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Annex A - Licensing Standards For Primary Care Facilities
Annex A - Licensing Standards For Primary Care Facilities
2020- 0047
ANNEX A
PERSONNEL
A. Every PCF shall have a duly licensed physician, as head of the facility, to oversee
the clinical and administrative operations of the health facility.
B. For rural health units and urban health centers, the head of the facility shall also
oversee the clinical and administrative operations of barangay health stations
within their jurisdiction.
C. The minimum staffing standards such as staff composition and number/ratio
shall be set by DOH. Adjustments in the staffing pattern shall depend on the
workload and services being provided, using applicable workload assessment
tools.
D. The staff must be competent and shall have the appropriate learning and
development interventions and certification prescribed by DOH
worker.
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E. There shall be staff development and continuing education program at all levels
of organization to upgrade the knowledge, attitude and skills of staff.
Every PCF shall have physical facilities with adequate and appropriate areas to safely,
effectively, and efficiently provide health services to patients. As such, it shall:
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of Floor Plans for Primary Care Facility (ANNEX C).
C. Have an approved DOH Permit to Construct (DOH-PTC) in
accordance with the
planning and design guidelines prepared by DOH (ANNEX C).
Every PCF shall have available and operational equipment, instruments, materials and
supplies consistent with the services it will provide. As such, it
shall:
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repair of equipment.
C. Have a contingency plan in case of equipment breakdown and matron,
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IV. SERVICE DELIVERY
Every PCF shall ensure that the services being delivered to patients comply with the
standards in the Assessment Tool for Licensing of PCF (ANNEX B) and other related
relevant issuances.
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K. PCFs that provide primary care services through digital technologies for health
and mobile health services, shall adhere to the existing or
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telemedicine guidelines issued by DOH Knowledge Management and
Information Technology Service (KMITS).
Every PCF shall establish and maintain a system for continuous quality improvement
activities.
Every PCF shall maintain a system of communication, recording and reporting and
releasing of patient’s results, in adherence to Republic Act (RA) No. 10173 also known
as the “Data Privacy Act of 2012” and RA No. 11332 also known as the “Mandatory
Reporting of Notifiable Diseases and Health Events of Public Health Concern Act.”
A. Medical Records
B. Validated Electronic Medical Records (EMR)
C. Proof of submission of data to National Database of Human Resources for Health
Information System (NDHRHIS)
D. Technical records/logbooks of:
1. Sentinel/adverse events
2. Navigation, coordination and referrals of patients through the Primary Care
Provider Network and Health Care Provider Network
E. Administrative records of:
Minutes of the Meeting
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Attendance logbook
201 Personnel Staff files
Reports of DOH inspection and monitoring activities
ANP
Preventive and corrective maintenance of equipment
. Maintenance and monitoring of health facility
F. Records Management
1. There shall be documented policies and procedures on access to and
confidentiality of patient’s information. Likewise, the right of the patient to
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obtain records of treatment and other relevant medical information shall be
observed.
2. Retention and disposal of medical records and other relevant information
whether paper-based or electronic media shall be in accordance with the
standards promulgated by DOH or by competent authorities for such
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Vil. ENVIRONMENTAL MANAGEMENT
PCF shall ensure that the environment is safe for its patients and staff, including the
general public.
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There shall be a contingency plan in case of accidents and emergencies.
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