· .,

UBND TiNH KON TUM CQNG BOA xA HQI CHU NGHiA VI¥T NAMSOY TE DQc IfP - TV do- H,nh phuc

S6: 38 IPTN-SYTKon Tum, ngay 04 thong 12 ruim 2018

PH lEU TIEP NH~HB SO'cong b6 CO'sir KCB du di~u ki~n tiem chiing

Ten co sa nQPh6 sa: Phong kham Bac sy Chien.£>iachi: 541-Hung Vuong, TT. £>akHa, huyen £>akHa, Kon Tum.£>i~nthoai: 0914915127Sa y tS da nhan h6 sa bao gorn:1.Van ban thong bao co sa du diSu kien tiem chung,2. Ban ke khai danh sach dang ki hanh nghe tiem chung3. Ban ke khai co sa v~t chat, nhan hrc4. Ban ke khai thiet bi y tS cua co sa kham benh, chua benh5. Ban sao gi§.yphep hoat dong cua co sa kham benh, chua benh6. Ban sao co chimg thirc chirng chi hanh nghe, bang c§.pva gi§.ychirng nhan t~phu§.nvS tiem chung cua cac ca nhan co lien quan7. Ban sao co clnrng thirc Gi§.ychirng nhan dang ky thue,

Noi nltpn:- Ca sa t\l cong b6;- Luu h6 sa.

TrtrO'ng An

TiSp nh~ h6 sa b6 sung l§n 01, ngay thang nam Ky nh~nN9i dung, tcli li~u b6 sung: ..... ••••• •••••••••• •••• ••••••••• ••• ii Ii oo - ••••

.......... .

Ti~p nh~n h6 sa b6 sung l~n 02, ngay thang nam Ky nh~nN9i dung, tai li~u b6 sung: .

TiSp nh~ h6 sa b6 sung l§n 03, ngay thang nam Ky nh~nN9i dung, tai li~u b6 sung: .

so Y TE TINH KON TUMPHONG NGHI:eP VlJ Y

CONG HoA xA HOI CHU NGHiA VIET NAM. . .DQcl~p - Tl}'do - Hanh plnic

Kon Tum, ngay 14 thdng 12 ndm 2018

PHIEUTRlNHV~vi~c phong kham b~nh Bac sy Nguy~nDinh Chi~n cong b8 c?,SO'

du di~u ki~n tiem chung tren Trang thong tin di~n til' SO'Y te

Kinh trinh: Lanh dao Sa Y tS.

1.Tom t~t nQidung c§n trinh:Xem xet, phe duyet va cong b6 tren Trang thong tin dien illSa Y ts co sa du

di~ukien tiem chung.

Tom t~t noi dung h6 sa nhu sau:

1.1.Thong tin v~co SO':

- Ten co sa: Phong kham benh bac sy NguySnDinh ChiSn.

- Dia chi: S6 547 duong HUngVuong, thi tdn Dak Ha, huyen Dak Ha, tinhKonTum.

-NguCridai dien co sa:NguySnDinh ChiSn

- S6 dien thoai: 0914.915.127. Email: chien.ytdh127@gmail.com.

1.2.Thanh ph§n hBso bao gBm:- Van ban thong bao cc sa du di~u kien tiem chung (dung, dfiy du nQi

dung theo m~u quy dinh).

- Danh sach nhan S\f lam vi~c tC;liphong tiern chung v~c xin dich V1,l, kernban sao chUng nh~n tham d\f t~p hufuI v~ tiem chl'mg, hgp d6ng him vi~c, chUngchi hanh ngh~, b~ng t6t nghi~p trung c~p chuyen nghi~p.

- Ban ke khai trang thiSt bi phong tiem chung v~c xin dich V1,l.

- Ban ke khai ca s6 v~t ch~t, nhan Ivc.

- Gi~y phep hOC;ltdQng kham b~nh, chua b~nh.

- Gi~y chung nh~n dang kY thu~.

2.y ki~nd~xuAtcua ngU'Oitrinh: H6 sa dfiydu, dUngtheo quy dinh tC;li £)i~u9, M1,lc3, Chuang II Nghi dinh s6 104/2016/N£)-CP ngay 01/7/2016 cua Chinh philquy dinh v~hOC;ltdQngtiem chling.

1

3. Y ki~n eiia Truong phong: Dll kiem tra, ra soat h6 sa dam bao theo dungquy dinh cua thu tuc hanh chinh "Cong b6 co sa du diSu kien tiem chung" diroc banhanh tai Quyet dinh s6 600IQD-UBND ngay 2111112017 cua Chu tich Uy ban nhandan tinh Kon Tum.

Kinh trinh lanh dao SaY ts xem xet, phe duyet viec cong b6 tren Trang Thongtin di~n tir SaY tS./.

NGUOI TRINH

Pham Th] Thu Phuong

NO'inh~n:- Lanh dao Sa y t~;- Trang Thong tin dien hi Sa Y t~;- Luu: Phong chuyen man.

LANH D~O fiO x'J'EGIAM E>OC

D~ng C8ng Lan DilO Duy Khanh

2

sa YTE KON TUM CONG HOA xA HOI cnu NGHiA VIET NAM. . .PHONG KHAM B¥NH BS CHIEN DQc l~p - TV do - H~nh phuc

S6: 01/PKBBSCHIEN »si n« ngay 03 thang 12 nam 2018

THONGBAoCO'sO'du di~u ki~n tiem chiing

Kinh gifi: SO'Y t~ tinh Kon Tum

Ten co sa thong bao: Phong kham benh Bac sy Chien

Dia chi: 547 Hung Vuong, thi trfin Dak Ha, huyen Dak Ha, tinh Kon Tum

Ngiroi dirng d~u co sa: NGUYEN DlNH CHIEN

Di~n thoai: 0914915127 :Email (nSuco):chien.ytdh127@gmail.com

Can ell Nghi dinh s6 104/20 16/ND-CP ngay 01 thang 07 nam 2016 cuaChinh phu quy dinh vS hoat dinh vS hoat dQng tiem chung, kinh dS nghi Quy coquan xem xet, dang tai thong tin thea quy dinh,

PHV TRAcH PHONG KHAM B~NH

Nguy~n Binb Cbi~n

------- - - - -

CoosO'kham, tiem chiing xin gUi kern theo h(} h8 SO' g8m cac giAy to'sau:

l.Ban sao co chimg thuc gi§.ychirng nhan dang dang Icy thuS2.Ban sao co clnrng thirc van bang chuyen mon, chirng chi hanh nghe cua Dnguoi chiu trach nhiem chuyen mon kY thuat, va cac nhan vien tham giahoat dQng kham sang IQcva tiem chung. D3. Ban sao co chirng thuc chimg nhan tham du t~p huan vS tiem chung cuat§.t ca ngiroi hanh nghe trong co sa kham benh, tiem chung thuoc dienduoc c§.pchtmg chi hanh nghe D4.Danh sach nguoi dang ky hanh nghe tiem chung5.Ban ke khai co sa v~t chat, thiSt bi y tS, D6.HQ'Pd6ng lam viec ngoai gio cua cac ca nhan tham gia D7. Ban sao gi§.yphep hoat dong kham benh, chua b~nh. D8. Tai li~u chUng minh co sa kham, tiem chung dap Ung diSu ki~n vS co sa Dv~t ch§.t, trang thiSt bi, nhan S\l va diSu ki~n v~ sinh moi truang phil hQ'P DvOi ph~m vi ho~t dQng tiem chUng dff quy dinh trong cac Chuang, DiSu,diSm cua thong tu s6 104/20 16/N£)-CP, ngay 01 thang 07 nam 2016.

NGUm TONG HQI>(Ky, ghi ro hQ ten)

l~Nguy~n Binh Chi~n

CONG HOA xA HOI CHU NGHiA vier NAMDQc l~p - T\f do - H~nh phuc

Diik Ha, ngay 03 thong 12 ndm 2018

KE KHAI VE THIET BJ Y TE CUA CO sa KHAM B:E:NH,TIEM CHUNG

STT Ten thi~t hi Ky hi~u thi~t hi Cong Nurre Nam sA Tinh Gia thanh Ghi chu.(MODEL) ty san ? ? lU'gng trangsan san

" " xuit Stfxuat xuatdune

1 Til lanh dung LG LG Him 2018 01 Tot 19.000.000 Til lanh moitich 613 lit GR-B247IDS Quoc

2 Phich gift GldSTYLE Nhat 2014 01 Tot 1.000.0000lanh V~c xm Ban2,6 lit

3 Chi thi dong www.freeze- 2015 01 Tot 350.0000 EXP/LOT 2020-11/Cbang dien nr teg.ch

4 Nhiet ke do ill Lazada Vi~t 2017 01 Tot 80.000lanh Nam

5 Nhiet ke do Trung 2017 01 Tot 100.000nhiet dQmoi Quoctnrong

6 Binh tich lanh Lgloo Vi~t 2018 15 Tot 400.000thS tich 0,3 lit; Nam1 lit

7 Ong nghe tim YAMASU Nh~t 2013 02 Tot 270.000ph6i Bim

STT Ten thi~t b] Ky hi~u thi~t b] Cdng Nuoc Nam Sa Tinh Gia thanh Ghi chu(MODEL) ty san san san 1U'Q'ng trang

A A ,xuat xuat xuat sir

dun28 BQhuyet ap YAMASU Nh~t 2014 01 Tot 320.000

tre em Ban9 BQhuyet ap YAMASU Nh~t 2014 01 Tot 540.000

Ngiroi IOn Ban10 Nhiet ke thuy TECHNOLOGY Nh~t 2017 02 Tot 26000

ngan ban11 HQPthu?c Thanh phan hQP 250.0000 1;~dnalinlmg/lml x

chong soc thuoc cftp ciru 050ng(Thong tu phan v~ g6m. 2;Methylprednisolon40mg5112017/TT- x 0219BYT, ngay 3; Diphenhydramin 10mg29/12/2017) x 05 ongvaphac ~6 Bom tiern vo khuan loaichong soc xu lml x 02 caito phan img ; loai 5ml x 02 cai; loai 10sau tiem chung ml x 02 caithea quy dinh. Niroc c~t 5ml x 04 6ng

Day garo + bong, c6n(Phac d6, sa d6 xu tri c~pelm s6c phan v~ phu lucIII, Phu luc X)

12 Tu thuoc, v~t 01 450.000 Cac thuoc, v~t tu thiet~ph\lc vu ySu dung cho so",c~p ciru;cap ciru Bong AMBU, m~t na tre

nho; Bam xit salbutamol

STT Teo tbi~t b] Ky hi~u tbi~t bi Cong Niroc Nam sA Tinb Gii thanh Ghi chu(MODEL) ty sao san sao ItrQllg trang

J. J. J. sirxu at xu at xuatdYD2

x 01 hop; Dich truyenNatriclorid 0,9% x 02chai; day chuyen dich x02 b9.

13 Ban 02 360.000

14 Ghe ngoi cho 10 120.0000

15 S6 sach bieu S6 va cac bieu mftu baomftughi chep cao dam baa thea qui dinhthea doi thea tiem chung MR.thea qui dinhDung cu chua, ,chat thai y te

16 thea quy dinhcua B9 tnrongBe>YtS.

THAY~TCOSO

Nguy~n Dinh Chi~n

, ..., , "'" :.. A '?

DANH SACH DANG KY HANH NGHE TIEM CHUNG

CONG HOA xA HOI cnuNGHiA VI¥T NAMDQc I~p - TV do - H~nh phuc

1. Ten CO' SO' tiem chung: (in hoa) PHONG TIEM CHUNG BAc SY CfIlEN.

2. Dja chi: 547 HUng Vuong, thi tr~n Dak Ha, huyen Dak Ha, tinh Kon Tum.

3. NguiYj dung dAu cO'sO': Bac sy; Nguyen Dinh Chien,

4. Tho'i gian hoat dQng cua co' SO' tiem chung: Ngoai gio (ngay thuong bu6i trua tir 11 gio 30 dSn 13 giaOO, bu6i chieu nr17 gio 30 dSn 20 giaOO; Thir bay, chu nhat, ngay IS nr 08 gio dSn 20 giaOO)t6ng cong 40 gialtu~.

5. sa dien thoai: 0914.915127; 0971941708.

6. Email: chien.ytdhI27@gmail.com

Ph~m vi Sa clnrng chi ThOi gian Vi tri Bang hanh ngh~ tai CO'sir kham bfnh,STT HQva ten ngrroi hanh hoat dQng hanh ngh~ dii dang Icy chuyen chua benh khac

ngh~ chuyen dUQ'ccip lam vifC A Khoog C02: Trung tam y t~ huyju BakmooA tai co sir Hamon

tiem ThOi B~a diem Vi trichung gian chuyen

mfin

1 Nguyen Dinh Chien Bs da 000478/KT- Ngoai gio Phu trach Trong gio Khoa lam Bac SI h~khoa, sO' bQ CCRN' hanh chinh chung v€ hanh sang, di€u tri,ngo~ichAn cAp ngay chuyen chinh b~ vi~nthuO'llg 07/8/2013 mono huy~n,

369/QD-SYT DakHa2 Tran Thi Dong YSI 0004791KT- Ngoai gio Chiu trach Trong gio Tr~Y Y sl,

CCRN hanb chinh nhi~m hanh t~ thi kham

Cap ngay kham, sang chinh rran, dieu tri,07/8/2013, va lQC, illvan, huy~n thuc hiengi~y chirng theo doi tre, DakHa cac

nhan t~p huan va xu tri chuangv~ tiern chung

phan irngtrinh y tequoc gia.

sau tiem.

3 Nguyen Hoang Danh Dieu 0004711KT- Ngoai gio Thuc hien Trong gio Tr~mY Dieudu5ng CCHNC~p hanh chinh cac Icy thuat hanh t~Ha du5ng

ngay 7/8/2013,,

trung hoc ve tiem chinh Mon,Dakva giay clnrng chUng Hanh~n t~p hufutv~ tiem chung

4 Nguyen Thi Ly Dieu 0004931KT- Ngoai gio Thl,Ichien Trong gio Tr~mY Dieudu5ng CCHN hanh chinh cac ~Y thuat hanh t~ thi du5ng

trung hoc C~p ngay ve tiem chinh Tran,07/8/2013, va chUng DakHagi~y chimgnhan t~p huanv~ tiem chung

Dak Ha, ngay 03 thang 12 nam 2018NguOi dung dAu 'CO' s(r Imam b~nh, tiem chung

(ky va nghi ro hQten)

J--Nguy~n Binh Chi~n

CONG HOA xX HOI cnu NGHiA VIET NAM. . .DQc lip - TV do - H~nh phtic

DakHa, ngay 03 thang 12ndm 2018

BAN ICE KHAI CO sa v~T CHAT, NHAN Ll/C

I. CoosO'vit ch§t ciia Co' S(r tiem chung cB djnh

a. Co' sO'vit ch§t:

- Dien tich mat bang khoang 90 met vuong.

- Nha duoc xay dung c~p 4 nrong gach day 20 em, cao 5,5 met, co trfu1g6chong nong va chong bui, nen nha va khoang lat gach men, thuan tien cho viecv~ sinh.

b. Di~n tich xiiy dung Stf dung;- Khoang 71 m2

c. Di~n tich cac khu Vl}'C, phong chuyen mon:

- Khu Vl!C cho co mai ton che, va thong thoang (san) co dien tich 15 m2

- Khu VlJC thirc hien tu v~n co dien tich 8,5 m2

- Khu V\lC thirc hien tiem chung co dien tich 9 m2

- Khu VlJC then doi va xu tri phan irng sau tiem chung co dien tich 16 m2

c. BB tri cac khu Vl}'C theo nguyen tic mQt cbi~u:

- Tir ngoai van trong:

+ Khu V\lC ng6i cho tnroc khi tiem chung co d~y du nghS ng6i, dam baoche duqc mua, n~ng,va thong thoang.

+ Khu thvc hi~n tu v~ co ban, ghS ng6i duqc ngan nhom kinh cao 2,5met co d~t mQt giuemg, cua dong khi ra van dam bao kin dao.

+ Khu vvc tiem chUng duqc ngan nhom kinh cao 2,5 met co d~t mQt caiban, cua ra van .

+ Khu VlJC then d5i va xu tn phan ling sau tiem duqc b6 tri mQt giuangn~m va co d~y du cac trang thiSt bi then thong tu.

d.Cac di~u ki~n v~ sinh moi trU'O'ng:

+ Hqp d6ng v&i b~nh vi~n huy~n v@xu ly rac thai y tS ; co sa co trachnhi~m thu gOffi,phan lo~i dong bi nilon, v~t s~c nhQn b6 van hQp an toan dambao v~n chuySn an tom, dam bao dung then qui diM v@rac thai trong y tS, col~p s6 giao nh~ vai nguai qUID ly rac thai b~nh vi~n.- D6i rac thai sinh ho~t: co

sa thu gom t~p trung vao thung rae cong cong dS moi tnrong huyen thu gomhang ngay, dam bao dung qui dinh.

+ Bam bao du anh sang va b6 tri theo nguyen t~c mQt chieu tai cac khuvue.

II. NbaD I,!c Taog cQog 04 ogtrOi:G6m Bac sy; 01 ngiroi; Y sy; 01 nguoi; Bi~u dueng trung hoc; 02 nguoi,

THAYMATCaSO.

Nguy~oDlnh Cbi~o