FORM OF INSPECTION OF PRIVATE HOSPITALS

Name & designation of inspection Authority .......................................................................

Name of team members with designation .........................................................................

Date of inspection .......................................................................................................

Place & District ...........................................................................................................

Name of Hospital/Lab/Nursing Home ................................................................................

Complete address : No...................... Ward ........................ Mohalla ............................

Lane .................. Area ................... City ............ District ....... (M.P) Pin Code ................

Name of owner/Director :..................................... Qualification ......................................

Telephone No:........................................... E-mail ........................................................

Address:....................................................................................................................

Year & month of establishment: ....................................................................................

Whether income tax return is filed ? IT No.: ....................................................................

Audit certificate of last two years may be attached .........................................................

Infrastructure details about building (Attach Map) ...........................................................

Surroundings of facility (cleanliness, drainage, dampness, harmful & unhygienic surroundings) :.........................................................................................................

.............................................................................................................................

Cleanliness of premises : ............................................................................................

Board showing Rate list/Charge for investigation & Services : ...........................................

Inquiry counter : .....................................................................................................

Details of the investigations / Procedures / Services applied for recognition: ......................

............................................................................................................................

Interior of facility (specially mention about Light, open air, dampness & cleanliness of rooms

and interior ) .........................................................................................................

Comments on availability of floor space as per norm (100 sq. ft per bed) .......................... ...........................................................................................................................

Arrangements of clean potable water for patients ........................................................ ...........................................................................................................................

Cleanliness of toilet / Flush system ........................................................................... ..........................................................................................................................

Manpower position of the facility (Names with qualifications & skills, attach separate sheet

mentioning No. of trained & untrained staff/ Doctors / Specialists/ (Norm - One doctor for

every 15 indoor bed & /or 40 OPD cases) ...................................................................

..........................................................................................................................

Number of rooms, Laboratories, Wards, Examination Rooms, OPD rooms, Special investigation

rooms (Attach a Map showing all facilities, opinion about adequacy and quality of maintenance

& quality of services provided:..................................................................................

..........................................................................................................................

Duty room for doctors & nurses available & details: ......................................................

Comments on Duty roaster of Doctors & staff: ............................................................

What is the system of record keeping for patients. Is the stock register, patient register indoor

& outdoor investigation register maintained ? (average patient related statistics may be shown) :..........................................................................................................................

Are facility for emergency services available, Emergency equipments, drugs, oxygen & resuscitation

facility available ? comment on adequacy & quality : ..................................................... ...........................................................................................................................

..........................................................................................................................

Provision of keeping infected cases separately : ...........................................................

Arrangement for indoor patients - Cots, mattress, Linen, Bed side locker & other facility available /

adequate & comments on quality : .............................................................................. .............................................................................................................................

............................................................................................................................

List of equipments available for the investigations, there make if important, quality & arrangements

for AMC, Logbook etc. (investigation requested for recognition): ................... .............................................................................................................................

.............................................................................................................................

Arrangements available for pathological & biochemical & Bacteriological investigations: ........... ..............................................................................................................................

Comments on operation theatre, space, No. of rooms, its adequacy in relation to No. of operation

performed, Autoclaving arrangements, Details of equipments anesthesia used, and instruments

availability, emergency light arrangements, facility for dealing with emergency (this is required in

case an operative procedure is requested fro recognition): ............................................... ..............................................................................................................................

..............................................................................................................................

Comments on skill of Doctors/Specialist/ No. of operation performed by them if essential there

skill may be seen during surgery: ................................................................................. .............................................................................................................................

.............................................................................................................................

Opinion regarding other specialised services available: ....................................................

Give specific opinion that the facility requested for recognition is essential & is not available in

the Govt. Hospitals locally : .......................................................................................

.............................................................................................................................

Comments on rates quoted as per the quality of services provided: ...................................

.............................................................................................................................

Overall comments of the team members: ......................................................................

.............................................................................................................................

Signatures	Signatures	Signatures
Name	Name	Name
Designation	Designation	Chief Medical & Health Officer
Date	Date	Date