ngy 28 thng 6 nm 2013 ca Ch tch UBND tnh ng Thp)

...

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

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: (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
a) Tng s Y, Bc s
- Tin s y hc
- Thc s y khoa
- Chuyn khoa II
- Chuyn khoa I
- Bc s
- Y s lm cng tc iu
tr
b) Tng s Dc
- Thc s
- Chuyn khoa II
- Chuyn khoa I
- Dc s i hc
- Dc s Trung
hc/KTV dc TH
- Dc t (s hc)
c) Tng s iu dng

Phng hnh
chnh

Lm sng

Cn lm
sng

Dc

Mu 56
(Ban hnh km theo Quyt nh s 617/Q-UBND-HC
ngy 28 thng 6 nm 2013 ca Ch tch UBND tnh ng Thp)

- Tin s / Thc s iu
dng
- i hc iu dng
- Cao ng iu dng
- Trung hc iu dng
- S hc iu dng
d) Tng s N h sinh
- Thc s h sinh
- i hc h sinh
- Cao ng h sinh
- Trung hc h sinh
- S hc h sinh
e) Tng s K thut
vin Y
- Thc s
- i hc
- Cao ng
- Trung hc
- S hc
f) Tng s cc cn b
khc:
- Thc s/ Tin s
- i hc
- Cao ng
- Trung hc
- S hc
Tng s
TT

Chc danh
a) Tng s Y, Bc s
- Tin s y hc
- Thc s y khoa
- Chuyn khoa II
- Chuyn khoa I
- Bc s
- Y s lm cng tc
iu tr
b) Tng s Dc
- Thc s
- Chuyn khoa II

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

Mu 56
(Ban hnh km theo Quyt nh s 617/Q-UBND-HC
ngy 28 thng 6 nm 2013 ca Ch tch UBND tnh ng Thp)

- Chuyn khoa I
- Dc s i hc
- Dc s Trung
hc/KTV dc TH
- Dc t (s hc)
c) Tng s iu
dng
- Tin s / Thc s iu
dng
- i hc iu dng
- Cao ng iu dng
- Trung hc iu
dng
- S hc iu dng
d) Tng s N h
sinh
- Thc s h sinh
- i hc h sinh
- Cao ng h sinh
- Trung hc h sinh
- S hc h sinh
e) Tng s K thut
vin Y
- Thc s
- i hc
- Cao ng
- Trung hc
- S hc
f) Tng s cc cn b
khc:
- Thc s/ Tin s
- i hc
- Cao ng
- Trung hc
- S hc
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 ................................................................

Mu 56
(Ban hnh km theo Quyt nh s 617/Q-UBND-HC
ngy 28 thng 6 nm 2013 ca Ch tch UBND tnh ng Thp)

- Trn nh chng bi v c chiu cao ti thiu l 3,1 m:

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 .khoa, trong :
+ Khoa .+ Khoa ..
+ Khoa + Khoa ..
+ Khoa + Khoa ..
- C s c bin hiu ng qui nh (tn c s, a ch, gi lm vic, ngi ph
trch, in thoi..)
t
Khng t
4.1. Phng tip nhn:
- C ni tip n ngi bnh
t
Khng t
- C ni ngi bnh ngi ch
t
Khng t
4.2. Phng cp cu:
- C din tch 12m 2
t
Khng t
4.3. Phng lu bnh:
- C din tch 15m2 (nu c 02 ging lu bnh) hoc 05 m2/ ging
(nu c 03 ging lu bnh)
t
Khng t
4.4. Phng khm:
- Mi phng khm chuyn khoa c din tch 10m2
- Mi bung th thut/ tiu phu (i vi c din tch 10m2
- Bung vn ng tr liu (nu c) din tch 40m2
TT

Tn Phng khm, bung th thut

4.5. Phng X quang, CT Scan, MRI:

a. Phng X quang c b tr:
- C ni tip n ngi bnh

Din tch

Khng t

Khng t

Mu 56
(Ban hnh km theo Quyt nh s 617/Q-UBND-HC
ngy 28 thng 6 nm 2013 ca Ch tch UBND tnh ng Thp)

- C ni ngi bnh ngi ch

t
Khng t
- Phng ra phim, in nh
t
Khng t
- C bng quy nh vn hnh thit b
t
Khng t
- S lu kt qu
t
Khng t
- H thng lu tr, bo qun phim (t , nhit k,)
t
Khng t
- H thng PCCC
t
Khng t
b. Vic thit k, xy dng phng X quang phi m bo cc yu cu sau:
- Phng t thit b phi thong rng, trn nh cao t nht 3m50
t
Khng t
- Tng gch trt bart
t
Khng t
- Ca c p tm ch
t
Khng t
- Nn nh cao ro
t
Khng t
- ng in m bo an ton v cng sut cho my hot ng
t
Khng t
4.6. Phng Siu m:
- Phng siu m phi rng 10 m2, c mn che nh sng, iu ha
nhit , ging, gh ch,...
t
Khng t
- C bng quy nh v s dng v bo qun my, trang thit b.
t
Khng t
4.7. Phng xt nghim
- Din tch ti thiu 14 m2 (3 bn xt nghim)
t
Khng t
- Sn:
+ Sn gia cc khng gian khng chnh ct, khng c g ca m bo
phng, nhn, khng trn trt, chu c ho cht, chng thm v d c ra v
sinh.
t
Khng t
+ Sn bn trong cc phng ra tit trng, chun b mi trng chun b
mu phi chng trn, thu nc khi c ra.
t
Khng t
+ Giao tuyn ca sn vi tng m bo d v sinh, chng ng v bm
bi.
t
Khng t
- Tng:
+ Tng c hon thin bng vt liu cht lng cao m bo lp che
ph b mt phng, nhn.
t
Khng t
+ Tng bn trong cc phng labo s dng vt liu chng thm, chng n
mn ho cht, d c ra, sn khng khun.
t
Khng t
- Trn:

Mu 56
(Ban hnh km theo Quyt nh s 617/Q-UBND-HC
ngy 28 thng 6 nm 2013 ca Ch tch UBND tnh ng Thp)

Trn phi c b mt phng, nhn (khng bm bi) chng thm v phi p

ng lp t c cc thit b (chiu sng, phng chy cha chy, iu ho khng
kh v cc thit b k thut...)
t
Khng t
- Phng xt nghim v sinh sch s, khng dn giy, ng inh ln tng
t Khng t
- Thng rc c np y theo ng quy nh rc
t Khng t
(Trng hp Phng khm c t chc phng xt nghim vi sinh phi m
bo theo tiu chun quy nh ti Thng t s 29/2012/TT-BYT ngy 04/12/2012
ca B trng B Y t Quy nh th tc cp mi, cp li giy chng nhn phng
xt nghim t tiu chun an ton sinh hc)
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. Trang thit b dng c y t:
- Danh mc trang thit b y t (nh km bin bn)
t
Khng t
- C s thuc v dng c cp cu ng quy nh
t
Khng t
- Lp l lch, xy dng ni quy, quy nh vn hnh thit b, thc hin ch
bo dng thng xuyn v nh k (nu c s dng my)
t
Khng t
7. Phm vi hnh ngh c th:

..
..
..
8. 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. Thc hin vic k n thuc, bnh n
t
Khng t
4. Ghi s lu kt qu y
t
Khng t

Mu 56
(Ban hnh km theo Quyt nh s 617/Q-UBND-HC
ngy 28 thng 6 nm 2013 ca Ch tch UBND tnh ng Thp)

9. 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
gi
pht, cng ngy.
TRNG ON
PHNG Y T
TH K

I DIN C S C THM NH