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Name of Hospital _______________________________________________________________ Address ______________________________________________________________________ Date of Internship ______________________________________________________________ SURVEY TOOL FOR HOSPITAL PHARMACY Dear Students: You are requested to fill up completely this evaluation tool. There is no right or wrong answer. Your honest evaluation is important to have an accurate conclusion. Thank you for your time. Pharmacy Internship Committee DIRECTIONS: Using the scale below, please encircle the code opposite each item to rate the extent by which each item is practiced in the hospital pharmacy. 4 = Great Extent (GE) 3 = Moderate Extent (ME) 2 = Little Extent 1 = Negligible or Not At All

I. General Provisions: 1. The hospital pharmacy conducts training of pharmacy students affiliated with the hospital that meets the requirements of the DOH NCATS/RCATS. (AO 70-A s. 1989) 2. There is a well-organized Pharmacy Service conducted in accordance with ethical and professional practices and properly licensed by the BFAD in the issuance of an LTO in accordance with the Food, Drugs, Devices and Cosmetics Act ([FDDCA] RA 3720 as amended) and the Bureau of Licensing in accordance with the Hospital Licensure Act (RA 4226) and the Dangerous Drugs Act. 3. The hospital pharmacy provides orientation to the interns prior to the start of the internship. 4. There is a registered pharmacist who supervises the intern during the internship. 5. The physical presence of a licensed pharmacist is ensured especially when the pharmacy is open for service and/or the pharmacy renders 24 hours service. 6. There is a PTC that provides rational drug therapy. 7. The hospital pharmacy ensures continuous supply of drugs and medicines of the highest standards to patients by maintaining an adequate quantity of stocks in the hospital pharmacy. 8. The hospital pharmacy conducts the preparation and compounding of bulk sterile and non sterile pharmaceuticals approved by PTC. Pharmacy Internship Program UST Faculty of Pharmacy (AY 2011-2012)

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9. Provides IV admixture program. 10. There are adequate provisions for equipment, chemicals for 4 compounding and dispensing (standard laboratory equipment, laminar flowhood, prescription balance, pill tile, mortar and pestle, etc. 11. There are adequate provisions for reference books and record 4 books duly registered with BFAD (PNDF, USP/NF RPS, Goodman and Gilman Pharmacological Basis of Therapeutics, R.A. 6675, R.A. 5921, R.A. 8203, Prescription Book and Dangerous Drug Book, Exempt Preparation and Poison Book) 12. The hospital pharmacy conducts the screening, filling and proper dispensing of drugs in accordance with the laws, rules and regulations pertinent thereto. (RA Nos. 5921, 3720, 6425, 6675) 13. Maintains records, files and submit reports on dangerous drugs and other pharmaceuticals in compliance with pertinent laws, rules and regulations. 14. The hospital pharmacy controls the labeling and packaging of drugs that complies with standards and legal requirements. 15. There is enough space for a pharmacist to observe and supervise all interns assigned in the pharmacy department. 16. There is a Policy and Procedure Manual on training/internship which is implemented consistently. 17. The physical-set up of the pharmacy department is in accordance to the acceptable standard. 18. The hospital pharmacy serves as Drug Information Center to all hospital personnel, students and patients. 19. The hospital pharmacy is properly lighted, well-ventilated and has an area of not less than 15 sq. m. with concrete tile or wooden flooring. 20. There is a unit dose drug distribution system used in the hospital. 21. The arrangement of furniture allows enough space for movement and work. 22. The pharmacy department provides a suitable place for adequate storage of drugs and biological products specified on the labels. 23. The appearance of the pharmacy department is aesthetically neat and orderly. 24. There are clear provisions in the preparation and signing of the Requisition Issue Vouchers (RIVs) with complete specifications of drugs indicating the quantity and cost based on the official Price Schedule for actual procurement. 25. There are clear provisions for the invoices indicating the lot number/batch number of the manufactures stock pursuant to BFAD, file of prescription filled consecutively numbered, dry Pharmacy Internship Program UST Faculty of Pharmacy (AY 2011-2012) 4 4 4 4 4

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seal or rubber stamp, red or white label indicating the number and address of the hospital. There is a summative evaluation of the internship activities and the student performance upon completion of the required number of hours by the intern. A drug inventory system is maintained by the hospital pharmacy adopting the FIFO method in dispensing and distributing drug stocks. The institution develops a pharmaceutical research. There is a provision for continuing education for pharmacy staff and support personnel A pharmacist on duty always wears the prescribe uniform

II. Pharmacist/Personnel Attitudes and Competencies 1. Plans and conceptualize internship activities 2. Meets the needs of the intern 4. Is willing to work long in a traditional hours in order to assist interns. 4. Delegates the task fairly 5. Guides the interns in their work of: a. compounding, labeling and packing b. TPN preparation c. preparing stock solution d. handling of ethical and dangerous drugs e. pricing the prescription f. recording of prescription g. dispensing of drugs h. disseminating drug information i. preparing inventory of drugs and other resources of drugstore. 6. Monitors and evaluates the activities and performance of the interns professionally and fairly 7. Is willing to share his/her management and professional experience/training. 8. Provides or suggests solutions to problems 9. Inspires the interns to work with commitment. 10. Encourages the interns to be respectable and trustworthy. 11. Performs consistently the tasks (student related activity) within the Drugstore. 12. Adapts easily to constant change of people, places and things. 13. Treats all interns fairly and honestly. 14. Is courteous and tactful to interns. 15. Relates well to staff and interns

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III. Facilities 1. Sufficient facilities in good condition are available. 2. Up-to-date facilities are available 3. The physical and material resources are arranged orderly. 4. There is flexibility for the physical and material resources. 5. The physical facilities and compounding areas are clean. 6. The interior design of the hospital pharmacy is simple and attractive. IV. Location 1. The site is convenient to patients 2. The hospital pharmacy is accessible to public transportation. 3. The hospital pharmacy has enough parking space 4. The hospital pharmacy has adequate provision for expansion. 5. The hospital pharmacy has enough security measures for safety i.e adequate lights, presence of security guard V. Patient Service 1. The hospital pharmacist has the competencies required. 2. The hospital pharmacist renders prompt and quality service 3. The hospital pharmacists are courteous and approachable. 4. The frontline staff is friendly. 5. The hospital pharmacist communicates clearly with the patients specially on dosing regimen and how the drug should be taken 6. The hospital pharmacists attend to patients comments and feedbacks.

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Pls. rate the hospital pharmacy as a whole from 1-5 with 5 as the highest point. _________. Would you personally recommend this hospital pharmacy as a training site for Pharmacy students in Hospital Pharmacy? A. Yes B. No Remarks: ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________

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