Mu 68

(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
TRM Y T .............................................
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:
5. Ngi i din:.; Chc v:
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:
+ Trung tm y t (gim st):
1. ..
2.
+ Trm Y t:
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.
- Cn c Quyt nh s
/Q-SYT ngy
/ /20
ca S Y t v vic
thnh lp on thm nh c s khm bnh, cha bnh cng lp.
- Theo n ngh cp giy php hot ng khm bnh, cha bnh ca trm y
t
IV. NI DUNG THM NH
1. H s php l: (Lit k y cc giy t c lin quan)

Mu 68
(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: Trng trm

b. B phn chuyn mn:

+ Phng .+ Phng ..
+ Phng + Phng ..
+ Phng + Phng ..
+ Phng + Phng ..
+ Phng + Phng ..
+ Phng + Phng ..
+ Phng + Phng ..
+ Phng + Phng ..
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
- Chuyn khoa II
- Chuyn khoa I
- Bc s
- Y s lm cng tc iu
tr
b) Tng s Dc
- Dc s i hc
- Dc s Trung
hc/KTV dc TH
- Dc t (s hc)
c) Tng 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
- i hc h sinh
- Cao ng h sinh

Phng hnh
chnh

Lm sng

Cn lm
sng

Dc

Mu 68
(Ban hnh km theo Quyt nh s 617/Q-UBND-HC
ngy 28 thng 6 nm 2013 ca Ch tch UBND tnh ng Thp)

- Trung hc h sinh
- S hc h sinh
e) Tng s K thut
vin Y
- i hc
- Cao ng
- Trung hc
- S hc
f) Tng s cc cn b
khc:
- i hc
- Cao ng
- Trung hc
- S hc
Tng s
TT

Chc danh
a) Tng s Y, Bc s
- Chuyn khoa II
- Chuyn khoa I
- Bc s
- Y s lm cng tc
iu tr
b) Tng s Dc
- Dc s i hc
- Dc s Trung
hc/KTV dc TH
- Dc t (s hc)
c) Tng 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
- i hc h sinh
- Cao ng h sinh
- Trung hc h sinh
- S hc h sinh

Hp ng lm vic
thng xuyn (ton thi
gian)

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

Tng s

Mu 68
(Ban hnh km theo Quyt nh s 617/Q-UBND-HC
ngy 28 thng 6 nm 2013 ca Ch tch UBND tnh ng Thp)

e) Tng s K thut
vin Y
- Cao ng
- Trung hc
- S hc
f) Tng s cc cn b
khc:
- 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 ................................................................
- C s ng k .phng, trong :
- C s c bin hiu ng qui nh (tn c s, a ch, in thoi..)
t
Khng t
4.1. Yu cu v khu t xy dng v mt bng tng th
a. Khu t xy dng
- Khu t xy dng trm y t c s phi bo m cc yu cu sau :
+ V tr khu t xy dng cn t gn cc trc giao thng lin x qua cc
khu vc trung tm x, phng, th trn; thun tin cho c dn ti trm chm
sc sc kho ban u v khm - cha bnh.
t
Khng t
+ Khu t xy dng phi thong, cao ro, t tn km v bin php x l
nn mng hay thot nc mt, nc thi.
t
Khng t
+ Khu t xy dng phi m bo c ngun cung cp nc sch thng
xuyn.
t
Khng t
+ Khu t xy dng phi ph hp vi quy hoch chung v m bo bn
knh phc v.
t
Khng t
- Din tch t xy dng trm y t c s khong t 600 1200m2 b
tr cc hng mc:
+ Xy dng nh trm, cng trnh ph tr (nh bp, nh v sinh, ln i v
nh xe).
t
Khng t
+ ng giao thng ni b v din tch xy dng cng, tng ro.
t
Khng t
+ Sn vn cy xanh (cy cnh v cy to bng mt).
t
Khng t
+ Khu trng cy dc liu, thuc nam, vn mu. t Khng t
- Mt xy dng cho php khng ln hn 30 35 % din tch khu t

Mu 68
(Ban hnh km theo Quyt nh s 617/Q-UBND-HC
ngy 28 thng 6 nm 2013 ca Ch tch UBND tnh ng Thp)

t
Khng t
- Khong cch gii hn t mp ngoi tng ro cng chnh ti mt trc nh
trm khng c nh hn 6m.
t
Khng t
b. Cy xanh
- T l din tch cy xanh (gm din tch trng cy bng mt kt hp vn
hoa v vn cy thuc Nam) t 30 40 % tng din tch khu t.
t
Khng t
- Vn mu trng cy dc liu, thuc Nam (gm 60 loi cy cha 9 loi
bnh thng thng) phi cch mp tng ngoi nh trm ln hn 2m.
t
Khng t
- Trong khu t xy dng khng trng cc loi cy c nha c, c gai, cy
c hoa qu thu ht rui mui, cn trng.
t
Khng t
c. Li ra vo, ng i v sn trong
- Trong mt bng tng th khu t xy dng trm y t c s phi c ro bo
v ngn gia sc, gia cm.
t
Khng t
- ng i gia cc b phn trong khun vin trm y t c s c chiu rng
ti thiu l 1,2m.
t
Khng t
- Pha ngoi nh trm y t phi c sn ch, bi xe cho khch v nhn vin.
t
Khng t
- i vi trm y t tip gip sng (knh, rch) cn b tr xy dng bn
thuyn a n bnh nhn.
t
Khng t
4.2. Ni dung cng trnh v nhng yu cu v gii php thit k
a. Dy chuyn hot ng c b tr phi m bo nguyn l sch bn mt
chiu
t
Khng t
b. Cc phng khm - cha bnh, phng v phng thc hin cc dch v
KHHG phi c b tr ring bit, m bo iu kin v khun.
t
Khng t
c. Chiu cao cc phng trong trm y t c s phi ln hn 3,3m. Cc phng
ph tr v sinh t ngoi nh, chiu cao ti thiu 2,8m.
t
Khng t
d. Chiu rng cho hnh lang, ca i, cu thang c quy nh.
Hnh lang rng 1,5 2,8m.
t
Khng t
. Ca i: Chiu cao ca t 2,1m 2,4m
t
Khng t
+ Ca i c chuyn cng c chiu rng khng nh hn 1,4m.
t
Khng t
+ Ca phng chiu rng khng nh hn 1,2m.
t Khng t
+ Ca phng thng thng c chiu rng 1,0m; ca phng khu v sinh v
bp rng 0,7m.
t
Khng t
e. Cu thang (nu c): Chiu rng m bo 1,2m t Khng t
+ dc phi m bo: 30
t Khng t
+ Chiu rng chiu ngh phi m bo: 1,2m
t Khng t
g. Ni dung cng trnh
- Snh tip n t ngay li ca chnh, c hnh lang lin h trc tip vi cc
khng gian chc nng, din tch 8 12m2
t Khng t

Mu 68
(Ban hnh km theo Quyt nh s 617/Q-UBND-HC
ngy 28 thng 6 nm 2013 ca Ch tch UBND tnh ng Thp)

. Snh tip n phi c din tch b tr gh i khm bnh v bn lm th

tc tip n.
t
Khng t
. Snh c th b tr kt hp vi khng gian a nng, khng gian khm bnh.
t
Khng t
. Quy, t thuc c th kt hp t trong khng gian snh.
t
Khng t
- Khng gian tuyn truyn t vn, phc v cc chng trnh TCMR v ung
vc xin (khng gian a nng), din tch 14 16m 2 (c sc cha 10 ngi ln vi
tiu chun 1,4 1,6 m2/ngi).
t
Khng t
- Khng gian a nng b tr gn li vo, c th kt hp cc chc nng snh
tip n, khm bnh thng thng.
t
Khng t
. Phng a nng phi c din tch b tr cc bng gh i, nghe tuyn truyn,
t vn v hi hp, c bng pan tuyn truyn c ng cng tc chm sc sc
kho, c t trng by, lu tr.
t
Khng t
. Phng a nng cn l ni thc hin vic TCMR, tim phng, cho ung
thuc theo chin dch ca cc cc chng trnh y t quc gia ti x, phng, th
trn.
t
Khng t
- Phng khm - cha bnh Ty y thc hin cng tc khm cha cc bnh
thng thng v t chc s cu ban u c din tch t 12 14m2.
t
Khng t
. Phng khm - cha bnh Ty y phi c din tch b tr bn lm vic,
ging khm, chu ra tay.
t
Khng t
. Nu c kt hp chc nng th thut, phng tim ti ch c th tng din
tch thm t 2 4m2.
t
Khng t
- Phng khm - cha bnh theo phng php Y hc c truyn c din tch t
12 14m2.
t
Khng t
. Phng khm cha - bnh theo phng php Y hc c truyn phi c din
tch b tr ging xoa bp, bm huyt v chm cu. t Khng t
. i vi cc c s c lng y k n bc thuc ti ch nn c t thuc y
hc dn tc v bn bc thuc, bt mch.
t
Khng t
. Phng khm cha - bnh theo phng php Y hc c truyn c th kt hp
vi hnh lang ph phi sy, cht, thi thuc ....
t Khng t
- Phng c din tch 13 15m2
t Khng t
. Phng c din tch b tr 1 bn v bn n tr s sinh, ch ra tay, xe
y ng dng c.
t
Khng t
. Phng lin h vi khu tit trng cn phi c vch ngn v c ca ring
a bn, nhim khun. Dy chuyn sch bn (ra tay v dng c) mt chiu,
c t dng c sch.
t
Khng t
- Phng thc hin cc dch v KHHG c din tch t 13 15m2 t lin st
phng v khu ra tit trng.
t
Khng t
. Phng thc hin cc dch v KHHG phi c din tch b tr chu ra tay,
bn th thut c li lin h vi khu tit trng (chung vi khu tit trng phng ),
dy chuyn sch bn mt chiu.
t
Khng t

Mu 68
(Ban hnh km theo Quyt nh s 617/Q-UBND-HC
ngy 28 thng 6 nm 2013 ca Ch tch UBND tnh ng Thp)

- Phng ra, tit trng dng c c din tch t 5 7m 2 , c ca ring thot ra

ngoi; m bo dy chuyn sch bn mt chiu.
t Khng t
2
- Phng lu sau c din tch t 12 14m , b tr 2 ging bnh nhn, c
v tr st gn phng .
t
Khng t
. iu kin cho php nn c v sinh ring (1 x, 1 ra) cho sn ph vi din
tch 3 5m2 lin phng khp kn.
t
Khng t
- Phng lu bnh nhn thng thng c din tch t 12 14m2 (i vi
phng 2 ging) hoc 18 20m2 (i vi phng 3 ging) v gn khu v sinh
chung
t
Khng t
- Phng v sinh chung (cn b CNV v bnh nhn) c din tch 4 6m2 (1 x,
1 tiu, 1 tm ra).
t
Khng t
2
- Kho dng c, thit b c din tch t 4 6m (c th tn dng phn xp pha
trn phng ra tit trng).
t
Khng t
2
- Phng bp nu c din tch t 4 6m , t v tr cui hng gi, pha sau
cng trnh chnh.
t
Khng t
2
- Quy thuc c din tch t 4 6m t v tr d tip cn trc tip, gn
cng chnh, snh (c t quy qun l thuc, dc phm). t Khng t
- Ton b din tch hnh lang, li i bn trong nh khng cho php vt qu
35 % tng din tch xy dng nh trm.
t
Khng t
4.3. Nhng yu cu v cc gii php k thut
a. Chiu sng v thng thong t nhin
- Trong trm y t c s, cc phng phi c chiu sng t nhin trc tip v
thng gi t nhin.
t
Khng t
- H thng chiu sng t nhin cho cc phng (theo phng php tnh ton
ri bn trong DF trung bnh) theo tiu chun sau:
T l (%)
Loi phng
(Din tch ca s/Din
tch sn)
1. Cc phng ch yu
Khng nh hn 20%
t Khng t
2. Cc phng tm lu, phng Khng nh hn 15%
t Khng t
ph tr
b. K thut h tng
- Cp in
. Trm y t c s phi c cung cp in y cho chiu sng v s dng
cc thit b.
t
Khng t
. Mng in s dng dy dn rut ng v PVC 2 lp i trong ng t ni
hoc chm trong tng, trn, b tr cu dao t ngt ti tng phng m bo an
ton.
t
Khng t
- Cp nc
. Trm y t c s phi c cp nc lin tc sut ngy m t ngun nc
my ( th); ging khoan ( nng thn) v cc b d tr. Nc qua x l
m bo tiu chun v sinh, cht lng theo QCVN 02:2009/BYT do Cc Y t
d phng v Mi trng bin son v c B trng B Y t ban hnh theo

Mu 68
(Ban hnh km theo Quyt nh s 617/Q-UBND-HC
ngy 28 thng 6 nm 2013 ca Ch tch UBND tnh ng Thp)

Thng t s 05/2009/TT - BYT ngy 17/6/2009.

t
Khng t
. Tiu chun cp nc ca mt trm y t c s t 3.000 4.000lt/ngym.
t
Khng t
- Thot nc
Trm y t c s phi c h thng thot nc mt bo m hot ng ti
trm v khng nh hng n mi trng xung quanh. H thng thot nc nn
dng bin php t chy.
t
Khng t
- Nc thi
Trm y t c s phi c h thng x l nc thi, nc thi t khu k thut
KBCB (phng v phng thc hin cc dch v KHHG, ...), nc sn khi c
ra phi c h thng ng kn thu nc, x l ring m bo v sinh mi
trng.
t
Khng t
- Cht thi rn
Cc cht thi rn phi c ni tp trung cc cht thi rn ring, c l hu
cht thi hoc hp ng x l cht thi rn nguy hi.
t Khng t
c. Yu cu v phng chy, cha chy
- Trm y t c s l cng trnh chu la bc III (theo Tiu chun Vit Nam
TCVN 2748-1991)
t
Khng t
. Trm y t c s phi c bnh cu ha t trong nh.
t
Khng t
. Phi c b tr nc cu ho va phc v sinh hot khi ma kh, c th
tch 6 - 8m3.
t
Khng t
. Nu c iu kin, nn c h ct d tr cu ha gn cng trnh.
t
Khng t
d. Yu cu v kt cu v hon thin cng trnh
- Tng cc phng , phng thc hin cc dch v KHHG phi p gch
men knh hoc sn chng thm t sn ti trn nh. Cc phng khm - cha bnh
phi c p gch chn tng. Phn tng cn li c th sn hoc qut vi mu
sng.
t
Khng t
- 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
- 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
- Ca s trong trm y t c s bng pan hoc chp v c h thng hoa st
bo v.
t
Khng t
- Ca i trong trm y t c s phi bo m an ton, bn vng. 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

Mu 68
(Ban hnh km theo Quyt nh s 617/Q-UBND-HC
ngy 28 thng 6 nm 2013 ca Ch tch UBND tnh ng Thp)

- Cc hng mc cng trnh trm y t c s phi c kt cu bn vng, c

xy dng, ci to hon thin c ni, ngoi tht theo ng cc tiu chun xy dng
hin hnh v yu cu ring ca cng trnh y t.
t
Khng t
5. Trang thit b dng c y t:
- Danh mc trang thit b y t p ng nhu cu thc hin chc nng, nhim v
t
Khng t
- Danh mc trang thit b (nh km bin bn)
Tt: 75%
t: T 50% - <75%
Khng t: < 50%
- 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
6. Phm vi hnh ngh c th:

..
..
7. Quy trnh k thut
7.1. C bng quy trnh k thut y
t
Khng t
7.2. Bo m an ton cho ngi bnh khi thc hin cc k thut
t
Khng t
7.3. Thc hin vic k n thuc, bnh n
t
Khng t
7.4. Ghi s lu kt qu y
t
Khng t
8. Nim yt bng gi dch v
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)
......
..
..
..
..
..

Mu 68
(Ban hnh km theo Quyt nh s 617/Q-UBND-HC
ngy 28 thng 6 nm 2013 ca Ch tch UBND tnh ng Thp)

..
..
Bin bn kt thc lc

gi

pht, cng ngy.

TRNG ON

TH K

I DIN C S C THM NH