PART IV - LEVEL 3 HOSPITAL

Instruction: In the appropriate box, place a check mark (√) if the hospital is compliant or X-mark if not compliant.

ATTACHMENT 3.A - PERSONNEL

NUMBER /
POSITION QUALIFICATION EVIDENCE COMPLIED REMARKS
RATIO

TOP MANAGEMENT (Should be full-time)

Chief of DOCUMENT REVIEW 1

Licensed physician
Hospital/Medical  Diploma for Master’s
Director Degree
Government
Hospital:  Updated Physician PRC
(a) Master’s Degree license
in Hospital  Certificates of Trainings
Administration or attended
related course  Proof of Employment/
(MPH, MBA, Appointment (notarized)
MPA, MHSA,  Service
etc.) AND at least Record/Certificate of
five (5) years Employment (proof of
hospital hospital
experience in a supervisory/managerial
supervisory or experience)
managerial
position
(b) Grandfather’s
Clause may be
accepted in place
of the Master’s
Degree in
Hospital
Administration
(or related
course), provided
that the individual
is fifty-five (55)
and above, AND
currently holding
the position for at
least five years.

Private Hospital:
Master’s Degree in
Hospital
Administration or
related course (MPH,
MBA, MPA, MHSA,
etc.) AND/OR at least
five (5) years hospital
experience in a
supervisory or
managerial position

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 NUMBER /
POSITION QUALIFICATION EVIDENCE COMPLIED REMARKS
RATIO
Chief of Clinics /  Licensed physician DOCUMENT REVIEW
Chief Medical  Fellow/diplomate of  Diploma/Certificate
Professional a specialty/ from Specialty society,
Services subspecialty society if applicable
 At least five (5)
 Updated PRC license
years hospital
experience in a  Certificates of Trainings
clinical supervisory attended
or managerial  Proof of Employment /
position 1
Appointment
(notarized)
 Service
Record/Certificate of
Employment (proof of
clinical
supervisory/managerial
experience in hospital)
Department Head  Licensed physician DOCUMENT REVIEW
(Specialty)  Fellow / diplomate  Diploma/Certificate
in a specialty / from Specialty society 1 per
Subspecialty society department
 Updated PRC license
of the department
he/ she heads  Certificates of Trainings
Training Officer  Licensed physician attended
for Physicians  Fellow / diplomate  Proof of Employment /
in a specialty / Appointment 1
Subspecialty society (notarized)
of the department
he/ she heads
Chief Nurse /  Licensed nurse DOCUMENT REVIEW
Director of Nursing  Master’s Degree in  Diploma
Nursing AND at  Updated PRC license
least five (5) years  Certificates of Trainings
of clinical attended
experience in a  Proof of Employment / 1
supervisory or Appointment (notarized)
managerial position  Service
in nursing Record/Certificate of
(R.A. No. 9173) Employment (proof of
supervisory/managerial
experience in nursing)
Chief Government DOCUMENT REVIEW
Administrative Hospital:  Diploma for Master’s
Officer/ Hospital (a) Master’s Degree Degree
Administrator in Hospital
 Updated PRC license
Administration or
 Certificates of Trainings
related course
attended
(MPH, MBA,
MPA, MHSA,  Proof of Employment / 1
etc.) AND at least Appointment (notarized)
five (5) years  Service
hospital Record/Certificate of
experience in a Employment (proof of
supervisory or hospital
managerial supervisory/managerial

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 NUMBER /
POSITION QUALIFICATION EVIDENCE COMPLIED REMARKS
RATIO
position experience)
(b) Grandfather’s
Clause may be
accepted in place
of the Master’s
Degree in
Hospital
Administration
(or related
course), provided
that the individual
is fifty-five (55)
and above, AND
currently holding
the position for at
least five years.

Private Hospital:
Master’s Degree in
Hospital
Administration or
related course (MPH,
MBA, MPA, MHSA,
etc.) AND/OR at least
five (5) years hospital
experience in a
supervisory or
managerial position
ADMINISTRATIVE SERVICES
Certified Public DOCUMENT REVIEW
Accountant Accountant (may be  Diploma / Certificate of 1
outsourced) units earned
Billing Officer With Bachelor’s  Updated PRC license 1
Degree relevant to the (if applicable)
Book keeper job  Certificates of Trainings
Budget / Finance attended 1
Officer  Proof of Employment/
Cashier Appointment (notarized) 1
Human Resources
Management
1
Officer / Personnel
Officer
Clerk, pool 1:50 beds
Engineer (full Licensed Engineer DOCUMENT REVIEW
time)  Diploma
 Updated PRC license
1
 Proof of Employment /
Appointment
(notarized)
Supply Officer/- With appropriate DOCUMENT REVIEW
Storekeeper training and 1
 Certificates of Trainings
experience
attended
Laundry Worker 1
 Proof of Employment /

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 NUMBER /
POSITION QUALIFICATION EVIDENCE COMPLIED REMARKS
RATIO
Appointment
(notarized)
Medical Records  Bachelor's Degree DOCUMENT REVIEW
officer  Training in ICD 10  Diploma
 Training in Medical  Certificates of Trainings
Records attended 1
Management
 Proof of Employment /
Appointment
(notarized)
Medical Social Licensed Social DOCUMENT REVIEW
worker (Full Time) Worker  Diploma / Certificate of
units earned 1
 Updated PRC license
Nutritionist- Licensed Nutritionist- Certificates of Trainings
Dietician (Full Dietician attended
Time)  Proof of Employment / 1
Appointment
(notarized)
Driver Licensed driver DOCUMENT REVIEW 1
Cook  Proof of Employment /
Appointment 1
(notarized)
Building May be outsourced. DOCUMENT REVIEW
Maintenance Man /  Relevant Training 1 per shift
Utility Worker Security guard must be  License, if applicable
Security Guard licensed.  Proof of Employment /
Appointment
(notarized) 1 per shift
 Notarized MOA if
outsourced
CLINICAL SERVICES
Consultant Staff in  Licensed physician DOCUMENT REVIEW All consultants
Ob-Gyn,  Fellow/Diplomate must be board
Pediatrics,  ACLS certified (for  Certificate from
certified
Medicine, Surgery, Surgeons and Specialty society, if
and Anesthesia Anesthesiologists) applicable (for Board
Certified)
*Hospital may have
additional  Residency Training
consultants from Certificate (for Board
other specialties. Eligible)
Intensive Care  Licensed physician  Certificate of A team
Unit:  Fellow/Diplomate Residency Training / composed of at
Multidisciplinary Medical Specialists least 1 per
(*DOH Medical specialty
Team composed of,
Specialist, last exam (May be part
but not limited to, was in 1989) time or visiting
board certified  Updated PRC license consultant/s)
Cardiologist,  Certificates of OR an
Pulmonologist, Trainings attended
intensivist
Neurologist,  Proof of Employment/
Pulmonologist, Appointment

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 NUMBER /
POSITION QUALIFICATION EVIDENCE COMPLIED REMARKS
RATIO
Surgeon, (notarized)
Anesthesiologist
OR an Intensivist
Neonatal Intensive  Licensed physician A team
DOCUMENT REVIEW
Care Unit:  Fellow/Diplomate composed of at
least 1 per
Multidisciplinary  Certificate from
specialty
team composed of, Specialty society, if
(May be part
but not limited to, applicable (for Board
Certified) time or visiting
pediatric
 Residency Training consultant) OR
cardiologist,
Certificate (for Board a neonatologist
pediatric
Eligible)
nephrologist,
 Certificate of
pediatric Residency Training /
pulmonologist OR Medical Specialists
a neonatologist (*DOH Medical
High Risk  Licensed physician Specialist, last exam General
Pregnancy Unit:  Fellow/Diplomate was in 1989) Obstetricians,
General  Updated PRC license Perinatologist,
 Certificates of and IM
Obstetricians,
Trainings attended specialists
preferably with a  Proof of Employment/ (May be part
Perinatologist, and Appointment time or visiting
a referral team of (notarized) consultant)
IM specialists
Resident Physician Licensed physician DOCUMENT REVIEW Wards - 1:20
on Duty (Shall not  Updated PRC license beds at any
go on duty for  Certificates of given time
Trainings attended PLUS
more than 48 hours
 Proof of Employment/ ER – at least 1
straight).
Appointment at any given
(notarized) time
 Schedule of duty *This ratio does
approved by Medical not include
Director/Chief of Resident
Hospital Physicians on
Duty that shall
be required for
add-on services
such as dialysis
facility. It shall
be counted
separately.
Rehabilitation  Licensed physician DOCUMENT REVIEW 1
Medicine Specialist  Fellow/Diplomate  Certificate from
Specialty society, if
applicable (for Board
Certified)
 Residency Training
Certificate (for Board
Eligible)
 Updated PRC license
 Certificates of
Trainings attended

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 NUMBER /
POSITION QUALIFICATION EVIDENCE COMPLIED REMARKS
RATIO
 Proof of Employment/
Appointment
(notarized)
NURSING SERVICES
Assistant Chief  Licensed nurse DOCUMENT REVIEW
Nurse  At least twenty (20)  Diploma/Certificate of
units towards Units Earned
 Updated PRC license
Master’s Degree in
 Certificates of
Nursing
Trainings attended
 At least three (3)  Proof of Employment/
years-experience in Appointment 1:100 Beds
supervisory/ (notarized)
managerial position  Service
in nursing Record/Certificate of
Employment (proof of
supervisory/
managerial experience
in nursing)
Supervising  Licensed nurse DOCUMENT REVIEW 1 per
Nurse/Nurse  With at least nine  Diploma/Certificate of Department –
Managers (9) units of Master's Units Earned office hours
Degree in Nursing  Updated PRC license (8am – 5pm)
 At least two (2)  Certificates of
years-experience in Trainings attended
general nursing  Proof of Employment/
service Appointment
administration. (notarized)
 Service
Record/Certificate of
Employment (Proof of
general nursing
service administration
experience)
Head Nurse/Senior  Licensed nurse DOCUMENT REVIEW
1 per shift per
Nurse  With at least 2
clinical
years-hospital  Diploma
department
experience  Updated PRC license
 BLS certified  Certificate of trainings
Staff Nurse  Licensed nurse attended 1:12 beds at
 BLS certified  Proof of employment any time (1
(notarized) reliever for
 If nursing staffing is every 3 RNs)
Staff Nurse in  Licensed nurse outsourced: Validity of
every Critical Unit  Certificate of the contract of
(CCU, ICU, NICU, Training in Critical employment should be
PICU, SICU, Care Nursing, ACLS at least one (1) year and 1:3 beds at any
HRPU etc.) within the validity time per shift
period of the hospital’s (plus 1 reliever
LTO. per 3 CCU
 Schedule of duty RNs)
approved by Chief
Nurse

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 NUMBER /
POSITION QUALIFICATION EVIDENCE COMPLIED REMARKS
RATIO
Nursing Attendant  Highschool DOCUMENTS REVIEW 1:24 beds at
graduate  Certificates of Trainings any time (1
 With relevant attended reliever for
health-related  Proof of Employment every 3
training ( notarized ) NA/MWs)
Nursing Attendant (may be in house
in CCUs training) 1:12 beds at
any time (plus
1 reliever for
every 3 NAs)

Operating Room Training OR Nursing DOCUMENT REVIEW 1 SN and 1 CN

Nurse per functioning
 Diploma OR per shift
-Scrub Nurse (SN)  Updated PRC license (plus 1 reliever
-Circulating Nurse  Certificate of trainings for every 3
(CN) attended nurses)
Delivery Room  Training in  Proof of employment 1 per 3
Nurse Maternal and Child (notarized) delivery table
Nursing (may be in  If nursing staffing is per shift
house training or outsourced: Validity of (plus 1 reliever
training in Essential the contract of for every 3
Integrated Newborn employment should be nurses)
Care [EINC]) at least one (1) year and
 Training in BLS and within the validity
ACLS period of the hospital’s
LTO.
Emergency Room  Licensed nurse  Schedule of duty 1:3 beds per
Nurse  Training in Trauma approved by Chief shift
Nursing, ACLS and Nurse (plus 1 reliever
other relevant for every 3
training nurses)
Outpatient  Licensed nurse 1
Department Nurse  Training in BLS Office hours
only
(8am – 5pm)
Dentist – MOA or Licensed dentist DOCUMENT REVIEW 1
outsourced but  Diploma Office hours
should be within  Updated PRC license only
the vicinity of  Certificates of (8am – 5pm)
hospital Trainings attended
Physical Therapist
Licensed physical  Proof of Employment/ 1
therapist Appointment
Licensed respiratory
(notarized)
therapist or licensed
 If outsourced: Validity
nurse with respiratory of the contract of
Respiratory therapy training employment should be 1 per shift
Therapist at least one (1) year
and within the validity
period of the
hospital’s LTO.

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 ATTACHMENT 3.B - PHYSICAL PLANT

DOCUMENTS COMPLIED REMARKS

1. DOH -Approved PTC

2. DOH Approved Floor Plan

3. Checklist for Review of Floor Plans (accomplished)

OBSERVATIONS/FINDINGS (may use separate additional sheets if needed):

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 ATTACHMENT 3.C –EQUIPMENT/INSTRUMENT

EQUIPMENT/INSTRUMENT
QUANTITY AREA COMPLIED REMARKS
(Functional)

ADMINISTRATIVE SERVICE
Ambulance
 Available 24/7
1 Parking
 Physically present if not being used
during time of inspection/monitoring
Administrative
Computer with Internet Access 1
Office
lobby, hallway,
1 per unit or nurses' station,
Emergency Light
area office/unit and
stairways
lobby, hallway,
1 per unit or nurses' station,
Fire Extinguishers
area office/unit and
stairways
Conference
LCD Projector 1
Room
Generator set with Automatic Transfer
1 Genset house
Switch (ATS)
KITCHEN/DIETARY
Exhaust fan 1
Food Conveyor or equivalent (closed-
1
type)
Food Scale 1
Blender/Osteorizer 1
Oven 1 Kitchen
Stove 1
Refrigerator/Freezer 1
Utility cart 1
Garbage Receptacle with Cover (color- 1 for each
coded) color
EMERGENCY ROOM
Bag-valve-mask Unit
- Adult 1
- Pediatric 1
Calculator for dose computation 1
Clinical Weighing scale 1
Defibrillator with paddles 1
Delivery set, primigravid 2 sets
Delivery set, multigravid 2 sets
ECG Machine 1 ER
EENT Diagnostic Set with
1
Ophthalmoscope and Otoscope
Emergency Cart (for contents, refer to
1
separate list)
Examining table 1
Examining table (with Stirrups for OB-
1
Gyne
Gooseneck lamp/Examining Light 1
Instrument/Mayo Table 1

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Minor Instrument Set (May be used for
Tracheostomy, Closed Tube 2 sets
Thoracostomy, Cutdown, etc.)
Nebulizer 1
Negatoscope 1
Neurologic Hammer 1
OR Light (portable or equivalent) 1
Oxygen Unit
Tank is anchored/chained/ strapped or 2
with tank holder if not pipeline
Pulse Oximeter 1
Sphygmomanometer, Non-mercurial
- Adult Cuff 1
- Pediatric Cuff 1
Stethoscope 1 ER
Suction Apparatus 1
Suturing Set 2 sets
Thermometer, non-mercurial
- Oral 1
- Rectal 1
1 for each
Vaginal Speculum, Different Sizes
different size
Wheelchair 1
Wheeled Stretcher with guard/side rails
1
and wheel lock or anchor.
OUT- PATIENT DEPARTMENT
Clinical Height and Weight Scale 1
EENT Diagnostic Set with
1
ophthalmoscope and otoscope
Gooseneck lamp/Examining Light 1
Examining table with wheel lock or
1
anchor
Instrument/Mayo Table 1
Minor Instrument Set 1
Neurologic Hammer 1
Oxygen Unit
Tank is anchored/chained/ strapped or 1
with tank holder if not pipeline
OPD
Peak flow meter
- Adult 1
- Pediatric 1
Sphygmomanometer, Non-mercurial
- Adult cuff 1
- Pediatric cuff 1
Stethoscope 1
Thermometer, non-mercurial
- Oral 1
- Rectal 1
Suture Removal Set 1
Wheelchair / Wheeled Stretcher 1
OPERATING ROOM
Air conditioning Unit 1
Anesthesia Machine 1
OR
Cardiac Monitor with Pulse Oximeter 1
Ceasarian Section Instrument 1

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Defibrillator with paddles 1
Electrocautery machine 1
Emergency Cart (for contents, refer to
1
separate list)
Instrument / Mayo Table 1
Laparotomy pack (Linen pack) 1 per OR
Laparotomy / Major Instrument Set 1 per OR
Laryngoscopes with different sizes of
1
blades
Operating room light 1 per OR
Operating room table 1 per OR
Orthopedic Instrument Set 1 set
OR
Oxygen Unit
Tank is anchored/chained/ strapped or 1 per OR
with tank holder if not pipeline
Rechargeable Emergency Light (in case
1 per OR
generator malfunction)
Sphygmomanometer, Non-mercurial
- Adult cuff 1 per OR
- Pediatric cuff 1 per OR
Spinal Set 1
Stethoscope 1
Suction Apparatus 1
Thermometer, non-mercurial
- Oral 1
- Rectal 1
Wheeled Stretcher with guard/side rails
1
and wheel lock or anchor.
POST ANESTHESIA CARE UNIT RECOVERY ROOM
Air conditioning Unit 1
Cardiac Monitor 1
1 (if separate
Defibrillator with paddles from the OR
Complex )
1 (if separate
Emergency Cart (for contents, refer to
from the OR
separate list)
Complex )
Mechanical / patient bed, with guard
1 PACU/RR
side rails and wheel lock or anchored
Oxygen Unit
Tank is anchored/chained/ strapped or 1
with tank holder if not pipeline
Sphygmomanometer, Non-mercurial
- Adult cuff 1
- Pediatric cuff 1
Stethoscope 1
Thermometer, non-mercurial 1
LABOR ROOM
Fetal Doppler 1
Oxygen Unit
Tank is anchored/chained/ strapped or 1
with tank holder if not pipeline Labor Room
Patient Bed 1
Pulse Oximeter 1
Sphygmomanometer, Non-mercurial 1

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Stethoscope 1
Thermometer, Non-mercurial 1 Labor Room
DELIVERY ROOM
Air-conditioning Unit 1
Bag valve mask unit (Adult and
1
pediatric)
Bassinet 1
Clinical Infant Weighing Scale 1
1
1 (if DR is
Defibrillator with paddles separate from
the OR
Complex )
Delivery set, primigravid 1 set
Delivery set, multigravid 2 sets
Delivery room light 1
Delivery room table 1
Dilatation/Curettage set 1 set
1
DR
Emergency Cart (for contents, refer to (if DR is
separate list). separate from
OR Complex)
Instrument/Mayo Table 1
Kelly Pad or equivalent 1
Laryngoscope with different sizes of
1
blades
Oxygen Unit
Tank is anchored/chained/ strapped or 1
with tank holder if not pipeline
Rechargeable Emergency Light (In case
1
of generator malfunctions)
Sphygmomanometer -Non-mercurial 1
Stethoscope 1
Suction Apparatus 1
Wheeled Stretcher 1
HIGH RISK PREGNANCY UNIT
Cardiac Monitor with Pulse Oximeter 1
Cardiotocography (CTG) Machine 1
Fetal Doppler 1
Oxygen Unit HRPU
Tank is anchored/chained/ strapped or 1
with tank holder if not pipeline
Patient bed with side rails 1
Suction Apparatus 1
NEONATAL INTENSIVE CARE UNIT (NICU)
Air conditioning unit 1
Bassinet 1
Bilirubin Light / Phototherapy machine
1
or equivalent
Cardiac Monitor with pulse oximeter 1
NICU
Clinical Infant Bag-valve mask unit 1
Clinical Infant weighing scale 1
Defibrillator with paddles 1
EENT Diagnostic Set with
1
ophthalmoscope and otoscope

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Emergency Cart (for contents, refer to
1
separate list)
Glucometer 1
Incubator 1
Infusion pump / Syringe pump 1
Laryngoscope with neonatal blades of
1
different sizes
Mechanical Ventilator (May be NICU
outsourced)
Neonatal Stethoscope 1
Oxygen Unit
Tank is anchored/chained/ strapped or 1
with tank holder if not pipeline
Refrigerator for Breast milk storage 1
Sphygmomanometer, Non-mercurial
1
- Neonate
Suction apparatus 1
Thermometer, Non-mercurial 1
Umbilical Cannulation set 1
INTENSIVE CARE UNIT (ICU) – For all types of ICU (PICU, SICU, Medical ICU, etc.)
Air conditioning unit 1
Bag-valve-mask Unit
- Adult 1
- Pediatric 1
Cardiac Monitor with Pulse Oximeter 1
Defibrillator with paddles 1
Emergency Cart (for contents, refer to
1
separate list)
EENT Diagnostic Set with
1
ophthalmoscope and otoscope
Infusion pump 1
Laryngoscope with different sizes of
1
blades
Depending on
Mechanical Bed the number of
beds declared ICU
Mechanical Ventilator / Respirator (May
1
be outsourced)
Minor Instrument Set (May be used for
Tracheostomy, Closed Tube 1
Thoracostomy, Cutdown, etc.)
Oxygen Unit
Tank is anchored/chained/ strapped or 1
with tank holder if not pipeline
Sphygmomanometer, non-mercurial
(reserved for sudden breakdown of
cardiac monitor)
- Adult cuff for adult unit 1
- Pediatric cuff for pediatric unit 1
Stethoscope 1
Suction Apparatus 1
NURSING UNIT/WARD
Bag-Valve-Mask Unit
- Adult 1 NURSING
- Pediatric 1 UNIT/ WARD
Clinical Height and Weight Scale 1

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 Nursing units located on the
same floor may share the
defibrillator and the E-card,
Defibrillator with paddles 1
provided that they are not
more than 50 meters away
from each other.
Emergency cart or equivalent (refer to
1
separate list for the contents)
EENT Diagnostic Set with
1
ophthalmoscope and otoscope
NURSING
Laryngoscope with different sizes of
1 UNIT/ WARD
blades
Mechanical/Patient bed With locked, if
ABC
wheeled; with guard or side rails
Bedside Table ABC
Nebulizer 1
Neurologic Hammer 1
Oxygen Unit
1
tank is anchored/chained if not pipeline
Sphygmomanometer, Non- Mercurial
- Adult cuff 1
- Pediatric cuff 1
Stethoscope 1
Suction Apparatus 1
Thermometer, non-mercurial
- Oral 1
- Rectal 1
DIALYSIS CLINIC
(Specify if Hemodialysis or Peritoneal Dialysis or both)
Refer to Assessment Tool for Dialysis Clinics
AMBULATORY SURGICAL CLINIC
Refer to Assessment Tool for ASC
RESPIRATORY / PULMONARY UNIT
ABG Machine 1
Pulmonary Function Test (PFT) or Peak
Expiratory Flow Rate (PEFR) Tube Respiratory /
Pulmonary Unit
Spirometer 1
Nebulizer 1
PHYSICAL MEDICINE AND REHABILITATION UNIT
Bicycle ergonometer 1
Cervical Traction 1
Cold Therapy Products 1
Diagonal mirrors 1
Dynamometer 1
Exercise Plight / Bed 1
Exercise Stairs with Rails 1
Goniometer 1 PMRU
Hot Therapy Products 1
Light Therapy 1
Lumbar Traction 1
Overhead pulley 1
Paraffin Wax 1
Parallel Bars 1
Pedometer 1

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Pulley System 1
Therapy machine 1
Therapy mats 1
Therapy rolls 1
Therapy wedges 1
Transcutaneous Electric Nerve
1
Stimulator (TENS)
DENTAL CLINIC – not required if service is by Referral
Air compressor 1
Autoclave 1
Bone file, stainless 1
Cotton pliers 1
Cowhorn Forceps 1
Dental Chair unit 1
Explorer, double-end 1
Forceps, No. 8 1
Forceps, No. 17 Upper molar 1
Forceps, No. 18 Upper molar 1 DENTAL
Forceps, No. 150 Maxillary Universal 1 CLINIC
Forceps, No. 150 S Primary Teeth 1
Forceps, No. 151 Lower Universal 1
Forceps, No. 151 Mandibular Pre-molar 1
Forceps, No. 151 S Lower Primary
1
Teeth
Gum separator 1
High speed handpiece with Burr
1
remover
Low speed handpiece, Angled head 1
Mouth mirror explorer 1
Periosteal elevator No. 9, double-end 1
Rongeur 1
DENTAL
Root elevator 1
CLINIC
Scaler Jacquettes Set No. 1, 2, and 3 1
Surgical Chisel 1
Surgical Malette 1
CENTRAL STERILIZING & SUPPLY ROOM
Autoclave/Steam Sterilizer 1 CSSR
MORGUE
Autopsy table 1
Autopsy instrument set 1
MORGUE
Cadaver freezer 1
Cadaver Shower 1

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 ATTACHMENT 3.D - EMERGENCY CART CONTENTS FOR LEVEL 3 HOSPITAL

EMERGENCY CART CONTENTS ER OR DR ICU NICU HRPU NS 1 NS 2 NS 3 NS 4 NS 5 NS 6 NS 7 OTHERS OTHERS REMARKS

Adenosine 6 mg/2mL vial

Amiodarone 150mg/3mL ampule
Anti-tetanus serum (either equine-based
antiserum or human antiserum)
Aspirin USP grade (325 mg/tablet)
Atropine 1mg/ml ampule
Β-adrenergic agonists (i.e. Salbutamol 2mg/ml)
Benzodiazipine (Diazepam 10mg/2ml ampule
and/or Midazolam) (in high alert box )
Calcium (usually calcium gluconate 10%
solution in 10 mL ampule)
Clopidogrel 75 mg tablet
D5W 250 mL
D50W 50mg/vial
Digoxin 0.5mg/2mL ampule
Diphenhydramine 50mg/mL ampule
Dobutamine 250mg/5mL ampule
Dopamine 200 mg/5mL ampule/vial
Epinephrine 1mg/ml ampule
Furosemide 20mg/2ml ampule
Haloperidol 50mg/mL ampule
Hydrocortisone 250mg/2mL vial
Lidocaine 10% in 50mL spray
Lidocaine 2% solution vial 1g/50ml
Magnesium sulfate 1g/2mL ampule
Mannitol 20% solution in 500ml/bottle
Methylprednisolone 4mg/tablet

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Metoclopramide 10mg/2mL ampule

Morphine sulfate 10mg/mL ampule (in high
alert box )
Nitroglycerin inj. 10 mg/10mL ampule or
Isosorbide dinitrate 5mg SL tablet or 10
mg/10mL ampule
Noradrenaline 2mg/2mL ampule
Paracetamol 300mg/ampule (IV preparation)
Phenobarbital 120mg/ml ampule IV or 30mg
tablet (in high alert box )
Phenytoin 100mg/capsule or 100 mg/2mL
ampule
Plain LRS 1L/bottle
Plain NSS 1L/bottle – 0.9% Sodium Chloride
Potassium Chloride 40mEq/20mL vial (in high
alert box )
Vitamin B1/6/12 vial (1g B1, 1g B6, 0.01gB12
in 10 mL vial)
Sodium bicarbonate 50mEq/50mL ampule
Verapamil 5 mg/2 ml ampule
EQUIPMENT/SUPPLIES
Airway adjuncts
Airway / Intubation Kit ( with stylet and bag
valve masks )
Alcohol disinfectant
Aseptic bulb syringe
Calculator
Capillary Blood Glucose (CBG) Kit
Cardiac Board
Cardiac / EKG Leads

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Endotracheal Tubes, all sizes

Flashlights or Pen lights
Gloves , sterile
Gloves, non-sterile
Laryngoscope with different sizes of blades
Nasal cannula
Protective face shield or mask or goggles
Standard face mask
Sterile gauze ( pre-folded and individually
packed )
Syringes (different volumes)
Urethral catheter
Urine collection bag
Waterproof aprons

*Notes:
ER – Emergency Room
OR – Operating Room
DR – Delivery Room
NS – Nurses’ Station

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