Republic of the Philippines

Department of Health
REGIONAL OFFICE __

ASSESSMENT TOOL FOR LICENSING A BIRTHING HOME

I. FACILITY INFORMATION

Name of Facility BAGULIN PRIMARY CARE FACILITY

: ____________________________________________________________________
Complete Address : ____________________________________________________________________
PUROK 1 SUYO
No. & Street Barangay
BAGULIN LA UNION I
____________________________________________________________________
City/Municipality Province Region
Contact Number (072) 712-0496/ 09952637880
: ____________________________ [email protected]
E-mail Address: __________________________
Name of Owner LOCAL GOVERNMENT UNIT OF BAGULIN, LA UNION
: ______________________________________________________________
ANTHONY S. CERENO, MD
Name of Head of the Facility : ______________________________________________________________
01-083-23-BH-1
Latest DOH License Number (if renewal): _____________________
Authorized Bed Capacity: 3
_____________________
Classification According to
Ownership: / Government Private

Institutional Character: Free-standing / Institution-Based

II. TECHNICAL REQUIREMENTS
Instruction: In the appropriate box, place a check mark (√) if the birthing home is compliant or x mark (X) if it
is not compliant.

STANDARDS AND REQUIREMENTS COMPLIANT REMARKS

A. PERSONNEL
A birthing facility shall be managed and supervised by healthcare professional(s) who have complied with the minimum and
valid licensing requirements. Every birth must be attended by skilled birth attendants.
1. Physician
a. Valid PRC license /
b. Certificate of Completed Training from an institution
with an Accredited Residency Program (for Obstetrician N/A
and Gynecologist, and Pediatrician)
c. A valid certificate of Good Standing from the
Accredited Professional Organization (APO) of
Physicians of PRC and/or any DOH recognized /
association of physicians (for Family Medicine
Physicians, Municipal Health Officers and General
Practitioners)
d. Certificate of Training on BEmONC (for Family Medicine
Physicians, Municipal Health Officers and General /
Practitioners)
e. Notarized Contract of
Employment/Appointment/Designation (for /
employees)
2. Nurse
a. Valid PRC License /
b. Certificate of good standing from the Accredited
Professional Organization (APO) of Nurses of PRC /
and/or any DOH recognized association of nurses.
c. Notarized Contract of Employment (for employees) /
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3. Midwife
a. Valid PRC License /
b. Valid Certificate of Good Standing from the Accredited
Professional Organization (APO) of Midwives of PRC
/
and/or any DOH recognized association of midwives
c. Certificate of Training on BEmONC (not required for /
those who finished the four (4) year Midwifery Course)
d. Certificate of Training in Basic Life Support /
e. Notarized Contract of Employment (for employees) /
4. Administrator
a. Notarized Contract of Employment (for employees) /
5. Clerk
a. Notarized Contract of Employment (for employees) /
6. Utility Worker (1/5 beds/shift)
a. Notarized Contract of Employment (for employees) /
7. Driver (on call 24/7) or MOA with a transport provider
a. Notarized Contract of Employment (for employees) /
B. EQUIPMENT, INSTRUMENTS/SUPPLIES, BASIC MEDICINES (Refer to List of Equipment,
Instruments/Supplies, Basic Medicines) Every health facility shall have available medicines and operational
equipment and instruments consistent with the services it shall provide.
C. PHYSICAL FACILITY
Every health facility shall have physical facility with adequate areas in order to safely, effectively, and
efficiently provide health services to patients.
1. DOH Approved Permit to Construct (PTC) /
2. DOH Approved Floor Plan /
3. Business Permit /
4. Posted in conspicuous area /
a. License to Operate (for renewal) /
b. Local Permits /
c. Vision and Mission /
d. Organizational Chart /
5. Signages
a. Information /
b. Direction /
c. Prohibition and Warning /
d. No Smoking Sign /
e. Evacuation Plan /
f. Process Flow of Clinical Services /

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 III. FACILITY OPERATIONS

STANDARDS AND REQUIREMENTS COMPLIANT REMARKS

A. MANUAL OF OPERATIONS/STANDARD OPERATING PROCEDURES
1. Vision and Mission /
2. Organizational Chart /
2. 3. Documented policies and procedures on provision
/
3. of clinical services in the facility
a. Antepartum Care /
b. Spontaneous vaginal delivery including /
essential intrapartum care
c. Postpartum Care /
d. Newborn Care /
d.1 Essential Newborn Care based on A.O. No.
/
2009-0025
d.1.1 Time Bound interventions /
d.1.2. Non time bound interventions including
birth doses of recommended vaccines /
(BCG and first dose Hepa B)
d.1.2.1 Routine newborn care /
d.1.2.2 Postnatal care /
e. Detection of high risk pregnancies and early /
referral
f. Family Planning /
f.1 Natural Family Planning Methods pursuant to
/
A.O. No. 132 s. 2004
f.2 Artificial Family Planning Methods /
g. Health Education /
g.1 Birth Planning and Preparedness /
g.2 Maternal and Newborn Care (Unang Yakap) /
g.3 Infant and Young Child Feeding and
/
Lactation Management (Breastfeeding TSek)
g.4 Hygiene /
4. Documented Policies and procedures on
transfer/referral system to a health facility of higher /
capability
5. Documented policies and procedures on administration
of life-saving medications such as magnesium sulphate,
/
oxytocin, steroids, and oral antibiotics pursuant to A.O.
No. 2010-0014.
6. Documented policies and procedures on Infection /
Control
7. Healthcare Waste Management
/
Documented policy and procedures on proper collection,
segregation, treatment and disposal of generated waste.
a. Written policy and procedures on waste
/
Management
b. Proper collection, segregation, coding, storage and /
disposal of wastes (for both solid and liquid wastes)
c. Use of protective equipment and clothing
appropriate for handling, storage, and disposal of /
wastes.
d. Wastes are properly segregated, coded and labelled /
as follows:
d.1 General/Non-infectious/Dry – Black /
d.2 General/Non-infectious/Wet – Green /
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d.3 Infectious/Pathological – Yellow /

d.4 Sharps – Sharps container /
8. Preventive maintenance program for equipment. /
a. Plan for essential equipment replacement in case of
breakdown /
b. Record of equipment /
c. Operational manuals of all equipment and
/
instruments
9. Documented policies and procedure for handling
complaints, reporting and analysis of incidents, adverse /
events, etc.
10. Pest and vermin control program /
a. Documented policies for pest and vermin control
Program
/
11. Medical Records /
a. Confidentiality of patient information /
b. Policy and procedures for retention and disposal of
medical records in accordance with Department /
Circular No. 70 S. 1996
B. RECORDS/FILES

Each patient record shall be kept confidential and shall contain sufficient information to identify the patient and to
justify the diagnosis and treatment.
1. Patient’s Clinical Record /
a. Maternal Clinical Charts with duly accomplished /
Partograph
Contents of Maternal Clinical Chart: /
a.1 Identification Data /
a.2 History of Present Condition /
a.3 Physical Examination /
a.4 Admitting Diagnosis /
a.5 Physician’s Order Sheet (if seen by a
/
physician)
a.6 Clinical Laboratory Report and results of other
/
diagnostic procedures done, if any
a.7 Consultation/Referral Notes /
a.8 Medication/Treatment Record /
a.9 Postpartum Monitoring /
a.10 Informed Consent /
a.11 Final Diagnosis, if seen by a physician /
b. Newborn Clinical Chart /
b.1 Identification data /
b.2 APGAR Scoring/Ballard’s Maturational Score /
2. Logbooks for Consultations, Admissions, Discharges,
Deliveries and Sentinel Events (For sentinel events, /
include correction, corrective and preventive actions done)
3. Copies of Birth/Death Certificates (including Fetal
Deaths) submitted to local civil registrar /

4. Copies of Annual Birthing Home Statistical Report

received by the regional office /

5. Records of transfer/referral of patient to another health

facility /

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 STANDARDS AND REQUIREMENTS COMPLIANT REMARKS
6. Certificate (from UPNIH) as a Newborn Screening
Facility pursuant to RA No. 9288 and AO No. 2008- /
0026

7. Assurance and notarized certification (from a Notary

Public) that the birthing facility does not perform
/
Dilatation and Curettage.

8. Assurance and notarized certification (from a Notary

Public) that the birthing facility does not perform
permanent sterilization procedures such as Bilateral /
Tubal Ligation (BTL) and vasectomy.

9. Notarized Memorandum of Agreements for outsourced

/
services
a. Patient Transport service provider (if outsourced) /
b. Waste management service (if outsourced) /
c. Pest and vermin control service (if outsourced) /
10. Notarized Memorandum of Agreement if birthing home
is manned by: N/A
d.1.Obstetrician – MOA with Pediatrician or Medical
practitioners and/or local government N/A
physicians trained on BEmONC
d.2 Pediatrician – MOA with Obstetrician or Medical
practitioners and/or local government N/A
physicians trained on BEmONC
d.3 Nurse – MOA with Obstetrician and
Pediatrician or a General
Physician with a Certificate of N/A
Completion of a training
on BEmONC
d.4 Midwife – MOA with Obstetrician and Pediatrician
or a General Physician with Certificate of N/A
Completion Training on BEmONC

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 Checklist of Requirements on Equipment, Instruments/Supplies, and Basic Medicines
for Birthing Home

A. General Administrative Service

MINIMUM MINIMUM
REQT. COMPLIANT REQT. COMPLIANT

EQUIPMENT/INSTRUMENTS

1. Bench 1 / 7. Fire Extinguisher 1 /

2. Cabinet 1 / 8. Open Shelf 1 /

9. Standby Generator or (battery operated
3. Calculator 1 / 1 /
rechargeable emergency light)
10. Transport vehicle or MOA with a service
4.Chair 1/staff / 1 /
provider

5. Desk 1/staff / 11. Typewriter/Computer 1 /

12. Refrigerator/ cooler (for breast milk,
6. Electric Fan 1 / medications and vaccines such as Hepatitis 1 /
B and BCG)

B. Clinical Service

MINIMUM MINIMUM
REQT. COMPLIANT REQT. COMPLIANT

EQUIPMENT/INSTRUMENTS

Sterilization Area

1. Autoclave/Steam sterilizer or its equivalent 1 / 2. Soaking or decontaminating solution 1 /

Treatment Room (same as Outpatient Area)

1. Clinical weighing scale (adult) 1 / 5. Stethoscope 1 /

2. Examining table 1 / 6. Tape measure 1 /

3. Foot stool 1 / 7. Vaginal speculum 2 /

4. Gooseneck/ examining light 1 /

Ward (includes Labor Room and Recovery Room)

1. Lubricant (water-based) 1 / 5. Thermometer (non-mercurial) 1 /

2. Sphygmomanometer (non-mercurial) 1 / 6. Wall clock with second hand 1 /

3. Sterile gloves 2 / 7. Bed with guard rail 1 /

Depends on
4. Stethoscope 1 / 8. Bed sheets the number of /
beds

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 MINIMUM MINIMUM
REQT. COMPLIANT REQT. COMPLIANT

EQUIPMENT/INSTRUMENTS

Birthing Room
1 per 2
1. Delivery set / 6. Instrument table 1 /
beds
a. Hemostatic/Kelly Forceps, curve or
2 / 7. Instrument cabinet 1 /
straight
b. Kidney basin 1 / 8. IV stand 1 /
c. Needle holder, 8 inches 1 / 9. Kelly pad 1 (optional) /
10. Oxygen unit (with humidifier and
d. Surgical scissors (straight mayo) 1 / 1 /
regulator, min. 5 lbs.)
e. Bandage scissors 1 / 11. Pail 1 /
f. Thumb forceps 1 / 12. Stool 1 /
13. Suction apparatus (not for routine
g. Tissue forceps (with teeth) 1 / suctioning, may be used for newborns 1 /
whose airway may be blocked)
h. Sterile plastic umbilical cord clamp(s) 14. Pair(s) of slippers (exclusive for birthing
1 / 2 pairs /
or ties room use)
15. Room thermometer (non-mercurial),
i. Umbilical cord scissors 1 / maintain room temperature between 25-28 1 /
degrees Celsius
2. Delivery table with stirrups and with
for Birthing
provision for semi-upright position of the 1 / 16. Gowns or patients’ gown /
Room use
birthing mother
3. Emergency light/ flashlight 1 / 17. Linen for drying newborns 1 per bed /
4. Foot stool 1 / 18. Sterile drapes 1 per bed /
5. Gooseneck/ examining lamp 1 / 19. Scrub suits 1 per staff /

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 MINIMUM MINIMUM
REQT. COMPLIANT REQT. COMPLIANT

EQUIPMENT/INSTRUMENTS

Newborn Resuscitation Area

1. Emergency kit or cart/ Portable kit or
trolley (should contain the basic medicines, 1 /
equipment and supplies listed)
Basic Medicines Basic Supplies
a. Intravenous catheter set (adults and
a. Atropine 1mg/ml ampule 1 / 1 1 each /
newborns)
b. BCG vaccines (stored inside ref at
1 / b. 70% Isopropyl alcohol 1 bottle /
temp between 2-8° Celsius
c. Betamethasone (Diprospan)7mg per c. Disposable syringes (1 cc, 3 cc, 5 cc, 10
ampule (preferred) or Dexamethasone 1 / 1 each /
cc) with needles
(Scancortin) 5mg/ml per ampule (alternative)
d. Calcium gluconate 10 mg/ampule 1 / d. IV tubings (macro and micro-drip sets) 1 each /
e. Diphenhydramine 50 mg/ampule 1 / e. Nasal cannulas or plastic face masks 1 /

f. Epinephrine 1 mg/ml ampule 1 / f. Plaster 1 /

g. Erythromycin ophthalmic ointment 0.5% or /
1 / g. Povidone-iodine solution 1 bottle
Oxytetracycline ophthalmic ointment
h. Hepatitis B vaccines (stored inside ref at
1 / h. Sterile absorbable sutures 1 /
temp. between 2°-8° Celsius
i. IV fluids (stand by) such as:
i. D5 LR or Plain LR 1 L per bottle 3 bottles / i. Sterile cotton balls 1 pack /
ii. Plain NSS 1 L per bottle 2 bottles
1 vial if
j. Local anesthetic such as Lidocaine 2%
50ml, 5 pcs. / j. Sterile cotton pledgets 1 pack /
solution 50ml vial or 5ml carpule
if carpules
k. Magnesium Sulfate ampule 1 / k. Sterile gauzes 1 pack /
l. Oxytocin 10 units per ampule or Oxytocin
in pre-filled, single- dose, non-reusable 2 / l. Sterile gloves 1 box /
injection
m. Tetanus toxoid containing vaccines 2 / m. Surgical caps 1 box /
n. Tranxenamic acid ampule 1 / n. Surgical masks 1 box /
o. Vitamin K ampules 2 / o. Sharps container 1 /
p. Suction catheters (adult and newborn
Basic Equipment 1 per bed /
sizes)
a. Self-inflating bag-valve-mask devices (one
for adult, one for newborn) or masks for adult
1 each /
and masks for the newborn (one size 1 for
term and one size 0 for pre-term)
1-adult
b. Stethoscope /
1-pediatric
c. Sphygmomanometer (non-mercurial) with
1 /
adult cuff and neonatal cuff
d. Thermometer (non-mercurial) 1 /
e. Weighing scale for newborn 1

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Name of Health Facility: BAGULIN PRIMARY CARE FACILITY

Date of Inspection:

RECOMMENDATIONS:

A. For Inspection Process:

[ ] For issuance of License as Birthing Home.

Validity from to

[ ] Issuance depends upon compliance to the recommendations given and submission of the
following within days from the date of inspection:

[ ] Non-Issuance: Specify reason/s.

Inspected by:

Printed Name Signature Position/Designation

Received by: / Assessed by:

Signature
Printed Name PRESCILLA S. SALDO, RN
Position/Designation NURSE II
Date 11/05/2024

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Name of Health Facility:

Date of Monitoring:

RECOMMENDATIONS:
A. For Monitoring Process:

[ ] Issuance of Notice of Violation

[ ] Non-issuance of Notice of Violation

[ ] Others (Specify)

Monitored by:

Printed Name Signature Position/Designation

Received by:

Signature
Printed Name
Position/Designation
Date

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