CLINIC AUDIT AND COMPLIANCE REVIEW REPORT (Based on MMSR)

Project /Facility:
Location:
Date:

1st 2nd 3rd

No. Standard RAC FORM 1508 – Clinic Audit & Compliance Review Report Comments/ Recommendations
Audit Audit Audit
The building has adequate space and layout that satisfy patient
flow and functional needs (e.g. stretcher cases and stretcher
bearers can easily and directly access the treatment room. ER set
up with equipment readily available)
Emergency exit and exit signs.
Patient bathroom.
Privacy for patient.
1 Building requirements Emergency lights in case of power failure.
Clinic signs inside- including all rooms, offices and areas within the
facility and directional signs outside.
Notices are posted to indicate operating hours with contact details,
emergency contact number.
Janitor room is provided with storage facility. The room is clean
and organized.
Ambulance bay.
Entrance ramp available for stretcher and wheelchair cases.
There is a quick reference medical disaster response plan.
Have a minimum of 01 emergency response bag.

Contents of bag as per section 10.4 of MMSR Manual.

2 Disaster Response Capability
Drug content of each bag is determined by the responsible for
clinic supervision (Physician).
Provided with an appropriate and dedicated communication device
(Mobile GSM).
RAC FORM 1503 – Delivery Note

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Healthcare, Qualification and
3 courses/lectures. Nurses are required to obtain a minimum of 15
Education
Emergency Medical Equipment and
4 Entonox unit, portable
Supplies
RAC FORM 1508 – Clinic Compliance Review Report
There is documentary evidence that TMC uses an authorized
medical insurance company (BUPA).
Nurse is on duty at all times during working hours. Registered by
the SCFHS and licensed by MOH.
Staffs (doctors, nurses and drivers) have valid BLS/AED Certificate.
Staffs (doctors, nurse and driver) have a valid First Aid Certificate and
have a following mandatory class: Infection Control and Fire Safety.
Documentary evidence that doctors and nurses are attending
hours/yr (SCFHS rules) while 30 hours/ year for the doctor.
Written protocol of Chest Pain Management is in place.
Management of Anaphylactic Shock.
Drug Familiarization program.
Emergency Response Preparedness.
Airway management
IV I therapy administration
BVM: Ambu bag and mask CO2 indicator, Adult, Disposable
Oral airways- different sizes
Pocket mask with O2 niplet/inlet
AED Automated external defibrillator Portable with monitoring
capabilities, print strip, Blood preasure; eg.; Lifepak 12
Infusion pump
IV tubing
LMA+ Holder (disposable)
O2 supplies with accessories
Suction: portable unit, with rechargeable batteries Laerdal
Stretchers/emergency backboards/basket stretcher
Hare Traction Unit
Head immobilizer
Portable emergency eye irrigation unit
Glucometer
Nebulizer set
Burn sheet/Burn pad/ Multi trauma dressing
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Emergency Medical Equipment and
4 Medical staff can demonstrate competency in operating any of the
Supplies
5 Medicines and Drug Formulary
Safety, Environmental Health and
6 Written guideline is available for Needle Sticks/Sharps Injury.
Infection Control
Safety, Environmental Health and
6
Infection Control
RAC FORM 1508 – Clinic Compliance Review Report
1st Aid Supplies (36 Unit)
Miscellaneous dressings/ Disposable dressing set
Medical staff with documentary evidence having skills competency
training/refresher training every 2 yrs in operating the above
equipments
above equipment
Documentary evidence for driver having an OJT regarding
familiarization with ambulance equipment and how to perform
some basic functions
Equipment replacement
Drug formulary is formulated/approved by a physician with clear
guidelines (SO/RO/TO/consultation/drug reference system) as to
the administration and dispensing of drugs by nurses especially in
the absence of a physician at site.
System is in place for documenting TO
Documentary evidence showed that nurse has successfully
completed a drug familiarization prior dispensing drugs from the
formulary
Dispensing procedures meet minimum requirements (appropriate
container and labeling)
Evidence of an inventory system to ensure drug validity status
(current/not expired)
Disposal of expired drugs meet minimum requirements. Disposal
procedure available.
Items requiring refrigeration must be stored at a Temp. 2 degrees
C to 8 degrees C (35.6F- 46.4F). Fridge temp. must be recorded
daily.
Medications refrigerator has no foods contents. Maintained at the
correct temperature.
All staff knows and can demonstrate appropriate hand washing
technique.
Wall mounted container for sharps.
Blood spills kit is available. Policies and procedures to clean up
spills available. Clinic staff and janitor are familiar with the
procedure.
Staff Health as per MOH regulations: Staff including clinic
assigned janitor must be screened and immunized as follows.
Documentary evidence of completion available:
1. Chest X Ray
2. Tuberculin skin test (PPD)
3. HBV and HCV
4. HIV
Staff has attended/completed their yearly infection class. Review
of relevant presentation available on the web is acceptable.
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 Safety, Environmental Health and
6 Janitor uses separate cleaning equipment for toilet areas.
Infection Control
Storage- adequate storage space is available. All materials shall
be stored at least 15 cm (6") above floor on racks, shelves or
pallet.
There is a system in place for the periodic maintenance of patient
care equipment.
Fire extinguisher are available and with a proof of inspection.
Fire evacuation plan and procedures are posted.
Staff can verbalize/demonstrate the proper use of fire extinguisher
and familiar with the acronym RACE and PASS.
Injury log/summary report is available.
Ambulance unit
Stretcher and blankets
Portable O2
Splints for bone fracture
Bandages/ rubber tourniquet
Sterile wash water
First Aid Kit
7 Ambulance Services
Ambulance checklist- completed daily
Preventive maintenance of ambulance shall be performed and
documented. PM sticker available
Ambulance is clean and in sanitary condition.
Stock list of supplies is checked and logged daily. No expired
items.
Ambulance driver undergo orientation and OJT program to ensure
site familiarization, their role and responsibilities.
Ambulance driver knows the location and route to all nearby
7 Ambulance Services designated facilities.
Ambulance driver completed a 1st Aid and BLS training.
Patient processing, documentation Medical file is available for each workman.
8
and medical records Log system is available to document's patient's attendance.
LEGEND:
0= NIL
1= Partial
2= Complete
NA= Not Applicable

REMARKS:

Prepared by: Inspected by:

RAC FORM 1508 – Clinic Compliance Review Report 4 of 5 Revision 000

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RAC FORM 1508 – Clinic Compliance Review Report 5 of 5 Revision 000