Republic of the Philippines Department of Health HEALTH FACILITIES AND SERVICES REGULATORY BUREAU ANNEX H-4 A.O.No. 2016-_0042~ CHECKLIST FOR REVIEW OF FLOOR PLANS. AMBULATORY SURGICAL CLINIC Name of Health Facility. Address: Date Review. 1 2 a 4. PHYSICAL PLANT 1.1 Administrative Service 444 Information Counter! Admitting Area Patient Waiting Area Toilet 1.1.2 Business Office 1.1.2.1 Cashier/Billing 1.1.3 Medical Records Area 71.1.4 Parking Area for Patient Transport Vehicle 1.2 Clinical Service 1.21 All Ambulatory Surgical Clinics (except those performing Lithotripsy ONLY or No-Scalpel Vasectomy ONLY) 1.2.1.1 Operating Room 71.2.1.2 — Scrub-up Area with sink Sterilizing Room Sterile Instrument, Supply and Storage Area Clean-up Area Dressing Room with sink and toilet Recovery Room Consuitation/Examination/Treatment Area Room with radiation hazard-protected walls and indproofed (for ASC performing Lithotripsy) 1.2.2. Ambulatory Surgical Clinic performing Lithotripsy ONLY 1.22.1 Room with radiation hazard-protected walls and soundproofed 1.22.2 __ Consultation/Examination/Treatment Area 123 ‘Ambulatory Surgical Clinic performing No-Scalpel Vasectomy ONLY 1.2.3.1. Consultation/Examination/Treatment Room __1.2.3.1.1 Consultation/Examination/Treatment Area ___1.2.3.1.2 Scrub-up Area with sink 12.32 Clean-up Area 71.233 Dressing Area 1.2.3.4 Sterile instrument, supply and storage Area 71.235 Sterilizing Area 1.23.6 Recovery Area Reveono0 tears2. PLANNING AND DESIGN 2.1 Floor plans property identified and completely labeled 2.2 Conforms to applicable codes as part of normal professional service: 2.2.1 Exits restricted to the following types: door leading directly outside the building, interior stair, ramp, and exterior stair 1um of two (2) exits, remote from each other, for each floor of the ‘9 __2.2.3 Exits terminate directly at an open space to the outside of the building 2.3 Meets prescribed functional programs: __2.3.1 Main entrance of the ambulatory surgical clinic directly accessible from public road 2.3.2 Business Office located near the main entrance of the ambulatory surgical clinic 2.3.3 Operating Room/Treatment Room (for No-Scalpel Vasectomy) located and arranged to prevent non-related traffic through the room 2.3.4 Dressing Room/Dressing Area arranged to avoid exposure to dirty ‘Areas after changing to surgical garments 2.3.5 Scrub-up Area recessed into anal cove or other open space out of the ‘main traffic COMMENTS: ag 2otRepublic of the Philippines, Department of Health HEALTH FACILITIES AND SERVICES REGULATORY BUREAU Name of Health Facility Address: COMMENTS: HEALTH FACILITIES EVALUATION AND REVIEW COMMITTEE (HFERC) L 1Approved I] Disapproved ‘Chairperson, HFERC Vice-Chairperson, HFERC Member Member ‘Meniber Member Wenbar Member Reveont0 Page sd