Professional Documents
Culture Documents
Department of Health
HEALTH FACILITIES AND SERVICES REGULATORY BUREAU
ANNEX C
A.O. No. 2018- 000i
I. GENERAL INFORMATION
Complete Address:
Email
Tel/Fax Nos: Address:
Name of Owner:
Category:
Ownership:
E] Government: Cl Private
El Local D Corporation
Institutional Character:
Type of application:
El Initial Cl Renewal
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ANNEX C
A.O. No. 2018- OOOI
II. TECHNICAL REQUIREMENTS
Instruction: In the appropriate box, place a check mark (\/) if the ambulance or ambulance service
provider is compliant or X-mark if not compliant.
For Institution-based:
For Non-institution-based:
A. SERVICE DELIVERY
Every ambulance service provider shall ensure that the services delivered to patients comply with the
standard quality embodied in the Assessment Tool for licensure of land ambulances, other policy guidelines
and/or related issuances.
1. Documented policies and
procedures on:
a. Administrative and technical
standard operating
procedures (SOP) for the
provision of its services
b. Establishment of its referral
system
For health facilities (ex.
hospitals, infirmaries and
birthing facilities) with
outsourced ambulance services:
Notarized Memorandum of
Agreement (MOA) between the
health facility and ASP
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ANNEX C
A.O. N0. 2018- 000!
Notarized Memorandum of
Agreement (MOA) with a
hospital
3. Schedule of Retention and
Disposal of Records and other
relevant information
4. Quality Assurance Program
5. Continuous Quality
Improvement
a. Client satisfaction survey
with analysis
b. Handling and resolution of
complaints
6. Copies of the clinical protocol
for each specific case
B. INFORMATION MANAGEMENT
Every ambulance service provider shall maintain a system of communication, recording and reporting of the
patient’s condition as well as the results of examinations which may include electronic communications or
otherwise allowed under RA. 8792 known as “Electronic Commerce Act of 2000.” Moreover, management
of data or information should be in adherence to RA. 10173 also known as the “Data Privacy Act of 2012.”
1. Hospital Referral Form-
completely and accurately filled
out; kept secured and
confidential
2. Logbook - completely and
accurately filled out with the
following contents:
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ANNEX C
A.O. N0. 2018- 000!
STANDARDS
, TypeI \
,;\
C. ENVIRONMENTALMANAGEMENT
Every ambulance service provider shall ensure that the environment is safe for its patients and staff
including members of the public as necessary and that the following measures and/or safeguards shall be
observed.
1. The ambulance shall be properly
ventilated, lighted, clean and
safe.
2. Written plan and program of
proper disinfection and
preventive maintenance of the
ambulance vehicles
3. Adequate personal protective
equipment (PPEs)
4. Procedures for the proper
disposal of infectious wastes and
toxic and hazardous substances
in accordance with RA. 6969
known as “Toxic and Hazardous
Substances and Nuclear Wastes
Act” and other related policy
guidelines and/or issuances
D. EQUIPMENT, MEDICINES AND SUPPLIES
Every ambulance shall have available and operational prescribed equipment, medicines and supplies.
1. There shall be a program for
calibration, preventive
maintenance and repair of
equipment, including
decontamination and
disinfection.
There shall be a contingency
plan in case of equipment
breakdown and malfunction,
especially during patient
transport.
There shall be a program for the
management of temperature
sensitive medication.
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ANNEX C
50- No- 2.9185 0 ,
, V
Tylpel «
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TypeIllCéll’Itl ”
LTO PLATE OR CONDUCTION STICKER NUMBER:
E. AMBULANCE BODY
An ambulance vehicle shall be able to accommodate the patient, and the required number of personnel and
equipment.
1. Safety non-porous partition
(separating the driver and the
body of the ambulance
2. Electric (internal and external)
supply bulbs
3. Overhead grab rail on the
ceiling on top of the
patient/stretcher
4. Inverter power source
5. Licensed Ambulances shall bear
the following markings:
a. Front: The reflectorized and
capitalized word
“AMBULANCE” which is
spelled out in reverse (mirror
image). The height of each
letter shall be no less than 10
centimeters and the word
shall be seen at least six (6)
meters away.
b. Side: Each side of the
ambulance body shall have
the capitalized word
“AMBULANCE” not less
than 15 cm in height.
c. Rear: The reflectorized and
capitalized word
“AMBULANCE” not less
than 15 cm in height and the
prescribed DOH ambulance
logo to be issued by the
DOH once the application
for a license is approved
No other signage or pictures
outside of what is prescribed.
(May opt to mount the blue
“Star of Life” emblem on
any part of the ambulance
vehicle)
6. Adequate and stable cabinet/s
that can appropriately store the
required equipment, medicines
and supplies
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ANNEX C
A.O. N0. 2018- 0001
STANDARDS AND
REQUIREMENTS Type I Type II , COMPLIANT REMARKS
(AMBULANCE VEHICLE)
7. Emergency Warning Light
System and Siren-Public
Address System
F. PERSONNEL
Each ambulance shall be manned by an adequate number of qualified, trained and competent staff to ensure
efficient and effective delivery of quality ambulance services.
1. Minimum of two (2) ambulance
personnel excluding the driver is
required for every ambulance
dispatched.
,
.
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ANNEX C
A.O. No. 2018- ODQI
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ANNEX C
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ANNEX C
A.O. N0. 2018- 01
.M
K. IV Therapy Supplies
1. IV Administration set
(Macro/Micro)
2. IV cannula (019, 20, 21, 23, 25,26)
3. Syringes (50ml, 30ml, 10m1, 3ml lml)
L. Medicines / Fluids
1. Activated Charcoal
Salbutamol nebules
3. Sterile water for irrigation, 1
liter
4. Sterile water for injection,
10ml
5. Intravenous fluids
- D5 LRS 1 Liter
- D5 NSS 1 Liter
- D5 Water 1 Liter
- D5 0.3NaCl 500ml
- Plain LRS
- Plain NSS
6. Normal saline water
(injectable)
7. Dextrose 50%/50ml vial
8. Plasma Expander
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ANNEX C
"
M. Controlled Medications
Sealed Drug / Code Box to be opened only under a Physician 0r Paramedics supervision.
This should be regularly checkedfor expired items by Physician-in—charge 0r Paramedics
1. Atropine Sulfate 1mg/m1
ampule
E9 Epinephrine 1mg/1ml tubaxes
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ANNEX C
Name of Ambulance
A°O' N 0' 2018'Ml_
Service Provider:
Date of Inspection:
RECOMMENDATIONS:
For Licensing
[ ] For Issuance of License To Operate as AMBULANCE SERVICE PROVIDER
Validity from to
LTO Plate or Conduction Sticker Number (Vehicle/s):
1. 4.
2. 5.
3 6.
*Use additional sheet/s if needed
[ ] Issuance depends upon compliance to the recommendations given and submission of the following
within days from the date of inspection
Inspected by:
Printed name Signature Position/Designation
Received by:
Signature:
Printed Name:
Position/Designation:
Date:
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ANNEX C
A.O. N0. 2018- QQQ]
Name of Ambulance
Service Provider:
Date of Monitoring:
DOH License Number
(ASP):
LTO Plate or Conduction Sticker Number (Vehicle/s):
1.
2. .V'
3.
*Use additional sheet/s if needed
RECOMMENDATIONS:
For Monitoring
[ ] Issuance of Notice of Violation
[ ] Others. Specify
Monitored by:
Printed name Signature Position/Designation
Received by:
Signature:
Printed Name:
Position/Designation:
Date:
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