Revised Provider Outlet Inspection-general

PROVIDER OUTLET INSPECTION Name of Hospital/Clinic: Address of Location: Availability of parking space: Building:

Purpose-built

Assessment Date: Hospital Director or Doctor in Charge: Assessment Visit Conducted by: Other Assessment Team Members: Converted

Shared With Other Business Concerns Main Services:

DESCRIPTION Available Further DETAILS/COMMENTS/ACTION Functional Rating Ass risk-based necessary items are **Note: Total minimum score here is only suggestive. In spite of this score where very essential Y/N clinic or agree with clinic to fill Required missing or not functional. Contract to consider alternative gap within reasonable period. Y/N

Std

Actual

1. GENERAL 1.1, Registration with Govt authorities – showing original certification 1.2, Can produce professional licences and certification of Doctors, nurses, pharmacists, radiographers etc. 1.3, Possession of malpractice insurance 1.4, There is 24hr emergency service 1.5, There is 24hr Nurse/Doctors cover for in-patient services 1.6, Emergency access with ramp

4

1.7, Mosquito net screening

4

1.8, Access road is passable to the clinic all year round 1.9, Alternative electricity power source or standby power generator 1.10, Patients waiting room clean good seats and well ventilated 1.12, Availability of waste disposal facilities. 2. CONSULTING ROOM 2.1, Examination couch 2.2, Wash Hand basin 2.3, Adequate lighting 2.4, Diagnostic set 2.5, Stethoscope and sphygmomanometer 2.6, Thermometer

4

DESCRIPTION

4 4 4 3 3

4 3 3 4 2 2 3 4 4

Available Functional Y/N

Rating

Std 3.IN PATIENT FACILITIES 3.1, Admission facilities present – single beds, clean, good housekeeping. 3.2, Admission for isolation cases 3.3, Supporting bedside facilities – lockers, call buttons, lights, bedside tables. 3.4, Separate wards for male, female and children 3.5, A locker and an overhead table for each bed 3.6, Adequate lighting 3.7, Toilet Facilities with adequate water supply 3.8, Availability of ward screens 3.9, Nurses’ bay and doctors’ room 4. OPERATING THEATER 4.1, Operating table 4.2, Anaesthetic Machine 4.3, Autoclave 4.4, Air conditioning unit 4. 5, Adequate resuscitative equipment 4.6, Operating Light source 5. PHARMACY

4 3 3 3 2 2 4 2 2 4 4 4 3 3 3

Further Ass Required Y/N

DETAILS/COMMENTS/ACTION

Actual State room total occupancy sizes