Pertamina Hulu Mahakam

HEALTH PLAN

Name of Medical Facility :

Location :
Conducted :
Inspector :
PIC :
HP & Email DoD on board :

1. General condition – administration

N DESCRIPTION COMMENTS SCORE

O
1 Are the premises clean (floor, walls, furniture)?

2 Are the surfaces distributed consistently to define

A consultation – treatment area?
An emergency area?

3 Are the lighting and temperature correct?

4 Have all work surfaces been disinfected?

Is there a supply of disposable paper for the
examination couch?

5 Is the consultation register complete and up to date?

6 Are all medical files stored in a secure place?

7 Are all personnel present?

8 When was the last inventory?

Equipment
Pharmaceutical supplies
Expire date of main medicines

9 Are toxic products stored in secure place?

10 When was the last maintenance operation

Of electronic medical equipment

Of the sterilization equipment carried out?

Total 14/15

2. Equipment

NO DESCRIPTION COMMENTS SCORE

Pertamina Hulu Mahakam
HEALTH PLAN

1 Is the emergency bag fully equipped? Yes 1

Do all members of medical personnel know the
2
contents?
Evaluation of the contents of the emergency bag:
Ventilation equipment
3 Equipment for perfusions
Injectables
Diagnostic equipment
Monitoring equipment: condition and quality
Cardio scope
4
SPo2
Arterial pressure
Defibrillators: condition and quality
5 Manual
Semiautomatic (two AED)
Oxygen
Quantity
6
When were the bottles last overhauled
Immobilization equipment: condition and quality
Vacuum mattress
Spinal Board
7 Basket stretcher (paraguard)
Scoop stretcher
Cervical collar
Splints for limbs
Other equipment: condition and quality
Syringe pumps
Mucus suction machine
Electrocardiograph
8
Mechanical ventilation machine
Peak flow meter
Glucometer
Anti shock trousers
9 Display of emergency protocols?
Consistency of storage of intubations equipment
Ambu with regulator and masks
Guedel airways and mouth opener
Filters
10 Laryngoscope and blades (1.5 V batteries)
Intubation tubes and guide wire
Guide wire and catheter attachment device
Syringe 10 cc
Xylocain 5%
Consistency of oxygen connections:
11 Regulator – respirator
Regulator – flow meter – inhalation mask
Total 33/40

General total (55)

Pertamina Hulu Mahakam
HEALTH PLAN