Licensing Requirements - DOH

RECORDSThe clinic shall maintain a record system to provide readily available information onthe following:1. Patient care• Dialysis charts• Standing order for hemodialysis – updated quarterly• Physician’s order• Completed consent form – updated annually• Patient’s monitoring sheet• Standing order for medication• Laboratory results• Confinements with corresponding date and name of hospital• History and physical examination• Problem list• Transfer/referral slip (for patients that will be transferred or referred toanother health facility)2. Incident and accident (in logbooks)• Complications related to dialysis procedure• Complications related to vascular access• Complications related to disease process• Dialysis adequacy of patients on thrice weakly treatments• Outcomes• Staff/patient’s hepatitis status3. Staff and patient vaccination• Hepatitis B (double dose) – 0, 1,2,6 months• Influenza – annually• Pneumococcal – every 5 years4. Water treatment• Bacteriological• Chemical5. Administrative• Minutes of the facility’s staff meetings• Reports of DOH inspections6. Facility and equipment maintenance schedule• Preventive maintenance• Corrective measuresRECORDING AND REPORTINGThe clinic shall register their patients to the Renal Disease Registry in support to theREDCOP of the DOH and in coordination with the Philippine Society of Nephrology.Likewise, an annual statistical report shall be submitted to REDCOP.Page 4 of 5

POLICIES AND PROCEDURESThe clinic shall provide a policy and procedure manual, which is designed to ensureprofessional and safe care for the patients.QUALITY ASSURANCE PROGRAMThe clinic shall provide a quality assurance program to evaluate the provision ofpatient care. The program shall have a written plan and implementation shall becontinuous with periodic review.WASTE MANAGEMENT PROGRAMThe clinic shall have written and established waste management program withspecial treatment on infectious/pathological waste. Waste management shall be inaccordance with the revised Manual on Health Care Waste Management.EXHIBITION OF LICENSEThe license to operate of the clinic shall be posted in a conspicuous space readilyseen by the public. A copy of these rules and regulations shall be readily availablefor reference and guidance of the clinic staff and personnel.Page 5 of 5