Republic of the Philippines

Department of Health
OFFICE OF THE SECRETARY
January 16, 2019

DEPARTMENT MEMORANDUM
N0. 2019 - 0003

TO: ALL UNDERSECRETARIES: ASSISTANT SECRETARIES:

DIRECTORS OF BUREAUS/ SERVICES. REGIONAL OFFICES AND
SERVICES. CHIEFS OF MEDICAL CENTERS, HOSPITALS: AND
ALL OTHER CONCERNED OFFICES

SUBJECT: Guidelines in the Implementation of Recognition for the Adolescent-

Friendlv Health Facilities and Preparation of Proposals for the Cash
Grants Amounting to One Hundred Thousand Pesos

I. BACKGROUND AND RATIONALE

Adolescent health has recently been given focus due to the ever-growing health and
development issues the young people faced such as early pregnancy, sexually-transmitted
infections including HIV and AIDS, substance abuse, violence, depression and mental illness.
Like other group of people from all age-groups, they should be given every opportunity to
realize their rights to attain the highest standards of health. However, adolescents prevent
seeking help from health care providers and facilities when faced with barriers such as
crowding facilities, unsupportive and judgmental health care providers.

To minimize these barriers and ensure that health services are adolescent-friendly and
available at various levels of the health care system, the Adolescent Health and Development
Program (AHDP) of Disease Prevention and Control Bureau (DPCB) crafted the standards for
Adolescent- Friendly Health Facility (AFHF) in coordination with partner agencies working
for and with adolescents. This was disseminated through Department Memorandum No.
2017-0098 in pursuant to the Administrative Order 2013-0013 entitled “National Policy and
Strategic Framework on Adolescent Health and Developmen ” which include the program
strategy of improving access to quality and adolescent—friendly health care services and
information for adolescents, including access to quality hospitals and health care facilities
following the National Standards and Implementation Guide for Adolescent-Friendly Health
Services. Further, this will guide Local Government Units (LGUs) in establishing adolescent-
friendly health facilities in carrying out activities like health examination and counselling of
adolescents.

Building 1, San Lazaro Compound, Rizal Avenue, Sta. Cruz, 1003 Manila 0 Trunk Line 651-7800 local 1113, 1108, 1135 Direct Line:
711-9502; 71 1-9503 Fax: 743-1829 0 URL: http://www.d0h.gov.ph;e—mail: ftdugue@doh.gov.ph
II. OBJECTIVES

. To recognize health facilities for their valuable contribution to the Adolescent Health and
DevelopmentProgram through the establishment of Adolescent-FriendlyHealth Facilities.

. To encourage health facilities to achieve Level III standards for Adolescent-Friendly

Health Facility.

III. GENERAL GUIDELINES

. A national recognition for Level III AFHF (hospitals, rural health units, city health offices
and barangay health stations are allowed to participate) shall be conducted by 2019 and to
coincide with the DOH Harmonized Awarding to be done every 3 years.
. Preparation of the winner’s proposals for the AFHF recognition cash grants amounting to
Php 100,000.00.
. Accomplishments and sustainability assessment shall be based on a 3-year performance of
the health facility. Assessment and monitoring of health facilities accomplishments shall
be conducted yearly by the regions.

IV. SPECIFIC GUIDELINES

. The validation of health facilities 'for Levels I to III shall be conducted by the following:
A. Level I — Provincial Offices
B. Level II — DOH Centers for Health Development
C. Level III — DOH Central Office
. The DOH Regional Offices shall submit endorsement letter to DOH Central Office with
names of health facilities that have been evaluated according to Level III standards. This
nominated health facilities shall be validated by the national validation team, composed of
the following:
Department of Health (DPCB and HPCS)
National Youth Commission
Department of Social Welfare and Development
Department of Education
mwwp0w>

Participating UN Agencies and International Development Partners

Participating Non-Government and Civil Society Organizations
. Other partner agencies
. A deli eration process shall be conducted by the national validation team together with the
AHDP technical working group to determine final list of Level III AFHF for recognition.
Health facilities that are compliant ONLY to the criteria within the standard evaluation
tool (see Annex) for Level III AFHF in accordance to the following set scoring range shall
be included in the final list.

CRITERIA SCORE
HOSPITAL RHU/BHS
Advocacy and Promotional Activities/Materials 6 6
Health Facility Policies and Guidelines 20 23
Delivery of Health Services 11 12
Partnership and Collaboration 5 9
TOTAL 42 5/0
Innovations/Best Practices 8 8
PASSING SCORE 38 above 45 above
 4. Nominated health facilities that do not meet the criteria within the AFHF standard
evaluation tool of the set scoring range shall be automatically dropped from the final list
and shall be informed thru the region.
5. Plaque of recognition/trophy, insignia and mock cheque amounting to one hundred
thousand pesos (Php 100,000.00) shall be given to the awardees during the recognition.
6. The winners can redeem the cash prize (Php 100,000.00) upon submission of the
adolescent-related project proposal thru the Centers for Health Development (CHD)
coordinators endorsed to the DOH Central Office. The proposal should have the
following contents:
Title
Introduction
9-9.7!”

Objectives
Activities (i.e. trainings, seminars, development and production of IEC materials,
adolescent related events/activities, improvement of the adolescent friendly health
facilities and services)
Budgetary breakdown
Timeline
P‘qorw

Responsible Person
Signature of Local Chief Executive (i.e. Mayor) and/ or Chief of Hospitals

The project proposal shall be addressed to the Director IV of Disease Prevention and Control
Bureau.

Upon receipt of endorsement of the proposal from CHD, a check amounting to Php
100,000.00 will be issued to the winner during the recognition. In return, the LGU shall
issue an Official Receipt to the Event Organizer as a proof that they received the check.

V. ROLES AND RESPONSIBILITIES

l. DOH Central Office

A. Disease Prevention and Control Bureau (DPCB)
0 Develop guidelines and terms of reference and provide funding for the conduct
of recognition ceremonies and cash awards.
0 Convene the Adolescent Health and Development Program (AHDP) Technical
Working Group to provide technical assistance/support to the conduct of
deliberation and recognition of health facilities.
0 Provides overall directions in the conduct of recognition ceremony
o Monitors the preparation and implementation of the recognition ceremony.
o Responsible for the timely provision of all resources, access, information and
decision making under its control necessary for the activity.
0 Coordinates with CHD for the conduct of the recognition ceremony.

Health Promotion and Communication Service (HPCS)

0 Provides clearance for all materials and other collaterals which will be
developed.
0 Provides guidance in the development and implementation of the program for
the recognition ceremony.
o Coordinates with DOH Regional Offices - Health Education and Promotion
Officers in the preparation and implementation of the recognition ceremony.
 . .

o Oversees the conduct of the recognition ceremony.

2. Centers for Health Development

VV
Facilitate the conduct of screening and evaluation of Level II AFHF.
Evaluate and endorse Level II AFHF to DOH Central Office for national validation of
Level III AFHF.
V Convene the regional TWG: to provide technical assistance to the implementation of
the national validation team.
VV
Organize the participation of health facilities to the conduct of recognition ceremony.
Assessment and monitoring of health facilities accomplishments shall be conducted
yearly by the regions.

3. Health Facilities
> Conduct self-assessment and evaluation for Level I, II and III AFHF.
> Participate in the conduct of recognition ceremony.
> The health facility awardees must submit an adolescent-related project proposal signed
by the local chief executive / chief of hospital / municipal or city health officer to the
DOH CHD.

VI. BUDGET SOURCE

All expenses for the said activity (ceremony, awards and cash prizes) shall be charged
against the funds of Public Health Management of the DOH Central Office. These are subject
to the usual accounting and auditing rules and regulations.

For information, dissemination and compliance.

By Authority of the Secretary of Health:

MARIA ROSARIO . VERGEIRE, MD, MPH, CESO IV

OIC-Undersecretary f Health
Public Health Servic 5 Team
 DOH ADOLESCENT FRIENDLY HEALTH FACILITY LEVEL 3 RECOGNITION
VALIDATION TOOL
/
Region: Date:
Province:
Municipality/City:
Name of Adolescent Friendly Health Facility (for Level 3) Class of Municipality:
Name of Governor:
Name of Mayor:
Name of DMO: Designation: Contact Information:
Name of Provincial/City Coordinator: Designation: Contact Information:
Name of AFHF LGU Coordinator] Focal Person: Designation: Contact Information:

Instructions:
1. Please indicate the points and note the remarks or recommendations in their columns.
Total the points and check the score card matrix.

(A)
:
/ % ;
Advocacy and Promotional Activities/Materials
/
0 1) Welcome signage with name of facility Welcome signage with name of facility must be: 0: none
1 a. Posted visible at the entrance. 1: a
0 2) IEC plan with budget appropriation to a. Copy of IEC plan with budget appropriation 0: none
1 include: b. Presence of [EC materials and educational 1: a

.
2
3
/ IEC materials developed,
reproduced and disseminated
materials for adolescents of diverse
types/platforms display and used by the facility
1: b
1: c
focusing on adolescent health as indicated in the plan 2: a + b; a + c
(e.g. pamphlets, leaflets, social c. Presence of IEC inventory and distribution list: 3: a + b + c
cards, posters, broadcaster’s Name of receiving party
manuals, banners, TV/Radio ad Quantity provided
and etc.) \\\\\
Name of material(s) provided
Materials applicable for Date received
adolescents (for in facility use) Signature of receiving party
e.g. educational materials (books,
videos, magazines), musical
materials (instruments, musical
pieces, musical videos), and/or
sports instruments (sport
equipment, sport videos)

1|Pag'e'”
Adolescent Friendly Health Facility Validation Tool
 DOH ADOLESCENT FRIENDLY HEALTH FACILITY LEVEL 3 RECOGNITION
VALIDATION TOOL

0 3) Conduct of advocacy and promotional a. Copy of advocacy plan with budget 0: none
1 activities appropriation 1: a or b
2 b. Complete documentation (pictures, 2: a + b
minutes/narrative/program and attendance
sheet) of advocacy and promotional activities
conducted as stipulated in the plan
(H) Health Facility Policies and Guidelines
0 1) Clinic Schedule Presence of clinic schedule with the following: 0: none
1 a. Clinic hours must include schedule (with day 1: a or b
2 and time) specifically for adolescents. 2: a + b
b. Schedule of clinic hours must be visible in the
entrance area.
.0 2) Algorithm for patient flow visible at the Algorithm for patient flow must contain the following: 0: none
1 entrance or posted in a strategic area. a. Flow from admission/ registration to delivery 1: a
2 of services up to follow-up 2: a + b; a +c
3 b. Average time needed for each step to be 3: a + b + c
accomplished
c. Section/Department responsible
0 3) Trained designated person must be a 3.1 Designated person must have the following:
1 permanent employee and have access a. Copy of signed executive/office order as 0: none
2 to records. designated person with access to client’s 1: a
records 2: a + b
b. With alternate trained designated person with
access to records

3.2 Certificates of the following the trainings:

0 a. Adolescent Job Aid Training (NA) 0: none
1 b. Adolescent Health Education and Practical 1: a
2 Training (ADEPT) 2: a + b; a + c
3 c. Healthy Young Ones Training (HYO) 3: a + b + c
O 4) Designated room/s or space for a. Room/s or space designated for consultation, 0: none
1 adolescents’ consultation, treatment treatment and/or counselingseparated by 1: a or b
2 and/or counseling walls, curtains, blinds or dividers. 2: a + b
b. Must ensure privacy and confidentiality.
0 5) Clinical Guidelines in the provision of Presence of Clinical Guidelines in the provision of 0: none
1 Adolescent— Friendly Health Services Adolescent-FriendlyHealth Services: 1: a
2 a. Adolescent Job Aid Manual 2: a + b
b. AHDP Manual of Operations

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Adolescent Friendly Health Facility Validation Tool
 DOH ADOLESCENT FRIENDLY HEALTH FACILITY LEVEL 3 RECOGNITION
VALIDATION TOOL

0 6) Protocols and gurdelines for patient- a. Copy of the adoped and signed prtocols ad 0= none
1 provider interaction must be adopted guidelines for patient— provider interaction. =a
and signed by the local official.
0 7) Standard Operating Procedure for a. Copy of Standard Operating Procedure for 0: none
1 Facility Maintenance. Facility Maintenance. 1: a
0 8) Policy regarding flexible time schedule /
Copy of signed Executive Order Resolution /
1 to accommodate adolescents. Ordinance on Flexible Time Schedule of Health
2 Workers. Flexible time can be either: 0: none
3 a. On weekdays, 8am-5pm 1: a
b. On weekdays, Sam-5pm with a referral 2: a + b; a + c
agreement with schools (especially in 3: a + b + c
emergency cases)
c. On weekdays, 1-2 hours after 5 pm
0 9) Policies and procedures to ensuring Presence of at least one policy ensuring 0: none
1 privacy and confidentiality. privacy and confidentiality. 1: a or b
2 b. Posted policy at a strategic area. 2: a + b
0 10) Policies on payment schemes for a. Presence of a policy (Resolution/Ordinance) 0: none
1 adolescent needs providing financial risk protection schemes 1: a
2 and/payment schemes specifically for 2: a + b
adolescents.
b. Financial risk protection or payment schemes
(e.g. PhilHealth MDR of teenage mothers) is
posted
(D) Delivery of Health Servicesl
0 1) Policies for provision of services 3. Presence of Executive Order/ Resolution/ 0: none
1 specifically for adolescents. Health Ordinance on the provision of services for 1: a
2 Services must include: adolescents. 2: a + b; a + c
3
4
/ Clinical (Physical Examination,
Screening and Counseling)
b. List of health services for adolescents provided
by the facility must be posted visible at the
3: a + b + c
4: a + b + c + d
\/ Laboratory entrance.
/ Medicines/ Commodities c. List of patients provided with clinical or
laboratory services including medicines and
Client registration and referral logbook commodities should be reflected in the client’s
must contain the following: registration and referral logbooks.
\/ Name d. Accomplishment report
// Address
Age & Sex (disaggregated) (Note: If the facility is using electronic recording, verify
records)

Adolescent Friendly Health Facility Validation Tool

3|Page
 DOH ADOLESCENT FRIENDLY HEALTH FACILITY LEVEL 3 RECOGNITION
VALIDATION TOOL

{a /
\/ Clinical Impression
/
\/
Services given/provided
Date and time of visit and referral
(if any)
\/ Place and person/department
referred to
\/
Reason for referral

0
/Result of referral
2) Memorandum of Agreement/ a. Copy of completely signed and notarized 0: none
1 Memorandum of Understanding for Memorandum of Agreement / Memorandum 1: a
services that needed referral (SDN) of Understanding.

0 3) Individual Treatment Records must a. Presence of Individual Treatment Records with 0: none
1 contain the following: complete data (sample randomly 5 ITRs) kept 1: a
2
3
/Chief complaint
‘/ Findings on Examination
in separate envelopes and in a filing cabinet
with a lock and key secured by the designated
2: a + b
3: a + b + c
/Clinical Impression
\/ Management of Clients
person in charge of the access to client’s
records
b. Attached/Compiled Accomplished HEEEADSSSS
ITRs must be kept in separate envelopes form
and in a filing cabinet with a lock and key c. Attached/Compiled Return Referral Slips
secured by the designated person in charge
of the access to client’ 5 records (Note: If the facility is using electronic recording, verify
individualrecords)
0 4) Stock Cards showing the delivery and a. Presence of Stock Cards with date and quantity 0: none
1 utilization of medicines, commodities of delivery and utilization of medicines and 1: a
2 for adolescent health care other commodities 2: a + b
b. Presence of expiration dates

(Note: If the facility is using electronic recording, verify

date of delivery and utilization of medicines)
0 5) Client Satisfaction a. Presence of suggestion box specific for 0: none
1
'
adolescent health and survey form 1: a
2 b. Summary of results and actions taken 2: a + b
(P) Partnership and Collaboration
0 1) Presence of technical working group a. Copy of signed policy (i.e. executive/office 0: none
1 must at least composed of but not order, hospital order, resolution, ordinance) for =a
2 limited to the following: the creation or appointment of the Technical 2: a + b

4 I P a g e
Adolescent Friendly Health Facility Validation Tool
 DOH ADOLESCENT FRIENDLY HEALTH FACILITY LEVEL 3 RECOGNITION
VALIDATION TOOL

a, A Z
J/ Local Chief Executives
a .
/ “/4 age; A
c M
W rking Group or adaption of the Local Health
.C

For hospital: Chief of Hospital, Board with indicated roles/responsibilities of

Department Heads members and schedule of TWG meetings
J DSWD, NYC, POPCOM, DepEd and b. Complete minutes of the meeting (quarterly or
other agencies in municipal, city or monthly or as per agreement) with attendance
provincial level sheet and pictures of meetings
J CSOs and/or other partners
J Youth groups/student
organizations
0 2) Trained peer educators assisting in a. Copy of signed policy with the roles and 0: none
1 clinic operations and providingservices responsibilities of a trained peer educator 1: a or b
2 (lectures, counseling, etc) b. Copy of certificates of training of peer 2: a + b; a + c; b+c
3 educators and their list of schedule assisting in 3: a + b + c
clinic operation
c. Presence of COMPLETE documentation of
activities conducted/participated by peer
educators.
0 3) Presence of directory of organizations a. The directory of organizations for referral 0: none
1 purposes must contain the following: =a
2 J Name of Organizations 2=a + b
J Address
J Contact Person and Number
b. Services provided and schedule of services

0 4) Adolescent-related plans, strategies, a. Copy of either one of the following: 0: none

1 activities, initiatives must be J Local Investment Plan for Health =a
2 included/reflected in the formulation of (Barangay/Municipal) 2: a + b
plans with budget allocation. J Local Development Plan
J Annual Operational Plan
b. Copy and signed budget utilization report
Innovations/Good Practices: Documentation of all innovations and good practices A=2
Advocacyand Promotional Activities/Materials related to AHDP H=2
_ljealth Facility Policies and Guidelines D=2
I_J_e|ivery of Health Services P=2
Partnership and Collaboration A+H+D+P=8

TOTAL SCORE:
DENOMINATOR: 50
5 P age
I

Adolescent Friendly Health Facility Validation Tool

 DOH ADOLESCENT FRIENDLY HEALTH FACILITY LEVEL 3 RECOGNITION
VALIDATION TOOL

Score Card Matrix

CRITERIA SCORE SCORE

Advocacy a nd Promotional Activities/Materials 6

flealth Facility Policies and Guidelines 23

Qelivery of Health Services 12
Partnership and Collaboration 9
TOTAL 50
Additional Points for Innovations/Good Practices 8
Passing Score 45 above

National Assessment Team:

Signature over Printed Name Signature over Printed Name Signature over Printed Name

Signatureover Printed Name Signature over Printed Name Signature over Printed Name

Adolescent Friendly Health Facility Validation Tool

6|Page
 DOH ADOLESCENT FRIENDLY HEALTH FACILITY LEVEL 3 RECOGNITION
VALIDATION TOOL

I I I, I) I ,

Region: Date:
Province:
Municipality/City:
Name of Adolescent Friendly Health Facility (for Level 3)
Name of Governor:
Name of Mayor:
Name of Chief of Hospital: Designation: Contact Information:
Name of AFHF Coordinator] Focal Person: Designation: Contact Information:

Instructions:
1. Please indicate the points and note the remarks or recommendations in their columns.
2. Total the points and check the score card matrix.

. M :
,ZZ?
/ / , , 4
(A) Advocacy and Promotional ActIVItIes/ Materials
a;
0 1) Welcome signage with name of facility Welcome signage with name of facility must be: 0: none
a. Posted visible at the entrance. 1: a
0 2) IEC plan with budget appropriation to a. Copy of IEC plan with budget appropriation 0: none
1 include: b. Presence of IEC materials and educational 1: a
2 \/ IEC materials developed, materials for adolescents of diverse 1: b
3 reproduced and disseminated types/platforms display and used by the facility 1: c
focusing on adolescent health as indicated in the plan 2: a + b; a + c
(e.g. pamphlets, leaflets, social c. Presence of IEC inventory and distribution list: 3: a + b + c
cards, posters, broadcaster’s \/ Name of receiving party

//
manuals, banners, TV/Radio ad Quantity provided
and etc.) Name of material(s) provided
\/ Materials applicable for \/ Date received
adolescents (for in facility use) V Signature of receiving party
e.g. educational materials (books,
videos, magazines), musical
materials (instruments, musical
pieces, musical videos), and/or
sports instruments (sport
equipment, sport videos)

0 3) Conduct of advocacy and promotional to Copy of advocacy plan with budget 0: none
1 activities appropriation 1: a or b

Adolescent Friendly Health Facility Validation Tool

llPage
 DOH ADOLESCENT FRIENDLY HEALTH FACILITY LEVEL 3 RECOGNITION
VALIDATIONTOOL

m/J/fl/
2 b. Complete documentation (pictures, =a+b
minutes/narrative/program and attendance
sheet) of advocacy and promotional activities
conducted as stipulated in the plan
(H) Health Facility Policies and Guidelines
0 1) Clinic Schedule Presence of clinic schedule with the following: 0: none
1 a. Clinic hours must include schedule (with day 1: a or b
2 and time) specifically for adolescents. 2: a + b
b. Schedule of clinic hours must be visible in the
entrance area.
0 2) Algorithm for patient flow visible at the Algorithm for patient flow must contain the following: 0: none
1 entrance or posted in a strategic area. a. Flow from admission/ registration to delivery 1: a
2 of services up to follow-up 2: a + b; a+c
3 b. Average time needed for each step to be 3: a + b + c
accomplished
c. Section/Department responsible
O 3) Trained designated person must be a 3.1 Designated person must have the following:
1 permanent employee and have access a. Copy of signed executive/office order as 0: none
2 to records. designated person with access to client’s 1: a
records 2: a + b
b. With alternate trained designated person with
access to records

3.2 Certificates of the following the trainings:

0 a. Adolescent Job Aid Training (AJA) 0: none
1 b. Adolescent Health Education and Practical 1: a
2 Training (ADEPT) 2: a + b; a + c
3 . Healthy Young Ones Training (HYO) 3: a + b + c
0 4) Designated room/s or space for a. Room/s or space designated for consultation, 0= none
1 adolescents’ consultation, treatment treatment and/or counselingseparated by 1: a or b
2 and/or counseling walls, curtains, blinds or dividers. 2: a + b
b. Must ensure privacy and confidentiality.
O 5) Clinical Guidelines inthe provision of Presence of Clinical Guidelines in the provision of 0: none
1 Adolescent- Friendly Health Services Adolescent-FriendlyHealth Services: 1: a
2 a. Adolescent Job Aid Manual 2: a + b
b. AHDP Manual of Operations

Adolescent Friendly Health Facility Validation Tool

2|Page
 DOH ADOLESCENT FRIENDLY HEALTH FACILITY LEVEL 3 RECOGNITION
VALIDATION TOOL

0 6) Protocols and guidelines for patient— a. Copy of the adopted and signed protocols and 0: none
1 provider interaction must be adopted guidelines for patient— provider interaction. =a
and signed by the local official.
0 7) Standard Operating Procedure for a. Copy of Standard Operating Procedure for 0: none
1 Facility Maintenance. Facility Maintenance. 1: a
O 8) Policies and procedures to ensuring a. Presence of at least one policy ensuring 0: none
1 privacy and confidentiality. privacy and confidentiality. 1: a or b
2 b. Posted policy at a strategic area. 2: a + b
0 9) Policies on payment schemes for a. Presence of a policy (Resolution/Ordinance) 0: none
1 adolescent needs providing financial risk protection schemes 1: a
2 and/payment schemes specifically for 2: a + b
adolescents.
b. Financial risk protection or payment schemes
(e.g. PhilHealth MDR of teenage mothers) is
posted
(D) Delivery of Health Services
0 1) Policies for provision of services a. Presence of Executive Order/ Resolution/ 0: none
1 specifically for adolescents. Health Ordinance on the provision of services for 1: a
2 Services must include: adolescents. 2: a + b; a + c
3 J Clinical (Physical Examination, b. List of health services for adolescents provided 3: a + b + c
4 Screening and Counseling) by the facility must be posted visible at the 4: a + b + c + d
// Laboratory
Medicines/Commodities c.
entrance.
List of patients provided with clinical or
laboratory services including medicines and
Client registration and referral logbook commodities should be reflected in the client’s
must contain the following: registration and referral logbooks.
Name d. Accomplishmentreport
Age & Sex (disaggregated) (Note: If the facility is using electronic recording, verify
\\\\\\
Address records)
Clinical Impression
Services given/provided
Date and time of visit and referral
(if any)
\ Place and person/department
referred to
Reason for referral
\\ Result of referral

Adolescent Friendly Health Facility Validation Tool

3|Page
 DOH ADOLESCENT FRIENDLY HEALTH FACILITY LEVEL 3 RECOGNITION
VALIDATION TOOL

0
M/»/Records must
2) IndIVIdual Treatment
12 , fig. M
Presence of IndIVIdualTrea tment Records wuth 0: none
1 contain the following: complete data (sample randomly 5 ITRs) kept =a

///
2 Chief complaint in separate envelopes and in a filing cabinet 2: a+b
3 Findings on Examination with a lock and key secured by the designated 3: a+b+c
ClinicalImpression person in charge of the access to client's
\/ Management of Clients records
b. Attached/Compiled Accomplished HEEEADSSSS
ITRs must be kept in separate envelopes form
and in a filing cabinet with a lock and key c. Attached/Compiled Return Referral Slips
secured by the designated person in charge
of the access to client’s records (Note: If the facility is using electronic recording, verify
individualrecords)
0 3) Stock Cards showing the delivery and a. Presence of Stock Cards with date and quantity 0: none
1 utilization of medicines, commodities of delivery and utilizationof medicines and 1: a
2 for adolescent health care other commodities 2: a + b
b. Presence of expiration dates

(Note: If the facility is using electronic recording, verify

date of delivery and utilization of medicines)
0 4) Client Satisfaction 3. Presence of suggestion box specific for 0: none
. 1 adolescent health and survey form 1: a _

2 b. Summary of results and actions taken 2: a + b

(P) Partnership and Collaboration
0 1) Trained peer educators assisting in a. Copy of signed policy with the roles and 0: none
1 clinic operations and providing services responsibilities of a trained peer educator 1: a or b
2 (lectures, counseling, etc) b. Copy of certificates of training of peer 2: a + b; a + c; b+c
3 educators and their list of schedule assisting in 3: a + b + c
clinic operation
c. Presence of COMPLETE documentation of
activities conducted/participated by peer
educators.
0 2) Adolescent-related plans, strategies, a. Copy of Hospital Operational Plan 0: none
1 activities, initiatives must be b. Copy and signed budget utilization report 1: a
2 included/reflected in the formulation of 2: a + b
plans with budget allocation.

4|Page
Adolescent Friendly Health Facility Validation Tool
 DOH ADOLESCENT FRIENDLY HEALTH FACILITY LEVEL 3 RECOGNITION
VALIDATION TOOL

Innovations/Good Practices Documentation of all innovations and good practices A=2

Advocacy and Promotional Activities/Materials related to AHDP H=2
Health Facility Policies and Guidelines D=2
Qelivery of Health Services P=2
_Partnership and Collaboration A+H+D+P=8

TOTAL SCORE:
DENOMINATOR: 42

Score Card Matrix

CRITERIA SCORE SCORE

Advocacy a nd Promotional Activities/Materials 6

Health Facility Policies and Guidelines 20

Qelivery of Health Services 11
Partnership and Collaboration 5
TOTAL 42
Additional Points for Innovations/Good Practices 8
Passing Score 38 above

National Assessment Team:

Signature over Printed Name Signatureover Printed Name Signature over Printed Name

Signature over Printed Name Signatureover Printed Name Signature over Printed Name

5 P age
l

Adolescent Friendly Health Facility Validation Tool